Evolution of Pleural Solitary Fibrous Tumors Causing Severe Hypoglycemia after Exceptionally Long Asymptomatic Periods: Report of Two Surgical Cases

Non-islet cell tumor hypoglycemia (NICTH) is one of the paraneoplastic syndromes manifesting severe hypoglycemia caused by aberrant production of high-molecular-weight insulin-like growth factor 2 (big-IGF2). Two surgical cases of extremely large thoracic solitary fibrous tumors (SFT) with unusual history of NICTH are presented. One case manifested severe hypoglycemia after four years of the first complete surgical resection of the tumor with potential malignant transformation, and the other case showed severe hypoglycemia after ten years of the first detection of the tumor. Meticulous laboratory testing, including serum endocrinological tests and western immunoblotting before and after surgery was performed, and both cases were diagnosed as NICTH. Both patients underwent open thoracic surgery. The patients showed normal glucose and hormone levels immediately after the resection of responsible tumors with elevated blood insulin concentration. SFTs are generally considered benign; however, life-threatening hypoglycemia can happen regardless of treatment. Careful follow-up of the tumor growth is warranted.

[Rapidly growing giant solitary fibrous tumor of the pleura]

A pleura solitaer fibrosus tumora viszonylag ritkán előforduló, mesenchymalis sejtekből kiinduló daganat. A legtöbb beteg még nagy tumorméret ellenére is sokáig teljesen tünetmentes. Általában jóindulatú, ám gyakori a lokális recidíva, így különösen fontos az ép széllel történő eltávolításuk. Esetünkben a 77 éves férfi beteget nehézlégzéses panaszok miatt készült mellkasi röntgenfelvétel alapján szűrték ki. A mellkas-CT-vizsgálat egy jobb oldali, rekesz fölötti, éles szélű, dorsalisan elhelyezkedő terimét írt le. Transthoracalis ’core’ (vastagtű-) biopszia történt, mely igazolta a pleura solitaer fibrosus tumorát. Műtét során egy 17 × 16 × 5 cm-es tumort in toto sikerült eltávolítani. Az enyhe tünetekkel jelentkező betegek mellkasröntgen-felvételén látott homogén, éles szélű elváltozások kapcsán gondolni kell a solitaer fibrosus tumor lehetőségére. Mivel kialakulhat a szövettanilag benignus solitaer fibrosus pleuratumor malignus transzformációja, a műtét során teljes reszekcióra kell törekedni. A lokális recidíva lehetősége miatt a beteg szoros klinikai és radiológiai utánkövetése javasolt. Orv Hetil. 2024; 165(19): 754–758.

Solitary fibrous tumor of the pleura with air cystic component

We present an uncommon case of a solitary fibrous tumor of the pleura with the appearance of an air-containing cystic mass. We discuss the differential diagnosis through the imaging findings, the hypothetical origins of the air component, and the possible relationship between the air component and the aggressivity of the tumor.

Occult solitary fibrous tumour of the pleura presenting as recurrent spontaneous pneumothorax

A woman in her 30s, non-smoker, presented at the emergency department two times because of spontaneous pneumothorax. The first episode was treated with small bore catheter drainage, while during the second episode-occurring only 1 week later-thoracoscopic talcage was attempted. The postoperative course was characterised by slow clinical and radiological resolution, and recurrence 3 days after discharge. Eventually, multiportal video-assisted thoracoscopic exploration identified an interfissural solid mass. Resection and further work-up revealed the diagnosis of 'low-risk' solitary fibrous tumour (SFT) stage pT1N0M0. The interdisciplinary tumour board advised no adjuvant therapy. A CT thorax was scheduled in 1 year for follow-up. The patient was discharged without complications and has had no recurrences of pneumothorax at 6 months of follow-up. This report shows that SFT can easily be missed on initial presentation and should be considered in the differential diagnosis of pneumothorax, especially when frequently recurring.

