Vascular leiomyosarcoma originating from the right ovarian vein: a case report and literature review

Inferior vena cava resection for a leiomyosarcoma: A case report

INTRODUCTION AND IMPORTANCE

Leiomyosarcomas of the inferior vena cava are scarce. Surgery is the only potential curative treatment. Such a surgery is complex and technically demanding, requiring a huge experience in both visceral and vascular surgery. Indeed, enlarged visceral resection may be needed to achieve a free tumor margins as the tumor may invade the duodenum, the head of the pancreas and the liver. Moreover, vascular reconstruction is mandatory which might be complex as both venal reins are usually invaded by the tumor like in our case below.

CASE PRESENTATION

A 53-year-old woman presented with abdominal vague pain. Imaging consisting in abdominal CT-scan with contrast and magnetic resonance angiography were suggestive of the diagnosis of leiomyosarcoma of the inferior vena cava. A surgical complete resection with free margins was conducted. A primary repair of the inferior vena cava and the right renal vein walls. End-to-side anastomosis with a polytetrafluorethylene (PTFE) prosthesis was mandatory to reconstruct the renal left vein to the inferior vena cava. Postoperative outcomes were uneventful. Pathology examination confirmed the diagnosis.

DISCUSSION

The optimal management of leiomyosarcoma of inferior vena cava is controversial. Surgery remains the cornerstone of treatment. However, not all patients are qualified for surgical resection. The prognosis depends on the early diagnosis and histology type.

CONCLUSION

The management of leiomyosarcomas of inferior vena cava requires a multidisciplinary consensus involving experienced surgery and oncology teams.

Primary Leiomyosarcoma of the Ovarian Vein Causing Obstructive Uropathy: A Case Report

Retroperitoneal vascular leiomyosarcoma (RVLMS) are rare soft-tissue sarcomas that most commonly arise from large blood vessels and have a poor prognosis. We present the case of a 61-year-old woman who presented with isolated left flank pain. Abdominal computed tomography and magnetic resonance imaging revealed a 5 cm retroperitoneal soft-tissue mass that was contiguous with the left ovarian vein and connected to the proximal ureter, causing hydronephrosis. As ureteroscopy suggested extrinsic compression of the ureter, a percutaneous biopsy of the mass was obtained, whereupon diagnosis of leiomyosarcoma was made. Radical en-bloc excision of the tumor, including the involved upper urinary tract and the gonadal vein, was performed. The tumor proved to be a leiomyosarcoma arising from the ovarian vein wall. No adjuvant therapy was planned, and no recurrence was noticed at her 24-month follow-up. Primary RVLMS of the ovarian vein is an uncommon condition. To date, only a few sporadic cases have been reported in the literature. What makes the present case further interesting is the unusual tumor’s relationship with the patient’s ureter, raising both diagnostic and management challenges. To our best knowledge, this is so far the fourth reported case of its kind to cause ureteral obstruction.

Leiomyosarcoma arising from the ovarian vein as a gynecologic malignancy: Two case reports and a review of the literature

Leiomyosarcoma arising from the ovarian vein has rarely been reported. Herein, we report two cases from a single institute. Given their direct connections to ovarian vessels, both leiomyosarcomas were initially suspected to be gynecological malignancies. In one case, leiomyosarcoma was discovered incidentally without any clinical symptoms; it had a close connection with the ovarian vein, was removed surgically, and the patient has survived for over 12 years. In another case, bowel obstruction caused by the tumor helped to identify metastatic leiomyosarcoma. Blood flow was supplied by the ovarian artery and grew into the lumen of the ovarian vein without invading adjacent organs. After surgical resection, the patient underwent 18 months of chemotherapy prior to palliative care. We propose that leiomyosarcoma arising from the ovarian vein should be treated as a gynecologic malignancy, especially if it develops in the lower abdomen.

Clinical experience with the treatment of retroperitoneal vascular leiomyosarcoma originating from large veins

BACKGROUND

Retroperitoneal vascular leiomyosarcoma (RVLMS) is an extremely rare disease in clinical practice, and it has poor prognosis. This article is to explore the diagnosis and treatment of RVLMS and present our experience.

METHODS

Data of RVLMS patients were continuously collected in our hospital from August 2018 to February 2020: two males and two females with a median age of 56 (min-max = 33-61) years were included. Patients in whom paraganglioma could not be excluded were asked to take phenoxybenzamine before surgery. A multi-disciplinary team (MDT) meeting had been held and surgery was recommended. The operation procedures varied based on the tumor location, shape, and stage, and the core steps were "exposure of the retroperitoneum and tumor, identification of vital blood vessels, blocking the bloodstream, complete removal of the tumor and tumor thrombus, and release of blood flow". A Satinsky clamp was used to partially block the blood vessels. Follow-up was conveyed by revisits and phone calls.

RESULTS

One patient underwent open surgery, and three patients underwent laparoscopic surgery, one of whom underwent conversion to open surgery. The procedures were finished successfully, with a median operative time of 314.5 (min-max = 224-467) mins. The median amount of intraoperative bleeding was 550 (min-max = 200-1500) ml, and three patients had transfusion during the operation. The mass was irregular in shape, with a median maximum size of 7.45 (min-max = 4.2-10.7) cm, and the pathological examination confirmed RVLMS, which has spindle-shape, high mitotic activity and atypia. One week after the operation, the median serum creatinine level was 85 (min-max = 70-99) µmol/L. The median follow-up time was 16 (min-max = 13-21) months, and 1 case reported asymptomatic recurrence.

CONCLUSION

Uncharacteristic manifestations and imaging features contribute to the problematic diagnosis of RVLMS. Comprehensive preoperative evaluation and careful surgical planning are essential. Multicenter research is needed in the future to reach a dominant consensus.