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Solitary Fibrous Tumor of the Pleura: Evaluation of the Origin with 3D CT Angiography
IMAGE
OF THE
MONTH
Solitary Fibrous Tumor of the Pleura: Evaluation of the Origin with 3D CT Angiography Noriyasu Usami, MD,* Shingo Iwano, MD,† and Kohei Yokoi, MD*
(J Thorac Oncol. 2007;2: 1124–1125)
S
olitary fibrous tumor of the pleura (SFTP) usually arises from the visceral pleura, although an origin from the parietal or the diaphragmatic pleura has been reported in about 20% of the cases.1 Complete, en bloc surgical resection is the mainstay of therapy for SFTP. In cases of small, pedunculated tumors located on the visceral pleura, thoracoscopic approaches can be safely used to resect. But large, sessile tumors can be difficult to resect because of extensive adhesion, and they may occasionally require lobectomy or pneumonectomy to achieve complete resection.2 Thus, preoperative evaluation of the blood supply to a SFTP can be helpful for a treatment plan and safe resection.3 We present a case of a patient with SFTP in which preoperative computed tomography (CT) angiography was helpful in the accurate evaluation of the blood supply and in detecting the origin. A 57-year-old man was admitted to our institute complaining of right-chest discomfort. Chest roentgenogram showed a well-defined mass above the right diaphragm. CT scans revealed a well-circumscribed, smooth, inhomogeneous contrast uptake mass measuring 10 cm in diameter, images of which were obtained with a 64-row, multislice CT scanner (Aquilion; Toshiba Medical Systems, Tokyo, Japan) with a collimation of 1 mm and 0.5 sec/tube rotation (Figure 1). One hundred milliliters of 320 mgI/ml nonionic contrast medium was administered at an injection rate of 3.0 ml/sec, using a power injector via the right-medial cubital vein. The scanning delay was automatically determined with bolus tracking in the descending aorta, and scanning started when a predetermined threshold of 150 HU was reached. On magnetic resonance imaging, T1-weighted images demonstrated low signal intensity, and T2-weighted images showed mixed signal intensity. The border between the diaphragm and the mass lesion was clearly demonstrated with a sagittal section of Departments of *Thoracic Surgery and †Radiology, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan. Disclosure: The authors declare no conflict of interest. Address for correspondence: Noriyasu Usami, MD, Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-ku, Nagoya 466-8550, Japan. E-mail: [email protected] Copyright © 2007 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/07/0212-1124
1124
FIGURE 1. Computed tomography scans revealed a wellcircumscribed, smooth, inhomogeneous contrast uptake mass above the right diaphragm.
magnetic resonance imaging. To evaluate the blood supply and the origin of this mass, three-dimensional CT angiography was reconstructed from the volume data on a workstation (ZIOSTATION; Ziosoft, Tokyo, Japan). The blood supply into the lesion was continuing from the lung, not from the chest wall or the diaphragm, which were distributed radially into the tumor shadow (Figure 2). Three-dimensional CT angiography showed only relatively large vessels for demonstrating the origin of the blood supply, so there might be a paucity of vessels in the tumor compared with that suggested on the conventional images. With the preoperative image information, it was speculated that this mass was a solitary fibrous tumor originating from visceral pleura of the right lower lobe of the lung with a pedicle. At operation, via a right thoracotomy, a 10 ⫻ 6.5 ⫻ 5 cm, well-capsulated solitary mass was completely resected; it originated from the visceral pleura with a pedicle (Figure 3). The gross feature was consistent with the diagnostic imaging. A microscopic examination revealed fibroblast-like structures within the collagen deposits. No atypical cytological differentiation or necrosis was present in the areas where mitosis was rarely seen. These findings confirmed the diagnosis of benign SFTP. At 8 months after surgery, the patient is still healthy.
Journal of Thoracic Oncology • Volume 2, Number 12, December 2007
Journal of Thoracic Oncology • Volume 2, Number 12, December 2007
Image of the Month
FIGURE 2. Three-dimensional computed tomography angiography showed that the blood supply into the lesion was continuing from the lung, not from the chest wall or the diaphragm, which were distributed radially into the tumor shadow (arrow).
We consider that three-dimensional CT angiography is helpful in the accurate evaluation of the blood supply and in detecting the origin of SFTP. 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;47:2678–2689. 2. Cardillo G, Facciolo F, Cavazzana AO, et al. Localized (solitary) fibrous tumors of the pleura: an analysis of 55 patients. Ann Thorac Surg 2000;70:1808–1812. 3. Kaul P, Kay S, Gaines P, et al. Giant pleural fibroma with an abdominal vascular supply mimicking a pulmonary sequestration. Ann Thorac Surg 2003;76:935–937.
FIGURE 3. (A) Tumor originated from the visceral pleura with a pedicle. (B) Resected solitary fibrous tumor was a 10 ⫻ 6.5 ⫻ 5 cm, well-capsulated mass.
