A vena caval mass: A challenging Dx with a rare complication
The present case has been recently reported in the journal LANCET.

A 46-year-old woman with a history of chronic hepatitis B infection presented with a 1-month history of malaise and epigastric fullness. Blood tests showed that her serum creatinine concentration was elevated to 89 µmol/L with an estimated glomerular filtration rate of 69 mL/min/1·73m².

CT scan revealed a 7·1×6·8×6·5 cm inferior vena caval mass closely associated with the caudate lobe of the liver and an almost complete occlusion of the caval lumen. The preoperative differential diagnosis was hepatocellular carcinoma at the caudate lobe with inferior vena cava invasion, retroperitoneal sarcoma, or leiomyosarcoma of the vena cava that compromised venous return of both kidneys.

A tumor biopsy was not considered possible because of the deep tumour location and risk of bleeding from the inferior vena cava.

The tumour, together with the involved segment of the inferior vena cava, was surgically removed en-bloc with a right hepatectomy and caudate lobectomy. The inferior vena cava continuity was restored by an interpositional cadaveric iliac vein graft. Postoperative recovery was uneventful. The glomerular filtration rate was restored to above 90 mL/min/1·73 m².

Pathology confirmed a diagnosis of leiomyosarcoma with full thickness involvement of the inferior vena cava wall and focal protrusion into the inferior vena cava lumen with fibrin thrombus formation. No lymphovascular permeation was seen and the resection margin was clear.

Surveillance CT scan of the abdomen 1 month after surgery confirmed complete tumour clearance with patent inferior vena cava graft. Adjuvant chemoradiotherapy was declined by the patient. She remained well and disease-free at 4 months after surgery.

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