Summary: Work-up included laboratory evaluation for hypercoagulable state
along with imaging workup for occult malignancy as a possible cause
of Trousseau syndrome. Initial ultrasonographic abdominal survey
reveals right hydronephrosis (not shown) and CT was recommended
(figure 1). Figure 2 is a vena cavagram at the time of IVC filter
placement and figure 3 is microscopic section of an aspiration
biopsy.
Diagnosis
Leiomyosarcoma of the inferior vena cava (IVC) (IVC sarcoma)
Findings
The IVC is patent at the level of the renal vein. Right
hydronephrosis is demonstrated (figure 1A). More inferiorly, a
large 5 cm heterogeneously enhancing retroperitoneal mass extends
from the renal hilar level to the iliac bifurcation (figure 1B),
centered within and obliterating the IVC. The intraluminal filling
defect surrounded by contrast above the iliac bifurcation (figure
1C) could represent an intraluminal component of the tumor mass or
bland thrombus.
The patient underwent successful biopsy of the mass
percutaneously with CT guidance. The aspirates and cell block
(figure 3) demonstrate pleomorphic and cohesive groups of spindle
cells, which are positively stained with vimentin and muscle
specific actin (special stains not shown) indicating spindle cell
neoplasm of smooth muscle differentiation, highly suspicious for
leiomyosarcoma.
Laboratory evaluation confirmed antiphospholipid antibody
syndrome, which, in combination with the IVC sarcoma, contributed
to his recurrent and progressive DVT despite appropriate coumadin
therapy. Because of retroperitoneal bleeding related to the biopsy
procedure and the concern of possible pulmonary embolism, a
suprarenal Greenfield stainless steel IVC filter was inserted. The
vena cavogram. at the time of filter placement (figure 2) shows
complete occlusion of the IVC just below the renal vein
orifices.
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