The role of adjuvant radiotherapy in the treatment of resectable desmoid tumors

Multifocal Desmoid-Type Fibromatosis: Case Series and Potential Relationship to Neuronal Spread

Multifocal desmoid-type fibromatosis (DTF) is very rare and usually regional. We report three cases that initially appeared to be multifocal, but subsequent detailed imaging revealed unsuspected tracking along nerves in two cases. This neural spread is reminiscent of neuromuscular choristoma (NMC), a rare developmental lesion in which mature skeletal muscle cells, or rarely smooth muscle cells, infiltrate and enlarge peripheral nerves. NMC is frequently associated with DTF. These two cases suggest that DTF spread along nerves and appeared as distinct multifocal lesions while actually being contiguous. The third case was felt to represent true multifocal tumor development, possibly due to tumor seeding at the time of chest surgery. The relationship of DTF to NMC is discussed.

Iodine-125 brachytherapy for a desmoid tumor in the abdomen-thorax: A retrospective study

PURPOSE

To investigate the safety and efficacy of iodine-125 seed implantation in the treatment of abdomen-thorax desmoid tumors (DTs).

METHODS AND MATERIALS

Data from 14 DT patients who received brachytherapy with iodine-125 seeds were retrospectively collected from 2014 to 2020. The operation was completed using CT guidance and the treatment plan system (TPS). The number of lesions and the target dosimetry parameters were recorded. After brachytherapy, the lesions were evaluated using response evaluation criteria in solid tumors (RECIST).

RESULTS

Fourteen patients with 18 lesions were enrolled in this study; eleven lesions were in the thorax, seven were in the abdomen, and the lesion gross tumor volume (GTV) was 82.10 cc (interquartile range [IQR]: 40.37, 203.42 cc). The median number of seeds was 88 (IQR: 35, 158), and the median prescription dose was 120 Gy (IQR: 115, 120 Gy). The D90 was 123 ± 16.7 Gy, the V90 was 97% (IQR: 95.00, 97.25%), and the V200 was 27% (IQR: 14.50, 33.00%). The median follow-up time for each lesion was 34 (IQR: 23, 67) months, and the local response rate was 100%. Following brachytherapy, the overall survival was 52.3 ± 30.72 months. One year after brachytherapy, one patient experienced persistent worsening of a brachial plexus injury; another received a ureteral stent. No brachytherapy-related complications were observed in the remaining patients.

CONCLUSIONS

Iodine-125 brachytherapy is a novel treatment option for DT of the abdomen and thorax. Although it is a safe and effective treatment, the radiation dose of iodine-125 brachytherapy for DT-embedded organs at risk must be investigated further.

Does the Addition of Mutations of CTNNB1 S45F to Clinical Factors Allow Prediction of Local Recurrence in Patients With a Desmoid Tumor? A Local Recurrence Risk Model

BACKGROUND

The initial approach to the treatment of desmoid tumors has changed from surgical resection to watchful waiting. However, surgery is still sometimes considered for some patients, and it is likely that a few patients would benefit from tumor removal if the likelihood of local recurrence could be predicted. However, to our knowledge, there is no tool that can provide guidance on this for clinicians at the point of care.

QUESTION/PURPOSE

We sought to explore whether a combined molecular and clinical prognostic model for relapse in patients with desmoid tumors treated with surgery would allow us to identify patients who might do well with surgical excision.

METHODS

This was a retrospective, single-center study of 107 patients with desmoid tumors who were surgically treated between January 1980 and December 2015, with a median follow-up of 106 months (range 7 to 337 months). We correlated clinical variables (age, tumor size, and localization) and CTNNB1 gene mutations with recurrence-free survival. Recurrence-free survival was estimated using a Kaplan-Meier curve. Univariate and multivariable analyses of time to local recurrence were performed using Cox regression models. A final nomogram model was constructed according to the final fitted Cox model. The predictive performance of the model was evaluated using measures of calibration and discrimination: calibration plot and the Harrell C-statistic, also known as the concordance index, in which values near 0.5 represent a random prediction and values near 1 represent the best model predictions.

RESULTS

The multivariable analysis showed that S45F mutations (hazard ratio 5.25 [95% confidence interval 2.27 to 12.15]; p < 0.001) and tumor in the extremities (HR 3.15 [95% CI 1.35 to 7.33]; p = 0.008) were associated with a higher risk of local recurrence. Based on these risk factors, we created a model; we observed that patients considered to be at high risk of local recurrence as defined by having one or two factors associated with recurrence (extremity tumors and S45F mutation) had an HR of 8.4 compared with patients who had no such factors (95% CI 2.84 to 24.6; p < 0.001). From these data and based on the multivariable Cox models, we also developed a nomogram to estimate the individual risk of relapse after surgical resection. The model had a concordance index of 0.75, or moderate discrimination.

CONCLUSION

CTNNB1 S45F mutations combined with other clinical variables are a potential prognostic biomarker associated with the risk of relapse in patients with desmoid tumors. The developed nomogram is simple to use and, if validated, could be incorporated into clinical practice to identify patients at high risk of relapse among patients opting for surgical excision and thus help clinicians and patients in decision-making. A large multicenter study is necessary to validate our model and explore its applicability.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Desmoid Tumor of the Posterior Neck: A Case Report

Desmoid tumors are rare. They account for roughly 0.03% of all neoplasms and less than 3% of all soft tissue tumors. They are locally aggressive tumors with no known metastatic potential or dedifferentiation. A 29-year-old woman with no family history of neoplasms presented with a mass in the cervical region and moderate pain that had developed a year before. The patient underwent marginal resection of the bilateral posterior and lateral compartments of the neck. The histopathological report confirmed the diagnosis of desmoid tumor with nuclear positivity for beta-catenin. The patient received radiotherapy but did not show a favorable response; she has stable disease and takes colchicine at one-year follow-up.

Postoperative Adjuvant Radiotherapy Can Delay the Recurrence of Desmoid Tumors After R0 Resection in Certain Subgroups

Background: When patients with desmoid tumors (DTs) present uncontrolled clinical symptoms, surgery is an effective treatment, but the high postoperative recurrence rate is a major problem. The significance of adjuvant radiotherapy has been debated for many years, and the significance of aggressive surgery has not been reported. Methods: Medical records for DT patients were collected. KM analysis and the Mann-Whitney U-test were performed to evaluate the role of radiotherapy and aggressive surgery in the entire cohort and different subgroups. Results: Of 385 DT patients, 267 patients with R0 resection were included in the final analysis. A total of 53 patients (19.85%) experienced recurrence. Although radiotherapy showed no significant effect on recurrence-free survival (RFS) or time to recurrence (TTR) in the entire cohort, radiotherapy delayed recurrence in the age ≤ 30 years old subgroup (TTR = 35 months with surgery plus radiotherapy, TTR = 11 months with surgery alone; p = 0.014) and the tumor diameter >5 cm subgroup (TTR = 26 months with surgery plus radiotherapy, TTR = 11 months with surgery alone; p = 0.02) among patients with a single tumor. Aggressive surgery improved RFS in the tumor diameter >5 cm subgroup (p = 0.049) but not the entire cohort. Conclusions: Although radiotherapy cannot improve RFS, it can delay recurrence in the age ≤ 30 years old subgroup and the tumor diameter >5 cm subgroup among patients with a single tumor. For patients with large invasive tumors and multiple involved sites, aggressive surgery could be selected to achieve complete tumor resection to improve RFS.

