Primary leiomyosarcoma of the inferior vena cava: A 2-institution analysis of outcomes

Extent of macroscopic vascular invasion predicts distant metastasis in primary leiomyosarcoma of the inferior vena cava

BACKGROUND

In retroperitoneal leiomyosarcoma (RP LMS), the predominant issue is distant metastasis (DM). We sought to determine variables associated with this outcome and disease-specific death (DSD).

METHODS

Data were retrospectively collected on patients with primary RP LMS treated at a high-volume center from 2002 to 2023. For inferior vena cava (IVC)-origin tumors, the extent of macroscopic vascular invasion was re-assessed on each resection specimen and correlated with preoperative cross-sectional imaging. Crude cumulative incidences were estimated for DM and DSD and univariable and multivariable models were performed.

RESULTS

Among 157 study patients, median tumor size was 11.0 cm and 96.2% of cases were intermediate or high grade. All patients underwent complete resection, 56.7% received chemotherapy (43.9% neoadjuvant) and 14.6% received radiation therapy. Only tumor size and grade and not site of tumor origin (e.g., IVC vs. other) were associated with DM and DSD (p < 0.05). Among 64 patients with IVC-origin tumors, a novel 3-tier classification was devised based on the level of intimal disruption, which was associated with both DM (p = 0.007) and DSD (0.002).

CONCLUSION

In primary RP LMS, only tumor size and grade are predictive of DM and DSD. In IVC-origin tumors, the extent of macroscopic vascular invasion is also strongly predictive of these outcomes.

Aggressive surgical approach with vascular resection and reconstruction for retroperitoneal sarcomas: a systematic review

BACKGROUND AND AIM

Surgery is the mainstay of treatment and completeness of surgical resection is critical to achieve local control for retroperitoneal sarcoma (RPS). En-bloc resection of adjacent organs, including major abdominal vessels, is often required to achieve negative margins. The aim of this review was to summarise the available evidence to assess the relative benefits and disadvantages of an aggressive surgical approach with vascular resection in patients with retroperitoneal sarcoma (RPS).

METHODS

We searched PubMed, the Cochrane Library, and EMBASE for relevant studies published from inception up to August 1, 2022. We performed a systematic review of the available studies to assess the safety and long-term survival results of vascular resection for RPS.

RESULTS

We identified a total of 23 studies for our review. Overall postoperative in-hospital or 30-day mortality rate of patients with primary iliocaval leiomyosarcoma was 3% (11/359), and the major complication rate was 13%. The recurrence-free survival (RFS) rates after the follow-up period varied between 15% and 52%, and the 5-year overall survival (OS) rates ranged from 25 to 78%. Overall postoperative in-hospital or 30-day mortality rate of patients with RPSs receiving vascular resection was 3%, and the major complication rate was 27%. The RFS rates after the follow-up period were 18-86%, and the 5-year OS rates varied between 50% and 73%. There were no significant differences in the rates of RFS (HR: 0.97; 95% CI: 0.74-1.19; p = 0.945) and OS (HR: 1.01; 95% CI: 0.66-1.36; p = 0.774) between the extended resection group and tumour resection alone group.

CONCLUSIONS

With adequate preparation and proper management, for patients with RPSs involving major vessels, aggressive surgical approach with vascular resection can achieve R0/R1 resection and improve survival.

Rare presentation of retroperitoneal leiomyosarcoma mimicking a myoma in a 46-year-old woman: A case report

Retroperitoneal sarcoma is relatively uncommon. We share our experience in encountering retroperitoneal sarcoma with vascular and urethral adhesion in a 46-year-old woman. Given the rarity of these tumors, evaluation and management should ideally be performed in a center equipped with multidisciplinary expertise in treating sarcomas.

Incidentally Diagnosed Extraluminal Leiomyosarcoma of Infrarenal Inferior Vena Cava: A Case Report and Literature Review from a Radiologist's Perspective

Background

Vascular leiomyosarcoma is a rare but most common vascular tumor of the inferior vena cava.

Case presentation

We present the case of an incidentally diagnosed extraluminal leiomyosarcoma of the inferior vena cava in a 62 year old patient who presented with abdominal pain following blunt trauma. Ultrasonography showed a lobulated hypoechoic lesion in the upper abdomen. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a circumscribed lobulated near homogeneously enhancing retroperitoneal lesion in anterior relation to the infrarenal inferior vena cava, right paramedian in location with imperceptible vena caval lumen at the site of maximum contact. In positron emission tomography (PET) CT the lesion showed mild fluorodeoxyglucose (FDG) uptake with no distant metastases. CT guided biopsy with immunohistochemical analysis showed leiomyosarcoma. Patient underwent surgical resection with inferior vena cava reconstruction.

