Giant primary liposarcoma of the anterior mediastinum: A case report

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.

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%).

Giant Retroperitoneal Liposarcoma: Correlation Between Size and Risk for Recurrence

Soft tissue sarcomas (STSs) are rare tumors that represent almost 1% of adult malignant tumors. The annual incidence rate for such tumors is 2 - 5/100,000 population. The most common type of STS in adults is liposarcoma, which represents 15-20% of adult STSs. It is of mesodermic origin derived from adipose tissues, and known as the most common primary malignant tumor of the retroperitoneum. Other sites of involvement include the extremities, trunk and to a lesser extent the pleural cavity, esophagus, mediastinum and others. Due to the potential large retroperitoneal space, retroperitoneal liposarcoma (RPL) is usually asymptomatic during the initial phase, developing symptoms at a late stage due to large mass compressing nearby retroperitoneal structures. The average diameter and weight of RPL during diagnosis is 20 - 25 cm and 15 - 20 kg, respectively. Several factors were labelled as risk factors for recurrence, such as histological type, tumor grade, age, resectability and tumor size. Controversy exists regarding the relationship between tumor size and recurrence rate, thus, tumor size as a risk factor for recurrence should be clarified. Although there is no consensus regarding the precise definition of giant RPL, it is defined by several literatures as an RPL of greater than 30 cm in diameter or with weight of more than 20 kg. The main purpose of this article is to review the current English literature regarding giant RPL and examine the relationship between tumor size and risk for recurrence.

Mediastinal Liposarcoma With Anterior and Posterior Mediastinal Involvement: A Thoracic Oncovascular Case Report

A 64-year-old patient presented with shortness of breath and chest pressure. The initial examination was unremarkable, and a chest X-ray revealed a large mediastinal mass. Computed tomography (CT) scan demonstrated a lobulated mediastinal mass involving the great vessels and mass effect on the trachea, esophagus, and heart. A CT-guided biopsy showed a monotonous, evenly spaced population of mature, normal-appearing adipocytes consistent with a well-differentiated lipoma-like liposarcoma/atypical lipomatous tumor. The patient underwent a median sternotomy with en bloc tumor resection without adjuvant chemoradiation. Three-year follow-up CT imaging shows no evidence of tumor recurrence.

Imaging and Clinical Findings in a Series of Six Cases of Rare Primary Mediastinal Liposarcoma

Primary mediastinal liposarcoma is a rare, fat-containing malignant lesion that can manifest incidentally with varied imaging appearances. The size and location within the mediastinum can vary among patients. Here, the authors describe the clinical presentation, radiographic characteristics, management, and prognosis in a series of six patients with primary mediastinal liposarcoma. The following case series suggests that even simple-appearing fatty intrathoracic lesions may lead to the development of malignant imaging features. Keywords: Conventional Radiography, CT, MR Imaging, PET/CT, Soft Tissues/Skin, Thorax, Mediastinum ©RSNA, 2022.

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.

Pathological prognostic factors of retroperitoneal liposarcoma: comprehensive clinicopathological analysis of 124 cases

Background

Retroperitoneal liposarcoma (RLS) is a type of rare malignant tumor. The aim of the present study was to study the correlations between the clinicopathological characteristics and the prognostic factors of RLSso as to delineate independent pathological indicators affecting prognosis.

Methods

The RLS pathological specimens were collected at Beijing Shijitan Hospital Affiliated to Capital Medical University from 2008 to 2018, and were used to study the histopathological features, including tumor size, histological types, lymphatic metastasis, tumor emboli in the blood and lymph vessels, and nerve invasion; immunohistochemical features, including Ki-67 and P53 proteins; and molecular pathological features, such as MDM2 (murine double minute2) gene amplification. Clinical treatment and follow-up data were collected, and the survival rate was calculated by Kaplan-Meier method. Univariate and multivariate survival analyses were performed to study the independent pathological factors.

Results

Of the 124 RLS cases, 63 were males (50.8%) and 61 were females (49.2%), with a median age of 52 years (range, 22-80 years). There were 51 cases (41.1%) of well-differentiated liposarcoma, 73 cases (57.3%) of dedifferentiated liposarcoma (DDL); 3 cases (2.4%) with lymph node metastases; 4 cases (3.2%) with tumor emboli in the vessels; 21 cases (16.9%) with Ki-67 label index <20% and 103 cases (83.1%) with Ki-67 label index ≥20%; and 81 cases (65.3%) with P53 <60% and 43 cases (24.7%) with P53 ≥60%. Fluorescence in situ hybridization studies revealed MDM2 gene amplification. Univariate analysis found the following pathological factors were correlated with prognosis: histopathological classification, recurrence, mitosis, tumor necrosis, Ki-67 label index, and P53. Multivariate analysis by Cox proportional hazard model found the following three independent pathological prognostic factors: age [hazard ratio (HR): 1.798, P=0.018], tumor site (HR: 1.263, P=0.002), tumor necrosis (HR: 1.984, P=0.024), and recurrence (HR: 2.161, P=0.049).

Conclusions

Age, tumor necrosis, tumor site, and recurrence could be independent pathological prognostic factors for RLS.

