Intravenous leiomyomatosis with extension to the heart: rare or underestimated?

Surgical management of intravenous leiomyomatosis with intracardiac extension

Intravenous leiomyomatosis is a rare smooth muscle tumor that is associated with uterine leiomyomas. Intravenous leiomyomatosis often presents with nonspecific abdominal and cardiac symptoms, making the diagnosis difficult. We present a comprehensive review of a case of a 52-year-old woman with intravenous leiomyomatosis with intracardiac extension, who was successfully treated with complete surgical resection.

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.

Intravascular leiomyoma‑A rare case in the context of Covid‑19 outbreak: A case report

The present study reported a case of a uterine leiomyoma with an unusual growth pattern featuring areas of intravascular leiomyomatosis, rarely described in the international literature available in English. It presented the case of a 44-year-old woman who, fearing the Covid-19 outbreak, postponed the recommended surgical intervention to remove a uterine leiomyoma. The two-year delay worsened the symptoms, doubled the size of the tumor, and facilitated the development of intravascular leiomyomatosis. It was possible to establish the correct diagnosis only after the histopathological examination of the excised uterine myoma, as it was not suspected prior to surgery. No other vascular tumors were identified via magnetic resonance imaging and computed tomography imaging investigations. The careful follow-up of recovering patients is essential because of the high recurrence rate of such tumors and their potential to behave aggressively, possibly even fatally. Clinicians should be aware of this rare condition and its cardiovascular implications to improve the initial and long-term management of such cases.

Differentiating uterine sarcoma from leiomyoma: BET1T2ER Check!

Although rare, uterine sarcoma is a diagnosis that no one wants to miss. Often benign leiomyomas (fibroids) and uterine sarcomas can be differentiated due to the typical low T2 signal intensity contents and well-defined appearances of benign leiomyomas compared to the suspicious appearances of sarcomas presenting as large uterine masses with irregular outlines and intermediate T2 signal intensity together with possible features of secondary spread. The problem is when these benign lesions are atypical causing suspicious imaging features. This article provides a review of the current literature on imaging features of atypical fibroids and uterine sarcomas with an aide-memoire BET¹T²ER Check! to help identify key features more suggestive of a uterine sarcoma.

Intravenous leiomyomatosis: Case series and review of the literature

Introduction

Intravenous leiomyomatosis (ILV) is a rare pathology, part of leiomyoma beyond the uterus (LBU), characterized by benign smooth muscle cell tumor outside of the uterus and mainly affecting premenopausal woman with a medical history of leiomyoma or gynecologic surgical treatment. The treatment depends on the localization of the tumor, age of the patient, initial size, symptoms and the suitability for surgery but should always aims in toto surgical resection.

Case presentation

Retrospective case series and review of literature.

Clinical discussion

Symptoms presented by the patient were aspecific and only localized in the pelvic area. All cases were fortuitous histopathological diagnosis. No relapse was. Two out of 5 patients have pulmonary nodules, only one was biopsied and diagnosed with PBML (pulmonary benign metastasizing leiomyoma).

Conclusion

IVL and BML are rare disease that can co-exist. Because of tumoral hormonal receptors, hormonotherapy could be an optional treatment but to date no clear efficacy is demonstrated. In case of high recurrence risk such as voluminous initial mass, impairment of broad ligament, failure of total surgical resection, adjuvant hormonotherapy could be useful. Recurrence rate is about 16.6-30% and can occur even dozen years later and even after radical surgery, justifying a regular follow up.

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Leiomyomas beyond the uterus (LBU) is defined by benign smooth muscle cell tumor outside of the uterus. Sub classification of this entity are intravenous leiomyomatosis (IVL), benign metastasizing leiomyomas (BML), diffuse peritoneal leiomyomatosis (DPL), retroperitoneal leiomyomas and parasitic leiomyomas.

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The differential diagnosis of IVL should include benign myoma, thrombus, leiomyosarcoma, soft tissue sarcoma, lymphoma, cardiac myxoma, tumor thrombosis of Wilms tumor or metastasis.

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Treatment of IVL is usually surgery but there is no consensus about the the optimal approach. Adjuvant therapy sur as bilateral salpingoophorectomy followed by hormonothetherapy have to be balanced with their side effects.