Conclusions

Leiomyosarcoma of the inferior vena cava is a rare tumor of vascular origin. Imaging plays an imperative role in the diagnosis and preoperative evaluation. This article also provides a comprehensive literature review of the radiological features of inferior vena caval leiomyosarcoma that would aid in optimal preoperative characterization and evaluation.

Surgical management strategy for leiomyosarcoma of Zone I-II inferior vena cava: A case series

OBJECTIVES

Leiomyosarcoma of inferior vena cava (IVC) is a rare clinical entity with severe vascular involvement. Surgical management of leiomyosarcoma is still challenging.

METHODS

This a retrospective study of consecutive patients referred to our hospital from January 2017 to June 2019. Depending on the anatomical site of affected IVC, leiomyosarcomas were categorized into zone I-II. The clinical data including baseline information, surgical parameters, peri-operative management, short- and mid-term outcomes were observed.

RESULTS

Four patients with leiomyosarcoma of zone I-III underwent radical resection without intraoperative mortality. Prosthetic grafts were interpositioned in all patients to instruct vena cava. Renal vein reconstruction was perfumed in two patients due to involvement to renal veins. Median blood loss was 450 mL (200-600 mL), median operative time was 215 minutes (150-240 minutes). No Clavien-Dindo IIIa or higher complication was observed. No organ dysfunction and recurrence were observed with median follow-up of 25.5 months.

CONCLUSIONS

Curative resection of zone I-II leiomyosarcoma is associated with longer survival in selected cases, en-bloc resection with complex vascular reconstruction could be considered.

Leiomyosarcoma of inferior vena cava (IVC): do we really need to reconstruct IVC post resection? Single institution experience

BACKGROUND

Inferior vena cava (IVC) leiomyosarcomas (LMS) are a rare group of retroperitoneal tumors. R0 surgical resection is the only curative modality of treatment. IVC resection for retroperitoneal sarcoma is a complex surgery with no definitive guidelines for reconstruction.

METHODS

Retrospective review of all patients who underwent surgical resection of primary leiomyosarcoma of the IVC requiring resection from 2010 to 2020 at our tertiary care center was performed.

RESULTS

Among 24 patients who required IVC resection for LMS, only 7 (29%) required reconstruction of IVC. According to Clavien-Dindo classification, there was one grade 3 or more morbidity and 1 post-operative mortality. Seventeen patients underwent R0 resection whereas 7 patients had R1 resection on final histopathology. At a median follow-up of 25 months (range 8-91 months), the median OS was 40 months with median DFS of 28 months. Two patients presented with local recurrence while 13 patients developed systemic recurrence on follow-up.

CONCLUSION

Careful preoperative multidisciplinary planning can make IVC resection without reconstruction feasible with acceptable perioperative morbidity, mortality, and oncological outcomes for IVC LMS.

Surgical and reconstructive outcomes in primary venous leiomyosarcoma

OBJECTIVES

Primary venous leimyosarcomas (PVL) are rare and pose challenges in surgical management. This study evaluates the clinical outcomes and identifies predictors of survival in our surgical series of PVL.

METHODS

A retrospective review was performed of patients who had resection of PVL at three centers between 1990-2018. Patient demographics, comorbidities, intraoperative data, survival, and graft related outcomes were recorded. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression.

RESULTS

Seventy patients with a diagnosis of PVL were identified between 1990 and 2018. Fifty-four patients (77%) had PVL of the IVC and 16 (23%) had peripheral PVL. Mean follow up for the series was 55.0 months (range 1-217 months). Fifty one patients (96%) with IVC PVL needed caval reconstruction and 3 (4%) had resection only. There were no deaths within thirty days of surgery. Five patients (9%) required early re-intervention including one (2%) IVC stent. Sixteen peripheral PVL were identified. Eight patients (50%) had venous reconstructions performed and 8 (50%) had the vein resected without reconstruction. There were no deaths within thirty days. Five year survival was 57.5% for IVC PVL and 70.0% for peripheral PVL . Kaplan-Meier survival analysis for IVC and peripheral PVL revealed no difference in overall survival (p = 0.624) at 5 years.

CONCLUSIONS

PVL is a rare and aggressive disease even with surgical resection. We found no difference in survival between IVC and peripheral lesions suggesting aggressive management is warranted for PVL of any origin. Management of PVL requires a multidisciplinary approach to provide patients with the best long term outcomes.

