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Radical resection of a giant, invasive and symptomatic malignant Solitary Fibrous Tumour (SFT) of the pleura
Lung Cancer 64 (2009) 117–120
Contents lists available at ScienceDirect
Lung Cancer journal homepage: www.elsevier.com/locate/lungcan
Case report
Radical resection of a giant, invasive and symptomatic malignant Solitary Fibrous Tumour (SFT) of the pleura Pier Luigi Filosso a,∗ , Sofia Asioli b , Enrico Ruffini a , Paolo Rovea c,1 , Luigia Macri’ b , Anna Sapino b , Sergio Bretti d , Paraskevas Lyberis a , Alberto Oliaro a a
University of Torino Italy, Department of Thoracic Surgery, San Giovanni Battista Hospital, Via Genova, 3, 10126 Torino, Italy Dept Biomedical Sciences and Human Oncology University of Turin, Italy via Santena, 4 10126 Torino, Italy San Giovanni Battista Hospital Service of Radiotherapy, Via Cavour 12, 10126 Torino, Italy d Service of Oncology ASL 9 Ivrea, Via Aldisio 2, 10015 Ivrea, Torino, Italy b c
a r t i c l e
i n f o
Article history: Received 23 July 2008 Received in revised form 30 September 2008 Accepted 1 October 2008 Keywords: Pleura Solitary fibrous tumour Surgery Prognostic factors Radiotherapy Outcome
a b s t r a c t Solitary Fibrous Tumours (SFTs) of the pleura are rare neoplasms, with unpredictable biological behaviour. Although usually benign, malignant SFTs are described, and they are often associated with large, necrotic and locally invasive tumours. Radical resection represents the treatment of choice in all cases; recurrences are uncommon, and redo-surgery should be considered. The case of a giant, invasive, radically resected malignant SFT, is described. The role of postoperative radiotherapy, to reduce the risk of recurrence, is also discussed. © 2008 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Primary tumours of the serosal membranes (pleural and peritoneal serosa) are classified first into two major categories: diffuse and localized forms [1] and secondarily into localized tumours that can be benign or malignant. To our knowledge, all diffuse neoplasms of the serosal membranes, with the exception of diffuse forms or well-differentiated papillary mesothelioma, are malignant, and most, with the exception of some cases of peritoneal mesothelioma, are at present incurable. On the other hand, patients with even malignant forms of localized serosal tumours may have a very good long-term prognosis if the tumour is completely resected, even though it may be microscopically similar to a diffuse neoplasm. Mesotheliomas are most common diffuse pleural neoplasms while localized ones comprised a variety of entities, the most frequent of which is Solitary Fibrous Tumour (SFT) of the pleura. The histogenesis of many of the SFTs is obscure, with arguments in the literature about an origin from mesothelial cells,
∗ Corresponding author. Fax: +39 011 6705365. E-mail address: pierluigi.fi[email protected] (P.L. Filosso). 1 Fax: +39 011 6705365. 0169-5002/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2008.10.006
submesothelial mesenchymal cells, and uncommitted stem cells. Mesothelial cells display a remarkable morphologic plasticity, manifested by their ability to develop as a wide variety of epithelial and spindle forms. SFT epitomizes this problem. More than 80% of SFTs are benign and asymptomatic, albeit malignant and symptomatic forms are described. Complete surgical resection offers the best chance of cure. Local recurrences are rare; generally they occur after the resection of a giant malignant tumour. In case of tumour recurrence, redo-surgery is indicated, and complete resection is usually achieved. Postoperative radiotherapy is sometimes used [2] in case of large and invasive SFT, to prevent recurrences, even if there is a paucity of evidence in the literature. We present a successful resection of a giant, locally invasive, symptomatic SFT; the role of postoperative radiotherapy is discussed. 2. Case report A 72 year-old woman was referred to us because of a giant rightsided thoracic lesion associated with ipsilateral pleural effusion (Fig. 1a), discovered for thoracic pain, dyspnoea, digital clubbing and hypoglycaemia. In particular she had a history of recurrent fasting hypoglycaemic attacks, with blood-sugar levels of 46–53 mg/dl.
