Recurrent desmoids determine outcome in patients with Gardner syndrome: a cohort study of three generations of an APC mutation-positive family across 30 years

Colectomy and desmoid tumours in familial adenomatous polyposis: a systematic review and meta-analysis

Desmoid tumours (DT) are one of the main causes of death in patients with familial adenomatous polyposis (FAP). Surgical trauma is a risk factor for DT, yet a colectomy is inevitable in FAP to prevent colorectal cancer. This systematic review and meta-analysis aimed to synthesize the available evidence on DT risk related to type, approach and timing of colectomy. A search was performed in MEDLINE, EMBASE and the Cochrane Library. Studies were considered eligible when DT incidence was reported after different types, approaches and timing of colectomy. Twenty studies including 6452 FAP patients were selected, all observational. No significant difference in DT incidence was observed after IRA versus IPAA (OR 0.99, 95% CI 0.69-1.42) and after open versus laparoscopic colectomy (OR 0.88, 95% CI 0.42-1.86). Conflicting DT incidences were seen after early versus late colectomy and when analysing open versus laparoscopic colectomy according to colectomy type. Three studies reported a (non-significantly) higher DT incidence after laparoscopic IPAA compared to laparoscopic IRA, with OR varying between 1.77 and 4.09. A significantly higher DT incidence was observed in patients with a history of abdominal surgery (OR 3.40, 95% CI 1.64-7.03, p = 0.001). Current literature does not allow to state firmly whether type, approach, or timing of colectomy affects DT risk in FAP patients. Fewer DT were observed after laparoscopic IRA compared to laparoscopic IPAA, suggesting laparoscopic IRA as the preferred choice if appropriate considering rectal polyp burden. PROSPERO REGISTRATION NUMBER: CRD42020161424.

Desmoid-type fibromatosis of the lower extremity: A unique case of complete lesion resolution following core needle biopsy

Desmoid-type fibromatosis (DF) is a rare neoplasm characterized by fibroblastic and myofibroblastic proliferation. While characterized as a benign lesion that does not metastasize, desmoid-type fibromatosis exhibits a wide range of behavior from aggressive local tissue invasion and post-surgical recurrence to spontaneous regression. Tumor regression can occur following systemic medical therapy or rarely may occur in the absence of therapy. We present a case of a 50-year-old female with a left thigh vastus medialis intramuscular mass which underwent imaging work-up and subsequent core needle ultrasound-guided biopsy showing results of desmoid-type fibromatosis. Following biopsy, the tumor showed prompt, complete regression with complete MRI resolution 2 months following biopsy. The patient showed no evidence of disease recurrence out to one year on MRI surveillance. This case report will discuss desmoid-type fibromatosis imaging features, treatment strategies, spectrum of disease behavior, and atypical behavior such as the spontaneous tumor regression as seen in this case report. To our knowledge there have been no reported cases of DF spontaneous regression 2 months following a core needle biopsy. Understanding the variable behavior of desmoid-type fibromatosis can assist the radiologist in guiding management of these lesions with the goal of optimizing clinical outcomes and preventing unnecessary aggressive treatments for stable or regressing disease.

Benign and non-neoplastic tumours of the duodenum

This review study describes the problem of duodenal tumours, which are rare but important in gastrological practice. The most common location of small intestinal tumours is the duodenum, and this observation is probably partly due to the greater diagnostic availability for most proximal segments of the small intestine. Among tumours the following should be mentioned – benign: adenomas, lipomas, haemangiomas, and leiomyomas; and malignant: malignant tumours of epithelial origin, primary gastrointestinal stromal tumours, neuroendocrine tumours and carcinoids, lymphomas, sarcomas, teratomas, and secondary metastases. Early duodenal tumour recognition, especially with histological assessment, plays a crucial diagnostic role with future therapeutic implications. In recent years the prevalence of benign duodenal tumours has been rising due to a higher level of clinicians’ doubts and the convenience of gastrointestinal endoscopy; hence, knowledge of this problem is important in routine clinical practice. The method of duodenal tumour treatment should be selected on an individual basis.

