Echocardiographic Characteristics and Contrast-Enhanced Imaging of Intravenous Leiomyomatosis With Intracardiac Extension

Right atrial tumor revealing intravascular leiomyomatosis: about a case and literature review

Intravascular leiomyomatosis (IVL) is a very rare extension of uterine leiomyoma through the pelvic vessels. It is a benign pathology with malignant potential with a possibility of intra-cardiac extension and metastases (cerebral, pulmonary, lymph node); early diagnosis is very difficult. Prognosis depends on involvement of the inferior vena cava and extension to the right cavities. We report a case of complications of IVL, precisely the extension in the right atrium, in a 49-year-old woman. The objective of our work is to highlight the importance of imaging in the diagnosis of the vascular extension of leimyomatosis.

The usefulness of contrast echocardiography in the evaluation of cardiac masses: a multicenter study

BACKGROUND

Cardiac masses can encompass a variety of conditions, such as tumors, thrombi, vegetations, calcific lesions, and other rare diseases. Treatment and management of these types of cardiac masses differ considerably. Thus, accurately distinguishing among thrombi, benign tumors, and malignant tumors in the heart is of great importance. Contrast echocardiography (CE) has emerged as a promising technology. Although published guidelines suggest that CE can enhance image quality and assist in differentiating between benign and malignant lesions, most studies on CE diagnosis of cardiac masses are limited to case reports or retrospective/small-sample-sized prospective cohorts. This study aims to evaluate the diagnostic accuracy of CE in patients with suspected cardiac masses and address the insufficient evidence for differential diagnosis using CE.

METHODS

Between April 2018 and July 2022, a prospective multicenter study was conducted, which included 145 consecutive patients suspected to have cardiac masses based on transthoracic echocardiography. All patients underwent CE examinations. The echocardiographic diagnosis relied on qualitative factors such as echogenicity, boundary, morphology of the base, mass perfusion, pericardial effusion, and motility as well as quantitative factors such as the area of the masses and the peak intensity ratio of the masses to adjacent myocardium (A1/A2).

RESULTS

The final confirmed diagnoses were as follows: 2 patients had no cardiac mass, 4 patients had pseudomass, 43 patients had thrombus, 66 patients had benign tumors, and 30 patients had malignant tumors. The receiver operating characteristic (ROC) analysis indicated that an optimal A1/A2 cutoff value of 0.499 distinguished a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.977, 97.9%, 90.7%, 95.9%, and 95.1%, respectively. The optimal A1/A2 cutoff value of 1.583 distinguished a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.950, 93.3%, 93.9%, 87.5%, and 96.9%, respectively.

CONCLUSIONS

Combined with qualitative and quantitative analyses, CE has the potential to accurately differentiate among different types of cardiac masses.

Update on clinical characteristics and molecular insights for uterine intravenous leiomyomatosis (Review)

Intravenous leiomyomatosis (IVL) is a rare benign disease, which typically develops along vascular vessels and extends to the inferior vena cava and right atrium of the heart. In the early stages of the disease, the clinical manifestations and the results of imaging examinations are not uniform among patients. Thus, a high rate of misdiagnosis and missed diagnosis is common. When the tumor extends along the venous system to the pelvic floor vein or through the inferior vena cava involving the right atrium of the heart or the pulmonary artery, severe symptoms occur, such as ascites, dyspnea, heart failure and even sudden mortality. Improving the understanding of IVL to identify and evaluate this disease in its early stages is important. Complete tumor resection remains the primary treatment option for IVL. The recurrence rate of the disease varies depending on multiple factors, such as type of surgical procedure performed. Therefore, long-term follow-up is necessary for patients with IVL. The review of recent findings on the molecular and clinicopathological characterization of IVL is important to understand the pathogenesis of IVL. In the present study, the clinical manifestations, pathogenesis, differential diagnosis, treatment and prognosis of IVL are summarized in order to provide a single source of insightful information on IVL.

Diagnostic experience of intravenous leiomyomatosis with emphasis on conventional ultrasonography imaging: a single-center study

Objective

Intravenous leiomyomatosis (IVL) is a rare and aggressive tumor type that has the potential to extend into the inferior vena cava (IVC) and is susceptible to be misdiagnosed and neglected. Despite its clinical significance, there is a paucity of research that has focused on the specific manifestations of IVL on ultrasonography. Therefore, this study aims to systematically analyze the specific ultrasound features of IVL and augment its diagnostic accuracy.

Materials and method

Prospective inclusion was granted to patients admitted to our hospital between December 2016 and March 2021 for an IVC-occupying lesion. Multi-modal ultrasonography, encompassing gray-scale and color Doppler, was conducted. Lesions were categorized as IVL or non-IVL based on pathological or follow-up data. Two ultrasound sonographers with over 5 years of experience read and recorded ultrasound data for all lesions, which were subsequently comparatively analyzed to identify specific signs of IVL.