Solitary pleural fibroma causing IGF-2-mediated hypoglycaemia in a non-diabetic patient

A patient without a diagnosis of diabetes mellitus presented to the hospital due to a fall and hypoglycaemia on admission. The patient was found to have recurrent nocturnal fasting hypoglycaemia. CT revealed a large lung mass consistent with a solitary pleural fibroma, a rare tumour associated with insulin-like growth factor 2 (IGF-2) production. This case is an important reminder that potential causes of hypoglycaemia should be considered in non-diabetic patients.

Anesthetic management of thoracotomy for massive intrathoracic solitary fibrous tumor of the pleura: a case report

BACKGROUNDS

Solitary fibrous tumor of the pleura (SFTP) is a rare thoracic tumor and usually asymptomatic. Massive SFTP may affect adjacent organs and tissues including pulmonary vasculature, bronchus and heart. A thoracotomy for massive SFTP is necessary in severe case. Therefore, it is important for anesthesiologists to understand the condition of patients with massive SFTP and develop an appropriate anesthetic management strategy. A 76-year-old woman with massive SFTP presented to our clinical center and was evaluated as requiring thoracotomy. She received multidisciplinary cooperation treatment from the radiology, cardiac, thoracic surgery and anesthetic teams. The perioperative management of anesthesiologists played a crucial role in the great prognosis of this woman.

CONCLUSIONS

This case report demonstrates the importance of comprehensive and meticulous perioperative management and provides guidance to the multidisciplinary team on the potential risk and the rational treatment strategy of patients with massive SFTP during the perioperative period.

Pleural-based giant solitary fibrous tumour with associated hypoglycaemia: unusual presentation with pulmonary hypertension in a patient with Doege-Potter syndrome

Refractory hypoglycaemia in a patient with a solitary fibrous tumour (SFT) is very rare and was first reported in 1930 independently by Doege and Potter, leading to it being named 'Doege-Potter syndrome'. Here, we report the unusual case of a 77-year-old woman with a giant solitary fibrous pleural tumour who presented with complicating pulmonary hypertension and associated heart failure with hypoglycaemia, and subsequently underwent curative resection of the pleural mass with clinical improvement.

Doege-Potter Syndrome; A Case of Solitary Fibrous Pleura Tumor Associated with Severe Hypoglycemia: A Case Report in Internal Medicine

BACKGROUND

Doege-Potter syndrome is a rare paraneoplastic entity that is often diagnosed incidentally during the work-up of hypoglycemia of unclear etiology. It is characterized by a non-islet cell tumor hypoglycemia mostly associated with solitary fibrous tumors. These uncommon tumors have been reported in <5% of solitary fibrous tumors. Although not unique in its kind, this case is extremely important as this syndrome often conceals unrecognized tumors that can be surgically resolved.

CASE PRESENTATION

We present the case of a 59-year-old non-diabetic man with a 2-month history of severe and recurrent fasting hypoglycaemia presenting with severe dyspnea and sweating. Further workup revealed low insulin, C-peptide, and IGF-1 levels and a large right in-trathoracic solitary fibrous tumor. Unfortunately, bioassays for IGF-2 were unavailable at our hos-pital. Nevertheless, as hypoglycemia completely resolved after resection of the mass, Doege-Potter syndrome was highly suspected.

CONCLUSION

Doege-Potter syndrome is a complication of rare tumors. If hy-poglycemia is unexplained, this syndrome should always be suspected, and the presence of un-known masses should be investigated.

Solitary fibrous tumour of the pleura: a rare cause of digital clubbing

A woman in her early 70s was found to have incidental finger clubbing at a fracture clinic consultation for an unrelated problem. She reported no associated respiratory symptoms and was referred back to her General Practitioner for further investigation. A chest radiograph revealed a large left-sided mass. This was characterised as a pleural-based mass on CT, resulting in localised atelectasis and mediastinal shift. A CT guided biopsy revealed histology consistent with a solitary fibrous tumour of the pleura and the patient was referred for thoracotomy and resection.

