Curative resection of leiomyosarcoma with resection and reconstruction of inferior vena cava

doi:10.4236/crcm.2013.26090

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Vol.2, No.6, 335-337 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.26090

Curative resection of leiomyosarcoma with resection

and reconstruction of inferior vena cava

Yashiro Motooka1, Daisuke Hashimoto1, Hisashi Sakaguchi2, Akira Chikamoto1, Toru Beppu1,

Michio Kawasuji2, Hideo Baba1*

1Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan;

*Corresponding Author: [email protected]

2Department of Cardiovascular Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan

Received 7 June 2013; revised 8 July 2013; accepted 20 July 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Leiomyosarcoma of the inferior vena cava (IVC)

is a rare tumor, and it needs complete surgical

resection for cure. In addition, the reconstruc-

tion of IVC is necessary in many cases. Herein,

we indicate the case of a 57-year-old female with

leiomyosarcoma in segment I of the IVC, which

grew deep into vascular lumen. She underwent

complete en bloc resection of the tumor and IVC

reconstruction by an artificial pericardium p atch.

Keywords: Leiomyosarcoma; Inferior Vena Cava;

Reconstruct

1. INTRODUCTION

Leiomyosarcoma is a rare malignant tumor of smooth

muscle cell, and rarely develops from inferior vena cava

(IVC) with intraluminal and/or extraluminal growth [1-6].

Because the long-term survival is not favorable (5-year

survival 38%, 10-year survival 14%) [7], curative en

bloc resection with IVC and reconstruction of that is

important to cure. The location of leiomyosarcoma of the

IVC is divided into three levels: segment I, lower level

(IVC below the renal veins); segment II, middle level

(renal veins to hepatic veins, most frequently affected);

and segment III, upper level (entry of hepatic veins to the

right atrium) [8].

In this report, we indicate the case of a 57-year-old

female with leiomyosarcoma in segment I of the IVC.

She underwent complete en bloc resection of the tumor

and IVC reconstruction.

2. CASE REPORT

A 57-year-old female with no complaint received health

screening abdominal ultrasound, which found retroperi-

toneal tumor. Enhanced computed tomography (CT) scan

revealed a tumor (diameter: 2.5 cm) on the right side of

IVC with growth into the IVC (Figures 1(A) and (B)).

Maximum standardized uptake value (SUV max) of the

tumor in positron emission tomography (PET)-CT was

4.4 → 5.3, and no distant metastasis was found.

Therefore, we planned a surgical resection with the

patient’s informed consent. Laparotomy showed that

30mm tumor existed on the right side wall of IVC below

the right renal vein junction (segment I), invading IVC

widely (Figure 2(A)). An incision was made onto the

clamped IVC, and it showed that the tumor protruded

into the cavity of IVC. The tumor was resected en-block

with IVC. Deficient hole of IVC was 2.5 × 2.3 cm (Fig-

ure 2(B)), and reconstructed by GORE-TEX® Cardio-

vascular Patch (W. L. Gore & Associates, Inc. Flagstaff,

Figure 1. Preoperative findings. Enhanced CT revealed a tumor

(arrowheads) on the right side of IVC with growth into the IVC

((A), (B)). SUV max of the tumor (arrowheads) in positron

emission tomography (PET)-CT was 4.4 → 5.3 (C).

Y. Motooka et al. / Case Reports in Clinical Medicine 2 (2013) 335-337

336

AZ) with 6-0 polypropylene non-absorbable monofila-

ment suturing (Figure 2(C)). Macroscopically, the tumor

was elastic hard and the size was 5 × 2.5 × 2 cm (Figure

3(A)). Postoperative pathological diagnosis was leiomy-

osarcoma (Figure 3(B)). No sign of recurrence was ob-

Figure 2. Surgical findings. Laparotomy show-

ed that a tumor (arrowheads) existed on the

right side wall of IVC below the right renal

vein junction (segment I), invading IVC wide-

ly (A). Deficient hole (arrowheads) of IVC

after en-block resection of the tumor was 2.5

× 2.3 cm (B). Reconstructed by GORE-TEX®

Cardiovascular Patch (arrowheads) was per-

formed (C).

Figure 3. Pathological findings. Mac-

roscopically, the tumor was elastic hard

and the size was 5 × 2.5 × 2 cm (A)

(arrowheads; resected IVC). HE stain-

ing showed cellular eosinophilic spin-

dle cell tumor with nuclear atypia and

mitosis, then pathological diagnosis

was leiomyosarcoma (B).

served and the patency of IVC was retained completely

10 months after the operation.

3. DISCUSSION

Aggressive curative en bloc surgical treatment to

achieve extirpation of primary caval neoplasms or large

abdominal tumors with caval involvement may prolong

survival in selected patients [1-5]. Whereas a complete

resection of the IVC is necessary in most cases, man-

agement of IVC after tumor resection is still controver-

sial [8]. IVC reconstruction is performed by such as pri-

mary ligation, cavoplasty or graft replacement [9].

Kieffer et al. indicated that simple ligation is possible

after complete or subtotal resection of the infra-renal

IVC (segment I) with the assumption that slow tumor

growth allows sufficient collaterals developing [8]. How-

ever, in cases without enough sufficient collateral grow-

ing, simple ligation can make low limb edema with sig-

nificant functional impairment [9]. Thanks to advances

in surgical techniques for venous reconstruction, pros-

thetic replacement of the IVC is now feasible whenever

considered necessary [8].

In this case, leiomyosarcoma invaded the IVC widely.

However, the IVC was not obstructed, and then collat-

erals were not developed. Aggressive curative en bloc

surgical resection with IVC and reconstruction with an

artificial patch were performed successfully and showed

the successful long-term outcome without tumor recur-

rence. The patency of IVC has been kept, without any

thrombosis.

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