Intravenous Leiomyomatosis with Intracardiac Extension: First Reported Case in Australia

Case report: Cardiac metastatic uterine intravenous leiomyomatosis excision with extracorporeal venous shunt under the guidance of 3-dimensional printing

Intravenous leiomyomatosis (IVL) is relatively rare, and the incidence of cardiac IVL is even lower. The case report introduces a 48-year-old woman with two episodes of syncope in 2021. Echocardiography showed a cord-like mass in the inferior vena cava (IVC), right atrium (RA), right ventricle (RV) and pulmonary artery. Computed tomography venography and magnetic resonance imaging showed strips in RA, RV, IVC, right common iliac vein, and internal iliac vein, as well as a round-like mass in the right uterine adnexa. Combined with the patient's prior surgical history and rare anatomical structures, surgeons used cardiovascular 3-dimensional (3D) printing technology to create patient-specific preoperative 3D printed model. The model could help surgeons to visually and accurately understand the size of IVL and its relationship to adjacent tissues. Finally, surgeons successfully performed a concurrent transabdominal resection of cardiac metastatic IVL and adnexal hysterectomy with off-cardiopulmonary bypass. Preoperative evaluation and guidance of 3D printing may play a critical role to ensure this surgery for the patient with rare anatomical structures and high surgical risk. Clinical Trial Registration: [ClinicalTrials.gov], Protocol Registration System [NCT02917980].

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.

Intravenous leiomyomatosis: A case study and literature review

The dissertation presents a case of intravenous leiomyomatosis and conducts the literature review. A 31-year-old woman with a hysteromyomectomy history presented with abnormal uterine bleeding and anemia, a large pelvic tumor, underwent excision of the uterine and bilateral salpingo-oophorectomy. A pathological diagnosis determined it as intravenous leiomyomatosis. The patient recovered well, and no recurrence was noted after 1 year of follow-up. Intravenous leiomyomatosis is rare. Imaging is helpful, but the final diagnosis of intravenous leiomyomatosis is usually made following surgical excision and histopathology. Early surgical resection is a better treatment modality.

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

OBJECTIVES

Intravenous leiomyomatosis (IVL) is a histologically benign but biologically aggressive tumor. This study aimed to summarize the echocardiography and contrast-enhanced ultrasound (CEU) characteristics of IVL to provide a basis for clinical diagnosis and therapy.

METHODS

Fourteen IVL patients with uterus leiomyoma history (female, 46.4 ± 5.6 years) were enrolled in this study from March 2008 to December 2020 in our hospital. Preoperative imaging examination data were collected, including echocardiography computed tomography data; six patients also underwent CEU. All patients underwent successful resection, confirmed by histopathology.

RESULTS

Echocardiographic characteristics: The mean sizes of intracardiac parts of IVL tumors were 54.0 ± 17.9 mm (length) and 24.6 ± 9.8 mm (width). IVL tumors exhibited two echocardiography types: isoechoic solid mass (71.4%, 10/14) and anechoic cystic conduits (28.6%, 4/14), with enlargements of the right atrium (57.1%,8/14), right ventricle (1 patient, 7.1%), and inferior vena cava (57.1%, 8/14). About 21.4% of the patients (3/14) had right ventricular dysfunction. Right heart obstruction was observed in 42.8% (6/14) of the patients. CEU characteristics: the solid mass type exhibited an earlier perfusion and lower perfusion intensity than the conduits type. CEU was helpful in determining origins and pathways: from the internal iliac vein (pathway I, 71.4%), from the ovarian vein (pathway II, 14.3%), or both (14.3%). The echocardiographic appearances of the 14 cases were consistent with the features of the resection specimens.

CONCLUSION

Combined echocardiography and CEU can provide a more valuable information for the diagnosis of IVL and essential basis for treatment.

Non-open-heart surgery for intravascular leiomyomatosis extending from the inferior vena cava to the right heart chamber

OBJECTIVE

In the present study, we analyzed the advantages and feasibility of non-open-heart surgery without cardiopulmonary bypass for intracardiac intravenous leiomyomatosis.

