Role of pre-operative assessment in the surgical management of leiomyoma extended to the right heart chambers: a compendium of information from isolated reports

Intracaval Leiomyoma with Intracardiac Extension

The aim of the study is to provide a guide on how to achieve a complete resection of an intravascular leiomyoma. A 48-year-old female was referred to our institution with progressive dyspnea on exertion, lightheadedness, and previous history of total abdominal hysterectomy and bilateral salpingoophorectomy for a uterine leiomyoma echocardiography, CT and MRI of heart and abdomen/pelvis were performed and an intracaval mass with extension into the right heart and pulmonary artery was identified. After multidisciplinary review, a single stage sternotomy-laparotomy procedure on cardiopulmonary bypass (with beating heart, mild hypothermia, and no deep hypothermic circulatory arrest) ensured complete resection of a giant intravenous leiomyoma. Multidisciplinary approach, multimodality imaging, and single stage sternotomy-laparotomy procedure on cardiopulmonary by-pass (with heart beating and mild hypothermia) ensure complete resection of intravenous leiomyoma.

Intracaval Leiomyoma with Intracardiac Extension

The objective of this study was to explain step by step how to achieve a complete resection of an intravascular leiomyoma. A 48-year-old woman was referred to our institution with progressive dyspnea on exertion, lightheadedness, and previous history of total abdominal hysterectomy and bilateral salpingo-oophorectomy for a uterine leiomyoma echocardiography, computed tomography, and magnetic resonance imaging of the heart and abdomen/pelvis were performed and an intracaval mass with extension into the right heart and pulmonary artery was identified. After multidisciplinary review, a single-stage sternotomy–laparotomy procedure on cardiopulmonary bypass (with beating heart, mild hypothermia, and no deep hypothermic circulatory arrest) ensured complete resection of a giant intravenous leiomyoma (IVL). Multidisciplinary approach, multimodality imaging, and single-stage sternotomy–laparotomy procedure on cardiopulmonary bypass (with heart beating and mild hypothermia) ensure complete resection of IVL.

Abdominopelvic leiomyoma with large ascites: A case report and review of the literature

BACKGROUND

Leiomyoma of the uterus is relatively common, but uterine leiomyoma of the greater omentum is rare.

CASE SUMMARY

Here, we report the case of a 22-year-old woman who presented with a 3 mo history of progressive abdominal distension and a hypervascular abdominopelvic mass. Due to a high serum concentration of CA125, the preoperative diagnosis was unclear. During surgery, 5 L of ascites was removed. An 18.8 cm solid mass, which was pedunculated from the uterine fundus and exhibited complex adhesion to the greater omentum, was removed. The CA125 level was reduced postoperatively, and a pathologic study confirmed that the mass was a leiomyoma that originated in the uterus.

CONCLUSION

Uterine leiomyoma can share vessels with the greater omentum. This case highlights the difficulty of diagnosing pseudo-Meigs syndrome and the importance of imaging and laboratory examinations.

Surgical Strategy for Intravenous Cardiac Leiomyomatosis

Intravenous-cardiac leiomyomatosis (IVCL) is a rare, histologically benign but biologically aggressive tumour. Accurate diagnosis and appropriate treatment choices are important for prognosis. The best surgical approach remains unclear owing to limited evidence. This study aimed to assess surgical strategies for treating IVCL and to propose individualised surgical strategies. We searched PubMed, Web of Science, and the Cochrane Library to identify case reports and case series published in English over the last 10 years. Two (2) reviewers independently screened the literature according to the inclusion and exclusion criteria, and subsequently extracted data. One hundred and ten (110) cases were included. According to our analysis, IV cardiac leiomyomatosis is most common in the fifth decade, and the mean age at detection is 45.71±7.67 years. Most patients had undergone previous hysterectomy/myomectomy, or had a co-existing uterine leiomyoma when admitted. The most common clinical presentations were dyspnoea, palpitation, pelvic mass, and leg oedema. More patients benefited more from one-stage surgery. Seventy-eight per cent (78%) of cases experienced a surgical approach of thoracic and abdominal incisions. Extractions of IVCL were varied. Eighty-seven (87) patients experienced cardiopulmonary bypass and deep hypothermic circulatory arrest was performed on 64.4% of them. Total hysterectomy and bilateral oophorectomy, together with pelvic leiomyoma excision, were done in 76.0% of patients. Overall, surgical strategies for IVCL are varied; the optimal strategy required consideration of multiple factors. Complete resection is recommended for both single- and two-stage operations. Once complete resection is achieved, recurrence is rare.

