Leiomyosarcoma of the renal vein: imaging and surgical reconstruction

Resection of primary left renal vein leiomyosarcoma with renal preservation following an unusual clinical presentation

An elderly man was referred to vascular surgery on incidental discovery of a left retroperitoneal mass ultimately found to be of left renal vein (LRV) origin. He initially presented with recurring lower back pain. CT of the abdomen/pelvis showed a 6.0×5.5 cm lobulated retroperitoneal mass anterior to the infrarenal aorta. Resection of the mass necessitated a multidisciplinary team consisting of medical oncologists, radiation oncologists, urologists and vascular surgeons. In efforts to obtain an R0 margin, en-bloc resection of the LRV from its confluence with the inferior vena cava (IVC) was necessary. A primary repair of the IVC was performed with preservation of the left kidney. The patient's back pain has since resolved after the surgery. A literature search found IVC reconstructions to be safe and effective in the removal of vascular leiomyosarcomas.

Clinical experience and treatment strategy of leiomyosarcoma originating from the renal vein

Background

Leiomyosarcoma originating from the renal vein (RVLMS) is extremely rare. RVLMS lacks specific clinical manifestations and specific imaging features. This article discusses the epidemiological characteristics and diagnostic difficulties of RVLMS, as well as imaging features, differential diagnosis, treatment strategy, and prognostic factors of this disease.

Method

A case of RVLMS at our center, and 55 cases from the literature based on the PubMed search.

Results

Total operation time was 224 min, and total blood loss during the surgery was 200 ml. Resected tumor was irregular in shape, with negative margins. On the 6th day after the operation, the drainage tube was removed, and the patient was discharged from the hospital. Postoperative pathological results confirmed the renal vein leiomyosarcoma: spindle cell sarcoma, diffuse severe atypia, S-100 (-), SMA ( +), desmin ( +), CD34 (−), CD99 ( +).  Twenty-seven months after the surgery, the patient is alive, and without local recurrence or distant metastases.

Conclusion

Unspecific clinical manifestations and imaging features make the diagnosis of RVLMS difficult. Most patients are diagnosed intra-operatively or following postoperative pathology. Differential diagnosis with paraganglioma (PG) and retroperitoneal sarcoma (RPS) should be made. Early and complete resection is considered as the first choice of treatment, and whether to preserve the kidney is based on the patient's condition. RVLMS is highly malignant, and may recur locally or metastasize to distant locations; therefore, adjuvant therapy and regular follow-up should be carried out after surgery.

Leiomyosarcoma of the Renal Vein Mimicking a Primitive Renal Cell Carcinoma: Case Report of an Unusual Presentation

Primary leiomyosarcomas (LMS) of vascular origin are rare tumors, and more than half of the cases arise in the inferior vena cava (IVC). Primary LMS of the renal vein are extremely rare tumors with only a few cases reported in the literature. Their diagnosis is made only by pathological features. Histologically, they are made of atypical spindle-shaped cells arranged in long intersecting fascicles. Tumor cells stain positive for myogenic markers in immunohistochemistry. Standard treatment consists of radical nephrectomy followed by chemotherapy and/or radiotherapy. Because of insufficient histological data and follow-up, the prognosis factors are not well identified. Overall prognosis of renal vein LMS is poor. We report here an exceptional case of a huge LMS of the right renal vein mimicking a primitive renal cell carcinoma, occurring in a 56-year-old male patient.

Inoperable Left Renal Vein Leiomyosarcoma Refractory to Chemotherapy Invades Inferior Vena Cava and Right Atrium: A Case Report

Mesenchymal stem cells differentiate into a plethora of cell types. These differentiated cell types include osteoblasts, chondrocytes, myocytes, and adipocytes. Sarcomas occur secondary to malignant transformation of these mesenchymal, pluripotent stem cells. Involuntary smooth muscle is responsible for the make up of hollow organs and vasculature in our body and is regulated by our autonomic nervous system, hormones, as well as chemical and local mediators. Cancer involving smooth muscle cells is designated as leiomyosarcoma (LMS). LMS can arise from any location in the body where smooth muscle is present and is frequently reported in the abdomen and pelvis, as well as the trunk, extremities, and throughout the retroperitoneum. 

Atypical Presentation of Renal Leiomyosarcoma: A Case Report

Primary renal sarcomas are rare comprising from 0.8 to 2.7% of adult renal tumours. They cannot be distinguished clinically or radiologically from the more common renal cell carcinomas. Leiomyosarcoma is the most common histological subtype accounting for around 50-60% of renal sarcomas. Leiomyosarcomas arise from the renal capsule, renal vein or the renal pelvis. They present with nonspecific clinical symptoms and signs and usually have a dismal outcome. Rarely atypical presentations such as acute tumour rupture and hematuria are encountered. We report a 27-year-old woman who presented with malignant hypertension. The hypertension was controlled emergently with antihypertensive agents. In view of the young age, a thorough workup was conducted to identify the cause of hypertension. Imaging studies revealed a solid enhancing renal tumour compressing the renal vasculature. As the staging workup did not reveal any evidence of metastases, the patient underwent right-sided open radical nephrectomy after adequate control of hypertension. The histological examination uncovered the renal tumour to be a leiomyosarcoma. Postoperative period was uneventful and she was doing well on one year follow up. Surprisingly the blood pressure normalised postoperatively and the patient was weaned off of her antihypertensive medications. This case is presented to highlight the atypical acute presentation of primary renal leiomyosarcoma with relatively good prognosis. Timely diagnosis and meticulous surgical resection improved the prognosis of this aggressive renal malignancy.

