Intravenous leiomyomatosis

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.

Clinical features and prognostic factors analysis of intravenous leiomyomatosis

Background

The treatment and prognostic factors of intravenous leiomyomatosis (IVL) remain lacking systematic evidence.

Methods

A retrospective study was conducted on IVL patients from the Qilu Hospital of Shandong University, and IVL cases were published in PubMed, MEDLINE, Embase and Cochrane Library databases. Descriptive statistics were used for the basic characteristics of patients. The Cox proportional hazards regression analysis was used to assess the high-risk factors related to the progression-free survival (PFS). The comparison of survival curves was performed by Kaplan-Meier analysis.

Results

A total of 361 IVL patients were included in this study, 38 patients from Qilu Hospital of Shandong University, and 323 patients from the published literature. Age ≤45 years was observed in 173 (47.9%) patients. According to the clinical staging criteria, stage I/II was observed in 125 (34.6%) patients, and stage III/IV was observed in 221 (61.2%) patients. Dyspnea, orthopnea, and cough were observed in 108 (29.9%) patients. Completed tumor resection was observed in 216 (59.8%) patients, and uncompleted tumor resection was observed in 58 (16.1%) patients. Median follow-up period was 12 months (range 0-194 months), and 68 (18.8%) recurrences or deaths were identified. The adjusted multivariable Cox proportional hazard analysis showed age ≤45 years (vs. >45) (hazard ratio [HR] = 2.09, 95% confidence interval [CI] 1.15-3.80, p = 0.016), and uncompleted tumor resection (vs. completed tumor resection) (HR = 22.03, 95% CI 8.31-58.36, p < 0.001) were high-risk factors related to the PFS.

Conclusion

Patients with IVL have a high probability of recurrence after surgery and a poor prognosis. Patients younger than 45 years and with uncompleted tumor resection are at higher risk of postoperative recurrence or death.

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.

Benign Metastasizing Leiomyomatosis to the Skin and Lungs, Intravenous Leiomyomatosis, and Leiomyomatosis Peritonealis Disseminata: A Series of Five Cases

Benign metastasizing leiomyomatosis (BML) is a rare disease that typically occurs in women with a history of uterine leiomyomatosis. Benign metastasizing leiomyomatosis occurs more frequently in the lungs but may also develop in other organs and tissues. Other unusual variants of extra-uterine leiomyomatosis include intravenous leiomyomatosis (IVL) and leiomyomatosis peritonealis disseminata (LPD). In this article, three cases of BML are presented. One case, in a premenopausal woman, presented cutaneous metastases. We also present a case of IVL and a case of LPD, which occurred in postmenopausal women. Given the rarity of BML, IVL, and LPD, the authors reviewed the literature and herein discuss the implications for treatment in all five cases. Evidence for treating BML, IVL, and LPD is still scarce, and data available from our series and other small series seem to point to the patient’s hormonal status playing a fundamental part in the treatment plan. Furthermore, a collecting bag when performing excision of uterine leiomyomas may help avoid the potential spreading of leiomyomatosis. Hysterectomized patients with chronic cough, frequent respiratory infections, abdominal discomfort, right heart failure, or non-specific symptoms should be actively screened for BML, IVL, and LPD. Treatment should be individualized according to each patient’s hormonal status and desires.

Clinicopathologic features and clinical outcomes of intravenous leiomyomatosis of the uterus: A case series

RATIONALE

Intravenous leiomyomatosis (IVL) is a rare and special type of smooth muscle tumor originating in the uterus. It is classified as a benign disease according to its histological features but shows the behavioral characteristics of a malignant tumor. It is easily misdiagnosed and recurrent. The purpose of this study was to retrospectively analyze clinicopathological data of 25 cases of IVL in order to enhance clinicians' understanding of this rare disease.

PATIENT CONCERNS

We screened and identified 25 cases of IVL at our hospital from October 2013 to January 2020. Five patients had tumors.

DIAGNOSES

The diagnosis in each case was pathologically confirmed after surgical treatment.

INTERVENTIONS

All patients were managed surgically. Although the surgical procedures were different, the surgical approach was geared towards achieving complete excision. Three patients received hormonal therapy with gonadotropinreleasing hormone agonists after surgery.

