Leiomyosarcoma of intravascular origin--a rare tumor entity: clinical pathological study of twelve cases

[Portal leiomyosarcoma: An extremely rare location!]

Leiomyosarcomas of large vessels are rare. It is a malignant tumour and the vast majority of these tumours arose from the inferior vena cava. We report a rare case of portal vein leiomyosarcoma, in a 56-years-old female patient admitted for chronic abdominal pain with abdominal mass in the right hypochondrium all evolving in a context of deterioration in general condition. We performed an abdominopelvic CT scan and then a MRI with contrast agent which objectified a large tissue mass containing areas of necrosis at the level of the duodeno-pancreatic compartment communicating at a large angle with the portal trunk over its entire length from the hepatic hilum to the spleno-mesenteric confluence responsible for a portal cavernoma downstream. This is associated with multiple secondary nodular tissue hepatic lesions. We also noted a respect for the fatty border separating the mass of the duodenal tract and the head of the pancreas, and also the absence of dilation of the pancreatic ducts making a pancreatic origin unlikely. To eliminate a duodenal origin of the mass we performed an upper digestive endoscopy which came back without any abnormality. An ultrasound-guided trans parietal biopsy of a secondary hepatic lesion was done and the pathological result of which speaks of a secondary hepatic lesion of a leiomyosarcoma.

Morbidity and Mortality after Surgery for Retroperitoneal Sarcoma

Retroperitoneal sarcoma (RPS) is a rare disease with over 100 histologic types and accounts for 10-15% of all soft tissue sarcomas. Due to the rarity of RPS, sarcoma centers in Europe and North America have created the Transatlantic RPS Working Group (TARPSWG) to study this disease and establish best practices for its management. Current guidelines dictate complete resection of all macro and microscopic disease as the gold standard for patients with RPS. Complete extirpation often requires a multi-visceral resection. In addition, recent evidence suggests that en bloc compartmental resections are associated with reduced rates of local recurrence. However, this approach must be balanced by the potential for added morbidity. Strategies to mitigate postoperative complications include optimization of the patient through improved preoperative nutrition and pre-habilitation therapy, referral to a high-volume sarcoma center, and implementation of enhanced recovery protocols. This review will focus on the factors associated with perioperative complications following surgery for RPS and outline approaches to mitigate poor surgical outcomes in this patient population.

Leiomyosarcoma of the splenic vein with a history of bilateral retinoblastoma: A case report and review of the literature

Diagnosing leiomyosarcomas of the splenic vein is challenging, and a treatment strategy has not yet been established for this condition. We herein report the case of a 45-year-old female patient with a history of retinoblastoma who underwent pancreatosplenectomy for a primary leiomyosarcoma originating from the splenic vein and transcatheter arterial chemoembolization for metastatic hepatic lesions observed 5 months postoperatively. An initial medical check-up using abdominal ultrasound revealed a 40-mm mass behind the pancreatic tail. Imaging tests revealed a well-circumscribed mass compressing the pancreas posteriorly, without invasion into the pancreatic duct. The splenic vein was torn, with the epiploic veins developed as collateral blood vessels, which was an atypical finding for carcinoma. The patient was followed up regularly. At 5 years after the first visit, an abdominal ultrasound showed that the mass had increased in size to 50 mm, and had developed into a tumor embolus within the splenic vein, causing an obstruction of the vessel. Pancreatosplenectomy was performed due to suspicion of malignancy. The final diagnosis was leiomyosarcoma arising from the splenic vein. The patient was discharged on postoperative day 15 and was followed up regularly thereafter. Imaging studies performed 5 months postoperatively revealed four hepatic lesions. The hepatic masses were histologically diagnosed as metastatic leiomyosarcomas, and transcatheter arterial chemoembolization was performed using epirubicin. Since then, regular follow-ups have been conducted without observed recurrence. Leiomyosarcoma of the splenic vein is exceedingly rare, and the number of reported cases is not sufficient to establish clinical guidelines. Therefore, it is crucial to collect more reports on the occurrence and treatment of this disease.