Extra-abdominal desmoid tumor fibromatosis: a multicenter EMSOS study

Background

Extra-abdominal desmoid tumor fibromatosis (DTF) is a rare, locally aggressive soft tissue tumour. The best treatment modality for this patient cohort is still object of debate.

Questions/purpose

This paper aimed to (1) to compare the outcomes of DTF after different treatment modalities, (2) to assess prognostic factors for recurrence following surgical excision, and (3) to assess prognostic factors for progression during observation.

Methods

This was a retrospective multicenter study under the patronage of the European Musculoskeletal Oncology Society (EMSOS). All seven centres involved were tertiary referral centres for soft tissue tumours. Baseline demographic data was collected for all patients as well as data on the diagnosis, tumour characteristics, clinical features, treatment modalities and whether they had any predisposing factors for DTF.

Results

Three hundred eighty-eight patients (240 female, 140 male) with a mean age of 37.6 (±18.8 SD, range: 3–85) were included in the study. Two hundred fifty-seven patients (66%) underwent surgical excision of ADF, 70 patients (18%) were observed without therapy, the residual patients had different conservative treatments. There were no significant differences in terms of tumour recurrence or progression between the different treatment groups. After surgical excision, younger age, recurrent disease and larger tumour size were risk factors for recurrence, while tumours around the shoulder girdle and painful lesions were at risk of progression in the observational group.

Conclusion

Local recurrence rate after surgery was similar to progression rates under observation. Hence, observation in DTF seems to be justified, considering surgery in case of dimensional progression in 2 consecutive controls (3 and 6 months) and in painful lesions, with particular attention to lesions around the shoulder girdle.

Management of aggressive fibromatosis

Aggressive fibromatosis or desmoid tumor is a rare disease resulting from fibroblasts which do not metastasize. However, desmoid tumors belong to low-grade malignant tumors since they have high potential to infiltrate surrounding tissues, causing high local recurrence rates and may affect surrounding organs, threatening life quality and expectancy. Although surgery, watch and wait, radiotherapy, chemotherapy, high intensity focused ultrasound, ablation techniques or several agents have all been frequently investigated for the treatment of this type of disease, none are deemed as standard therapy for high recurrence rates that have been supported by any data. The present review retrieved literature on treatment options for desmoids to summarize the latest treatment modalities and refine their efficacy, as well as their side effects, in order to provide a more comprehensive treatment reference for clinicians.

Pediatric recurrent aggressive spinal fibromatosis with progressive kyphosis and neurological deficits

Aggressive fibromatosis is a benign, locally invasive fibroblastic proliferation that can cause compressive effects on adjacent structures. The primary cure of this disease rests in wide excision of the tumor. Unfortunately even when surgical margins are clear of tumor, recurrence rates are high. Postoperative radiotherapy is indicated following surgical excision. We present a 13-year-old girl who had been operated for the intraspinal mass in upper thoracic spine and paraparesis with thoracic limited laminectomy and excision of the tumor mass elsewhere. The histopathological examination was reported to be aggressive fibromatosis. After 2 years, she presented again with 1-year duration of progressive deformity in the upper thoracic spine and weakness of both lower limbs. Focal kyphosis at T4-T5 was measuring 68°. Magnetic resonance imaging (MRI) showed recurrent tumor involvement of posterior elements of T2-T5 and paravertebral soft tissues with signal changes in the cord at T2-T5 vertebral levels with focal kyphosis and internal gibbus. She underwent posterior spinal revision decompression with internal gibbectomy and instrumented fusion. The histopathology showed features suggestive of aggressive fibromatosis. After wound healing at 2 weeks, she underwent 3-D conformal radiotherapy, based on the preoperative tumor extent on MRI (dose of 45 Gy in 25 fractions over 5 weeks). She had normal neurology at 2-year follow-up and was tumor free on MRI. Hence, aggressive fibromatosis can recur following successful surgical wide excision. Multilevel thoracic laminectomy in growing children can cause progressive spinal deformity and neurological deficits. Operative treatment of recurrent tumor involves en bloc excision with instrumented fusion followed by local radiotherapy. This is the first pediatric recurrent spinal fibromatosis reported with successful treatment as per author's knowledge.

Definitive radiation therapy in patients with unresectable desmoid tumors: a systematic review

Background

Desmoid tumors are rare soft tissue tumors. Wide local excision has been the standard surgical treatment for desmoid tumors. However, this procedure results in high local recurrence rates, so non-surgical treatments should be considered. The aim of this systematic review was to evaluate the effect of radiation therapy on patients with desmoid tumors, especially those with unresectable disease.

Methods

We evaluated studies published between 1 January 1990 and 31 August 2017 and cited in PubMed and Ichushi (in Japanese). All studies evaluating the effect of radiation therapy on desmoid tumors were included. Data regarding radiation dose, recurrence and adverse events were recorded.

Results

Among 218 identified studies, only 6 were finally included in this review. Local control was achieved in 253 of 317 patients with unresectable or unresected tumors who underwent definitive radiation therapy (the crude rate of local control was 79.8%). Toxicity was evaluated in patients who underwent definitive radiation therapy or surgery plus radiation therapy. One of the most common acute complications was skin toxicity. Frequent late complications of radiation therapy included fibrosis/contracture/joint stiffness, skin disorders, lymphedema and pain. Six patients developed secondary malignancies in the radiation field.

Conclusions

In patients treated unsuccessfully with surgery, watchful waiting and pharmacotherapy, radiation therapy may be an option as salvage therapy because of the high rate of local control. Because desmoid tumors frequently develop in young individuals, children and young patients who receive radiation therapy for the treatment of desmoid tumors should be followed up on a long-term basis with periodic monitoring for late radiation toxicities.

PROMIS Function Scores Are Lower in Patients Who Underwent More Aggressive Local Treatment for Desmoid Tumors

BACKGROUND

Desmoid tumors of the extremities often present with pain and functional limitation, but treatment can lead to morbidity and recurrence is common. The impact of treatment with respect to traditional "oncologic" metrics (such as recurrence rate) has been studied extensively, with a shift in recent years away from local therapies as first-line management; however, little is known about the association between treatment modality and long-term functional outcomes for patients with this benign disease.

QUESTIONS/PURPOSES

In a retrospective review of consecutive patients treated at two institutions, we asked: (1) Is event-free survival (EFS) different between patients who undergo local treatment and those who do not for primary as well as for recurrent desmoid tumors? (2) What treatment-related factors are associated with worse Patient-reported Outcomes Measurement Information System (PROMIS) function scores at a minimum of 1 year after treatment?