OUTCOMES

We retrospectively reviewed all medical records and analyzed the clinicopathologic features and clinical outcomes of this disease as well as the correlations between the clinical features and risk of recurrence. Neither the symptoms nor the preoperative imaging results were suggestive of IVL in any of the cases. Except for two patients who were lost to follow-up, twenty-three patients who were followed up are still alive. Three patients experienced a recurrence.

LESSONS

The clinical manifestations and ultrasound images of IVL in the early stages are not typical; thus, IVL is easily misdiagnosed as uterine leiomyoma. Radiologists, pathologists, and surgeons should have a thorough understanding of IVL and a high index of vigilance for IVL in clinical practice. Surgery should always be aimed at achieving complete tumor excision. Patients with large lesions (≥7 cm) and lesions extending to the broad ligament may have an increased risk of recurrence. Early detection, diagnosis, and treatment are very important; once the diagnosis is confirmed, regular follow-ups are crucial.

Intravenous Leiomyomatosis of the Uterus: A Retrospective Single-Center Study in 14 Cases

Purpose

This study aimed to retrospectively review the diagnosis and surgical treatment of uterine intravenous leiomyomatosis (IVL).

Methods

The clinical data of 14 patients with uterine IVL admitted to our hospital between 2013 and 2018 were retrospectively analyzed, including their demographics, imaging results, surgical procedures, perioperative complications, and follow-up results.

Results

The tumors were confined to the pelvic cavity in 7 patients, 1 into the inferior vena cava, 4 into the right atrium, and 2 into the pulmonary artery (including 1 into the superior vena cava). Only one case was misdiagnosed as right atrial myxoma before the operation, which was found during the surgery and was treated by staging surgery; all the other patients underwent one-stage surgical resection. Three patients underwent complete resection of the right atrial tumor through the abdominal incision, and one patient died of heart failure in the process of resection of heart tumor without abdominal surgery. During the 6–60 months of follow-up, 4 patients developed deep venous thrombosis of the lower extremity, and 1 patient developed ovarian vein thrombosis and pulmonary embolism. After anticoagulation treatment, the symptoms disappeared. One patient refused hysterectomy and the uterine fibroids recurred 4 years after the operation.

Conclusion

Specific surgical plans for uterine IVL can be formulated according to cardiac ultrasound and computed tomography (CT). For the first type of tumor involving the right atrium, the right atrium tumor can be completely removed through the abdominal incision alone to avoid thoracotomy. The disease is at high risk of thrombosis and perioperative routine anticoagulation is required.

Perivascular Leiomyomatosis: A Unique Case Report

There are 3 histologically benign smooth muscle neoplasms that have unusual growth patterns. These include intravascular leiomyomatosis, benign metastasizing leiomyoma, and leiomyomatosis peritonealis desseminata. We report a unique case of perivascular leiomyomatosis. The tumor showed multiple nodules of benign smooth muscle with some of the nodules closely associated with the periphery of the medial muscle layer of venous channels. All the neoplastic nodules were located on the outer surface of venous channels, thus precluding a diagnosis of intravascular leiomyomatosis. To the best of our knowledge, this is the first documentation of such an entity.

Different surgical strategies of patients with intravenous leiomyomatosis

Intravenous leiomyomatosis (IVL) is a rare benign tumor. The study aimed to assess outcomes of patients treated surgically for IVL.Between November 2002 and January 2015, 76 patients were treated for IVL. The stage of IVL was evaluated preoperatively by echocardiography and enhanced computerized tomography (CT) scan, and graded into 4 stages according to intravascular tumor progression. We recorded age, lower limb edema before surgery, surgical parameters, and hospitalization expenses. Patients were followed up every 6 months and tumor recurrence was assessed by CT and ultrasound. Patients were followed up for a mean of 4.5 ± 2.5 years (range 1-13 years) and there was no operative, hospital, or long-term mortality or were lost to follow-up.The rate of lower extremity edema, amount of blood loss, postoperative transfusion, length of intensive care unit (ICU) stay, postoperative hospitalization, and hospitalization expenses differed significantly between patients at different presurgery stages. Tumors recurred in 4 of 7 patients with stage I IVL that opted for surgery that preserved the ovaries and uterus. No recurrence was observed in patients graded stage II or more, in all of which the uterus and ovaries were removed. Recurrence was observed in only 4 of 76 cases of IVL, all of whom opted for surgery that spared the ovaries and uterus.Different surgical strategies should be decided based on the staging to completely remove the tumor and ensure the safety of patients. Removal of both ovaries is necessary for inhibiting tumor growth and avoiding recurrence.

