Computerized tomography and 3-D rendering help to select surgical strategy in leiomyosarcoma of the inferior vena cava

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

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignant tumor, accounting for 2% of all LMSs. Less than 400 cases have been reported in literature. Computed tomography (CT) is the most accurate imaging method in assessing the location of the tumor within the IVC and magnetic resonance imaging (MRI) accurately identifies its extent and the potential for surgical resection. We present the case of a patient with inferior vena cava leiomyosarcoma (IVCL), for whom the pathological diagnosis was different from the initially expected one, the tumor appearance on pre-operative imaging mimicking renal cell carcinoma. The intraoperative difficulty of approaching renal hilum and IVC was a factor suggesting the vascular origin of the tumor, which was confirmed at pathological analysis. The extensive defect in the IVC after tumor excision led to the decision of complete transverse suturing of IVC, as significant collateral venous circulation was already present. Because IVCL is a rare disease, there is scarce data regarding the prognosis and treatment options. Long-term survival depends on the extent of the surgery. The need of vascular reconstruction is not always mandatory. Despite high recurrence rates, no consensus regarding adjuvant treatment exists yet. A multidisciplinary approach including surgical oncologists and vascular surgeons is mandatory to achieve the best patient outcomes. Perioperative planning, coordination and adherence to oncological techniques are critical.

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

Inferior vena cava leiomyosarcoma (IVCL) is a rare tumor with a poor prognosis, and its surgical resection remains a challenge. To date, surgery is the only potentially curative treatment for IVCL with a 5-year survival rate of 55%. The main challenge is to combine oncological surgery with clear margins and vascular reconstruction of the inferior vena cava (IVC). In this review, we discuss the different approaches to vascular reconstruction after IVCL resection, using a prosthetic or autologous patch, direct suture or simple ligation without IVC reconstruction. The reconstruction of IVC depends of tumor location and its extension. We recommend no reconstruction if venous collaterality is well-established. When vascular reconstruction is required, we prefer prosthetic PTFE graft. These patients should be referred to high-volume centers with a multidisciplinary team of sarcoma surgeons with cardiothoracic, vascular and hepatic specialties.

Primary Leiomyosarcoma in the Inferior Vena Cava Extended to the Right Atrium: A Case Report and Review of the Literature

A 38-year-old woman had developed an abdominal distention, lower extremity edema, and dyspnea. Imaging examination revealed a large mass in the right atrium which was connected to lesions within the inferior vena cava. Although complete resection of the mass was not possible, partial surgical tumor resection was performed to avoid pulmonary embolization and circulatory collapse. Leiomyosarcoma was diagnosed histologically, and chemotherapy (doxorubicin) followed by radiotherapy was started. By reviewing papers published in the past 10 years that included 322 patients, we also discuss the clinical presentations and prognosis of leiomyosarcoma in the inferior vena cava.

Duodenocaval Fistula in a Patient with Inferior Vena Cava Leiomyosarcoma Treated by Surgical Resection and Caval Polytetrafluoroethylene Prosthesis

Inferior vena cava (IVC) leiomyosarcoma represents an extremely rare disease that commonly involves the segment between the inflow of the renal veins and the inflow of the hepatic veins (46% of cases). We report the case of a patient affected by an IVC leiomyosarcoma, treated with surgical resection, caval reconstruction with polytetrafluoroethylene (PTFE), and right nephrectomy, followed by external beam radiotherapy. Oncological follow-up was negative for 17 years after this combined treatment, since the patient developed a duodenocaval fistula (DCF).

ADAM-10 could mediate cleavage of N-cadherin promoting apoptosis in human atherosclerotic lesions leading to vulnerable plaque: a morphological and immunohistochemical study

Atherosclerosis remains a major cause of mortality. Whereas the histopathological progression of atherosclerotic lesions is well documented, much less is known about the development of unstable or vulnerable plaque, which can rupture leading to thrombus, luminal occlusion and infarct. Apoptosis in the fibrous cap, which is rich in vascular smooth muscle cells (VSMCs) and macrophages, and its subsequent weakening or erosion seems to be an important regulator of plaque stability. The aim of our study was to improve our knowledge on the biological mechanisms that cause plaque instability in order to develop new therapies to maintain atherosclerotic plaque stability and avoid its rupture. In our study, we collected surgical specimens from atherosclerotic plaques in the right or left internal carotid artery of 62 patients with evident clinical symptoms. Histopathology and histochemistry were performed on wax-embedded sections. Immunohistochemical localization of caspase-3, N-cadherin and ADAM-10 was undertaken in order to highlight links between apoptosis, as expressed by caspase-3 immunostaining, and possible roles of N-cadherin, a cell-cell junction protein in VSMCs and macrophages that provides a pro-survival signal reducing apoptosis, and ADAM-10, a "disintegrin and metalloproteases" that is able to cleave N-cadherin in glioblastomas. Our results showed that when apoptosis, expressed by caspase-3 immunostaining, increased in the fibrous cap, rich in VSMCs and macrophages, the expression of N-cadherin decreased. The decreased N-cadherin expression, in turn, was linked to increased ADAM-10 expression. This study shows that apoptotic events are probably involved in the vulnerability of atherosclerotic plaque.