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Despite being histologically benign, BML shows the metastatic potential of LBU.

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Because of a high rate of recurrence estimated of 16.6% to 30%, long term follow up is recommended even after radical surgery.

Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion

A broad range of abdominal and pelvic tumors can manifest with or develop intraluminal venous invasion. Imaging features at cross-sectional modalities and contrast-enhanced US that allow differentiation of tumor extension within veins from bland thrombus include the expansile nature of tumor thrombus and attenuation and enhancement similar to those of the primary tumor. Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies-including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma-and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis. Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular distribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein. By accurately diagnosing tumor venous invasion, especially in tumors where its presence may not be a typical feature, radiologists can help referring clinicians develop the best treatment strategies for their patients. ^©RSNA, 2020.

Intravascular Leiomyomatosis as a Rare Cause of Nonthrombotic Pulmonary Embolism

Intravascular leiomyomatosis (IVL) is a very rare condition. It is characterized by the proliferation of benign smooth muscle cells within vascular structures without invasion of these tissues. Symptoms depend on the site of origin and the extent of invasion. Rarely, this neoplasm is located in the inferior vena cava or in the pulmonary vasculature potentially causing symptoms of dyspnea, chest pain, or syncope. We report the case of a 53-year-old woman who was referred to our hospital with extensive pulmonary embolism comprising of a subtotal occlusion of the right pulmonary artery with extension into the left pulmonary artery. Due to persistent dyspnea (New York Heart Association class II) despite anticoagulation, after a six-week period, imaging was repeated and showed stable findings. As she was not responding to adequate anticoagulant therapy, intima sarcoma of the pulmonary artery was suspected, and a pulmonary endarterectomy (PEA) was performed. A smooth, white, intravascular mass was easily and completely removed. Analysis demonstrated a lesion consisting of cells without atypia, showing expression of alpha-smooth muscle actin (alpha SMA) and desmin with partial expression of estrogen receptor (ER) and progesterone receptor (PR), leading to the diagnosis of intravascular leiomyomatosis. The patient fully recovered. Complete surgical removal of the intravascular tumor is recommended to relieve symptoms and prevent possible complications. Clinicians have to be aware that in unresolved pulmonary embolism, nonthrombotic and rare causes, like an intima sarcoma or intravascular leiomyomatosis, should be considered.

Uterineintravenous leiomyomatosis with cardiac involvement

Intravenous leiomyomatosis is a histologically benign smooth muscle tumor that arises either by direct extension of a uterine leiomyoma into the adjacent veins or by vascular intimal smooth muscle proliferation. Herein, we report the case of a 60-year-old female who was noted to have suspected cardiac mass on elective echocardiography done electively for abnormal electrocardiographic findings. Computed tomography and cardiac magnetic resonance indicated the presence of an intravenous leiomyoma originating from the uterus and extending to the inferior vena cava and right atrium. The patient was managed with a single-stage surgery involving cardiopulmonary bypass and excision of the right atrial mass, excision of the inferior vena cava tumor thrombus, and total abdominal hysterectomy and bilateral salpingo-oophorectomy.

A 50-Year-Old Woman With Uterine Myomatosis, Rapidly Progressive Dyspnea, and Lower Extremity Edema

CASE PRESENTATION

A 50-year-old woman with morbid obesity (BMI, 49 kg/m²) was admitted to the ED due to shortness of breath triggered by mild to moderate efforts over the previous 3 weeks that rapidly progressed to dyspnea at rest and became associated with oppressive chest pain and edema of the lower extremities. Four months prior to admission, she had been diagnosed with a uterine mass (18 × 21 cm²) suggestive of a leiomyoma, manifesting with abnormal vaginal bleeding and microcytic hypochromic anemia (Fig 1).

Intravenous leiomyomatosis extending into right heart: A case report

Intravenous leiomyomatosis is a rare and special tumor which is exclusively seen in premenopausal women. Herein, we present a 46-year-old female case diagnosed with intravenous leiomyomatosis through an exploratory sternotomy and pathological examination.

