Multidisciplinary Surgical Approach to a Locally Advanced Leiomyosarcoma of the Right External Iliac Vein.

Abstract

Soft tissue sarcomas are rare mesenchymal tumors accounting for less than 1% of all cancers, originating intra-abdominally or retroperitoneally in 40% of cases.¹ Leiomyosarcomas are among the most common retroperitoneal sarcomas (RPS), with surgery as primary treatment option whenever an R0 resection is feasible.² Taken into account the concept of histology-guided surgery for RPS, surgery for leiomyosarcomas often does not require wide resections, allowing preservation of adjacent organs when not directly infiltrated.³ Nevertheless, high-grade leiomyosarcomas of abdominal major vessels may require extendend multi-organ resections and complex reconstructions, thus requiring a multidisciplinary surgical approach.^4-8 All these factors highlight the need to manage such cases in referral centers.⁹ METHODS: We present the case of a 65-year-old patient with a locally advanced leiomyosarcoma of the right external iliac vein, infiltrating the ipsilateral external iliac artery, ureter and psoas major muscle. After multidisciplinary discussion, the patient underwent surgery with removal of the mass en bloc with infiltrated structures. The reconstructive phase was carried out with the assistance of vascular surgery and urology teams. The postoperative course was complicated by a ureterovesical anastomotic leak, treated conservatively. This video demonstrates the step-by-step radical removal of a locally advanced vascular leiomyosarcoma, highlighting the related critical aspects of vascular control and complex reconstructions, as well as the importance of management of these cases in referral centers and with a multidisciplinary surgical approach. Although surgical management of locally advanced vascular leiomyosarcomas is often challenging, a multidisciplinary approach and adequate surgical expertise can reduce surgery-related risks and lead to improved outcomes.