Unique 9-cm Tumor Thrombus Extension to the Heart in Metastatic Recurrence of Endometrial Stromal Sarcoma

A 51-year-old Saudi woman presented with chronic lower back pain, which started six months ago. The patient reported occasional complaints of postural dizziness associated with Pre-syncope attacks, pleuritic chest pain, and shortness of breath. Past surgical history was notable for total abdominal hysterectomy and bilateral salpingo-oophorectomy for LG-ESS 12 years ago. The imaging findings are strongly suggestive of a metastatic recurrence of LGESS with vascular invasion. The tumor thrombus extends from the common iliac vein into the inferior vena cava (IVC) and reaches the right atrium, indicating advanced disease. Despite previous tumor resection, the propensity of LGESS for recurrence and its affinity for venous invasion is evident. Enhanced CT performed showed an intracardiac larger thrombus within the right atrium extending into the inferior vena cava and common iliac veins. MRI showed expansion of the IVC by the filling defect with post-contrast enhancement of the tumor thrombus: leiomyosarcoma with tumor, RCC with tumor, uterine leiomyoma with vascular, primary IVC, bland The patient was referred to vascular surgery as a case of intravascular mass, most likely secondary to metastatic LG-ESS. The patient underwent cytoreduction of the intravenous tumor through thoracotomy and laparotomy done by multidisciplinary team members including cardiac surgery, vascular surgery, and gynecology surgery. Final histopathology confirmed metastatic LG-ESS of the right atrium, inferior vena cava, and common iliac veins.