Challenges in diagnosing aortic leiomyosarcoma post endovascular repair of abdominal aortic aneurysm

Figures

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  Fig 1. Preoperative computed tomography (CT) angiogram (CTA) in 2012 with innocent looking homogenous thrombus within the abdominal aortic aneurysm (AAA) and no alarming findings in the aortic sac or periaortic tissue (A) CTA axial view, documenting AAA with thrombus and no alarming findings in the aortic sac. B, CTA coronal view, documenting AAA with thrombus along the lateral aortic wall, the thrombus appears homogenous without any suspicion of any abnormality. C, CTA sagittal view, documenting AAA with thrombus along the anterior and posterior aortic wall, the thrombus seems to be homogenous without any suspicion of any abnormality.

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  Fig 2. Preoperative and postoperative operative three-dimensional (3D) reconstructed scans. A, Preoperative 3D reconstruction scan in 2012. B, Post endovascular aneurysm repair (EVAR) follow-up scans in 2016, showing normal appearing aorta with the EVAR stent. C, Post redo EVAR and representation in 2019, showing lack of contrast through the left limb of the EVAR graft.

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  Fig 3. Abdominal/gluteal computed tomography (CT) and positron emission tomography (PET) scans. A, CT scan showing an increase in the sac size to 7.4 cm. B, CT scan showing the changes in the contour of the vessel along with thrombosis of the left main limb of the graft. C, D, PET scan showing high fluorodeoxyglucose avidity in the aorta and active nodule in the right gluteal region.

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  Fig 4. Hematoxylin and eosin histopathologic sections. A, The tumor is highly cellular and composed of spindle cells in sheath, showing nuclear atypia and abundant mitoses (magnication 40 HPF). B, Low-power view of the tumor with adjacent tumor necrosis (magnication 10 HPF). C, High-grade epithelioid appearance of the tumor (magnication 40 HPF). D, Actin immunohistochemistry showing the spindle and the epithelioid component of the tumor strongly positive for smooth muscle actin (magnication 10 HPF).