METHODS

Between 1991 and 2017, 102 patients with desmoid tumors of the extremities (excluding those of the hands and feet) were treated at two institutions; of those, 85 patients with 90 tumors were followed clinically for at least 1 year (median [range] 59 months follow-up [12 to 293]) and were included in the present analysis. We attempted to contact all patients for administration of PROMIS function (Physical Function Short Form [SF] 10a and Upper Extremity SF v2.0 7a) and Pain Interference (SF 8a) questionnaires. Complete survey data (minimum 1 year follow-up) were available for 46% (39 of 102) of patients with 40 tumors at a median of 125 months follow-up; only these patients were included in PROMIS data analyses. Though there was no formal institutional treatment algorithm in place during the study period, surgical resection typically was the preferred modality for primary tumors; radiation therapy and systemic treatments (including cytotoxic or hormonal agents earlier in the study period, and tyrosine kinase inhibitors later) were often added for recurrent or very symptomatic disease. We coded treatment for each patient into discrete episodes, each defined by a particular treatment strategy: local treatment only (surgery and/or radiation), systemic treatment only, local plus systemic treatment, or observation; treatment episodes rendered at other institutions (that is, before referral) were not included in the analyses. Treatment failure was defined as recurrence after surgical resection, or clinically significant radiologic and/or symptomatic progression after systemic treatment, and EFS was defined as time from treatment initiation to treatment failure or final follow-up. Episodes of treatment for recurrent tumors were analyzed in a pooled fashion, wherein discrete treatment episodes for patients with multiple recurrences were included separately as independent events. We analyzed 56 primary tumors (54 patients), and 101 discrete treatment episodes for recurrent tumors (88 patients). Kaplan-Meier survival curves were constructed separately for the primary and recurrence cohorts, both comparing EFS among patients who received any local treatment (local treatment and local plus systemic treatment groups) versus those who did not (systemic treatment and observation groups). PROMIS function data were analyzed on the bases of patient- and treatment-specific variables, including the PROMIS Pain Interference score as a potential explanatory variable.

RESULTS

Within both the primary and recurrence cohorts, there were no differences between the local treatment, systemic treatment, and local plus systemic treatment groups with respect to gender, age, axillary/hip girdle location, or tumor volume. Among primary tumors, 5-year EFS was 44% (95% CI 24 to 80) for the systemic-only group versus 15% (95% CI 5 to 44) for the local treatment group (p = 0.087). Within the pooled recurrence treatment episode cohort, 5-year EFS after systemic-only treatment was 70% (95% CI 52 to 94) versus 56% among patients receiving any local treatment (95% CI 44 to 70; p = 0.46). PROMIS function scores were lowest among patients who underwent two or more resections (39 versus 51 versus 47 for ≥2, 1, and 0 resections, respectively; p = 0.025); among those who received both surgery and radiation at any point, either concurrently or in separate treatment episodes, as compared with those who did not (39 versus 46; p = 0.047); and among those with higher levels of pain interference (38 versus 47 for pain interference scores > 50 versus < 50; p = 0.006).

CONCLUSIONS

Patients treated with local modalities (surgery and/or radiation, with or without additional systemic therapy) did not experience improved EFS as compared with those treated without local modalities; this was the case for both the primary and the recurrent tumor cohorts. However, PROMIS function scores were lowest among patients who underwent two or more surgical interventions and among those treated with surgery and radiation at any time, suggesting that more aggressive local treatment may be associated with poorer long-term functional outcomes. Prospective collection of patient-reported outcomes data at multiple time points will allow for more direct correlations between treatment modality and impact on function and will help to elucidate the ideal management strategy for these benign but often-symptomatic tumors.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The management of desmoid tumours: A joint global consensus-based guideline approach for adult and paediatric patients

Desmoid tumor (DT; other synonymously used terms: Desmoid-type fibromatosis, aggressive fibromatosis) is a rare and locally aggressive monoclonal, fibroblastic proliferation characterised by a variable and often unpredictable clinical course. Previously surgery was the standard primary treatment modality; however, in recent years a paradigm shift towards a more conservative management has been introduced and an effort to harmonise the strategy amongst clinicians has been made. We present herein an evidence-based, joint global consensus guideline approach to the management of this disease focussing on: molecular genetics, indications for an active treatment, and available systemic therapeutic options. This paper follows a one-day consensus meeting held in Milan, Italy, in June 2018 under the auspices of the European Reference Network for rare solid adult cancers, EURACAN, the European Organisation for Research and Treatment of Cancer (EORTC) Soft Tissue and Bone Sarcoma Group (STBSG) as well as Sarcoma Patients EuroNet (SPAEN) and The Desmoid tumour Research Foundation (DTRF). The meeting brought together over 50 adult and pediatric sarcoma experts from different disciplines, patients and patient advocates from Europe, North America and Japan.

Bone Sarcomas and Desmoids

Bone sarcomas are rare tumors arising in bone, representing only a small fraction of solid malignant tumors. Desmoids are benign, infiltrative soft tissue neoplasms. Because of their scarcity and a paucity of data, the management of these tumors can be challenging, especially for clinicians who infrequently encounter these tumors. This article reviews the current literature regarding the diagnosis, work-up, and treatment of these uncommon mesenchymal tumors.

Postoperative radiotherapy in primary resectable desmoid tumors of the neck: a case-control study

PURPOSE

Desmoid tumors (DTs) are rare soft tissue tumors, which frequently recur after surgery. The optimal treatment approach is still controversial due to lack of randomized data. The purpose of the study was to review a relative large series of DTs of the neck with emphasis on the value of postoperative radiotherapy (RT).

METHODS

A total of 68 patients with DTs of the neck region with or without postoperative RT between 1/2008 and 12/2017 were included. They were individually matched for factors including age, gender, tumor size and margin status with a cohort of patients who underwent operative without postoperative RT. The event-free survival (EFS) was compared in the two groups.

RESULTS

For the study, 34 patients and 34 matched control subjects were identified. The two groups did not differ in terms of age (p = 0.810), gender (p = 0.328), tumor size (p = 0.803) and margin status (p = 0.799). Patients who received surgery plus RT had a significantly higher 3‑year EFS than those who received surgery alone (74.6% vs. 13.3%, P < 0.001). Factors including postoperative RT and margin status were independent factors of EFS. The values of P were <0.001 and 0.003 and the hazard ratios (95% confidence interval) were 11.929 (4.732-30.072) and 0.299 (0.133-0.671), respectively. None of the patients treated with RT developed serious complications.

CONCLUSIONS

According to our results, postoperative radiotherapy is an effective treatment in desmoid tumors of the neck. Multi-institutional and prospective studies are warranted to further validate our findings.

Recurrent aggressive mesenteric desmoid tumor successfully treated with sorafenib: A case report and literature review

BACKGROUND

Desmoid tumors (DT) are locally advanced but histologically benign monoclonal neoplasms that can occur from any musculoaponeurotic structure. The aim of this report is to analyze a rare clinical case of an aggressive intra-abdominal DT successfully treated with sorafenib.

CASE SUMMARY

A 36-year-old man presented with increasing colicky abdominal pain and a self-palpable mass in his left abdomen. Fourteen years earlier he was diagnosed with a large intra-abdominal tumor, which adhered to the left colonic flexure, part of the major gastric curvature and the spleen. Subsequent exploratory laparotomy revealed a voluminous mass in the epigastrium, arising from the posterior surface of the stomach and invading the superior mesenteric vessels, transverse mesocolon and the small bowel mesentery. As the tumor was unresectable, a jejunojejunal bypass was performed. Traditional therapeutic interventions proved insufficient, and the patient was started on sorafenib with a subsequent full-disease response.

