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Journal of Obstetrics and Gynaecology
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: https://www.tandfonline.com/loi/ijog20
Two-stage surgery for extra pelvic intravenous
leiomyomatosis: report of a case
Denizhan Bayramoglu, Atilla Orhan, Ayhan Gul, Gozde Sahin, Zeliha Esin
Celik, Mustafa Koplay & Cetin Celik
To cite this article: Denizhan Bayramoglu, Atilla Orhan, Ayhan Gul, Gozde Sahin, Zeliha Esin Celik, Mustafa Koplay & Cetin Celik (2020) Two-stage surgery for extra pelvic intravenous leiomyomatosis: report of a case, Journal of Obstetrics and Gynaecology, 40:5, 731-732, DOI: 10.1080/01443615.2019.1624950
To link to this article: https://doi.org/10.1080/01443615.2019.1624950
Published online: 29 Jul 2019.
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CASE REPORT
Two-stage surgery for extra pelvic intravenous leiomyomatosis: report of a case
Denizhan Bayramoglua , Atilla Orhanb , Ayhan Gula , Gozde Sahina , Zeliha Esin Celikc , Mustafa Koplayd and Cetin Celika
a
Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Selc¸uk University, Konya, Turkey;bDepartment of Cardiovascular Surgery, Selc¸uk University, Konya, Turkey;cDepartment of Pathology, Selc¸uk University, Konya, Turkey;dDepartment of Radiology, Selc¸uk University, Konya, Turkey
Introduction
Intravenous leiomyomatosis (IVL) is a variant of leiomyoma characterised by intravascular proliferation and originates from the uterine mesoderm. The main pathogenesis of IVL has not been exactly assessed, yet (Xu et al. 2013; Li et al.
2014). There are two main theories; the first one is: a tumour arises from the walls of venous structures and the second one is: a primary tumour (e.g. myoma) directly spreads into adjacent small venouses (Moniaga and Randall 2012). The early studies have reported an incidence of 0.25–0.41% of IVL in patients with uterine fibroid tumours (Ma et al.2016; Low et al.2017). Here, we presented a case suspected of IVL dur-ing the operation; although it was reported as uterine sar-coma and vena cava inferior thrombus on radiological imaging methods, pre-operation.
Case report
A 42-year-old multiparous, premenopausal woman applied Selcuk University Obstetrics and Gynecology clinic with com-plaints of menometrorrhagia and pelvic pain. On physical examination, a palpable mass with a moderate hardness, extending to the right upper quadrant from the lower midline of abdomen was observed. The tumour markers, haemograms and biochemical markers were normal. In ultrasonography (USG), numerous masses were observed, in which the largest – about 7 cm size – contained heterogeneous structures with multiple cystic occurrences. It could not be clearly distin-guished as degenerative myomas or sarcomas. A heteroge-neous mass was observed using computer tomography (CT). The mass had a total size of approximately 1510 cm, and adjacent intestinal structures that could not be clearly sepa-rated from the ovaries or uterus and hypodense areas in favour of the thrombus in IVC (Figure 1(A,B)). Probe curettage was reported as secretory endometrium. An operation planned with the pre-diagnosis of a uterine sarcoma.
During the operation, masses which were approximately 15 cm in diameter, white, smooth, spindle, small, macroscop-ically compatible with myoma and a continued throughout uterine venules and the ovarian vein of the right infundibulo-pelvic ligament were seen and IVL was thought to be
possible. After total abdominal hysterectomy (TAH) þ bilateral salpingectomy and right oophorectomy were done, initial operation was finished. Contrast MRI and angiography imaging were performed in the postoperative period. Magnetic resonance imaging (MRI) has reported that lesions consistent with leiomyoma extending from the right ovarian vein to the right renal vein in IVC were observed and a filling defect has been seen in VCI angiography (Figure 1(C)). Ultimate pathology was reported as IVL.
Therefore, a second operation was planned in consultation with cardiovascular surgeons after about one month from the first surgery. Then, cardiovascular surgeons placed a vena cava filter before the second operation so it could be pro-tected against a possible embolism during the procedure (Figure 1(D)). In the second laparotomy, the residual lesion extending to the right renal vein entry of inferior vena cava from the beginning right ovarian vein was excised success-fully (Figure 1(E)). After a 12-month follow-up, the case remains uncomplicated without potential recurrence or symptoms.
Discussion
Although IVL has a benign character histologically, also can be aggressive biologically and clinically. IVL consists of smooth muscle tissue with no malignancy histopathological characters (Li et al. 2013). In early stages, it is usually asymp-tomatic, but there may be different symptoms according to the location. Usually pelvic mass and abdominal pain is seen. Extra pelvic disease (intra cardiac) can mimic primary heart disease. In our case, the patient had complaints of pain and menometrorrhagia.
IVL is typically caused by uterine origin and may involve ovarian veins. Surgery is needed for diagnosis and treatment in IVL patients (Du et al. 2011; Low et al. 2017). The best treatment is hysterectomy, bilateral salpingo-oophorectomy and complete removal of all other lesions. In cases of extrin-sic vasculature, it is sometimes possible to perform in two steps (sometimes with only one step) with multidisciplinary surgery (Li et al. 2013). Two-stage surgery was performed in our case.
CONTACTDenizhan Bayramoglu dbayramoglu2002@hotmail.com Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Selc¸uk University, Konya, Turkey
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
JOURNAL OF OBSTETRICS AND GYNAECOLOGY 2020, VOL. 40, NO. 5, 731–732
Although IVL is defined as a benign lesion, up to 30% recurrence has been observed in some studies (Low et al.
2012). At the same time, low-grade endometrial stromal sar-coma and leiomyosarsar-coma involving vascular invasion must be distinguished.
If the presence of thrombosis is mentioned in radiological methods in the cases of leiomyomatosis or if there are find-ings, such as increased blood pressure, which may be caused by intravascular lesion in the patient. IVL suspicion should be kept in mind. In our case, hypodense areas were reported in favour of thrombosis in IVC in CT. IVL is a rare clinical entity often presenting difficulties in diagnosis and treatment. Therefore, larger case series are needed to determine opti-mal treatment.
Here, we presented the patient whom we treated with a two-stage surgery in our clinic with a diagnosis of IVL, and which was reported as uterine sarcoma and thrombus in IVC in radiological imaging methods, before operations.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Denizhan Bayramoglu http://orcid.org/0000-0002-6183-8398 Atilla Orhan http://orcid.org/0000-0003-0110-3290
Ayhan Gul http://orcid.org/0000-0003-3681-8712 Gozde Sahin http://orcid.org/0000-0003-3067-9125
Zeliha Esin Celik http://orcid.org/0000-0002-3220-7845 Mustafa Koplay http://orcid.org/0000-0001-7513-4968 Cetin Celik http://orcid.org/0000-0001-6165-5092
References
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Figure 1. (A) The pre-operative CT view of the IVL which begins from the uterus and lying throughout right infundibulopelvic ligament, up to the entry of right renal vein in VCI. (B) Pre-operative axial, CT view of the IVL in VCI (shown by arrow). (C) Filling defect in VCI shown by angiography. (D) Vena cava filter (shown by arrow). (E) The excised infundibulopelvic ligament and right ovarian vein, which is in bigger than normal size, due to myomas filling inside.
