Desmoid tumorsA clinical review of 30 patients with more than 20 years’ follow-up

Laparoscopic gastric wedge resection and spleen-preserving distal pancreatectomy performed on a 6-cm gastric desmoid tumour with pancreatic invasion

Desmoid tumours are rare tumours originating from fibroblasts, and are characterised by local infiltration and no metastasis. When complete resection is possible, surgical resection is considered a first-line treatment. In the case of large desmoid tumours, it is mainly performed by laparotomy, not laparoscopy. We report a case of a 43-year-old female patient presenting with a hypodense mass of approximately 5 cm in the posterior wall of the gastric antrum on computed tomography. There was no history of familial adenomatous polyposis, trauma or abdominal surgery. The patient underwent laparoscopic gastric wedge resection and spleen-preserving distal pancreatectomy without peri-operative complications. Pathological analysis revealed a desmoid tumour, which originated from the stomach and invaded the pancreas. Despite the large size and the locally infiltrative characteristics of these tumours, laparoscopic surgery can be an optimal treatment option due to its advantages.

Effect of Tranilast on the Frequency of Invasive Treatment for Extra-Abdominal Desmoid Fibromatosis

BACKGROUND

Active surveillance (AS) has been suggested for managing extra-abdominal desmoid fibromatosis (EADF), but a substantial percentage of such patients transitioned to invasive secondary treatments. The anti-keloid medication tranilast is frequently used in Japan but its effectiveness for EADF is not well understood.

METHODS

We retrospectively analyzed the medical records of EADF patients treated with tranilast between January 2009 and March 2021. EADF has been reported to shrink spontaneously, so the effects of all drugs must be compared with AS. To assess the effect of tranilast, we compared the clinical courses of patients receiving tranilast with those managed by AS (as identified in a systematic review). A systematic review of AS outcomes was conducted on July 22, 2021, in accordance with PRISMA guidelines. The primary endpoint was rate of conversion to secondary treatment. Secondary endpoints were progression-free survival, objective response rate (ORR), disease control rate (DCR), and adverse events. The rates of conversion to secondary treatment, ORRs, and DCRs were compared between the two groups by using the Fisher exact test.

RESULTS

Eighteen patients who received tranilast as initial treatment for EADF were included. Two patients (11.1%) underwent surgical resection for treatment of tumor growth and persistent pain. The rate of conversion to secondary treatment was significantly lower for tranilast than for a pure AS approach (40.1%; p = 0.01). ORR and DCR did not differ between groups.

CONCLUSIONS

Tranilast was better than AS for initial management of EADF.

Periscapular Fibromatosis With Intrathoracic Invasion in a 3-Year-Old Boy

Fibromatosis is an extremely rare tumor that arises from the myofascial tissue and has high rates of infiltration and recurrence. Fibromatosis of the chest wall is even less common, and wide surgical resection is the preferred treatment alternative to radiation therapy, chemotherapy, and systemic treatments. We report the case of a 3-year-old boy with radiologically and pathologically confirmed fibromatosis of the periscapular region who underwent wide resection. We discuss diagnosis, treatment options, and technical pearls for a desmoid tumor of the chest wall. The resection should go through healthy tissue because of the infiltrative nature of the tumor. Although visceral involvement did not occur in this case, surgeons should be aware of its possibility, and surgery should be performed by a multidisciplinary team, including a pediatric orthopedic surgeon, a thoracic surgeon, and an anesthesiologist. [Orthopedics. 2022;45(5):e276-e279.].

Desmoid fibromatosis: is the current picture changing?

Desmoid fibromatosis is a locally aggressive tumor with an unpredictable clinical course. Surgery was once the mainstay of treatment, but the treatment protocol has been constantly evolving and currently active surveillance is the front-line approach. There have been significant insights into the molecular biology with the addition of mutational analysis of CTNNB1 adding to prognostic information. We present a review of the literature with current practice guidelines, also including novel therapeutic targets and ongoing clinical trials, to unravel the next step in the management of sporadic desmoid fibromatosis.

Targeted therapy in advanced desmoid tumors: Current perspectives

Background

Desmoid tumors/aggressive fibromatosis (DTs/AF) are cytological bland fibrous neoplasms originating from the musculoaponeurotic structures throughout the body. The exact cause still remains unknown, however, they may present sporadically or as a manifestation of a hereditary syndrome called familial adenomatous polyposis (FAP). Although they lack the capacity to establish metastases, DTs/AF may be devastated and occasionally fatal. As a result of the heterogeneity of DTs/AF, treatment needs to be individualized to improve local tumor control and maintain patients’ quality of life. Therefore, after a multidisciplinary approach, all treatment options should be discussed with patients. Where systemic chemotherapy has been shown to be unsuccessful with marked side effects in case of advanced DTs/AF, new therapeutic options are needed.

Methods

A Medline search was conducted and published articles in different studies from 2000 to the present were reviewed.

Conclusion

More research is needed to illustrate both the prognostic and predictive factors of the targeted therapy and the value of their combinations with or without other treatment modalities to get the best result for the treatment of advanced DTs/AF.

Factors Associated with Disease Stabilization of Desmoid-Type Fibromatosis

Background

Spontaneous disease stabilization of desmoid-type fibromatosis (DF) has been demonstrated in many reports, and the watchful waiting approach without any frontline treatment is becoming popular as an initial management strategy. In this study, we aimed to assess the disease stabilization rate and identify predictive factors for disease stabilization of DF in patients with conservative treatment.