CONCLUSION

DT’s pathogenesis has been associated with mutations in the adenomatous polyposis coli (APC) gene or beta-catenin gene CTNNB1, sex steroids or previous surgical trauma. Local treatment modalities, such as surgery or radiotherapy, are implemented in aggressively progressing or symptomatic patients. Sorafenib is a hopeful therapeutic option against DTs, while several pharmacological agents have been successfully used.

Survival outcomes after adjuvant radiotherapy for aggressive fibromatosis depend on time frame and nuclear β-catenin

PURPOSE

To identify prognostic factors influencing progression-free survival (PFS) of aggressive fibromatosis (AF) after postoperative radiotherapy (PORT) and assess correlations between immunohistochemistry (IHC) features of β-catenin/smooth muscle actin (SMA) and PFS.

MATERIALS AND METHODS

Records of 37 patients with AF treated by PORT from 1984 to 2015 were retrospectively reviewed. Fifteen patients underwent wide excision for AF and 22 patients received debulking operation. The median total dose of PORT was 59.4 Gy. IHC staining results of β-catenin and SMA were available for 11 and 12 patients, respectively.

RESULTS

The median follow-up duration was 105.9 months. Five-year PFS rate was 70.9%. Tumor size or margin status was not related to PFS in univariate analysis (p = 0.197 and p = 0.716, respectively). Multivariate analysis showed that increased interval from surgery to PORT (>5.7 weeks) was a marginal risk factor for PFS (p = 0.054). Administration of PORT at the initial diagnosis resulted in significantly improved PFS compared to deferring PORT after recurrence (p = 0.045). Patient with both risk factors of deferring PORT after recurrence and interval from surgery to PORT >5.7 weeks had significantly lower 5-year PFS than patients without risk factor (34.1% vs. 100.0%; p = 0.012). Nuclear β-catenin intensity tended to inversely correlate with 5-year PFS, although it did not reach statistical significance (62.5% at low vs. 100.0% at high; p = 0.260). SMA intensity was not related to PFS (p = 0.700).

CONCLUSION

PORT should be performed immediately after surgery irrespective of margin status or tumor size especially in recurrent case. Nuclear β-catenin staining intensity of IHC might correlate with local recurrence.

Single institution experience of split course radiotherapy in patients with desmoid tumors

Purpose

This study aimed to assess the feasibility of split course radiotherapy (SCRT) and reports long-term outcomes in patients with desmoid tumors (DT).

Patients and methods

Between 2001 and 2004, 31 patients with recurrent (n=19) or primary large desmoid fibromatosis (≥10 cm) (n=12) who were treated with SCRT were retrospectively analyzed. All patients were treated with two phases of radiotherapy with a median interval time of 99 days (range: 81–122 days) and a median total dose of 6,399 cGy (range: 5,013–7,039 cGy). The median dose for the first phase was 3,969 cGy/22 Fx (range: 2,999–4,305 cGy), and 2,495 cGy/14 Fx (range: 1,982–3,039 cGy) for the second phase. Progression-free survival (PFS) in response to radiotherapy was evaluated using the Kaplan–Meier method and compared using the log-rank test. The prognostic factors associated with survival were evaluated by univariate and multivariate analyses.

Results

The median age of all patients was 30 years (range, 7–58 years). With a median follow-up of 60.4 months (range, 2–187 months), eight patients experienced disease progression after treatment. The PFS rate at 3 and 5 years for the whole population was 90% and 71.3%, respectively. PFS for patients with split course of <100 days or ≥100 days interval was 100% vs 78.6% at 3 years, and 80.4% vs 62.9% at 5 years, respectively (P=0.189). In multivariate analysis, the radiotherapy (RT) interval time was an independent prognostic factor for PFS (≥100 days vs <100 days, HR 11.544, 95% CI 1.034–128.878, P=0.047). PFS was not significantly influenced by age, gender, surgery, tumor location, RT technology, or RT dose. Radiation-related acute complications occurred in nine (29%) patients after RT, and RT-related long-term complications occurred in three (9.7%) patients.

Conclusion

SCRT with an appropriate treatment interval (<100 days) is well tolerated by DT patients with favorable long-term outcomes.

Optimal radiotherapy strategy for primary or recurrent fibromatosis and long-term results

Purpose

Although locally invasive or recurrent fibromatosis is primarily treated with surgery, radiotherapy (RT) produces local control for recurrent/unresectable tumors or those with positive surgical margins. Herein, we describe our updated institutional experience with RT to treat fibromatosis.

Methods

Forty-seven patients with fibromatosis received RT between 1990 and 2015, and were followed for ≥12 months. Eight patients received RT for gross tumors, and 39 received postoperative RT after single/multiple prior surgeries. A median dose of 54 Gy was prescribed for definitive RT; 48.6, 50.4, and 54 Gy were prescribed for R0, R1, and R2 resected tumors, respectively. Recurrences were classified as in-field, marginal, or out-field. Prognostic factors were also evaluated.

Results

Seven recurrences were noted, including 2 in-field, 4 marginal, and 1 out-field, after a median follow-up of 60 months. In-field recurrences occurred in 1 patient who received 40.5 Gy of salvage RT after postoperative recurrence and another who received 45 Gy for R1 resection after multiple prior operations. All marginal failures were due to insufficient clinical target volume (CTV) margins regardless of dose (3 with 45 Gy and 1 with 54 Gy). On multivariate analysis, a CTV margin ≥5 cm and dose >45 Gy were significant predictors of non-recurrence (p = 0.039 and 0.049, respectively). Subgroup analysis showed that patients with both an CTV margin ≥5 cm and a dose >45 Gy showed a favorable outcome.

Conclusions

RT is a valuable option for treating aggressive fibromatosis; doses ≥45 Gy and a large field produce optimal results. For in-field control, a higher dose is more necessary for gross residual tumors than for totally excised lesions.

Safety and efficacy of intralesional steroid injection for aggressive fibromatosis

Background

Treatment of recurrent aggressive fibromatosis (AF) following surgical resection is a clinical challenge. Non-steroidal anti-inflammatory drugs (NSAIDs) have been reported to be an effective option for controlling the disease. However, long-term NSAID use can result in unfavorable complications. This study was a trial of the use of intralesional steroid injection (ILSI) including investigation of safety margins and clinical outcomes of high-dose steroids for local use treatment of AF.

Methods

A prospective cohort study was conducted to evaluate the safety and efficacy of particulate corticosteroids for AF. Intralesional steroid injections of Kanolone® guided by ultrasound were given monthly for three consecutive months with 1 mg/kg/episode (a total of 3 mg/kg). Patients were followed up monthly for 3 months at the time of each monthly injection and then for an additional 3 months after the last injection. Complications from the procedure and clinical outcomes were monitored.

Results

Eight recurrent AF patients completed the full 6-month evaluation process. No procedure-related complications were reported either during the injection period or the follow-up period. None of the patients developed Cushingoid features. The highest number of complication events, all of which were mild or detectable only by laboratory analysis, occurred during the month following the second injection. Triamcinolone levels were significantly increased 24 h after injection, and four of the eight cases developed hypothalamic-pituitary-axis suppression. Tumors were stabilized in 83.3% of the cases during the study period, and pain and functional ability scores improved significantly.

Conclusions

Intralesional steroid injection appears to be a safe and effective alternative treatment for recurrent AF.

