AUCTORES
Globalize your Research
Case Report
*Corresponding Author: Zuilma Y. Vásquez-Ortiz MD, PhD. Echocardiography Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Vasco de Quiroga #15, Tlalpan, Mexico city. PC 14349.
Citation: Vásquez-Ortiz Zuilma Yurith, Fernández-Campos Beatriz A, Aceves-Velázquez Eduardo D, Ramírez-Cervantes Rolando D, Oseguera-Moguel, Jorge (2022). Extensive Intravascular Leiomyomatosis with Cardiac Involvement, Clinicopathological and Imaging Characteristics: A Case Report. J. Clinical Cardiology and Cardiovascular Interventions, 5(7); Doi:10.31579/2641-0419/266
Copyright: © 2022 Zuilma Y. Vásquez-Ortiz, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 25 April 2022 | Accepted: 17 May 2022 | Published: 01 June 2022
Keywords: intravascular leiomyomatosis; uterine myomatosis; heart failure; echocardiography
Intracardiac masses are a rare differential diagnosis in patients who present heart failure symptoms, these are classified by many authors as neoplastic or non-neoplastic, dependent or not on the heart chambers. Being able to differentiate and classify intracardiac masses is very important because treatment and prognosis depend on it. Intravascular leiomyomatosis is one of the rarest tumors, characterized by direct overgrowth of a uterine leiomyoma through adjacent veins with an unusual growth pattern. To date, less than 300 cases have been reported, with proliferation to the heart chambers being even rarer. We present the case of a female who presented to the emergency department due to dyspnea and palpitations, during his approach, a mass from the inferior vena cava was found causing intermittent tricuspid obstruction. Later it was documented as coming directly from the uterus, diagnosing intravascular leiomyoma by pathology.
Intravascular leiomyoma is a very rare benign neoplasia which depending on its extension can be asymptomatic until causing heart failure symptoms or pulmonary hypertension, the first imaging study indicated in heart failure symptoms is the transthoracic echocardiogram. The differential diagnosis of intracardiac masses must always be considered, although they are rare, their timely detection can lead to a better evolution of the patient.
Intravascular leiomyoma (IVL) is a rare benign neoplasia described first by Birsh-Hirshfeld in 1896 [1]. It´s characterized by the histological proliferation of benign smooth muscle cells through vascular structures without invasion of other tissues. Generally, IVL affects premenopausal and multiparous women, with symptoms depending on the site of origin (intrauterine venules or the myometrium) and the extent of invasion. There are no specific clinical manifestations of IVL, symptoms depend on the extension and size of the tumor, it can range from pelvic pain, abnormal uterine bleeding to infertility. If there is invasion to the cardiac cavities, it can cause fatigue, palpitations, chest pain, dyspnea, ascites, abdominal pain and hepatomegaly, syncope and even sudden death. [2,3] IVL has a serpentine appearance, proliferates throughout the venous system, but doesn´t invade it. Usually grows in the iliac veins or the inferior vena cava although there are very few reported cases with direct extension to the right atrium and causing symptoms of acute heart failure. [3,4]
A 51-year-old woman presented to the emergency department with progressive dyspnea of 2 weeks' duration progressing to rest (New York Heart Association Functional Class IV), palpitations, general state attack and lower limb edema. Five years ago, she was diagnosed with uterine myomatosis, morbid obesity, and mixed dyslipidemia. Transthoracic and transesophageal echocardiograms on admission showed a heterogeneous mass in the right atrium of large dimensions and regular borders, that emerged from the inferior vena cava, without adherence to the interatrial septum or other neighboring structures. This mass protruded into the right ventricle in each cardiac cycle, conditioning intermittent obstruction and tricuspid stenosis with a mean gradient of 8mmHg (Figure 1).
Once it was observed that the tumor came from the inferior vena cava, an abdominal contrast computed tomography (CT) was performed. CT showed a tumor originated in the uterus, adjacent to the anterior and lower left wall. The lesion was observed with 3.7 centimeters thick, tubular, and hypodense course, following a posterior and cephalic path, decreasing in caliber in the distal portion. The extension was observed starting through the left ovarian vein to the ipsilateral renal vein, which continued its course through the inferior vena cava showing filling defects until it falls into the right atrium. (Figure 2).
Faced with sudden hemodynamic deterioration, it was decided to undertake emergency surgery jointly by a multidisciplinary surgical team. An open resection of the right atrial tumor was performed in a single surgical time together with total abdominal hysterectomy and bilateral salpingo-oophorectomy to reduce tumor recurrence. Microscopic analysis demonstrated a uterine lesion with intertwined muscle bundles of spindle cells, homogeneous size, with oval nuclei with positive immunohistochemistry for smooth muscle markers (desmin and smooth muscle actin) and estrogens and progesterone, concluding leiomyoma, without evidence of malignancy. (Figure 3)
A1) Hematoxylin and eosin staining of uterine lesion with spindle-shaped cells and homogeneous size. B1) Hematoxylin and eosin staining showing abundant extracellular stroma and spindle cells, no cellular irregularities or nuclear pleomorphisms. C1) Immunohistochemical staining is positive for smooth muscle markers. D1) Intracavitary tumor is positive immunohistochemical staining for estrogen receptors.