Methods

We reviewed 76 patients with sporadic extra-abdominal DF who were managed with frontline conservative treatment in our institute. The minimum follow-up was 12 months. Stabilization was defined as radiological evidence of no change or continuous decrease in size of the tumor for six months or more. The primary endpoint was stabilization of DF. Possible patient-, disease-, and treatment-related factors predictive of disease stabilization were analyzed with multivariate analysis.

Results

At final follow-up, 54 of the 76 tumors (71%) were stable, and mean time to stabilization was 30.4 months (range, 7 to 112 months). On Kaplan-Meier survival analysis, the spontaneous stabilization rate was 25.4% at one year, 52.7% at two years, and 70.9% at three years. The mean time to spontaneous stabilization was longer in patients with ≤ 40 years of age (p = 0.022) or recurrence (p = 0.041). On multivariate analysis with the Cox proportional hazard method, recurrence (hazard ratio [HR], 1.79; p = 0.041) and younger age (HR, 2.04; p = 0.022) were identified as independent prognostic factors for longer time to disease stabilization.

Conclusions

Frontline conservative treatment seems to be the optimal treatment for most patients with DF. Younger patients or those with recurrence may require longer time to spontaneous disease stabilization.

A case of intrathoracic desmoid tumor with pulmonary Mycobacterium abscessus disease

A 68-year-old man who was on treatment for pulmonary Mycobacterium avium complex complained a worsening of sputum. Although he archived negative sputum culture two months ago, sputum culture tests revealed the newly isolation of Mycobacterium abscessus repeatedly. Chest computed tomography showed newly-appeared extra-pulmonary mass lesion in contact with a cyst at the bottom of his right lung. From the results of contrast-enhanced magnetic resonance imaging, we first suspected loculated pleural effusion due to Mycobacterium abscessus infection. A thoracoscopic examination was performed as the right pneumothorax developed, and the pleural lesion was successfully resected and diagnosed as an intrathoracic desmoid tumor. Intrathoracic desmoid tumor is very rare, and this is the first report of a case with pulmonary Mycobacterium abscessus disease.

Orbital Desmoid-Type Fibromatosis: A Case Report and Literature Review

Purpose

Desmoid-type fibromatosis is a benign fibrous neoplasia originating from connective tissue, fascial planes, and musculoaponeurotic structures of the muscles. Currently, there is no evidence-based treatment approach available for desmoid fibromatosis. In this article, a case of a patient in the pediatric age affected by desmoid fibromatosis localized in the orbit is presented. The aim of the article is to describe this unusual and rare location for the desmoid fibromatosis and outline the principle phases in the decision-making process and the therapeutic alternatives for a patient affected by desmoid fibromatosis.

Methods

The protocol of this review included study objectives, search strategy, and selection criteria. The primary end point of this study was to analyze the head and neck desmoid fibromatosis. The secondary end point was to identify the available therapies and assess their specific indications.

Results

The mean age of patients was 18.9 years ranging from 0 to 66, and 52% were female. A bimodal age distribution was observed, and two age peaks were identified: 0–14 years (57%) and 28–42 years (18%). The most common involved areas were the mandible (25%) followed by the neck (21%). In 86% of the cases, the treatment was the surgical resection of the disease, and only in 5% of the cases, the surgical resection was followed by adjuvant radiotherapy.

Conclusion

The orbital location is extremely rare, especially in the pediatric population. The management of desmoid fibromatosis is based on the function preservation and the maintenance of a good quality of life, but in case of symptomatic patients or aggressive course of the disease or risk of functional damages, the surgical approach may be considered. Therapeutic alternatives to surgical resection are radiotherapy and systemic therapy.

Systematic Review of Clinical Outcomes Following Various Treatment Options for Patients with Extraabdominal Desmoid Tumors

BACKGROUND

Desmoid tumors (DT) are rare clonal proliferations that arise from mesenchymal cells. These tumors do not metastasize but are locally aggressive, and their growth may lead to significant morbidity. Their clinical course is both variable and unpredictable; tumors may rapidly progress but in other instances remain stable or regress without intervention.

AIMS

To examine current treatment of DT and assist with decision-making at time of presentation.

METHODS

A literature search was conducted of MEDLINE and Cochrane databases for published studies (1995-July 2015) using the search terms fibromatosis aggressive, desmoid with drug therapy, radiation therapy, prevention and control, radiotherapy, surgery, and therapy. Articles were categorized as surgery, radiation, surgery + radiation, systemic therapy, and front-line observation. Articles were included if they reported a retrospective or prospective comparative or observational study with an analyzed sample size of 10 patients or more with confirmed diagnosis of desmoid tumor and described one of the following clinical outcomes: relapse- or progression-free survival, local control rate, response rate.

RESULTS

258 articles were reviewed; following screening for eligibility, 54 were identified; following full-text screen, 31 were included in final evaluation. The control rate for patients treated with a "wait and see" observational approach compared favorably with management with surgery and resulted in disease control rates of between 60 and 92%.

CONCLUSIONS

Decision-making in this rare tumor is complicated by the range of treatment options available. Our evidence supports use of an upfront observational approach.