Solitary fibrous tumour of the pleura: an incidental finding

We herein report a relatively rare case of a woman in her 30s with an incidental lung finding. She subsequently underwent resection for what was considered to be a solitary fibrous tumour of the pleura (SFTP). SFTPs are rare, slow-growing neoplasms from mesenchymal origin. These tumours are histologically characterised by proliferation of bland-looking spindled cells, arranged in a patternless pattern, with hypocellular and hypercellular areas set in a hyalinised stroma. Complete en bloc surgical excision (with margin negativity) is the treatment of choice for both benign and malignant SFTPs. Due to the possibility of local recurrence with benign and malignant SFTPs, clinical and radiological follow-up is recommended.

[Giant Solitary Fibrous Tumour of the Pleura Compressing the Left Ventricle:Report of a Case]

A 71-year-old woman with chest pain and exertional dyspnea was referred to our hospital. Computed tomography revealed a huge intrathoracic tumor with left parietal pleural dissemination. Transthoracic echocardiography showed the left ventricular dysfunction due to external compression by the tumor. After excision of the tumor, marked improvement of the left ventricular dysfunction was obtained for eight years. But the patient died due to cardiac invasion of the tumor 9th year after surgery.

68Ga-DOTATOC PET/CT in Pleural Solitary Fibrous Tumors

ABSTRACT

Solitary fibrous tumor of the pleura (SFTP) is a rare mesenchymal neoplasm. Preoperative diagnosis is usually difficult and based on radiological findings only. We report the imaging results observed in 5 patients with SFTP (2 malignant) obtained by 68Ga-DOTATOC PET/CT. At qualitative analysis, all tumors showed uptake of 68Ga-DOTATOC. Mean tumor SUVmax was 9.9 ± 5.7. The expression of SST2 (somatostatin receptors subtype 2) was confirmed by immunohistochemistry in 2 tumor samples, and by gene amplification of SST2 mRNA in all cases. These data suggest a diagnostic role of radioreceptor PET/CT in SFTP, and open novel potential treatment options in unresectable/metastatic disease.

Localized malignant mesothelioma, an unusual and poorly characterized neoplasm of serosal origin: best current evidence from the literature and the International Mesothelioma Panel

Localized malignant mesotheliomas (LMM) is an uncommon and poorly recognized neoplasm. Its pathologic diagnosis is often surprising in patients with serosal/subserosal based localized tumors that are clinically suspicious for metastatic lesions or primary sarcomas. Once a tumor is diagnosed as "mesothelioma", LMM is often mistaken for diffuse malignant mesothelioma (DMM). Best currently available evidence about LMM was collected from the literature and cases diagnosed by members of the International Mesothelioma Panel (IMP). One hundred and one (101) LMM have been reported in the English literature. Patients had localized tumors with identical histopathologic features to DMM. Patients ranged in age from 6 to 82 years; 75% were men. Most (82%) of the tumors were intrathoracic. Others presented as intrahepatic, mesenteric, gastric, pancreatic, umbilical, splenic, and abdominal wall lesions. Tumors varied in size from 0.6 to 15 cm. Most patients underwent surgical resection and/or chemotherapy or radiation therapy. Median survival in a subset of patients was 29 months. Seventy two additional LMM from IMP institutions ranged in age from 28 to 95 years; 58.3% were men. Sixty tumors (83.3%) were intrathoracic, others presented in intraabdominal sites. Tumors varied in size from 1.2 to 19 cm. Median survival for 51 cases was 134 months. Best evidence was used to formulate guidelines for the diagnosis of LMM. It is important to distinguish LMM from DMM as their treatment and prognosis is different. A multidisciplinary approach is needed for the diagnosis of LMM as it shows identical histopathology and immunophenotype to DMM.

