Surgical approach to pleuropulmonary solitary fibrous tumour in the anterior mediastinum: Case series at a third-level centre

Surgical approach to pleuropulmonary solitary fibrous tumour in the anterior mediastinum: Case series at a third-level centre | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Surgical approach to pleuropulmonary solitary fibrous tumour in the anterior mediastinum: Case series at a third-level centre Amelia Fernández-Avendaño, Mónica Martínez-Ferman, Pablo Gomes-da Silva de Rosenzweig, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8000935/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Solitary fibrous tumour (SFT) is an uncommon neoplasm, and its occurrence in the anterior mediastinum is particularly rare, as other differential diagnoses would initially be considered. Clinically, SFTs are typically asymptomatic and are often discovered incidentally through imaging studies. Definitive treatment is achieved through complete surgical resection with negative margins, followed by subsequent histopathological analysis. We present three cases of anterior mediastinal SFT managed at our institution in 2024, treated via both open surgery and a minimally invasive approach using robotic-assisted thoracic surgery. Additionally, we discussed the clinical considerations and criteria guiding the choice between open and robotic surgical approaches. Pleuropulmonary neoplasia anterior mediastinum robot-assisted surgery solitary fibrous tumour Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Solitary fibrous tumour (SFT) accounts for approximately 3.7–5% of soft tissue sarcomas and mesenchymal neoplasms. Between 12% and 32% of cases exhibit malignant behaviour, typically affecting individuals between 50 and 70 years of age. Its pathogenesis is associated with a chromosomal inversion at 12q13, resulting in the fusion of the NAB2 and STAT6 genes ( 1 – 2 ). These tumours typically arise from serous membranes, with approximately 30% occurring within the thoracic cavity ( 3 ). Of thoracic cases, most originate from the visceral pleura and are often attached to the lung by a pedicle. The clinical presentation is variable and often nonspecific, presenting with symptoms such as cough, dyspnea, and chest pain ( 4 – 5 ). The standard treatment for SFT is complete surgical resection with negative margins. Historically, this has been achieved through thoracotomy; however, given the advantages of minimally invasive approaches, such as reduced intraoperative blood loss and shorter length of hospital stay, both video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) have emerged as feasible alternatives for tumour resection ( 6 – 8 ). The objective of this case series is to present our experience in managing SFT using both conventional open surgery and a minimally invasive robotic-assisted approach. Case series Case 1 (Fig. 1 ) A 67-year-old female presented with a one-month history of progressive dyspnea, which advanced to orthopnea, rendering her unable to tolerate the supine position. A chest X-ray revealed a mass in the anterior mediastinum. A computed tomography (CT) guided biopsy confirmed the diagnosis of a SFT, and subsequent magnetic resonance imaging (MRI) demonstrated a mass measuring 15 × 15 × 10 cm. Given the tumour’s size, a median sternotomy was performed. The mass was carefully dissected using harmonic energy, preserving the thymic margins. En bloc resection was achieved, including the pedicle arising from the right pulmonary apex. A 32 French pleural drain was placed. Intraoperative bleeding (IOB) was 200 mL, and the operative time was 1.5 hours. In the immediate postoperative period, the patient experienced hemodynamic instability requiring vasopressor support and transfusion of blood products. She was managed in the intensive care unit (ICU) with advanced airway support for two days, followed by an uneventful recovery. The pleural drain was removed at 48 hours, and the patient was discharged on postoperative day four. Histopathological analysis confirmed a malignant grade 2 SFT. Immunohistochemistry was positive for CD34, STAT6, and BCL2 (Fig. 2 ). Case 2. (Fig. 3) A 54-year-old female with no significant medical history was admitted to the emergency department with a diagnosis of influenza-related pneumonia. A CT scan incidentally revealed a mass in the left anterior mediastinum. An ultrasound-guided biopsy confirmed the diagnosis of a SFT. The patient was scheduled for resection via RATS, utilising four robotic arms. Under general anaesthesia, she was positioned in the right lateral decubitus position. A single 8 mm port was placed in the 7th intercostal space (ICS) for CO₂ insufflation. Under direct visualisation, additional ports were placed at the 7th and 8th ICS along the posterior axillary line, and a 12 mm accessory