Four different treatment strategies in aggressive fibromatosis: A systematic review

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Relative good overall local control rate of all four different treatment groups of  >75%.

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Multivariate analysis shows deep seated tumors, age (<30 years) and extracompartmentally situated tumors as negative predicting markers of local outcome.

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The radiotherapy alone group did not have better local control rates than the observation group (p = 0.355).

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In case of recurrent disease, adjuvant radiotherapy has a definite advantage over surgery alone (p = 0.001).

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Radiotherapy alone gives in 50% of cases partial or complete regression, and in 14% complete regression. Eventually 23% develop local progression.

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Observation could be considered as first line treatment in patients with tumors not in close adherence to important structures and no symptoms.

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Stabilization of the tumor arose after a median time of  >1 year after observation, and a local recurrence or progression occurred after a median time of <3 years.

Background

The treatment approach for aggressive fibromatosis is changing. Although surgery is the mainstay in common practice, recent literature is reporting a more conservative approach. We compared the local control rate for surgery, surgery with radiotherapy, radiotherapy alone and a wait and see policy in a systematic review.

Methods

A comprehensive search of the databases PubMed/Medline, Embase and Cochrane, of the medical literature published in 1999 till March 2017 was performed by two reviewers, including articles about extra abdominal aggressive fibromatosis without the genetical variants. A total of 671 studies were assessed for eligibility, and 37 studies were included for analysis, representing 2780 patients.

Results

The local control rates for surgery alone, surgery and radiotherapy, radiotherapy alone and observation were 75%, 78%, 85% and 78%, respectively. For patients with recurrent disease observation had a better local control rate than surgery alone (p = 0.001). In the observation group, stabilization of the tumor was seen in median 14 (range 12–35) months. The time to local recurrence in the treatment group was median 17 (range, 11–52) months.

Conclusion

A watchful conservative first line approach with just observation and closely monitoring, by means of physical examination and MRI, appears to be justified in a subgroup of patients without clinical symptoms and no possible health hazards if the tumor would progress.

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.

Intrathoracic Desmoid Tumor Presenting as Multiple Lung Nodules 13 Years after Previous Resection of Abdominal Wall Desmoid Tumor

Desmoid tumors are rare soft tissue tumors considered to have locally infiltrative features without distant metastasis until now. Although they are most commonly intraabdominal, very few cases have extra-abdominal locations. The origin of intrathoracic desmoid tumors is predominantly the chest wall with occasional involvement of pleura. True intrathoracic primary desmoid tumors with no involvement of the chest wall or pleura are extremely rare. We recently experienced a case of true intrathoracic desmoid tumor presenting as multiple lung nodules at 13 years after resection of a previous intraabdominal desmoid tumor.

Retroperitoneal fibromatosis presenting as a presacral mass

Aggressive fibromatosis arising from the retroperitoneum is extremely rare. It may occur in association with previous trauma, abdominal surgery, drugs, Gardner's syndrome, or familial adenomatous polyposis. We report a case of retroperitoneal fibromatosis presenting as a presacral mass with an infiltrating nature, relatively intense enhancement on enhanced computed tomography scanning, and low-signal intensity on T2-weighted magnetic resonance imaging in a patient with no significant medical or surgical history.

Extra-abdominal desmoid fibromatosis--a sarcoma unit review of practice, long term recurrence rates and survival

INTRODUCTION

Desmoid fibromatosis (DF) carries a significant morbidity and a recognised mortality. Despite this there are currently limited diagnostic or treatment algorithms specific to cases of extra-abdominal DF. Historically surgical excision has formed the cornerstone of treatment. Recently however a paradigm shift has meant many practitioners now adopt a more conservative approach, placing emphasis on active surveillance, function preserving resections, and non-surgical oncologic therapies.

METHODS

We performed an 8-year retrospective review of all cases of extra-abdominal DF managed within our region to assess the consistency of diagnostics, management and long-term outcome.

RESULTS

47 eligible cases were identified. Mean age at diagnosis was 41.3 years (1-81 years). Disease location and speciality of diagnosing practitioners were varied. Management was generally inconsistent. Variation was seen in imaging, biopsy techniques, MDT involvement and management. At a median follow up of 4.9 years our local recurrence rate was 19%.

DISCUSSION

The optimal management of DF is unknown. This has led to a lack of formalised guidance for practitioners managing this challenging condition, resulting in inconsistencies and areas for improvement in current management. We propose a diagnostic pathway which may improve consistency of care, reduce potentially unnecessary surgery and the associated morbidity, and significantly increase the rate of complete (R0) surgical resections when surgery is deemed appropriate whilst not significantly worsening oncological outcome. Specifically we propose all cases should be imaged appropriately (usually with MRI), undergo a planned biopsy (by radiologically guided core needle biopsy) and be managed centrally in conjunction with multidisciplinary sarcoma units.

Desmoid Tumor Formation following Posterior Spinal Instrumentation Placement

Study Design Case report.

Objective The objective of the article is to illustrate a case of desmoid tumor (DT) formation after posterior instrumentation of the thoracic spine.

Methods A 57-year-old woman presented with lower extremity clumsiness, balance, and ambulation difficulty resulting from spinal cord compression due to an upper thoracic atypical vertebral hemangioma. Ten months after undergoing embolization, resection, and placement of instrumentation for this lesion, the patient developed a growing mass at the rostral end of the incision. Biopsy revealed desmoid fibromatosis. The mass was removed via an en bloc resection. Histology revealed an infiltrative DT above the laminectomy site abutting the instrumentation.