Ex Vivo Liver Resection and Autotransplantation as Surgical Option for Zone II-III Leiomyosarcoma of IVC: A Case Report and Literature Review

We report the first documented case of leiomyosarcoma at zone II-III of inferior vena cava with thrombi in three hepatic veins undergoing ex vivo liver resection and autotransplantation (ELRA) and hepatic veins thrombectomy. A 33-year-old female patient presented with abdominal distention and lower extremities edema. Abdominal wall varicosis and shifting dullness were positive on physical examination. Her liver function was classified as Child-Pugh B and a solid tumor at retro-hepatic vena cava extending to right atrium with thrombi in three hepatic veins were confirmed. The diagnosis of leiomyosarcoma with Budd-Chiari syndrome was highly suspected with preoperative ultrasound, echocardiogram, CT scan, and three-dimensional reconstruction. A zone II-III leiomyosarcoma of IVC origin was confirmed at surgery and ex vivo liver resection and autotransplantation, and hepatic vein thrombectomy with atrial reconstruction were performed under cardiopulmonary bypass (CPB). Operative time, anhepatic time, and CPB time were 12 h, 128 min, and 84 min, respectively. The patients experienced post-operative liver dysfunction and was cured with conservative therapy. Hepatic recurrence two years after surgery was managed with radiofrequency. The patient was alive with liver metastasis three years after surgery. Despite being regarded as an extremely aggressive procedure, ELRA could be considered in the treatment of advanced leiomyosarcoma with Budd-Chiari syndrome and hepatic vein thrombi.

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.

Chemoradiotherapy for Inoperable Carotid Body Leiomyosarcoma: A Case Report and Review of Literature

Vascular leiomyosarcoma is an extremely rare tumor and is associated with poor prognosis among leiomyosarcoma. Surgical resection remains the main treatment option. But outcome of definitive treatment with chemoradiotherapy in inoperable patients is not clear. Here, we report treatment and outcome of definitive chemoradiotherapy in a case of vascular leiomyosarcoma. A 64-year-old man with the initial presentation of pulsatile right neck mass was diagnosed with right carotid body leiomyosarcoma. He refused surgical intervention due to risk of carotid body injury and ischemic stroke. Successful tumor control was achieved with carboplatin-based concurrent chemoradiotherapy. Investigational liquid biopsy for circulating sarcoma cells was also performed to analyze drug sensitivity profile of this rare tumor. One year after treatment, the disease remained well controlled and there was no evidence of baroreflex failure or treatment-related late toxicities. To our best knowledge, this is the first case report of right carotid body leiomyosarcoma controlled with definitive concurrent chemoradiotherapy. The approach of personalized multi-modality treatment will be a focus of our future investigation.

Ex Vivo Resection and Autotransplantation for Conventionally Unresectable Tumors - An 11-year Single Center Experience

BACKGROUND AND AIMS

Ex vivo surgery may provide a chance at R0 resection for conventionally unresectable tumors. However, long-term outcomes have not been well documented. In this study, we analyze our 11-year outcomes to define its role.

STUDY DESIGN

We retrospectively analyzed 46 consecutive patients who underwent ex vivo surgery at our institution 2008-2019.

RESULTS

The types of tumors were: carcinoma (n = 20), sarcoma (n = 20) and benign to low grade tumor (n = 6). The type of ex vivo surgery was chosen based on tumor location and vascular involvement. The most commonly performed procedure was ex vivo hepatectomy (n = 18), followed by ex vivo resection and intestinal autotransplantation (n = 12), ex vivo Whipple procedure and liver autotransplantation (n = 8) and multivisceral ex vivo procedure (n = 7). Twenty-three patients (50%) are currently alive with median follow-up of 4.0-years (11 months-11.8 years). The overall survival was 70%/59%/52%, at 1-/3-/5-years, respectively. Patient survival for benign to low grade tumors, sarcoma, and carcinoma was 100%/100%/100%, 65%/60%/50%, and 65%/45%/40%, at 1-/3-/5-years, respectively. Ninety-one percent patients had R0 resection, and 57% had no recurrence to date with median follow-up of 3.1-years. Two patients (4.3%) died within 30 days due to sepsis and gastroduodenal artety (GDA) stump blowout. Two additional patients died between 30 and 90 days due to sepsis. Perioperative mortality in the last 23 consecutive cases was limited to 1 patient who died of sepsis between 30 and 90 days.

CONCLUSIONS

For a selected group of patients with conventionally unresectable tumors, ex vivo surgery can offer effective surgical removal with a reasonably low perioperative mortality at experienced centers.

A Case of a Huge Inferior Vena Cava Leiomyosarcoma: Precise Preoperative Evaluation with Gadobutrol-Enhanced MRI

Background

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumour with poor prognosis. Surgical resection is the first line of treatment to achieve the best possible outcome. However, precise preoperative evaluation is essential to guide therapeutic decisions. Here, the preoperative evaluation potential of gadobutrol-enhanced magnetic resonance imaging (MRI) was assessed in the management of a 42-year-old patient with a large IVC mass.

