Primary Leiomyosarcoma in the Inferior Vena Cava Extended to the Right Atrium: A Case Report and Review of the Literature

Vena cava leiomyosarcoma surgery results in a retrospective cohort of 41 patients from two centers

BACKGROUND

Leiomyosarcoma of the vena cava (LMS-VC) is a rare entity with poor oncological outcomes and a lack of histological staging prognostic factors.

METHODS

Outcomes of consecutive patients operated on LMS-VC between March 2003 and May 2022, in two specialized sarcoma centers were reported.

RESULT

Forty-one patients were identified. Median size of LMS-VC was 9 cm with 68% of complete obstruction. After surgery, severe complication rate was 30%. No postoperative mortality was reported. Microscopic complete excision was obtained for 71% of patients, R1 for 27% and one patient presented an R2 resection. Grade 3 was found in 24%. After a median follow-up of 70 months, 3 years disease-free survival (DFS) and 5 years DFS were 34% and 17%, and 3 years overall survival (OS) and 5 years OS were 74% and 50%. Distant metastasis concerned 54% of recurrences, local 7% and local and distant 5%. Multivariate analysis showed that FNCLCC grade (p < 0.001) and perioperative chemotherapy (p = 0.026) were significant factors for DFS. In multivariate analysis, FNCLCC grade was a significant factor for OS (p = 0.004).

DISCUSSION

Perioperative chemotherapy may have a role to play in lowering the risk of recurrence for LMS-VC, particularly in high-grade tumor.

Primary Leiomyosarcoma of Suprahepatic Inferior Vena Cava with Metastases

A 67-year-old female presented with shortness of breath, weight loss, abdomen, and back pain for 2 months. Ultrasound of the abdomen revealed multiple focal liver lesions. 18F-Fluorodeoxyglucose whole-body positron emission tomography/computed tomography revealed a hypermetabolic lesion in the suprahepatic inferior vena cava extending into the right atrium. Multiple hypermetabolic lesions were seen in liver, bones, and abdominal lymph nodes, suggestive of metastases. Histopathology and immunohistochemistry of the lesions revealed it to be metastatic leiomyosarcoma.

Treatment of a Double Cancer Patient With Primary Inferior Vena Cava Sarcoma and Lung Adenocarcinoma: A Case Report and Literature Review

Background

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignancy. Here, we present the case of a 38-year-old woman with a primary IVC leiomyosarcoma and lung adenocarcinoma.

Case Report

The patient, a 38-year-old Chinese female, presented to the general surgical outpatients clinic with a 18-month history of intermittent right upper abdominal pain. Contrast-enhanced computed tomography (CT) showed a tumor of IVC (3.4^*2.7 cm) extending to the renal veins. In addition, chest CT revealed a mass lesion in the upper left lung lobe. Then, the patient underwent resection of the IVC tumor and wedge resection of the upper lobe of the left lung. The patient then received gefitinib (250 mg/day) as a maintenance therapy until the tumor recurrence or metastasis in the follow-up period. Pulmonary metastasis of the sarcoma were first diagnosed 20 month after the resection of the IVC leiomyosarcoma. So the patient again received thoracoscopic wedge pneumonectomy, and it was confirmed to be metastasis of IVC leiomyosarcoma. The patient received oral anlotinib treatment (12 mg once daily) after the last operation. During on-going regular follow-up visits no evidence of recurrence or metastasis was observed from December 2020 to October 2021.

Conclusions

The patient with a primary IVC leiomyosarcoma and lung adenocarcinoma is extremely rare. Surgery is still an effective treatment for patients with a primary IVC leiomyosarcoma and lung adenocarcinoma at present.

Surgical resection of leiomyosarcoma of the inferior vena cava: A case series and literature review

OBJECTIVES

We review our institution's experience in treating leiomyosarcomas involving the inferior vena cava, and we offer guidance on the management.

METHODS

A text-based search was performed to identify all patients who underwent surgical resection between January 2002 and October 2020. Clinicopathologic data, intraoperative variables, and outcomes were extracted from chart review.