Intravenous leiomyomatosis of the uterus: a clinicopathologic study of 18 cases, with emphasis on early diagnosis and appropriate treatment strategies

Intravenous leiomyomatosis is a rare variant of leiomyoma that could result in death. Early and accurate diagnosis and appropriate treatment strategies play a dominant role in good prognosis. Eighteen cases of Intravenous leiomyomatosis , along with clinicopathologic data, were retrieved from our database. Most of the patients who ranged in age from 33 to 54 years (median, 44 years) presented with a pelvic mass or abnormal uterine bleeding. The diagnosis was confirmed by a immunohistochemical staining for smooth muscle actin, CD34, and Ki67. Surgical exploration confirmed the presence of a uterine mass (mean size, 5.08 cm). Wormlike plugs were identified within the broad ligament in 5 cases. The tumor penetrated to the inferior vena cava in 1 case. Histologic variants were noted in 33.33% (6/18) of our cases, which were classified as cellular intravenous leiomyomatosis (3 cases) and intravenous leiomyomatosis with papillary-like contour (1 case) and with fat metaplasia (2 cases). The 18 cases are made up 0.097% of all genital smooth muscle tumor cases of the hospital. The ratios of intravenous leiomyomatosis with uterine leiomyoma, with adenomyosis, with uterine leiomyoma and adenomyosis were 38.89% (7/18), 11.11% (2/18), and 27.78% (5/18), respectively. Follow-up information was available for 16 patients, with a follow-up duration of 26 to 104 months (mean, 55 months). Three cases (16.67%) recurred in patients younger than 40 years (33, 34, and 37 years). We propose that young patients undertake hysterectomy and unilateral salpingo-oophorectomy if they do not have any birthing requests. The cases of intravenous leiomyomatosis were underestimated because early diagnosis was easily missed. It is important to adequately sample all uterine leiomyomas and carefully examine the soft tissue on either side of the lower uterine segment below the peritoneal reflection to identify early-stage intravenous leiomyomatosis.

Intravenous leiomyomatosis with inferior vena cava and heart extension

BACKGROUND

Intravenous leiomyomatosis (IVL) is a rare tumor that is histologically benign but biologically malignant. Less than 200 cases of IVL have been reported, most of them were individual reports.

METHODS

Six patients with IVL involving the inferior vena cava were analyzed.

RESULTS

Three patients received one-stage operations and two received two-stage operations. All operations were successful. No perioperative death or other complications were observed. Primary tumors and intravenous tumorous emboli were completely resected from four patients. Residual tumor remained in one patient who had serious adhesions due to multiple previous surgeries; however, with antiestrogen therapy, the residual tumor significantly regressed. All patients had tumor relapse after the operation.

CONCLUSIONS

IVL should be given more attention by vascular surgeons, although it is extremely rare. Many therapeutic methods are available for uterine leiomyomatosis involving inferior vena cava, among which operation is the best choice.

Increased hyaluronan and CD44 expressions in intravenous leiomyomatosis

BACKGROUND

To determine the influence of hyaluronan and its receptor CD44 in the angiogenesis and invasiveness of intravenous leiomyomatosis (IVL).

METHODS

Paraffin-embedded sections from four IVL cases and 10 uterine leiomyoma cases were immunohistochemically stained for CD34, CD44, basic fibroblast growth factor (bFGF), vascular endothelial growth factor, and platelet-derived growth factor and assayed for microvessel densities. Hyaluronan was immunostained by biotinylated hyaluronan-binding peptide and the results were clinically correlated.

RESULTS

CD34 labeling showed significantly increased microvessel counts in IVL (156.6+/-3.7), when compared to uterine leiomyomas (61.3+/-27.3; P<0.001). Hyaluronan and its receptor CD44 were prominently expressed in IVL when compared to leiomyomas and associated with an elevation in bFGF expression.

CONCLUSIONS

IVL is a highly vascular neoplasm with elevated microvessel counts. The increase of hyaluronan and CD44 expression in IVL suggests that it is highly angiogenic and has an invasive potential. Elevation of hyaluronan may play a possible role in the pathogenesis of IVL.