Methods

The patient first underwent enhanced computed tomography (CT), but the relationship between the left renal vein and the mass in the dilated IVC was ambiguous, and it remained unclear whether the right hepatic vein was invaded by the lesion. To make a precise assessment of the tumour, the patient subsequently underwent high-resolution MRI angiography examination combined with high-concentration contrast medium gadobutrol.

Results

MRI demonstrated the integrity of the right hepatic vein and the left renal vein. Following a multidisciplinary consultation, a complicated surgery including complete resection of the mass, artificial vessel replacement of IVC, total hepatectomy, and bilateral nephrectomy with liver and kidney auto-transplantation was performed successfully. The surgical plan formulated after reviewing the MRI preoperatively was adhered to the course of the surgery. Postoperative CT re-examination showed that the blood flow of the artificial blood vessel and the right hepatic vein was unobstructed. Histopathological examination confirmed the tumour to be a leiomyosarcoma.

Conclusion

Preoperative imaging diagnosis and assessment have important implications for the surgical planning of IVC leiomyosarcoma. High-resolution MRI angiography examination with high concentration contrast medium gadobutrol may be of particular benefit in IVC tumours.

Primary iliocaval leiomyosarcomas: The path beyond surgery

INTRODUCTION

Iliocaval leiomyosarcoma (ICLM) is a rare and aggressive form of sarcoma within the retroperitoneum. Surgery is the mainstay of treatment, with no consensus on the benefit of chemoradiotherapy in the neo/adjuvant setting. This study aims to describe the natural history of a chemotherapy-naïve ICLM treated in a tertiary cancer centre and to explore potential directions to improve oncological outcome.

MATERIALS AND METHODS

A prospective database was used to identify patient demographics, clinicopathological variables and oncological outcomes in 30 patients who underwent surgical resection in our institution for primary non-metastatic ICLM between 2003 and 2018.

RESULTS

There was no 90-day mortality. With a median follow-up time of 70.0 months (95% CI 52.6-87.4), 5/30 patients (16.7%) developed local recurrence while 11/30 (36.7%) developed distant metastatic disease. 1 patient (3.3%) developed both local and distant recurrence. Median overall survival of our cohort was 41.0 months (95% CI 33.6-48.4) and 5-year overall survival rate was 32.1%. Multivariate survival analysis using the Cox proportional hazard model identified tumour grade and blood loss of more than 600 mL as key prognostic factors in our model.

CONCLUSION

Management of ICLM should be centralised in high-volume sarcoma centres with expertise in the management of retroperitoneal sarcomas. Integration of tumour biology with a concerted effort to conduct conclusive multi-centre phase III in histological and molecularly defined sarcoma subgroups is necessary to improve patient outcome. We eagerly await the results of STRASS 2 study to gain more insights to the efficacy of neoadjuvant chemotherapy on patient prognosis.

Caval Reconstruction with Undersized Ringed Graft after Resection of Inferior Vena Cava Leiomyosarcoma

BACKGROUND

The en bloc resection of inferior vena cava (IVC) leiomyosarcoma often necessitates IVC reconstruction. The objective of this study is to examine outcomes after IVC reconstruction and determine optimal graft sizing.

METHODS

A retrospective review was conducted of all IVC reconstructions after IVC leiomyosarcoma resection at a single institution. Cross-sectional dimensions at the IVC resection margins were measured on preoperative imaging. The tumor location was based on the most superiorly involved region of the IVC and was classified as infrarenal, between hepatic and renal veins, or superior to the hepatic veins. Perioperative details and long-term outcomes including graft sizing, graft patency, morbidity, and mortality were recorded.

RESULTS

Between 2007 and 2017, 12 patients (6 females, mean age: 64.5 years, age range: 46-80 years) underwent IVC leiomyosarcoma resection and reconstruction. All reconstructions were performed with ringed polytetrafluoroethylene (PTFE); graft sizes ranged from 12 mm to 16 mm. The tumor location was exclusively infrarenal in seven patients, between the renal and hepatic veins in two patients, and involved multiple segments in three patients. Larger graft sizes were utilized in reconstructing more superior segments of the IVC. Grafts were typically undersized and based on the diameter of the superior resection margin with 12 mm grafts approximately correlating to a 20 mm diameter, 14 mm to 25 mm, and 16 mm to 30 mm. The average undersizing ratio was 0.6. At a mean follow-up time of 43 ± 27 months, radiographic graft patency was 92%, overall survival was 83%, and disease-free survival was 25%.

CONCLUSIONS

After en bloc resection of IVC leiomyosarcoma, caval reconstruction with an undersized ringed PTFE has acceptable patency. Grafts sizes should be based on the IVC diameter superior to the tumor and undersizing by approximately 40% appears to be associated with acceptable patency rates. Further multiinstitutional studies should be performed to best determine the optimal treatment of this rarely encountered tumor.