Results At 2-year follow-up, there was no evidence of recurrence of the tumor.

Conclusion Paraspinal DTs have been reported in the literature to develop after surgical procedures of the spine. Often times, patients attribute swelling or fullness at the site of their surgery to scar tissue formation or instrumentation. One must consider the possibility of a DT in the setting of reported surgical site fullness or mass after spine surgery. It is thought that postoperative inflammation present in the surgical bed may promote formation of DTs. Instrumentation may also contribute to inflammation and increase the likelihood of developing a DT. Generous margins must be taken to prevent recurrence.

Diagnosis and treatment of extraabdominal desmoid fibromatosis

INTRODUCTION

The desmoid fibromatosis is a very rare connective tissue disease which is recognized as semimalignant. The aim of this work is to review the relevant literature and to analyze the management of our patient collective.

MATERIAL AND METHOD

Surgery was performed on 7 patients with extraabdominal desmoid fibromatosis between August 1998 and May 2007. MRI examination as well as biopsy was carried out in all cases. All patients were operated on; the mean follow up was 4 years (1-7). Upon follow up, every patient has undergone clinical and MRI examination.

RESULTS

The results show that we have achieved R0 resection in 4 cases and R1 in two cases and Rx in one case. In 4 patients, no recurrence was observed after the single surgery performed in our hospital. In 2 patients a single revision surgery was performed in each case and yielded no further recurrence. In only one case, multiple surgeries (one primary and two revision surgeries) were necessary, after which no recurrence was reported.

CONCLUSION

The early diagnosis of the disease is of utmost importance to the success of the outcome. MRI examination and biopsy are mandatory. Surgery is the therapy of choice. The recurrence rate is high and is linked to the difficulty of recognition of the exact infiltrative extent of the tumour. This necessitates a close follow-up.

Spinal fibromatosis: a report of two cases and review of the literature

BACKGROUND CONTEXT

Spinal fibromatosis is a unique subset of fibromatosis that is only anecdotally described in the literature in sporadic case reports. According to our review of the literature, only 11 cases of spinal fibromatosis have been previously documented. This paucity of clinical data limits our understanding of its presentation and treatment.

PURPOSE

The authors present the first two cases of spinal fibromatosis encountered at their institution, and review the literature of reported cases to elucidate the presentation and outcomes of patients with this rare tumor.

STUDY DESIGN

A report of two cases and review of the literature.

METHODS

The two patients in our case report were women aged 45 and 38 years. Both of the patients presented to our clinic after previous excisional biopsy of a spinal mass, 17 years and 1 year later, respectively, with pain and paresthesias that recapitulated their former symptoms. Thirteen cases, including the two described in the current article, were culled from the literature.

RESULTS

Magnetic resonance imaging revealed an enhancing lesion in the posterior elements of the spinal column in the first case and a paraspinal soft tissue mass in the second case. The tumors were histologically defined by haphazardly arranged, elongated, and slender spindle cells separated by abundant collagen without mitoses or necrosis. Surgical management resulted in intralesional resection in the first case and en bloc resection in the second case. By 40 and 10 months after surgery, both patients remain without neurologic deficits.

CONCLUSIONS

Among 13 cases of spinal fibromatosis, pain with or without a mass is the most common symptom at presentation. Tumor etiology is evenly distributed between de novo origin and surgical trauma. Treatment outcomes, although, cannot be determined from the limited data currently available.

Local control of extra-abdominal desmoid tumors: systematic review and meta-analysis

The local control of desmoid tumors constitutes a continuing treatment dilemma due to its high recurrence rates. The purpose of this systematic review was to critically examine the current treatment of these rare tumors and to specifically evaluate the local failure and response rates of surgery, radiation and systemic therapy. We comprehensively searched the literature for relevant studies across Cinahl, Embase, Medline and the Cochrane databases. Articles were categorized as surgery, radiation, surgery + radiation and systemic therapy (including cytotoxic and non cytotoxic). Methodological quality of included studies was assessed using the Newcastle-Ottawa Scale. Pooled odd ratios (OR) for comparative studies and weighted proportions with 95% confidence intervals (CI) are reported. Thirty-five articles were included in the final analysis. Weighted mean local failure rates were 22% [95% CI (16–28%)], 35% [95% CI (26–44%)] and 28% [95% CI (18–39%)] for radiation alone, surgery alone and surgery + radiation respectively. In the analysis of comparative studies, surgery and radiation in combination had lower local failure rates than radiation alone [OR 0.7 (0.4, 1.2)] and surgery alone [OR 0.7 (0.4, 1.0)]. Weighted mean stable disease rates were 91% [95% CI (85–96%)] and 52% [95% CI (38–65%)] for non cytotoxic and cytotoxic chemotherapy respectively.

The current evidence suggests that surgery alone has a consistently high rate of local recurrence in managing extra-abdominal desmoid tumors. Radiation therapy in combination with surgery improves local control rates. However, the limited data on systemic therapy for this rare tumor suggests the benefit of using both cytotoxic and non cytotoxic chemotherapy to achieve stable disease.

