A fifty two year old male was admitted via Emergency department with complaints of shortness of breath. Patient had history of intermittent episodes of shortness of breath for last two years with each episode being worsened from the previous one. The last episode started one month ago restricting his physical activity only to few steps; Shortness of breath is partially relieved by lying laterally. It was also associated with productive cough with white scanty, non-foul smelling sputum, occasionally mixed with blood. Patient also received ATT (anti tuberculosis therapy) for last fifteen days without any betterment in his status. He holds past two year record of admissions, where he was treated for pneumonia initially; later two admissions were done with extensive workup firstly in August 2012 and latter January 2013. Biopsies were done both the time and both confer the diagnosis of solitary fibrous tumor. Patient was advised for followup in both institutes, but never returned and finally landed in our institute in order to avoid a possible surgical resection.
Clinically patient was restless, tachycardic and tachypneic but maintained oxygen saturation on 3-4 liter of oxygen. His chest examination showed decrease right sided movements with dull percussion note, decrease breath sounds. Lab investigations further revealed anemia with Hemoglobin of 8.0 gm/dl, blood gases showed mild hypoxia with PO2 of 80mm Hg while rest of his metabolic panel & co-agulation profile were within normal limit.
Chest X-ray showed a large homogenous opacity on right side with mediastinal shift. CT Scan of chest confirmed the finding of a large heterogeneous mass with few sparks of calcification occupying almost whole of the right hemi thorax. Medially the mass was abutting and pushing superior vena cava, Aorta, right pulmonary artery and heart. Mass was also causing compression effects on the right hemi-diaphragm. It is displacing the mediastinal contents on to the left and caused compression collapse of right medial and lover lobe. Minimal pleural effusion with pleural thickening was also noted. (Fig. 1 and 2)
After thorough discussion and multiple settings; patient was counselled for surgical removal of the mass and its catastrophic outcome in case of further delay. Explorative thoracotomy was done and a huge extra pleural mass was removed. Right upper lobe of the lung was also adherent to the mass. Careful incision was performed to remove the mass preserving the surrounding vascular structures with minimal blood loss. The size of excised mass 24 x 20cm x 8cm and it was 3150gm in weight. (Fig.3). The lower and middle lobe collapse was relieved partially and later fully. Two drains were placed and wound was approximated.
The pathological examination revealed a single multi nodular encpsulated pale white firm piece of tissue. On serial sectioning two collapsed cavities were also indentified with larger one measuring 5 x5 cm filled with yellow pleurant exudate. A flap of pleura id identified too measuring 12x6 cm.
Microscopic examination revealed demarcated lesion composed of spindloid cells. The nuclei are oval to elongated with evenly dispersed chromatin. Cytoplasm is abundant. Scattered mitotic figures are seen. Areas of hyalinization and fibrosis are noted. Conclude as neoplastic lesion; solitary fibrous tumor as possibility.
Patient was kept on mechanical ventilation, but, as per plan, the ICU team could not wean him off in next two days. Patient also developed fever spikes and later developed ventilator associated pneumonia. Tracheal cultures revealed acinetobacter. Intravenous anti-biotics were given as per sensitivity and after six days patient was finally extubated. Drains were removed on third day of surgery. Physical capacity continues to increase slowly and patient was able to walk short distances without any discomfort.