Solitary fibrous tumor of the pleura as a rare cause of severe hypoglycemia: Doege-Potter syndrome

INTRODUCTION

Doege-Potter syndrome is a rare syndrome characterized by hypo-insulinemic hypoglycemia. It is caused by excessive ectopic secretion of insulin-like growth factor II from a solitary fibrous tumors of intrapleural or extrapleural origin. Laboratory tests reveal low levels of C-peptide and insulin, on the contrary insulin-like growth factor II level is elevated, which is characteristic for Doege-Potter syndrome. Majority of solitary fibrous tumors present no symptomatology, recurrent hypoglycemia is relatively rare, but it may be the only clinical manifestation. The therapy is surgical, consisting of radical en-bloc tumor resection.

CASE REPORT

Authors present a case report of a patient with recurrent hypoglycemia caused solely by solitary fibrous tumor. Hypoglycemia resolved immediately after surgical resection and there were no recurrences.

CONCLUSION

Doege-Potter syndrome should be considered as the differential diagnosis in a patient with suspicion on thoracic malignancy if accompanied by features suggestive of hypoglycemia. Prolonged follow up is strongly advised because of the risk of disease recurrence, even in patients with benign solitary fibrous tumors of the pleura (SFTP).

CT diagnosis and differentiation of benign and malignant varieties of solitary fibrous tumor of the pleura

To investigate computed tomography (CT) characteristics of benign and malignant solitary fibrous tumors of the pleura (SFTPs).Preoperative CTs for 60 SFTP cases (49 benign and 11 malignant) with subsequently confirmed diagnoses were retrospectively analyzed.Tumor morphologies included mounded or mushroom umbrella-shape (19 cases, 31.7%), quasi-circular or oval-shape (30 cases, 50%), and growth resembling a casting mould (12 cases, 20%). Maximum tumor diameters were 1.1 to 18.9 cm (average: 6.4 ± 4.8 cm). Fifty-seven cases had clear boundaries, and 3 had partially coarse boundaries. Twenty-seven cases showed homogeneous density; 33, "geographic"-patterned inhomogeneous density; 6, calcifications; 12, intratumor blood vessels; and 3, thick nourishing peritumoral blood vessels. Pleural thickening (regular and irregular) was found adjacent to tumors in 4, compression of adjacent ribs with absorption and cortical sclerosis in 2, and location adjacent to ribs with bony destruction in 1. Four cases had a small amount of lung tissue enfolded along the boundary, 2 had multiple peritumoral pulmonary bullae, and 9 had small ipsilateral pleural effusions. Compared with benign and malignant SFTPs were larger (P < .001), had inhomogeneous density, and were more commonly associated with intratumor blood vessels and pleural effusions (P < .01).CT revealed characteristic patterns in SFTPs, including casting mould-like growth, rich blood supply, and "geographic"-patterned enhancement. In addition, larger tumor size, inhomogeneous intensities, abundant intratumor blood vessels, and pleural effusions were more common with malignancy. Lastly, multislice CT angiography can reveal feeding arteries and help guide surgical management.

Solitary Pleural Fibroma: A Case Report and Review of Literature

Solitary fibrous tumors ofthe pleura (SFTP) are uncommon. They tend to be discovered incidentally or during workup for unexplained cough or paraneoplastic effects. It is important to recognize the entityand perform a surgical excision because of the possibility of subsequent malignant transformation and local compressive effects. We present the case of a SFTP discovered on chest imaging. Our patient had surgical excision with good response. A review of the literature is also presented.

Case report of medical thoracoscopy and endobronchial ultrasound bronchoscopy in the workup of giant solitary fibrous tumor of the pleura

Solitary fibrous tumor of the pleura (SFTP) is a rare tumor of fibroblastic origin. It can be quite vascular, and its surgical management carries the risk of a major intra-operative bleed. The pre-operative use of endobronchial ultrasound (EBUS) to visualize the vascular supply of the tumor has not been reported.We report a case of a patient presenting with progressive shortness of breath and cough who was found to have a very large pleural-based tumor. We describe the use of medical thoracoscopy and EBUS to establish the diagnosis of SFTP and to characterize the blood supply of the tumor.In the future, EBUS may provide an alternative to conventional angiography for both mapping and embolizing tumor blood supply.

