Intravenous Leiomyoma with Extension to Heart: A Case Report

Abstract

Leiomyoma is a benign smooth muscle tumor that very rarely becomes cancer. Uterine leiomyoma or uterine fibroid is a benign tumor of uterus arising from smooth muscle cells of myometrium. Intravenous leiomyoma with intracardiac extension is a very rare clinical entity usually develops exclusively in women arising from either uterine venous wall or uterine leiomyoma [1] which is commonly misdiagnosed as primary cardiac tumor, such as Myxoma. We report the case of 48 year old woman with intravenous leiomyoma arising from left common iliac vein and extended to the heart through the inferior vena cava presented with symptoms of hemodynamic disorder. The patient had the history of uterine fibroid. Thoracoabdominal CT was performed to finalize the diagnosis. The intravenous tumor with its extension to the right atrium was ultimately resected via cardiotomy without the need of prolonged hypothermia during cardiopulmonary bypass. Keywords:Myxoma; Cardiopulmonary bypass; Leiomyoma; Inferior vena cava Case ReportA 48 year old woman referred to our department from the department of obstetrics and gynecology who came for the routine checkup after showing a lesion in the right atrium which considered being a blood clot or a primary cardiac tumor. She had the history of total hysterectomy 5 years ago in a local hospital due to a large uterine fibroid. She was fine for the last 5 years after the surgery, but recently she started to have symptoms of breathlessness, swelling of lower limbs, intermittent abdominal pain and giddiness.On physical examination she was afebrile, conscious, cooperative, and normotensive with slight engorgement of the right jugular vein. Pelvic vascular ultrasound revealed thrombotic features in inferior vena cava and pelvic veins. On further investigation, computed tomography showed a large mass arising from the iliac veins, mainly the left side. It was confirmed that the patient has lesion arising from the pelvic veins and extended via the inferior vena cava up to the right atrium (Figures 1 and 2). After the proper and illustrative diagnosis, it was confirmed that the patient has a leiomyoma with extension to the right atrium. Patient was explained about her condition and the way of treatment. After the consent papers were signed, she was ready for the operation.The surgical approach was through median sternotomy. The usual process of establishing cardiopulmonary bypass was performed for any emergency purposes of mass bleeding. The aortic cannulation was done and connected to the extracorporeal machine with a single superior venous cannulation into the superior vena cava. The right atrium was palpated and felt the tumor. After the temperature was slightly

Point of care ultrasound facilitated diagnosis of right ventricular mass as the etiology of syncope; A case report of intravenous leiomyomatosis

“…However, while CT and MRI are considered to be the most sensitive imaging techniques in diagnosing IVL, bedside ultrasonography can play an important role in expediting the diagnosis of this pathology in the appropriate patients. Many studies have used transthoracic and transabdominal ultrasound as a supplemental imaging technique to identify intracardiac masses and uterus masses [2 , 5 , 11 , 17 , 20] . Depending on the degree of extension into the heart, ultrasound imaging can elucidate a free-floating echogenic mass within the right atrium in addition to echoic masses within the internal iliac vein and IVC indicative of IVL with intracardiac extension [21] .…”

“…Once intracardiac, patients may experience syncope, pulmonary embolism, or heart failure [9 , 10] . Because intracardiac extension of this tumor is clinically very rare and the clinical presentation of the condition can be similar to heart failure, it is often misdiagnosed as other cardiac tumors or malignant thrombus [11] . Consequently, IVL is frequently treated incorrectly without appropriate imaging or management.…”