Analysis of giant thoracic neoplasms: Correlations between imaging, pathology and surgical management

Abstract

Background: A giant thoracic neoplasm is extremely rare and poorly understood. Our systemic study introduced computed tomography angiography (CTA) with three-dimensional (3D) reconstruction imaging and evaluated correlations between imaging, pathology, and surgical management.

Methods: Data from 45 patients undergoing surgery for giant thoracic neoplasm in our institution between May 2007 and November 2015 were collected. The clinical characteristics, imaging manifestations, preoperative biopsy, surgical management, postoperative pathology, and prognosis and their correlation were analyzed.

Results: The clinical characteristics, imaging manifestations, and pathological types were complicated. Four patients underwent CTA with 3D reconstruction imaging and feeding vessels were found in three cases. Twenty-four selected patients accepted preoperative biopsy, eight of which were inconsistent with postoperative pathology. Complete resection was performed in 39 cases, 20 of which underwent extended excision. The median survival duration of all patients was 58 months (range 3.0-118.0). The one, three, and five-year survival rates were 86.0%, 64.4%, and 47.0%, respectively. Univariate analyses showed tumor size and resection status were prognostic factors for survival (P = 0.003 and P < 0.001, respectively).

Conclusions: A giant thoracic neoplasm should preferably be treated in experienced centers for precise diagnosis and optimal therapy schemes with comprehensive consideration of clinical characters, imaging manifestations, pathology, surgical management, and prognosis. Innovative CTA with 3D reconstruction imaging together with preoperative biopsy are feasible and effective in therapeutic decision-making and surgical planning. Complete surgical resection remains the mainstay of curative therapy for all resectable tumors.

Keywords: Computed tomography angiography; giant thoracic neoplasm; surgical management; three-dimensional reconstruction.

Figure 1

(a) A giant thoracic neoplasm was located in the right hemithorax. (b) Large numbers of tortuous vessels were found within the tumor body and on the surface of the adjacent diaphragm on a contrast‐enhanced computed tomography scan. Vessels in the upper portion of the tumor seemed to be closely related to branches of the right upper pulmonary artery. (c) An aberrant artery originating from the right renal artery was distributed into the right side of the diaphragm and thoracic tumor body. (d,e) As confirmed by surgery, the tumor was solitary and completely encapsulated with a wide‐basement vascular pedicle from the diaphragm. Ligation and suture of the pedicle was followed by complete resection. (f) The resected specimen measured 23 × 20 × 11 cm³ and weighed about 3.0 kg. Pathology revealed solitary fibrous tumor of the pleura.

Figure 2

(a) A giant thoracic neoplasm was located in the left hemithorax. (b,c) Large numbers of tortuous vessels were found within the tumor body in the arterial phase, especially in the posterior of the tumor body. An aberrant artery originating from the anterior wall of the thoracic aorta travelled forward and downward along the right side of the tumor body (see white arrow). (d–f) The adjacent T5–10 intercostal arteries were dilated and tortuous. Their circuitous branches were radially distributed into the tumor body. As confirmed by surgery, the blood supply to the tumor was abundant. The tumor was removed piece by piece with extended excision of the partial pleura, aortic adventitia, and left pneumonectomy. Pathology revealed synovial sarcoma.

Figure 3

(a) A giant thoracic neoplasm was located in the left hemithorax. (b) An aberrant arterial branch originating from the internal mammary artery was distributed downward into the tumor body (see white arrow). (c) Large numbers of tortuous vessels were found within the tumor body in the arterial phase. The tumor was speculated to be solitary and completely encapsulated, with a wide‐basement pedicle from the mediastinum. This speculation was confirmed by surgery. (d) The resected specimen measured 16.0 × 16.0 × 6.0 cm³. Pathology revealed thymic carcinoid.

Figure 4

Kaplan–Meier survival curves for each single factor. (a) Patients with tumors ≤20 cm showed significantly better survival than patients with larger tumors (P = 0.033). (b) Survival was significantly different when stratified by tumor resection status (P < 0.001). (c) Pathology group was closely correlated with prognosis (P = 0.001).