Successful One Stage Surgical Removal of Intravenous Leiomyomatosis with On Pump Beating Heart Technique

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.

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.

Experience in the diagnosis and treatment of intravenous leiomyomatosis involving the inferior vena cava and/or right cardiac chambers

OBJECTIVE

This study aimed to summarize our experience with the diagnosis and treatment of intravenous leiomyomatosis (IVL) involving the inferior vena cava (IVC) or right cardiac chambers.

METHODS

This study retrospectively analyzed clinical data from 10 patients diagnosed with IVL involving the IVC or right cardiac chambers between May 2009 and October 2019 at one medical center.

RESULTS

All patients were females aged 35 to 56 years (average, 46.8 years) with a history of uterine leiomyoma. Of these 10 patients, 8 manifested clinical symptoms and 2 were asymptomatic. Four were diagnosed with lesions involving the right cardiac chambers, four had lesions that extended into the suprahepatic IVC, and an additional two had lesions extending into the infrarenal IVC. All patients underwent surgery. Three of the four patients with extension into the right cardiac chambers underwent a two-stage operation, and an additional patient was managed with a one-stage operation. Patients who underwent a two-stage operation experienced less hemorrhaging and a shorter intensive care unit stay than the patient who underwent a one-stage operation. Six patients with intracaval extension alone underwent laparotomy, including four with a lesion extending into the suprahepatic IVC, under transesophageal echocardiography monitoring. Bilateral adnexectomy and ovariectomy were performed in seven patients, and unilateral adnexectomy and ovariectomy were performed in two patients; antiestrogen therapy was administered to two patients who retained a unilateral ovary and to one patient who retained bilateral ovaries. One patient suffered deep vein thrombosis in the left lower extremity after surgery that improved after treatment. All patients received conventional anticoagulant treatment postoperatively. All pathologic findings confirmed IVL, and the follow-up period ranged from 27 to 120 months (average, 57.5 months). Recurrence was not observed in the iliac vein or IVC, excluding one case of pelvic leiomyoma that recurred at one year postoperatively.

CONCLUSIONS

IVL should be highly suspected when an IVC mass occurs in a patient with a history of uterine leiomyoma. Surgery is the gold standard treatment for IVL; a two-stage operation is more beneficial for patient recovery if the lesion exhibits intracardiac involvement, and transesophageal echocardiography is a helpful tool to monitor safety during surgical procedure for patients with a lesion invading the IVC above the level of the renal vein.