METHODS

We retrospectively reviewed 23 cases of intracardiac intravenous leiomyomatosis and divided them into a noncardiopulmonary bypass (NCPB) group (9 cases) and a cardiopulmonary bypass (CPB) group (14 cases) according to the surgical treatment received. The clinical characteristics and anatomic features, including the diameter of the tumor, right atrium, and inferior vena cava, were recorded, and the perioperative data, including the operation time, blood loss, postoperative hemoglobin change, and follow-up results, were analyzed and compared between the two groups.

RESULTS

The NCPB group had required a shorter operation time (321.9 ± 104.2 minutes vs 526.3 ± 95.6 minutes; P < .001) and had experienced less blood loss (456.3 ± 249.9 mL vs 815.4 ± 435.6 mL; P = .048) compared with the CPB group. The NCPB group had a small maximum cross-sectional area of the tumor inside the right atrium (475.5 ± 509.6 mm²), a low proportion of the maximum cross-sectional area of the entrance of the right atrium (average, 26.1%), no tricuspid valve or atrial wall involvement, and high mobility inside the inferior vena cava and heart chamber. All 23 patients had recovered well postoperatively, and no recurrence had developed during 24 months of follow-up.

CONCLUSIONS

For intravenous leiomyomatosis with a smaller cross-sectional area in the right atrium that can be mobilized, surgery without CBP is feasible and should be considered.

Ultrasound appearance of intravenous leiomyomatosis: A case report

RATIONALE

Intravenous leiomyomatosis (IVL) is a rare benign smooth muscle tumor that can develop from the pelvic or uterine veins and spread into the central veins and heart. Here, we report a case of recurrent IVL in a 48-year-old woman. To the best of our knowledge, this is the first case report of IVL that describes the characteristic ultrasound features of the tumor, including the rainbow sign.

PATIENT CONCERNS

A 48-year-old woman developed a solid-cystic lesion in the inferior vena cava (IVC) 3 years after undergoing a right heart tumor resection and 5 years after undergoing hysterectomy.

DIAGNOSES

Physical examination was unremarkable. However, ultrasonography showed a solid-cystic lesion in the IVC, and a diagnosis of IVL was made.

INTERVENTIONS

The patient underwent complete surgical removal of the tumor by a multidisciplinary team. The tumor was resected successfully.

OUTCOMES

Pathological examination confirmed that the IVC tumor thrombus was consistent with IVL. During follow-up, there were no signs of local or distant recurrence.

LESSONS

The preoperative diagnosis of IVL is difficult, and the tumor is usually misdiagnosed as a thrombus or right atrial myxoma. A thorough understanding of the characteristic imaging features of IVL is essential for an accurate preoperative diagnosis. The lesion in our patient showed multiple tracts, a honeycomb appearance, and vividly colorful blood flow that resembled a rainbow, which we termed the rainbow sign.

Intravenous leiomyomatosis with intracardiac extension depicted on computed tomography and magnetic resonance imaging scans: A report of two cases and a review of the literature

Intravenous leiomyomatosis (IVL) is defined as a benign smooth muscle tumor, growing within systemic veins. IVL with intracaval and intracardiac extension has rarely been reported in radiological and oncological journals. The present study describes 2 cases of IVL extending from the inferior vena cava to the right atrium and ventricle, and discusses the imaging findings and differential diagnosis of this tumor entity. The two patients, who complained of palpitations, shortness of breath or syncope, were surgically treated, with complete resection of the cardiac and intracaval tumors. Pathological examinations were suggestive of IVL. The postoperative course of the two patients was uneventful, and no signs of recurrence were observed on follow-up. Computed tomography and magnetic resonance imaging played a vital role in the diagnostic process and presurgical assessment. The results of the present study indicate that IVL should be considered upon presentation of a soft mass in systemic veins, even when the mass extends to the right cardiac chambers, in female patients, particularly in patients with a history of uterine myoma.

Intravenous leiomyomatosis disguised as a large deep vein thrombosis

Intravenous leiomyomatosis is a benign smooth muscle tumor which despite its histology can have devastating consequences. Furthermore, the clinical manifestations are variable and nonspecific, typically leading to delayed or missed diagnosis. Thus, it is critical for clinicians to be aware of this condition and have a high index of suspicion in a middle-aged woman with a history of uterine leiomyoma presenting with an inferior vena cava mass to enable early diagnosis and treatment. We report a case of a large intravenous leiomyoma which was initially considered to be a very large deep venous thrombosis; with thorough preoperative planning, it was successfully removed intact and in entirety with a single-stage operation.

