A 60‐year‐old, morbidly obese woman presented with one week of worsening left lower extremity (LLE) edema. She was tachycardic, but in no respiratory distress. Physical exam revealed pitting edema, warmth and erythema of the LLE and a firm, irregular and fixed periumbilical abdominal mass. Ultrasound confirmed a DVT extending from the external iliac distally, and CT showed a thrombus in the main pulmonary artery at the bifurcation extending distally bilaterally. The patient underwent staged catheter‐directed thrombolysis (CDT) procedures targeting the pulmonary arteries, IVC and LLE venous system with placement of an IVC filter. Additional workup revealed Factor V Leiden (FVL) heterozygosity, and abdominal CT showed a large uterine mass with central necrosis and bilateral hydronephrosis secondary to mass compression. Hysterectomy was delayed due to the PE, but progressively worsening renal function prompted discussion of a less invasive uterine artery embolization (UAE) procedure. Nephrostomy tubes were instead temporarily placed, and eventual surgery noted a 31 cm fibroid‐like uterine mass distorting pelvic anatomy. Subsequent pathology identified the mass as a lipoleiomyoma, but also revealed the diffuse presence of deeply infiltrative endometrial adenocarcinoma.
Lipoleiomyoma is a rare benign tumor defined histologically by the presence of mature adipocytes without atypia admixed with smooth muscle cells. There are no reports in the literature of the incidental discovery of endometrial adenocarcinoma following surgery for lipoleiomyoma. Venous and ureteral compression by this giant mass presented several difficult internal medicine management questions in the context of multiple venous thromboembolic (VTE) risk factors (FVL, malignancy) and hydronephrosis with renal compromise. CDT is a safe and effective option to treat such a dramatic clot burden with placement of an IVC filter appropriately indicated given treatment‐refractory DVT in this pre‐operative patient for whom PE recurrence would be catastrophic. Catheter‐directed UAE has been used successfully to treat symptomatic fibroids and offered an attractive possibility in our high surgical risk patient. However, limited data exists demonstrating comparable success between UAE and surgery in resolution of renal complications secondary to uterine obstructive uropathy.
More aggressive interventions like CDT are an appropriate option for triple‐threat VTE resulting from FVL, malignancy and venous stasis by mass compression. In the face of pre‐operative PE, UAE offers an appealing option in lieu of surgery for compressing uterine masses in particular. However, limited data on UAE and worsening obstructive uropathy leaves surgery the definitive treatment. Unfortunately, more data is also needed to guide the timing of management of patients with pre‐existing PE that require surgery, particularly when surgical delay potentiates VTE recurrence risk.
To cite this abstract:Campbell S, Gill B, Torres S. Saddle Pulmonary Embolism with Coexisting Giant Uterine Lipoleiomyoma and Endometrial Carcinoma. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 363. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/saddle-pulmonary-embolism-with-coexisting-giant-uterine-lipoleiomyoma-and-endometrial-carcinoma/. Accessed April 1, 2020.