PMC9475251_01
(A) Preoperative chest x-ray: left side uniformly white with mediastinal shift; (B) preoperative chest CT showing the mass with abnormal angiogenesis (arrow), coronal scan; (C) preoperative chest CT, sagittal scan; (D) preoperative chest CT showing the abnormal tumor angiogenesis (round), axial scan; (E) lung perfusion scintigraphy; (F) transcatheter arterial embolization (TAE) of X, XI, XII left intercostal arteries (round), left superior phrenic artery (inferior arrow), left internal mammary artery (superior arrow).
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F1
Chest x-ray showed a left side uniformly white with mediastinal shift, thus a diagnosis of massive left pleural effusion was suspected (Figure 1A). It demonstrated a huge enhancing left pleural mass, with a diameter of 18.4 x 16.0 x 11.2 cm, causing compression atelectasis of the left lung and mediastinal shift, with abnormal tumor neovascularization (Figures 1B-D). The preoperative assessment included Lung Perfusion Scintigraphy showing complete hypoperfusion of the left lung related to the mass (left lung 12.8%, right lung 87.2%) (Figure 1E). Transcatheter angiography through the right femoral artery revealed vascular supply from X, XI, XII left intercostal arteries, left superior phrenic artery, left internal mammary artery (Figure 1F) and TAE was carried out with coils.
(A) Intraoperative view of hemiclamshell incision; (B) left lung en-bloc with mass; (C) postoperative chest x-ray; (D) hematoxylin-eosin, (10x, 4x) leiomyosarcoma of the lung; (E) immunohistochemistry, smooth muscle actin and muscle-specific actin (10x); (F) CT scan showing left gluteal metastasis.
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F2
The patient underwent a sterno-thoracotomy (hemiclamshell incision) at the fifth left intercostal space (Figure 2A). An intrapericardial left pneumonectomy with radical en-bloc mass resection was performed (Figure 2B). On the third postoperative day (POD), the patient was discharged from ICU and returned to the ward, where the chest tube was removed (Figure 2C). The surgical pathology report revealed a large malignant mesenchymal tumor (17 x 15 x 9 cm) characterized by spindle cells with significantly increased areas of mitotic activity (Figure 2D). Immunohistochemistry (IHC) showed malignant spindle cell positivity for Actin 1A4, Actin HHF-35, Caldesmon, and Desmin (Figure 2E). The left enhancing gluteal lesion presented increasing in size (diameter of 28 x 20 mm), therefore an ultrasound-guided needle biopsy was performed, but it revealed non-diagnostic (Figure 2F).
Table showcasing of care timeline.
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F3
The care timeline is shown in Figure 3.