Primary external iliac vein leiomyosarcoma in a young female diagnosed by contrast-enhanced ultrasound: A case report

RATIONALE

Venous leiomyosarcoma (LMS) is a malignant tumor arising from the smooth muscle cell of the vein wall. The diagnosis of venous LMS is usually delayed owing to its rarity, absence of serological markers, and mimicry with deep vein thrombosis (DVT). Herein, we report a case of a primary external ilian vein LMS characterized by long-term, unexplained DVT in the left lower limb. Contrast-enhanced ultrasound (CEUS) played a crucial role in the preoperative diagnosis. No improvement was observed in the lower limb status; a rapid, high-level, heterogeneous wash-in and wash-out mass of the vein, as seen with CEUS, could indicate angiogenic malignancy. CEUS also helped evaluate the percent of intratumoral necrosis, which is an important parameter for predicting the prognosis.

PATIENT CONCERNS

A 37-year-old Chinese women presented to the Vascular Surgery Department of our hospital for accurate diagnosis of her condition. She began experiencing edema and pain in her left leg 2 years ago. She was diagnosed with DVT in the left lower extremity and was administered anticoagulant therapy since then. However, her symptoms started to aggravate 8 months ago.

DIAGNOSES

The laboratory results including D-dimer, prothrombin time (PT), activated partial thrombin time (APTT), and prothrombotic conditions screening were within normal ranges. A pelvic ultrasound detected a heterogeneous, hypoechoic mass compressing the external iliac vein and obstructing the venous drain of the lower extremity. The mass showed a rapid, high-level, heterogeneous wash-in and wash-out on CEUS, which suggested angiogenic malignancy. Contrast-enhanced CT (CECT) confirmed the result of CEUS but revealed no metastasis.

INTERVENTIONS

She underwent complete surgical removal of the tumor, which was resected successfully. There was no infiltration in the inguinal nodes sent for the study.

OUTCOMES

Pathological examination and immunohistochemistry confirmed that the mass was a well-differentiated LMS originating from the external iliac vein. There was no sign of local recurrence or distant metastasis during a 12-month follow-up.

LESSONS

Effective imaging techniques and differential diagnosis of venous LMS is vital and should be considered for patients with chronic thrombosis presenting with normal laboratory results.

Intravascular schwannoma: A review of a rare diagnosis

While schwannoma is one of the most common types of benign peripheral nerve tumors in adults, a very unique and specific variant of schwannoma, the intravascular variant, is exceedingly rare. There have only been three previously published cases of intravascular schwannomas. Here we describe a fourth case of an intravascular schwannoma in a 47-year-old man with an enlarging subcutaneous nodule on his posterior calf. This is the second case of an intravascular schwannoma contained within a vein. Also included is an overview of intravascular schwannomas, including a description and discussion of the histopathological diagnosis, differential diagnoses, and schwannoma variants.

Leiomyosarcoma of the inferior vena cava: A case report of a rare tumor entity

INTRODUCTION

Leiomyosarcomas are rare and heterogeneous group of tumors that account for less than 1% of adult malignancies. More than 50% of all vascular leiomyosarcomas occur in the lower part of vena cava. Since the first description of Perl and Virchow in 1871, only approximately 450 cases have been reported in literature.

PRESENTATION OF CASE

The patient presented due to abdominal pain and weight loss. Based on the imaging evaluations a retroduodenal tumor with compression of the inferior vena cava was observed. In the explorative laparotomy a leiomyosarcoma originating from the inferior vena cava was identified. Considering the extensive intramural and intraluminal tumor manifestation, the patient underwent a segmental resection of the vena cava. Reconstruction was achieved by implanting a polytetrafluoroethylene (PTFE) prosthesis. Postoperatively a stenosis developed due to a pericaval haematoma with consecutive compression of the prosthesis. An angiographic implantation of a stent was successfully performed. In the 24-month follow-up, the patient is free of symptoms and tumors.