Surgical treatment of intravenous leiomyomatosis involving the right heart: a case series

Objective

This study was performed to investigate the surgical treatment of intravenous leiomyomatosis involving the right heart.

Methods

The clinical data of five patients with intracardiac leiomyomatosis treated from April 2002 to October 2017 at a single center were retrospectively analyzed.

Results

All five patients underwent successful intravenous and right atrial tumor removal via abdominal and inferior vena cava incisions. In three patients, these incisions were combined with thoracotomy and a right atrial incision, and in two patients, they were combined with uterine and bilateral fallopian tube and ovarian resection. One patient with advanced disease underwent a one-stage procedure and died thereafter. Of the remaining four patients who underwent follow-up for 1.5 to 12.0 years, one developed recurrence at 1 year postoperatively. The recurrent tumor, which was pathologically confirmed to be an intravenous leiomyoma, was removed via inferior vena cava and internal iliac vein incisions without subsequent recurrence.

Conclusions

The main treatment goal for inferior vena cava leiomyomas involving the right heart is to first address the severe obstruction of cardiac blood flow and then pursue second-stage surgery. Concurrent thoracotomy appears unnecessary because moderately sized right heart tumors can be gently removed via the inferior vena cava.

Unusual Case of a Torted Mesenteric Fibroid

Extrauterine leiomyomas are very rare and present a clinical and diagnostic challenge due to their unusual growth patterns and behaviours. A 47-year-old woman was transferred to our tertiary specialist obstetrics and gynaecology hospital with acute abdominal pain and a palpable abdominal mass. She was taken immediately to theatre with the presumptive diagnosis of an ovarian torsion. Intraoperatively, a large necrotic mass originating from the mesentery and attachments to the bowel at the ileocaecal junction was noted. When converted to laparotomy due to limited access and poor visualisation, the uterus, ovaries, and tubes were found to be normal. A right partial hemicolectomy was performed with the assistance of the colorectal surgeon due to suspicion of bowel malignancy. Histology revealed a benign infarcted leiomyoma with adhesions to the adjacent ileum. The diagnosis of a primary torted mesenteric fibroid was made.

Contrast-enhanced CT findings of intravenous leiomyomatosis

AIM

To characterise the contrast-enhanced computed tomography (CT) imaging findings of nine patients with intravenous leiomyomatosis (IVL).

MATERIALS AND METHODS

The contrast-enhanced CT imaging findings of nine patients with histopathologically proven IVL were examined. The location, morphology, extension pathway, adhesion, and degree and pattern of enhancement of the tumour were assessed.

RESULTS

Four patients had tumours located within the inferior vena cava, and five had tumours that involved the right heart. Seven patients with residual uterus myoma showed enhanced heterogeneous contrast of the uterus. Eight tumours extended into the inferior vena cava through the iliac veins and one through the bilateral iliac veins. All the IVLs demonstrated heterogeneous enhancement on contrast-enhanced CT and appeared to have lower density than the contrast-enhanced venous blood. On the coronal and sagittal images, tumours were continuous and, when the right heart was involved, the lesions displayed a characteristic "walking stick head" or "snake head" appearance. The lesion looked similar to a "sieve" on axial contrast-enhanced CT images, and a "luffa sponge" on post-processing coronal or sagittal images.

CONCLUSION

Contrast-enhanced CT imaging has unique advantages in the diagnosis of IVL, namely, luffa sponge and sieve appearance, which can be helpful for differential diagnosis. Contrast-enhanced CT can demonstrate tumour location and full-scale extension pathway, which are important for diagnosis, surgical planning, and follow-up of the tumour.