Large desmoid tumors in familial adenomatous polyposis: a successful outcome

Desmoid tumors develop from connective tissue, fasciae, and aponeuroses, and may occur in the context of familial adenomatous polyposis or may arise sporadically; also, they may be extra-abdominal, intra-abdominal, or located in the abdominal wall. These benign tumors have a great aggressiveness with a high rate of local recurrence. Familial adenomatous polyposis is an inherited condition with autosomal dominant transmission, and is characterized by the development of multiple colonic and rectal adenomatous polyps, as well as desmoid tumors. We present the case of a 54-year-old woman with germline APC gene mutation, who underwent a total colectomy, subsequently developing two large infiltrative solid intra-abdominal lesions consistent with desmoid tumors. Medical treatment with Cox-2 inhibitors was initiated without result. She was submitted to resection for intestinal obstruction, but developed local recurrence. The lesions were also unresponsive to tamoxifen, and chemotherapy was initiated with dacarbazine plus doxorubicin, switching to vinorelbine plus methotrexate, achieving a good response in all lesions after 12 months. The approach to these intra-abdominal lesions should be progressive, beginning with observation, then a medical approach with non-steroidal anti-inflammatory drugs or with an anti-hormonal agent. Afterwards, if progression is still evident, chemotherapy should be started. Surgery should be reserved for resistance to medical treatment, in palliative situations, or for extra-abdominal or abdominal wall desmoids tumors.

A Case of Spontaneous Regression of Recurrent Desmoid Tumor Originating From the Internal Obturator Muscle After Delivery

Desmoid-type fibromatoses are pathologically benign but locally aggressive tumors. We report the case of a desmoid tumor that disappeared spontaneously after recurrence. A 21-year-old woman was referred to our hospital because of left lower limb weakness during menstruation. The following day this weakness had disappeared but menstrual colic remained; consequently, the patient underwent an internal examination that revealed an intrapelvic tumor. Magnetic resonance imaging demonstrated an enhanced mass (diameter, 8 cm) arising from the internal obturator muscle and attached to the urinary bladder. The tumor was diagnosed as a desmoid-type fibromatosis after histologic evaluation of a transvaginal biopsy; marginal resection was carried out at < 1 month after the first hospital admission. The patient experienced recurrence at 2 years after surgery, which was confirmed as two enhanced masses (diameter, 1 cm) using magnetic resonance imaging. Eleven months later, the diameters of these masses had increased to 1.8 cm; however, there was no further increase in size beyond this point. The patient delivered successfully at 5 and 7 years after surgery; at 8 years, the recurrent tumors had disappeared completely as confirmed by magnetic resonance imaging. This case involving recurrence is rare for two reasons. The first was that no change in the size of the tumors occurred during pregnancy and after delivery, and the second was that the patient experienced complete remission of the recurrent tumors after only simple observation. Thus, it is important to recognize that even a recurrent desmoid tumor can sometimes exhibit spontaneous regression.

Intestinal perforation during chemotherapeutic treatment of intra-abdominal desmoid tumor in patients with Gardner's syndrome: report of two cases

Background

A minority of intra-abdominal desmoid tumors is associated with Gardner’s syndrome in which desmoid tumors become an important cause of morbidity and mortality if they are surgically unresectable.

Case presentation

Here, we report two cases of intestinal perforation during chemotherapy in patients with Gardner’s syndrome-associated intra-abdominal desmoids. One female and one male patients who developed inoperable desmoids were given the chemotherapeutic regimen of doxorubicin plus dacarbazine, followed by meloxicam. Significant tumor regression was observed clinically. However, intestinal perforation happened in both patients. They were subjected to emergency surgery, follow-up management, and survived up to now.

Conclusions

The doxorubicin plus dacarbazine chemotherapy is an effective treatment for intra-abdominal demoid tumors in patients with Gardner’s syndrome. On the other hand, given severe adverse events might occur, clinicians should pay more attention that tumor quick regression may cause intestinal perforation in which urgent surgical intervention is necessary.

Multiple desmoid tumors in a patient with Gardner's syndrome - Report of a case

INTRODUCTION

Desmoid tumor (DT) is a common manifestation of Gardner's Syndrome (GS), although it is a rare condition in the general population. DT in patients with GS is usually located in the abdominal wall and/or intra-abdominal cavity.

PRESENTATION OF CASE

We report a case of a 32 years-old female patient with familial adenomatous polyposis (FAP), who was already submitted to total colectomy and developed multiple DT, located in the abdominal wall and in the left breast. The patient underwent several surgical procedures, with a multidisciplinary team of surgeons. Wide surgical resections of the left breast and the abdominal wall tumors were performed in separate steps. Polypropylene mesh reconstruction and muscle flaps were needed to cover the defects of the thoracic and abdominal walls. After partial necrosis of the adipose-cutaneous flap in the abdomen that required a new skin graft, she had a satisfactory outcome with complete healing of the surgical incisions.

DISCUSSION

DT is frequent in GS, however, breast localization is very rare, with few cases reported in the literature. Recurrence of DT is not negligible, even after a wide surgical resection. GS patients must be followed up closely, and clinical examination, associated with imaging studies, should be performed to detect any signs of tumor.

CONCLUSION

DT represents one of the most significant causes of the morbidity and mortality that affects FAP patients following colectomy. In general, the surgical procedures to excise DT are highly complex, requiring a multidisciplinary team.