[Leiomyosarcoma of the splenic vein]

Vascular leiomyosarcoma (LMS) is an extremely rare disease. Venous lesion is approximately 5 times more common than arterial. LMS is usually found in retroperitoneal veins and in inferior vena cava. Lesion of the splenic vein is extremely rare. A 52-year-old woman with recurrent abdominal pain is reported in the article. Abdominal contrast-enhanced CT revealed a 6 cm tumor of the pancreatic tail. The patient underwent laparoscopic distal pancreatectomy with splenectomy en bloc. Histological and immunohistochemical studies revealed LMS originating from the smooth muscles of the splenic vein. Surgery was followed by adjuvant chemotherapy. There was no local recurrence in 1 year after surgery. In this article, we analyze the available information on leiomyosarcoma of the splenic vein.

Simultaneous Surgery for Inferior Vena Cava Leiomyosarcoma with Multiple Hepatic Metastases: A Justified Challenge

Patient: Male, 42

Final Diagnosis: IVC leiomyosarcoma with multiple liver metastases

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: IVC resection with hepatectomy

Specialty: Surgery

Liver transplantation for inferior vena cava leiomyosarcoma: from a Maslow's hammer to the Occam's razor

Leiomyosarcoma (LMS) of primary vascular origin is a rare entity with only potentially curative option being complete surgical resection; despite which the prognosis remains dismal. Tumour recurrence is very common, and the benefits of adjuvant therapy are undefined. A 39-year-old woman presented with 6 months' history of abdominal pain, abdominal distension and pedal oedema. On evaluation, she was diagnosed to have chronic Budd-Chiari syndrome (BCS) secondary to a tumour arising from the inferior vena cava (IVC) on evaluation. Her liver decompensation included jaundice, gastrointestinal bleed and ascites. Following a detailed multidisciplinary team discussion, she underwent complete excision of the tumour along with a segment of the IVC with living donor liver transplantation. She remains disease-free 24 months following surgery. This is the first reported case of liver transplantation for IVC LMS causing chronic BCS.

Resection of the Inferior Vena Cava for Retroperitoneal Sarcoma: Six Cases and a Review of Literature

Resection of the inferior vena cava (IVC) for malignancy is a technically demanding procedure. We present a series of six cases of resection of the IVC for retroperitoneal sarcomas, four of which were primary caval tumors. We outline the technical difficulties faced in these complex procedures and discuss the oncological outcomes of these rare tumors. We performed a retrospective review of six patients operated for retroperitoneal masses involving the inferior vena cava between April 2015 and July 2016 at our tertiary care institute. Six patients underwent resection of the IVC, three of which required a multivisceral resection. An artificial prosthesis was used to reconstruct the IVC in three patients, whereas two patients underwent primary repair of the vein wall. One patient did not require any reconstruction. Margins were microscopically positive in two out of six patients. All patients received radiotherapy, either in the neo-adjuvant or adjuvant setting. Two patients developed local recurrences with a median follow-up of 24.5 months. Resection of the IVC for extirpation of retroperitoneal sarcomas is a technically complex and difficult procedure. The availability of a multidisciplinary team of surgeons and state-of-the-art intensive care support is essential for good outcomes.

Resection of retroperitoneal sarcoma en-bloc with inferior vena cava: 20 year outcomes of a single institution

BACKGROUND

Margin negative resection offers the best chance of long-term survival in retroperitoneal sarcoma (RPS). En-bloc resection of adjacent structures, including the inferior vena cava (IVC), is often required to achieve negative margins. We review our 20-year experience of en-bloc IVC and RPS resection.

METHODS

Retrospective review of patients with RPS resection involving the IVC were matched 1:3 by age and histology to RPS without IVC resection. Prognostic factors for overall survival (OS) and disease free survival (DFS) were assessed.

RESULTS

Thirty-two patients underwent RPS resection en-bloc with IVC. They were matched with 96 cases of RPS without IVC resection. Median OS of 59 months and DFS 18 months in IVC resection group was comparable to RPS resection without vascular involvement: median OS 65 months, DFS 18 months (P = 0.519, P = 0.604). On multivariate analyses, R2 margin (OS: HR = 6.52 [95%CI: 1.18-36.09], P = 0.032) was associated with inferior OS. R2 margin and increased number of organs resected (DFS: HR = 5.07, [1.15-22.27], P = 0.031, HR = 1.28 [1.01-1.62], P = 0.014) were associated with inferior DFS. Reconstructions included graft (n = 19, 59%), patch (n = 4, 13%), primary repair (n = 6, 19%), and ligation (n = 4, 13%).

CONCLUSIONS

RPS resection en-bloc with IVC can achieve equivalent rates of DFS and OS to patients without vascular involvement.

