Surgical Management of Retroperitoneal Leiomyosarcoma Arising from the Inferior Vena Cava
The patient is a 62-year-old female involved in a motor vehicle accident. Upon presentation, she complained of back pain and underwent magnetic resonance imaging (MRI) demonstrating an incidental finding of a 5-cm retroperitoneal soft tissue mass adjacent to the aorta and extending inferiorly from the right renal artery and vein. Further workup with contrast-enhanced computed tomography (CT) of the abdomen and pelvis was obtained demonstrating a 4.6 cm × 4.1 cm × 4.4 cm mass inferior to the right renal vein and posterior to the inferior vena cava with no other associated abnormalities (Fig. ). She then underwent image-guided core needle biopsy of this lesion with pathology demonstrating a spindle cell neoplasm consistent with leiomyosarcoma.\nDue to the proximity of the lesion to the aorta and renal vasculature, she underwent neoadjuvant radiation therapy to a dose of 50 Gy with a boost up to 55 Gy. An MRI of the abdomen and pelvis performed 4 weeks after radiotherapy was completed and redemonstrated the mass, now measuring 5.5 cm × 3.3 cm × 3.4 cm and extending from just below the left renal vein to 3 cm above the confluence of the common iliac veins without invasion of the aorta (Fig. ). She then underwent resection of the mass, which necessitated complete resection of the inferior vena cava (IVC), with reconstruction utilizing a Gore-Tex graft (W.L. Gore & Associates Inc., Flagstaff, AZ; Fig. ). Final pathology demonstrated >75 % of tumor cytoreduction and closest margin of 1 mm. Postoperatively, she was placed on a heparin drip and discharged on lifelong warfarin and aspirin per our vascular surgery protocol. At her 12-month follow-up appointment, she was doing well with a patent graft. Unfortunately, follow-up imaging obtained 14 months after surgery revealed evidence of extensive pulmonary metastases, not amenable to resection, and partial thrombosis of her graft.