port was inserted in the 9th ICS along the anterior axillary line. The tumour was identified with firm adhesions to the visceral pleura of the left upper lobe. A wedge resection of the anterior segment was performed using a 60 mm stapler. A 24Fr drain was placed posteriorly, with adequate lung expansion confirmed. IOB was 150 mL, and the procedure lasted 1.5 hours. The patient was successfully extubated in the operating room and experienced an uneventful recovery. The pleural drain was removed on postoperative day two, and she was discharged the same day. Histopathological examination confirmed a benign SFT measuring 9 × 6 × 5 cm and weighing 156 grams, with an R0 resection. The tumour exhibited a fibrous stroma and positive immunohistochemical staining for CD34, Bcl-2, and CD99. Case 3 ( Fig. 3 ). A 71-year-old female with a history of breast cancer and prior mediastinal tumour resection, with histopathology confirming a SFT, presented after a follow-up CT scan revealed a new mediastinal mass, suggestive of SFT recurrence. The patient was scheduled for RATS resection through 4 ports. Three 8 mm robotic ports and one 12 mm accessory port were utilised. Intraoperatively, multiple loose adhesions were encountered. The tumour was located over the ascending aorta, with displacement of the left brachiocephalic venous trunk. Tumour resection was performed using bipolar energy, achieving complete excision. A 24 Fr drain was placed with full lung re-expansion. IOB was 50 mL, and the operative time was 3 hours. The patient was successfully extubated in the operating room and had a favourable postoperative course. The pleural drain was removed on postoperative day four, and she was discharged the same day. Histopathological analysis confirmed a malignant SFT measuring 6.3 × 4.4 × 3.5 cm and weighing 46 grams. R0 resection was achieved. The tumour exhibited positive staining for CD34 and BCL2. Discussion Pleuropulmonary SFTs are rare, with an estimated incidence of 2.8 cases per 100,000 people annually. In Mexico, 26 cases were reported between 2007 and 2017, with a mean age of 52 years and a higher prevalence in females, as described by Ríos-Pascual et al. ( 9 ). The diagnosis is most often incidental, with symptoms typically appearing once the tumour reaches sufficient size to compress adjacent structures. In our series, as well as in the literature, CT scanning is the preferred diagnostic modality for benign tumours, which usually demonstrate a hyperdense, encapsulated mass with a pedunculated growth often attached to the left basal region, arising from the visceral pleura. In contrast, malignant tumours tend to show more invasive growth with organ infiltration, hemorrhagic necrosis, and a higher risk of recurrence ( 10 – 11 ). For diagnostic confirmation, biopsy may be performed, with immunohistochemical positivity for markers such as CD34, CD99, and Bcl-2 ( 9 ). Although most SFTs are benign ( 12 ), when malignant, they may be negative for CD34, which can be explained by tumour dedifferentiation, leading to changes in the expression of surface proteins. As exemplified by our cases, the location of the intrathoracic SFT should guide consideration of the differential diagnosis. For anterior mediastinal tumours, a practical mnemonic is the “4Ts”: thymoma, teratoma, thyroid pathology, and “terrible” lymphoma ( 13 ). Attention to paraneoplastic manifestations may also aid diagnostic certainty. Doege-Potter syndrome, characterised by hypoglycemia due to ectopic insulin-like growth factor production, is described in up to 22% of SFT cases. Pierre-Marie-Bamberg syndrome, although rarer and reported in fewer than 5% of cases, is another recognised paraneoplastic presentation with digital clubbing and hypertrophic osteoarthropathy ( 12 ). The treatment for SFT is surgical resection, which, depending on the extent of the tumour, may require the removal of adherent or invaded tissues. However, Wang et al. reported no significant differences in disease-free survival at five years when comparing organ-sparing versus en bloc resections. This finding, though, should be interpreted with caution, as it may be influenced by the small sample size of the study ( 14 ). Conventionally, resection has been carried out through open surgery, particularly when larger than 5 cm. However, the recent development of minimally invasive thoracic surgery has offered an alternative for the treatment of SFT ( 15 – 16 ). Video-assisted thoracoscopic surgery (VATS) has demonstrated favourable outcomes, as shown in studies by Magdeleinat et al. and Zhou et al. ( 16 – 17 ). Similarly, RATS has emerged as a safe and effective option for SFT resection, as exemplified by our series of patients. Nevertheless, it´s important to note that most published reports remain limited to case series, and no studies