Trial registration

TCTR20150409001; Registered date: 9 April 2015; The safety and result of intratumoral steroid injection for aggressive fibromatosis.

Electronic supplementary material

The online version of this article (10.1186/s12957-017-1262-9) contains supplementary material, which is available to authorized users.

Outcome of surgery for primary and recurrent desmoid-type fibromatosis. A retrospective case series of 174 patients

BACKGROUND

The best management of relapsing desmoid-type fibromatosis, a benign but locally infiltrative soft-tissue tumour, is largely undecided. Our aim was to investigate the incidence and the factors influencing local relapse after surgery for primary and recurrent disease of the trunk and extremities.

PATIENTS AND METHODS

Retrospective analysis of 174 patients who had surgical treatment for desmoid-type fibromatosis. The quality of the surgical margins and use of adjuvant radiotherapy or chemotherapy were analysed regarding local recurrences in primary and recurrent disease.

RESULTS

Clear margins were achieved in 41% of cases. 10-year local control rate was 58% for clear primary resections as compared to 37% with intralesional primary resections (p = 0.030). Extremity tumours had a higher risk of local recurrence compared to trunk and pelvic ones (p < 0.001). Attempted resection of recurrent disease was associated with an approximately 90% incidence of relapse after each procedure, despite the quality of the surgical margins being equivalent to primary resections. Quality of surgical margins was not important for local control of recurrent lesions. Adjuvant treatments (radiotherapy and chemotherapy) had a no significant effect on the local control rate of recurrent disease (odds ratio 0.693 and 0.969 respectively).

CONCLUSIONS

A complete primary excision is the best window of opportunity to achieve local control of desmoid-type fibromatosis. Once the disease relapses, surgical intervention is accompanied with a high risk of failure, irrespective of the quality of the margins and adjuvant treatment given.

Radiotherapy in desmoid tumors : Treatment response, local control, and analysis of local failures

BACKGROUND

Desmoid tumors (aggressive fibromatosis) are rare soft tissue tumors which frequently recur after surgery. Desmoid tumors arise from musculoaponeurotic tissue in the extremities, head and neck, abdominal wall, or intra-abdominally. Our aim was to examine the outcome of radiotherapy of desmoid tumors in a single institution series.

PATIENTS AND METHODS

We evaluated 41 patients with desmoid tumors treated with 49 radiotherapies between 1987 and 2012. Radiologic images for response evaluation were reassessed and responses to treatment registered according to RECIST criteria 1.1. For patients with local failures radiation dose distribution was determined in each local failure volume using image co-registration. Recurrences were classified as in-target, marginal, or out-of-target. Prognostic factors for radiotherapy treatment failure were evaluated.

RESULTS

Radiotherapy doses varied from 20-63 Gy (median 50 Gy) with a median fraction size of 2 Gy. The objective response rate to definitive radiotherapy was 55% (12/22 patients). Median time to response was 14 months. A statistically significant dose-response relation for definitive and postoperative radiotherapy was observed both in univariate (p-value 0.002) and in multivariate analysis (p-value 0.02) adjusted for potential confounding factors. Surgery before radiotherapy or surgical margin had no significant effect on time to progression. Nine of 11 (82%) local failures were classified as marginal and two of 11 (18%) in-target. None of the recurrences occurred totally out-of-target.

CONCLUSIONS

Radiotherapy is a valuable option for treating desmoid tumors. Radiotherapy dose appears to be significantly associated to local control.

Bilateral perirenal space fibromatosis with renal infiltration: case report and review of literature

Fibromatosis and/or desmoid tumors which constitute less than 1% of all neoplasms and 3.0% of all soft-tissue tumors are pathologically benign proliferations of the fibroblasts but are locally aggressive with infiltrative type of growth and tendency toward recurrence. Bilateral symmetrical perirenal involvement has been described in many conditions which can be renal, subcapsular, or perirenal in origin. However, bilateral perirenal fibromatosis as an isolated presentation was very uncommon. We report an exceptionally rare case of bilateral perirenal fibromatosis with renal infiltration.

Primary and recurrent sporadic desmoids: Prognostic factors influencing recurrence-free survival after complete gross resection

INTRODUCTION

There is continuing controversy over the significance of prognostic factors in sporadic desmoid-type fibromatosis (DF). Further, only limited data is available in the literature concerning second recurrence in patients with recurrent DF. The purpose of this study was to identify prognostic factors influencing recurrence-free survival (RFS) and to determine rates of local recurrence (LR) in patients with primary and recurrent DF.

METHODS

Fifty-three consecutive patients with DF who underwent surgery at a single institution were identified. As a result of strict exclusion criteria, a homogeneous cohort of thirty-two patients who received macroscopically complete resection was included in this study and split into a primary (PG) and recurrent disease (RG) group. Clinicopathological parameters and immunohistochemical markers were retrospectively and independently analyzed in both groups.

RESULTS

The local recurrence rate was 35% for the PG and 33% for the RG. The PG's calculated median time to relapse was 17 months, and the RG's was 29 months. The estimated 1-, 5-, and 8-year RFS rates for the PG were 75%, 64%, and 55% while the corresponding RFS rates for the RG were 69%, 69%, and 52%, respectively. In primary disease, extraabdominal tumor location was the only significant adverse prognostic factor associated with worse RFS (p = 0.008). Whereas in recurrent disease, age ≥40 yrs (p = 0.022) and R0 margin status (p = 0.049) correlated with a significantly better outcome.

CONCLUSION

Recurrence in primary and recurrent DF is characterized by different predictive factors and benefits from distinct therapeutic strategies. Immunohistochemical markers are valuable tools in the diagnosis of DF, although have limited potential in predicting the outcome.

The Role of Radiotherapy in the Treatment of Primary or Recurrent Desmoid Tumors and Long-Term Results

BACKGROUND

Desmoid tumors are uncommon and benign mesenchymal neoplasms. The optimal treatment of patients with desmoid tumors is still controversial. Surgery is the primary treatment for locally invasive or recurrent desmoid tumors. Also, radiotherapy is a treatment option for patients at high risk for local failure such as those with positive margins or recurrent and unresectable tumors.

AIMS

To report our institutional experience and long-term results of patients with desmoid tumors who received radiotherapy.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

Between 1980 and 2009, 20 patients who received radiotherapy (RT) in our institution were analyzed. The majority of patients (80%) were referred with a recurrent tumor after previous surgery. Thirteen patients underwent marginal resection, 4 had wide local excision and 3 patients had only biopsy. Resection margin was positive in 15 (75%) patients. All patients received radiation therapy. The median prescribed dose was 60 Gy. Five patients received less than 54 Gy.

RESULTS

The median follow-up time was 77.5 months (28-283 months). Nine patients developed local recurrence after RT. Seven local failures (78%) were in field. Time to local recurrence ranged from 3-165 months (median 33 months). The 2-5 year local control (LC) rates were 80% and 69%, respectively. On univariate analysis, the 5 year local control rate was significantly better in the patients treated with ≥54 Gy than in patients who received <54 Gy (p=0.023). The most common acute side effect was grade 1-2 skin toxicity. As a late side effect of radiotherapy, soft tissue fibrosis was detected in 10 patients and lymphangitis was seen in 1 patient. One patient developed radiation-induced sarcoma.