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P.L. Filosso et al. / Lung Cancer 64 (2009) 117–120
nuclei. Immunophenotypically the tumour demonstrated reactivity for vimentin (Fig. 2a), CD34 (Fig. 2b), CD99 (Fig. 2c) and bcl2 (Fig. 2d), and it was typically negative for keratin, EMA, desmin, actins, S100 protein, collagen type IV and CD31. A morphological and immunohistochemical diagnosis of huge aggressive solitary fibrous tumour of the pleura was made. The postoperative course was uneventful and the blood-sugar values returned to normal within 6 days after the operation. Fifty-five Gy postoperative radiotherapy was administered to reduce the risk of local tumour recurrence. No radiological or clinical evidences of recurrence are present 26 months after surgery. 3. Discussion
Fig. 1. (a) Thoracic CT scan of the large right-side SFT associated with ipsilateral pleural effusion, (b) The intraoperatory view of the 20 cm × 20 cm × 12 cm resected SFT of the pleura.
Transthoracic fine needle aspiration biopsy revealed benign appearing spindle cells, suggesting the diagnosis of a benign pleural fibrous tumour. The patient underwent surgery through a right posterolateral thoracotomy: the tumour originated from the parietal pleura, without any pedicle. It was invasive both in the thoracic wall and in the lung. Fifth, 6◦ and 7◦ rib resection, a partial parietal posterior pleurectomy, and a large pulmonary wedge resection were necessary for a complete tumour resection. The chest wall was reconstructed using a polipropylene mesh. Macroscopic examination of the resected specimen showed a lobulated mass measuring 20 cm × 20 cm × 12 cm, surrounded by pleural tissue (Fig. 1b). It was tan-gray in colour, and vaguely whorled with foci of mucoid change. The mass weighed 2024 g. Microscopically the tumour showed a solid spindle cell growth and fusiform cells were arranged in random arrays (a “patternless pattern”), with some variation in cellularity from region to region within the neoplasm. At high power, a nuclear overlapping with vesicular change in chromatin was observed. Mitotic activity was present (3 mitoses out of 10 HPF). The labelling proliferative index (positivity for Ki67) ranged from 5% to 20% of positive
SFTs represent a rare clinical entity, and about 800 cases have been reported in the literature [3]. Most of the cases show a benign clinical outcome, even if malignant forms may occur up to 12% of cases. The criteria to recognize malignant SFT form were first described by England et al. [4]: as compared with benign lesions, malignant SFTs tend to be larger, more often atypically located (originating from the parietal pleura, with intralobar location or exhibiting inverted growth into the pulmonary parenchyma) and show areas of necrosis and/or haemorrhage. Most commonly malignant SFTs present with symptoms: chest pain, dyspnoea and fever are the most frequent ones. SFTs may be associated with paraneoplastic syndromes, such as hypoglycaemia (Doege-Potter syndrome) [5,6] or hypertrophic pulmonary osteoarthropathy (Pierre-Marie-Bamberg syndrome) [4]. Hypoglycaemia is attributed to the production of insulin-like growth factor II (IGF-II), which lowers the blood glucose and impairs the growth hormone counter-regulatory response to hypoglycaemia. It is described with an incidence of 11% in malignant SFTs as compared with 3% of benign ones, according to the data of England et al. [4]. SFTs larger than 20 cm, or with high mitotic rate are often associated with reactive hypoglycaemia [4,6]. Hypertrophic osteoarthropathy is due to the abnormal production of hyaluronic acid by tumour cells, and affects up to 20% of the patients. Our patient had a 20 cm × 20 cm × 12 cm tumour, originating from the parietal pleura, without a pedicle, deeply invasive on the thoracic wall, associated with hypoglycaemia and osteoarthropathy, therefore meeting the criteria for malignant SFT. Resection of three ribs, partial parietal pleurectomy and pulmonary wedge resection were required for a complete tumour exeresis. Similar results are reported by Magdeleinat et al. [7] in case of large invasive lesions: en bloc chest wall resection or diaphragmatic, parietal pleura and/or pericardium exeresis occurred in 6 out of 60 patients of their series. Complete surgical resection represents the treatment of choice for SFTs: the completeness of the excision represents the primary objective of surgery. Wide tumour-free margins (1–2 cm or more), possibly confirmed by frozen sections, should be achieved in all cases, especially in large SFTs. In our opinion every suspected or proven SFT should be operated, because clinical or radiological criteria cannot accurately distinguish benign forms from malignant ones. Recurrences are possible, even if rare, especially in malignant SFTs. England reports 1.4% recurrence rate in his series [4]. The reasons for the recurrence in pathologically complete resections are unknown. Magdeleinat et al. described 2 local recurrences out of 21 patients with malignant SFTs [7]. The recurrences occurred after the resection of giant SFTs. Surgery, when feasible, represents the treatment of choice, even when recurrence develops: SFTs have, in fact, a low sensitivity to chemotherapy.
