A silent intruder: intravenous leiomyomatosis extending to the heart and inferior vena cava

A 43-year-old female was admitted with a 10-day history of abdominal distension. She had a history of gravida 1, para 1 (G1P1), with no known history of uterine fibroids. Transthoracic echocardiography revealed a large hypoechoic mass (46 mm × 41 mm) in the right atrium (Panel A; Supplementary data online, Video S1), extending into the dilated inferior vena cava (29 mm). Abdominal computed tomography (CT) angiography showed an irregular mass extending from the right iliac veins into the inferior vena cava and right atrium, with partial tricuspid valve crossing during systole and heterogeneous enhancement (Panels B–E; Supplementary data online, Video S2). A large, heterogeneous mass (150 mm × 65 mm) was also seen in the right adnexa. These findings confirmed intravenous leiomyomatosis (IVL) with intracardiac extension. After multidisciplinary discussion, the patient underwent hysterectomy and right salpingo-oophorectomy, with postoperative histopathology confirming the imaging diagnosis (Panels F and G). The postoperative course was uneventful, and the patient was discharged 2 weeks later with no tumour recurrence over 4 years of follow-up. IVL is a rare benign condition characterized by the growth of smooth muscle tissue within veins, forming tumour thrombi. IVL is known for its unique venous growth pattern and low malignant potential, typically extending along blood vessels and rarely involving the inferior vena cava and heart. Early clinical manifestations and abdominal ultrasound findings are usually non-specific. Contrast-enhanced CT angiography highlights the unique imaging features of IVL, providing a clear visualization of the tumour’s extension, which is crucial for planning appropriate surgical interventions. Supplementary data are available at European Heart Journal - Cardiovascular Imaging online. Funding: This work was funded by the Wuhan Clinical Medical Research Center for Cardiovascular Imaging and the Open Fund of Imaging Center (project no. CMRC202302). Ethical approval: Hospital is exempted from ethics review in view of retrospective cases. Consent: This report has obtained the patient’s informed consent for the publication of their anonymised clinical data. Data availability: The data that support the findings of this study are available from the corresponding author.