Solitary fibrous tumor of the pleura a rare mesenchymal tumor presented with hypoglycemi
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This document describes a case study of a 49-year-old woman who presented with right chest pain and repeated hypoglycemic attacks. Imaging revealed a 10cm solitary fibrous tumor (SFT) of the right pleura. The patient underwent thoracotomy and complete resection of the encapsulated tumor. Histological and immunohistochemical examination confirmed the diagnosis of benign pleural SFT. The patient's hypoglycemic episodes were attributed to Doege-Potter syndrome, a rare paraneoplastic syndrome caused by inappropriate IGF-II secretion from large SFTs. Complete surgical resection is the treatment of choice for SFT and resulted in resolution of the patient's symptoms.
![Creative Commons 4.0
Solitary fibrous tumor of the pleura: A rare mesenchymal tu-
mor presented with hypoglycemia
Yasser Ali Kamal a, *
a Department of Cardiothoracic Surgery, Faculty of Medicine, Minia University, El-Minya, Egypt.
* Corresponding author: Yasser Ali Kamal
Mailing address: Department of Cardiothoracic Surgery, Faculty
of Medicine, Minia University, El-Minia, 61111, Egypt.
E-mail: yaser_ali_kamal@yahoo.com, Yasser.Ali@mu.edu.eg
Received: 09 December 2020 / Accepted: 23 February 2021
INTRODUCTION
The primary tumors of the pleura are less common
than secondary metastatic ones. Malignant mesothelio-
ma is the most common primary tumor; however, other
rare pleural tumors exist including solitary fibrous tu-
mor (SFT), lipoma, lymphoma, sarcoma, Askin tumor,
extra-skeletal osteosarcoma, and histiocytoma [1]
.
SFT of the pleura is a relatively rare mesenchymal tu-
mor that had earlier names of localized mesothelioma
and pleural fibroma as it was thought to have a meso-
thelial origin. Most of the cases of SFT occur within the
pleura, but it can arise from other sites including sub-
cutaneous tissues, orbit, salivary glands, thyroid gland,
nasal cavity, nasopharynx, lung, pericardium, adrenal
glands, liver, GI tract, urinary bladder, and prostate [2,3]
.
Here, we describe a case of SFT of the pleura with mild
right chest pain and unexplained hypoglycemia.
CASE REPORT
Case Report
A 49-year-old previously healthy woman presented to
our clinic with a 3-month history of mild right chest
pain and repeated attacks of confusion and drowsiness
improved after eating. There was laboratory evidence
of hypoglycemia during the last attack (blood glucose
level of 40 mg/dl). Chest X-ray showed an opaque
shadow on the lower zone of the right side of the chest
(Figure 1). The past medical history was unremarkable
with normal laboratory investigations. A computed
tomography (CT) scan revealed a well-defined right
pleural-based soft tissue mass with a long axis diam-
eter of 10 cm (Figure 2). CT-guided core needle biopsy
revealed a spindle cell tumor. The patient underwent
the right posterolateral thoracotomy. During surgery,
the tumor was located in the right inferior hemithorax
within the fifth and sixth intercostal spaces and it was
attached to the parietal pleura by a fibrous pedicle. The
tumor was completely resected. Grossly, the resected
mass was round firm, well circumscribed encapsulated
of 4.5×3 cm in diameter and the cut surface with gray-
ish, yellow and mucoid (Figure 3). Microscopically,
there was a bland spindle cell proliferation distributed
in a patternless fashion separated by dense collagen
stroma, with low mitotic figures less than 3/10 HPFs
(Figure 4). On immunohistochemical examination, the
tumor was positive for cluster of differentiation (CD-
34), CD99, and Vimentin and negative for S-100. The
Abstract
Solitary fibrous tumor (SFT) is a relatively rare primary tumor of the pleura, originating from the mesenchymal
cells. The tumor has a non-specific clinical, laboratory, and radiological features. Patients may be asymptom-
atic or have non-specific clinical features including chest pain, dyspnea, cough, and paraneoplastic symptoms.
