Leiomyosarcoma of the inferior vena cava. Our experience and a review of the literature

Unresectable leiomyosarcoma of the inferior vena cava with right atrium tumor thrombus: when to deem this tumor inoperable? A case report and literature review

Leiomyosarcomas (LMS) of the inferior vena cava (IVC) are a rare form of retroperitoneal malignancy, and their venous extension to the right atrium is an even rarer event. These tumors pose a unique surgical challenge and often require a multidisciplinary team-based approach for their surgical treatment. We present a case of a 68-year-old man with primary LMS of the IVC with a tumor thrombus extending into the right atrium that was initially deemed inoperable. After extensive neoadjuvant chemo-radiation with minimal tumor effect, the patient underwent en bloc surgical resection of the tumor along with removal of the infrarenal IVC and right kidney and adrenal without the need for cardiopulmonary bypass. This case demonstrates the successful management of a primary LMS of the IVC with right atrial extension using a multimodal approach of neoadjuvant chemo-radiation and en bloc surgical resection without cardiopulmonary bypass. This strategy may offer a curative option for selected patients with these rare and aggressive tumors, improving their survival and quality of life.

Case Report: Multidisciplinary management of primary inferior vena cava leiomyosarcoma: a comprehensive case study

Introduction

Primary Inferior vena cava (IVC) leiomyosarcoma, a rare malignant tumor, presents unique challenges in diagnosis and treatment due to its rarity and the lack of consensus on surgical and adjuvant therapy approaches.

Case Report

A 39-year-old female patient presented with lower limb swelling and mild fatigue. Contrast-enhanced CT identified a tumor mass within the dilated IVC. Abdominal MRI revealed primary IVC leiomyosarcoma extending into the right hepatic vein. A multidisciplinary consultation established a diagnosis and devised a treatment plan, opting for Ex-vivo Liver Resection and Auto-transplantation (ELRA), tumor resection and IVC reconstruction. Pathological examination confirmed primary IVC leiomyosarcoma. Postoperatively, the patient underwent a comprehensive treatment strategy that included radiochemotherapy, immunotherapy, targeted therapy, and PRaG therapy (PD-1 inhibitor, Radiotherapy, and Granulocyte-macrophage colony-stimulating factor). Despite the tumor's recurrence and metastasis, the disease progression was partially controlled.

Conclusion

This case report emphasizes the complexities of diagnosing and treating IVC leiomyosarcoma and highlights the potential benefits of employing ELRA, IVC reconstruction, and PRaG therapy. Our study may serve as a valuable reference for future investigations addressing the management of this rare disease.

A Contemporary Clinicopathologic Analysis of Primary Sarcomas of the Perinephric Soft Tissue and Hilar Vessels Including a Subset Secondarily Involving the Kidney

A variety of primary malignant mesenchymal neoplasms can arise from the perinephric soft tissue and hilar vessels and potentially involve the kidney, mimicking primary renal tumors. A search was made at our institution for patients that underwent radical nephrectomy with associated perinephric or hilar sarcomas from 2010 to 2021. Twenty-six patients were identified. Mean patient age was 60 years (range: 34-83 years), with 16 (62%) females and 10 (38%) males. The mean tumor size was 21.6 cm (range: 8.1-36.5 cm). Among the perinephric/retroperitoneal sarcomas, 14/20 (70%) were dedifferentiated liposarcoma, 4/20 (20%) were well-differentiated liposarcoma, and 2/20 (10%) were leiomyosarcoma. There were 4 grade 1 (20%; all well-differentiated liposarcoma), 9 grade 2 (45%), and 7 grade 3 (35%) tumors. All 6 sarcomas arising from the renal vein/inferior vena cava were leiomyosarcoma: grade 2 in 1 (17%), grade 3 in 4 (67%), and ungraded (due to neoadjuvant therapy effect) in 1 (17%) patient. Four of the 26 (15%) tumors involved the ipsilateral kidney. All 4 tumors were grade 3 sarcomas. On follow-up, 8/26 (31%) patients developed local recurrence and/or metastasis. The mean time for recurrence was 22 months (range: 7-48 months). Two patients progressed with metastasis to the lungs, both of which were grade 3 leiomyosarcoma, and appeared 11 months after the initial diagnosis. Our data suggest that while local recurrence is prevalent with most subtypes of perinephric sarcomas, high-grade leiomyosarcoma has a distinct proclivity for distant metastasis, with the lungs being the most common site.