DISCUSSION

Leiomyosarcomas of the vena cava are classified anatomically according to their relationship to the liver and renal vessels. The clinical symptoms depend on the affected segment. The therapy of choice is radical en bloc tumor resection. After resection, the options for reconstruction include placement of a synthetic graft, primary repair and patch repair.

CONCLUSION

Due to a variety of topographic and tumor biological sarcoma manifestations, no standard has been established for the resection of this entity. The extent of resection should be planned individually.

[Leiomyosarcoma of the splenic vein]

Vascular leiomyosarcoma (LMS) is an extremely rare disease. Venous lesion is approximately 5 times more common than arterial. LMS is usually found in retroperitoneal veins and in inferior vena cava. Lesion of the splenic vein is extremely rare. A 52-year-old woman with recurrent abdominal pain is reported in the article. Abdominal contrast-enhanced CT revealed a 6 cm tumor of the pancreatic tail. The patient underwent laparoscopic distal pancreatectomy with splenectomy en bloc. Histological and immunohistochemical studies revealed LMS originating from the smooth muscles of the splenic vein. Surgery was followed by adjuvant chemotherapy. There was no local recurrence in 1 year after surgery. In this article, we analyze the available information on leiomyosarcoma of the splenic vein.

Leiomyosarcoma of the Inferior Venacava: A Case Report

Leiomyosarcoma of inferior venacava is a rare tumor. Female are most commonly affected and middle segment of inferior vena cava is the commonest site. The diagnosis can sometimes be challenging as patients present with non-specific symptoms. We present a case of a 65-year-old female who presented with pain in right hypochondrium and epigastric region since 4 months along with weight loss, anorexia and vomiting. Histopathological examination revealed a capsulated, multilobated tumor arising from muscle layer of inferior venacava with extraluminal growth pattern and tumor cells showing cytoplasmic positivity for immuno-histochemical stain smooth muscle actin. With the diagnosis of leiomyosarcoma of inferior venacava, excision of tumor was done with tangential excision of 4 cm length of inferior venacava with primary repair. Keywords: inferior venacava; leiomyosarcoma; smooth muscle actin.

Physics of growing biological tissues: the complex cross-talk between cell activity, growth and resistance

For many organisms, shapes emerge from growth, which generates stresses, which in turn can feedback on growth. In this review, theoretical methods to analyse various aspects of morphogenesis are discussed with the aim to determine the most adapted method for tissue mechanics. We discuss the need to work at scales intermediate between cells and tissues and emphasize the use of finite elasticity for this. We detail the application of these ideas to four systems: active cells embedded in tissues, brain cortical convolutions, the cortex of Caenorhabditis elegans during elongation and finally the proliferation of epithelia on extracellular matrix. Numerical models well adapted to inhomogeneities are also presented. This article is part of the theme issue 'Rivlin's legacy in continuum mechanics and applied mathematics'.

Primary External Iliac Vein Leiomyosarcoma

Leiomyosarcomas of vascular origin are uncommon. They arise from the smooth muscles of tunica media of major blood vessels. Most of the cases are present in women. We report one such case of external iliac vein leiomyosarcoma in a 77-year-old female and discuss the clinical, radiological, and histopathological findings and the available treatment options.

Leiomyosarcomas affecting main vessels in the lower extremities

OBJECTIVE

To evaluate the results of bloc resection and vascular reconstruction of leiomyosarcomas with involvement of main vessels in the lower extremities.

MATERIAL AND METHODS

From January 1983 to December 2016, 42 patients with leiomyosarcomas were diagnosed. Six of these leiomyosarcomas affected main vessels of the lower extremities (called vascular). Epidemiological data, imaging studies, surgery performed, adjuvant treatments, complications, as well as recurrences and mortality were retrospectively recorded.

RESULTS

All the patients were affected by high-grade leiomyosarcomas (ii-iii FNCLCC classification), with a larger tumour average diameter of 9.1cm(6-15) and a mean follow-up of 23 months (7-36). The average age was 64 years (29-84). The first symptom was a palpable tumour in 4 of them. The other 2 cases debuted with thromboembolic phenomena. In 5 cases the origin was the femoral vessels, while one case was at the popliteal level. Although all cases preserved the limb, in 3 cases (50%) they presented pulmonary dissemination,2 cases (33%) hepatic dissemination and one case had local recurrence. Two cases died at the end of the study and there was one case of loss to follow-up.

