Resection of Primary Leiomyosarcoma of the Inferior Vena Cava and Reconstruction with a Cadaveric Homograft

Abstract

Background: Leiomyosarcoma (LMS) is a rare malignancy arising from the smooth muscle, which affects the inferior vena cava (IVC) in 30-40% of cases; the cure relies on complete surgical resection,¹ demanding meticulous oncological and vascular planning. The efficacy of preoperative chemotherapy is currently under investigation.² Restoration of vessel continuity and blood flow must be tailored to each individual case. This video presents an IVC LMS case, in which the retroperitoneal sarcoma (RPS) six-stage procedure³ was customized for LMS, with IVC flow restored using a cadaveric aortic homograft.

Patients and methods: A 64-year-old woman presented with a 6 cm IVC mass with neoplastic thrombosis and intense PET uptake. Suspecting an IVC LMS, the tumor board recommended up-front surgery.

Results: An en bloc resection of the tumor and the involved IVC segment II-III with homograft interposition was performed. The procedure involved division of the right gonadal, caudate lobe, lumbar and left adrenal veins; isolation of the IVC and renal veins; followed by cross-clamping and resection under vascular control with hemodynamic stability and no need for veno-venous bypass. Frozen margins on the IVC and renal veins were negative. Blood flow was restored using a cryopreserved cadaveric aortic homograft, trimmed to the appropriate length and implanted end-to-end on the IVC. The right renal vein was anastomosed end-to-side on the graft, while the left renal vein was reconnected using a jump graft crafted from the remaining portion of the cadaveric graft.

Conclusions: Resection of retroperitoneal leiomyosarcoma requires both oncological and vascular expertise to achieve optimal curative outcomes and restore physiological vascular flow when necessary.