One-stage complete resection of giant intracardiac leiomyomatosis with moderate hypothermia extracorporeal circulation and beating heart technique with 36 months follow-up-a case report

BACKGROUND

Intracardiac leiomyomatosis (ICL) is a rare benign neoplasm of the smooth muscle in the uterus extending into the heart. Complete resection is difficult because of the extensive range.

CASE PRESENTATION

We report a case of one-stage complete resection of a giant ICL with moderate hypothermia extracorporeal circulation and beating heart technique.

CONCLUSIONS

The outcome of 36 months follow-up was very good.

Intravenous leiomyomatosis with intracardiac extension: echocardiographic study and literature review

Uterine leiomyomatosis is a common disease in women; however, intravenous leiomyomatosis with intracaval and intracardiac tumor extension is rare. We sought to analyze the clinical and echocardiographic features of intracardiac leiomyomatosis. From January 2003 through July 2012, 7 women (age range, 24-59 yr) underwent surgical resection of histopathologically diagnosed intracardiac leiomyomas at our hospital. Most of the patients had histories of hysterectomy or uterine leiomyoma. We retrospectively analyzed their preoperative echocardiograms. We found that the tumors had no stalks, did not adhere to the wall of the right side of the heart, were highly mobile, and moved back and forth in the right atrium near the tricuspid orifice. All tumors originated from the inferior vena cava and had borders well demarcated from that structure's wall. Most of the masses extended into the inferior vena cava and right atrium through the right internal and common iliac veins. Computed tomograms revealed pelvic tumors and contiguous filling defects in 6 patients. When echocardiograms reveal a right-sided cardiac mass that originates from the inferior vena cava, particularly in women who have a history of hysterectomy or uterine leiomyoma, intracardiac leiomyomatosis should be suspected. If the mass has no stalk and freely moves within the inferior vena cava and right-sided cardiac chambers without attachment to the endothelial surface or endocardium, intracardiac leiomyomatosis should be diagnosed. We discuss our findings and briefly review the relevant medical literature.

Intravenous leiomyomatosis with intracardiac extension - a review of diagnosis and management with an illustrative case

Intravenous leiomyomatosis with intracardiac extension is an uncommon pathologic progression of uterine leiomyomata. It is a histologically benign condition, however due to interfence with right sided cardiac function patients may present with marked cardiovascular compromise and present a diagnostic dilemma to clinicians who are unfamiliar with this condition. Given the rarity of this condition, experience in individual institutions is usually limited to a few cases. We present an illustrative case and provide a review of the clinical presentation, preoperative assessment, operative approach, pathology and postoperative issues. The importance of a multidisciplinary approach to diagnosis and management is highlighted. Operative management aims to completely resect all tumour in the safest manner for the patient, most commonly via single or two stage operation. Where complete resection is achieved, recurrence appears to be a rare event.

Echocardiographic characteristics of intravenous leiomyomatosis with intracardiac extension: a single-institution experience

BACKGROUND

Intravenous leiomyomatosis (IVL) is a rare smooth-muscle proliferation arising from a uterine myoma and occasionally extending into cardiac chambers.

METHODS AND RESULTS

A series of 10 consecutive patients with histologically and surgically proven intracardiac IVL between 2000 and 2010 in our hospital were reviewed. The echocardiographic features of 10 cases with IVL and extensive spread into the right-sided cardiac chambers were described for the first time. All patients were female and the mean age was 42±7 years old. The first symptoms of six patients (60%) were exertional dyspnea and palpitation of cardiac origin. Echocardiography showed that all the tumors originated from the inferior vena cava (IVC) and located in cardiac right chambers (70% in right atrium alone, 30% in right ventricle and atrium). Eight masses (80%) were oval, whereas the others (20%) were serpentine, all with well-demarcated borders and most (70%) with heteroechogenic texture. Five tumors (50%) intermittently prolapsed into right ventricle through the tricuspid valve. Two patients with nodules adhering to the top of the tumors had pulmonary tumorous thromboembolism.

CONCLUSION

Echocardiography is a simple and important technique to diagnose IVL with intracardiac extension. This disease should be considered in a female patient presenting with an extensive mass from IVC with well-demarcated border in the right-sided cardiac chambers.