DISCUSSION AND CONCLUSIONS

Vascular leiomyosarcomas are highly aggressive tumours with a low survival rate at 5 years. In our study, 50% of the patients remain in complete remission with a mean follow-up of 23 months. Their onset frequently associates the presence of tumour mass with thrombotic phenomena (33% of our cases). Tumour resection surgery usually compromises the main vascular structures, which implies resection and vascular reconstructive techniques to salvage the limb.

Leiomyosarcoma of the great saphenous vein (vena saphena magna) with granular cell change: Report of a superficial neoplasm

The great saphenous vein (GSV) corresponds to the main superficial large-caliber vessel affected by leiomyosarcoma (LMS). Given its superficial location and because signs of vascular origin may not be clinically apparent, LMS of the GSV may be misinterpreted clinically as superficial nonvascular soft tissue mass. Herein, we report a case on the distal portion of the right GSV of a 57-year-old man. The histopathological recognition of a large-caliber vein-associated LMS (with granular cell change) in an incisional biopsy specimen was crucial to guide radiological evaluation and confirmation of a superficial vascular LMS before surgical treatment. Recognizing this entity in small biopsies is important as its surgical treatment and prognosis differ substantially from nonvascular superficial (ie, subcutaneous and dermal) LMSs. In addition, because vascular LMSs can involve long vessel segments, underestimation of extent of disease is a risk. To the best of our knowledge, granular cell change has not been documented in LMS of the GSV.

Leiomyosarcoma of the splenic vein: A case report

Leiomyosarcomas (LMSs) originating from the wall of blood vessels are aggressive and rare neoplasms. The current study describes a case of a 52-year-old man who presented with intermittent abdominal pain without weight loss or diarrhea. Computed tomography of the abdomen identified a 4-cm, solid, heterogeneous tumor in the tail of the pancreas, while a hypodense lesion was also noted in the right hepatic lobe. The patient subsequently underwent splenic pedicle tumor resection, splenectomy and liver tumor resection. Notably, immunohistochemical and histological analyses identified LMS, which had originated from the smooth muscle of the splenic vein. Currently available information regarding LMSs of the splenic vein and their management is also discussed, with the aim of improving diagnostic accuracy.

Primary leiomyosarcoma of the jugular vein in a dog

A four-year-old, male, Labrador retriever was referred for removal of a spindle cell sarcoma involving the right jugular vein. A post-contrast CT scan showed a seven-centimeter subcutaneous mass originated from the right external jugular vein, which was partially obstructed and showing contrast stasis, suggested a primary intravascular tumor of the jugular vein. The mass was resected, and histological evaluation was consistent with grade II intravenous spindle cell sarcoma of the jugular vein. Immunohistochemical positivity for vimentin, desmin, and αSMA antibody and negativity for S-100 protein confirmed venous leiomyosarcoma. The dog received five doses of intravenous doxorubicin, and there was no recurrence of the tumor 30 months post treatment. In dogs, primary intravascular sarcomas are rare and primary venous leiomyosarcoma has not been described. A venous tumor may be considered as a differential diagnosis in dogs with ventral neck swelling.

Primary Leiomyosarcoma in the Inferior Vena Cava Extended to the Right Atrium: A Case Report and Review of the Literature

A 38-year-old woman had developed an abdominal distention, lower extremity edema, and dyspnea. Imaging examination revealed a large mass in the right atrium which was connected to lesions within the inferior vena cava. Although complete resection of the mass was not possible, partial surgical tumor resection was performed to avoid pulmonary embolization and circulatory collapse. Leiomyosarcoma was diagnosed histologically, and chemotherapy (doxorubicin) followed by radiotherapy was started. By reviewing papers published in the past 10 years that included 322 patients, we also discuss the clinical presentations and prognosis of leiomyosarcoma in the inferior vena cava.

