Surgical resection of a giant primary liposarcoma of the anterior mediastinum

Mediastinal liposarcoma: a case report and review of the literature

BACKGROUND

Mediastinal Liposarcoma (ML) is an exceedingly rare neoplasm, accounting for less than 1% of all liposarcomas. Surgical resection is the most effective therapeutic modality, while adjuvant radiation therapy may be recommended for unresectable tumors.

CASE PRESENTATION

This case report presents a rare case of a 52-year-old Syrian male patient with well-differentiated mediastinal liposarcoma (ML) who presented with exertional dyspnea, cough, and weight loss. Imaging studies revealed a large tumor causing extrinsic compression on the right lung, as well as compression of the heart and great vessels. CT-guided biopsy confirmed a diagnosis of well-differentiated liposarcoma, and the patient underwent surgical resection. The patient had a rapid postoperative recovery and was discharged on the fourth day post-operation, displaying an excellent postoperative status. The patient was followed up for 3 months postoperatively with no recurrence.

CONCLUSION

This report highlights the significance of incorporating ML into the differential diagnosis of mediastinal masses, particularly in individuals presenting with exertional dyspnea and weight loss. Furthermore, this report provides a comprehensive review of previously reported cases of ML in the medical literature.

Clinicopathological Features of Intrathoracic Liposarcoma-A Systematic Review with an Illustrative Case

BACKGROUND

Liposarcoma (LPS) is one of the most common soft-tissue sarcomas. However, intrathoracic LPS is rare, as only 1% of all LPS cases are found in the thorax.

METHODS

A systematic literature review through PubMed and Embase databases was performed. Only eligible case reports and case series reporting intrathoracic LPS in adult patients were included. Kaplan-Meier curves were calculated to evaluate the survival rate of included patients based on the histological subtype of LPS.

RESULTS

123 studies reporting 197 patients were included. We added a case of a 69-year-old female patient with recurrent giant intrathoracic LPS. The primary tumor measured 15.1cm × 22.9 cm × 21.9 cm and weighed 3100 g. Six months later, the patient was admitted to the hospital with another intrathoracic tumor measuring 9.5 cm × 9 cm× 1.4 cm. The immunohistochemical studies showed expression of murine double minute 2 (MDM2) antigen in both primary and recurrent tumor cells.

CONCLUSIONS

Dyspnea, chest pain, and cough were the most common symptoms reported in included studies. Overall, the 5-year survival rate was 62%. The highest survival was observed in well-differentiated LPS patients (80%) and the lowest in myxoid LPS (31%).

Trends, Symptoms, and Outcomes of Resectable Giant Mediastinal Tumors

Describing the changes in surgical procedures and factors affecting the surgical outcome of patients who have undergone complete resection of giant mediastinal tumors (GMTs, diameter ≥ 10 centimeters) could improve preoperative decision-making and prognostic evaluations. We accessed data from three sources, which are case reports on surgical treatment of GMTs from PubMed, Web of Science, and EMBASE until June 1, 2019; patients with resected GMT from the Surveillance, Epidemiology, and End Results (SEER) database; and retrospective review of medical records in our institution from 2000 to 2019. The worldwide distribution, clinicopathological characteristics, symptom profile, prognosis of patients with GMT resection, and nomogram for surgical outcome prediction are reported. A total of 242 rare GMT cases from four continents (Asia, North America, South America, and Europe) were included. The median age of the patients was 40 (IQR: 27, range: 13–83) years, and the male-to-female ratio was 1.57:1. Dyspnea, shortness of breath, cough, and chest pain or discomfort were the major symptoms at presentation. The prognosis of benign and low-grade malignant GMTs was superior to that of high-grade malignant GMTs. Tumor malignancy played the most critical role in predicting postoperative survival, followed by longest tumor diameter and a posterior mediastinum location. The findings of this study suggest that the number of successful GMT surgeries has increased over the last decade and describe clinical features of GMTs. Physicians should prioritize tumor malignancy as a leading factor in predicting outcome rather than tumor size.

Primary mediastinal dedifferentiated liposarcoma: Five case reports and a review

Background

Liposarcoma has been subclassified histologically into well‐differentiated, myxoid, pleomorphic, and dedifferentiated types. The dedifferentiated type generally shows poorer prognosis than the well‐differentiated type. Because of its rarity, the clinicopathological features and clinical outcomes of primary mediastinal dedifferentiated liposarcoma remain unclear.

Methods

Five patients with primary mediastinal dedifferentiated liposarcoma were treated at Shinshu University Hospital between January 2012 and August 2017. We investigated the clinical characteristics, including age, gender, radiographic findings, pathological status, and clinical and treatment outcomes.

Results

Four of the five patients initially underwent radical surgical resection. One patient was disease‐free after surgery, but the remaining three patients developed local recurrence in the mediastinum after surgical resection. Two of these patients underwent repeat surgical resection, resulting in long survival (60 and 40 months, respectively), while the other underwent proton beam therapy and showed no evidence of recurrence as of 17 months after treatment. The remaining patient was treated with chemotherapy using doxorubicin because of advanced inoperable disease, but failed to show a response and died within a month of the initiation of chemotherapy. Although the maximum standardized uptake values on fluorodeoxyglucose‐computed tomography were relatively low, there was a slight positive relation between these values and the Ki‐67‐positive ratio in the tumor.

Conclusion

Aggressive treatment by surgical resection should be considered for mediastinal dedifferentiated liposarcoma, even in cases with local recurrence.

Devascularization of the superior mesenteric vein without reconstruction during surgery for retroperitoneal liposarcoma: A case report and review of literature

A 61-year-old female patient with chronic hepatitis B virus infection was diagnosed with liposarcoma in a community hospital. Fine needle aspiration biopsy confirmed the diagnosis of well-differentiated liposarcoma. Abdominal computed tomographic angiography (CTA) showed that the mass adhered to and constricted the main trunk and branch of the superior mesenteric vein (SMV), especially the ileocolic vein, and collateral circulation was observed during the vascular reconstruction scan. The abdominal liposarcoma was resected. Because of the collateral circulation, devascularization of the SMV was attempted, and we resected the eroded SMV. The condition of the blood vessels was evaluated 20 d after surgery using CTA, which showed that the SMV had disappeared. Significant improvements in SMV collateral circulation and the inferior mesenteric vein were observed after vascular reconstruction. The patient had an uneventful postoperative course except for transient gastroplegia. Twenty months after surgery, the patient had a recurrence of liposarcoma. She underwent tumor resection to remove the distal small intestine and right hemicolon. We learned that (1) direct devascularization of the main SMV trunk without a vein graft is possible. The presence of collateral circulation can increase the success rate of patients undergoing radical surgery and prevent the occurrence of serious postoperative complications. In addition, (2) this case demonstrated the clinical value of 3D reconstruction.

Resection of giant mediastinal liposarcoma via '⊣ shape' incision

Primary mediastinal liposarcomas are extremely rare conditions often resected through standard median sternotomy or lateral thoracotomy. However, the management of a very huge mediastinal tumor involving hemithorax through these two common surgical approaches is always challenging. Herein, we report a case of applying median sternotomy with a sternum transection plus a right fourth intercostal thoracotomy (‘⊣ shape’ incision) to resect a giant primary anterior mediastinal liposarcoma extending into the whole right thorax. The final pathological diagnosis was a well-differentiated liposarcoma. The patient experienced an uneventful recovery. The ‘⊣ shape’ incision is a good backup for the extension of standard median sternotomy and provides a better exposure for both mediastinum and hemithorax.