Complete surgical resection is indicated in all cases to avoid recurrence of the tumor. We described a 49-year-
old woman who presented with unexplained right chest pain and repeated attacks of hypoglycemia, associated
with pleural SFT.
Keywords: Pleura; thoracic oncology; solitary fibrous tumor; paraneoplastic hypoglycemia; Doege-Potter
syndrome
Yasser Ali Kamal 22
Clin Surg Res Commun 2020; 5(1): 22-25
DOI: 10.31491/CSRC.2021.03.070](https://image.slidesharecdn.com/solitaryfibroustumorofthepleura-araremesenchymaltumorpresentedwithhypoglycemi-210819061923/85/Solitary-fibrous-tumor-of-the-pleura-a-rare-mesenchymal-tumor-presented-with-hypoglycemi-1-320.jpg)
![final diagnosis was benign pleural SFT. The postopera-
tive course was uneventful, with freedom from symp-
toms and tumor recurrence within two years of follow-
up after surgery.
DISCUSSION
SFT is a mesenchymal cell tumor most commonly
occurs in middle-aged adults, with an equal gender
distribution [4]
. The thoracic SFT occurs equally on
the right and left sides and arises from the pleura in
most cases, followed by lung, anterior mediastinum,
and diaphragm [5]
. The etiology of SFT remains unclear
with the absence of association to smoking or asbestos
exposure [6]
. However, there is a genetic evidence rec-
ognizing SFT as a translocation-associated neoplasm,
with a consistent association with NAB2-STAT6 gene
fusions arising from recurrent intrachromosomal rear-
rangements on chromosome 12q [7]
.
Clinically, SFT presented as a slowly growing painless
mass that may produce symptoms due to its large size
or pressure effects on the adjacent structures. More
than 50% of cases with SFT are asymptomatic and de-
tected incidentally on chest radiographs or CT. Symp-
tomatic SFT presented with non-specific complaints
such as pleuritic chest pain, cough, and shortness of
breath [8]
. The CT features are often quite suggestive
but not pathognomonic. On CT scan with contrast, SFT
appears as a heterogeneous tumor with acute angles
at pleural interface for large masses and obtuse angles
for smaller tumors [9]
. A biopsy is recommended be-
fore starting treatment of SFT through open incisional
biopsy or by a core needle with a preference for radio-
logical guided biopsy if it is applicable.
Histologically, SFT is a benign tumor although ma-
lignant transformation occurs in 20% of patients [10]
.
Also, SFT has a wide differential diagnosis on the his-
tological examination due to the similarity in cellular
architecture and vascular pattern with other tumors
such as schwannoma, spindle cell/pleomorphic lipo-
mas, gastrointestinal stromal tumors, and liposarcoma
[7]
. Immunohistochemistry is useful for the diagnosis
and differentiation of SFT from other spindle cell mes-
enchymal tumors. The most important and valuable
immunohistochemical positive markers in SFT are
CD34, CD99, Vimentin, Bcl-2 and STAT-6. Additionally,
some markers are negative in cases of SFT according to
the tumor location, such as S100, smooth muscle actin
(SMA), desmin, and calretinin [11]
.
Surgery is the gold standard treatment for all types of
SFT, as its benefit outweigh the risks and the prognosis
for malignant SFT is favorable with surgical resection
[10]
. Chemotherapy and consecutive selective emboli-
zation of the feeding arteries are alternative options
when the SFT is non-resectable or metastatic [12]
. The
goal of the surgical management of SFT relies on wide
resection margins and preservation of the surrounding
structures. Complete resection with adequate negative
margins is essential to reduce the rates of local recur-
rence and progression to metastatic disease [13,14]
.
SFT is usually cured after complete surgical resec-
Yasser Ali Kamal 23
Figure 1. Postero-anterior view of chest X-ray shows an
opaque shadow in the lower zone of the right hemi-thorax.
Figure 2. Axial view of chest CT scan shows a right pleural-
based mass.
