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Chest Imaging and Pathology for Clinicians |

Patient With Slow-Growing Mediastinal Mass Presents With Chest Pain and Dyspnea FREE TO VIEW

Abhishek Biswas, MD; Daniel Urbine, MD; Ashish Prasad, MD; Eric S. Papierniak, DO; Michelle Weber, MD; Paras Malhotra, MD; Peruvemba S. Sriram, MD
Author and Funding Information

CORRESPONDENCE TO: Abhishek Biswas, MD, University of Florida, Department of Pulmonary, Critical Care and Sleep Medicine, 1600 SW Archer Ave, Gainesville, FL 32610


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(1):e17-e23. doi:10.1016/j.chest.2015.10.043
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Published online

A 52-year-old white woman presented with severe pain over the right upper abdomen and nonpleuritic, right-sided, lower chest-wall pain. Her pain had progressively gotten more frequent and severe over the last 5 months. It was also associated with a nonexertional, pressure-like sensation in the central chest. The patient denied any shortness of breath, fevers, cough, or any sputum production. She was taking levothyroxine for hypothyroidism and was a 30-pack-year current smoker; there was no history of drug abuse or occupational exposure. Previous chest radiographs dating back to 5 years consistently showed an elevated right-sided hemidiaphragm without any infiltrates or effusions; cardiomediastinal structures were unremarkable. She had not had a previous workup for these abnormal findings.

Figures in this Article

Physical examination revealed a mildly overweight, hemodynamically stable woman in no apparent distress. The patient was afebrile, with BP of 135/91 mm Hg, pulse rate of 76/min, respiratory rate of 17/min, and oxygen saturation of 98% on room air. Her physical examination was remarkable for reduced breath sounds on the right-side middle and lower zones on the anterior, lateral, and posterior aspects of the chest, with dullness on percussion in these areas. No adventitious sounds were audible over both lungs. Blood tests revealed a hemoglobin concentration of 13.8 g/dL, hematocrit of 42.3%, and WBC count of 10.8 × 109 cells/L with a normal differential. She had normal kidney and liver function profiles.

Chest radiographs (Figs 1, 2) demonstrated an elevated right-side hemidiaphragm without any evidence of pleural or parenchymal opacities. A CT scan of her chest (Figs 3,4,5) revealed a large (11 × 14 × 11 cm) mass within the right-side hemithorax. It appeared to contain soft tissue and fat, and had features suggesting intralesional hemorrhage. The inferior and lateral part of the mass demonstrated coarse calcifications (Fig 5). The mass appeared to be contained between two layers of the pleura and compressed the inferior vena cava as it entered the thorax, but did not invade the thoracic cage. The mass demonstrated low fluorodeoxyglucose avidity with a maximum standardized uptake value of 3.26 on PET scan, along with nonspecific uptake in a few nonenlarged mediastinal nodes. The patient underwent “clamshell thoracotomy” with complete resection of the mass, which measured 22.0 × 15.0 × 14.0 cm and weighed 1,510 g (Fig 6). Mobilization was difficult because the mass was strongly adherent to the pericardium, a strip of which had to be removed. The tumor did not invade the lung or pleura.

Figure 1
Figure Jump LinkFigure 1 Chest radiograph. Posteroanterior view at the time of surgery demonstrates an elevated right-side hemidiaphragm with clear costophrenic angles. The lungs appear clear and the heart size appears normal.Grahic Jump Location
Figure 2
Figure Jump LinkFigure 2 Lateral view of the chest again demonstrates the elevated right-side hemidiaphragm with some fullness in the right posterior costodiaphragmatic recess, indicating the possibility of a small pleural effusion.Grahic Jump Location
Figure 3
Figure Jump LinkFigure 3 CT scan of the chest at the level of the ventricles shows an inhomogeneous tumor arising from the right side of the heart and occupying more than one-half of the right side of the thoracic cavity.Grahic Jump Location
Figure 4
Figure Jump LinkFigure 4 CT scan of the chest (mediastinal window) displays near obliteration of the right side of the thoracic cavity at a lower level than the previous image.Grahic Jump Location
Figure 5
Figure Jump LinkFigure 5 Coronal section displays a right-side thoracic mass occupying the lower part of the chest. It has an inhomogeneous appearance, with areas having attenuation coefficients of −75.71 Hounsfield units (HU) and −65.63 HU. This confirms the presence of fat (< −20 HU) in the tumor. Also noted are areas of calcifications, marked with a black arrow at the inferior aspect of the tumor. These were thought to be dystrophic calcification in areas with prior necrosis.Grahic Jump Location
Figure 6
Figure Jump LinkFigure 6 A 22.0 × 15.0 × 14.0 cm mass weighing 1,510 g was resected from the right side of the thoracic cavity. The only point of attachment of the mass to the thoracic structures was through the pericardium.Grahic Jump Location