RESULTS

Twelve of 16 patients (75%) had localized disease; the remaining had limited metastatic disease. Seven of 16 patients (44%) received neoadjuvant chemotherapy or radiation; three patients had partial responses, and four patients had stable disease using RECIST 1.1 criteria. IVC reconstruction was performed in 14 of 16 patients (88%); IVC was ligated for the remaining two patients. Half of all patients had R0 resection on final pathology; the remaining had R1 resections. Progression-free survival (PFS) and overall survival (OS) were not statistically different between patients with R0 and R1 resection. Median PFS was 1.8 years (95% CI 0.89 - not reached); median OS was 6.5 years (1.8 - not reached). Only one patient (6%) experienced local disease recurrence; 4 of 16 patients (25%) experienced disease recurrence distally without local recurrence.

CONCLUSIONS

Resection of IVC leiomyosarcomas at a sarcoma referral center with experience in vascular reconstruction can lead to many years of recurrence-free survival. Surgical resection should be offered to patients with a low volume of metastatic disease to reduce local complications from the primary tumor, many of which exert significant mass effect on surrounding organs. For patients with metastatic disease or large, high-risk tumors, neoadjuvant chemotherapy can provide a biologic test of disease stability prior to resection.

A systematic review of the current management approaches in leiomyosarcoma of inferior vena cava-Results from analysis of 118 cases

INTRODUCTION

Primary intravenous leiomyosarcomas are rare vascular tumors with aggressive disease biology. The diagnosis and management have been challenging as little data exist from large databases.

METHODS

A literature search was done to identify all cases of primary leiomyosarcomas in the last five years. Clinicopathological features and management strategies were evaluated.

RESULTS

The median age was 53 years, predominantly females (2.5:1), presenting as metastases in up to 12.1% cases. Most tumors were locally advanced with a median size of 10cm. Inferior vena cava involvement from renal veins to infrahepatic veins remains the most frequent site (57.1%cases) while nearly half (52.8%) proceeded for surgery without histological proof. Most patients could undergo upfront resection (88.0%) with few patients receiving neoadjuvant chemotherapy (4.3%) or neoadjuvant radiotherapy (2.2%). Significant multivisceral resections included right nephrectomy (41.3%), liver resection (25.7%) and left nephrectomy (2.2%). Most patients (91.8%) needed an inferior vena cava graft placement with remarkable microscopically negative margins (85.5% cases). Doxorubicin and ifosfamide were the most frequently used combination chemotherapy regimens in both pre and postoperative settings with partial responses. The median overall and disease free survival among operated patients was 60 months and 28 months respectively. In multivariate analysis large tumor, extensive inferior vena cava involvement, and need for adjuvant chemotherapy appeared significant predictors for overall survival.

CONCLUSIONS

Aggressive upfront surgical resection with clear margin remains the key for long-term survival. Doxorubicin-based regimens were preferred as neoadjuvant chemotherapy while adjuvant treatment with chemotherapy, radiotherapy, or both may be considered in high-risk patients.

Surgical resection and graft replacement for primary inferior vena cava leiomyosarcoma: a multicenter experience

OBJECTIVE

Primary leiomyosarcoma of the inferior vena cava (IVC) is best managed with surgical resection when technically feasible. However, consensus is lacking regarding the best choice of conduit and reconstruction technique. The aim of the present multicenter study was to perform a comprehensive assessment through the VLFDC (Vascular Low Frequency Disease Consortium) to determine the most effective method for caval reconstruction after resection of primary leiomyosarcoma of the IVC.

METHODS

A multicenter, standardized database review of patients who had undergone surgical resection and reconstruction of the IVC for primary leiomyosarcoma from 2007 to 2017 was performed. The demographics, periprocedural details, and postoperative outcomes were analyzed.

