Contrast-enhanced endoscopic ultrasonography for diagnosis of leiomyosarcoma of the inferior vena cava

Abstract

Figures

Contrast-enhanced computed tomography scan showed a mass of approximately 7 cm in diameter in the right retroperitoneum.

Endoscopic ultrasound showed a 7-cm hypoechoic mass originating from the inferior vena cava.

Contrast-enhanced endoscopic ultrasonography showed a heterogeneous hyper-enhancing pattern into the lesion.

Histopathology of tissue mass samples by endoscopic ultrasound-guided fine-needle aspiration. a Original magnification of hematoxylin and eosin stain (×5). b Local magnification showed large areas of spindle cells (×200). c Tumor cells showed diffuse SMA expression (×200). d Tumor cells showed negativity for CD34 (×200).

Full text

Endoscopic ultrasound (EUS) has become an important diagnostic tool for various diseases 1 . Contrast-enhanced (CE)-EUS has emerged as an effective technique that is complementary to conventional EUS and allows visualization of microvessels and parenchymal perfusion, and more accurate characterization of the lesion 2 .

We report the case of a 46-year-old woman with abdominal pain. On a contrast-enhanced computed tomography scan, a mass of approximately 7 cm in diameter was discovered in the right posterior peritoneum, with compression of the duodenum and inferior vena cava (IVC) ( Fig. 1 ). We decided to perform CE-EUS for this patient ( Video 1 ).

Contrast-enhanced computed tomography scan showed a mass of approximately 7 cm in diameter in the right retroperitoneum.

Contrast-enhanced endoscopic ultrasonography for diagnosis of leiomyosarcoma of the inferior vena cava.Video 1

On CE-EUS, we discovered a solid hypoechoic lesion originating from the IVC wall, independent of the duodenum ( Fig. 2 ). After injection of contrast reagent (Sonovue; Bracco, Milan, Italy), the lesion showed heterogeneous hyper-enhancement into the lesion ( Fig. 3 ). For a pathological diagnosis, EUS-guided fine-needle aspiration (EUS-FNA) of the lesion was performed with a 22-gauge needle (SharkCore; Medtronic, Minneapolis, Minnesota, USA).

Endoscopic ultrasound showed a 7-cm hypoechoic mass originating from the inferior vena cava.

Contrast-enhanced endoscopic ultrasonography showed a heterogeneous hyper-enhancing pattern into the lesion.

Histological examination revealed an abnormal high proliferation of spindle cells, obvious nuclear atypia, and mitotic activity. The immunohistochemical stains revealed positivity for B-cat, EMA, and SMA, and negativity for CD34, CD117, CgA, S100, SOX11, and SYN ( Fig. 4 ). We suspected a malignant spindle cell tumor originating from the IVC, most compatible with leiomyosarcoma. The patient accepted surgical resection and vascular reconstruction.

Histopathology of tissue mass samples by endoscopic ultrasound-guided fine-needle aspiration. a Original magnification of hematoxylin and eosin stain (×5). b Local magnification showed large areas of spindle cells (×200). c Tumor cells showed diffuse SMA expression (×200). d Tumor cells showed negativity for CD34 (×200).

Finally, the specimen confirmed the diagnosis of leiomyosarcoma. Immunostains showed diffuse positivity for caldesmon, calponin, desmin, EMA, and SMA but negativity for CD10, CD34, CD117, Muc-4, S100, and STAT6.

Primary leiomyosarcoma of the IVC is a rare soft tissue sarcoma 3 . This is the first instance where CE-EUS was applied in the preoperative diagnosis of IVC leiomyosarcoma. The essential role of CE-EUS and EUS-FNA in evaluating IVC leiomyosarcoma preoperatively is remarkable.

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