ANT PUBLISHING CORPORATION
Published online: 29 March 2021](https://image.slidesharecdn.com/solitaryfibroustumorofthepleura-araremesenchymaltumorpresentedwithhypoglycemi-210819061923/85/Solitary-fibrous-tumor-of-the-pleura-a-rare-mesenchymal-tumor-presented-with-hypoglycemi-2-320.jpg)
![may be life-threatening when food intake decreased [19]
.
It is important to consider DPS in a patient with SFT
and hypoglycemia, especially when the tumor size is
larger than 8 cm which is thought to be a risk factor for
this syndrome [20]
. The diagnosis of DPS is based on the
clinical presentation of hypoglycaemic episodes with
SFT in absence of alternative causes or on laboratory
findings of increased IGF-II to IGF-I ratio and hypoin-
sulinemia during attacks of hypoglycemia [21]
. Treat-
ment of DPS associated with SFT should initially aim
to normalize the blood glucose level by high-glucose
diet and continuous intravenous infusion of 50% glu-
cose (up to 50 g/hr), followed by tumor size reduction
through surgical resection, chemotherapy, radiother-
apy, brachytherapy, and photodynamic therapy. How-
ever, complete surgical resection of SFT is the curative
therapy for DPS [22]
.
CONCLUSION
SFT is a relatively rare soft tissue tumor that often
originates from the mesenchymal cells of the pleura.
The diagnosis of SFT is difficult due to the absence
of symptoms in most of the cases, in addition to non-
specific clinical, laboratory, and radiological features.
Some cases may present with paraneoplastic hypo-
glycemia, known as Doege–Potter syndrome. Surgical
resection is the mainstay in the treatment of SFT with
or without hypoglycemia. Complete surgical resection
is essential to avoid the recurrence of both benign and
malignant tumors.
DECLARATIONS
Authors’ contributions
The author contributed solely to the article.
Conflict of interest
The author declared that there are no conflicts of in-
terest.
Ethical approval
Not applicable.
Consent for publication
The consent was obtained from the patient.
REFERENCES
1. Sureka, B., Thukral, B. B., Mittal, M. K., Mittal, A., & Sinha,
M. (2013). Radiological review of pleural tumors. The
Indian journal of radiology & imaging, 23(4), 313.
2. Brunnemann, R. B., Ro, J. Y., Ordonez, N. G., Mooney, J., El-
Yasser Ali Kamal 24
tion; however, a recent systematic review found that
SFTs recurred after 5 years of surgery in at least 23%
of cases and the authors of the review recommended
a longer follow up schedule [15]
. Moreover, the local
recurrence has been reported in about 10% of benign
SFT [16]
and in more than 60% of malignant SFTs, which
indicates surgical re-resection in cases with positive
surgical margins [17]
. The possibility of repeated recur-
rence after surgery indicates extended surgical resec-
tion if the pleural SFT invades the chest wall, lung,
diaphragm, or pericardium [18]
.
Our case of pleural SFT presented with paraneoplas-
tic hypoglycemia, which is known as Doege–Potter
syndrome (DPS). This rare entity occurs due to inap-
propriate secretion of a high molecular-weight form
of insulin-like growth factor type II (IGF-II). This big
IGF-II activates insulin receptors, inhibits hepatic glu-
coneogenesis, and increases glucose uptake with sub-
sequent hypoglycemia [12]
. Thus, DPS is characterized
by non-islet cell hypoinsulinemic hypoglycemia, which
Figure 3. Gross appearance of the surgically excised well-
circumscribed encapsulated tumor (A), with grayish yellow cut
surface (B).
Figure 4. Histopathological image shows spindle-shaped cells
with patternless pattern arranged on a collagenous stroma
(H&E × 100).