Leiomyosarcoma of the inferior vena cava: Survival rate following radical resection

Leiomyosarcoma (LMS) of inferior vena cava (IVC) is a rare neoplasm affecting approximately 1/100,000 people. The prognosis is poor and potential curative intent occurs through challenging operations, such as vena cava resection, occasionally multivisceral when required, and vascular reconstruction. There are few retrospective series regarding this retroperitoneal neoplasm, and the aim of the present study was to discuss the experience at the São Paulo Cancer Institute and Clinics Hospital of University of São Paulo Medical School, São Paulo, Brazil. The current study is a retrospective review of 7 patients treated in the two tertiary hospitals between 2005 and 2013. Oncological and operative aspects were discussed, primarily regarding surgical aspects highlighting en bloc resection, vascular reconstruction, and the overall survival and recurrence rates. All the patients were treated with radical intent, 4 of whom underwent multivisceral resection, with the kidney being the most resected organ. The location of the IVC tumor was described using Kulaylat's description and the median tumor size was 10 cm. Vascular reconstruction was necessary in 4 patients. The overall survival rate at 3 and 5 years was 100, and 25%, respectively. The disease-free survival rate at 3 and 5 years was 57 and 20%, respectively. In conclusion, IVC LMS is a rare and severe retroperitoneal neoplasm, with multivisceral resections remaining a surgical challenge. The treatment requires numerous experienced surgeons and the impact of microscopic free margins remains unclear. Vascular reconstruction depends on several aspects regarding primarily the topography of the tumor.

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.

Sarcoma Resection With and Without Vascular Reconstruction: A Matched Case-control Study

OBJECTIVE

To examine the impact of major vascular resection on sarcoma resection outcomes.

SUMMARY BACKGROUND DATA

En bloc resection and reconstruction of involved vessels is being increasingly performed during sarcoma surgery; however, the perioperative and oncologic outcomes of this strategy are not well described.

METHODS

Patients undergoing sarcoma resection with (VASC) and without (NO-VASC) vascular reconstruction were 1:2 matched on anatomic site, histology, grade, size, synchronous metastasis, and primary (vs. repeat) resection. R2 resections were excluded. Endpoints included perioperative morbidity, mortality, local recurrence, and survival.

RESULTS

From 2000 to 2014, 50 sarcoma patients underwent VASC resection. These were matched with 100 NO-VASC patients having similar clinicopathologic characteristics. The rates of any complication (74% vs. 44%, P = 0.002), grade 3 or higher complication (38% vs. 18%, P = 0.024), and transfusion (66% vs. 33%, P < 0.001) were all more common in the VASC group. Thirty-day (2% vs. 0%, P = 0.30) or 90-day mortality (6% vs. 2%, P = 0.24) were not significantly higher. Local recurrence (5-year, 51% vs. 54%, P = 0.11) and overall survival after resection (5-year, 59% vs. 53%, P = 0.67) were similar between the 2 groups. Within the VASC group, overall survival was not affected by the type of vessel involved (artery vs. vein) or the presence of histology-proven vessel wall invasion.

CONCLUSIONS

Vascular resection and reconstruction during sarcoma resection significantly increases perioperative morbidity and requires meticulous preoperative multidisciplinary planning. However, the oncologic outcome appears equivalent to cases without major vascular involvement. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma resection.

"Caval Reconstruction for Lower-Extremity Sarcoma Metastasis Trapped within Inferior Vena Cava Filter"

This report describes the management of a hematogenously spread metastasis from a lower-extremity sarcoma found trapped within an inferior vena cava (IVC) filter. Although endovascular techniques for treating thrombosed IVC filters are successful in a majority of cases, the malignant nature of this lesion required a novel approach. In this unique case, the segment of infrarenal IVC with the thrombosed filter was resected and reconstruction performed with an interposition prosthetic graft. There were no early or late complications, and the patient remains clinically free of recurrence at 24-month follow-up.

Inferior vena cava leiomyosarcoma: preoperative diagnosis and surgical management

Inferior vena cava (IVC) leiomyosarcoma is a rare malignant neoplasm more commonly seen in women in the fifth to sixth decade of life. Complete resection of the tumor with negative margins is the only therapeutical option that has demonstrated a survival benefit. This report presents a case of a 67-year-old woman affected by a lower segment IVC leiomyosarcoma incidentally detected during a chronic abdominal pain study. The patient was treated with tumorectomy, resection and ligation of the infrarenal IVC without signs or recurrence on a 12-month follow-up.

