Management of desmoid tumours including a case report of toremifene

Nodular fasciitis of the breast mimicking breast cancer

Nodular fasciitis is a benign proliferative lesion that is usually found in the soft tissue of the upper extremity and trunk in young to middle-aged persons. It has rarely been described in the breast. A 35-year-old woman had noticed a mass in her left breast. It was elastic-hard, 13 mm in size, and located mainly in the upper inner quadrant of the left breast. Mammography did not detect the mass. Ultrasonography revealed a hypoechoic lesion with an irregular margin. Neither fine-needle aspiration cytology nor core needle biopsy established a definitive diagnosis. Excisional biopsy was therefore performed. Histologically, the excised tumor tissue results were consistent with a diagnosis of nodular fasciitis of the breast. We report a case of nodular fasciitis of the breast, a rare histological type of breast tumor.

Anti-oestrogen therapy in the treatment of desmoid tumours: a systematic review

AIM

The treatment of desmoid tumours (DTs) is controversial. Anti-oestrogen therapy has frequently been used, but clear information of its efficacy is lacking. In this systematic review we have undertaken a comprehensive analysis to assess the effectiveness of anti-oestrogen therapy in terms of ability to induce partial or complete regression of DTs.

METHOD

A systematic review of articles published in English between January 1983 and December 2009 was carried out according to the RECIST criteria. A literature search was performed on electronic databases including: United States National Library of Medicine (MEDLINE-PubMed), Excerpta Medica (EMBASE), Cochrane Library and Google search engine. Two-hundred articles dealing with DTs were identified but only fourty-one were were selected as appropriate for the study. The chi-square test was used for statistical analysis.

RESULTS

Data on 168 DTs treated with anti-oestrogen agents, alone or in combination with nonsteroidal anti-inflammatory drugs, were identified with an overall response rate of 51%. There was no difference in response according to the type of DTs or between different anti-oestrogen therapies. Combination with anti-inflammatory drugs did not improve the outcome. Toremifene was sometimes effective in cases resistant to tamoxifen. Response did not seem to be related to oestrogen receptor status.

CONCLUSIONS

Despite potential inaccuracies in the methodology, the results of the review indicate that anti-oestrogen therapy produces some effect in about one half of patients with DTs. Its indication compared with other treatments is discussed.

A Case of Ovarian Fibromatosis and Massive Ovarian Oedema Associated With Intra-Abdominal Fibromatosis, Sclerosing Peritonitis and Meig's Syndrome

Purpose:To discuss a case of ovarian fibromatosis/massive ovarian oedema, intra-abdominal fibromatosis, sclerosing peritonitis and Meig's syndrome. To review the reported therapeutic options.

Patients: Case report of a 27-year-old female with the combined pathology of ovarian fibromatosis/massive ovarian oedema, intra-abdominal fibromatosis, sclerosing peritonitis and Meig's syndrome.

Methods: This patient was treated with supportive care and cytotoxic chemotherapy.

Results: Despite the benign nature of the ovarian pathology, this patient presented with life-threatening complications. Response to treatment was probably multi-factorial combining the effects of cytotoxics, use of steroids and good supportive care. She remains in complete remission 4 years post completion of chemotherapy.

Conclusion: There are reports in the literature of ovarian fibromatosis/massive ovarian oedema, luteinised thecomas, intraabdominal fibromatosis and Meig's syndrome occurring together in a variety of combinations. Treatment has been described with radiotherapy, cytotoxic and non-cytotoxic chemotherapy regimens. This case provides a link between ovarian fibromatosis/massive ovarian oedema, intra-abdominal fibromatosis, sclerosing peritonitis and Meig's syndrome not previously described.

Stabilization and regression of a recurrent desmoid tumor with the antiestrogen toremifene

OBJECTIVE

To report a case of a pelvic desmoid tumor that was treated with the antiestrogen toremifene after a failed attempt at surgical excision.

DESIGN

Case report.

SETTING

University reproductive endocrine practice.

PATIENT(S)

A reproductive-aged woman with a recurrent desmoid tumor.

INTERVENTION(S)

After surgical excision of a desmoid tumor that presented during childbirth, subsequent recurrence resulted in the use of toremifene for tumor stabilization.

MAIN OUTCOME MEASURE(S)

Magnetic resonance imaging was used to monitor desmoid tumor size.