Intravenous leiomyomatosis of the uterus: A clinicopathologic analysis of 13 cases with an emphasis on histogenesis

The object of this study is to investigate the prognosis and potential histologic origin of uterine intravenous leiomyomatosis (IVL). We retrospectively analyzed the clinicopathologic and immunohistochemical features of 13 cases of IVL from a single institute. The patients underwent hysterectomy (3 with bilateral salpingo-oophorectomy, and 8 with excision of the broad ligaments and/or parametrium). They survived with no evidence of disease for 6-90 months. Intravascular worm-like plugs were macroscopically identified in the myometrium in 10 of 13 cases (76.9%). Six patients (46.1%) had extra-uterine involvement. Histopathologically, the intravascular tumor foci were covered with endothelium. We found the presence of congested vessels in the tumor and the surrounding myometrium in 9 of 13 cases (69.2%). The concurrent entities included seven uterine leiomyomas, one leiomyoma with adenomyosis, one adenomyosis, and one pulmonary benign metastasizing leiomyoma. Estrogen receptor and desmin were positive in IVL, and negative in the vascular wall. We conclude that IVL confined to the uterus may have a favorable prognosis, and we believe IVL is likely to originate from contiguous leiomyoma or myometrium.

One-stage surgery for removal of intravascular leiomyomatosis extending to right ventricle

RATIONALE

Intravascular leiomyomatosis (IVL) is a rare nonmalignant tumor that can be fatal if untreated.

PATIENT CONCERNS

A 49-year-old nulliparous Asian woman who underwent hysterectomy and left salpingo-oophorectomy for multiple uterine leiomyomas 18 months prior presented complaining of intermittent palpitation and chest tightness for approximately 1 month. Echocardiography revealed a large mobile tumor mass extending from the inferior vena cava (IVC) to the right atrium that partially obstructed IVC flow and tricuspid inflow. Thoracicabdominopelvic computed tomography revealed a left adnexal tumor (4.8 × 2.5 cm) causing intravascular obstruction extending from the left internal iliac vein to the IVC, right atrium, and right ventricle.

DIAGNOSIS

IVL with right heart involvement INTERVENTIONS:: Under cardiopulmonary bypass, a one-stage surgery combining sternotomy and laparotomy was performed. The tumor was approached and extracted via sternotomy, and tumor detachment and removal of residual tumors was accomplished via laparotomy.

OUTCOMES

A firm, smooth, and regularly shape tumor 15.5 × 5.5 × 2.5 in size was completely removed and histopathologically confirmed as IVL. The patient tolerated the surgical procedure well and no postoperative complication was noted.

LESSONS

We describe a one-stage surgical approach to completely remove an IVL extending to the right ventricle.

Inguinal pain and fullness due to an intravascular leiomyoma in the external iliac vein

Intravascular leiomyomatosis (IVL) is a benign smooth muscle tumor that evolves from the pelvic veins and can spread to the central veins and heart. Cardiac involvement is the most commonly reported presentation. Initial diagnosis is difficult, and IVL is commonly misdiagnosed as thrombus or atrial myxoma. Appropriate imaging and a high clinical suspicion are required for accurate diagnosis. We report a rare case of IVL in the external iliac vein that recurred 4 years after hysterectomy. Only four cases have been reported in the literature to involve the external iliac vein as it has no direct connection to pelvic venous drainage.

Ectopic thyroid mass in the right ventricle: A case report

Ectopic thyroid is a rare congenital embryonic anomaly. Ectopic thyroid tissue can be located anywhere during its descent, but it is found primarily at the base of the tongue and in the mediastinum. It is very rarely found in the heart. Here, we report a rare case of cardiac ectopic thyroid tissue in a 53-year-old woman who presented with chest pain. Echocardiography revealed an intracardiac mass that was removed successfully. Histopathology confirmed that the mass was thyroid tissue without malignancy.

Disseminated peritoneal leiomyomatosis: a rare cause of enigmatic peritoneal masses

Disseminated peritoneal leiomyomatosis (DPL) is an unusual extrauterine form of leiomyoma that has been found to coexist with its intrauterine counterpart in individuals who have previously undergone laparoscopic myomectomy. The presence of extrauterine masses with the density of smooth muscle on CT imaging and/or with a low signal intensity similar to that of smooth muscle on T₂ weighted MRI in a patient presenting with associated intrauterine leiomyoma and/or a history of previous laparoscopic myomectomy suggests the possibility of DPL. Imaging studies help in diagnosing and delineating the location and extent of the lesion and also follow-up the masses to look for sarcomatous transformation. Here we report the case of a 43-year-old female who presented initially with right lower quadrant pain. Her CT scan and MRI demonstrated a fundal fibroid with multiple intraperitoneal soft tissue masses of similar appearance and contrast enhancement in the sigmoid mesocolon, the left paracolic gutter and adjacent to the ascending colon. The suspected diagnosis of DPL was confirmed during abdominal hysterectomy, bilateral salphingo-oophorectomy and excision of peritoneal masses.