Extra-abdominal desmoid tumours: a review of the literature

Extra-abdominal desmoid lesions, otherwise known as aggressive fibromatosis, are slow-growing benign lesions which may be encountered in clinical practice. Recent controversies exist regarding their optimal treatment. Given their benign nature, is major debulking surgery justified, or is it worth administering chemotherapy for a disease process which unusually defies common teaching and responds to such medications? We present a literature review of this particular pathology discussing the aetiology, clinical presentation, and various current controversies in the treatment options.

Current perspectives on desmoid tumors: the mayo clinic approach

Desmoid tumors are a rare group of locally aggressive, non malignant tumors of fibroblastic origin that can lead to significant morbidity due to local invasion. Despite advances in the understanding of these tumors, their natural history is incompletely understood and the optimal treatment is still a matter of debate. Local control is the main goal of treatment and there has been a change in philosophy regarding the management of these tumors from aggressive surgical resection to function preservation. A multidisciplinary approach is essential to plan local control with acceptable morbidity. The current Mayo Clinic algorithm for the treatment of these tumors is based on institutional experience and the available evidence in the literature: asymptomatic/non progressive lesions away from vital structures are managed with observation and regular imaging; primary or recurrent desmoid tumors which are symptomatic or progressive or near vital structures are managed with wide surgical resection when wide surgical margins are possible with minimal functional and cosmetic loss. When positive or close surgical margins are likely, surgical resection with adjuvant radiotherapy or definitive radiotherapy is preferred. If likely functional or cosmetic deficit is unacceptable, radiotherapy is the treatment of choice. Unresectable lesions are considered for radiotherapy, chemotherapy or newer modalities however an unresectable lesion associated with a painful, functionless, infected extremity is managed with an amputation.

Cholangiocarcinoma accompanied by desmoid-type fibromatosis

BACKGROUND

Cholangiocarcinoma complicated by intra-abdominal desmoid-type fibromatosis (DTF) is uncommon. There are no reports on patients with this type of fibromatosis, in which the pre-operative treatment (including diagnosis), surgical approach, post-operative pathologic reports, and prognosis are discussed.

METHOD

The clinicopathological features of a 49-year-old man were retrospectively analyzed.

RESULTS

Cholangiocarcinoma located in the inferior segment of the bile duct was considered pre-operatively on the basis of clinical findings. At the time of pancreaticoduodenectomy, the mesojejunum was stiff without nodules or a mass at a distance of approximately 80 cm from the ligament of Treitz. Complete excision of the entire lesion of the intestinal mesenteric contracture and its subsidiary was performed. Post-operative pathologic findings confirmed an adenocarcinoma located at the extremity of the common bile duct and infiltrating the full thickness of the common bile duct as well as the deep muscular layer of the duodenum. The contracted jejunal mesentery was shown to have DTF. The patient was alive with no evidence of recurrence after a follow-up of 6 months.

CONCLUSIONS

The patient had a rare hereditary disease with intra-abdominal DTF, which manifests the characteristics of an aggressive growth pattern and a high rate of local recurrence; conservative therapy is recommended. Complete excision of the fibromatous lesion during pancreaticoduodenectomy may maximally decrease the risk of local recurrence.

Primary or recurring extra-abdominal desmoid fibromatosis: assessment of treatment by observation only

INTRODUCTION

Extra-abdominal desmoid fibromatosis (EADF) is a benign tumoral condition, classically managed by more or less radical and sometimes mutilating excision. This treatment strategy is associated with a recurrence rate of nearly 50% according to various reports.

HYPOTHESIS

EADF may show spontaneous stabilization over time.

METHODS

A retrospective series of 26 cases of EADF managed by simple observation was studied to assess spontaneous favorable evolution and identify possible factors impacting evolution. Eleven cases were of primary EADF with no treatment or surgery, and 15 of recurrence after surgery with no adjuvant treatment. MRI was the reference examination during follow-up.

RESULTS

Twenty-four cases showed stabilization at a median 14 months; there were no cases of renewed evolution after stabilization. One primary tumor showed spontaneous regression, and one recurrence still showed evolution at end of follow-up (23 months). The sole factor impacting potential for evolution was prior surgery. No radiologic or pathologic criteria of evolution emerged from analysis.

DISCUSSION

The present series, one of the largest dedicated to EADF managed by observation, confirmed recent literature findings: a conservative "wait-and-see" attitude is reasonable and should be considered when large-scale resection would entail significant functional or esthetic impairment.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Surgical treatment for local control of extremity and trunk desmoid tumors

INTRODUCTION

Surgical treatment has been the mainstay for extremity and trunk desmoid tumors with a negative surgical margin. However, even when resection with a wide surgical margin is achieved, the local recurrence rate remains high. The purpose of this study was to analyze the clinical outcome of patients with extremity and trunk desmoid tumors after surgical treatment and to determine the factors influencing local recurrence.

MATERIALS AND METHODS

Between January 1991 and December 2003, 30 of 58 patients with desmoid tumors referred to our institutions and surgically treated and followed up for more than 2 years were selected for this study. Patient age, gender, tumor size, location, status of disease (primary or recurrent), and surgical margins were analyzed as possible risk factors for recurrence.

