Metastatic leiomyoma is a rare benign tumor affects women with history of uterine leiomyoma. The primary tumor generally extends or spreads via intravascular to the right heart cavities several years after hysterectomy [1]. The symptoms are usually produced by a mass effect and compression of the tissues where the metastasis settles [2,3].

A 52-year-old woman with history of smoking and arterial hypertension underwent hysterectomy 15 years ago because of uterine leiomyoma. She was admitted in our hospital because of transient cerebral ischemic accident. The routine laboratory results were within normal limits. Electrocardiogram, Holter 24 hours, and Echo-Doppler of great vessels of aortic arch were normal. Cerebral computer tomographic (CT) scan showed infarction in the territory of the left postero-inferior cerebellar artery. Transthoracic echocardiogram showed a mobile mass of 53X10 mm arisen from the inferior vena cava (IVC) and extended to the right atrium (RA). Cardiac magnetic resonance image (MRI) revealed a pedunculated mass of 56 × 15 mm arisen from the suprahepatic segment of IVC 2 - 3 cm away from the RA. Thoracoabdominal CT scan did not reveal any another tumor. The early differential diagnoses were organized thrombus, metastatic leiomyoma, or fibroma.

After full neurological recovery, the patient was admitted again for surgery. A consensus was reached initially to excise the tumor without caval replacement. She was placed on normothermic cardiopulmonary bypass using a double venous cannulation of superior vena cava and right femoral vein. The RA was opened and a Foley catheter (18 French) was introduced into the IVC, inflated and connected to the pump suction to avoid venous return to the RA (Figure 1). The tumor was excised and sent for histopathogical study. The base of implantation was carefully scraped. The postoperative course was unremarkable and the patient was discharged one week after surgery.

The histopathogical study showed predominant stroma, spindle cells interlaced with vascular structures, and focal calcifications without evidence of mitosis, necrosis or signs of malignancy. Desmin, actin and Caldesmon were positive for metastasizing uterine leiomyoma (Figure 2). One year follow-up at out-patient clinic, she was asymptomatic in functional class I (NYHA). Thoraco-abdominal CT scan and transthoracic echocardiogram showed no evidence of recurrent metastatic disease.

Metastatic leiomyoma is a rare benign tumor spreads from uterine leiomyomatosis via intravascular and usually affects lungs, brain, bone, lymph, heart, and skin. The tumor is incidentally discovered by echocardiography or thoraco-abdominal CT scan [2]. The symptoms are produced by a mass effect and compression of the

tissues where the metastasis settles. The treatment varies according to the affected organ. Surgical excision of the tumor is recommended in cardiac involvement to avoidserious complications such as pulmonary thromboembolism, obstruction of right ventricular out-tract or IVC drainage [4,5].

The tumoral involvement of IVC is classified into 3 groups: segment I, infrarenal; segment II, interand suprarenal up to but not including the main suprahepatic veins; and segment III, suprahepatic with possible intracardiac extension. Fabre et al., use venovenous shunting with selective hypothermia hepatic perfusion in surgical treatment of tumors involving the suprarenal segment of the IVC [6]. Kieffer et al., recommend circulatory arrest at 18˚C for surgical excision of tumors involving supraheptic segment of IVC with intracardiac extension so as to perform in a blood-free operating field. They use cardiopulmonary bypass with double venous cannulation; one through the appendage of RA and the other in femoral vein or infrarenal IVC [7]. Based on experience of Hardwigsen et al., the material of choice for caval replacement is reinforced PTFE. They also strongly recommend the creation of an arteriovenous fistula to ensure patency and eliminate the need for long-time anticoagulation therapy [8].

Herein, we describe a simplified and efficacious technique for excision of a metastatic leiomyoma as a benign tumor involving the suprahepatic segment of IVC with intracardiac extension. Normothermic cardiopulmonary bypass using a double venous cannulation; superior vena cava and right femoral vein, and introduction of a Foley catheter into IVC do not only eliminate the side effects of circulatory arrest but also provide an excellent exposure with blood-free operating field and prevent the falling of tumor down into IVC.