have directly compared outcomes between RATS and VATS or RATS and open surgery, despite the early, promising results of robotic resections. While minimally invasive resections offer benefits such as reduced postoperative pain and faster recovery, careful incision planning is essential to ensure an adequate working space and to allow safe tumour extraction while minimising the risk of tumour seeding ( 18 ). Moreover, conversion to open thoracotomy should always be considered when complete resection with clear margins cannot be achieved ( 19 ). In general, SFTs have a good prognosis, with reported overall survival rates of 89–100% at 5 years ( 16 , 20 ). However, this favourable outcome largely applies to benign SFTs. Malignant tumours carry a higher risk of recurrence, with a reported 5-year disease-free status of around 58% and an overall survival of approximately 67% ( 21 ). Although our series is not representative of the typical distribution of benign and malignant SFTs (with a predominance of malignant cases), the cornerstone of treatment remains complete surgical resection. Adjuvant radiotherapy and/or chemotherapy may help reduce recurrence rates in this set of patients; however, their benefit has only been demonstrated in a small number of studies, and overall efficacy remains uncertain ( 5 , 21 ). The limitations of our study include its retrospective nature and the small number of patients in our series. However, a clear need remains for prospective, comparative studies evaluating the outcomes of minimally invasive resections for SFT compared to conventional open approaches. Conclusion The diagnosis of SFT is often incidental, and complete surgical resection is the treatment of choice. Minimally invasive surgery, such as RATS resection, appears to be effective for tumours smaller than 10 cm, with a good postoperative recovery and reduced frequency of complications. Despite its good prognosis, postoperative surveillance is crucial due to the possibility of recurrence in the first two years. A multidisciplinary approach is essential to ensure proper management and optimise outcomes. Abbreviations solitary fibrous tumour (SFT) video-assisted thoracic surgery (VATS) robotic-assisted thoracic surgery (RATS) computed tomography (CT) magnetic resonance imaging (MRI) intensive care unit (ICU) intercostal space (ICS) intraoperative bleeding (IOB) Declarations Data availability Not applicable. Acknowledgements None Funding None provided Ethics approval Patients provided informed consent for publication. Competing interests None declared Author Contribution [AMF, MMF, PGD, DAV, LFA, XLV, LGS ,FVB] performed the literature review and contributed to manuscript drafting. [ LGS ,FVB] supervised the project and critically revised the final version. All authors reviewed and approved the manuscript. References Franzen D, Diebold M, Soltermann A et al. Determinants of outcome of solitary fibrous tumors of the pleura: an observational cohort study. BMC Pulm Med. 2014;14:138. Published 2014 Aug 12. 10.1186/1471-2466-14-138 Schweizer L, Koelsche C, Sahm F, et al. Meningeal hemangiopericytoma and solitary fibrous tumors carry the NAB2-STAT6 fusion and can be diagnosed by nuclear expression of STAT6 protein. Acta Neuropathol. 2013;125(5):651–8. 10.1007/s00401-013-1117-6 . Martin-Broto J, Mondaza-Hernandez JL, Moura DS, Hindi N. 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00:34:13","extension":"xml","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":53400,"visible":true,"origin":"","legend":"","description":"","filename":"72af0795a084409ebe5da8f1db2215c01structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8000935/v1/984ccfb267d314a9b6741801.xml"},{"id":101018771,"identity":"93420242-56da-415d-9c92-40a8e49e8c08","added_by":"auto","created_at":"2026-01-24 00:34:13","extension":"html","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":62652,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8000935/v1/b8e2b2270580f39e1a3455bd.html"},{"id":101018756,"identity":"3a3cd4a9-7473-4e34-93b1-86ccb37b44d0","added_by":"auto","created_at":"2026-01-24 00:34:13","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":329114,"visible":true,"origin":"","legend":"\u003cp\u003eClinical case 1, a)Initial anteroposterior chest X-ray showing a radiopaque mass occupying the left hemithorax (yellow arrows) with rightward tracheal deviation due to compression, b) MRI showing the mediastinal tumour 15x15x10 cm (yellow arrow), c) Thoracotomy with Finochietto retractor, directly visualising the solitary fibrous tumour in the anterior mediastinum, d) Solitary fibrous tumour extracted. 15.5 x 13.5 x 5.5 cm, 934 gr.