Management of a malignant solitary fibrous tumor of lung by uniportal video-assisted pneumonectomy : a case report

doi:10.21203/rs.3.rs-5293610/v1

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Case Report

Management of a malignant solitary fibrous tumor of lung by uniportal video-assisted pneumonectomy : a case report

https://doi.org/10.21203/rs.3.rs-5293610/v1

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Background: Solitary fibrous tumor (SFT) is a rare condition, first described by Klemperer and Robin in 1931. Malignant SFTs accounts for approximately 80% of all SFTs cases, and the 5-year survival of malignant SFTs is 81%. Few reports have described managing SFTs using uniportal video-assisted pneumonectomy.

Case presentation: A 35-year-old man with tumor in the left pulmonary was assessed by preoperative 3D-computed tomography (3D-CT) reconstruction and treated by uniportal video-assisted pneumonectomy. A pathological diagnosis of SFT was confrmed.

Conclusions: The 3D-CT reconstruction could help to provide an appropriate operative programme for surgeons. It is necessary to control the main pulmonary arterial trunk to avoid hemorrhage when preoperative evaluation does not exclude the possibility of intraoperative hemorrhage. The choice of surgery area is affected by size and location of SFT.

Solitary fibrous tumor

3D-CT reconstruction

case report

Solitary fibrous tumor (SFT) is first described by Klemperer and Robin in 1931 [1], which is a rare condition and originated from dendritic stromal cells. Most patients have no obvious symptoms, however, some patients with large tumor may have diverse syndrome, such as thoracalgia, dyspnea and cough. Patients with SFT of lung are treated with surgical options including lung wedge resection, lobectomy, but rarely pneumonectomy. A 35-year-old patient with a low malignant SFT was assessed by 3D-computed tomography (3D-CT) reconstruction before surgery and underwent a complete surgical resection by uniportal video-assisted pneumonectomy in this case report.

A 35-year-old man complained mild thoracalgia and dyspnea for more than a month and did not respond to oral medication. There were no other obvious findings by physical examination. The patient had no relevant previous medical history and there was no relevant family history. The patient reported a large 6.7 × 4.8 cm lesion in the left lung lobe and closely related to left pulmonary arteries on his enhanced chest computerized tomography (CT) (Fig. 1A, B). A 3D-CT reconstruction [2] made by Mimics Medical 21.0 indicated appeared to be obvious compression and invasion of the surrounding blood vessels, mediastinal and tracheal shift (Fig. 1C, D). Bronchoscopy showed that tracheobronchial airway was compressed by extratracheal lesion.

Uniportal video-assisted thoracoscopic surgery (VATS) was carried out through a 3.5 cm incision in the fifth intercostal anterior-axillary space after general anesthesia with a right double-lumen tube. The tumor was discovered on the left interlobar fissure. The tumor invaded the great vessels in the hilus region of the lung and grew across the Interlobar fissure. First, the frozen section biopsy of tumor was picked up by biopsy forceps and indicated malignancy during the operation, so the left pneumonectomy was selected. And then, the left pulmonary arterial trunk (LPAT) was dissected to expose and controlled proximally by using a vascular tourniquet. The left superior pulmonary vein (LSPV) and inferior pulmonary vein (LIPV) were exposed and controlled proximally by using a vascular tourniquet (Fig. 2A, 2B, 2C). Although, we injured interlobar pulmonary artery inadvertently during the surgery, the LPAT was already controlled proximally to avoid uncontrolled arterial bleeding. Left pulmonary arteries and veins were ligated using by staplers. The left principal bronchus was then clamped by using staplers. The tumor was removed (Fig. 3A). A pathological diagnosis of malignant SFT was confirmed (Fig. 3B). Finally, the mediastinal lymph node dissection was identified.

The condition of SFTs occurs mainly due to mesenchymal cells beneath the mesothelial lining of the pleura [3], so majority of SFTs grow slowly. However, malignant SFTs accounts for approximately 80% of all SFTs cases, and the 5-year survival of malignant SFTs is 81% [4]. Most patients with benign SFTs are asymptomatic. However, malignant SFTs are usually more aggressive than benign tumors, and may causing chest tightness, pain, dyspnea, and respiratory insufficiency, when compressing the adjacent trachea and lung tissue [5].

If a malignant SFT showing invasion and severe peritumoral adhesion, or originating from the visceral pleural fold at the interlobar fissure, it may more resemble a malignant pulmonary mass than a pleural tumor [6]. Because the tumor located in the hilus of the left pulmonary in this case, CT-guided puncture before surgery is dangerous and unnecessary. It is difficult to distinguish between a malignant SFT and lung cancer before the surgery, so the frozen section biopsy during the operation is critical.

Three points were remarkable during this treatment. First, 3D-CT technology helps to illustrate more easily the relationship of the tumor and its adjacent organs and important blood vessels. Because 3D-CT reconstruction revealed the great vessels in the hilus region of the lung infringed by a huge tumor, at least lobectomy or pneumonectomy may be chosen. Precise 3D-CT reconstructions analysed the risks before the surgery and predicted an appropriate operative programme for surgeons.