Results

A total of 284 patients diagnosed with IVC-occupying lesions were included in the study. The lesion types comprised of IVL (n=67, 23.6%), IVC thrombus (n=135, 47.5%), tumor thrombus of renal carcinoma involving the IVC (n=35, 12.4%), tumor thrombus of liver carcinoma involving the IVC (n=24, 8.5%), leiomyosarcoma of the IVC (n=14, 4.9%), and tumor thrombus of adrenocortical adenocarcinoma (n=9, 4.1%). The presence of "sieve hole" and "multi-track" signs was observed in 20 IVL lesions under the grey-scale modality, while both signs were absent in the non-IVL group (P<0.01). The study found no statistically significant differences in the presentation of "sieve hole" and "multi-track" signs under the grey-scale and color Doppler modalities in cases of intravascular lithotripsy (IVL) (P>0.05). Using these two signs as diagnostic criteria for IVL, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), miss rate, misdiagnosis rate, and accuracy were determined to be 29.9%, 100%, 100%, 82.2%, 70.1%, 0, and 83.5%, respectively (AUC ROC=0.649; 95%CI: 0.537-0.761).

Conclusion

IVL exhibits distinct ultrasound presentations, including "sieve hole" and "multi-track" signs, which demonstrate high specificity and accuracy as diagnostic indicators. Furthermore, these signs are corroborated by pathological evidence and effectively distinguish IVL from other lesions occupying the IVC.

Contrast-enhanced echocardiographic diagnosis of benign and malignant cardiac tumors and its correlation with pathology

Background

This study aimed to explore the diagnostic value of contrast-enhanced echocardiography (CEE) in benign and malignant cardiac tumors and detect the correlation of CEE parameters and immunohistochemistry (IHC) markers.

Methods

The data of 44 patients with cardiac tumors confirmed by pathology were reviewed. Lesions were examined before surgery using transthoracic echocardiography (TTE) and CEE with time-intensity curve analysis. The expression of CD31, VEGF and Ki67 was measured by IHC staining. Microvessel density (MVD) was quantified via IHC for CD31. The clinical variables, TTE, CEE and IHC parameters were compared between benign and malignant cardiac tumors. Receiver operating characteristic curve were used to analyze the value of factors in predicting malignant cardiac tumors. The correlation between CEE and IHC parameters was analyzed.

Results

Among 44 cardiac tumors, 34 were benign and 10 were malignant. There were significant differences in the TTE parameters (pericardial effusion, tumor boundary, diameter, basal width), CEE parameters (tumor peak intensity (TPI), peak intensity ratio of tumor to myocardium (TPI/MPI), area under time-intensity curve (AUTIC)) and IHC parameters (Ki67, MVD, CD31, VEGF) between the benign and malignant tumor groups (all P < 0.05). Receiver operating characteristic curve analysis showed that the CEE and IHC parameters had diagnostic value in malignant cardiac tumors. There was a correlation between TPI/MPI and Ki67 (r = 0.62), AUTIC and Ki67 (r = 0.50), and AUTIC and CD31 (r = 0.56).

Conclusion

TTE and CEE parameters were different between benign and malignant cardiac tumors. CEE is helpful to differentiate the properties of cardiac tumors. There is a correlation between CEE parameters and IHC markers. AUTIC and TPI/MPI can reflect the proliferation and invasion of tumors.

Diagnostic value of contrast-enhanced ultrasound in intravenous leiomyomatosis: a single-center experiences

Objective

Intravenous leiomyomatosis (IVL) is a rare disease, and few studies have focused on the diagnostic value of contrast-enhanced ultrasound (CEUS) in this condition. This study aimed to investigate the diagnostic value of CEUS in IVL and summarize the specific CEUS characteristics of IVL.

Materials and Method

From December 2016 to March 2021, 93 patients admitted to our hospital with inferior vena cava (IVC) occupying lesions were prospectively enrolled and underwent detailed ultrasound multi-modality examinations, including conventional and contrast-enhanced ultrasound scans. The diagnostic value of CEUS and conventional ultrasound (CU) in IVL was compared, and the specific IVL signs were summarized.

Results

Among the 93 patients with inferior vena cava mass, 67 were IVL while 26 were non-IVL. The inter-observer agreement of the two senior doctors was good, with Kappa coefficient = 0.71 (95% CI: 0.572–0.885). The area under the ROC curve of CU for IVL diagnosis was 0.652 (95% CI: 0.528–0.776), and its sensitivity, specificity, accuracy, positive predictive value, negative predictive value, missed diagnosis rate, and misdiagnosis rate were 61.1%, 69.2%, 63.4%, 83.7%, 40.9%, 38.8%, and 30.8%, respectively. The area under curve (AUC) for IVL diagnosis by CEUS was 0.807 (95% CI: 0.701–0.911), and the sensitivity, specificity, accuracy, positive predictive value, negative predictive value, missed diagnosis rate, and misdiagnosis rate were 82.0%, 84.6%, 82.8%, 93.2%, 64.7%, 15.4%, and 17.9%, respectively. In CEUS mode, “sieve hole sign” and “multi-track sign” were detected in 57 lesions, and the detected rate was higher than that of CU (https://loop.frontiersin.org/people/1014187 < 0.01).

Conclusion

CEUS can better show the fine blood flow inside the IVL, which is important for IVL differential diagnosis. Moreover, CEUS can obtain more information about IVL diagnosis than CU, compensating for the shortcomings of CU in detecting more blood flow within the lesion. Thus, this technique has great significance for IVL diagnosis.