Surgical resection of retrohepatic inferior vena cava leiomyosarcoma without vascular reconstruction: case report

Inferior vena cava leiomyosarcoma (IVCL) is a rare malignant mesenchymal tumor. Surgical treatment is a challenge because it must combine free surgical margins with vascular reconstruction, using prosthetic or autologous grafts, primary suture, or simple ligation without vein reconstruction. The ligation option is possible thanks to the slow growth of the tumor, allowing collateral venous circulation to develop. We present a case of an IVCL treated with radical resection without vascular reconstruction. The patient was a 48-year-old female with abdominal pain in the right upper quadrant, asthenia, and postprandial dyspeptic symptoms. Abdominal tomography revealed a mass with an expansive formation located in the infrahepatic segment of the inferior vena cava and reduced vessel lumen. During surgery, vein clamping did not provoke hemodynamic repercussions, suggesting sufficient collateral circulation formation. It was decided to perform a radical resection of the entire portion of the retrohepatic vena cava and ligate the vena cava without vascular reconstruction. The patient recovered without complications.

Case report: Reconstruction of the left renal vein with resected autologous right renal vein interposition after excision of an inferior vena cava leiomyosarcoma

Background

Leiomyosarcoma of the inferior vena cava (IVC) was a rather rare disease with the characteristics of invading the adjacent viscera. Surgical resection is the only potential curative treatment, and radiation therapy and chemotherapy for leiomyosarcoma are not definite. There is few literature reporting the leiomyosarcoma of the IVC.

Case presentation

A previously healthy 64-year-old female was admitted to the First Affiliated Hospital of China Medical University with the complaint of right lower quadrant abdominal pain for almost three years and worsening with a radiating ache in the waist recently. Contrast-enhanced computed tomography(CT) scans revealed a large (7.8 cm*5.5 cm*5.0 cm) irregular hypodense retroperitoneal mass with heterogeneous enhancement and invasion of the IVC, and the right ureter was compressed with proximal ureteral dilatation and hydrops. Three-dimensional CT of the IVC revealed that the IVC was encircled by the tumor with moderate invasion. During the operation, the tumor was resected en bloc with the IVC (from the suprarenal to infrarenal segment), the right kidney with ureter, and the duodenum seromuscular layer. As the left renal vein was involved, it was also partly resected. IVC reconstruction was performed with the interposition of a 20 mm diameter polytetrafluoroethylene (PTFE) prosthesis, and the right renal vein was anastomosed between the left renal vein and the reconstructed IVC to guarantee the left renal vein reflux. The patient had an uneventful recovery process with normal renal function after the operation. However, follow-up CT indicated that the left renal vein was blocked two weeks after the surgery. The patient was discharged two weeks after the operation. She continues well and has no evidence of disease fourteen months after the surgery.

Conclusions

Wide excision of the tumor en bloc with the IVC is the main treatment for leiomyosarcoma of the IVC. IVC reconstruction with prosthetic PTFE grafts is recommended. When the left renal vein is partly resected due to involvement of the tumor, reconstruction of left renal vein should also be performed to avoid renal impairment. If the right renal vein does not show tumor involvement, the resected right renal vein can be used to reconstruct the left renal vein.

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.