P.L. Filosso et al. / Lung Cancer 64 (2009) 117–120
119
Fig. 2. Immunohistochemical features of Solitary Fibrous Tumour (SFT). The neoplastic cells showed diffuse immunoreactivity for vimentin (A), CD99 (C), and bcl2 (D), and weakly positivity for CD34 (B).
Table 1 Large SFTs treated with surgery and postoperative radiotherapy. Case
Sex
Age
Location of SFT
Size of tumour
Radicality
Postoperative RT
Follow-up (months)
Status of follow-up
1 2 3 4 5 Present
F M M F F F
65 73 75 69 66 72
Left Right Right Left Right Right
15 cm × 21 cm 19 cm × 17 cm 14 cm × 19 cm 18 cm × 12 cm 13 cm × 12 cm 20 cm × 20 cm
Yes Yes Yes Yes Yes Yes
48 Gy 50 Gy 50 Gy 55 Gy 45 Gy 55 Gy
18 13 10 5 12 26
NED NED NED NED REC NED
M, male; F, female; NED, no evidence of disease; REC, recurrence.
Due to the rarity of these tumours, there is no systematic assessment of the role of adjuvant therapy in SFTs, at present. Only few brief reports have been published about the role of chemotherapy in recurrent malignant forms [8,9]. Following resection radiotherapy can be considered for recurrent or malignant SFTs, particularly in the sessile variety [3,10], or in case of incomplete resection [11]. Our patient received 55 Gy postoperative radiotherapy and she is free of local recurrences 26 months after surgery. We treated with the same postoperative protocol 5 other radically resected large SFTs: only one local relapse was observed (Table 1). In conclusion, large symptomatic SFTs may be considered potentially malignant and a complete surgical resection, (including en bloc chest wall resection, or diaphragm or pericardium or lung resection) is required. Postoperative radiotherapy may theoretically reduce the risk of local recurrence, but a long follow-up is mandatory and redo-surgery can be considered in case of local tumour relapse.
Conflict of interest None declared. References [1] Briselli M, Mark EJ, Dickersin GR. Solitary fibrous tumors of the pleura: eight new cases and review of 360 cases in the literature. Cancer 1981;47:2678–89. [2] Mahesh B, Clelland C, Ratnatunga C. Recurrent localized fibrous tumor of the pleura. Ann Thorac Surg 2006;82:342–5. [3] de Perrot M, Fisher S, Brundler MA, Sekine Y, Keshavjee S. Solitary fibrous tumors of the pleura. Ann Thorac Surg 2002;74:285–93. [4] England DM, Hochholzer L, McCarty MJ. Localized benign and malignant fibrous tumor of the pleura. Am J Surg Pathol 1989;13:640–58. [5] Doege KW. Fibrosarcoma of the mediastinum. Ann Surg 1930;92:955–61. [6] Balduyck B, Lauwers P, Govaert K, Hendriks J, De Maeseneer M, Van Schil P. Solitary fibrous tumor of the pleura with associated hypoglycaemia: DoegePotter syndrome. J Thorac Oncol 2006;1:588–90. [7] Magdeleinat P, Alifano M, Petino A, Le Rochais JP, Dulmet E, Galateau F, et al. Solitary fibrous tumors of the pleura: clinical characteristics, surgical treatment and outcome. Eur J Cardiothorac Surg 2002;21:1087–93. [8] Veronesi G, Spaggiari L, Mazzarol G, De Pas M, Leo F, Solli P, et al. Huge malignant localized fibrous tumor of the pleura. J Cardiovasc Surg 2000;41:781–4.
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[9] De Pas T, Toffalorio F, Colombo P, Trifirò G, Pelosi G, Della Vigna P, et al. Brief report: activity of Imatinib in a patient with Platelet-Derived-Growth-Factor receptor positive malignant solitary fibrous tumor of the pleura. J Thorac Oncol 2008;3:938–41.
[10] Robinson LA. Solitary fibrous tumor of the pleura. Cancer Control 2006;13:264–9. [11] Bar I, Papiashvilli M, Zukerman B, Stav D, Sandbank J. Large solitary fibrous tumour of the pleura: analysis of six cases. Heart Lung Circ 2007;16:282–4.