A B
Clin Surg Res Commun 2020; 5(1): 22-25
DOI: 10.31491/CSRC.2021.03.070](https://image.slidesharecdn.com/solitaryfibroustumorofthepleura-araremesenchymaltumorpresentedwithhypoglycemi-210819061923/85/Solitary-fibrous-tumor-of-the-pleura-a-rare-mesenchymal-tumor-presented-with-hypoglycemi-3-320.jpg)
Solitary fibrous tumor of the pleura a rare mesenchymal tumor presented with hypoglycemi
- 1. Creative Commons 4.0 Solitary fibrous tumor of the pleura: A rare mesenchymal tu- mor presented with hypoglycemia Yasser Ali Kamal a, * a Department of Cardiothoracic Surgery, Faculty of Medicine, Minia University, El-Minya, Egypt. * Corresponding author: Yasser Ali Kamal Mailing address: Department of Cardiothoracic Surgery, Faculty of Medicine, Minia University, El-Minia, 61111, Egypt. E-mail: [email protected], [email protected] Received: 09 December 2020 / Accepted: 23 February 2021 INTRODUCTION The primary tumors of the pleura are less common than secondary metastatic ones. Malignant mesothelio- ma is the most common primary tumor; however, other rare pleural tumors exist including solitary fibrous tu- mor (SFT), lipoma, lymphoma, sarcoma, Askin tumor, extra-skeletal osteosarcoma, and histiocytoma [1] . SFT of the pleura is a relatively rare mesenchymal tu- mor that had earlier names of localized mesothelioma and pleural fibroma as it was thought to have a meso- thelial origin. Most of the cases of SFT occur within the pleura, but it can arise from other sites including sub- cutaneous tissues, orbit, salivary glands, thyroid gland, nasal cavity, nasopharynx, lung, pericardium, adrenal glands, liver, GI tract, urinary bladder, and prostate [2,3] . Here, we describe a case of SFT of the pleura with mild right chest pain and unexplained hypoglycemia. CASE REPORT Case Report A 49-year-old previously healthy woman presented to our clinic with a 3-month history of mild right chest pain and repeated attacks of confusion and drowsiness improved after eating. There was laboratory evidence of hypoglycemia during the last attack (blood glucose level of 40 mg/dl). Chest X-ray showed an opaque shadow on the lower zone of the right side of the chest (Figure 1). The past medical history was unremarkable with normal laboratory investigations. A computed tomography (CT) scan revealed a well-defined right pleural-based soft tissue mass with a long axis diam- eter of 10 cm (Figure 2). CT-guided core needle biopsy revealed a spindle cell tumor. The patient underwent the right posterolateral thoracotomy. During surgery, the tumor was located in the right inferior hemithorax within the fifth and sixth intercostal spaces and it was attached to the parietal pleura by a fibrous pedicle. The tumor was completely resected. Grossly, the resected mass was round firm, well circumscribed encapsulated of 4.5×3 cm in diameter and the cut surface with gray- ish, yellow and mucoid (Figure 3). Microscopically, there was a bland spindle cell proliferation distributed in a patternless fashion separated by dense collagen stroma, with low mitotic figures less than 3/10 HPFs (Figure 4). On immunohistochemical examination, the tumor was positive for cluster of differentiation (CD- 34), CD99, and Vimentin and negative for S-100. The Abstract Solitary fibrous tumor (SFT) is a relatively rare primary tumor of the pleura, originating from the mesenchymal cells. The tumor has a non-specific clinical, laboratory, and radiological features. Patients may be asymptom- atic or have non-specific clinical features including chest pain, dyspnea, cough, and paraneoplastic symptoms. Complete surgical resection is indicated in all cases to avoid recurrence of the tumor. We described a 49-year- old woman who presented with unexplained right chest pain and repeated attacks of hypoglycemia, associated with pleural SFT. Keywords: Pleura; thoracic oncology; solitary fibrous tumor; paraneoplastic hypoglycemia; Doege-Potter syndrome Yasser Ali Kamal 22 Clin Surg Res Commun 2020; 5(1): 22-25 DOI: 10.31491/CSRC.2021.03.070
