Pulmonary artery extension of uterine leiomyoma

When Heart Team Really Counts: Radical Excision of Intracardiac Leiomyomatosis

Intravenous leiomyomatosis (IVL) are rare and complex tumors, characterized by high rates of recurrences after surgical removal and the capability of multi-organ involvement including pulmonary embolization. Regarding the surgical treatment of Intracardiac Leiomiomatosis (ICL), only few articles have been published and no controlled data are available. A combined approach that involves a Team of Cardiologists, Heart Surgeons, Vascular surgeons and Radiologists seems to be successful in treating ICL.

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.

Clinical analysis of uterine intravenous leiomyomatosis: A retrospective study of 260 cases

Methods

We collected the clinical data of 260 patients admitted to the hospital from April 2003 to September 2019 with pathologically confirmed intravenous leiomyomatosis (IVL) and followed up with these patients regularly. Univariate and multivariate logistic regression analyses were carried out on the relevant recurrence factors.

Results

A total of 166 patients were regularly followed up, the median follow‐up time was 36 (range 2–168) months, 14 (5.4%) patients eventually relapsed, and the median recurrence time was 8.5 (range 2–42) months. The univariate analysis showed that age (p = 0.003) and surgical type (p < 0.001) were associated with recurrence, and multivariate regression analysis demonstrated that surgical type was the only factor associated with recurrence (p < 0.001, OR 20.01).

Conclusions

The use of gonadotrophin releasing hormone agonist (GnRHa) cannot reduce the postsurgical recurrence rate of patients with UIVL. Compared to total hysterectomy and bilateral salpingo‐oophorectomy (TH‐BSO), total hysterectomy (TH) does not increase the odds of recurrence, but the chance of recurrence with tumorectomy (TE) is 20 times higher than that of TH‐BSO.

Primary Leiomyoma of the Visceral Pleura: An Unexpected Occurrence

BACKGROUND/AIM

Leiomyoma is a rare benign tumor originating from smooth muscle fibres. In the respiratory tract, these tumors are rare and in the pleura, cases are exceptional, with only a few reported so far. This is the main reason we decided to present this case of primary leiomyoma of the visceral pleura.

CASE REPORT

We present a case of a 51-year-old asymptomatic patient who, during a routine medical examination using standard chest radiography, presented with a 3 by 2 cm homogenous mass in the right superior pulmonary area, tangent to the chest wall (same level with the 3rd rib). Further investigation using computed tomography (CT) in the chest confirmed the presence of a 31/18 mm solid mass in the right upper lobe, in contact with the parietal pleura. Surgery was performed for two reasons: i) removal of the tumoral mass and ii) establishing a histopathological diagnosis. Intraoperatively, a well-defined, homogenous, ivory white non-infiltrating mass was discovered in the right upper lobe on the visceral pleura and in close proximity to the minor fissure. The mass was removed with negative surgical margins and was left with healthy tissue. Histopathological examination and immunohistochemistry came as a surprise, establishing our diagnosis of leiomyoma.

CONCLUSION

Primitive pleural leiomyoma must remain a possibility when considering the differential diagnosis of pleural tumors. The main course of treatment is complete surgical resection. In our case, long-term follow up did not present any local recurrence.

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.

Surgical treatment strategies for extra-pelvic intravenous leiomyomatosis

BACKGROUND

Extra-pelvic intravenous leiomyomatosis (IVL) extending into inferior vena cava (IVC) or heart (i.e. intracardiac leiomyomatosis, ICL) is an extremely rare benign disease. No consensus has been reached on the optimal surgical strategy. The aim of this study is to introduce four types of one-stage surgical strategies including less invasive options and a guideline to select patient-specific strategy for this disease.

METHODS

Twenty-four patients of extra-pelvic IVLs receiving one-stage resections at the Zhongshan Hospital from July 2011 to November 2019 were reviewed retrospectively. Base on the initial experiences of the indiscriminate choices of tumor thrombectomies through sterno-laparotomy under cardiopulmonary bypass (CPB) in 6 ICLs, an anatomy-based guideline for four types of surgical strategies was developed and applied for the next 18 patients.

RESULTS

Under the direction of guideline, tumor thrombectomies through single laparotomy were applied without CPB in 2 ICLs and 4 IVLs confined in IVC, or with CPB in 7 ICLs. Guideline-directed double-incisions with CPB were applied in only 5 ICLs, including 1 receiving mini-thoracotomy and 4 receiving sternotomy because of tumor adherences with right atriums in 2 and with pulmonary arteries in 2. All 24 patients accomplished one-stage panhysterectomy, bilateral adnexectomy and complete resections of intracaval and intracardiac tumors. For residual pelvic intravenous tumors in 19 patients, 17 received macroscopically complete resections while the other 2 failed because of high risk of hemorrhage. Intraoperative blood losses, operation time and hospitalization expense in the single-laparotomy non-CPB group were significantly lesser than the other groups. In CPB groups, inpatient stay and hospitalization expense in the single-incision group were significantly lesser than the double-incisions group. All patients were alive and free of recurrences during a mean follow-up of 35.4 ± 27.2 months (range, 1-100 months). The pelvic tumor residues in 2 patients remained unchanged for 51 and 52 months since operation, respectively.

CONCLUSIONS

For various extra-pelvic IVLs, the 4 types of surgical strategies including less invasive options are feasible, providing these are selected by a guideline base on the tumor extension and morphology. The proposed guideline is believed to accommodate more patients receiving less invasive surgery without compromising the curative effect.

Uterine intravenous leiomyomatosis with femoral vein, intracaval, intracardiac and pulmonary artery extension

We report a 54-year-old female with recently diagnosed multiple cardiac thrombi and pulmonary embolism that was treated with thrombolytics and anticoagulants. She presented again with worsening dyspnea and was found to have persistent large cardiac thrombi on echocardiogram. Surgical findings revealed a single right atrial mass originating from inferior vena cava and extending into the pulmonary artery. The mass was successfully removed. Final pathology revealed a benign smooth muscle and vascular mass with estrogen and progesterone receptor positivity favoring uterine intravenous leiomyoma. She was discharged on warfarin and leuprolide therapy. This diagnosis requires a high index of suspicion, especially in a middle-aged woman with right atrial mass and history of an existing leiomyoma, hysterectomy or myomectomy.

Intravenous leiomyomatosis with intracardiac extension depicted on computed tomography and magnetic resonance imaging scans: A report of two cases and a review of the literature

Intravenous leiomyomatosis (IVL) is defined as a benign smooth muscle tumor, growing within systemic veins. IVL with intracaval and intracardiac extension has rarely been reported in radiological and oncological journals. The present study describes 2 cases of IVL extending from the inferior vena cava to the right atrium and ventricle, and discusses the imaging findings and differential diagnosis of this tumor entity. The two patients, who complained of palpitations, shortness of breath or syncope, were surgically treated, with complete resection of the cardiac and intracaval tumors. Pathological examinations were suggestive of IVL. The postoperative course of the two patients was uneventful, and no signs of recurrence were observed on follow-up. Computed tomography and magnetic resonance imaging played a vital role in the diagnostic process and presurgical assessment. The results of the present study indicate that IVL should be considered upon presentation of a soft mass in systemic veins, even when the mass extends to the right cardiac chambers, in female patients, particularly in patients with a history of uterine myoma.

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.