Contents lists available at ScienceDirect
Lung Cancer journal homepage: www.elsevier.com/locate/lungcan
Case report
Radical resection of a giant, invasive and symptomatic malignant Solitary Fibrous Tumour (SFT) of the pleura Pier Luigi Filosso a,∗ , Sofia Asioli b , Enrico Ruffini a , Paolo Rovea c,1 , Luigia Macri’ b , Anna Sapino b , Sergio Bretti d , Paraskevas Lyberis a , Alberto Oliaro a a
University of Torino Italy, Department of Thoracic Surgery, San Giovanni Battista Hospital, Via Genova, 3, 10126 Torino, Italy Dept Biomedical Sciences and Human Oncology University of Turin, Italy via Santena, 4 10126 Torino, Italy San Giovanni Battista Hospital Service of Radiotherapy, Via Cavour 12, 10126 Torino, Italy d Service of Oncology ASL 9 Ivrea, Via Aldisio 2, 10015 Ivrea, Torino, Italy b c
a r t i c l e
i n f o
Article history: Received 23 July 2008 Received in revised form 30 September 2008 Accepted 1 October 2008 Keywords: Pleura Solitary fibrous tumour Surgery Prognostic factors Radiotherapy Outcome
a b s t r a c t Solitary Fibrous Tumours (SFTs) of the pleura are rare neoplasms, with unpredictable biological behaviour. Although usually benign, malignant SFTs are described, and they are often associated with large, necrotic and locally invasive tumours. Radical resection represents the treatment of choice in all cases; recurrences are uncommon, and redo-surgery should be considered. The case of a giant, invasive, radically resected malignant SFT, is described. The role of postoperative radiotherapy, to reduce the risk of recurrence, is also discussed. © 2008 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Primary tumours of the serosal membranes (pleural and peritoneal serosa) are classified first into two major categories: diffuse and localized forms [1] and secondarily into localized tumours that can be benign or malignant. To our knowledge, all diffuse neoplasms of the serosal membranes, with the exception of diffuse forms or well-differentiated papillary mesothelioma, are malignant, and most, with the exception of some cases of peritoneal mesothelioma, are at present incurable. On the other hand, patients with even malignant forms of localized serosal tumours may have a very good long-term prognosis if the tumour is completely resected, even though it may be microscopically similar to a diffuse neoplasm. Mesotheliomas are most common diffuse pleural neoplasms while localized ones comprised a variety of entities, the most frequent of which is Solitary Fibrous Tumour (SFT) of the pleura. The histogenesis of many of the SFTs is obscure, with arguments in the literature about an origin from mesothelial cells,
∗ Corresponding author. Fax: +39 011 6705365. E-mail address: pierluigi.fi[email protected] (P.L. Filosso). 1 Fax: +39 011 6705365. 0169-5002/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2008.10.006
submesothelial mesenchymal cells, and uncommitted stem cells. Mesothelial cells display a remarkable morphologic plasticity, manifested by their ability to develop as a wide variety of epithelial and spindle forms. SFT epitomizes this problem. More than 80% of SFTs are benign and asymptomatic, albeit malignant and symptomatic forms are described. Complete surgical resection offers the best chance of cure. Local recurrences are rare; generally they occur after the resection of a giant malignant tumour. In case of tumour recurrence, redo-surgery is indicated, and complete resection is usually achieved. Postoperative radiotherapy is sometimes used [2] in case of large and invasive SFT, to prevent recurrences, even if there is a paucity of evidence in the literature. We present a successful resection of a giant, locally invasive, symptomatic SFT; the role of postoperative radiotherapy is discussed. 2. Case report A 72 year-old woman was referred to us because of a giant rightsided thoracic lesion associated with ipsilateral pleural effusion (Fig. 1a), discovered for thoracic pain, dyspnoea, digital clubbing and hypoglycaemia. In particular she had a history of recurrent fasting hypoglycaemic attacks, with blood-sugar levels of 46–53 mg/dl.
