Inferior Vena Cava Leiomyosarcoma: What Method of Reconstruction for Which Type of Resection?

Robotic resection of left renal vein with preservation of left kidney for leiomyosarcoma: Case report and review of the literature

INTRODUCTION

Radical surgical resection with negative margins is the mainstay of treatment for retroperitoneal vascular leiomyosarcomas. Given the retroperitoneal location of these tumors, open surgery is, historically, the chosen surgical approach, however, it is burdened with high postoperative morbidity. In selected cases, the small dimension of the tumor and a favorable location, allow to perform a minimally invasive treatment.

PRESENTATION OF CASE

A 67-year-old female patient with a diagnosis of a leiomyosarcoma arising from the left renal vein underwent a robotic resection of the left renal vein with preservation of the left kidney and a relative outflow trough the gonadal vessels. The patient was discharged on the fourth postoperative day without any complications and there was no tumor recurrence noted during the 24-month follow-up period.

DISCUSSION

Vascular retroperitoneal leiomyosarcomas are very rare tumors requiring a complete en bloc gross tumor resection in order to achieving microscopically negative margins on the vein of origin. Thanks to the preoperative histological diagnosis and radiological study of the neoplasm, it was possible to proceed to a highly personalized and minimally invasive treatment with respect of oncological criteria.

CONCLUSION

In selected cases, a minimally invasive surgery of vascular leiomyosarcoma could be a feasible and safe treatment option.

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.

Retroperitoneal Paraganglioma Treated With Tumor Resection and Replacement of the Inferior Vena Cava

Retroperitoneal paragangliomas are tumors of neuroectodermal origin rarely appearing in the pediatric population. We report a case of a large paraganglioma infiltrating the right kidney and inferior vena cava in a 16-year-old boy who initially presented with a right-sided varicocele. Right retroperitoneal paraganglioma was embolized preoperatively, followed by total tumor excision, right nephrectomy, inferior vena cava resection, and reconstruction using a prosthetic vascular graft. Retroperitoneal tumors requiring surgery can successfully be treated by radical resection and replacement of the inferior vena cava in experienced centers.

Leiomyosarcoma of the inferior vena cava: An uncommon malignancy requiring unique reconstructive approaches

Surgery is considered for patients without metastatic disease and with resectable primary tumor. Pre-operatively, high quality imaging is reviewed to determine the likely extent of resection, specifically including the need for potential en-bloc resection of adjacent organs. In cases where up-front surgical approach would expose the patient to excessive morbidity (such as bilateral nephrectomy, multi-visceral resection, or prohibitively high risk of positive margins), neoadjuvant chemotherapy and/or chemoradiotherapy is considered. Though data are sparse in LMS, a neoadjuvant regimen of doxorubicin and dacarbazine is typically considered for borderline resectable tumors at our institution; patients may be treated for up to 4 months with interval imaging every 2 months to evaluate for tumor response. Postoperatively, adjuvant systemic therapy or radiation may be considered for patients with positive surgical margins or high-grade tumors.

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.

Inferior vena cava resection for a leiomyosarcoma: A case report

INTRODUCTION AND IMPORTANCE

Leiomyosarcomas of the inferior vena cava are scarce. Surgery is the only potential curative treatment. Such a surgery is complex and technically demanding, requiring a huge experience in both visceral and vascular surgery. Indeed, enlarged visceral resection may be needed to achieve a free tumor margins as the tumor may invade the duodenum, the head of the pancreas and the liver. Moreover, vascular reconstruction is mandatory which might be complex as both venal reins are usually invaded by the tumor like in our case below.

CASE PRESENTATION

A 53-year-old woman presented with abdominal vague pain. Imaging consisting in abdominal CT-scan with contrast and magnetic resonance angiography were suggestive of the diagnosis of leiomyosarcoma of the inferior vena cava. A surgical complete resection with free margins was conducted. A primary repair of the inferior vena cava and the right renal vein walls. End-to-side anastomosis with a polytetrafluorethylene (PTFE) prosthesis was mandatory to reconstruct the renal left vein to the inferior vena cava. Postoperative outcomes were uneventful. Pathology examination confirmed the diagnosis.

DISCUSSION

The optimal management of leiomyosarcoma of inferior vena cava is controversial. Surgery remains the cornerstone of treatment. However, not all patients are qualified for surgical resection. The prognosis depends on the early diagnosis and histology type.