Challenging diagnostic and therapeutic modalities for leiomyosarcoma of inferior vena cava

Leiomyosarcoma of the inferior vena cava (IVCL) is a rare malignant tumour originating from the smooth muscle cells of the media with intra- or extra-luminal growth. The type of the lesion is further divided into three levels in relation to hepatic and renal veins respectively. The aim of this review was to evaluate the results of surgical treatment of IVCL with special reference to the extent of its histological spread and to analyse the recent literature in order to provide an update on the current concepts of diagnostic and therapeutic management of this entity. IVCL's patients may present with non-specific complaints such as dyspnoea, malaise, weight loss, nausea, vomiting, fever and abdominal pain. Haematogenous metastasis is frequent. At a later stage, IVCL may also spread through lymphatic. Multiple diagnostic imaging techniques have been proposed for accurate preoperative diagnosis, including Doppler ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI), individually or in combination with cavography echocardiography or CT-guided biopsy. Despite recent research on the therapeutic strategies against IVCL, surgical resection appears the only potentially curative approach. Unfortunately, a mere minority of patients is eligible to undergo surgical intervention. In addition, surgical removal of IVCL does not necessarily guarantee patient's long-term survival. Alternative therapies, such as radio- and chemo-therapy often proved insufficient. Debate continues regarding the optimal management of the IVC after tumour resection, with primary repair, ligation and IVC reconstruction all have been utilized with varying success.

Resection of primary leiomyosarcoma of the inferior vena cava (IVC) with reconstruction: a case series and review of the literature

BACKGROUND

Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor which presents a unique surgical challenge. We present a series of six cases of leiomyosarcoma resection performed with IVC reconstruction.

METHODS

Retrospective chart review was performed for patients undergoing initial operative resection of primary leiomyosarcoma with IVC reconstruction, at a tertiary care center.

RESULTS

Between 2005-2013, six patients underwent resection with reconstruction. Half were female, and the mean age at presentation was 57 ± 15.4 years. Three patients required en bloc resection with adjacent organs. Three patients were resected on venovenous bypass, and one on cardiopulmonary bypass. Three underwent IVC patch repair (bovine pericardium, n = 2; saphenous vein, n = 1), and three had IVC reconstruction with graft (Dacron, n = 1; PTFE, n = 1; aortic homograft, n = 1). All achieved grossly negative margins. Median disease-free survival was 34 months (IQR 7-52 months), and median disease-specific survival was 51 months (IQR 20-108). Five year disease-free and disease-specific survival rates were 30% and 66.7%, respectively.

CONCLUSIONS

Leiomyosarcomas of the IVC present a technical challenge to the surgeon. Careful preoperative workup and a collaborative team consisting of experienced cardiac and vascular surgeons and surgical oncologists can allow for a safe and successful operation despite extensive tumor involvement.

Diagnosis, prognosis, and management of leiomyosarcoma: recognition of anatomic variants

PURPOSE OF REVIEW

The purpose of this review is to present the most recent advances in the diagnosis of the more common leiomyosarcoma (LMS) anatomic variants, potentially useful prognostic markers that have recently been identified and the systemic approaches currently used or under evaluation to improve the outcome of patients with this disease.

RECENT FINDINGS

Over the last few years emphasis has been placed on incorporating effective imaging tools and using pathological biomarkers in the diagnostic workup of LMS. Moreover, efforts are being made to identify meaningful prognostic and predictive parameters that will aid the development of effective novel therapeutics. The number of systemic therapies available to treat LMS has increased over the last decade, but the selection of systemic therapy is not based on the anatomic origin of LMS.

SUMMARY

Currently, the only curative option in LMS is surgery and despite progress in systemic therapy the outcome of patients with advanced/metastatic disease remains poor. Better understanding of the underlying biology of the LMS variants, improved diagnostics and more effective, less toxic therapeutic agents are required.

Leiomyosarcoma of the splenic vein

Leiomyosarcomas arising from the wall of blood vessels are rare and aggressive neoplasm. We report a case of a previously healthy 66-year-old woman who presented with intermittent abdominal pain, progressive constipation, and weight loss. Abdominal computed tomography showed a 12 cm solid heterogeneous tumor in the tail of the pancreas. The patient subsequently underwent surgical resection of the pancreatic mass. Surprisingly, histological and immunohistochemical analyses revealed leiomyosarcoma arising from the smooth muscle of the splenic vein. After surgery, she received adjuvant chemotherapy. One year later, there was no evidence of local recurrence. In this paper, we discuss the available information about leiomyosarcomas of splenic vein and its management.

Leiomyosarcoma of the inferior vena cava incidentally detected

This report presents the case of a 78-year-old man affected by retroperitoneal tumor arising from the lower segment of the inferior vena cava. The patient underwent excision of the tumor and resection of the vena cava. Postoperative histopathologic examination revealed the diagnosis of leiomyosarcoma of the inferior vena cava, a rare tumor of mesenchymal origin.