RESULT(S)

One year after postsurgical recurrence of the desmoid tumor, the patient began treatment with the antiestrogen toremifene. Tumor stabilization and regression with symptomatic relief was observed. Nine years of antiestrogen use revealed no progression in tumor size or patient symptoms. After the patient demonstrated perimenopausal symptoms, toremifene administration was discontinued without a return of symptoms or tumor growth after 3 years.

CONCLUSION(S)

Our case demonstrates that toremifene is a safe and effective therapy that can be used for the stabilization and regression of desmoid tumors. An antiestrogen should be considered as adjuvant therapy after surgery and as a first-line treatment with disease recurrence. Discontinuation of antiestrogen therapy was shown to be done safely after the patient started to show signs of decreased endogenous estrogen production.

The pharmacological treatment of aggressive fibromatosis: a systematic review

BACKGROUND

Despite the use of surgery and radiotherapy, 20-35% of patients with aggressive fibromatosis (AF) will have local recurrence. The purpose of this review was to collect and analyze all available information regarding the role of non-cytotoxic and cytotoxic chemotherapy in AF that has been accumulated over the past few decades.

PATIENTS AND METHODS

A systematic review of published clinical trials, studies and case series was carried out using the Medline Express Databases and the Cochrane Collaboration Database from 1970 to October 2000.

RESULTS

Most studies published in the literature are in the form of successful case reports and single-arm series with small patient numbers. Most commonly used agents include hormonal agents, non-steroidal anti-inflammatory drugs (NSAIDs), interferons and cytotoxics. The literature data support the use of hormonal agents. Several questions, however, remain unresolved, such as which is the most suitable endocrine manipulation and what is the optimal dose and duration of treatment. NSAIDs and interferons have demonstrated activity against AF either alone or in combination with hormone therapy or chemotherapy but the precise mechanism of action is still unknown. Finally, there is growing evidence in the literature that chemotherapy is effective against AF with almost one in two patients being likely to respond.

CONCLUSIONS

The evidence in the literature supports the opinion that both non-cytotoxic and cytotoxic chemotherapies are effective against AF. However, the lack of sufficient patient numbers and randomized trials compromises the validity of the reported results and mandates further investigation with properly designed prospective studies including larger patient numbers, with main end points to include not only tumor response rate and survival but also quality-of-life issues.

Low-dose chemotherapy with methotrexate and vinblastine for patients with advanced aggressive fibromatosis

BACKGROUND

This Phase II study was undertaken to assess the activity of methotrexate plus vinblastine in the treatment of patients with inoperable aggressive fibromatosis (AF) and to observe the evolution of the disease after such low-dose chemotherapy.

METHODS

Thirty patients with a median age of 27 years who were affected by primary (20%) or recurrent (80%), advanced, inoperable AF were treated with weekly methotrexate at a dose of 30 mg/m(2) plus vinblastine at a dose of 6 mg/m(2) for a median interval of 1 year. Patients with recurrent disease had received surgery, radiotherapy, tamoxifen, and antracycline-based chemotherapy. Tumor response was assessed in all patients as well as time to disease progression.

RESULTS

Eighteen patients (60%) showed stable disease or minor tumor shrinkage along with symptom relief. A partial response was detected in 12 patients (40%). No complete responses were observed, and no patients had tumor progression during treatment. Four patients received fewer than 15 cycles of chemotherapy, mainly because of severe myelotoxicity. One of these patients died of local disease progression 33 months later, and the other three patients were stable. After a median follow-up of 75 months, the 10-year actuarial progression free interval is 67%.

CONCLUSIONS

Methotrexate plus vinblastine given every 7-10 days for several months is associated with prolonged stable disease in a substantial subset of patients with advanced (inoperable) aggressive fibromatosis.

Desmoid tumors

Because of the wide variety of anatomic locations and patient factors, there is no one treatment that is appropriate for all desmoid tumors. The type of treatment depends on tumor characteristics and location, as well as patient characteristics and preferences. Desmoid tumors can be persistent and frustrating to manage because no one treatment modality offers a high likelihood of remission. Multiple modalities may be necessary in some patients. Although mortality is rare and is usually due to local complications, significant disability or morbidity can result from desmoid tumors, their treatment, and complications arising from treatment. The entire clinical picture and the patient's preferences must be taken into account when deciding on an appropriate treatment plan. Patients with desmoid tumors are optimally managed in a multidisciplinary setting with close collaboration between surgeon, pathologist, diagnostic radiologist, radiation oncologist, and medical oncologist. When possible, surgical resection with negative margins is the preferred modality. When surgical resection with negative margins may prove disabling, surgery can be followed by postoperative radiation, although the role and efficacy of this are controversial. In locations where surgical extirpation is difficult or unfeasible, primary radiation, hormonal therapy, or chemotherapy should be considered. Familiar adenosis polyposis (FAP)-associated mesenteric lesions, sporadic tumors present without change for months or years, or tumors present in areas where progression will not present significant additional morbidity are candidates for observation only.