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8000935/v1/a0719db32d6b64aecc955699.jpg"},{"id":101018758,"identity":"ff8701cd-c33f-41b7-be1a-8d68e352547a","added_by":"auto","created_at":"2026-01-24 00:34:13","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":713949,"visible":true,"origin":"","legend":"\u003cp\u003eHistological images of clinical case 1, a) Proliferation of spindle-shaped cells is observed, with eosinophilic cytoplasm, spindle-shaped nuclei, granular chromatin, occasional nucleoli, arranged in a fascicular pattern and hemangiopericytoma-like pattern. In these areas, multiple atypical mitotic figures are observed, with increased cellularity and pronounced nuclear pleomorphism. b) In other fields, the neoplasm is interspersed with areas of necrosis. Immunohistochemically, the neoplastic cells are intensely and diffusely positive for BCL-2 (c), CD34 (d), and STAT6 (e). The cell proliferation index, measured with Ki67, is 20% (f). The morphological features and immunostaining characteristics are consistent with a grade 2 solitary fibrous tumour.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8000935/v1/ab084725ab962c645f0b9d60.jpg"},{"id":101018763,"identity":"2f2a5d0d-917c-46a8-98da-57c8a0246113","added_by":"auto","created_at":"2026-01-24 00:34:13","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":619735,"visible":true,"origin":"","legend":"\u003cp\u003eClinical case 2, a) Chest CT in the non-contrast phase showing a tumour of 5.3 x 5.9 x 9.3 cm (yellow arrow), in the left hemithorax with lobulated characteristics, well-defined contours, homogeneous, in contact with the chest wall and pericardium, displacing the adjacent lung parenchyma, b) Solitary fibrous tumour extracted. 9 x 6 x 5 cm.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8000935/v1/62aac118bceb8b8bb0bc3541.jpg"},{"id":101018762,"identity":"6673cdb6-888d-4db8-a700-d2c594900920","added_by":"auto","created_at":"2026-01-24 00:34:13","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":160381,"visible":true,"origin":"","legend":"\u003cp\u003eAxial CT. Clinical case 3, anterior mediastinal tumour with well-defined contours, lobulated margins, and homogeneous consistency, measuring 4.2x3.4 cm (yellow arrow)\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8000935/v1/fb39008f10ad605466c3a595.jpg"},{"id":101207898,"identity":"68a89085-64d8-42c0-b5d1-808f19032b3b","added_by":"auto","created_at":"2026-01-27 10:07:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2261917,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8000935/v1/2adf69e4-93e8-46b7-a081-98b9ea6bba50.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical approach to pleuropulmonary solitary fibrous tumour in the anterior mediastinum: Case series at a third-level centre","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSolitary fibrous tumour (SFT) accounts for approximately 3.7\u0026ndash;5% of soft tissue sarcomas and mesenchymal neoplasms. Between 12% and 32% of cases exhibit malignant behaviour, typically affecting individuals between 50 and 70 years of age. Its pathogenesis is associated with a chromosomal inversion at 12q13, resulting in the fusion of the NAB2 and STAT6 genes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These tumours typically arise from serous membranes, with approximately 30% occurring within the thoracic cavity (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Of thoracic cases, most originate from the visceral pleura and are often attached to the lung by a pedicle. The clinical presentation is variable and often nonspecific, presenting with symptoms such as cough, dyspnea, and chest pain (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe standard treatment for SFT is complete surgical resection with negative margins. Historically, this has been achieved through thoracotomy; however, given the advantages of minimally invasive approaches, such as reduced intraoperative blood loss and shorter length of hospital stay, both video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) have emerged as feasible alternatives for tumour resection (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The objective of this case series is to present our experience in managing SFT using both conventional open surgery and a minimally invasive robotic-assisted approach.\u003c/p\u003e"},{"header":"Case series","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCase 1 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA 67-year-old female presented with a one-month history of progressive dyspnea, which advanced to orthopnea, rendering her unable to tolerate the supine position. A chest X-ray revealed a mass in the anterior mediastinum. A computed tomography (CT) guided biopsy confirmed the diagnosis of a SFT, and subsequent magnetic resonance imaging (MRI) demonstrated a mass measuring 15 \u0026times; 15 \u0026times; 10 cm. Given the tumour\u0026rsquo;s size, a median sternotomy was performed. The mass was carefully dissected using harmonic energy, preserving the thymic margins. En bloc resection was achieved, including the pedicle arising from the right pulmonary apex. A 32 French pleural drain was placed. Intraoperative bleeding (IOB) was 200 mL, and the operative time was 1.5 hours.