A cut section revealed a heterogeneous yellowish-tan to tan-white, solid to myxoid, and gelatinous mass with scattered areas of calcification. Microscopically, two separate morphologies were noted. There were areas with mature-appearing fat cells with hyperchromatic nuclei and multivacuolated lipoblasts (Figs 7, 8). Other areas demonstrated a myxoid matrix with hyperchromatic fat cells, lipoblasts, and a delicate capillary vascular network, all of which appeared to be suspended in the matrix (Fig 9). Extensive areas of necrosis (> 50%) were noted without any hemorrhage. Cytologic atypia was frequently noted with scant mitoses. Immunohistochemistry demonstrated tumor positivity for S-100, focal positivity for CD34, and weak positivity for CD117 (c-kit); the cells were negative for HMB-45 and calretinin expression. Fluorescence in situ hybridization (FISH) was negative for rearrangements in MDM2, FUS, EWSR1, and DDIT3 genes in multiple tissue blocks. Mature pericardial tissue without any evidence of malignancy was adherent to the mass (Fig 10). All margins of resection were free of any cancer cells.

Figure 7
Figure Jump LinkFigure 7 Two distinct morphologies were seen within the tumor. Areas consistent with well-differentiated liposarcoma exhibit mature-appearing fat with frequent hyperchromatic nuclei and multivacuolated lipoblasts. Areas typical of myxoid liposarcoma demonstrate hyperchromatic cells and lipoblasts suspended in a myxoid matrix with a distinctive delicate capillary vascular network in the background. (Hematoxylin-and-eosin, × 100 magnification).Grahic Jump Location
Figure 8
Figure Jump LinkFigure 8 Lipoblasts seen within areas of well-differentiated liposarcoma. (Hematoxylin-and-eosin, × 400 magnification).Grahic Jump Location
Figure 9
Figure Jump LinkFigure 9 Myxoid liposarcoma with lipoblasts and distinctive “chicken wire” vasculature. (Hematoxylin-and-eosin, × 200 magnification).Grahic Jump Location
Figure 10
Figure Jump LinkFigure 10 Portion of pericardium adherent to surface of the liposarcoma. This is the only site of attachment of tumor mass to surrounding structures. (Hematoxylin-and-eosin, × 400 magnification).Grahic Jump Location

What is the diagnosis?

Diagnosis: Intermediate grade pericardial liposarcoma

Clinical Discussion

Liposarcoma is a common form of sarcoma in adults, mostly arising from the lower extremities and the retroperitoneum. However, primary liposarcoma of the mediastinum is an extremely rare tumor, accounting for 0.13% to 0.75% of all mediastinal tumors. These usually arise from the posterior mediastinum., Fewer than 150 cases have been reported in the medical literature. Primary liposarcoma of the pericardium, as described in this case, is one of the rarest forms of mediastinal liposarcoma., Although this may affect people aged between 9 months and 77 years, it is mostly a disease of adults. Presenting symptoms arise from compression of adjacent viscera and include dyspnea, cough, chest pain, and weight loss, but patients may also be asymptomatic. Obstruction of the superior vena cava may lead to superior vena cava syndrome. Patients can present with cardiac tamponade, acute pericarditis, chest wall involvement, metastases to other organs, syncope, or angina., Involvement of the lungs, aortic arch, atria, and pulmonary artery, by extension of the tumor, has been reported.

