Resection of giant mediastinal liposarcoma via '⊣ shape' incision

The significance of a 'T shaped' incision for resection of giant mediastinal tumors: a case report

A 37-year-old male, with a 5-year history of liposarcoma of the right thigh, was incidentally diagnosed with two huge thoracic metastases following a fall. One of these masses, measuring 22 cm, was located in the right chest apex, adjacent to a second 20 cm mass situated in the anterior mediastinum, partially invading the left chest. The patient underwent surgical intervention for mass resection that commenced with a hemi-clamshell incision, but was then extended by completing the lower median sternotomy in order to create a T shaped incision. This type of incision provides ample access for large mediastinal tumors that extensively extend into one side of the thoracic cavity, encompass the anterior mediastinum, and partially reach into the opposite cavity. It enhances visualization, facilitates access to vital organs, allows for precise surgical maneuvers, minimizes the risk of inadvertent tissue damage, and enables thorough oncological resection.

Perioperative strategies and management of giant anterior mediastinal tumors: a narrative review

Background and Objective

Giant anterior mediastinal tumors sometimes may cause circulatory collapse and respiratory failure, known as mediastinal mass syndrome (MMS). The prediction and prevention of MMS is challenging. The aim of this study is to summarize the evaluation methods for MMS and formulate treatment strategies for giant anterior mediastinal tumors.

Methods

We performed a thorough analysis of recent international literature on giant anterior mediastinal tumors (>10 cm in diameter) and MMS published in the PubMed database. The search spanned the duration of the preceding 10 years from August 19, 2023, and only studies published in English were included.

Key Content and Findings

Mature teratomas and liposarcomas are the most common giant anterior mediastinal tumors and MMS develops most frequently in case of malignant lymphomas. Here, we propose a new treatment strategy for giant anterior mediastinal tumors. Based on imaging findings, giant anterior mediastinal tumors can be classified as cystic or solid and further blood investigation data are useful for a definitive diagnosis. When malignant lymphoma or malignant germ cell tumor is highly suspected, the first choice of treatment is not surgery but chemotherapy and radiotherapy. Moreover, image-guided drainage may be effective if giant cystic anterior tumors develop into MMS. The risk classification of MMS is important for treating giant anterior mediastinal tumors. If the MMS risk classification is 'unsafe' or 'uncertain', the intraoperative management deserves special attention. The surgical approach should however be based on tumor localization and invasion of surrounding tissues. Multidisciplinary team coordination is indispensable in the treatment of giant anterior mediastinal tumors.

Conclusions

When giant anterior mediastinal tumors are encountered, it is important to follow the appropriate treatment strategy, focusing on the development of MMS based on imaging findings and symptoms.

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.

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.

Resection of a giant mediastinal atypical lipomatous tumor involving the esophagus

Liposarcoma is one of the common soft tissue tumors but barely arises from the mediastinum. Complete surgical resection with a negative surgical margin is required for the treatment; however, mediastinal liposarcomas tend to be large due to its slow-growing nature. A 57-year-old man was referred to us for having an abnormal mediastinal shadow in a chest X-ray. Computed tomography scanning revealed a giant posterior mediastinal tumor, completely involving the esophagus. Because of the unusual size and location of the tumor, we took a bilateral video-assisted thoracoscopic approach. First, the soft lipomatous compartment of the tumor was dissected from the esophagus and the descending aorta via the left thoracic cavity complete thoracoscopic procedure. Then, the patient was placed in the left lateral position, and the solid part of the tumor was completely resected using 13 cm of right-side thoracotomy. There was no complication or local recurrence in the first 26 months of follow-up.

Surgical treatment of giant mediastinal tumors

Background

This study aims to evaluate the surgical treatment outcomes of giant mediastinal tumors.

Methods

Between July 2013 and July 2018, medical data of a total of 31 patients (26 males, 5 females; mean age 27.7±8.2 years; range, 18 to 56 years) who underwent radical surgery for a giant mediastinal tumor in our center and 47 cases (26 males, 21 females; mean age 45.4±16.7 years; range, 19 to 62 years) of giant mediastinal tumors retrieved from the National Center for Biotechnology Information database were retrospectively reviewed. Two-year overall survival and disease-free survival rates of the patients were evaluated.

Results

All patients underwent radical surgery (R0 resection). Symptoms caused by giant mediastinal tumors were relieved after radical surgery during follow-up. The two-year overall survival and disease-free survival rates were 100% and 86.7%, respectively, indicating a good prognosis. The surgical procedures for malignancies were more difficult than those for benign pathologies.

Conclusion

Radical surgery is the mainstay for treatment of giant mediastinal tumors to relieve symptoms in a short period of time and to achieve a good prognosis for up to two years, regardless of adjuvant therapy. The surgical route should be cautiously planned before radical surgery to reduce complications.

Successful removal of giant mediastinal lipoma and liposarcoma involving both chest cavities: Two case reports

RATIONALE

Surgical removal of a giant mediastinal lipoma or liposarcoma involving both chest cavities is always challenging.

PATIENT CONCERNS

We present 2 cases of giant mediastinal tumor, one of which was a 22-year-old female who was admitted to our hospital due to a mild dyspnea after running. Computed tomography (CT) scan revealed a large mass with low density occupying the entire right hemithorax and extending anteriorly into the left. The other patient was a 43-year-old male, who was presented to the hospital with complaints of gradually progressive dyspnea. CT scan revealed a mass comprised of fat density with areas of soft-tissue density in-between, involving in both chest cavities, draping around the heart and great vessels.

INTERVENTIONS

Both of the patients receive complete resection through a standard median sternotomy.

DIAGNOSES

Histologic examination revealed lipoma for the first patient, and well differentiated liposarcoma for the second.

OUTCOMES

Both of their symptoms were improved after surgery and the postoperative courses were good.

LESSONS

Our experience indicated that complete surgical removal through a standard median sternotomy is a safe and efficient approach for the treatment of giant mediastinal lipoma and liposarcoma.