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Ann Thorac Surg 2002;73:983-985
© 2002 The Society of Thoracic Surgeons

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Case report

Preoperative embolization of a massive solitary fibrous tumor of the pleura

^a Department of Cardiothoracic Surgery, St George Hospital, Sydney, Australia

Accepted for publication June 18, 2001.

* Address reprint requests to Dr Horton, Suite 15, Level 4, St George Private Hospital & Medical Centre, 1 South St, Kogarah, NSW, 2217, Australia
e-mail: weissbx{at}usa.net

	Abstract

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We report the case of a 69-year-old woman with a massive fibrous tumor of the left hemithorax. Initial attempted removal by median sternotomy was abandoned due to the extremely vascular appearance of the tumor and the inability to gain safe control of the pedicle. Subsequent percutaneous embolization before removal through a left thoracotomy was successful, with little intraoperative blood loss. We recommend preoperative angiography for massive chest tumors that may be vascular and require piecemeal removal for total excision.

	Introduction

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Solitary fibrous tumors of the pleura are rare, usually benign, and may reach massive proportions before becoming symptomatic. Their large size may make resection hazardous, particularly when excision in one piece is unlikely, and there is a vascular pedicle which is inaccessible via the chosen operative route by virtue of the size of the tumor; such vascular pedicles may be present in nearly one-half of these tumors. We report the case of a 69-year-old woman who underwent percutaneous embolization of a massive solitary fibrous tumor of the left pleura, with successful subsequent removal via a left thoracotomy, with minimal intraoperative blood loss. We recommend preoperative angiography for massive chest tumors that may have a vascular pedicle amenable to embolization, particularly where piecemeal removal of the tumor may be necessary.

A 69-year-old woman presented with a 3-month history of increasing breathlessness. Chest roentgenogram revealed replacement of two-thirds of the left hemithorax by a tumor mass (Fig 1). Computed tomographic scan of the chest confirmed a massive tumor in the left chest, which appeared continuous with a mass enclosing the trachea in the region of the thyroid gland, associated with displacement of mediastinal structures to the right. Fine needle biopsy was nondiagnostic, and core needle biopsies of the lesion were consistent with a localized fibrous tumor of the pleura. The patient’s forced expiratory volume in 1 second was 0.86 L (34% of predicted) and arterial oxygen tension on room air was 63 mm Hg.

View larger version (133K): [in this window] [in a new window]   Fig 1. Chest roentgenogram of patient with massive left-sided solitary fibrous tumor of the pleura.

Selective percutaneous angiography of left subclavian artery, left thyrocervical trunk, left costocervical trunk, left internal thoracic, and left T7–L1 intercostal arteries was performed 2 months later, revealing an arterial supply from the costocervical trunk. This was successfully embolized with 2 mL of Ivalon Contour Emboli 150-µm granules (Boston Scientific Corporation, Watertown, MA) in suspension followed by two 2-cm by 3-mm coils (Cook Group Company, Bloomington, IN) (Fig 2).

View larger version (67K): [in this window] [in a new window]   Fig 2. (A) Pre- and (B) postembolization angiograms of the left costocervical trunk, the principal blood supply to the tumor, showing successful occlusion.

	Comment

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Solitary fibrous tumors of the pleura are rare [1]. Most are benign; however, even benign forms can recur many years after resection [2]. Origin is most frequently from visceral pleura, with only 20% arising from parietal pleura. Tumors more than 8 cm are more likely to have a parietal pleural origin and have a vascular pedicle [3]. A tumor more than 10 cm is more likely to be malignant [4]. Nearly one-half of solitary fibrous tumors of the pleura overall are attached to the pleura by a single pedicle [4]. Up to 47% are encapsulated by a membrane containing a vascular network [4, 5], as seen in this patient at initial operation.

These tumors require tissue for diagnosis [4], and preoperative fine-needle biopsy is unreliable [6]. Final diagnosis usually requires surgical resection [7].

Solitary fibrous tumors of the pleura can reach massive proportions [1], at times necessitating a change in surgical strategy and further investigations before definitive resection, as in this patient and others [1, 7, 8]. Resection is generally curative in all benign cases, and in approximately half of malignant cases [4, 9].

Angiography can be a valuable investigation to delineate any major feeding vessels, which may then be embolized preoperatively. This has rarely been described for solitary fibrous tumors of the pleura [1], but has been used before resection of other vascular intrathoracic tumors [8]. It is particularly relevant in solitary fibrous tumors of the pleura as these tumors are attached to the pleura by a highly vascularized pedicle in 38% to 46% of patients [4, 6], particularly if the tumor is large [7].

The histologic criteria for malignancy include high cellularity, mitotic rate more than 4 per 10 high power fields, cellular pleomorphism, and necrosis [4, 10]. Because embolization is likely to cause some degree of necrosis in the tumor, the histopathologist must be informed that preoperative embolization has been performed, and of the elapsed time period since embolization.

In conclusion, angiography and embolization are valuable adjuncts in the preoperative management of large chest tumors, particularly those with a propensity to a pedicled attachment containing significant vascular structures, such as solitary fibrous tumors of the pleura. We recommend angiography of all massive tumors in the chest before operation, particularly when they are so large that piecemeal excision may be anticipated.

	References

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1. Khan J.H., Rahman S.B., Clary-Macy C., et al. Giant solitary fibrous tumor of the pleura. Ann Thorac Surg 1998;65:1461-1464.[Abstract/Free Full Text]
2. Okike N., Bernatz P.E., Woolner L.B. Localized mesothelioma of the pleura: benign and malignant variants. J Thorac Cardiovasc Surg 1978;75:363-372.[Abstract]
3. Briselli M., Mark E.J., Dickersin G.R. Solitary fibrous tumors of the pleura: eight new cases and review of 360 cases in the literature. Cancer 1981;47:2678-2689.[Medline]
4. England D.M., Hochholzer L., McCarthy M.J. Localized benign and malignant fibrous tumors of the pleura. A clinicopathologic review of 223 cases. Am J Surg Pathol 1989;13:640-658.[Medline]
5. Harrison R.I., McCaughan B.C. Malignancy in a massive localized fibrous tumour of pleura. Aust NZ J Surg 1992;62:311-313.[Medline]
6. Suter M., Gebhard S., Boumghar M., Peloponisios N., Genton C.Y. Localized fibrous tumours of the pleura: 15 new cases and review of the literature. Eur J Cardiothorac Surg 1998;14:453-459.[Abstract/Free Full Text]
7. Pond F., Wilson A., McKelvie P. Localized fibrous tumour of the pleura: two case reviews. Aust NZ J Surg 1997;67:821-824.[Medline]
8. Morandi U., Stefani A., De Santis M., Paci M., Lodi R. Preoperative embolization in surgical treatment of mediastinal hemangiopericytoma. Ann Thorac Surg 2000;69:937-939.[Abstract/Free Full Text]
9. Martini N., McCormack P.M., Bains M.S., Kaiser L.R., Burt M.E., Hilaris B.S. Pleural mesothelioma. Ann Thorac Surg 1987;43:113-120.[Abstract]
10. Witkin G.B., Rosai J. Solitary fibrous tumor of the mediastinum. A report of 14 cases. Am J Surg Pathol 1989;13:547-557.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David A. Horton Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Weiss, B. Articles by Horton, D. A. Search for Related Content PubMed PubMed Citation Articles by Weiss, B. Articles by Horton, D. A.