Uterine Intravenous Leiomyomatosis with Intracardiac Extension and Pulmonary Benign Metastases on FDG PET/CT: A Case Report

A 48-year-old woman presented with a 50-day history of irregular vaginal bleeding and lower abdominal pain. Ultrasound indicated an extremely large occupying lesion in the pelvic cavity that was highly suggestive of malignancy. Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) was performed to further assess the nature of pelvic abnormality. PET/CT images demonstrated a diffusely lobulated mass ranging from cervix up to the inferior pole of kidneys with mild FDG uptake. Simultaneously, multiple nodules in bilateral lungs and a hypodense lesion in the right ventricle were shown without FDG-avidity. Based on the imaging results, the presumptive diagnosis was uterine intravenous leiomyomatosis with intracardiac extension and pulmonary benign metastases, which was subsequently confirmed by MRI and the lesion biopsy.

Orthostatic hypotension and right heart failure as the initial manifestation of intravenous leiomyomatosis

A 36-year-old woman, who had a history of myomectomy, presented with lightheadedness after changing position from sitting to standing and effort-related shortness of breath. Echocardiography demonstrated a hyperechoic elongated mobile mass extending from the inferior caval vein to the right atrium. The mass was surgically removed, and histological examination established the diagnosis of intravenous leiomyomatosis. This case caught the attention of our cardiology group to consider the diagnosis when an inferior caval vein or right atrium mass is found in a patient with a history of uterine leiomyomatosis.

Computerized tomography angiography in preoperative assessment of intravenous leiomyomatosis extending to inferior vena cava and heart

BACKGROUND

Intravenous leiomyomatosis (IVL) extending to inferior vena cava and heart is one of the most challenging conditions for surgical treatment. We explored the use of computerized tomography angiography (CTA) in preoperative assessment for this disease.

METHODS

A cohort of 31 patients with IVL extending to inferior vena cava and heart were reviewed from the year 2002 to 2014, focusing on the preoperative CTA imaging characteristics and the surgical procedures in clinical treatment.

RESULTS

All patients were diagnosed correctly combining the clinical medical history and CTA imaging. Thirteen patients had tumors confined within the inferior vena cava, and 18 patients had tumors intruding into the right heart. Furthermore, 15 tumors were located in the right atrium alone, and 3 tumors involved both the right atrium and the right ventricle. All patients had simple or multiple soft tissue masses from the pelvis, with 22 tumors extending into inferior vena cava through the iliac veins and 9 tumors through the ovarian veins. Three patients had tumors invading into lung and underwent tumor thrombus resection in the pulmonary artery. Patients received either one-stage surgery or two-stage surgery dependent on patient general condition and tumor status. All operations were successfully performed by multidisciplinary cooperation, including gynecology, cardiac surgery, and vascular surgery, without severe surgical-related complications or deaths.

CONCLUSIONS

CTA imaging can present location, size, and full-scale extension pathway of IVL lesions, and can be used as first-line imaging technique in preoperative assessment, having great significance in making surgical plan and obtaining successful outcome.

Intravenous leiomyomatosis with intracardiac extension: an unusual presentation of uterine leiomyoma and evaluation with 256-slice dual-source multidetector CT and cardiac MRI

We report a case of a 40-year-old woman who presented with breathlessness, palpitations and vague pelvic pain for 6 months. The dyspnoea was non-exertional and episodic. She was a non-diabetic, non-hypertensive and had no history of prior surgeries. ECG and chest radiograph were normal. Cardiac MRI and 256-slice dual-source multidetector CT evaluation revealed the presence of a uterine and left adnexal mass with intravenous extension into the inferior vena cava via the gonadal veins, and further cephalad extension into the right atrium and ventricle. The patient was referred to the cardiothoracic surgery department and underwent two-stage surgical procedures. The first stage consisted of thoracotomy and tumour removal from the right atrium and inferior vena cava. In the second stage, hysterectomy and bilateral salpingo-oophorectomy was performed. The histological analysis of the excised specimen was consistent with an intravascular leiomyoma.