CONCLUSION

The management of leiomyosarcomas of inferior vena cava requires a multidisciplinary consensus involving experienced surgery and oncology teams.

Surgical resection of primary leiomyosarcoma of retro-hepatic inferior vena cava extending from bilateral renal veins across the diaphragm

Vascular leiomyosarcoma of the inferior vena cava is a rare malignant soft tissue tumor that requires surgical treatment to prevent tumor-related symptoms such as pulmonary embolism and Budd-Chiari syndrome. However, a treatment strategy for surgical resection of advanced cases has not yet been determined. This report describes the case of advanced leiomyosarcoma of the inferior vena cava that was successfully treated with surgery and subsequent chemotherapy. A 44-year-old man was found to have a 12 × 10 cm retroperitoneal tumor on computed tomography. The tumor originated in the inferior vena cava and extended beyond the diaphragm into the renal vein. The surgical plan was determined in joint consultation with the multidisciplinary team. It was safely resected and the inferior vena cava was closed caudal to the porta hepatis without a synthetic graft. The tumor was diagnosed as leiomyosarcoma. Doxorubicin, followed by pazopanib were administered as treatment for metastatic disease. Eighteen months after the surgery, the patient's performance status was maintained.

Case report: Surgical resection of a retro-hepatic leiomyosarcoma involving atrial reconstruction, cardiopulmonary bypass, ex vivo tumor resection, and liver re-implantation

INTRODUCTION

Leiomyosarcomas (LMS) involving the inferior vena cava (IVC) is a clinically rare entity, accounting for approximately 0.5% of all adult sarcomas.

CASE PRESENTATION

A 67-year-old male presented to the emergency department with mild back and lower abdominal pain. During the workup, a computed tomography scan without contrast showed an area of decreased attenuation within the liver adjacent to the intrahepatic IVC. Magnetic resonance imaging confirmed the involvement of the retro-hepatic IVC; biopsy confirmed the diagnosis of LMS. Given the location of the involvement of the retro-hepatic IVC, liver explantation was deemed necessary for adequate tumor resection. The superior extension of the tumor toward the heart necessitated Cardio-Pulmonary (CPB). The patient successfully underwent a complex surgical procedure involving liver explantation with ex vivo back-table resection of the retro-hepatic LMS, replacement of the retro-hepatic vena cava with a ringed Gore-Tex graft, liver re-implantation, and hepatic vein-atrial reconstruction under cardiopulmonary bypass. There were no intraoperative or post-op complications.

DISCUSSION

The role of vascular reconstruction of the IVC varies depending on the level and extent of the tumor, with options ranging from primary repair, ligation, or reconstruction dictated. Surgical resection with negative margins remains the treatment of choice due to the lack of efficacy of adjuvant therapies. Importantly, liver explantation offers a chance for complete surgical resection and reconstruction. Similarly, the complex nature of the tumor necessitated a pioneering approach involving direct hepato-atrial venous anastomosis.

CONCLUSION

To the best of our knowledge, this is the first reported case in which the hepatic veins were anastomosed directly to the right atrium while also replacing the native vena cava with a separate graft.

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.

Surgical management strategy for leiomyosarcoma of Zone I-II inferior vena cava: A case series

OBJECTIVES

Leiomyosarcoma of inferior vena cava (IVC) is a rare clinical entity with severe vascular involvement. Surgical management of leiomyosarcoma is still challenging.

METHODS

This a retrospective study of consecutive patients referred to our hospital from January 2017 to June 2019. Depending on the anatomical site of affected IVC, leiomyosarcomas were categorized into zone I-II. The clinical data including baseline information, surgical parameters, peri-operative management, short- and mid-term outcomes were observed.

RESULTS

Four patients with leiomyosarcoma of zone I-III underwent radical resection without intraoperative mortality. Prosthetic grafts were interpositioned in all patients to instruct vena cava. Renal vein reconstruction was perfumed in two patients due to involvement to renal veins. Median blood loss was 450 mL (200-600 mL), median operative time was 215 minutes (150-240 minutes). No Clavien-Dindo IIIa or higher complication was observed. No organ dysfunction and recurrence were observed with median follow-up of 25.5 months.

CONCLUSIONS

Curative resection of zone I-II leiomyosarcoma is associated with longer survival in selected cases, en-bloc resection with complex vascular reconstruction could be considered.