Second, because the tumor invaded left pulmonary arteries and veins seriously and preoperative evaluation does not exclude the possibility of intraoperative hemorrhage, so the control of the left pulmonary trunk allowed the distally involved pulmonary parenchyma to be safely resected in the surgery. It is necessary to control the main pulmonary arterial trunk.

Third, surgical resection is definite and acceptable treatment for SFT. In our case, the SFT invaded the hilus of the left pulmonary blood vessels and interlobar fissure, we selected the left pneumonectomy. Recurrence and metastasis which via hematogenous and lymphogenous routes are both typical features of malignant SFT [7].Because of malignant and recurring potential of SFT, mass excision with a tumor-negative margin is suggested. Larger and more aggressive tumors are more associated with malignancy, thus tumor size is a potential of malignancy [8]. Besides, if the tumor invades the lung parenchyma, chest wall, pericardium, and diaphragm, resection of part of the chest wall, pericardium, diaphragm, lobectomy, even pneumonectomy is recommended [9,10]. So we think that the choice of surgery area is affected by size, location of SFT and tumor invasion.

In general, SFT is a rare condition. The 3D-CT reconstruction could help to provide an appropriate operative programme for surgeons. It is necessary to control the main pulmonary arterial trunk to avoid hemorrhage when preoperative evaluation does not exclude the possibility of intraoperative hemorrhage. The choice of surgery area is affected by size and location of SFT.

SFT

Solitary fibrous tumor

3D-CT

Three dimensional-computed tomography

Computed tomography

LPAT

Left pulmonary arterial trunk

LIPV

Left inferior pulmonary vein

LSPV

Left superior pulmonary vein

Ethics approval and consent to participate

Ethical approval was requested by the main author and granted by the hospital where he was operated on.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

All authors declare that they have no competing interests.

Funding

There was no fund used.

Author Contribution

Authors’contributionsRanhua Li is the first author of the manuscript. Yong Zhou andYanlong Yang made the 3D-CT reconstruction. Xiaochuan Yin, Jing Zhang, Yunping Zhao and Xiaobo Chen performed the operation, and substantially contributed to the drafting and revision of the manuscript. Ranhua Li, Guosheng Xiong, Yanan Bao and Yue Cui treated the patient after surgery. Xiaobo Chen and Xiaochuan Yin are equal contributors and co-corresponding authors to this paper. All authors read and approved the final manuscript.

Acknowledgement

We would like to thank Xiaobo Chen and Xiaochuan Yin at The First Affiliated Hospital of Kunming Medical University, for study design and critical review.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Klemperer P, Rabin LB. Primary neoplasms of the pleura: a report of five cases. Arch Pathol 1931;11:385– 412.
Fan C, Cheng J, Wu S, et al. Pulmonary Arteriovenous Malformation Detected by Three-dimensional Computed Tomographic Angiography[J]. Heart Lung Circ. 2017 Aug;26(8):e59-e61.
Furukawa N, Hansky B, Niedermeyer J, et al. A silent gigantic solitary fibrous tumor of the pleura: case report[J]. Journal of Cardiothoracic Surgery, 2011, 6(1):122.
Pusiol T, Piscioli I, Scialpi M and Hanspeter E. Giant benign solitary fibrous tumour of the pleura (> 15 cm): role of radiological pathological correlations in management. Report of 3 cases and review of the literature. Pathologi ca 2013; 105: 77–82.
Lahon B, Mercier O, Fadel E, Ghigna MR, Petkova B, Mussot S, Fabre D, Le Chevalier T and Dartevelle P. Solitary fibrous tumor of the pleura: outcomes of 157 complete resections in a single center. Ann Thorac Surg 2012; 94: 394–400.
Sung S H, Chang J W, Kim J, et al. Solitary fibrous tumors of the pleura: surgical outcome and clinical course.[J]. Annals of Thoracic Surgery, 2005, 79(1):303–307.
Slupski M, Piotrowiak I, Wlodarczyk Z. Local recurrence and distant metastases 18 years after resection of the greater omentum hemangiopericytoma[J]. World Journal of Surgical Oncology, 2007, 5(1):63.
Cardillo G, Carbone L, Carleo F, Masala N, Graziano P, Bray A, Martelli M: Solitary fibrous tumors of the pleura: An analysis of 110 patients treated in a single institution. Ann Thorac Surg 2009, 88:1632-7.
Mimi B A, Md L D, Atay S M, et al. A Modern Reaffirmation of Surgery as the Optimal Treatment for Solitary Fibrous Tumors of the Pleura[J]. The Annals of Thoracic Surgery, 2019, 107( 3):941–946.
Yanik F, Karamustafaoglu Y A, Yoruk Y. Surgical outcomes and clinical courses of solitary fibrous tumors of pleura[J]. Nigerian Journal of Clinical Practice, 2019, 22(10):1412.

No competing interests reported.

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You are reading this latest preprint version

Management of a malignant solitary fibrous tumor of lung by uniportal video-assisted pneumonectomy : a case report

Status:

Version 1

Abstract

Figures

Introduction

Case history

Discussion

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Funding

Author Contribution

Acknowledgement

Availability of data and materials

References

Additional Declarations

Status:

Version 1