RESULTS

Sixteen (53%) of the 30 patients had a local recurrence. Eight of the 19 patients (42.1%) with a negative surgical margin experienced a recurrence. Younger age (<30 years) was a significant risk factor for local recurrence (P < 0.05). Tumor size, surgical margin and previous surgical history were not associated with local recurrence. Younger age and female gender had a propensity for local recurrence, suggesting that the biological behavior of desmoid tumor may depend on the status of the disease at presentation.

CONCLUSIONS

These results suggest that radical surgical treatment causing severe functional impairment should be avoided in selected cases on the basis of patient characteristics, and that other novel therapeutic tools may be necessary for patients in whom a higher risk of local recurrence is assumed or severe complications after surgical treatment are predicted.

Multimodality management of desmoid tumors: how important is a negative surgical margin?

Desmoid tumors are rare, locally invasive mesenchymal tumors without metastatic potential. Their clinical behavior is heterogeneous and characteristically unpredictable; outcomes are influenced by anatomic location, proximity to vital organs, association with familial adenomatous polyposis. Surgery is the main treatment modality, but the significance of positive resection margins remains controversial since they may not increase the risk of recurrence: in this setting re-resection, adjuvant radiation or close clinical follow-up could all be appropriate options. We reviewed the current evidence for multimodality therapy of desmoids, with a focus on the importance of resection margins, and present our own algorithm for treatment.

Aspiration biopsy cytology of extraabdominal desmoid tumor concurrently occurring in a patient with tumoral calcinosis

Extraabdominal fibromatosis or desmoid tumor (DT) is a slow growing locally aggressive soft tissue tumor that can occur anywhere in the body. We report the aspiration biopsy cytology features of a case of DT of the right neck area in a 35-year-old man who had a long standing history of tumoral calcinosis. The aspirate was interpreted as "benign spindle cell lesion" and confirmed as DT on histologic examination of the resected mass. We discuss the possible differential diagnoses of other benign or malignant lesions on fine-needle aspiration (FNA) biopsy and especially discuss the aspiration cytology features of DT compared with those of tumoral calcinosis. We also discuss the value of immunohistochemical markers that help in differentiating DT from other entities.

Surgical management of large desmoid tumour of the anterior abdominal wall

Desmoid tumours are uncommon. They are locally invasive and incomplete excision leads to recurrence, which can pose a significant management challenge. Patients therefore require effective treatment, which essentially entails tumour excision with a clear surgical margin. The resulting wide defect may lead to difficulty in closure of the anterior abdominal wall. We report our experience in treating large desmoid tumours of the anterior abdominal wall. Between January 2000 and December 2001, three patients with large desmoid tumour of the anterior abdominal wall were treated with wide excision, which included a 3-cm margin of uninvolved tissues. This led to a considerable abdominal wall defect. The peritoneal defect was closed as a separate layer, though under considerable tension, while the abdominal wall musculature defect was closed with a polypropylene mesh. All three patients recovered well with no immediate or late postoperative morbidity. Follow-up until December 2006 has not revealed any tumour recurrence or hernia development. Wide excision of an anterior abdominal wall desmoid tumour with a clear margin of 3 cm including the peritoneum should be considered when managing such tumours. Closure under tension of the peritoneum did not seem to produce any morbidity.

Musculoskeletal desmoid tumors

Desmoid tumors are benign tumors that exhibit varying degrees of local aggressiveness and diverse growth patterns. Magnetic resonance imaging remains the modality of choice for assessment of the nature and size of the soft-tissue lesion and involvement of surrounding structures. Treatment strategies include surgery, chemotherapy, hormonal therapy, and radiation therapy, either individually or in combination. Despite the benign nature of these tumors, multidisciplinary care is needed to provide combined treatment options. Chemotherapy in low doses is an excellent first-round treatment in any patient in whom contemplated local treatment may produce local morbidity and adjacent tissue injury.

[Rating of tumoral growth in non-operated primary or recurrent extra-abdominal aggressive fibromatosis]

PURPOSE OF THE STUDY

Extra-abdominal aggressive fibromatosis (EAAF) is a benign desmoid tumor with a potentially aggressive behavior. Surgical treatment is compromised by a very high rate of recurrence, sometimes with significant morbidity. We conducted a prospective surveillance of our patients (clinical and MRI) with EAAF to search for prognostic factors.

MATERIAL AND METHODS

This cohort included 17 patients with EAAF. For nine patients, biopsy alone was performed. For eight, the tumor was a recurrence after surgical removal. Patients were seen for a clinical assessment and MRI every six months.

RESULTS

Median follow-up was 42 months (range 6-114). Three patients worsened clinically with pain or functional impairment. One patient required neurosurgery to control pain (good stable outcome). MRI showed progression for two tumors (12%) but with a short follow-up since diagnosis (9 and 14 months), in one case despite medical treatment. Three tumors regressed and twelve remained stable on successive MRI. On average the tumor growth lasted ten months.

DISCUSSION

Tumor growth was never noted beyond 36 months. This notion of an interruption in tumor growth is mentioned sporadically in reports on EAAF, which have generally included recurrent tumors. To our knowledge this is the first series reporting tumors left in place a followed with modern imaging techniques. The high rate of spontaneous interruption of tumor growth must be counterbalanced with the difficult task of local treatment: the risk of recurrence is particularly high after surgery and functional sequelae can be significant when wide resection is proposed in an anatomically difficult localization. The precise role for surgery, and combined radiotherapy, remain to be determined. There are only scarce reports on general treatments. Considering these facts, we propose that surgical resection should not be considered the only solution for the treatment of EAAF. Further work is needed to define the useful contribution of simple surveillance of these benign tumors.