Leiomiossarcoma de veia cava inferior como etiologia para dor abdominal crônica – um relato de caso

Inferior vena cava leiomyosarcomas are rare tumors that account for less than 0.7% of all retroperitoneal leiomyosarcomas. They are more common in women and cause nonspecific chronic abdominal pain. In this report, we present the case of a 53-year-old female patient complaining of chronic nonspecific periumbilical abdominal pain with initial onset 8 months previously who was diagnosed with inferior vena cava leiomyosarcoma by computed tomography angiography. The patient was treated with complete resection of the tumor and reconstruction of the inferior vena cava with interposition of a Dacron prosthetic graft. The treatment considered the gold standard consists of complete surgical excision, because these tumors are resistant to chemotherapy and radiotherapy. The prognosis of these patients is closely related to early diagnosis. Therefore, it is very important that vascular and general surgeons know that this disease is a possible differential diagnosis of chronic abdominal pains.

Leiomyosarcoma of the inferior vena cava as etiology of chronic abdominal pains – a case report

Abstract Inferior vena cava leiomyosarcomas are rare tumors that account for less than 0.7% of all retroperitoneal leiomyosarcomas. They are more common in women and cause nonspecific chronic abdominal pain. In this report, we present the case of a 53-year-old female patient complaining of chronic nonspecific periumbilical abdominal pain with initial onset 8 months previously who was diagnosed with inferior vena cava leiomyosarcoma by computed tomography angiography. The patient was treated with complete resection of the tumor and reconstruction of the inferior vena cava with interposition of a Dacron prosthetic graft. The treatment considered the gold standard consists of complete surgical excision, because these tumors are resistant to chemotherapy and radiotherapy. The prognosis of these patients is closely related to early diagnosis. Therefore, it is very important that vascular and general surgeons know that this disease is a possible differential diagnosis of chronic abdominal pains.

Surgical resection of leiomyosarcoma of the inferior vena cava: A case series and literature review

OBJECTIVES

We review our institution's experience in treating leiomyosarcomas involving the inferior vena cava, and we offer guidance on the management.

METHODS

A text-based search was performed to identify all patients who underwent surgical resection between January 2002 and October 2020. Clinicopathologic data, intraoperative variables, and outcomes were extracted from chart review.

RESULTS

Twelve of 16 patients (75%) had localized disease; the remaining had limited metastatic disease. Seven of 16 patients (44%) received neoadjuvant chemotherapy or radiation; three patients had partial responses, and four patients had stable disease using RECIST 1.1 criteria. IVC reconstruction was performed in 14 of 16 patients (88%); IVC was ligated for the remaining two patients. Half of all patients had R0 resection on final pathology; the remaining had R1 resections. Progression-free survival (PFS) and overall survival (OS) were not statistically different between patients with R0 and R1 resection. Median PFS was 1.8 years (95% CI 0.89 - not reached); median OS was 6.5 years (1.8 - not reached). Only one patient (6%) experienced local disease recurrence; 4 of 16 patients (25%) experienced disease recurrence distally without local recurrence.

CONCLUSIONS

Resection of IVC leiomyosarcomas at a sarcoma referral center with experience in vascular reconstruction can lead to many years of recurrence-free survival. Surgical resection should be offered to patients with a low volume of metastatic disease to reduce local complications from the primary tumor, many of which exert significant mass effect on surrounding organs. For patients with metastatic disease or large, high-risk tumors, neoadjuvant chemotherapy can provide a biologic test of disease stability prior to resection.

Infrarenal Vena Cava Leiomyosarcoma Treated With Surgical Resection and Vascular Reconstruction

Leiomyosarcoma of the inferior vena cava is a rare malignant tumor with a poor prognosis. We report a case of a 39-year-old woman admitted for a surgical resection of a retroperitoneal mass revealed by pain localised in the right lumbar fossa. Computed tomography of the abdomen revealed a heterogeneous retroperitoneal mass compressing the inferior vena cava. Surgical resection was performed with the reconstruction of the inferior vena cava using a Dacron prosthesis, the diagnosis of vessel wall leiomyosarcoma was revealed by histopathology. Surgical resection with clear margins remains the only treatment offering the best survival rate. The complex nature of the surgery of those tumors is a major therapeutic challenge for surgeons.