Case report: Benign yet aggressive: Intravascular extension of leiomyoma

Intravascular leiomyomatosis (IVL) is a rare, histologically benign condition characterized by the growth of smooth muscle tumors within vascular channels, often mimicking malignant behavior due to intravascular and potential cardiac extension. Despite its benign nature, IVL poses diagnostic and therapeutic challenges due to nonspecific symptoms and understudied malignant potential.

A 47-year-old woman presented with a significant uterine mass and suspected sarcoma, accompanied by tumoral thrombosis extending from the left ovarian to the renal vein. She underwent total hysterectomy with bilateral salpingo-oophorectomy and ligation of the left uterine vein, enabling complete thrombus extraction. Histopathology confirmed IVL, highlighting its unique vascular invasion despite benign histology.

IVL's aggressive growth necessitates complete surgical resection to prevent recurrence, as incomplete resection correlates with higher progression risk. Multidisciplinary collaboration is critical, particularly for cardiac involvement, to ensure safe tumor extraction and avoid catastrophic complications. Prognostic studies identify age ≤ 45 and incomplete resection as key recurrence factors, while postoperative hormone therapy (e.g., bilateral oophorectomy) may reduce relapse in estrogen-sensitive cases. Imaging modalities like MRI and CT are pivotal for preoperative planning and differential diagnosis from thrombi or malignancies.

This case underscores IVL's diagnostic complexity and the imperative for radical resection and multidisciplinary management. Increased awareness among gynecologic and cardiovascular specialists is essential to optimize outcomes for this rare, clinically aggressive entity.