Natural course of desmoid-type fibromatosis

BACKGROUND

Desmoid-type fibromatosis is a locally aggressive tumor known to have high potential for local recurrence after resection, while it exhibits self-limiting behavior and shows growth arrest or spontaneous regression in many patients. Thus, its natural course is not well known, and the proper treatment has not yet been established.

METHODS

We retrospectively reviewed clinical outcome and changes in tumor size in 11 consecutive patients with extremity and trunk desmoid-type fibromatoses, who were basically observed without any treatment after diagnosis.

RESULTS

For two patients in whom the tumors were initially incorrectly diagnosed as other tumors, surgical resection was performed. For another two patients, surgical resections were performed in the follow-up periods due to tumor enlargement or joint contracture. In all four patients who underwent surgery, tumors recurred shortly after resection and re-resection was not performed. During the follow-up periods with a median length of 56 months, ten tumors eventually stopped growing, and three of them regressed spontaneously. At the time of final follow-up, ten patients were alive with residual disease without severe morbidity. In one patient, the tumor enlarged to over 30 cm in diameter with a substantial functional deficit.

CONCLUSIONS

Simple observation is a noninvasive and function-preserving treatment for desmoid-type fibromatosis.

Control of aggressive fibromatosis by treatment with imatinib mesylate. A case report and review of the literature

OBJECTIVE

There has been only one report available that focuses on the treatment with imatinib mesylate of two individual persons with aggressive fibromatosis. The authors concluded that after long-term treatment, for 9 and 11 months, with imatinib mesylate, both patients demonstrated radiographic and clinical responses. The novel therapy should be considered as salvage in patients with aggressive fibromatosis expressed platelet-derived growth factor receptor-alfa, beta (PDGFR-alfa, PDGFR-beta), and/or c-kit, whose tumors are uncontrollable by the standard management. On the other hand, the number of kinases blocked by imatinib mesylate is notching up, for instance the tyrosine kinase, which is associated with macrophage-colony stimulating factor receptor (M-CSFR).

METHODS

The patient was suffering from aggressive fibromatosis after prior therapy including surgery (R2), radiotherapy, and systemic treatment with combination of tamoxifen and sulindac. The tumor specimen was immunostained for PDGFR-beta and c-kit (CD117), and PDGFR-alfa and cytokines platelet-derived growth factor-alfa and beta were not assessed. The tests for both assessed molecules revealed negative results. In spite of this, the patient underwent a unique treatment with imatinib mesylate at the dose of 400 mg orally once daily for 3 years and 2 months.

RESULTS

After three months of the therapy, radiographic (met criteria of SD but small decrease of the tumor was noted) and clinical responses were recorded for the first time. The same was seen after 6 and 13 months of therapy continuation with imatinib mesylate. Currently, the patient is treated with imatinib mesylate (400 mg orally once daily) without any toxicity effects. The last MRI revealed readily a smaller tumor (35 x 20 mm) after such a therapy lasted more than 3 years.

CONCLUSIONS

Treatment with imatinib mesylate has been a well-accepted therapy for chronic myelogenous leukemia (CML) and gastrointestinal stromal tumors (GIST). There have been established four kinases (p210(bcr/abl), c-kit, PDGFR-alfa, PDGFR-beta) suggested as the target for imatinib mesylate. Other potential targets will be discovered as it has lately been determined that M-CSFR kinase activity was blocked by imatinib mesylate. The salvage therapy for aggressive fibromatosis with imatinib mesylate seems to be an attractive opportunity for patients with the advanced disease, whose prior therapy failed.

Fine-needle aspiration cytology and core needle biopsy in the preoperative diagnosis of desmoid tumors

BACKGROUND

Desmoid tumors have a tendency to recur locally, and traditionally they have been treated surgically. No treatment is sometimes indicated, however; this requires a morphological diagnosis that is not based on a surgical specimen. In this study we aimed to identify the diagnostic accuracy of needle and core biopsy for the morphological diagnosis of desmoid.

METHODS

We compared the diagnostic accuracy of fine-needle aspiration (FNA) and core needle biopsy (CNB) in 69 and 26 patients, respectively, who had had surgical resections for desmoid. We also reviewed 15 additional cases that had been incorrectly diagnosed as desmoid on FNA but which had different diagnoses after surgery.

RESULTS

FNA-based diagnoses of desmoid/fibromatosis were rendered in 35 of 69 cases, and other benign spindle cell proliferations in 26 cases and spindle cell sarcoma in the remaining 4 cases. All 26 CNBs were either suggested to correspond to desmoid (24) or other benign spindle cell lesions (2). Of the 15 FNAs incorrectly diagnosed as desmoid, 2 were found to be sarcomas.

INTERPRETATION

FNA is fairly reliable for recognition of the benign nature of desmoids. Occasional over- and under-diagnosis of malignancy can occur, however. CNB appears to be more reliable.

Clinical and imaging observations of desmoid tumors left without treatment

BACKGROUND

Until now, surgical treatment has been the mainstay in the treatment of desmoid tumors, even though it is associated with a high recurrence rate. There have, however, been occasional case reports showing that desmoid tumors may spontaneously decrease in size or even disappear.