Treatment of choice is complete surgical resection. The degree of completeness of resection is an important prognostic factor. Five-year survival rates following surgery have ranged between 66% and 85%. However, recurrence rates of 30% to 40% have been reported and may occur late (eg, 14 years after resection). Radiation therapy has not been very successful, primarily because of the proximity of the heart to the radiation field and the possibility of radiation-induced mediastinal fibrosis. The role of adjuvant chemotherapy is mostly experimental at this time. Finally, prognostic factors have been defined, and they include age, site, degree of adjacent organ involvement, tumor size, surgical margins, surgical procedure, and the need for radiation therapy.,

Radiologic Discussion

The differential diagnosis for fat-containing mediastinal masses are wide. Those relevant to this case include the following: lipoma and lipomatosis, lipomatous hypertrophy of the interatrial septum, teratoma and teratocarcinoma, liposarcoma, lipoblastoma, thymolipoma, hamartoma, lipoid pneumonia, thoracic metastasis from clear renal cell carcinoma, and diaphragmatic defects and hernias (Morgagni and Bochdalek).

The location of the mass often helps identify the type of tumor. Lipomas and teratomas are generally noted in the anterior mediastinum, although teratomas can also occur in the posterior mediastinum. Thymolipomas, as their name suggests, arise from thymic parenchyma and are superior mediastinal masses. Lipoblastomas are tumors of infancy and early childhood. Cardiac tumors such as sarcomas, teratomas, teratocarcinomas, and malignant fibrous histiocytomas can also have a cystic component and should be considered in the differential diagnosis of lipoblastomas. Teratomas and teratocarcinomas often have a similar inhomogeneous appearance on CT scans but can be distinguished from other tumors by the presence of cysts, fluid collection, calcifications, and even teeth inside. Pre- and postcontrast CT images can help distinguish a cystic from a solid or necrotic lesion. Liposarcomas of the mediastinum and the heart appear as predominantly mediastinal masses with low attenuation (between −50 and −150 Hounsfield units), often making it difficult to distinguish this type of liposarcoma from lipoma. Cardiac liposarcomas typically originate from the right-side structures (myocardial and extramyocardial), as was seen with this patient (pericardial in this instance). The presence of a nonadipose component in the tumor, as observed in this case, carries an OR of 31.8 favoring liposarcoma over lipoma. Although it was felt to be unnecessary in this case, MRI can help distinguish lipomas from liposarcomas better than CT scans and thus can be very useful preoperatively.

Pathologic Discussion

According to the most recent classification by the World Health Organization, liposarcomas are classified histologically into atypical lipomatous tumor/well-differentiated liposarcoma (accounting for 40% to 45% of liposarcomas); myxoid liposarcoma (accounting for 15% to 20%); dedifferentiated liposarcoma (arising de novo and occurring in up to 10% of well-differentiated liposarcomas); and pleomorphic liposarcomas (rarest, accounting for 5%). Previously, round cell liposarcoma was considered a distinct entity, but it is now more appropriately included in the category of myxoid liposarcoma, as patient prognosis is similar and the genetic translocation is identical. Prior classification also included a category of mixed-type liposarcoma, which was reported as extremely rare. Most cases are now recognized according to their component tumors. Myxoid and pleomorphic liposarcomas are locally infiltrative and early metastasizing. They also have higher rates of local recurrence (local recurrence rate of 33% and metastases in 40% of cases).,,,

In comparison, well-differentiated variants have a < 10% risk of local recurrence and 0% risk of metastasis. Prognosis is worse with the dedifferentiated type, in which there is a combination of distinct areas of well-differentiated tumor and cellular nonlipogenic spindle cell or pleomorphic cells. To explain the trend toward recurrence, Kendall et al hypothesized that a “field change cancerization” effect might possibly explain the recurrent nature of the tumor. As an example, they described the case of a 40-year-old woman with pericardial liposarcoma who had seven histologically similar recurrences, all resected successfully from different areas of the pericardium.