118
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nuclei. Immunophenotypically the tumour demonstrated reactivity for vimentin (Fig. 2a), CD34 (Fig. 2b), CD99 (Fig. 2c) and bcl2 (Fig. 2d), and it was typically negative for keratin, EMA, desmin, actins, S100 protein, collagen type IV and CD31. A morphological and immunohistochemical diagnosis of huge aggressive solitary fibrous tumour of the pleura was made. The postoperative course was uneventful and the blood-sugar values returned to normal within 6 days after the operation. Fifty-five Gy postoperative radiotherapy was administered to reduce the risk of local tumour recurrence. No radiological or clinical evidences of recurrence are present 26 months after surgery. 3. Discussion
Fig. 1. (a) Thoracic CT scan of the large right-side SFT associated with ipsilateral pleural effusion, (b) The intraoperatory view of the 20 cm × 20 cm × 12 cm resected SFT of the pleura.
Transthoracic fine needle aspiration biopsy revealed benign appearing spindle cells, suggesting the diagnosis of a benign pleural fibrous tumour. The patient underwent surgery through a right posterolateral thoracotomy: the tumour originated from the parietal pleura, without any pedicle. It was invasive both in the thoracic wall and in the lung. Fifth, 6◦ and 7◦ rib resection, a partial parietal posterior pleurectomy, and a large pulmonary wedge resection were necessary for a complete tumour resection. The chest wall was reconstructed using a polipropylene mesh. Macroscopic examination of the resected specimen showed a lobulated mass measuring 20 cm × 20 cm × 12 cm, surrounded by pleural tissue (Fig. 1b). It was tan-gray in colour, and vaguely whorled with foci of mucoid change. The mass weighed 2024 g. Microscopically the tumour showed a solid spindle cell growth and fusiform cells were arranged in random arrays (a “patternless pattern”), with some variation in cellularity from region to region within the neoplasm. At high power, a nuclear overlapping with vesicular change in chromatin was observed. Mitotic activity was present (3 mitoses out of 10 HPF). The labelling proliferative index (positivity for Ki67) ranged from 5% to 20% of positive
SFTs represent a rare clinical entity, and about 800 cases have been reported in the literature [3]. Most of the cases show a benign clinical outcome, even if malignant forms may occur up to 12% of cases. The criteria to recognize malignant SFT form were first described by England et al. [4]: as compared with benign lesions, malignant SFTs tend to be larger, more often atypically located (originating from the parietal pleura, with intralobar location or exhibiting inverted growth into the pulmonary parenchyma) and show areas of necrosis and/or haemorrhage. Most commonly malignant SFTs present with symptoms: chest pain, dyspnoea and fever are the most frequent ones. SFTs may be associated with paraneoplastic syndromes, such as hypoglycaemia (Doege-Potter syndrome) [5,6] or hypertrophic pulmonary osteoarthropathy (Pierre-Marie-Bamberg syndrome) [4]. Hypoglycaemia is attributed to the production of insulin-like growth factor II (IGF-II), which lowers the blood glucose and impairs the growth hormone counter-regulatory response to hypoglycaemia. It is described with an incidence of 11% in malignant SFTs as compared with 3% of benign ones, according to the data of England et al. [4]. SFTs larger than 20 cm, or with high mitotic rate are often associated with reactive hypoglycaemia [4,6]. Hypertrophic osteoarthropathy is due to the abnormal production of hyaluronic acid by tumour cells, and affects up to 20% of the patients. Our patient had a 20 cm × 20 cm × 12 cm tumour, originating from the parietal pleura, without a pedicle, deeply invasive on the thoracic wall, associated with hypoglycaemia and osteoarthropathy, therefore meeting the criteria for malignant SFT. Resection of three ribs, partial parietal pleurectomy and pulmonary wedge resection were required for a complete tumour exeresis. Similar results are reported by Magdeleinat et al. [7] in case of large invasive lesions: en bloc chest wall resection or diaphragmatic, parietal pleura and/or pericardium exeresis occurred in 6 out of 60 patients of their series. Complete surgical resection represents the treatment of choice for SFTs: the completeness of the excision represents the primary objective of surgery. Wide tumour-free margins (1–2 cm or more), possibly confirmed by frozen sections, should be achieved in all cases, especially in large SFTs. In our opinion every suspected or proven SFT should be operated, because clinical or radiological criteria cannot accurately distinguish benign forms from malignant ones. Recurrences are possible, even if rare, especially in malignant SFTs. England reports 1.4% recurrence rate in his series [4]. The reasons for the recurrence in pathologically complete resections are unknown. Magdeleinat et al. described 2 local recurrences out of 21 patients with malignant SFTs [7]. The recurrences occurred after the resection of giant SFTs. Surgery, when feasible, represents the treatment of choice, even when recurrence develops: SFTs have, in fact, a low sensitivity to chemotherapy.