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 of the Uterus: A Retrospective Single-Center Study in 14 Cases

Purpose

This study aimed to retrospectively review the diagnosis and surgical treatment of uterine intravenous leiomyomatosis (IVL).

Methods

The clinical data of 14 patients with uterine IVL admitted to our hospital between 2013 and 2018 were retrospectively analyzed, including their demographics, imaging results, surgical procedures, perioperative complications, and follow-up results.

Results

The tumors were confined to the pelvic cavity in 7 patients, 1 into the inferior vena cava, 4 into the right atrium, and 2 into the pulmonary artery (including 1 into the superior vena cava). Only one case was misdiagnosed as right atrial myxoma before the operation, which was found during the surgery and was treated by staging surgery; all the other patients underwent one-stage surgical resection. Three patients underwent complete resection of the right atrial tumor through the abdominal incision, and one patient died of heart failure in the process of resection of heart tumor without abdominal surgery. During the 6–60 months of follow-up, 4 patients developed deep venous thrombosis of the lower extremity, and 1 patient developed ovarian vein thrombosis and pulmonary embolism. After anticoagulation treatment, the symptoms disappeared. One patient refused hysterectomy and the uterine fibroids recurred 4 years after the operation.

Conclusion

Specific surgical plans for uterine IVL can be formulated according to cardiac ultrasound and computed tomography (CT). For the first type of tumor involving the right atrium, the right atrium tumor can be completely removed through the abdominal incision alone to avoid thoracotomy. The disease is at high risk of thrombosis and perioperative routine anticoagulation is required.

A Challenging Case of Intracardiac Leiomyomatosis Accompanied by Pseudo-Meigs Syndrome Originating from Uterine Leiomyoma

BACKGROUND

Pseudo-Meigs syndrome is an unusual condition involving pelvic tumors, excluding ovarian fibroma, and is associated with ascites and hydrothorax. Pseudo-Meigs syndrome originating from uterine leiomyoma is an even rarer condition. Intravenous leiomyomatosis originating from uterine tumors, which extend from the inferior vena cava to the right heart chambers, is also extremely rare.

CASE REPORT

This report presents an extremely rare case of intravenous leiomyomatosis with intracardiac extension accompanied by Pseudo-Meigs syndrome caused by uterine leiomyoma. To the best of our knowledge, this is the first reported case of two different rare conditions originating simultaneously from one common pelvic benign tumor. We could only partially resect the tumor owing to its firm adherence to the vessel wall. It is crucial to remember that a pelvic neoplasm in a woman with various manifestations, such as hydrothorax, ascites, intravascular leiomyomatosis, intracardiac mass, and even elevated CA125 levels, does not always imply malignancy. All the accompanying symptoms can be resolved by simple surgical removal of the mass.

CONCLUSIONS

Accurate preoperative assessment and detailed preparation for the surgery according to the nature of the tumor may yield successful results.

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.

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

Intravascular Leiomyomatosis with Intracardiac Extension

Intravenous leiomyomatosis (IVL) is a rare nonmalignant tumor defined as a benign smooth muscle cell neoplasia in the veins. Patients with IVL may present with symptoms of a uterine leiomyoma such as pelvic pain and vaginal bleeding, or cardiorespiratory symptoms, including dyspnea and leg swelling. We report the case of a 65-year-old otherwise healthy Caucasian woman. Past medical history consisted of hysterectomy and left salpingo-oophorectomy 15 years before for multiple uterine fibromyomas associated with leiomyoma of vascular origin. A thoracoabdominal computed tomography (CT) scan confirmed the presence of a mass, measuring 76 × 37 × 44 mm, arising from the inferior vena cava (IVC) at the level of the left renal vein extending all the way into the right atrium and right ventricle. At laparotomy, a tumoral mass was excised from the left broad ligament up to the left renal vein and from the IVC up to its retrohepatic tract. Sternotomy was performed and cardiopulmonary bypass (CPB) was established among ascending aorta, upper vena cava, and right common femoral vein. After atriotomy, a voluminous and firm mass was excised from the right atrium, down to the level of the IVC. CPB was maintained for 80 min. Perioperative transfusion included two plasma and two red blood cells units. No adjuvant treatment was administered. Follow-up with annual CT scans was performed. Patient had no signs of recurrence after 3 years.