FISH techniques can help classify liposarcomas. Among well-differentiated and dedifferentiated liposarcomas, the amplification of the 12q13-15 region and the MDM2 gene is most often seen (approximately 97% of cases). Amplification of CDK4 is also seen in > 90% of cases. Gene fusions of DDIT3 with FUS, due to a t(12;16) (q13;p11) translocation, and of EWSR1, as a result of t(12;22)(q13;q12) translocation, which are exclusive of each other, have been found to be characteristic of myxoid liposarcoma. They have been reported to be identifiable in > 90% of such cases. The resulting chimeric transcription factor is suspected to drive the oncogenic process in myxoid liposarcomas. Approximately 5% of myxoid liposarcomas have the EWSR1-DDIT3 fusion gene. In cases of pleomorphic liposarcomas, a karyotypic analysis will demonstrate high chromosomal counts and complex structural rearrangements. The genetic alterations that characterize well-differentiated, dedifferentiated, and myxoid liposarcomas are absent in pleomorphic liposarcoma.

Immunohistochemistry does not have clear diagnostic value in liposarcomas but often a plays a role to exclude it from other types of sarcomas. In particular, the introduction of immunostains for MDM2 and CDK4 has proven useful in distinguishing dedifferentiated liposarcomas from other undifferentiated sarcomas and pleomorphic liposarcoma.

The most distinctive histopathologic feature of the present case is the interspersed areas of well-differentiated liposarcoma-like tumor with myxoid liposarcoma-like tumor. This is also a distinctive histopathologic feature of lipoblastoma, which should be considered in the differential diagnosis. Lipoblastomas, however, are benign tumors that lack the cytologic atypia seen in the present case. In addition, they are extremely rare in adults, with most reported cases occurring in children < 3 years of age. The two distinct morphologies also raise the question of a primarily myxoid liposarcoma with extensive lipomatous changes or a well-differentiated liposarcoma with myxoid degeneration. Unfortunately, the FISH analysis failed to confirm the characteristic molecular alterations of either myxoid liposarcoma or well-differentiated liposarcoma. A sarcoma with myxoid features and cytologic atypia, such as myxofibrosarcoma, must also be considered. Occasionally, the fibroblast-like cells of myxofibrosarcoma can become distended with cytoplasmic vacuoles of acid mucin, resembling lipoblasts. Classic areas of myxofibrosarcoma in which the tumor cells resemble fibroblasts should still be present but were not seen in our case. The morphology of the present case is most consistent with a liposarcoma, although further subclassification could not be possible.

This case is unique from multiple aspects: origin from the pericardium, with mixed myxoid and well-differentiated elements (pericardial liposarcomas in adults are very rare); and absence of all genetic rearrangements. This patient underwent successful surgery and had no recurrence of the tumor on PET scan 2 years later. Radiation therapy was not considered, since the resected margins were clear of tumor and the field would include the entire heart, thus putting the patient at risk for late cardiac complications from radiation. Adjuvant chemotherapy was not used in view of the low rate of mitosis and lack of adequate studies showing benefit in the treatment of axial liposarcomas.

Financial/nonfinancial disclosures: None declared.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

McLean T.R. .Almassi G.H. .Hackbarth D.A. .Janjan N.A. .Potish R.A. . Mediastinal involvement by myxoid liposarcoma. Ann Thorac Surg. 1989;47:920-921 [PubMed]journal. [CrossRef] [PubMed]
 
Schweitzer D.L. .Aguam A.S. . Primary liposarcoma of the mediastinum. Report of a case and review of the literature. J Thorac Cardiovasc Surg. 1977;74:83-97 [PubMed]journal. [PubMed]
 
Grobmyer S.R. .Luther N. .Antonescu C.R. .Singer S. .Brennan M.F. . Multiple primary soft tissue sarcomas. Cancer. 2004;101:2633-2635 [PubMed]journal. [CrossRef] [PubMed]
 
Kindl T.F. .Hassan A.M. .Booth R.L. Jr..Durham S.J. .Papadimos T.J. . A primary high-grade pleomorphic pericardial liposarcoma presenting as syncope and angina. Anesth Analg. 2006;102:1363-1364 [PubMed]journal. [CrossRef] [PubMed]
 