Management of recurrent desmoid tumor after surgery and radiation: role of cytotoxic and non-cytotoxic therapies

Desmoid tumors frequently reoccur after surgery and radiation. The therapy of recurrent desmoid tumors is often unsatisfactory. Additional surgery may not be feasible. Drug therapy can sometimes be helpful, and even remarkably successful. Unfortunately, the rarity of desmoids precludes conduct of large clinical trials. Most series are small, anecdotal, and lack internal consistency. The lack of real understanding of desmoid biology has meant that therapies have, until now, been empirical rather than rationally designed. Nevertheless, a range of drugs is available to be utilized, including hormonal or hormonal antagonist therapy, cyclooxygenase inhibitors, biologic agents and cytotoxic chemotherapy. This review will utilize a patient case report to illustrate the problems frequently encountered in choosing therapy for patients with recurrent desmoid tumors. Based on this case, the review will explore the options available, as well as the process through which treatment options may be evaluated.

Toremifene. A review of its pharmacological properties and clinical efficacy in the management of advanced breast cancer

The triphenylethylene antiestrogen toremifene is a chlorinated derivative of the antiestrogen tamoxifen, an agent which has been widely and successfully used in the treatment of breast cancer. Clinical trials investigating the efficacy of toremifene as first-line endocrine therapy in postmenopausal women with advanced breast cancer (estrogen receptor status positive or unknown) have shown this drug to have similar antitumour activity to that of tamoxifen. In multicentre comparative trials, objective responses (complete and partial) occurred in 20 to 29% of patients treated with toremifene (60 to 240 mg/day) and in 19 to 37.5% of tamoxifen (20 or 40 mg/day) recipients. The duration of response, time to disease progression and median overall survival time were generally similar in both treatment groups. Toremifene is well tolerated. Most drug-related adverse effects are mild or moderate in severity and rarely necessitate discontinuation of therapy. The tolerability profile of toremifene is similar to that reported for tamoxifen, the most common adverse effects being hot flushes, sweating, nausea and/or vomiting, dizziness, oedema, and vaginal discharge and/or bleeding. Thus, toremifene provides an equally effective and well tolerated alternative to tamoxifen for the first-line endocrine therapy of postmenopausal advanced breast cancer. Preclinical studies showing toremifene to have a lower carcinogenic potential than tamoxifen indicate that toremifene may be a preferable agent for long term treatment regimens; however, these findings require confirmation in the clinical setting.

Oral antitumour activity in murine L1210 leukaemia and pharmacological properties of liposome formulations of N4-alkyl derivatives of 1-beta-D-arabinofuranosylcytosine

The oral cytostatic activity in L1210 mouse leukaemia of the two new N4-alkyl derivatives of 1-beta-D-arabinofuranosylcytosine (AraC), N4-hexadecyl- and N4-octadecyl-1-beta-D-arabinofuranosylcytosine (NH-AraC, NO-AraC) was investigated. In contrast to AraC, both derivatives were highly cytostatic after oral application as liposome formulations. With treatment schedules of five consecutive dosages or with two applications on days 1 and 4 after intravenous tumour cell inoculation with a total dose of 470-1000 mg/kg NH-AraC or NO-AraC, 70%-100% of the treated animals were cured. The lethal dose in healthy ICR mice after a single intraperitoneal application, corresponding to the LD50, was 524 mg/kg for NO-AraC, whereas NH-AraC proved to be less toxic. The haematological toxicity remained moderate for both drugs with a mild leucopenia and a drop in platelet counts, which recovered 4-6 days after treatment. The erythrocytes were not affected and haemolytic toxicities were absent. As non-haematological toxicities, at high drug concentrations, a pronounced atrophy of the rapidly dividing epithelia of the small intestines and of the white pulp of the spleen were observed. The blood levels of NH-AraC given orally reached values comparable to those after parenteral application of a four-times lower dose of NH-AraC, suggesting a moderate bioavailability. Thus, these two lipophilic derivatives of AraC are compounds with a potential for the oral treatment of malignant diseases.