\u003c/p\u003e \u003cp\u003eIn the immediate postoperative period, the patient experienced hemodynamic instability requiring vasopressor support and transfusion of blood products. She was managed in the intensive care unit (ICU) with advanced airway support for two days, followed by an uneventful recovery. The pleural drain was removed at 48 hours, and the patient was discharged on postoperative day four. Histopathological analysis confirmed a malignant grade 2 SFT. Immunohistochemistry was positive for CD34, STAT6, and BCL2 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCase 2. (Fig. 3)\u003c/h3\u003e\n\u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA 54-year-old female with no significant medical history was admitted to the emergency department with a diagnosis of influenza-related pneumonia. A CT scan incidentally revealed a mass in the left anterior mediastinum. An ultrasound-guided biopsy confirmed the diagnosis of a SFT. The patient was scheduled for resection via RATS, utilising four robotic arms. Under general anaesthesia, she was positioned in the right lateral decubitus position. A single 8 mm port was placed in the 7th intercostal space (ICS) for CO₂ insufflation. Under direct visualisation, additional ports were placed at the 7th and 8th ICS along the posterior axillary line, and a 12 mm accessory port was inserted in the 9th ICS along the anterior axillary line.\u003c/p\u003e \u003cp\u003eThe tumour was identified with firm adhesions to the visceral pleura of the left upper lobe. A wedge resection of the anterior segment was performed using a 60 mm stapler. A 24Fr drain was placed posteriorly, with adequate lung expansion confirmed. IOB was 150 mL, and the procedure lasted 1.5 hours. The patient was successfully extubated in the operating room and experienced an uneventful recovery. The pleural drain was removed on postoperative day two, and she was discharged the same day. Histopathological examination confirmed a benign SFT measuring 9 \u0026times; 6 \u0026times; 5 cm and weighing 156 grams, with an R0 resection. The tumour exhibited a fibrous stroma and positive immunohistochemical staining for CD34, Bcl-2, and CD99.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 3\u003c/strong\u003e \u003cp\u003e \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003eA 71-year-old female with a history of breast cancer and prior mediastinal tumour resection, with histopathology confirming a SFT, presented after a follow-up CT scan revealed a new mediastinal mass, suggestive of SFT recurrence. The patient was scheduled for RATS resection through 4 ports. Three 8 mm robotic ports and one 12 mm accessory port were utilised. Intraoperatively, multiple loose adhesions were encountered. The tumour was located over the ascending aorta, with displacement of the left brachiocephalic venous trunk. Tumour resection was performed using bipolar energy, achieving complete excision. A 24 Fr drain was placed with full lung re-expansion. IOB was 50 mL, and the operative time was 3 hours.\u003c/p\u003e \u003cp\u003eThe patient was successfully extubated in the operating room and had a favourable postoperative course. The pleural drain was removed on postoperative day four, and she was discharged the same day. Histopathological analysis confirmed a malignant SFT measuring 6.3 \u0026times; 4.4 \u0026times; 3.5 cm and weighing 46 grams. R0 resection was achieved. The tumour exhibited positive staining for CD34 and BCL2.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePleuropulmonary SFTs are rare, with an estimated incidence of 2.8 cases per 100,000 people annually. In Mexico, 26 cases were reported between 2007 and 2017, with a mean age of 52 years and a higher prevalence in females, as described by R\u0026iacute;os-Pascual et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The diagnosis is most often incidental, with symptoms typically appearing once the tumour reaches sufficient size to compress adjacent structures. In our series, as well as in the literature, CT scanning is the preferred diagnostic modality for benign tumours, which usually demonstrate a hyperdense, encapsulated mass with a pedunculated growth often attached to the left basal region, arising from the visceral pleura. In contrast, malignant tumours tend to show more invasive growth with organ infiltration, hemorrhagic necrosis, and a higher risk of recurrence (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). For diagnostic confirmation, biopsy may be performed, with immunohistochemical positivity for markers such as CD34, CD99, and Bcl-2 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Although most SFTs are benign (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), when malignant, they may be negative for CD34, which can be explained by tumour dedifferentiation, leading to changes in the expression of surface proteins.