Wang J.-G. .Wei Z.-M. .Liu H. .Li Y.-J. . Primary pleomorphic liposarcoma of pericardium. Interact Cardiovasc Thorac Surg. 2010;11:325-327 [PubMed]journal. [CrossRef] [PubMed]
 
Can C. .Arpaci F. .Celasun B. .Günhan O. .Finci R. . Primary pericardial liposarcoma presenting with cardiac tamponade and multiple organ metastases. CHEST. 1993;103:328- [PubMed]journal. [CrossRef] [PubMed]
 
Grewal R.G. .Prager K. .Austin J.H. .Rotterdam H. . Long term survival in non-encapsulated primary liposarcoma of the mediastinum. Thorax. 1993;48:1276-1277 [PubMed]journal. [CrossRef] [PubMed]
 
Teschner M. .Lüllig H. . Diagnosis and treatment of primary mediastinal liposarcoma. Pneumologie. 2003;57:22-26 [PubMed]journal. [CrossRef] [PubMed]
 
Noji T. .Morikawa T. .Kaji M. .Ohtake S. .Katoh H. . Successful resection of a recurrent mediastinal liposarcoma invading the pericardium: report of a case. Surg Today. 2004;34:450-452 [PubMed]journal. [CrossRef] [PubMed]
 
Hahn H.P. .Fletcher C.D. . Primary mediastinal liposarcoma: clinicopathologic analysis of 24 cases. Am J Surg Pathol. 2007;31:1868-1874 [PubMed]journal. [CrossRef] [PubMed]
 
Steger C.M. . Primary liposarcoma of the heart. BMJ Case Rep. 2011;2011:- [PubMed]journal
 
Boland J.M. .Colby T.V. .Folpe A.L. . Liposarcomas of the mediastinum and thorax: a clinicopathologic and molecular cytogenetic study of 24 cases, emphasizing unusual and diverse histologic features. Am J Surg Pathol. 2012;36:1395-1403 [PubMed]journal. [CrossRef] [PubMed]
 
Gaerte S.C. .Meyer C.A. .Winer-Muram H.T. .Tarver R.D. .Conces D.J. Jr.. Fat-containing lesions of the chest. Radiographics. 2002;22:S61-S78 [PubMed]journal. [CrossRef] [PubMed]
 
Kransdorf M.J. .Bancroft L.W. .Peterson J.J. .Murphey M.D. .Foster W.C. .Temple H.T. . Imaging of fatty tumors: distinction of lipoma and well-differentiated liposarcoma. Radiology. 2002;224:99-104 [PubMed]journal. [CrossRef] [PubMed]
 
Zagars G.K. .Goswitz M.S. .Pollack A. . Liposarcoma: outcome and prognostic factors following conservation surgery and radiation therapy. Int J Radiat Oncol Biol Phys. 1996;36:311-319 [PubMed]journal. [PubMed]
 
Evans H.L. . Liposarcoma: a study of 55 cases with a reassessment of its classification. Am J Surg Pathol. 1979;3:507-523 [PubMed]journal. [CrossRef] [PubMed]
 
Kendall S.W. .Williams E.A. .Hunt J.B. .Petch M.C. .Wells F.C. .Milstein B.B. . Recurrent primary liposarcoma of the pericardium: management by repeated resections. Ann Thorac Surg. 1993;56:560-562 [PubMed]journal. [CrossRef] [PubMed]
 
Conyers R. .Young S. .Thomas D.M. . Liposarcoma: molecular genetics and therapeutics. Sarcoma. 2011;2011:483154- [PubMed]journal. [PubMed]
 
de Vreeze R.S. .de Jong D. .Koops W. .et al Oncogenesis and classification of mixed-type liposarcoma: a radiological, histopathological and molecular biological analysis. Int J Cancer. 2011;128:778-786 [PubMed]journal. [CrossRef] [PubMed]
 
