We report our multidisciplinary experience with primary chest wall sarcomas that included induction therapy in the majority of high-risk soft tissue and bony sarcomas and desmoid tumors. Despite aggressive preoperative treatments, acceptable surgical results with low morbidity and mortality can be achieved. Neoadjuvant systemic therapy may reduce local and distant recurrence and improve overall survival.
Solitary fibrous tumors of the pleura are rare neoplasms with both benign and malignant behaviors that are not reliably predicted by histologic findings. We report the case of a 55-year-old woman with recurrent pneumonias whose left mainstem bronchus was occluded by a 2.1-× 1.4-cm endobronchial mass that extended extraluminally into the subcarina. The mass was tissue diagnosed to be a solitary fibrous tumor preoperatively, and was completely resected by sleeve resection of the left mainstem bronchus with lung preservation. This report describes the challenging surgical management of an infrequently encountered tumor in a unique location.Solitary fibrous tumors of the pleura (SFTP) were first pathologically described by Klemperer and Rabin in 1931, and approximately 800 cases have been reported in the English literature [1]. A review by Briselli and colleagues [2] of 368 cases found that approximately 80% arise from the visceral pleura and 20% from the parietal pleura. The visceral pleural-based masses are typically pedunculated, encapsulated, peripheral masses with a well-vascularized stalk. Parietal-pleural based tumors are usually sessile and have a greater incidence of recurrence [3]. In case reports, there have been accounts of SFTP located entirely within the lung parenchyma, with no gross relationship to the pleura.Only 15 cases of intraparenchymal lung tumors have been described in the English literature, [1,[4][5][6], less than 2% of the roughly 800 reported cases. Proposed mechanisms for these atypical lung masses include (1) direct continuity of subpleural mesenchyma with the intralobular septae connective tissue, (2) origination of tumors from fibroblasts of the lung parenchyma itself, and (3) invagination of the visceral pleura, with mechanical forces causing growth away from the chest wall [6]. The occurrence of SFTP in an endobronchial location is an even rarer finding; to our knowledge, there have only been two published instances [1,5]. We report a case of an endobronchial SFTP that completely occluded the left mainstem bronchus and extended extraluminally into the subcarina.A 55-year-old woman, who was a nonsmoker with a history of asthma, presented with recurrent pneumonias since January 2008. In February 2009, computed tomography scanning and bronchoscopy revealed a 2.1-× 1.4-cm mass within the left mainstem bronchus that extended into the subcarina, with postobstructive collapse of the lingula and left lower lobe ( Fig 1A, Fig 2). Bronchoscopic biopsy revealed a solitary fibrous tumor.
We demonstrated that image-guided core needle biopsy when performed and reviewed by experienced radiologists and musculoskeletal pathologists is a safe and accurate diagnostic technique for chest wall sarcomas. Core needle biopsy should be considered in the multidisciplinary approach to chest wall musculoskeletal tumors, especially when induction therapy is considered.
angles, and kidney perfusion based on analysis of volumetric kidney parenchyma (VKP, Fig). Endovascular suitability was determined by RA diameter $4 mm, length to RA bifurcation $13 mm, and preservation of >60% of one or >75% of both kidneys by VKP analysis.Results: There were 222 juxtarenal (43%), 241 suprarenal (46%), and 57 type IV thoracoabdominal aortic aneurysms (11%). A total of 1009 RAs and 176 ARAs were analyzed. Endovascular incorporation was possible in 884 RAs (88%) and in 30 ARAs (17%). Using the proposed criteria, 97 patients (19%) had one or more factors rendering RA incorporation unsuitable, including early bifurcation in 45 (9%), small diameter in 29 (6%), or inability to preserve kidney parenchyma in 28 (5%). A total of 170 patients (33%) had other anatomic issues that would increase technical difficulty to RA incorporation, including excessive downward angulation in 125 (24%), high-grade stenosis in 51 (10%), or prior renal stents in 11 (2%).Conclusions: Independent of the endovascular technique selected to treat a complex AAA, one of five patients (19%) is not a candidate and one-third have anatomic challenges (33%) for RA incorporation. Patients with unsuitable RA anatomy may need open repair to maximize renal artery patency and preserve renal function.
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