Leiomyosarcoma of the renal vein: analysis of outcome and prognostic factors in the world case series of 67 patients

BACKGROUND

Leiomyosarcoma is a rare malignant mesenchymal tumour. Some cases of leiomyosarcoma of the renal vein (LRV) have been reported in the literature, but no analysis of data and search for prognostic factors have been done so far. The aim of this review was to describe the LRV, to analyse overall survival (OS), local recurrence free survival (LRFS) and distant metastases free survival (DMFS) in LRV world case series and to identify significant predictors of OS, LRFS and DMFS.

METHODS

Cases from the literature based on PubMed search and a case from our institution were included.

RESULTS

Sixty-seven patients with a mean age of 56.6 years were identified; 76.1% were women. Mean tumour size was 8.9 cm; in 68.7% located on the left side. Tumour thrombus extended into the inferior vena cava lumen in 13.4%. All patients but one underwent surgery (98.5%). After a median follow up of 24 months, the OS was 79.5%. LRFS was 83.5% after a median follow up of 21.5 months and DMFS was 76.1% after a median follow up of 22 months. Factors predictive of OS in univariate analysis were surgical margins, while factors predictive of LRFS were inferior vena cava luminal extension and grade. No factors predictive of DMFS were identified. In multivariate analysis none of the factors were predictive of OS, LRFS and DMFS.

CONCLUSIONS

Based on the literature review and presented case some conclusions can be made. LRV is usually located in the hilum of the kidney. It should be considered in differential diagnosis of renal and retroperitoneal masses, particularly in women over the age 40, on the left side and in the absence of haematuria. Core needle biopsy should be performed. Patients should be managed by sarcoma multidisciplinary team. LRV should be surgically removed, with negative margins.

Renal vein leiomyosarcoma and renal cell carcinoma presenting together: A case report and discussion on the follow-up

Leiomyosarcoma affecting the renal vein is rare, with about 30 documented cases in the English literature. The appearance on computed tomography can be difficult to interpret and is often confused with advanced renal cell carcinoma (RCC). This confusion can have implications on the perioperative care of patients presenting with this disease. We report a case with an usual radiological appearance of a renal vein leiomyosarcoma, alongside a separate RCC. This case highlights the need for a high index of suspicion in radiological reporting and provides a dilemma in regards to postoperative surveillance.

An uncommonly encountered perirenal mass: Robotic resection of renal vein leiomyosarcoma

Primary leiomyosarcoma (LMS) of the renal vein is a rare tumour and poorly described in the literature. Surgical resection, using open and laparoscopic approaches, is the mainstay of treatment. In this report, we describe a patient with left renal vein LMS, report the first robotic laparoscopic resection for this tumor, and review the typical presentation, imaging, pathology and treatment for this rare clinical entity.

Primary renal vein leiomyosarcoma: a case report

Primary renal vein leiomyosarcoma (LMS) is a rare tumor with only a few cases reported in the literature. Clinical diagnosis of renal vein LMS can be difficult because of nonspecific symptoms and nonpathognomonic radiological features. The primary treatment modality is radical nephrectomy followed by chemotherapy and/or radiotherapy. There is scarcity of literature regarding prognosis because of rarity of tumor; however, tumor size (>3 cm) determines the risk of local recurrence and distant metastasis. Overall prognosis of renal vein LMS is poor. Here, we describe clinical and histopathological features of a 50-year-old female patient with LMS of right renal vein.

Leiomyosarcoma of the renal vein

A 43-year-old woman was referred to our clinic for evaluation of a left retroperitoneal mass. She presented to our internal medicine department complaining of back pain. Computed tomography (CT) scan revealed a left retroperitoneal mass 55 mm in size in the hilum of the left kidney. Enhanced CT scan and magnetic resonance imaging (MRI) disclosed a poorly staining mass. Metaiodobenzylguanidine scintigraphy demonstrated no accumulation in the mass; moreover, endocrinologic examination was normal. Laparoscopic resection of the left retroperitoneal tumor was attempted; however, strong adhesion between the tumor and the left renal vein was encountered. Thus, left nephrectomy after open conversion was performed. Histological findings indicated leiomyosarcoma originating from the left renal vein. The postoperative course has been uneventful; neither recurrence nor metastasis is evident 2 years postsurgery.

Leiomyosarcoma of the renal vein: arterial encasement on contrast-enhanced dynamic computed tomography

We report a case of leiomyosarcoma of the renal vein, which is a rare tumor with no more than 30 cases found in the published English language literature. This case demonstrates encasement of the renal artery by the tumor mass, a previously unreported manifestation. The present study could be useful in considering this rare tumor in the differential diagnosis of renal hilar tumors.

Recurrent pulmonary embolism with non-mobile thrombus in a patient with leiomyosarcoma of the left renal vein

We describe the case of a man who suffered recurrent pulmonary embolisms despite well-conducted oral anticoagulant therapy. Echocardiography and helical computed tomography revealed a non-mobile right atrial mass related to a leiomyosarcoma of the left renal vein. The prognosis of such a disease is bad and the patient died at 1-year follow-up. Recurrent pulmonary embolism with well-conducted oral anticoagulant therapy requires further appropriate investigations, because of high suspicion of neoplastic process.

Leiomyosarcoma of the renal vein: case report and review of the literature

Leiomyosarcomas of vascular origin is a rare and aggressive pathology, its presentation on the renal vein is infrequent, of which 29 cases have been reported world-wide. We describe a case of a 76 year-old woman, who presented with intermittent left flank pain, irradiated to the lumbar region of 6 months duration. A left radical nephrectomy with en-bloc resection of a para-aortic tumor was performed. Microscopic examination of the specimen reported a moderately differentiated leiomyosarcoma, originated in the wall of the renal vein. The patient received adjuvant chemotherapy and radiation therapy. The tumor recurred in the liver. After 24 months from the primary surgery, the patient is alive with evidence of multiple metastatic spread to the liver. She is now under palliative care.