Surgery for cavoatrial extension of malignant tumors

Challenges in the diagnosis of the enigmatic primary adrenal leiomyosarcoma: two case reports and review of the literature

BACKGROUND

Primary adrenal leiomyosarcoma is a rare and aggressive mesenchymal tumor derived from the smooth muscle wall of a central adrenal vein or its tributaries; therefore, tumors tend to invade the inferior vena cava and cause thrombosis. The great majority of tumors grow rapidly, which makes the disease difficult to diagnose in its early clinical stages and needs differentiation from adrenocortical carcinomas for the selection of chemotherapy including mitotane which causes adrenal insufficiency.

CASE PRESENTATION

We presented two patients with adrenal leiomyosarcoma who were referred to our hospital with abdominal pain and harboring large adrenal tumors and inferior vena cava thrombosis. The endocrine findings, including serum catecholamine levels, were unremarkable. These two patients were considered clinically inoperable, and CT-guided core needle biopsy was performed to obtain the definitive histopathological diagnosis and determine the modes of therapy. The masses were subsequently diagnosed as primary adrenal leiomyosarcoma based on the histological features and positive immunoreactivity for SMA (smooth muscle actin), desmin, and vimentin.

CONCLUSIONS

Adrenal leiomyosarcoma derived from the smooth muscle wall of a central adrenal vein or its tributaries is rare but should be considered a differential diagnosis in the case of nonfunctioning adrenal tumors extending directly to the inferior vena cava. CT-guided biopsy is considered useful for histopathological diagnosis and clinical management of patients with inoperable advanced adrenal tumors without any hormone excess.

Pleomorphic Leiomyosarcoma of the Adrenal Gland in a Young Woman: A Case Report and Review of the Literature

Leiomyosarcoma usually arises in the uterus, abdominal and urologic viscera, and walls of large and small blood vessels. However, primary adrenal leiomyosarcoma is extremely rare with only 39 cases previously reported in English-language literature. We report a case of a 29-year-old previously healthy woman with an incidentally found right adrenal-occupying lesion. CT scan revealed a right adrenal mass measuring 3.3×3.4 cm in size. The tumor was successfully removed by laparoscopic adrenalectomy. Postoperative histopathologic examination showed spindle cells arranged in interlacing fascicles with pleomorphism and a high mitotic rate. An immunohistochemical examination showed positive staining for SMA, desmin, vimentin and H-caldesmon, and the diagnosis of a well-differentiated adrenal leiomyosarcoma was established. The patient received no other oncological treatment after surgery and currently has no evidence of residual disease or tumor recurrence according to imaging follow-up.

Anesthetic management of renal cavoatrial tumor thrombus during partial cardiopulmonary bypass

A 58-year-old male patient was scheduled for the surgical removal of a cavoatrial thrombus and renal tumors during cardiopulmonary bypass without circulatory arrest. Throughout the operation, continuous monitoring for pulmonary embolism was carried out by transesophageal echocardiography. A multidisciplinary team including anesthetists, urologists, and cardiovascular and gastrointestinal surgeons performed the operation successfully. This case report highlights the importance of anesthetic management in renal-cell carcinoma patients with a cavoatrial thrombus.

[Uneasy nephrectomies]

Kidney exeresis, which is usually a simple surgical procedure, may sometimes be uneasy due to multiple difficulties related to the size of the lesion or anatomic presentation. In this chapter, such difficulties and their related complications are considered from a pragmatic angle, in order to identify some practical solutions.

Leiomyosarcoma of the Right Atrium Masked by a Covering Thrombus: Conflicting Results of Echocardiography and Transvenous Biopsy-In Favor of Echocardiography

A 62-year-old woman was admitted for the evaluation of pedal edema and ascitis. Echocardiography revealed a right atrial (RA) mass invading the interatrial septum and extending into the inferior vena cava (IVC). Contrast enhanced computerized tomography scan excluded extravascular involvement. An organized thrombus was diagnosed by transvenous endomyocardial biopsy. The patient was treated with continuous intravenous heparin, and died soon after from hepatic failure. Postmortem histologic examination revealed a leiomyosarcoma surrounded by a thrombus involving RA, IVC, and hepatic veins. Endomyocardial biopsy played a misleading role that affected patient's management.