Vascular resection en-bloc with tumor removal and graft reconstruction is safe and effective in soft tissue sarcoma (STS) of the extremities and retroperitoneum

BACKGROUND

To analyze the outcome of a series of patients who underwent vascular resection as part of an excision of a soft tissue sarcoma (STS).

STUDY DESIGN

All consecutive patients affected by localized STS of an extremity or retroperitoneum treated between January 2000 and December 2013 with surgery including vascular resection were considered. Overall survival (OS), crude cumulative incidence (CCI) of local recurrence (LR) and distant metastases (DM) were estimated by Kaplan-Meier. Long-term vascular graft patency rate was assessed.

RESULTS

2692 patients received an operation for localized disease with 105 (3.9%) cases undergoing vascular resection. Median FU was 32 months. 5-year OS, CCI of LR and DM were 62%, 12% and 58% respectively. Vascular reconstructions consisted of 52 arterial and 16 venous grafts in extremities; 12 arterial and 33 venous grafts in the retroperitoneum. Graft thrombosis occurred in 16 patients (7/64 arterial and 9/49 venous reconstructions). Arterial occlusions occurred at a median of 36 months after surgery and were treated by prosthesis replacement (3), Fogarty catheter embolectomy (2), percutaneous angioplasty (1) and observation (1). One patient eventually required amputation. Venous occlusions occurred at a median of 4 months post surgery and were all treated conservatively. Overall arterial and venous reconstruction patency rates were 89% and 82% respectively.

CONCLUSIONS

Vascular resection to facilitate resection of STS has an acceptable long term patency rate. However it was associated to a high risk of distant spread. Although the encasement of the vascular bundle does not represent a contraindication to surgery there is an association with a high metastatic risk by virtue of the locally advanced nature of the disease and this should be considered when planning treatment.

A primary intravascular synovial sarcoma causing deep-vein thrombosis and pulmonary embolism in a 20-year-old woman

Primary intravascular synovial sarcoma is a rare malignancy with only a few cases documented in the literature. On presentation, this tumour usually resembles a deep venous thrombosis (dvt) or pulmonary embolism (pe). Here, we report the case of a 20-year-old woman complaining of shortness of breath who had a history of dvt 6 weeks before presentation at our institution. Vascular ultrasound detected a suspicious mass in the right groin, which was identified as a monophasic synovial sarcoma by surgical biopsy. The tumour extended from the right superficial femoral vein into the common iliac vein, profound femoral vein, and great saphenous vein. It caused pe with near-total occlusion of the right pulmonary artery. After initial treatment on the cardiac intensive care unit, the patient was referred to the oncology department for neoadjuvant radiochemotherapy with doxorubicin-ifosfamide according to the Interdisziplinäre Arbeitsgemeinschaft Weichteilsarkome [Interdisciplinary AG Sarcomas] protocol and surgical resection of the tumour. No signs of tumour recurrence were found during the subsequent course of the disease, but the patient died from treatment complications approximately 15 months after initial presentation. This case underlines the importance of screening for malignancies even in young patients presenting with dvt or pe. We also recommend whole-leg compression ultrasonography in patients with suspected dvt or pe (as opposed to venography or simple four-point ultrasound examination in the groin and popliteal fossa) to detect possible underlying causes for thrombosis.

Leiomyosarcoma of the retrohepatic vena cava: Report of a case treated with resection and reconstruction with polytetrafluoroethylene vascular graft

Leiomyosarcoma of the vena cava is a rare malignant tumor. A 61-year-old woman was admitted with right upper quadrant abdominal pain. Computed tomography revealed a retrohepatic vena cava tumor originating 2 cm below the confluence of the hepaic veins and ending 2 cm above the renal veins. The tumor was resected with 1 cm clear surgical margins, without requiring liver resection. Polytetrafluoroethylene vascular graft was used for reconstruction of the vena cava. Now 32 months postoperatively, there has been no recurrence or metastasis. Radical resection with negative surgical margins is the best curative therapy for leiomyosarcoma. Polytetrafluoroethylene vascular graft can be used in extensive tumors located at the vena cava.