- 2. final diagnosis was benign pleural SFT. The postopera- tive course was uneventful, with freedom from symp- toms and tumor recurrence within two years of follow- up after surgery. DISCUSSION SFT is a mesenchymal cell tumor most commonly occurs in middle-aged adults, with an equal gender distribution [4] . The thoracic SFT occurs equally on the right and left sides and arises from the pleura in most cases, followed by lung, anterior mediastinum, and diaphragm [5] . The etiology of SFT remains unclear with the absence of association to smoking or asbestos exposure [6] . However, there is a genetic evidence rec- ognizing SFT as a translocation-associated neoplasm, with a consistent association with NAB2-STAT6 gene fusions arising from recurrent intrachromosomal rear- rangements on chromosome 12q [7] . Clinically, SFT presented as a slowly growing painless mass that may produce symptoms due to its large size or pressure effects on the adjacent structures. More than 50% of cases with SFT are asymptomatic and de- tected incidentally on chest radiographs or CT. Symp- tomatic SFT presented with non-specific complaints such as pleuritic chest pain, cough, and shortness of breath [8] . The CT features are often quite suggestive but not pathognomonic. On CT scan with contrast, SFT appears as a heterogeneous tumor with acute angles at pleural interface for large masses and obtuse angles for smaller tumors [9] . A biopsy is recommended be- fore starting treatment of SFT through open incisional biopsy or by a core needle with a preference for radio- logical guided biopsy if it is applicable. Histologically, SFT is a benign tumor although ma- lignant transformation occurs in 20% of patients [10] . Also, SFT has a wide differential diagnosis on the his- tological examination due to the similarity in cellular architecture and vascular pattern with other tumors such as schwannoma, spindle cell/pleomorphic lipo- mas, gastrointestinal stromal tumors, and liposarcoma [7] . Immunohistochemistry is useful for the diagnosis and differentiation of SFT from other spindle cell mes- enchymal tumors. The most important and valuable immunohistochemical positive markers in SFT are CD34, CD99, Vimentin, Bcl-2 and STAT-6. Additionally, some markers are negative in cases of SFT according to the tumor location, such as S100, smooth muscle actin (SMA), desmin, and calretinin [11] . Surgery is the gold standard treatment for all types of SFT, as its benefit outweigh the risks and the prognosis for malignant SFT is favorable with surgical resection [10] . Chemotherapy and consecutive selective emboli- zation of the feeding arteries are alternative options when the SFT is non-resectable or metastatic [12] . The goal of the surgical management of SFT relies on wide resection margins and preservation of the surrounding structures. Complete resection with adequate negative margins is essential to reduce the rates of local recur- rence and progression to metastatic disease [13,14] . SFT is usually cured after complete surgical resec- Yasser Ali Kamal 23 Figure 1. Postero-anterior view of chest X-ray shows an opaque shadow in the lower zone of the right hemi-thorax. Figure 2. Axial view of chest CT scan shows a right pleural- based mass. ANT PUBLISHING CORPORATION Published online: 29 March 2021
