Leiomyosarcoma of the middle segment of the inferior vena cava: tactical problems raised by renal and caval revascularisation

INTRODUCTION: Leiomyosarcoma of the inferior vena cava is mesenchymal tumor accounting for 95% of primary tumors of the vena cava. Characteristic features include late invasion of adjacent structures and metastases, and delayed diagnosis. OBSERVATION: We report a case of inferior vena cava (IVC) leiomyosarcoma (LMS) found in a 53 year-old man who complained of abdominal pain. Morphologic exams found a very large polycyclic mass in the inferior vena cava involving the middle segment of the vena cava extending from the renal veins to the hepatic veins. An "en bloc" resection of the tumor was achieved. Caval outflow was restored using a ring-reinforced PTFE tube graft, the left renal vein was ligated and not re-implanted, the right renal vein was implanted in a lumbar sub-renal vein using a short prosthesis. Pathological examination documented a grade II leiomyosarcoma of the inferior vena cava and the patient was given adjuvant chemotherapy (anthracycline). One year later, there was no local or regional relapse. COMMENT: We emphasize the importance of restoring caval outflow which provides effective results when used with a ring-reinforced polytetrafluoroethylene (PTFE) prosthesis. Furthermore, the importance of restoring right renal outflow is highlighted because ligature of the renal vein can lead to renal ischemia and nephrectomy which should only be performed in specific cases. The tactical problems of renal and caval revascularisation, including the place of prosthetic replacement, are discussed.