Inferior vena cava leiomyosarcoma: preoperative diagnosis and surgical management

Inferior vena cava (IVC) leiomyosarcoma is a rare malignant neoplasm more commonly seen in women in the fifth to sixth decade of life. Complete resection of the tumor with negative margins is the only therapeutical option that has demonstrated a survival benefit. This report presents a case of a 67-year-old woman affected by a lower segment IVC leiomyosarcoma incidentally detected during a chronic abdominal pain study. The patient was treated with tumorectomy, resection and ligation of the infrarenal IVC without signs or recurrence on a 12-month follow-up.

Leiomyosarcoma of the splenic vein

Leiomyosarcomas arising from the wall of blood vessels are rare and aggressive neoplasm. We report a case of a previously healthy 66-year-old woman who presented with intermittent abdominal pain, progressive constipation, and weight loss. Abdominal computed tomography showed a 12 cm solid heterogeneous tumor in the tail of the pancreas. The patient subsequently underwent surgical resection of the pancreatic mass. Surprisingly, histological and immunohistochemical analyses revealed leiomyosarcoma arising from the smooth muscle of the splenic vein. After surgery, she received adjuvant chemotherapy. One year later, there was no evidence of local recurrence. In this paper, we discuss the available information about leiomyosarcomas of splenic vein and its management.

Leiomyosarcoma of the deep femoral vein. A rare cause of venous obstruction in lower limbs and an alternative diagnosis to chronic venous thrombus

Primary venous leiomyosarcoma of the extremities is an uncommon, but aggressive, tumoral entity with a high rate of local recurrence and early hematogenous metastasis. In the present article, we report a case of leiomyosarcoma of the vena profunda femoris. This pathology causes deep venous thrombosis-like symptoms. No improvement in lower limb status and a significant and progressive increase in the diameter of the vein as seen using ultrasonography could indicate tumor disease. Particular care must be taken to avoid biopsies due to the possible dissemination. We must complete the medical study with imaging techniques, and the tumor must be removed as soon as possible for histopathological diagnosis. After a follow-up of 12 months, there was no evidence of local or metastatic recurrence in our patient.

Leiomyosarcoma of the inferior vena cava extending into the right atrium. A rare differential diagnosis of a right atrial tumor with fatal outcome

A 54-year-old female patient presented with a progressive and deteriorating dyspnea at the slightest exertion in particular during the past few days before presentation. Transthoracic echocardiography revealed a large space-occupying lesion in the right atrium extending into the inferior vena cava (IVC). Abdominal magnetic resonance aortography showed an elongated space-occupying lesion in the IVC with a significant portion of the tumor and almost completely filling the right atrium accompanied by an infiltration of the hepatic and renal veins. A pronounced tumor infiltration of the IVC at the level of the liver was confirmed intraoperatively and immunohistochemical analysis showed a moderate to poorly differentiated leiomyosarcoma. The extended tumor was successfully removed by a complex operation of the thorax and abdomen but the procedure was accompanied by severe bleeding. A few hours following the procedure the patient died due to a further episode of irreversible intra-abdominal hemorrhage.

Primary superficial femoral vein leiomyosarcoma: report of a case

The majority of leiomyosarcomas occur in the muscular layers of the gastrointestinal tract and uterus. Primary leiomyosarcomas rarely arise in the veins of the lower extremities. Primary leiomyosarcoma of the superficial femoral vein is extremely uncommon. We herein present a case of a 69-year-old man with a primary leiomyosarcoma of the superficial femoral vein of his left thigh, which manifested as an anteromedial palpable painless mass in the middle third of his left thigh. Duplex ultrasonography revealed a 4 × 8-cm mass attached to the left superficial femoral vein. The mass was removed surgically en bloc. Histological examination showed a low-grade leiomyosarcoma. Seven months after the resection, a local recurrence of the tumor was observed, and the patient underwent another surgery. Five years after the second operation the patient remains free of illness.