PATIENTS AND METHODS

This is a retrospective review of 8 patients with abdominal (5) or extra-abdominal (3) desmoid tumors who were followed both clinically and with imaging techniques (sonography, CT or MRI). Mean follow-up time was 4.4 (0.8-7.5) years. Tumor volume was assessed in each investigation and followed over time.

RESULTS

3 tumors disappeared, 2 diminished in size, 1 did not change and 2 tumors became larger, 1 of which had tripled in volume at the latest follow-up.

INTERPRETATION

Desmoid tumors have probably been overtreated in the past. Many of them tend to regress spontaneously.

Aggressive postoperative lumbar fibromatosis after the placement of instrumentation for treatment of spondylolisthesis

✓ This 50-year-old woman presented with a paravertebral lumbar fibromatosis (desmoid tumor) after undergoing the placement of instrumentation for lumbar spondylolisthesis. The tumor developed just cranial to the previous skin incision. Fibromatoses, or desmoid tumors, are uncommon infiltrative lesions that affect musculoaponeurotic structures, most often of the trunk and limbs. They are known to occur in association with surgery-related scars or implants and only rare examples appear in the neurosurgical and spine-related literature. In cases involving well-defined tumors in which radical resection is possible, surgery is the treatment of choice; however, the recurrence rate is high. The patient in the present case was followed for 14 months postoperatively and did not undergo radiotherapy; there was no recurrence.

Although rare, this distinctive tumor should be considered in the differential diagnosis of postoperative paravertebral bulgings after neurosurgical and spinal operations.

Inoperable aggressive mesenteric fibromatosis with ureteric fistula. Case report and literature review

The purpose of our report is to illustrate an aggressive case of mesenteric fibromatosis in a 17-year-old girl with a ureteric fistula and to review imaging and pathological features, natural history and treatment options of this disease. Our patient underwent computed tomography that revealed a widespread intra-abdominal mass. The necrotic centre of this mass had a fistulous communication with the right ureter. Fibromatoses represent a spectrum of uncommon benign conditions characterised by proliferating fibrous tissue. The deep intra-abdominal form of mesenteric fibromatosis (MF), one of the rare subtypes of the 'fibromatoses' or 'desmoid tumours', grows rapidly and may become extensive. Surgery provides good results in limited disease and non-surgical modalities in cases of unresectable and residual disease.

Intra-abdominal desmoid tumor after successful treatment for Hodgkin disease

The risk of second malignancies after successful treatment for Hodgkin disease can be considerable. The most common malignancies are solid tumors arising in irradiated sites, such as the breast and thyroid gland after mantle field radiation. Sarcomas and other musculoskeletal tumors are also seen. We describe a young woman who developed an intra-abdominal desmoid tumor more than 4 years after completing therapy for Stage IIB Hodgkin disease, treated with combination chemotherapy (ABVD) and mantle irradiation. The tumor did not occur at either a surgical site or within a radiation field. She did not carry a mutation for familial adenomatosis polypoli.

Long-term follow-up of a recurrent multifocal desmoid tumour treated with tamoxifen: a case report

We report a long-term follow-up of a female patient with a multifocal extremity desmoid tumour. She had 3 local recurrences after excision and developed a second unresectable pelvic tumour that has remained unchanged in size for 14 years since starting tamoxifen treatment.

The management of extra-abdominal desmoid tumours

We performed a retrospective analysis of 35 cases of desmoid tumours (aggressive fibromatoses) that underwent treatment at our institutions between 1987 and 2002. The purpose was to evaluate the rate of local recurrence of desmoid tumours treated with surgical excision, to assess the impact of surgical margins on local recurrence and to define the role of radiotherapy in the treatment. Nine patients experienced a recurrence at an average of 16 months after initial treatment. Seven of the 15 patients with a less-than-wide margin had a local recurrence. Comparatively, only two of the 20 patients with a wide margin had a local recurrence. Thirty-three of the 35 patients were disease free at the last follow-up. We recommend wide excision with clear margins whenever possible. Marginal resections are appropriate when wide excision would severely compromise the function of the limb. Surgical resections and selective supplementation of adjuvant radiotherapy give excellent control rates.

Margins in extra-abdominal desmoid tumors: A comparative analysis

BACKGROUND AND OBJECTIVES

The main treatment of extra-abdominal desmoid tumors remains surgery, but recurrence rates up to 80% are reported. The impact of microscopic surgical margin status according to the Enneking classification system is discussed controversially.

METHODS

Therefore, the authors screened the published literature for reliable data on the importance of a wide or radical excision of extra-abdominal desmoid tumors. All studies with more than ten patients, a surgical treatment only, and margin status stated were included.

RESULTS

Only 12 out of 49 identified studies fulfilled the inclusion criteria. One hundred fifty-two primary tumors were excised with wide or radical microscopic surgical margins, while in 260 cases a marginal or intralesional excision was performed. In the first group 41 patients (27%) and in the second one 187 patients (72%) developed a recurrence. Therefore, microscopic surgical margin status according to the Enneking classification system is a significant prognostic factor (P < 0.001).

CONCLUSIONS

The data of this review underline the strategy of a wide or radical local excision as the treatment of choice. Furthermore, as a large number of studies had to be excluded from this analysis, exact microscopic surgical margin status should be provided in future studies in order to allow comparability. .