Surgical Treatment for an Invasive Leiomyosarcoma of the Inferior Vena Cava
A 49-year-old woman was admitted with right lumbar pain and edema of both legs. At admission, she was not very ill looking and had experienced no weight loss. Abdominal computed tomography (CT) showed a large low attenuated mass around and in the S7 segment of the liver: the mass measured 9×12 cm, and it involved the right kidney (). In addition, there were multiple enlarged mesenteric lymph nodes and multiple variably sized discrete nodules in both lungs (). Cavography showed subtotal occlusion of the inferior vena cava (). During cavography, intracaval biopsy was performed and spindle cell sarcoma was found.\nAn operation was performed via midline laparotomy with subcostal extension. Before beginning to resect the tumor, we checked the lymph nodes and the rectal shelf and omental seedings. All were negative on frozen biopsy. During dissection around the tumor, partial bypass (femoro-femoral) was inevitable due to massive bleeding of collateral vessels. Through the right femoral artery and vein, arterial and venous cannulation was done. The pump flow was 3 L/min and the total bypass time was 30 minutes. During en bloc resection of the mass from the hepatic vein to the iliac bifurcation, partial duodenal excision, partial liver resection, and right nephrectomy were performed due to tumor invasion.\nThe left renal vein was clamped for one hour because we had confirmed good drainage of the gonal vein. After resection, the IVC was replaced with a 12-mm vascular graft, and the left renal vein was re-implanted in the vascular graft. The gross findings are shown in . Histological analysis revealed a moderate grade malignant spindle cell tumor that arose in the IVC with intraluminal spread into the vena cava and the right renal vein. No lymph node involvement was found. The tumor border had infiltrated to the renal parenchyma, the adrenal gland, and the IVC, but the resection margins were clear. The patient's postoperative recovery was uneventful except for minor gastrointestinal troubles and the patient was discharged at the 24th day. The patient remained asymptomatic for 8 months when she was readmitted for radiation therapy and pulmonary metastasectomy. At this time, the vascular graft in the IVC was occluded on the CT angiography, but she did not complain of any symptoms such as leg edema or abdominal discomfort. Periodic follow-up is being conducted at the department of oncology.