Resection of malignant fibrous histiocytoma involving the thoracoabdominal aorta with staged emobolization of the intercostal arteries

Abstract

Clinical Summary A 53-year-old woman was admitted to investigate a loss of 12 kg body weight in a year. Computed tomography disclosed a huge (13 9 cm) mass contiguous with left lung, left chest wall, and thoracic vertebra, with invasion into the thoracic aorta (Figure 1). A diagnosis of MFH was made after open biopsy of the tumor. An angiogram demonstrated that the tumor was located around the descending aorta from T7 to the level of the celiac artery, and the left 10th intercostal artery supplied the anterior spinal artery through the artery of Adamkiewicz (Figure 2). Systemic screening showed no metastatic lesions. Serum tumor markers were all within normal limits. All ICAs and bronchial arteries were patent. To prevent intraoperative back bleeding from the ICAs and spinal cord ischemia, a staged embolization of the ICAs was performed. At first, the 8th to 11th ICAs were embolized. The 7th and 12th ICAs were embolized 7 days later. Finally, the inferior phrenic artery and esophageal artery were embolized. Cerebrospinal fluid drainage was performed preoperatively. A spiral incision was applied, and a huge mediastinal tumor was found to occupy the thoracoabdominal cavity, infiltrating the paravertebral region with adherence to lower left lobe of the lung, diaphragm, and esophagus but not to the pericardium. With partial cardiopulmonary bypass, the tumor was resected completely, combined with resection of the involved segment of the thoracoabdominal aorta (from T5 to above the celiac artery), the lower left lobe of the lung, and part of the diaphragm. The thoracoabdominal aorta was replaced with an 18-mm knitted polyester fabric (Dacron) graft, and the diaphragm was reconstructed with a composite expanded polytetrafluoroethylene (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, Ariz) mesh. Histologically, tumor invasion was not observed in any other organ. The tumor cell showed a storiform pattern and hemangiopericytomatous pattern. Immunohistochemical examination revealed that tumor cells were negative for epithelial membrane antigen, –smooth muscle antigen, S100 protein, and CD34. There were no postoperative complications, such as paraplegia, and the patient was discharged on the 17th day after surgery.