Truncal Sarcomas and Abdominal Desmoids

Management of Truncal Sarcoma

The management of truncal sarcoma presents unique challenges to the treating physician for reasons specific to this tumor location. First, the reconstruction options after resection of the abdominal or chest wall require a balance between cosmesis and structural integrity due to the multiplanar forces exerted on this region. Second, the histologies that commonly arise in this region are often associated with high local recurrence rates, which often require complex decision making due to prior therapy. Finally, sarcomas of the trunk in the inguinal region involve those organs in the genitourinary system, of which resection can have significant psychosocial implications.

A guide to oncological management of soft tissue tumours of the abdominal wall

INTRODUCTION

An abdominal mass is a common clinical presentation, and a small percentage of such patients will have an abdominal wall tumour with the two most common pathologies being fibromatosis and soft tissue sarcoma.

METHODS

Here we present the available literature on the diagnosis and management of both fibromatosis and soft tissue sarcoma, in the context of our experience in a tertiary referral centre for sarcoma.

RESULTS AND DISCUSSION

Appropriate cross-sectional imaging and a pre-operative tissue diagnosis by percutaneous core biopsy are necessary to define management. Desmoid fibromatosis can be managed initially by observation with serial imaging, with surgery being reserved for those patients who demonstrate progression. Soft tissue sarcoma can display a range of pathologies from relatively indolent tumours to locally aggressive sarcomas that can readily metastasise. An accurate pre-operative histological diagnosis and staging enables a multidisciplinary approach to management. This may include chemotherapy and radiotherapy, but the mainstay of treatment remains wide surgical resection and abdominal wall reconstruction. Patient outcomes are worse if referral is delayed or if the sarcoma is incompletely resected without an initial tissue diagnosis.

Surgical resection for non-familial adenomatous polyposis-related intra-abdominal fibromatosis

BACKGROUND

Intra-abdominal fibromatosis (IAF) in the context of familial adenomatosis polyposis (FAP) is associated with significant morbidity and high recurrence rates after surgical resection. Non-surgical treatments are therefore advocated. This study explored outcomes in patients with IAF not associated with FAP who underwent surgical resection.

METHODS

Data were analysed from a prospectively collected database at a sarcoma tertiary referral centre.

RESULTS

From 2001 to 2011, 15 patients without FAP underwent primary curative surgical resection of IAF. Their median (range) age was 42 (19-64) years. Median tumour size was 18 (8.5-25) cm and weight 1306 (236-2228) g. Complete macroscopic clearance was obtained in all patients. There were no deaths in hospital or within 30 days and only one patient developed a major complication. Median follow-up was 40 (6-119) months. During follow-up two patients developed a recurrence after a disease-free interval of 12 and 16 months.

CONCLUSION

In contrast to FAP-associated IAF, non-FAP-associated IAF has a very low recurrence rate after surgical resection. Surgical resection is therefore advocated as first-line treatment in patients with non-FAP-associated IAF when resection can be performed with low morbidity.

Synovial sarcoma of anterior abdominal wall

Sarcomas are connective tissue tumours, and can arise in any part of the body, more commonly in the extremities. Histological types and clinical presentation of truncal sarcomas are similar to those seen in any other anatomic locations. Radiological investigations may be contributory, but biopsy is conclusive. Surgical resection with wide margins is the initial standard treatment, however a multimodal approach including radiotherapy and chemotherapy is often favoured. Because of the high recurrence rate regardless of therapy, close follow-up is imperative. We present a case of synovial sarcoma of the anterior abdominal wall.

Desmoid tumors of the anterior abdominal wall: results from a monocentric surgical experience and review of the literature

BACKGROUND

Desmoid tumor, also known as aggressive fibromatosis, is a rare soft tissue tumor. For those cases localized in the anterior abdominal wall, radical resection and reconstruction with a mesh is indicated. Because the rarity of the disease, randomized trials are lacking, but in reported retrospective series, it is clear that although it is considered a benign lesion, local recurrence is not uncommon.

METHODS

We analyzed the records of 14 consecutive patients (3 men, 11 women, mean age 36 years, range 25-51 years) with desmoid tumor of the anterior abdominal wall treated at the European Institute of Oncology. The surgical strategy was the same in all cases: wide surgical excision and immediate plastic reconstruction with mesh after intraoperative confirmation by frozen sections of disease-free margins of >1 cm. We considered long-term outcomes by using the European Organization for the Research and Treatment of Cancer QLQ-C30 as an instrument to evaluate the overall quality of the treatment delivered to these patients.

RESULTS

No immediate postoperative complication was registered, and no patient developed recurrence after a median follow-up period of 55 months. Two women experienced mesh bulging within 1 year after the operation. The long-term mean global health status registered was 97 out of 100.

CONCLUSIONS

Radical resection aided by intraoperative margin evaluation via frozen sections followed by immediate mesh reconstruction is a safe procedure and can provide definitive cure without functional limitations for patients with desmoid tumors of the anterior abdominal wall.