A 10-year experience of leiomyosarcoma of the inferior vena cava

OBJECTIVES

Leiomyosarcoma of the inferior vena cava (IVC) is rare. The study reviewed patients with IVC leiomyosarcoma in our hospital in the past ten years.

METHODS

Twenty patients diagnosed with IVC leiomyosarcoma between October 2010 and October 2020 were enrolled. Their clinical manifestations, treatments, and follow-up results were analyzed.

RESULTS

The sarcoma was located in the lower IVC segment in six patients, with 13 in the middle and one in the upper IVC segment. Eighteen patients underwent R0 resection. After resection, 16 patients (80%) had primary repair of the IVC, while four patients underwent ligation. During a mean follow-up of 37.7 months, seven patients died due to tumor metastasis, four patients were alive with the tumor recurrence and other nine patients were alive without recurrence.

CONCLUSION

The management of the IVC after tumor resection depended on the tumor location and size. R0 resection provided a chance for long term survival.

Surgery Treatment of Primary Tumors of the Inferior Vena Cava

Background

Primary tumor of the inferior vena cava is a rare tumor, which arises from the smooth muscle of vascular walls. Surgery appears the only curative treatment. However, the optimal surgical methods and surgical management are not well-studied. In this article, we reviewed the successful treatment experience of patients in our center who had resection of primary tumor of the inferior vena cava and reviewed the relevant literature.

Methods

Four cases of patients who undergoing initial resection of primary tumors of the inferior vena cava from September 2017 to August 2021 in the Second Affiliated Hospital of Nanchang University were screened and followed up. They were discussed and cases reported in this field were reviewed.

Results

Among the four patients, three of them were female. The median age of the disease is 53.75 years (range 45–60 years). After surgical treatment, tumors were removed in all patients, and some patients had reconstruction of inferior vena cava. There were no disease-specific deaths, no serious complications, and no recurrence during follow-up in these cases.

Conclusions

Careful preoperative examination, correct surgical treatment methods, and multidisciplinary collaboration can lead to safe and successful operations, which improve the survival rate of patients.

Leiomyosarcoma of inferior vena cava (IVC): do we really need to reconstruct IVC post resection? Single institution experience

BACKGROUND

Inferior vena cava (IVC) leiomyosarcomas (LMS) are a rare group of retroperitoneal tumors. R0 surgical resection is the only curative modality of treatment. IVC resection for retroperitoneal sarcoma is a complex surgery with no definitive guidelines for reconstruction.

METHODS

Retrospective review of all patients who underwent surgical resection of primary leiomyosarcoma of the IVC requiring resection from 2010 to 2020 at our tertiary care center was performed.

RESULTS

Among 24 patients who required IVC resection for LMS, only 7 (29%) required reconstruction of IVC. According to Clavien-Dindo classification, there was one grade 3 or more morbidity and 1 post-operative mortality. Seventeen patients underwent R0 resection whereas 7 patients had R1 resection on final histopathology. At a median follow-up of 25 months (range 8-91 months), the median OS was 40 months with median DFS of 28 months. Two patients presented with local recurrence while 13 patients developed systemic recurrence on follow-up.

CONCLUSION

Careful preoperative multidisciplinary planning can make IVC resection without reconstruction feasible with acceptable perioperative morbidity, mortality, and oncological outcomes for IVC LMS.

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.

Current update on IVC leiomyosarcoma

Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare soft tissue sarcoma associated with poor prognosis. Patients are often asymptomatic or present with nonspecific abdominal symptoms, which delays initial diagnosis and contributes to poor oncologic outcome. Key imaging modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Characteristic imaging features include imperceptible caval lumen, dilation of the IVC, heterogeneous enhancement of the tumor, and development of extensive collateral circulation. Surgical resection is the mainstay of treatment, while chemotherapy and/or radiation may serve as therapy adjuncts. This article reviews the pathology, clinical findings, imaging features and management of IVC leiomyosarcoma.

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.

Novel use of the falciform ligament for reconstruction of the inferior vena cava and its tributary

Tumor invasion into the inferior vena cava (IVC) and hepatic vein (HV) is challenging in cancer surgery with curative intent. Appropriate techniques for venous reconstruction are essential. We have described in detail a novel technique of fashioning an interposition tube graft using the falciform ligament to reconstruct the IVC and HV. The falciform ligament maintains all the benefits of an autologous tissue graft, with the added advantage of its flexibility in customizing graft dimensions. Its use in IVC and HV reconstruction has rarely been reported. The short-term outcomes with this tube graft are promising.