CONCLUSION

According to our results, radiotherapy is especially effective in recurrent disease and provides a high local control rate in the patients received more than 54 Gy.

Desmoid Tumors: A Clear Perspective or a Persisting Enigma? A Case Report and Review of Literature

Desmoid tumors are benign but locally aggressive tumors of mesenchymal origin which are poorly circumscribed, infiltrate the surrounding tissue, lack a true capsule and are composed of abundant collagen. History of trauma or surgery to the site of tumor origin is elicited in up to one in four cases and they most commonly develop in the anterior abdominal wall and shoulder girdle but they can arise in any skeletal muscle. The clinical behavior and natural history of desmoid tumors are unpredictable and management is difficult with many issues remaining controversial, mainly regarding early detection, the role, type and timing of surgery and the value of non-operative therapies. We report a case of anterior abdominal wall desmoid tumor in a 40-year-old male with a previous history of surgery.

Spatio-temporal genetic heterogeneity of CTNNB1 mutations in sporadic desmoid type fibromatosis lesions

Desmoid type fibromatosis (DT) is a rare lesion of unclear pathogenesis that most often presents a mutation of the (β-catenin) gene. The natural history and clinical evolution are highly variable between patients and to date there is no consensus on optimal therapy. We report two cases of a patient with multiple DT lesions. Molecular investigations performed in both patients on multiple tumors at different anatomical sites revealed non-identical CTNNB1 mutations. The first patient was a 39-year-old man with a history of recurrent DT. In two of the DT lesions, three different mutations were found in codons 41 and 45, respectively. The lesions showed marked inflammatory features, characterized by IgG4 positive lymphoplasmacytic infiltrates and a foreign body reaction, which increased in intensity over time. The patient was eventually treated with a COX-2 inhibitor and the remaining mass was stabilized. In the two DT lesions of the second patient, CTNNB1 mutations S45P and T41A were found. The presence of different mutations in multiple focally recurrent sporadic DT lesions indicates that they do not have a clonal relationship. Our data suggest that a CTNNB1 mutation is a necessary event probably by providing a selective growth advantage. An IgG4 host antigen response is discussed as a potential predisposing factor for one of the patients.

Is wide resection obsolete for desmoid tumors in children and adolescents? Evaluation of histological margins, immunohistochemical markers, and review of literature

Desmoid fibromatosis is a benign fibroblastic neoplasm with high recurrence rates predominantly observed in pediatric and adolescent patients. The use of wide resection margins has been discussed controversially in literature. In addition, data on non-surgical treatment is limited as phase III studies are still missing. Nineteen patients under the age of 18 years were identified. Tumor location, surgical treatment for primary or recurrent tumors, resection margins, medical neo-/adjuvant treatment, time to recurrence as well as immunohistochemical markers (estrogen receptor, ER α and β, progesterone and androgen receptors, somatostatin, Ki-67, c-kit, platelet-derived growth factor receptors, PDGFRs, α and β, β-catenin) were evaluated. The mean age at diagnosis was 6.6 years, with a mean follow-up of 114 months. Recurrences were detected in four out of nineteen patients. Surprisingly, the recurrence rate was not influenced by type of resection used (R0, R1/2). All samples were tested negative for ER α, somatostatin, and progesterone receptor. In contrast, a majority of tumors showed positive results for PDGFR α and β and β-catenin. No correlation between positive immunohistochemical markers and tumor recurrences was detectable. In conclusion, recurrence rates are not depending on resection type and immunohistochemical markers seem to behave differently in children and adolescents in contrast to adult patients.

Vulvar fibromatosis: a clinical enigma

OBJECTIVE

To present a case of recurrent vulvar fibromatosis in an adolescent, discuss the specific difficulties of treating adolescents, and review the literature on available treatment.

METHODS

We present a case of recurrent vulvar fibromatosis in a 14-year-old girl, requiring several treatment modalities, including multiple surgeries, radiation therapy, and multiagent chemotherapy. We then discuss management strategies for these tumor types, and specifically examine how tumor location may impact their treatment.

RESULTS

Vulvar desmoids are extremely uncommon and they can be disfiguring and cause significant discomfort for women. Initial management of these tumors is surgical excision, yet failed surgery is often followed by other treatment modalities, including radiation, tyrosine kinase inhibitors, nonsteroidal anti-inflammatory drugs, hormonal therapy, and chemotherapy. This case clearly highlights the difficulties in managing these rare tumors, particularly in the adolescent population.

CONCLUSIONS

Desmoid tumors are nonmalignant, locally aggressive neoplasms most common in the 15 to 60 years age group. They are associated with high estrogen states, prior surgical trauma, and Gardner syndrome. Most commonly, desmoid tumors present in the abdominal wall, shoulder, neck, and chest, but can occur anywhere in the body. Given their rarity and lack of definitive therapy, vulvar desmoid tumors can be exceedingly difficult to treat, and are best managed with an interdisciplinary approach.

Treatment and follow-up strategies in desmoid tumours: a practice guideline

OBJECTIVES

We set out to determine the optimal treatment options-surgery, radiation therapy (rt), systemic therapy, or any combinations thereof-for patients with desmoid tumours once the decision to undergo active treatment has been made (that is, monitoring and observation have been determined to be inadequate).provide clinical-expert consensus opinions on follow-up strategies in patients with desmoid tumours after primary interventional management.

METHODS

This guideline was developed by Cancer Care Ontario's Program in Evidence-Based Care and the Sarcoma Disease Site Group. The medline, embase, and Cochrane Library databases, main guideline Web sites, and abstracts of relevant annual meetings (1990 to September 2012) were searched. Internal and external reviews were conducted, with final approval by the Program in Evidence-Based Care and the Sarcoma Disease Site Group.

RECOMMENDATIONS TREATMENTS

Surgery with or without rt can be a reasonable treatment option for patients with desmoid tumours whose surgical morbidity is deemed to be low.The decision about whether rt should be offered in conjunction with surgery should be made by clinicians and patients after weighing the potential benefit of improved local control against the potential harms and toxicity associated with rt.Depending on individual patient preferences, systemic therapy alone or rt alone might also be reasonable treatment options, regardless of whether the desmoid umours are deemed to be resectable.

RECOMMENDATIONS FOLLOW-UP STRATEGIES

Undergo evaluation for rehabilitation (occupational therapy or physical therapy, or both).Continue with rehabilitation until maximal function is achieved.Undergo history and physical examinations with appropriate imaging every 3-6 months for 2-3 years, and then annually.

A systematic review of active treatment options in patients with desmoid tumours

INTRODUCTION

We conducted a systematic review to determine the optimal treatment options in patients with desmoid tumours who have declined observational management.

METHODS

A search was conducted of the medline and embase databases (1990 to September 2012), the Cochrane Library, and relevant guideline Web sites and conference materials.

RESULTS

One systematic review and forty-six studies met the preplanned study selection criteria; data from twenty-eight articles were extracted and analyzed. For local control, three studies reported a statistically significant difference in favour of surgery plus radiotherapy (rt) compared with surgery alone, and one study did not; two studies reported the lack of a statistical difference between surgery plus rt and rt alone in maintaining local control. Multivariate risk factors for local recurrence included positive surgical margins and young patient age. Single-agent imatinib led to a progression-free survival rate of 55% at 2 years and 58% at 3 years. Methotrexate plus vinblastine led to a progression-free survival rate of 67% at 10 years. Significant toxicities were reported for all treatment modalities, including surgical morbidity, and rt- and chemotherapy-related toxicities.