[Hypoglycemia induced by a solitary fibrous tumor of the lung or Doege-Potter syndrome: Report of one case]

We report the case of a 75-year-old man who was admitted to the hospital with symptoms of severe hypoglycemia. He had a history of solitary fibrous tumor diagnosed by Pathology after its complete surgical resection eight years before. The laboratory examination reported hypoglycemia with inhibited Insulin secretion. A computed tomography of the thorax revealed a large solid heterogeneous mass in the left hemithorax. Solitary fibrous tumor is a rare neoplasm. The association of solitary fibrous tumor and paraneoplastic hypoglycemia is known as Doege-Potter syndrome and occurs in less than 5% of all solitary fibrous tumors.

Single port VATS resection of a sessile solitary fibrous tumour of the visceral pleura. A case report

The solitary fibrous tumour of the visceral pleura is a rare neoplasm that derives from mesenchymal cells adjacent to the mesothelial tissue of pleura. Surgical resection is the treatment of choice in benign lesions and healing resulting in half of malignant. Local recurrence can occur in malignant cases, but it is very rare in solitary benign tumors. It may be a result of an incomplete or conservative surgery, lack of identification of a tumor during the operation or a growth of a synchronous neoplasm independent from that removed. Surgical resection is also burdened with some difficulty as the size of the tumor, the relationship with the adjacent structures and identification of the vascular peduncle. We report a case of 72 years-old male with a sessile left solitary fibrous tumour of the visceral pleura. The mass of 10 x 7 x 5 cm was attached, thanks to large planting base, to lateral basal segment of left lower lobe. The patient was treated by single port video assisted approach with a 4 cm skin incision. This case, in our knowledge, represents the first resection by single port VATS of a sessile SFTP with a large plating base and, more generally, the third SFTP resection treated by single portal access.

KEY WORDS

Solitary fibrous tumour, Uniportal VATS.

Ordinary symptom for a serious pathology - giant solitary fibrous tumor of the pleura

The solitary fibrous tumor of the pleura (SFTP) is a rare primary tumor arising from mesenchymal cells in the areolar tissue subjacent to the mesothelial-lined pleura. From an epidemiological standpoint, solitary fibrous tumors of the pleura account for less than 5% of primary pleural tumors, and commonly affect patients in the sixth and seventh decades. We presented the case of a 38-year-old woman, without any significant pathological history, who presented at the emergency room for unspecific respiratory symptoms. Imagistic investigations showed a giant opacity in the upper half part of the left hemithorax. The patient underwent surgery and en bloc resection of the tumor (30/25 cm) in oncological limits was performed. Definite diagnosis - solitary fibrous tumor of the pleura - was obtained through histological examination and immunohistochemistry. Even if SFTP are benign tumors, a long follow-up period is mandatory as even patients with complete resection are at risk of recurrence several years after surgery.

Solitary fibrous tumor of the pleura: ultrasonographic imaging findings of 3 cases

Solitary fibrous tumor (SFT) of the pleura is a rare tumor of mesenchymal origin. Although radiographic findings of thoracic computed tomography and magnetic resonance imaging in the evaluation of SFTs of the pleura have been documented, the value of ultrasonography is uncertain. We presented the ultrasonographic findings of 3 pathologically proven cases of SFTs arising from the visceral pleura. In all the cases, thoracic ultrasonography demonstrated homogeneous, hypoechoic, hemicycle, extrapulmonary lesions, which showed respiratory movement with the adjacent lung, consistent with pedunculated tumors. Preoperative thoracic ultrasonography could be useful in the evaluation of patients with pleural tumors, especially SFTs.

