Abstract
Multiple giant mediastinal liposarcomas are rare and associated with a high propensity for recurrence. Surgical management is extremely challenging and carries substantial risks. Here we report the case of a 40-year-old male patient who underwent multiple surgical resections for mediastinal liposarcoma. In April 2016, the patient presented with an intrathoracic mass and underwent right thoracotomy at our institution; postoperative histopathology confirmed a myxoid liposarcoma. Over the following decade, the patient received six cycles of chemotherapy and two cycles of anlotinib. In 2025, due to progressive dyspnea and chest tightness, chest computed tomography revealed multiple giant masses in the mediastinum and pleural cavity. In December 2025, the patient underwent resection of mediastinal tumors via a left seventh intercostal thoracotomy, followed by another resection via a right seventh intercostal thoracotomy in April 2026. Postoperative recovery was uneventful.
Introduction
Liposarcoma is a heterogeneous malignant tumor derived from adipocytes and accounts for ~15%–20% of all soft tissue sarcomas [1]. Mediastinal liposarcoma is particularly rare, comprising only 0.13%–0.75% of mediastinal tumors, with very few clinical cases reported in the literature [2]. This tumor is more frequently observed in males and typically affects middle-aged and older adults, although it can also occur in adolescents. The tumor generally exhibits slow growth and lacks distinctive clinical features. Its significant heterogeneity, which arises from varying degrees of cellular differentiation, contributes to limited specificity in pharmacological treatment options [3]. Complete surgical resection with negative margins represents the optimal treatment strategy. We present a rare case of a complex and high-risk surgical scenario involving multiple large recurrent mediastinal liposarcomas. The aim is to provide valuable insights and practical guidance for the surgical management of this challenging condition.
Case report
In April 2016, a 40-year-old male underwent a right thoracotomy at our hospital. The procedure included the resection of a large mediastinal liposarcoma, ligation of the thoracic duct, and intrathoracic esophageal anastomosis. Postoperative pathological examination confirmed the lesion as a myxoid liposarcoma. In June 2018, the patient underwent surgical resection of the scapular mass, and Postoperative pathology confirmed the mass as a metastatic lesion of mediastinal liposarcoma. In September 2022, follow-up chest computed tomography (CT) revealed enlargement of the mediastinal tumor compared with previous imaging. After this finding, the patient was administered six cycles of chemotherapy with ifosfamide and doxorubicin. In April 2024, the patient received two cycles of treatment with anlotinib. In November 2025, the patient presented to our department with chief complaints of chest tightness and shortness of breath. Chest CT was performed for further evaluation. The scan revealed multiple oval-shaped masses in the mediastinum and bilateral hemithorax, which were predominantly composed of fat density. The CT images also demonstrated significant compression of the heart, which was displaced anteriorly, as well as rightward deviation and compression of the esophagus. The main bronchi were compressed and narrowed, with associated partial atelectasis in the lower lobes of both lungs. Based on these imaging findings, recurrence and metastasis of liposarcoma were suspected (Fig. 1). Surgical treatment was considered mandatory because of significant compression of adjacent vital structures by the tumors. However, the presence of multiple large mediastinal tumors in both thoracic cavities posed significant surgical risks, including the potential for severe surgical bleeding and extensive trauma to surrounding tissues. Therefore, a staged surgical approach was planned for this patient.
Chest CT with contrast: Axial sections (A, B and C), coronal section (D) and sagittal section (E and F) show multiple masses in the mediastinum and bilateral hemithorax. Date of imaging: November 2025.
In December 2025, the first stage of surgery was performed. The procedure was accessed through a left seventh intercostal thoracotomy. Intraoperatively, the tumor was found to be located in the posterior mediastinum, with most of its volume within the chest cavity. Partial invasion of the pericardium and superior pulmonary vein was also noted. The tumor presented as cystic masses of varying sizes, characterized by intact capsules and irregular shapes. Postoperative pathological analysis confirmed the lesion as dedifferentiated liposarcoma. Macroscopically, the largest tumor measured 16 × 12 × 10 cm, while the smallest was 1 × 0.7 × 0.5 cm. The cut surfaces of the tumors appeared grayish-white to grayish-yellow, exhibited a lobulated pattern, and had a texture similar to that of adipose tissue (Fig. 2).
(A) Specimen of the large mediastinal tumor after right thoracotomy resection. (B) Postoperative pathological examination confirmed the lesion as dedifferentiated liposarcoma. Date of imaging: December 2025.
In April 2026, the patient underwent the second stage of surgical treatment. This procedure was performed via a right seventh intercostal thoracotomy, with the goal of resecting the remaining mediastinal tumor. Postoperative pathological examination again confirmed the lesion as dedifferentiated liposarcoma, with components of well-differentiated liposarcoma and myxoid liposarcoma consistent with the first-stage specimen (Fig. 3). In summary, the complete treatment pathway experienced by the patient is depicted in Fig. 4.
(A) Specimen of the large mediastinal tumor after left thoracotomy resection. (B) Postoperative pathological examination confirmed the lesion as dedifferentiated liposarcoma. Date of imaging: April 2026.
The complete treatment path of the patient.
Discussion
Liposarcoma originates from primitive mesenchymal cells. It most commonly develops in the limbs and retroperitoneum, whereas primary mediastinal liposarcoma is exceedingly rare [4, 5]. The present report describes a case of a giant dedifferentiated liposarcoma located in the posterior mediastinum, which displayed marked invasiveness and metastatic potential.
In the early stages of liposarcoma, patients usually present with nonspecific clinical symptoms. Symptoms such as dyspnea, dysphagia, and thrombosis often emerge when the tumor compresses critical anatomical structures, including the trachea, esophagus, large blood vessels, and heart [6]. This case underscores the importance of long-term, regular follow-up for patients with liposarcoma to monitor tumor progression and enable timely intervention when clinical deterioration occurs.
Given the substantial tumor burden and intricate anatomical relationships, thoracotomy or median sternotomy is generally considered the optimal surgical access for giant mediastinal tumors. In addition, alternative surgical approaches, including clamshell incision, four-port video-assisted thoracoscopic surgery, and robot-assisted thoracic surgery, have been reported depending on individual patient characteristics [7–9]. The choice of a specific surgical approach depends on the tumor’s size, exact location, and its anatomical relationship with adjacent structures.
Conflicts of interest
None declared.
Funding
None declared.