Metastasizing leiomyoma to heart

Cardiac smooth muscle tumors are rare. Three different clinical settings for these tumors have been reported, including benign metastasizing leiomyoma from the uterus, primary cardiac leiomyoma and leiomyosarcoma, and intravenous cardiac extension of pelvic leiomyoma, which is the most common. We present a case of a 55-year-old woman with a benign metastasizing leiomyoma to the heart 17 years after hysterectomy and 16 years after metastasis to the lung. Immunohistochemical stains for smooth muscle actin, desmin, and estrogen and progesterone receptors were positive, indicating a smooth muscle tumor of uterine origin. To our knowledge, this is only the fourth reported case of benign metastasizing leiomyoma to the heart and the first case of long-delayed cardiac metastasis after successful treatment of pulmonary metastasis. It illustrates that benign metastasizing leiomyoma should be included in the differential diagnosis of cardiac tumors in patients with a history of uterine leiomyoma, especially when associated with pulmonary metastasis.

Leiomyomas beyond the uterus; benign metastasizing leiomyomatosis with paraaortic metastasizing endometriosis and intravenous leiomyomatosis: a case series and review of the literature

Uterine leiomyomas affect 20-30 % of women 35 years and older. Extrauterine leiomyomas are rare and present a greater diagnostic challenge. Those unusual growth patterns occur more often in women of reproductive age with a history of hysterectomy or surgery for uterine leiomyomas. They have been reported in the literature in case reports and small case series and include benign metastasizing leiomyoma (BML), disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis (IVL), parasitic leiomyomas, and retroperitoneal growth. In this case series we present a case of BML with a first report of concomitant endometriosis metastasis to paraaortic lymphnodes, and a case of IVL. The findings and surgical management of those cases, as well as a review of the literature pertinent to those entities, are also presented.

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.

Intracardiac leiomyomatosis: a comprehensive analysis of 194 cases

Intracardiac leiomyomatosis is rare but has been increasingly reported in recent years. Owing to its rarity, intracardiac leiomyomatosis has been reported only as isolated case reports and case series. This disorder is thought to be underestimated and easily overlooked in the clinic, while it is dangerous owing to the risk of sudden death caused by total outflow tract obstruction. We performed an electronic literature search for intracardiac leiomyomatosis and identified 194 cases that were reported in English from 1974 (the first reported case) to September 2012. Our aim is to provide a detailed and comprehensive review of the clinical presentation, diagnosis, histopathological characterization, treatment and prognosis of this disorder. According to our analysis, intracardiac leiomyomatosis is most common in the fifth decade, and the mean age of detection is ~50 years. Most patients had undergone previous hysterectomy/myomectomy or had a coexisting uterine leiomyoma when admitted. The most common clinical presentations were dyspnoea, syncope, oedema of the lower extremities and palpitation. Transoesophageal echocardiography, computed tomography and magnetic resonance imaging are helpful in the preoperative diagnosis and to guide the surgical management. Complete removal guarantees an excellent outcome, with no recurrence or postoperative death, while incomplete removal leads to recurrence in one-third of patients. Anti-oestrogen therapy is not imperative after incomplete removal owing to its inability to prevent recurrence.

Pulmonary artery extension of uterine leiomyoma

Intravenous leiomyomatosis is a rare tumor arising either from a uterine leiomyoma or from uterine vessel walls with extension into venous channels. Although intravenous leiomyomatosis is considered histologically "benign," intrusion to the cardiac chambers is almost malignant given its possibility for destruction of heart valves, extending into the pulmonary vasculature, and embolizing. We report a patient with an intravenous leiomyomatosis progressing through the left iliac vein, along the entire vena cava up to the right cardiac chambers and branches of pulmonary artery (PA), and review the literature on this subject.