Diagnosis and Prognosis of Retroperitoneal Liposarcoma: A Single Asian Center Cohort of 57 Cases

Background

Liposarcoma is a soft tissue malignancy, commonly observed in the extremities. However, retroperitoneal liposarcoma is seldom reported and its diagnosis is frequently neglected. This study aims to present the clinical characteristics, diagnosis, and prognosis of five liposarcoma subtypes and report our experience of patient treatment.

Methods

We conducted a single-center noninterventional retrospective study of 57 retroperitoneal liposarcoma patients admitted to Peking Union Medical College Hospital (PUMCH, Beijing, China) between July 2011 and December 2019. We collected and analyzed their demographic, clinical, imaging, histological, therapeutic, and prognostic data over a mean 4.5-year follow-up period.

Results

Twenty-five (44%) patients were asymptomatic prior to diagnosis, with abdominal distension as the chief complaint in 18 (32%) patients and abdominal pain observed in 16 (28%) patients. Masses were evaluated by computed tomography (n = 48, 84%) or ultrasound (n = 25, 44%). Laparotomy (n = 52, 91%) was the dominant therapeutic modality rather than laparoscopy (n = 5, 9%). All patients were treated with R0 resection except two patients who underwent R2 resection. We conducted regular follow-ups every six months after surgery for a mean duration of 4.5 years. Recurrence was experienced by 14 (25%) patients and a further 9 (16%) died during follow-up.

Conclusions

Abdominal distension and pain are chief complaints with liposarcoma. As the extremities are the main liposarcomas locations, the diagnosis of retroperitoneal liposarcoma is usually neglected. Since half of the patients are asymptomatic, timely diagnosis and treatment are highly dependent on regular ultrasound and computed tomography imaging. R0 resection is the key to retroperitoneal liposarcoma treatment. In comparison, patients who underwent R2 resection, which is considered a palliative treatment, had bad prognoses. Large, symptomatic dedifferentiated, and pleomorphic liposarcomas are more likely to have poor prognoses, while the prognosis for well-differentiated or myxoid liposarcoma is relatively good.

Successful intraoperative management in patients with abdominal compartment syndrome induced by giant liposarcomas: Two case reports

RATIONALE

Giant intra-abdominal liposarcomas weighing over 20 kg often increase the intra-abdominal pressure (IAP), which has severe effects on the cardiovascular and respiratory systems. Abdominal compartment syndrome is defined typically as the combination of a raised IAP of 20 mm Hg or higher and new onset of organ dysfunction or failure. The anesthetic management and perioperative management are very challenging.

PATIENTS CONCERNS

We presented 2 patients with rare giant growing liposarcoma of the abdomen, weighing 21 kg and over 35 kg, respectively. Circulatory management was particularly difficult in the first case, while respiratory management and massive blood loss was very challenging in the second one.

DIAGNOSIS

With a computed tomography scan and peritoneal-to-abdominal height ratio measurement, preoperatively the risk of developing intra-abdominal hypertension and abdominal compartment syndrome was recognized early in each patient. The inferior vena cava and right atrium of the first patient was compressed and malformed due to the uplifted diaphragm, while there was severe decreased lung volume and increased airway resistance, because of rare giant retroperitoneal liposarcomas in the second case. Histologic examination revealed dedifferentiated liposarcoma in both cases.

INTERVENTIONS

Both of the patients underwent resection surgery with multiple monitoring; transesophageal echocardiography monitoring in the first case and pressure-controlled ventilation volume guaranteed mechanical ventilation mode in both cases.

OUTCOMES

Intraoperatively and postoperatively no cardiopulmonary complications in both patients. The first patient was discharged without any complications on postoperative day 10, and the second patient underwent another surgery because of anastomotic leakage resulting from bowel resection.

LESSONS

Multiple monitorings, in particular transesophageal echocardiography should be considered in patients with increased IAP due to a giant mass, while an appropriate lung protection ventilation strategy is crucial in these patients.

Mediastinal liposarcoma masquerading as penetrating aortic ulcer in the descending aorta: a case report

A 56-year-old woman with a history of hypertension and cerebral infarction was admitted to the hospital complaining of progressive and severe chest pain for 1 day. CT scan revealed a descending penetrating ulcer. Accordingly, she underwent an uneventful endovascular repair with a thoracic endograft. One month later the patient presented to our clinic with chest and back pain again. The contrast CT indicated that the periaortic mass grew larger, which interpreted as hematoma resulting from endoleak. But no endoleak was found by angiography. CT-guided needle biopsy was carried out, the histology of the mass revealed a pleomorphic liposarcoma. Liposarcomas are malignant fat-containing tumors derived from mesenchymal cells that typically occur in the extremities and retroperitoneum, mediastinal liposarcoma account for less than 1% in mediastinal malignancies; pleomorphic liposarcoma is the least common liposarcomas. Cases of liposarcoma invading vascular system are seldom, to our knowledge, it is the first case of mediastinal pleomorphic liposarcoma invaded the descending aorta. It is worth mentioning that in the modern endovascular era, the majority of aortic diseases are being repaired by endovascular techniques. When patients with growing periaortic mass post endovascular repair and endograft-related causes have been excluded, the rare possibility of mediastinal liposarcoma should arise as a differential diagnosis. Promptly CT-guided biopsy help establish an early diagnosis.