CONCLUSIONS

In patients who have declined observational management, the local control rate was higher with surgery plus rt than with surgery alone. However, the additional rt-related complications should be considered in treatment decision-making. Surgery, rt, and systemic therapy are all reasonable treatment options for patients with desmoid tumours.

Desmoid tumor of the facet joint: a case report

Desmoid tumors represent a particular type of fibromatosis. The common sites for extra-abdominal desmoid tumors, known as aggressive fibromatosis, are the shoulder, chest wall, and thigh. Desmiod tumors are rare at facet joints of the spine. We describe a patient with a desmoid tumor of a lumbar facet joint.

Radiotherapy is effective for desmoid tumors (aggressive fibromatosis) - long-term results of a German multicenter study

BACKGROUND

Desmoids (aggressive fibromatosis) are defined as benign neoplasms of the connective tissue that arise from the deep muscle fascia, aponeurosis, tendons, and scar tissue. Recurrence rates between 40 and 80% were reported after surgery alone. We addressed the impact of radiation therapy (RT) in the management of aggressive fibromatosis.

PATIENTS AND METHODS

A large literature review was performed, and the data was compared with the results of a multicenter study of the German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD).

RESULTS

This analysis included 52 patients treated with RT. 37 patients received postoperative RT (20 patients after R2 resection and 17 patients after R1 resection). 15 patients received RT alone (6 patients with inoperable primary tumor and 9 patients with inoperable recurrent tumor). In the case of postoperative RT, a median dose of 50 Gy (range 50-60 Gy) was used; for definitive RT, a median dose of 55 Gy (range 55-65 Gy) was used. The local control rate was 79% for the whole group. The median follow-up was 44 month (range 8-62 months).

CONCLUSION

Given the large number of patients, these data show that RT is highly effective in the treatment of desmoid tumors. RT is an attractive alternative to mutilating surgery.

Targeted therapies for soft-tissue sarcomas

The past several decades have revealed certain challenges that are inherent to soft-tissue sarcomas with regards to devising, testing and setting treatment paradigms for such a rare and heterogeneous malignancy. Despite this, significant advances have been made through the efforts of scientists, clinicians and patients alike. We are now entering a molecular era of cancer and current biotechnology is beginning to unravel the pathogenic enigma of these often devastating tumors. As our understanding of these malignancies improves, so does our list of potential treatment options. The impetus now lies with the medical/scientific community to direct translational research and subsequently the development and clinical testing of novel compounds in a fashion that best serves this unique patient population. To do so, we must continue to integrate the lessons of the past with the resources and promise of the future. This review will outline current areas of therapeutic interest in soft-tissue sarcomas with regard to agents that have reached clinical testing.

Abdominal fibromatosis in a young child: a case study and review of the literature

Fibromatoses comprise many different entities of well-differentiated fibroblastic proliferation with variable collagen production and form a firm nodular mass. Abdominal fibromatosis is distinguishable from other forms of fibromatosis because of its location and its tendency to occur in women of childbearing age during or following pregnancy. Abdominal fibromatosis in children is an extremely rare condition. A 15-month-old boy presented with an abdominal wall mass that had recently increased in size. Mass excision was perfomed. The tumor was 4.3×4.1 cm and partly circumscribed. Histologically, the tumor was composed of parallel long fascicles of spindle-cells with a uniform appearance. The edges of the resected mass were infiltrative, and the surgical margins were positive. Mitotic figures were <1/10 high power fields. No cellular atypia or necrosis was present. The tumor cells were positive for vimentin and nuclear β-catenin staining.

A rare presentation of a large extra-abdominal desmoid tumor of the posterior neck and back

OBJECTIVE

To describe a difficult case of a large extra-abdominal desmoid fibroma of the posterior neck and back; to discuss the pathologic findings and treatment options of this case and to review the current literature for a rare presentation of this disease.

METHOD

A case report and review of the current relevant English literature, carried out using PubMed Medline, are presented.

RESULTS

We present a challenging case in which a locally invasive desmoid of the posterior neck and back had grown to such an extent that complete surgical excision in one procedure was not possible.

CONCLUSION

Extra-abdominal desmoid fibromas are rare tumors with multiple treatment options. The literature supports incomplete surgical resection when necessary to reduce postoperative morbidity. Further options described for residual or recurrent disease include repeat surgical excision, radiation therapy, and possible chemotherapy. For particularly large tumors, close observation and a planned second stage procedure are an appropriate choice.

Surgical resection and radiation therapy of desmoid tumours of the extremities: results of a supra-regional tumour centre

PURPOSE

Desmoid tumours of the extremity have a high recurrence rate. The purpose of this study was to analyse the outcome after resection of these tumours with special emphasis on recurrent disease and adjuvant therapeutic strategies.

METHODS

In this retrospective study we evaluated prognostic factors for recurrence-free survival after surgical treatment of desmoid tumours of the extremity in 27 patients with an average age of 41 years treated from 1997 to 2009. Adjuvant radiotherapy (50-60 Gy) was given in five cases with primary and in nine patients with recurrent disease. The average follow-up was 64 months.

RESULTS

The five-year recurrence-free survival in patients with primary disease was 33%. Patients with negative resection margins tended to have a better outcome than patients with positive resection margins, but the difference between both groups was not significant (56 vs 14%, p = 0.145). In patients with positive margins, adjuvant radiotherapy did not significantly improve recurrence-free survival (40 vs 14%, p = 0.523). Patients with local recurrence had a five-year further recurrence-free survival of 47%. In those patients further recurrence-free survival was significantly better after adjuvant radiation (89 vs 25%, p = 0.015). Two thirds of all patients suffered moderate or severe complications due to the treatment regimen.

CONCLUSIONS

Compared to desmoids of the trunk or the head and neck region, desmoids affecting the limbs show by far the worst outcome in terms of relapse or treatment-related morbidity. The importance of negative resection margins is still not clear. Particularly in recurrent desmoids adjuvant radiotherapy appears to reduce the further recurrence rate. Therefore, a general use of radiation should be considered for this high-risk group.

Desmoid tumor of posterior cruciate ligament of the knee: a case report

Background

Desmoid tumor is a rare type of cancer that develops in the tissues that form tendons and ligaments. These tumors, also called aggressive fibromatosis, are considered benign with no metastatic potential. They may invade nearby tissues and organs, however, and can be difficult to control. Desmoid tumor in the posterior cruciate ligament (PCL) of the knee has never been described in the literature.

Case presentation

A 49-year-old man presented with a 2-month history of posteromedial knee dull pain and decreased range of motion of the knee. He was diagnosed desmoid tumor of posterior cruciate ligament of the knee by intraoperative biopsy, and underwent successful PCL resection and reconstruction by Four-strand semitendinosus and gracilis tendon autograft arthroscopically, and fortunately five years after operation, there were no clues as to recurrence of the tumor examined by Magnetic Resonance Imaging (MRI).