P.L. Filosso et al. / Lung Cancer 64 (2009) 117–120
119
Fig. 2. Immunohistochemical features of Solitary Fibrous Tumour (SFT). The neoplastic cells showed diffuse immunoreactivity for vimentin (A), CD99 (C), and bcl2 (D), and weakly positivity for CD34 (B).
Table 1 Large SFTs treated with surgery and postoperative radiotherapy. Case
Sex
Age
Location of SFT
Size of tumour
Radicality
Postoperative RT
Follow-up (months)
Status of follow-up
1 2 3 4 5 Present
F M M F F F
65 73 75 69 66 72
Left Right Right Left Right Right
15 cm × 21 cm 19 cm × 17 cm 14 cm × 19 cm 18 cm × 12 cm 13 cm × 12 cm 20 cm × 20 cm
Yes Yes Yes Yes Yes Yes
48 Gy 50 Gy 50 Gy 55 Gy 45 Gy 55 Gy
18 13 10 5 12 26
NED NED NED NED REC NED
M, male; F, female; NED, no evidence of disease; REC, recurrence.
Due to the rarity of these tumours, there is no systematic assessment of the role of adjuvant therapy in SFTs, at present. Only few brief reports have been published about the role of chemotherapy in recurrent malignant forms [8,9]. Following resection radiotherapy can be considered for recurrent or malignant SFTs, particularly in the sessile variety [3,10], or in case of incomplete resection [11]. Our patient received 55 Gy postoperative radiotherapy and she is free of local recurrences 26 months after surgery. We treated with the same postoperative protocol 5 other radically resected large SFTs: only one local relapse was observed (Table 1). In conclusion, large symptomatic SFTs may be considered potentially malignant and a complete surgical resection, (including en bloc chest wall resection, or diaphragm or pericardium or lung resection) is required. Postoperative radiotherapy may theoretically reduce the risk of local recurrence, but a long follow-up is mandatory and redo-surgery can be considered in case of local tumour relapse.
Conflict of interest None declared. References [1] Briselli M, Mark EJ, Dickersin GR. Solitary fibrous tumors of the pleura: eight new cases and review of 360 cases in the literature. Cancer 1981;47:2678–89. [2] Mahesh B, Clelland C, Ratnatunga C. Recurrent localized fibrous tumor of the pleura. Ann Thorac Surg 2006;82:342–5. [3] de Perrot M, Fisher S, Brundler MA, Sekine Y, Keshavjee S. Solitary fibrous tumors of the pleura. Ann Thorac Surg 2002;74:285–93. [4] England DM, Hochholzer L, McCarty MJ. Localized benign and malignant fibrous tumor of the pleura. Am J Surg Pathol 1989;13:640–58. [5] Doege KW. Fibrosarcoma of the mediastinum. Ann Surg 1930;92:955–61. [6] Balduyck B, Lauwers P, Govaert K, Hendriks J, De Maeseneer M, Van Schil P. Solitary fibrous tumor of the pleura with associated hypoglycaemia: DoegePotter syndrome. J Thorac Oncol 2006;1:588–90. [7] Magdeleinat P, Alifano M, Petino A, Le Rochais JP, Dulmet E, Galateau F, et al. Solitary fibrous tumors of the pleura: clinical characteristics, surgical treatment and outcome. Eur J Cardiothorac Surg 2002;21:1087–93. [8] Veronesi G, Spaggiari L, Mazzarol G, De Pas M, Leo F, Solli P, et al. Huge malignant localized fibrous tumor of the pleura. J Cardiovasc Surg 2000;41:781–4.
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P.L. Filosso et al. / Lung Cancer 64 (2009) 117–120
[9] De Pas T, Toffalorio F, Colombo P, Trifirò G, Pelosi G, Della Vigna P, et al. Brief report: activity of Imatinib in a patient with Platelet-Derived-Growth-Factor receptor positive malignant solitary fibrous tumor of the pleura. J Thorac Oncol 2008;3:938–41.
[10] Robinson LA. Solitary fibrous tumor of the pleura. Cancer Control 2006;13:264–9. [11] Bar I, Papiashvilli M, Zukerman B, Stav D, Sandbank J. Large solitary fibrous tumour of the pleura: analysis of six cases. Heart Lung Circ 2007;16:282–4.