Leiomyosarcoma of the Inferior Vena Cava in an HIV-Positive Adult Patient: A Case Report and Review of the Literature

Incidentally Diagnosed Extraluminal Leiomyosarcoma of Infrarenal Inferior Vena Cava: A Case Report and Literature Review from a Radiologist's Perspective

Background

Vascular leiomyosarcoma is a rare but most common vascular tumor of the inferior vena cava.

Case presentation

We present the case of an incidentally diagnosed extraluminal leiomyosarcoma of the inferior vena cava in a 62 year old patient who presented with abdominal pain following blunt trauma. Ultrasonography showed a lobulated hypoechoic lesion in the upper abdomen. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a circumscribed lobulated near homogeneously enhancing retroperitoneal lesion in anterior relation to the infrarenal inferior vena cava, right paramedian in location with imperceptible vena caval lumen at the site of maximum contact. In positron emission tomography (PET) CT the lesion showed mild fluorodeoxyglucose (FDG) uptake with no distant metastases. CT guided biopsy with immunohistochemical analysis showed leiomyosarcoma. Patient underwent surgical resection with inferior vena cava reconstruction.

Conclusions

Leiomyosarcoma of the inferior vena cava is a rare tumor of vascular origin. Imaging plays an imperative role in the diagnosis and preoperative evaluation. This article also provides a comprehensive literature review of the radiological features of inferior vena caval leiomyosarcoma that would aid in optimal preoperative characterization and evaluation.

Treatment of a Double Cancer Patient With Primary Inferior Vena Cava Sarcoma and Lung Adenocarcinoma: A Case Report and Literature Review

Background

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignancy. Here, we present the case of a 38-year-old woman with a primary IVC leiomyosarcoma and lung adenocarcinoma.

Case Report

The patient, a 38-year-old Chinese female, presented to the general surgical outpatients clinic with a 18-month history of intermittent right upper abdominal pain. Contrast-enhanced computed tomography (CT) showed a tumor of IVC (3.4^*2.7 cm) extending to the renal veins. In addition, chest CT revealed a mass lesion in the upper left lung lobe. Then, the patient underwent resection of the IVC tumor and wedge resection of the upper lobe of the left lung. The patient then received gefitinib (250 mg/day) as a maintenance therapy until the tumor recurrence or metastasis in the follow-up period. Pulmonary metastasis of the sarcoma were first diagnosed 20 month after the resection of the IVC leiomyosarcoma. So the patient again received thoracoscopic wedge pneumonectomy, and it was confirmed to be metastasis of IVC leiomyosarcoma. The patient received oral anlotinib treatment (12 mg once daily) after the last operation. During on-going regular follow-up visits no evidence of recurrence or metastasis was observed from December 2020 to October 2021.

Conclusions

The patient with a primary IVC leiomyosarcoma and lung adenocarcinoma is extremely rare. Surgery is still an effective treatment for patients with a primary IVC leiomyosarcoma and lung adenocarcinoma at present.

A systematic review of the current management approaches in leiomyosarcoma of inferior vena cava-Results from analysis of 118 cases

INTRODUCTION

Primary intravenous leiomyosarcomas are rare vascular tumors with aggressive disease biology. The diagnosis and management have been challenging as little data exist from large databases.

METHODS

A literature search was done to identify all cases of primary leiomyosarcomas in the last five years. Clinicopathological features and management strategies were evaluated.

RESULTS

The median age was 53 years, predominantly females (2.5:1), presenting as metastases in up to 12.1% cases. Most tumors were locally advanced with a median size of 10cm. Inferior vena cava involvement from renal veins to infrahepatic veins remains the most frequent site (57.1%cases) while nearly half (52.8%) proceeded for surgery without histological proof. Most patients could undergo upfront resection (88.0%) with few patients receiving neoadjuvant chemotherapy (4.3%) or neoadjuvant radiotherapy (2.2%). Significant multivisceral resections included right nephrectomy (41.3%), liver resection (25.7%) and left nephrectomy (2.2%). Most patients (91.8%) needed an inferior vena cava graft placement with remarkable microscopically negative margins (85.5% cases). Doxorubicin and ifosfamide were the most frequently used combination chemotherapy regimens in both pre and postoperative settings with partial responses. The median overall and disease free survival among operated patients was 60 months and 28 months respectively. In multivariate analysis large tumor, extensive inferior vena cava involvement, and need for adjuvant chemotherapy appeared significant predictors for overall survival.

CONCLUSIONS

Aggressive upfront surgical resection with clear margin remains the key for long-term survival. Doxorubicin-based regimens were preferred as neoadjuvant chemotherapy while adjuvant treatment with chemotherapy, radiotherapy, or both may be considered in high-risk patients.

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.

Concomitant Aorto-Caval Reconstruction for Inferior Vena Cava Leiomyosarcoma

BACKGROUND

Leiomyosarcoma of the inferior vena cava (IVC) is a rare smooth muscle neoplasm typically presenting in the fifth to sixth decades of life with both intraluminal and extraluminal growth patterns. Surgical resection remains the gold standard for nonmetastatic disease and often requires vascular reconstruction. We present an atypical case of leiomyosarcoma involving both the IVC and infrarenal abdominal aorta necessitating reconstruction with intraoperative veno-venous bypass.

METHODS

A 63-year-old man initially presenting with back pain was found to have a large mass adjacent to the IVC on MRI, subsequently confirmed to be leiomyosarcoma by biopsy. After 6 months of neoadjuvant chemotherapy, the patient was taken for resection. However, intraoperatively the tumor was found to involve the aorta necessitating combined aorto-caval reconstruction. To facilitate en-bloc resection of the tumor, the aorta was reconstructed first followed by the inferior vena cava using veno-venous bypass.

RESULTS

Postoperatively, the patient was taken to the intensive care unit for resuscitation and had an uncomplicated hospital course. He was discharged to rehab 6 days postoperatively and at one year remains free of significant tumor burden with patent aorto-caval bypass grafts.

CONCLUSIONS

Primary leiomyosarcoma of the IVC is estimated to have aortic involvement in <10% of cases and concurrent aorto-caval reconstruction can be a well-tolerated option in good surgical candidates. Furthermore, veno-venous bypass can be a useful tool for accomplishing successful oncologic resections. With interdisciplinary collaboration between surgical oncologists, urologists, and vascular surgeons, difficult pathologies can be addressed with good patient outcomes.

Dyspnea due to an uncommon vascular tumor: leiomyosarcoma of the infrahepatic vena cava inferior

Background

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignancy that originated from the smooth muscle tissue of the vascular wall. Diagnoses, as well as, treatment of the disease are still challenging and to date, a radical surgical resection of the tumor is the only curative approach.

Case report

We report on the case of a 49-year old male patient who presented with suddenly experienced dyspnea. Besides bilateral pulmonary arterial embolism, a lesion close to the head of the pancreas was found using CT scan, infiltrating the infrahepatic IVC. Percutaneous ultrasound-guided biopsy revealed a low-grade LMS. Intraoperatively, a tumor of the IVC was observed without infiltration of surrounding organs or distant metastases. Consequently, the tumor was removed successfully, by en-bloc resection including prosthetic graft placement of the IVC. Histological workup revealed a completely resected (R0) moderately differentiated LMS of the IVC.

Conclusion

LMS of the infrahepatic IVC is an uncommon tumor, which may present with dyspnea as its first clinical sign. Patients benefit from radical tumor resection. However, due to the poor prognosis of vascular LMS, a careful follow-up is mandatory.