Binh M.B.N. .Sastre-Garau X. .Guillou L. .et al MDM2 and CDK4 immunostainings are useful adjuncts in diagnosing well-differentiated and dedifferentiated liposarcoma subtypes: a comparative analysis of 559 soft tissue neoplasms with genetic data. Am J Surg Pathol. 2005;29:1340-1347 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 Chest radiograph. Posteroanterior view at the time of surgery demonstrates an elevated right-side hemidiaphragm with clear costophrenic angles. The lungs appear clear and the heart size appears normal.Grahic Jump Location
Figure Jump LinkFigure 2 Lateral view of the chest again demonstrates the elevated right-side hemidiaphragm with some fullness in the right posterior costodiaphragmatic recess, indicating the possibility of a small pleural effusion.Grahic Jump Location
Figure Jump LinkFigure 3 CT scan of the chest at the level of the ventricles shows an inhomogeneous tumor arising from the right side of the heart and occupying more than one-half of the right side of the thoracic cavity.Grahic Jump Location
Figure Jump LinkFigure 4 CT scan of the chest (mediastinal window) displays near obliteration of the right side of the thoracic cavity at a lower level than the previous image.Grahic Jump Location
Figure Jump LinkFigure 5 Coronal section displays a right-side thoracic mass occupying the lower part of the chest. It has an inhomogeneous appearance, with areas having attenuation coefficients of −75.71 Hounsfield units (HU) and −65.63 HU. This confirms the presence of fat (< −20 HU) in the tumor. Also noted are areas of calcifications, marked with a black arrow at the inferior aspect of the tumor. These were thought to be dystrophic calcification in areas with prior necrosis.Grahic Jump Location
Figure Jump LinkFigure 6 A 22.0 × 15.0 × 14.0 cm mass weighing 1,510 g was resected from the right side of the thoracic cavity. The only point of attachment of the mass to the thoracic structures was through the pericardium.Grahic Jump Location
Figure Jump LinkFigure 7 Two distinct morphologies were seen within the tumor. Areas consistent with well-differentiated liposarcoma exhibit mature-appearing fat with frequent hyperchromatic nuclei and multivacuolated lipoblasts. Areas typical of myxoid liposarcoma demonstrate hyperchromatic cells and lipoblasts suspended in a myxoid matrix with a distinctive delicate capillary vascular network in the background. (Hematoxylin-and-eosin, × 100 magnification).Grahic Jump Location
Figure Jump LinkFigure 8 Lipoblasts seen within areas of well-differentiated liposarcoma. (Hematoxylin-and-eosin, × 400 magnification).Grahic Jump Location
Figure Jump LinkFigure 9 Myxoid liposarcoma with lipoblasts and distinctive “chicken wire” vasculature. (Hematoxylin-and-eosin, × 200 magnification).Grahic Jump Location
Figure Jump LinkFigure 10 Portion of pericardium adherent to surface of the liposarcoma. This is the only site of attachment of tumor mass to surrounding structures. (Hematoxylin-and-eosin, × 400 magnification).Grahic Jump Location

Tables

References

McLean T.R. .Almassi G.H. .Hackbarth D.A. .Janjan N.A. .Potish R.A. . Mediastinal involvement by myxoid liposarcoma. Ann Thorac Surg. 1989;47:920-921 [PubMed]journal. [CrossRef] [PubMed]
 
Schweitzer D.L. .Aguam A.S. . Primary liposarcoma of the mediastinum. Report of a case and review of the literature. J Thorac Cardiovasc Surg. 1977;74:83-97 [PubMed]journal. [PubMed]
 
Grobmyer S.R. .Luther N. .Antonescu C.R. .Singer S. .Brennan M.F. . Multiple primary soft tissue sarcomas. Cancer. 2004;101:2633-2635 [PubMed]journal. [CrossRef] [PubMed]
 
Kindl T.F. .Hassan A.M. .Booth R.L. Jr..Durham S.J. .Papadimos T.J. . A primary high-grade pleomorphic pericardial liposarcoma presenting as syncope and angina. Anesth Analg. 2006;102:1363-1364 [PubMed]journal. [CrossRef] [PubMed]
 
Wang J.-G. .Wei Z.-M. .Liu H. .Li Y.-J. . Primary pleomorphic liposarcoma of pericardium. Interact Cardiovasc Thorac Surg. 2010;11:325-327 [PubMed]journal. [CrossRef] [PubMed]
 
