Surgical resection of a >50 cm recurrent retroperitoneal spindle cell sarcoma complicated by pulmonary embolism: a...

Giant retroperitoneal sarcomas are rare, surgically demanding malignancies. When recurrent disease is further complicated by concomitant pulmonary embolism (PE) and extreme tumor burden, perioperative management becomes especially complex. Immunohistochemical (IHC) subtyping, the standard for definitive histologic classification, is not available in Uzbekistan and requires referral abroad, reflecting a resource limitation relevant to centers in similar settings.

A 63-year-old woman with a history of prior retroperitoneal tumor resection (reported as liposarcoma at the initial institution) presented with progressive abdominal distension and dyspnea. Contrast-enhanced CT demonstrated a massive heterogeneous retroperitoneal mass measuring 41 × 35 × 41 cm, with severe inferior vena cava compression and segmental PE. Following multidisciplinary assessment involving surgery, cardiology, oncology, and anesthesiology, the patient underwent open surgical resection via midline laparotomy. The gross specimen measured 52 × 50 × 12 cm. Histopathology revealed high-grade spindle cell sarcoma with necrosis and peritoneal invasion. Fourteen para-aortic lymph nodes and resection margins were all free of malignancy. The postoperative course was notable for transient anemia (hemoglobin nadir 7.1 g/dL) but was otherwise uncomplicated. The patient was discharged on postoperative day 8 with apixaban anticoagulation. Follow-up contrast-enhanced MSCT at 3 months post-resection revealed no evidence of local recurrence or distant metastases.

This case demonstrates that even extremely large recurrent retroperitoneal sarcomas, complicated by PE, can be successfully managed surgically when guided by multidisciplinary evaluation and meticulous operative planning. It also highlights the diagnostic challenge of definitive histologic subtyping in resource-limited settings, where IHC referral pathways are essential.