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.

Intravenous leiomyomatosis with right heart involvement-a report of 4 cases and literature review

Intravenous leiomyomatosis (IVL) is a rare benign neoplasm which originates from the smooth muscle cells and is usually confined to the pelvic venous system. Rarely, intracaval and intracardiac extension has been described. Death can occur as a result of intracardiac involvement. We reported 4 cases of IVL with right heart involvement (intracardiac leiomyomatosis, ICL). Three of them suffered recurrent sudden syncope, and the other one was totally asymptomatic. All of them were successfully treated through one-stage operation under extracorporeal circulation.

Intravenous leiomyomatosis with right heart involvement-a report of 4 cases and literature review

Intravenous leiomyomatosis (IVL) is a rare benign neoplasm which originates from the smooth muscle cells and is usually confined to the pelvic venous system. Rarely, intracaval and intracardiac extension has been described. Death can occur as a result of intracardiac involvement. We reported 4 cases of IVL with right heart involvement (intracardiac leiomyomatosis, ICL). Three of them suffered recurrent sudden syncope, and the other one was totally asymptomatic. All of them were successfully treated through one-stage operation under extracorporeal circulation.

Cardiopulmonary bypass as an adjunct for the noncardiac surgeon

The use of cardiopulmonary bypass (CPB) in noncardiac surgical settings has been increasingly developed and has greatly benefited noncardiac surgeon. A few years after the advent of CPB as well as profound hypothermic circulatory arrest in the early years, it was employed by neurosurgeons in cerebrovascular surgery and by general thoracic surgeons in carinal tumor resection. Indications for CPB were extended and modified year after year. It has facilitated not only the surgical management by surgeons of lesions that cannot be managed safely and effectively by conventional techniques, or conventional techniques carry significant risks to the patient, but also the preservation of the viability of multiple organ procurement, the practice of isolated limb perfusion for the treatment of malignancies of the extremities, and emergent cardiopulmonary resuscitation. Owing to the complications arising from CPB and profound hypothermic circulatory arrest, such as postoperative bleeding, coagulopathy, and neurologic deficits, efforts have been made to avoid these common hazards. Thus, innovative techniques including extracorporeal membrane oxygenation, percutaneous cardiopulmonary support, venovenous bypass, normothermic CPB, and minimally invasive approaches have emerged and played an important role as alternatives of standard CPB in decreasing morbidity and mortality and improving survival.

[Intravascular leiomyomatosis: an original tumor]

An unusual uterus benign tumor, intravascular leiomyomatosis is also a differential diagnosis of uterine fibromas. It is most likely to be diagnosed post operatively and must be treated in an adequate way to avoid a recidive.

Intracardiac leiomyomatosis: iliac vein to right-ventricular outflow tract

BACKGROUND

A 58-year-old female with a history of hypertension and asthma presented to an internist for a routine physical examination. A grade II/VI systolic ejection murmur and electrocardiogram abnormalities were noted. She was referred to a cardiologist for further assessment.

INVESTIGATIONS

Transthoracic echocardiography, transesophageal echocardiography, contrast-enhanced CT and MRI, exploratory laparotomy.

DIAGNOSIS

Intracardiac leiomyomatosis.

MANAGEMENT

Surgical excision.

Intravenous Uterine Leiomyosarcomatosis With Intracardial Extension

Uterine leiomyosarcoma is a rare malignant tumor of smooth muscle origin. We describe the case of a 64-year-old female with intravenous uterine leiomyosarcomatosis with the extension of the tumor mass into the inferior vena cava and right atrium. As initial tissue diagnosis of the tumor obtained from the uterine and right atrial masses suggested intravenous leiomyomatosis, surgical resection was carried out using a one-stage procedure via a laparotomy and median sternotomy with cardiopulmonary bypass and circulatory arrest. Subsequent histology revealed uterine leiomyosarcoma with an intravenous spread, which to our knowledge is only the second case that has been described.

Successful one-stage surgical removal of intravenous uterine leiomyomatosis with right heart extension

We report a 49-year-old woman with intravenous and intracardiac extension of uterine leiomyomatosis. After subtotal hysterectomy and salpingo-oophorectomy, an intravenous and intracardiac tumor was removed under normothermic cardiopulmonary bypass without cardiac arrest. Postoperatively, occlusion of the artery supplying the remaining uterine cervical stump was performed by the catheter coiling technique. More than 2 years after surgery, the patient is well without recurrence.