IVL occur mainly in caucasian premenopausal women with an average age of 40 years (between 20 and 70 years) with history of uterine leiomyomatosis [1,5,6]. Less than 300 cases of IVL have been reported in the literature and only 10% have had repercussions with the
characteristics of our patient. [4,7] The specific etiology of IVL is not clear, and there are two theories to explain the existence of this neoplasia: One theory is that the leiomyomas originate from the uterine vein wall growing through the vessels. Another theory is the invasion projections of uterine fibroids into blood vessels [8] and they have been associated with high levels of estrogens. Intravascular extension can occur concomitantly with uterine leiomyomas or occur even years after hysterectomy [5]. IVL macroscopically has a serpentine appearance and can range in size from a few centimeters to half a meter or more. Is a benign tumor by histology; however, it can invade surrounding tissues and have a high rate of recurrence. Can grow along the veins or lymphatic vessels and in addition to the vena cava, these tumors can extend into the hepatic and renal veins or can even reach the pulmonary arteries [1,2]. The main differential diagnosis to consider is atrial myxoma. Is the most common benign primary tumor, reaching up to 70-80% of all. Most are found in the left atrium and originate from the interatrial septum. [7,8]
The echocardiogram is considered the first-line imaging modality for the evaluation of intracardiac masses, can provide real-time information, helps to characterize them and the hemodynamic repercussion they cause. IVL appear as a mobile solid myxomatoid mass and long intravascular serpentine. [4] It is visualized emerging through the inferior vena cava and limited to the right cavities without invading them. The most common location is the right atrium and depending on its length, can be as a floating mass or can protruding through the tricuspid valve into the right ventricle, even across pulmonary arteries. [2,4,5]
The Cardiac computed tomography (CCT) can provide additional information about the location and size, the invasion of intracardiac structures and the secondary effects on the cardiac anatomy. IVL are seen
as low-density tumors with a “snakelike” image, with mild heterogeneous enhancement and don´t generate invasion of contiguous structures. It can also be used to assess the origin and extension of the IVL, can be found as filling defects in the veins and thickening of the vessels. [2,8,9] Can also be found incidentally on abdominal CT taken for another reason, with no apparent impact on adjacent organs. To assess tumor spread Guotao Ma, et al. classified the IVL into 4 stages: Stage I, tumors penetrate towards the uterine venous wall, but is limited to the pelvic cavity; Stage II, tumors has extended into the abdominal cavity, but had not overtaken the renal vein; Stage III, tumors overtake the renal vein and inferior vena cava, and even penetrate into the right atrium, but had not reached the pulmonary arteries; Stage IV, tumors overtake the pulmonary arteries and/or lung metastases were observed. [9]
Histologically the intravascular tumor, which often has a lobulated contour, resembles a typical uterine leiomyoma, findings include endothelium-covered of uniform spindle-shaped smooth muscle proliferations within the vascular lumen with neoplastic cells that show minimal atypia and a low mitotic index (2, 4). Some reports have found estrogen and progesterone receptors in the extracted pieces, although they are not consistent, they are associated with a better prognosis. The cytogenetic study has revealed an abnormal karyotype with 45,XX,der(14)t(12;14)(q15;q24) in different studies, however its etiology remains unknown to date. [2,10]
The complete surgical resection of the tumor and its intravascular implants is the only current effective treatment. The extension of the surgery depends on the extension of the IVL, can be done in one or two times depending on the surgical risk of the patient. In patients who are not candidates for surgery or if the entire tumor will not be removed, hormonal therapy with antiestrogens can be used with variable results. [2,9,10] Due to the rareness of the pathology, the recurrence rate is not exactly known, which can reach up to 30-40%. This due to micro or macroscopic remnants after surgery or new growth. For this reason, follow-up imaging studies are suggested every 3 to 6 months, because recurrence can be faster and fatal than the primary tumor. [2]
Intracardiac tumors are a rare differential diagnosis that we must not forget in a patient with heart failure. The correct and appropriate diagnosis can influence the prognosis and survival of the patient. IVL should be considered when a right atrium mass is found and does not depend on the walls of the myocardium. Especially in patients between the fourth and fifth decades of life and history of hysterectomy, myomectomy or concomitant uterine leiomyomas. Evaluation by echocardiography is essential to determine the origin and extension of intracardiac tumors as well as the hemodynamic repercussion caused. High-resolution CT or MRI can be used to determine the origin and extent. Each imaging modality can provide different information about the lesion and is complemented by others. The complete removal of the tumor has shown excellent results together with a close follow-up to monitor recurrences and to be able to offer timely medical or surgical treatment. The factor that most influences this type of pathology is timely detection. Having a high level of suspicion and performing multimodality cardiovascular imaging protocols early has a positive impact on the prognosis of patients.
The authors declare no conflict of interest.
No grants, contracts, and other forms of financial support were required.
The authors have no disclosures to declare.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