RESULTS

A total of 92 patients (60 women and 32 men), with a mean age of 60.1 years (range, 30-88 years) were treated. Metastatic disease was present in 22%. The tumor location was below the renal veins in 49 (53%), between the renal and hepatic veins in 52 (57%), and above the hepatic veins in 13 patients (14%). The conduits used for reconstruction included ringed polytetrafluoroethylene (PTFE; n = 80), nonringed PTFE (n = 1), Dacron (n = 1), autogenous vein (n = 1), bovine pericardium (n = 4), and cryopreserved tissue (n = 5). Complete R0 resection was accomplished in 73 patients (79%). In-hospital mortality was 2%, with a median length of stay of 8 days. The primary patency of PTFE reconstructed IVCs was 97% and 92% at 1 and 5 years, respectively, compared with 73% at 1 and 5 years for the non-PTFE reconstructed IVCs. The overall 1-, 3-, and 5-year survival for the entire cohort were 94%, 86%, and 65%, respectively CONCLUSIONS: The findings from our multi-institutional study have demonstrated that complete en bloc resection of IVC leiomyosarcoma with vascular surgical reconstruction in selected patients results in low perioperative mortality and is associated with excellent long-term patency. A ringed PTFE graft was the most commonly used conduit for caval reconstruction, yielding excellent long-term primary patency.

Successful Resection of a Retrohepatic Inferior Vena Cava Primary Leiomyosarcoma with Atrial Thrombus Extension in a 30-Week Pregnant Woman

Leiomyosarcomas are an uncommon malignant subset of tumors accounting for approximately 20% of soft tissue sarcomas. Primary vascular leiomyosarcomas (PVLs) are a rare subset of leiomyosarcomas that may originate in the arterial or venous circulation but most commonly affect the inferior vena cava (IVC). PVLs more commonly affect women to men in a 2:1 ratio and most frequently occur in the fourth to sixth decades of life. Few reports have described this infrequent pathologic state in the setting of advanced pregnancy. Presented is a case of a 44-year-old 30-week pregnant woman who presented with a PVL of the retrohepatic IVC, which was complicated by occlusion of the IVC and tumor thrombus extension into the hepatic veins and right atrium. Herein, we describe our multidisciplinary management of this rare problem with successful surgical resection of her tumor and IVC reconstruction.

Leiomyosarcoma of the Inferior Vena Cava in an HIV-Positive Adult Patient: A Case Report and Review of the Literature

Patient: Female, 64

Final Diagnosis: IVC leiomyosarcoma

Symptoms: Back pain • leg pain • leg swelling

Medication: —

Clinical Procedure: IVC filter placement • CT-guided IVC mass biopsy

Specialty: Oncology

Primary leiomyosarcoma of inferior vena cava adjacent to hepatic veins: complete off-pump resection and inferior vena cava graft reconstruction with application of external skin surface cooling

OBJECTIVES

Resection of a leiomyosarcoma of the inferior vena cava (IVC) requires venovenous bypass, especially if IVC clamping above the hepatic veins is planned. This report describes the application of external skin surface cooling for off-pump resection of a primary IVC leiomyosarcoma adjacent to the hepatic veins with graft IVC reconstruction in conditions of suprahepatic caval clamping and uninterrupted Pringle's manoeuvre.

METHODS

A 62-year-old woman presented with IVC leiomyosarcoma adjacent to the hepatic veins. After anaesthesia induction, the patient's head, neck, abdomen, chest, thighs and shanks were covered by polyethylene bags containing granulated ice. The ice bag was also placed between the internal surfaces of the thighs. After 108 min, the target oesophageal temperature (29°C) was achieved, all bags were removed, except the bags that were used for temperature control during the operation located on head, neck and between internal surfaces of the thighs. Off-pump resection of the tumour was performed in conditions of suprahepatic IVC and portal triad clamping via median laparotomy.

RESULTS

IVC clamping was accompanied by arterial hypotension of 55-65 mmHg well-tolerating in the hypothermic background for 69 min. The simultaneous application of an uninterrupted Pringle's manoeuvre was accompanied by low levels of transaminases and bilirubin. There was no local relapse of the tumour or metastases over a 6-month follow-up.

CONCLUSIONS

External skin surface cooling in cases demanding IVC clamping above the hepatic veins and Pringle's manoeuvre allows avoiding venovenous bypass. This method is safe, cost effective, easily performed and may be used in clinical cases involving systemic arterial hypotension.