Conclusion

Desmoid tumor is characterized by infiltrative growth and a tendency towards recurrence,as this tumor entity is rare, data giving evidence based recommendations for the optimal treatment algorithm for this disease is lacking. At present there is no definite and effective method of treatment. However, early detection of the tumor play an important role, MRI is now the most important method for the detection of tumor extent, which facilitates the treatment choice as well as the prediction of prognosis. In our case, we followed-up the patient five years postoperatively by MRI and got a good result.

Management of desmoid-type fibromatosis involving peripheral nerves

Desmoid-type fibromatosis is an uncommon and aggressive neoplasia, associated with a high rate of recurrence. It is characterized by an infiltrative but benign fibroblastic proliferation occurring within the deep soft tissues. There is no consensus about the treatment of those tumors. We present a surgical series of four cases, involving the brachial plexus (two cases), the median nerve and the medial brachial cutaneous nerve. Except for the last case, they were submitted to multiple surgical procedures and showed repeated recurrences. The diagnosis, the different ways of treatment and the prognosis of these tumoral lesions are discussed. Our results support the indication of radical surgery followed by radiotherapy as probably one of the best ways to treat those controversial lesions.

[Huge retrovesical tumor as an incidental finding: desmoid-type fibromatosis: a case report]

We report the case of a 57-year-old patient with a huge, retrovesical, aggressive desmoid fibromatosis detected incidentally during preoperative staging for radical prostatectomy. The tumor was locally invasive consisting of monoclonal and fibroblastic proliferations. The etiology of such tumors is not well known but they are mostly sporadic and aggressive fibromatosis is sometimes associated with familial adenomatous polyposis (FAP) or Gardner's syndrome. Such desmoid tumors are slow growing and locally invasive but lack metastatic potential. Complete resection with wide margins is the therapy of choice and the tendency to recur is high. Radiotherapy following surgery is controversial. We discuss the pathogenesis, clinical manifestations and therapy of such rare tumors.

Desmoid tumor: analysis of prognostic factors and outcomes in a surgical series

BACKGROUND

Desmoid tumors are rare and exhibit a highly unpredictable natural history. We sought to analyze prognostic factors associated with recurrence in a large single-institution study of patients with desmoid tumors.

METHODS

We performed a retrospective review of 177 patients with desmoid tumor who underwent macroscopically complete surgical resection, with or without the addition of radiotherapy (RT) or systemic therapy, from 1970 to 2009. We examined patterns of presentation, all known risk factors for recurrence, and their association with recurrence-free survival (RFS).

RESULTS

Twenty-two patients (12 %) had intra-abdominal desmoid tumors, and 155 (88 %) had extra-abdominal tumors. Patterns of presentation included primary (n = 133, 75 %) and locally recurrent (n = 44, 25 %) disease. Treatment was surgery alone in 125 patients (71 %), surgery and RT in 36 (20 %), and surgery and systemic therapy with or without RT in 20 (11 %). Median follow-up was 40 months. Overall, the local relapse rate was 29 %, and 10-year RFS was 60 %. R0 resection status was the only predictor of freedom from local recurrence on multivariate analysis (odds ratio 0.32; 95 % confidence interval 0.15-0.66; P = 0.002). The selective use of adjuvant RT appeared to improve local control in patients with positive margins.

CONCLUSIONS

For patients with desmoid tumors undergoing surgery, wide excision with negative margins should be the goal, but not at the expense of function, as fewer than half of patients with positive margins will experience recurrence.

Ultrasound-guided high intensity focused ultrasound treatment for extra-abdominal desmoid tumours: preliminary results

PURPOSE

The aim of this study was to evaluate the feasibility, safety and therapeutic effects of ultrasound (US)-guided high intensity focused US (HIFU) ablation in the treatment of extra-abdominal desmoid tumours.

MATERIALS AND METHODS

From May 2006 to May 2010, ten consecutive patients with pathologically proven extra-abdominal desmoid tumours were treated by US-guided HIFU ablation. Eight patients with multiple recurrent tumours were treated with a palliative aim, two patients with new solitary tumours were treated with a curative aim. The mean size of the largest tumour was 9.2 cm (range 5.9-12.8 cm). An acoustic power of 300-500 W was used according to the echogenic changes after energy exposure, intermittent HIFU exposure of 2-3 s was applied until the planned target area became hyperechoic on US. Outcome of HIFU ablation was observed by serial contrast-enhanced imaging examinations during follow up.

RESULTS

HIFU ablation was successfully performed without major complications. Large volume coagulation necrosis was obtained in all patients. During a mean follow up of 30 months (range 8-55 months), the treated tumours (n = 25) shrank significantly (>50% in volume). Complete tumour necrosis was observed in the two patients with solitary new tumours. Two patients received repeat HIFU ablation for enlarged residual tumours. No tumour spread along the treated area was observed in any patient.

CONCLUSION

US-guided HIFU ablation could be used as an effective minimally invasive therapy for local control of extra-abdominal desmoid tumours.

The role of postoperative irradiation in the treatment of locally recurrent incompletely resected extra-abdominal desmoid tumors

Background: To define the efficacy of postoperative irradiation in patients with recurrent extra-abdominal desmoid tumors in whom surgical intervention has resulted in microscopically or grossly positive surgical margins.

Methods: A retrospective analysis was performed on all patients referred to the department of radiation oncology at the Detroit Medical Center with a diagnosis of recurrent extra-abdominal desmoid tumor. This analysis includes all patients seen from 1 January 1990 through 31 December 1999. A total of 11 patients were treated to 13 sites. Ten had microscopically positive margins and three had gross residual disease. Three patients were noted to have multifocal disease at the time of initial representation. Local control, survival, follow-up, and subsequent development of new tumors are measured from the last day of treatment with irradiation.

Results: Thirteen sites were treated. Seven patients had received chemotherapy/hormonal therapy prior to surgery and/or irradiation. The most commonly used drug was tamoxifen (n=6). The type of radiation delivered included external beam irradiation alone (n=3), combined external beam irradiation and brachytherapy (n=4), brachytherapy alone (n=3) and 252-Cf neutron brachytherapy alone (n=3). Follow-up has ranged from 29 to 115 months (median=76 months). Three patients have failed locally at 17, 24 and 29 months. One of these was treated for gross residual disease. No patient has died of tumor-related causes. Salvage at the failed sites was possible in twom of three with re-irradiation using external neutrons and/or aggressive surgical intervention and systemic therapy. Complications were most often noted to include decrease range in motion, especially in joint areas, and skin reactions which were normal in presentation. In one site there was development soft tissue necrosis.

Conclusion: Based on our experience we recommend postoperative irradiation for all recurrent extra-abdominal desmoid lesions with microscopically or grossly positive surgical margins. Furthermore, patients with recurrent desmoid tumors involving the bony structures of the hand or feet are poor candidates for brachytherapy alone. For patients with extremity lesions, brachytherapy may be a reasonable treatment option provided adequate margins around the tumor bed are covered. The continued recommended use of irradiation in this group of patients is warranted.

A rare desmoid tumor of the shoulder--excision, implantation of brachytherapy applicators and wound closure by pedicle musculus latissimus dorsi flap

Desmoid tumors are non-metastatic mesenchymal tumors with an aggressive local growth. Depending on the anatomic location, morbidity varies. We report of a patient with a desmoid tumor of the right shoulder which was treated in our department by surgical excision, plastic-surgical wound closure and postoperative adjuvant radiation.