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

Abstract

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