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.

Current Trends in Management of Renal Cell Carcinoma with Venous Thrombus Extension

PURPOSE OF REVIEW

To review the evidence regarding the current trends in surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombosis. Recent published series have shown the role of minimally invasive surgery in IVC thrombectomy. This review article evaluates the present RCC with venous extent literature to assess the role of open and minimally invasive surgery in this scenario.

RECENT FINDINGS

Robotic urological surgery has shown to have known benefits in radical prostatectomy, partial nephrectomy, and pyeloplasty. Recent published series showed feasibility of robotic IVC thrombectomy even for level IV cases. With growing number of robot-assisted and laparoscopic surgeries worldwide, there is a current tendency to treat this complex and challenging pathology with a minimally invasive approach, without compromising oncological outcomes.

Role of Venous Stenting for Iliofemoral and Vena Cava Venous Obstruction

Venous stenting for CVD is being increasingly used as more evidence accumulates supporting the open vein hypothesis and supporting the safety, efficacy, and durability of these interventions. As such, they can be offered to patients with advanced age and complex comorbidities. Future studies should focus on reporting outcomes specific to the underlying venous pathologic condition (thrombotic vs nonthrombotic and acute vs chronic) to provide better evidence for stenting in CVD, and the outcomes of new stent design with dedicated venous indications.

[Renal angiomyolipoma with inferior vena cava thrombosis during pregnancy]

The diagnosis of angiomyolipoma with tumor thrombus from the renal vein into the inferior vena cava is rare, especially during pregnancy. We report the case of a 31-year-old pregnant woman who was diagnosed with a 9 cm angiomyolipoma of the right kidney with inferior vena cava thrombosis, managed by active surveillance during pregnancy and delayed surgery after childbirth.

Cardiopulmonary bypass with brain perfusion for renal cell carcinoma with caval thrombosis

AIM: To compare a modified technique preserving brain circulation during cardiopulmonary by-pass (CPB) for radical nephrectomy and caval thrombectomy, to the standard technique.

METHODS: Retrospective evaluation of an institutional database that collects the data of patients submitted to nephrectomy and removal of caval thrombosis with CPB since 1998. In period between 1998 and 2007, CPB followed a standard technique (group sCPB); then, since 2008, a variation in the perfusional technique was introduced, allowing the anterograde perfusion of brain circulation during circulatory arrest (group CPB + BP) with the aim to reduce the risk of ischemic damage to the brain and also the need of deeper hypothermia. Patients (age, gender, comorbidity) and tumor characteristics (side, histology, staging, level of thrombosis), as well as parameters of CPB (times of CPB, aortic clamping and circulatory arrest, minimum temperature reached during hypothermia), intra- and perioperative morbidity (complications in general, bleeding, renal and hepatic failure) and mortality were analyzed and compared between 2 groups (sCPB vs CPB + BP)

RESULTS: The data of 24 patients, respectively 9 in sCPB group and 15 in CPB + BP group, have been reviewed. No differences in the characteristics of patients and tumors were observed. Only 1 (11.1%) and 4 (26.0%) of sCPB and CPB + BP patients, respectively, didn’t experience any event of complication. In sCPB group were observed 15 events of complication (5 of which Clavien ≥ 3, 33% of the events), for a mean of 1.66 events/patient; 29 events (10 Clavien ≥ 3, 30.3%), in the CPB + BP group, for a mean of 2.1 events/patient. 1 (11.1%) and 2 (14.2%) deaths occurred, respectively. For patients submitted to CPB + BP, the minimum temperature reached was significantly higher (29.9 °C vs 26.4 °C, P = 0.001), the time of circulatory arrest was longer (17.4 min vs 13.7 min, NS), but the overall time of CPB shorter (76.1 min vs 92.5 min, NS), albeit these latter differences were not statistically significant. No differences in terms of bleeding, impairment of renal function (post-operative Cr > 2.0 mg/dL respectively in 44.4% vs 35.7% of cases, in the two groups, NS) or hepatic insufficiency (post-operative GOT or GPT > 50 U/L respectively in 44.4% and 66.7% of patients, NS) were noted. Average follow-up was 51 mo in patients undergoing a sCPB and 12 mo in the CPB + BP group of patients; at the last follow-up, 7 patients had died of progression of the condition (4 in the first group and 3 in the second group, respectively), 7 were alive in progression and 10 had no evidence of the disease.

CONCLUSION: The perfusional technique that maintains brain perfusion during circulatory arrest limits hypothermia and lowers time of CPB, without rising the risk of renal and hepatic injury.