\u003c/p\u003e \u003cp\u003eAs exemplified by our cases, the location of the intrathoracic SFT should guide consideration of the differential diagnosis. For anterior mediastinal tumours, a practical mnemonic is the \u0026ldquo;4Ts\u0026rdquo;: thymoma, teratoma, thyroid pathology, and \u0026ldquo;terrible\u0026rdquo; lymphoma (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Attention to paraneoplastic manifestations may also aid diagnostic certainty. Doege-Potter syndrome, characterised by hypoglycemia due to ectopic insulin-like growth factor production, is described in up to 22% of SFT cases. Pierre-Marie-Bamberg syndrome, although rarer and reported in fewer than 5% of cases, is another recognised paraneoplastic presentation with digital clubbing and hypertrophic osteoarthropathy (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe treatment for SFT is surgical resection, which, depending on the extent of the tumour, may require the removal of adherent or invaded tissues. However, Wang et al. reported no significant differences in disease-free survival at five years when comparing organ-sparing versus en bloc resections. This finding, though, should be interpreted with caution, as it may be influenced by the small sample size of the study (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConventionally, resection has been carried out through open surgery, particularly when larger than 5 cm. However, the recent development of minimally invasive thoracic surgery has offered an alternative for the treatment of SFT (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Video-assisted thoracoscopic surgery (VATS) has demonstrated favourable outcomes, as shown in studies by Magdeleinat et al. and Zhou et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Similarly, RATS has emerged as a safe and effective option for SFT resection, as exemplified by our series of patients. Nevertheless, it\u0026acute;s important to note that most published reports remain limited to case series, and no studies have directly compared outcomes between RATS and VATS or RATS and open surgery, despite the early, promising results of robotic resections. While minimally invasive resections offer benefits such as reduced postoperative pain and faster recovery, careful incision planning is essential to ensure an adequate working space and to allow safe tumour extraction while minimising the risk of tumour seeding (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Moreover, conversion to open thoracotomy should always be considered when complete resection with clear margins cannot be achieved (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn general, SFTs have a good prognosis, with reported overall survival rates of 89\u0026ndash;100% at 5 years (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, this favourable outcome largely applies to benign SFTs. Malignant tumours carry a higher risk of recurrence, with a reported 5-year disease-free status of around 58% and an overall survival of approximately 67% (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Although our series is not representative of the typical distribution of benign and malignant SFTs (with a predominance of malignant cases), the cornerstone of treatment remains complete surgical resection. Adjuvant radiotherapy and/or chemotherapy may help reduce recurrence rates in this set of patients; however, their benefit has only been demonstrated in a small number of studies, and overall efficacy remains uncertain (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe limitations of our study include its retrospective nature and the small number of patients in our series. However, a clear need remains for prospective, comparative studies evaluating the outcomes of minimally invasive resections for SFT compared to conventional open approaches.