Malignant fibrous tumor of the pleura: case report and literature review

Solitary fibrous tumours (SFT) of the pleura are uncommon and are incidental findings or discovered in patients with non-specific respiratory symptoms. We report a case of a 74 year old man diagnosed with a mesenchymal pleural neoplasm, associated with typical hypertrophic osteoarthropathy, referred to as Pierre-Marie-Bamberg syndrome. As reported in the literature, complete surgical resection is the gold standard for treatment of such lesions and recurrences. Radiotherapy and chemotherapy are of limited value in the curative treatment of pleural SFT. In our case surgical excision of the mass was performed. After a disease-free period of 3 years a second intervention was necessary because of recurrence. Until now our patient is free of complaints and no signs of reappearance were noted. Based on our experience and on literature findings we would like to underline the importance of regular long-term follow-up because of the substantial risk of recurrence.

A case of recurrence and rapid growth of pleural solitary fibrous tumor 8 years after initial surgery

A 69-year-old woman underwent resection of a solitary fibrous tumor (SFT) of the left pleura in April 1997 and of locally recurrent SFT in the left thoracic cavity in September 2003. A postoperative follow-up chest CT scan in March 2005 revealed pleural thickening at two sites of the left thoracic cavity. A further chest CT scan performed in September of the same year showed the enlarging tendency of the lesions, suggesting SFT recurrence, for which surgery was performed in January 2006. The two resected tumors were benign SFT, and were diagnosed as locally recurrent SFT in the left thoracic cavity. It has been reported that despite its benign histopathology, pleural SFT recurs more than once after surgery, and the interval between recurrences tends to shorten from the second recurrence. In this patient, the tumor recurred twice and showed a rapidly enlarging tendency at the time of the second recurrence, suggesting the need for careful follow-up at short intervals.

Giant solitary fibrous tumors of the pleura: two case reports

Solitary fibrous tumors of the pleura (SFTP) are rare neoplasms. We report two cases of giant SFTP treated by surgical resection. One of these was enormous (30 x 19 x 18 cm, weight: 4,050 g) and occupied the entire left pleural cavity with complete lung collapse and contralateral mediastinal shift. Both tumors were removed en bloc. The patients had no postoperative complications. Surgical treatment is curative in most patients; resection must be complete because of the possibility of recurrence and metastasis.

Tumor fibroso localizado de la pleura: hallazgos radiológicos

Localized fibrous tumors of the pleura are rare tumors that represent less than 5% of the pleural tumors, although they have also been described in extrathoracic locations such as the abdomen, head and neck or central nervous system. A total of 80% begin in the visceral pleura and are not related with environmental risk factors. They generally occur in patients over 50 with a mild predominance in the woman. Up to 50% of the patients are asymptomatic, so that it appears as an incidental finding on the chest X-ray. These are slow growing tumors. They are seen on the X-ray as well-defined rounded lesions dependent on the pleura and 50% are pediculated. It is important to know its radiological characteristics for its diagnosis of suspicion and correct treatment since surgical resection is generally curative. Local recurrence after the surgery is very common if it is not completely excised.

[Video-assisted thoracoscopic surgery treatment for solitary fibrous tumor of the pleura]

BACKGROUND

Solitary fibrous tumors of the pleura (SFTP) are rare neoplasm. Approximately 800 cases have been reported in the literature to 2004 year. Video - assisted Thoracoscopic Surgery (VATS) treatment may be the most promising surgical approach for the resection of SFTP.

AIM

This article reported a first case in Bulgaria of VATS diagnostic and treatment of SFTP.

PATIENTS

A 60 - year old woman had a routine chest roentgenogram and computed tomographic scan, and fibrobronchoscopy.

RESULT

The use of VATS was introduced for the diagnosis and treatment of intrathoracic lesions. Patient has included in a follow - up program that included clinical examination and x - ray chest graph after 6 months postoperatively, with no recurrence or metastasis of the tumor.

CONCLUSION

Complete surgical resection is the treatment of choice for SFTP. For the pedunculate tumors, therefore. VATS is a powerful and useful surgical approach.