- 3. may be life-threatening when food intake decreased [19] . It is important to consider DPS in a patient with SFT and hypoglycemia, especially when the tumor size is larger than 8 cm which is thought to be a risk factor for this syndrome [20] . The diagnosis of DPS is based on the clinical presentation of hypoglycaemic episodes with SFT in absence of alternative causes or on laboratory findings of increased IGF-II to IGF-I ratio and hypoin- sulinemia during attacks of hypoglycemia [21] . Treat- ment of DPS associated with SFT should initially aim to normalize the blood glucose level by high-glucose diet and continuous intravenous infusion of 50% glu- cose (up to 50 g/hr), followed by tumor size reduction through surgical resection, chemotherapy, radiother- apy, brachytherapy, and photodynamic therapy. How- ever, complete surgical resection of SFT is the curative therapy for DPS [22] . CONCLUSION SFT is a relatively rare soft tissue tumor that often originates from the mesenchymal cells of the pleura. The diagnosis of SFT is difficult due to the absence of symptoms in most of the cases, in addition to non- specific clinical, laboratory, and radiological features. Some cases may present with paraneoplastic hypo- glycemia, known as Doege–Potter syndrome. Surgical resection is the mainstay in the treatment of SFT with or without hypoglycemia. Complete surgical resection is essential to avoid the recurrence of both benign and malignant tumors. DECLARATIONS Authors’ contributions The author contributed solely to the article. Conflict of interest The author declared that there are no conflicts of in- terest. Ethical approval Not applicable. Consent for publication The consent was obtained from the patient. REFERENCES 1. Sureka, B., Thukral, B. B., Mittal, M. K., Mittal, A., & Sinha, M. (2013). Radiological review of pleural tumors. The Indian journal of radiology & imaging, 23(4), 313. 2. Brunnemann, R. B., Ro, J. Y., Ordonez, N. G., Mooney, J., El- Yasser Ali Kamal 24 tion; however, a recent systematic review found that SFTs recurred after 5 years of surgery in at least 23% of cases and the authors of the review recommended a longer follow up schedule [15] . Moreover, the local recurrence has been reported in about 10% of benign SFT [16] and in more than 60% of malignant SFTs, which indicates surgical re-resection in cases with positive surgical margins [17] . The possibility of repeated recur- rence after surgery indicates extended surgical resec- tion if the pleural SFT invades the chest wall, lung, diaphragm, or pericardium [18] . Our case of pleural SFT presented with paraneoplas- tic hypoglycemia, which is known as Doege–Potter syndrome (DPS). This rare entity occurs due to inap- propriate secretion of a high molecular-weight form of insulin-like growth factor type II (IGF-II). This big IGF-II activates insulin receptors, inhibits hepatic glu- coneogenesis, and increases glucose uptake with sub- sequent hypoglycemia [12] . Thus, DPS is characterized by non-islet cell hypoinsulinemic hypoglycemia, which Figure 3. Gross appearance of the surgically excised well- circumscribed encapsulated tumor (A), with grayish yellow cut surface (B). Figure 4. Histopathological image shows spindle-shaped cells with patternless pattern arranged on a collagenous stroma (H&E × 100). A B Clin Surg Res Commun 2020; 5(1): 22-25 DOI: 10.31491/CSRC.2021.03.070
- 4. Liu, X. (2017). Doege–Potter syndrome: a review of the literature including a new case report. Medicine, 96(27), e7417. 13. Sung, S. H., Chang, J. W., Kim, J., Lee, K. S., Han, J., & Park, S. I. (2005). Solitary fibrous tumors of the pleura: surgical outcome and clinical course. The Annals of thoracic sur- gery, 79(1), 303-307. 14. Kayani, B., Sharma, A., Sewell, M. D., Platinum, J., Olivier, A., Briggs, T. W., & Eastwood, D. M. (2018). A review of the surgical management of extrathoracic solitary fibrous tu- mors. American journal of clinical oncology, 41(7), 687- 694. 15. Mercer, R. M., Wigston, C., Banka, R., Cardillo, G., Bena- more, R., Nicholson, A. G., ... & Rahman, N. M. (2020). Management of solitary fibrous tumours of the pleura: a systematic review and meta-analysis. ERJ open research, 6(3), 0005-2020. 