[Mid-term, relatively tumor-stable outcome after an initially successful interdisciplinary surgical intervention with locally achieved R0 resection status including a multimodal therapeutic concept of a metastasized leiomyosarcoma of the inferior vena cava]

Progredient tumor-growth does not mean necessarily nihilism since (because of the latest multimodal therapeutic options) it might be possible to convert the malignant disease into a chronic stage depending on tumor entity, specific tumor-associated findings and expertise of the interdisciplinary oncological/oncosurgical team to utilize available and potential therapeutic measures. The aim of this report on an unusual case (with its patient-associated, therapeutic and prognostic aspects) of a leiomyosarcoma of the inferior vena cava with advanced tumor growth (characterized initially by pulmonary and hepatic, later on by additional vertebral metastases) is to illustrate its changeful clinical course after and during multimodal treatment episodes comprising surgical (abdomino-/vascular-/cardio- and neurosurgical-locally, R0 resection status), radiological and chemotherapeutic measures. A relatively stable disease over a specific time period of 5 years and 6 months was achieved. The 54-year old female patient with metastasized leiomyosarcoma of the inferior vena cava underwent local tumor resection en bloc with inferior vena cava segmental resection (following vascular surgical interposition of a prosthesis) and hemihepatectomy as well as resection of hepatic segment I. After recovery, a multistep and -modal treatment was initiated comprising of various protocols of systemic chemotherapy, thermoablation of recurrent hepatic metastases, various brachytherapy procedures (for hepatic and pulmonary metastases) and resection of a cerebral metastasis by a neurosurgeon including subsequent radiation.

CONCLUSIONS

The patient demonstrates impressively that even in case of advanced tumor stage with initial, novel and recurrent metastases, a relatively stable disease over an intermediate time period (of more than 5 years) with an acceptable quality of life was achieved despite several complications.

Surgical management of retroperitoneal leiomyosarcoma arising from the inferior vena cava

Retroperitoneal leiomyosarcomas are uncommon tumors, with approximately 300 documented cases in the literature. Management necessitates complete surgical resection in order to offer patients a chance at long-term cure. Resection often presents a challenge as these tumors are often large, involving adjacent structures, and may require reconstruction of the inferior vena cava (IVC). In this article, we will present background information on retroperitoneal leiomyosarcomas and the technical aspects of surgical resection and vascular reconstructive options of the IVC.

Inferior vena cava resection and reconstruction for retroperitoneal tumor excision

OBJECTIVE

This study reviews the results of en bloc resection of the inferior vena cava (IVC) for malignant tumor excision and reconstruction.

METHODS

A prospective database was reviewed. IVC resection was categorized as suprarenal, perirenal, infrarenal, or extensive (>one segment resected). Repairs were divided into primary, patch, or circumferential. Tumor type, perioperative morbidity, mortality, and graft patency were recorded.

RESULTS

Between 1990 and 2011, 47 patients (21 women; mean age, 56; range, 35-89 years) underwent IVC resection for en bloc tumor excision. Sarcomas were most common (36 [77%]: 30 primary IVC). Eleven patients had primary IVC repair, nine patch repair (two autogenous), and 27 had circumferential replacement with a polytetrafluoroethylene ringed graft. Extensive IVC reconstruction in 18 patients included the entire IVC, with renal (RV) and hepatic vein reimplantation in eight; suprarenal and perirenal in six (seven RVs reimplanted); and infrarenal and perirenal in four (four RVs reimplanted). Nine single-segment IVC replacements were infrarenal. Morbidity was 10.6%: one each with bowel obstruction, chyle leak, renal failure with complete recovery (left RV reimplant, right nephrectomy), reoperation for bleeding, and IVC graft thrombosis. Morbidity did not differ by type of reconstruction. There was no mortality. Follow-up ranged from 1.5 to 216 months (18 years) with a mean of 3.5 years. Computed tomography or duplex scans were available in 28 of 47 patients and in 15 of 27 patients in group 3 at a mean follow-up of 36 and 20 months, respectively. One IVC graft thrombosis was documented at 10 months after chemotherapy/sepsis. Tumor recurrence caused three graft stenoses. Cumulative 5-year patency in group 3 was 80% (imaging) and 92% (clinical). Lower extremity edema was universally avoided. Cumulative 5-year survival for the series was 45% ± 8.5%. Mean long-term survival was 5.8 ± 0.56 years (range, 4 months-17 years), with a significant difference between primary or patch (mean, 6.5 years) and circumferential or extensive repair (mean, 4.2 years; P < .005). Cumulative (47% vs 52%) and mean (3.1 vs 3.6 years; P > .12) survival was similar between patients with single-segment and extensive IVC resection and replacement.

CONCLUSIONS

IVC resection and reconstruction for en bloc tumor excision is safe, even when extensive repairs are necessary. Replacement of the IVC with prosthetic graft avoids extremity venous complications and likely contributes to quality of survival. Survival depends on tumor behavior and degree of IVC involvement, where primary and patch repair has a better prognosis than circumferential resection.