Copyright © 2007 by the International Association for the Study of Lung Cancer
1125
OF THE
MONTH
Solitary Fibrous Tumor of the Pleura: Evaluation of the Origin with 3D CT Angiography Noriyasu Usami, MD,* Shingo Iwano, MD,† and Kohei Yokoi, MD*
(J Thorac Oncol. 2007;2: 1124–1125)
S
olitary fibrous tumor of the pleura (SFTP) usually arises from the visceral pleura, although an origin from the parietal or the diaphragmatic pleura has been reported in about 20% of the cases.1 Complete, en bloc surgical resection is the mainstay of therapy for SFTP. In cases of small, pedunculated tumors located on the visceral pleura, thoracoscopic approaches can be safely used to resect. But large, sessile tumors can be difficult to resect because of extensive adhesion, and they may occasionally require lobectomy or pneumonectomy to achieve complete resection.2 Thus, preoperative evaluation of the blood supply to a SFTP can be helpful for a treatment plan and safe resection.3 We present a case of a patient with SFTP in which preoperative computed tomography (CT) angiography was helpful in the accurate evaluation of the blood supply and in detecting the origin. A 57-year-old man was admitted to our institute complaining of right-chest discomfort. Chest roentgenogram showed a well-defined mass above the right diaphragm. CT scans revealed a well-circumscribed, smooth, inhomogeneous contrast uptake mass measuring 10 cm in diameter, images of which were obtained with a 64-row, multislice CT scanner (Aquilion; Toshiba Medical Systems, Tokyo, Japan) with a collimation of 1 mm and 0.5 sec/tube rotation (Figure 1). One hundred milliliters of 320 mgI/ml nonionic contrast medium was administered at an injection rate of 3.0 ml/sec, using a power injector via the right-medial cubital vein. The scanning delay was automatically determined with bolus tracking in the descending aorta, and scanning started when a predetermined threshold of 150 HU was reached. On magnetic resonance imaging, T1-weighted images demonstrated low signal intensity, and T2-weighted images showed mixed signal intensity. The border between the diaphragm and the mass lesion was clearly demonstrated with a sagittal section of Departments of *Thoracic Surgery and †Radiology, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan. Disclosure: The authors declare no conflict of interest. Address for correspondence: Noriyasu Usami, MD, Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-ku, Nagoya 466-8550, Japan. E-mail: [email protected] Copyright © 2007 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/07/0212-1124
1124
FIGURE 1. Computed tomography scans revealed a wellcircumscribed, smooth, inhomogeneous contrast uptake mass above the right diaphragm.
magnetic resonance imaging. To evaluate the blood supply and the origin of this mass, three-dimensional CT angiography was reconstructed from the volume data on a workstation (ZIOSTATION; Ziosoft, Tokyo, Japan). The blood supply into the lesion was continuing from the lung, not from the chest wall or the diaphragm, which were distributed radially into the tumor shadow (Figure 2). Three-dimensional CT angiography showed only relatively large vessels for demonstrating the origin of the blood supply, so there might be a paucity of vessels in the tumor compared with that suggested on the conventional images. With the preoperative image information, it was speculated that this mass was a solitary fibrous tumor originating from visceral pleura of the right lower lobe of the lung with a pedicle. At operation, via a right thoracotomy, a 10 ⫻ 6.5 ⫻ 5 cm, well-capsulated solitary mass was completely resected; it originated from the visceral pleura with a pedicle (Figure 3). The gross feature was consistent with the diagnostic imaging. A microscopic examination revealed fibroblast-like structures within the collagen deposits. No atypical cytological differentiation or necrosis was present in the areas where mitosis was rarely seen. These findings confirmed the diagnosis of benign SFTP. At 8 months after surgery, the patient is still healthy.
Journal of Thoracic Oncology • Volume 2, Number 12, December 2007
Journal of Thoracic Oncology • Volume 2, Number 12, December 2007
Image of the Month
FIGURE 2. Three-dimensional computed tomography angiography showed that the blood supply into the lesion was continuing from the lung, not from the chest wall or the diaphragm, which were distributed radially into the tumor shadow (arrow).
We consider that three-dimensional CT angiography is helpful in the accurate evaluation of the blood supply and in detecting the origin of SFTP. 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;47:2678–2689. 2. Cardillo G, Facciolo F, Cavazzana AO, et al. Localized (solitary) fibrous tumors of the pleura: an analysis of 55 patients. Ann Thorac Surg 2000;70:1808–1812. 3. Kaul P, Kay S, Gaines P, et al. Giant pleural fibroma with an abdominal vascular supply mimicking a pulmonary sequestration. Ann Thorac Surg 2003;76:935–937.
FIGURE 3. (A) Tumor originated from the visceral pleura with a pedicle. (B) Resected solitary fibrous tumor was a 10 ⫻ 6.5 ⫻ 5 cm, well-capsulated mass.
Copyright © 2007 by the International Association for the Study of Lung Cancer
1125