Intravenous leiomyomatosis of the uterus with extension to the right heart

A 42-year-old woman admitted with debilitation and engorgement both lower extremities. Transthoracic two-dimensional echocardiography, abdominal ultrasound and computerized tomography revealed a lobulated pelvic mass, a mass within right internal iliac vein, both common iliac vein, as well as the inferior vena cava, extending into the right atrium. In addition, echocardiography and abdominal ultrasound showed the tumor of right atrium and inferior vena cave has no stalk and has well-demarcated borders with the wall of right atrium and inferior vena cave. Hence, the presumptive diagnosis of IVL was made by echocardiography and abdominal ultrasound and the presumptive diagnosis of sarcoma with invasion in right internal iliac vein, both common iliac vein, the inferior vena cava, as well as the right atrium was made by multi-detector-row computerized tomography. The patient underwent a one-stage combined multidisciplinary thoraco-abdominal operation under general anaesthetic. Subsequently the pathologic report confirmed IVL.

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.

Pulmonary artery embolization of intravenous leiomyomatosis extending into the right atrium

A 43-year-old woman was diagnosed with an intravenous leiomyomatosis at a previous hospital and transferred to our hospital to undergo surgical treatment. Emergency one-stage operation for coincidental removal of intra-abdominal, right atrial, and intravenous masses were planned. Upon arriving at the operating room, she suffered a sudden onset of severe dyspnea and showed hemodynamic instability. Intraoperative TEE showed pulmonary embolization of a right atrial mass. Removal of the pulmonary artery mass and the intra-abdominal mass, and the cardiopulmonary bypass were performed without any complications.

Pulmonary artery embolization of intravenous leiomyomatosis extending into the right atrium

A 43-year-old woman was diagnosed with an intravenous leiomyomatosis at a previous hospital and transferred to our hospital to undergo surgical treatment. Emergency one-stage operation for coincidental removal of intra-abdominal, right atrial, and intravenous masses were planned. Upon arriving at the operating room, she suffered a sudden onset of severe dyspnea and showed hemodynamic instability. Intraoperative TEE showed pulmonary embolization of a right atrial mass. Removal of the pulmonary artery mass and the intra-abdominal mass, and the cardiopulmonary bypass were performed without any complications.

Partial resection of intravenous leiomyomatosis with cardiac extension

Intravenous leiomyomatosis with cardiac extension is rare and may result in a fatal outcome. A 58-year-old woman with a surgical history of myoma uteri was admitted to our hospital for treatment of intravenous leiomyomatosis extending into the right atrium through the inferior vena cava. We partially resected the tumor inside the right atrium and the inferior vena cava via the right atrium using cardiopulmonary bypass. There is no progression of the residual tumor after 25 months of follow-up.

Radiologic Evaluation of Mesenchymal Tumors of the Female Genital Tract

Mesenchymal neoplasms of the female genital tract are a diverse group of tumors, of which the most common are smooth muscle tumors. There is a significant overlap in the imaging characteristics of benign and malignant tumors and final diagnosis often requires pathologic correlation. However, familiarity with typical radiologic features, common imaging pitfalls, and the utility of different imaging modalities can be valuable in the evaluation of mesenchymal tumors. This article highlights the imaging features of the most commonly encountered mesenchymal tumors in the female genital tract.

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.

Vascular smooth muscle tumors: Review of the literature

Vascular smooth muscle tumors are very rare. They can be benign or malign. Intravascular leiomyomatosis is a benign neoplasm that extends through the veins and caries significant morbidity. Angioleiomyoma is a benign neoplasm of the extremities that caries minimal morbidity. Vascular leiomyosarcomas are malign neoplasms derived from vascular smooth cells. They are usually localized to the inferior vena cava, but can also arise from the pulmonary arteries or veins or other peripheral vessels. This study reviews literature for epidemiology, clinical presentation, diagnosis and management of patients with vascular smooth muscle tumors.

Single-Stage Resection of a Mixed Endometrial Stromal Sarcoma and Smooth Muscle Tumor With Intracardiac and Pulmonary Extension

A case of mixed endometrial stromal sarcoma and smooth muscle cell tumor of the uterus with intravenous extension into the right heart and pulmonary artery is presented. The current literature and diagnostic and therapeutic strategies of pelvic tumors with intravenous extension are reviewed.