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe diagnosis of SFT is often incidental, and complete surgical resection is the treatment of choice. Minimally invasive surgery, such as RATS resection, appears to be effective for tumours smaller than 10 cm, with a good postoperative recovery and reduced frequency of complications. Despite its good prognosis, postoperative surveillance is crucial due to the possibility of recurrence in the first two years. A multidisciplinary approach is essential to ensure proper management and optimise outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003esolitary fibrous tumour (SFT)\u003c/p\u003e\n\u003cp\u003evideo-assisted thoracic surgery (VATS)\u003c/p\u003e\n\u003cp\u003erobotic-assisted thoracic surgery (RATS)\u003c/p\u003e\n\u003cp\u003ecomputed tomography (CT)\u003c/p\u003e\n\u003cp\u003emagnetic resonance imaging (MRI)\u003c/p\u003e\n\u003cp\u003eintensive care unit (ICU)\u003c/p\u003e\n\u003cp\u003eintercostal space (ICS)\u003c/p\u003e\n\u003cp\u003eintraoperative bleeding (IOB)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone provided\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients provided informed consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared\u0026nbsp;\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e[AMF, MMF, PGD, DAV, LFA, XLV, LGS ,FVB] performed the literature review and contributed to manuscript drafting. [ LGS ,FVB] supervised the project and critically revised the final version. All authors reviewed and approved the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFranzen D, Diebold M, Soltermann A et al. Determinants of outcome of solitary fibrous tumors of the pleura: an observational cohort study. BMC Pulm Med. 2014;14:138. Published 2014 Aug 12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2466-14-138\u003c/span\u003e\u003cspan address=\"10.1186/1471-2466-14-138\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchweizer L, Koelsche C, Sahm F, et al. Meningeal hemangiopericytoma and solitary fibrous tumors carry the NAB2-STAT6 fusion and can be diagnosed by nuclear expression of STAT6 protein. 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J Thorac Dis. 2011;3(2):99\u0026ndash;104. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3978/j.issn.2072-1439.2011.01.04\u003c/span\u003e\u003cspan address=\"10.3978/j.issn.2072-1439.2011.01.04\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pleuropulmonary neoplasia, anterior mediastinum, robot-assisted surgery, solitary fibrous tumour","lastPublishedDoi":"10.21203/rs.3.rs-8000935/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8000935/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSolitary fibrous tumour (SFT) is an uncommon neoplasm, and its occurrence in the anterior mediastinum is particularly rare, as other differential diagnoses would initially be considered. Clinically, SFTs are typically asymptomatic and are often discovered incidentally through imaging studies. Definitive treatment is achieved through complete surgical resection with negative margins, followed by subsequent histopathological analysis. We present three cases of anterior mediastinal SFT managed at our institution in 2024, treated via both open surgery and a minimally invasive approach using robotic-assisted thoracic surgery. Additionally, we discussed the clinical considerations and criteria guiding the choice between open and robotic surgical approaches.\u003c/p\u003e","manuscriptTitle":"Surgical approach to pleuropulmonary solitary fibrous tumour in the anterior mediastinum: Case series at a third-level centre","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-24 00:34:08","doi":"10.21203/rs.3.rs-8000935/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-05T10:16:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T10:52:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-01T17:47:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-01T17:05:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306194674643028865392139387452021303747","date":"2026-01-29T19:11:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225850540370183764426533691893596427059","date":"2026-01-28T14:47:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"340175924166667886804103124119420542981","date":"2026-01-25T19:22:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-24T15:33:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76327786544669587626467713609425968013","date":"2026-01-23T13:34:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232585895451766244746527208924164236452","date":"2026-01-22T06:17:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326677962229771681887286574940725104376","date":"2026-01-21T12:20:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-21T10:13:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-04T14:24:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-04T14:22:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-10-31T18:15:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"89629ee3-4409-4cd8-a6ad-fa74c1d422c3","owner":[],"postedDate":"January 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-11T10:24:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-24 00:34:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8000935","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8000935","identity":"rs-8000935","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}