16. Harrison–Phipps, K. M., Nichols, F. C., Schleck, C. D., Des- champs, C., Cassivi, S. D., Schipper, P. H., ... & Pairolero, P. C. (2009). Solitary fibrous tumors of the pleura: results of surgical treatment and long-term prognosis. The Journal of thoracic and cardiovascular surgery, 138(1), 19-25. 17. Robinson, L. A. (2006). Solitary fibrous tumor of the pleura. Cancer control, 13(4), 264-269. 18. Forster, C., Roumy, A., & Gonzalez, M. (2019). Solitary fi- brous tumor of the pleura with Doege–Potter syndrome: Second recurrence in a 93-year-old female. SAGE open medical case reports, 7, 2050313X18823468. 19. Schutt, R. C., Gordon, T. A., Bhabhra, R., Cathro, H. P., Cook, S. L., McCartney, C. R., & Weiss, G. R. (2013). Doege-Potter syndrome presenting with hypoinsulinemic hypoglyce- mia in a patient with a malignant extrapleural solitary fibrous tumor: a case report. Journal of medical case re- ports, 7(1), 1-7. 20. Zafar, H., Takimoto, C. H., & Weiss, G. (2003). Doege- Potter syndrome. Medical Oncology, 20(4), 403-407. 21. Ahluwalia, N., Attia, R., Green, A., Cane, P., & Routledge, T. (2015). Doege–Potter syndrome. The Annals of The Royal College of Surgeons of England, 97(7), e105-e107. 22. Jang, J. G., Chung, J. H., Hong, K. S., Ahn, J. H., Lee, J. Y., Jo, J. H., ... & Lee, J. K. (2015). A case of solitary fibrous pleura tumor associated with severe hypoglycemia: doege- potter syndrome. Tuberculosis and respiratory diseases, 78(2), 120. Naggar, A. K., & Ayala, A. G. (1999). Extrapleural solitary fibrous tumor: a clinicopathologic study of 24 cases. Modern pathology: an official journal of the United States and Canadian Academy of Pathology, Inc, 12(11), 1034- 1042. 3. Agarwal, V. K., Plotkin, B. E., Dumani, D., French, S. W., Becker, R., & Lee, P. (2009). Solitary fibrous tumor of pleura: a case report and review of clinical, radiographic and histologic findings. Journal of radiology case reports, 3(5), 16. 4. Demicco, E. G., Park, M. S., Araujo, D. M., Fox, P. S., Bas- sett, R. L., Pollock, R. E., ... & Wang, W. L. (2012). Solitary fibrous tumor: a clinicopathological study of 110 cases and proposed risk assessment model. Modern Pathology, 25(9), 1298-1306. 5. Gold, J. S., Antonescu, C. R., Hajdu, C., Ferrone, C. R., Hus- sain, M., Lewis, J. J., ... & Coit, D. G. (2002). Clinicopatho- logic correlates of solitary fibrous tumors. Cancer, 94(4), 1057-1068. 6. Davanzo, B., Emerson, R. E., Lisy, M., Koniaris, L. G., & Kays, J. K. (2018). Solitary fibrous tumor. Translational gastroenterology and hepatology, 3, 94. 7. Thway, K., Ng, W., Noujaim, J., Jones, R. L., & Fisher, C. (2016). The current status of solitary fibrous tumor: diagnostic features, variants, and genetics. International Journal of Surgical Pathology, 24(4), 281-292. 8. Hohenforst-Schmidt, W., Grapatsas, K., Dahm, M., Zar- ogoulidis, P., Leivaditis, V., Kotoulas, C., ... & Kosan, B. (2017). Solitary fibrous tumor: A center’s experience and an overview of the symptomatology, the diagnostic and therapeutic procedures of this rare tumor. Respiratory medicine case reports, 21, 99-104. 9. Salahudeen, H. M., Hoey, E. T. D., Robertson, R. J., & Darby, M. J. (2009). CT appearances of pleural tumours. Clinical radiology, 64(9), 918-930. 10. Supakul, R., Sodhi, A., Tamashiro, C. Y., Azmi, S. S., & Kadaria, D. (2015). Solitary fibrous tumor of the pleura: A Rare cause of pleural mass. The American journal of case reports, 16, 854. 11. Geramizadeh, B., Marzban, M., & Churg, A. (2016). Role of immunohistochemistry in the diagnosis of solitary fibrous tumor, a review. Iranian journal of pathology, 11(3), 195. 12. Han, G., Zhang, Z., Shen, X., Wang, K., Zhao, Y., He, J., ... & Yasser Ali Kamal 25 ANT PUBLISHING CORPORATION Published online: 29 March 2021