Can C. .Arpaci F. .Celasun B. .Günhan O. .Finci R. . Primary pericardial liposarcoma presenting with cardiac tamponade and multiple organ metastases. CHEST. 1993;103:328- [PubMed]journal. [CrossRef] [PubMed]
 
Grewal R.G. .Prager K. .Austin J.H. .Rotterdam H. . Long term survival in non-encapsulated primary liposarcoma of the mediastinum. Thorax. 1993;48:1276-1277 [PubMed]journal. [CrossRef] [PubMed]
 
Teschner M. .Lüllig H. . Diagnosis and treatment of primary mediastinal liposarcoma. Pneumologie. 2003;57:22-26 [PubMed]journal. [CrossRef] [PubMed]
 
Noji T. .Morikawa T. .Kaji M. .Ohtake S. .Katoh H. . Successful resection of a recurrent mediastinal liposarcoma invading the pericardium: report of a case. Surg Today. 2004;34:450-452 [PubMed]journal. [CrossRef] [PubMed]
 
Hahn H.P. .Fletcher C.D. . Primary mediastinal liposarcoma: clinicopathologic analysis of 24 cases. Am J Surg Pathol. 2007;31:1868-1874 [PubMed]journal. [CrossRef] [PubMed]
 
Steger C.M. . Primary liposarcoma of the heart. BMJ Case Rep. 2011;2011:- [PubMed]journal
 
Boland J.M. .Colby T.V. .Folpe A.L. . Liposarcomas of the mediastinum and thorax: a clinicopathologic and molecular cytogenetic study of 24 cases, emphasizing unusual and diverse histologic features. Am J Surg Pathol. 2012;36:1395-1403 [PubMed]journal. [CrossRef] [PubMed]
 
Gaerte S.C. .Meyer C.A. .Winer-Muram H.T. .Tarver R.D. .Conces D.J. Jr.. Fat-containing lesions of the chest. Radiographics. 2002;22:S61-S78 [PubMed]journal. [CrossRef] [PubMed]
 
Kransdorf M.J. .Bancroft L.W. .Peterson J.J. .Murphey M.D. .Foster W.C. .Temple H.T. . Imaging of fatty tumors: distinction of lipoma and well-differentiated liposarcoma. Radiology. 2002;224:99-104 [PubMed]journal. [CrossRef] [PubMed]
 
Zagars G.K. .Goswitz M.S. .Pollack A. . Liposarcoma: outcome and prognostic factors following conservation surgery and radiation therapy. Int J Radiat Oncol Biol Phys. 1996;36:311-319 [PubMed]journal. [PubMed]
 
Evans H.L. . Liposarcoma: a study of 55 cases with a reassessment of its classification. Am J Surg Pathol. 1979;3:507-523 [PubMed]journal. [CrossRef] [PubMed]
 
Kendall S.W. .Williams E.A. .Hunt J.B. .Petch M.C. .Wells F.C. .Milstein B.B. . Recurrent primary liposarcoma of the pericardium: management by repeated resections. Ann Thorac Surg. 1993;56:560-562 [PubMed]journal. [CrossRef] [PubMed]
 
Conyers R. .Young S. .Thomas D.M. . Liposarcoma: molecular genetics and therapeutics. Sarcoma. 2011;2011:483154- [PubMed]journal. [PubMed]
 
de Vreeze R.S. .de Jong D. .Koops W. .et al Oncogenesis and classification of mixed-type liposarcoma: a radiological, histopathological and molecular biological analysis. Int J Cancer. 2011;128:778-786 [PubMed]journal. [CrossRef] [PubMed]
 
Binh M.B.N. .Sastre-Garau X. .Guillou L. .et al MDM2 and CDK4 immunostainings are useful adjuncts in diagnosing well-differentiated and dedifferentiated liposarcoma subtypes: a comparative analysis of 559 soft tissue neoplasms with genetic data. Am J Surg Pathol. 2005;29:1340-1347 [PubMed]journal. [CrossRef] [PubMed]
 
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