Treatment of recurrent desmoid tumour with tamoxifen

Tamoxifen Upregulates Collagenase Gene Expression in Human Dermal Fibroblasts

Background

Tamoxifen is a known inhibitor of fibroblast transforming growth factor beta biosynthesis and wound scar formation. Tamoxifen is also known to be an estrogen antagonist and protein kinase C (PKC) inhibitor. Cells treated with tamoxifen and other PKC/calmodulin inhibitors depolymerize their membrane focal adhesion complexes and cytoskeletal protein structures. These effects result in substrate detachment, cell shape rounding, and upregulation of collagenase synthesis and extracellular matrix degradation. The purpose of our study was to test the hypothesis that tamoxifen treatment of human foreskin fibroblasts results in alteration of cytoskeletal protein organization, cell detachment and rounding, and increased collagenase synthesis similar to known PKC/calmodulin inhibitors such as H-7.

Methods

We characterized the effects of PKC/calmodulin inhibitors tamoxifen and H-7 on human dermal fibroblast morphology, cytoskeletal protein organization, and collagenase gene expression in monolayer culture and within collagen gels.

Results

We found that fibroblasts responded to tamoxifen by initiation of actin filament depolymerization followed by alteration from spindle to spheroidal shapes. This change in cell shape led to increased collagenase synthesis in cells treated with either tamoxifen or H-7 compared with controls. There was also a 23% increase of hydroxyproline release from tamoxifen-treated fibroblast-populated collagen matrices.

Conclusions

Tamoxifen may reduce scarring by inhibiting fibroblast PKC/calmodulin activity, which down-regulates pro-fibrotic transforming growth factor beta signaling and upregulates collagenase production. These effects mimic those of the known PKC/calmodulin inhibitor H-7. Overall, these findings suggest that tamoxifen and its analogues are promising agents for clinical investigation as small molecule regulators of fibrosis and scarring disorders.

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.

Desmoid-type fibromatosis of the breast: A case report

Desmoid-type fibromatosis of the breast (also referred to as desmoid tumor or aggressive fibromatosis) is exceedingly rare. Although it does not metastasize, desmoid-type fibromatosisis is frequently locally aggressive. Recurrence is common (up to 35%), even after presumed total excision of the primary tumor [1]. The breast is an unusual location for the development of this tumor, with relatively few cases reported in the literature. We report a case of desmoid-type fibromatosis in the breast in a 31-year-old female who presented with a four-month history of a palpable left breast mass. Her imaging was discordant, so she underwent surgical excision of the mass. Multiple positive margins were present. She underwent re-excision to the level of the sternum medially. Final pathology showed a focally positive posterior margin, without muscle or fascial involvement. The patient's case was discussed at the multidisciplinary tumor board conference and no further intervention was recommended. To our knowledge, this is the first case report in the literature in which negative margins were unable to be achieved for desmoid tumors of the breast operatively.

Transition of treatment for patients with extra-abdominal desmoid tumors: nagoya university modality

Treatment modalities for desmoid tumors have been changed because of the high recurrence rate, even after wide resection, and some cases experience spontaneous self-regression during clinical course. The treatment modality in our institutions before 2003 was surgical resection with wide surgical margin, however, meloxicam, which is a NSAID and a selective COX-2 inhibitor has been applied consecutively since 2003. We reviewed the previously reported outcomes of surgical and conservative treatment in our institutions. Among 30 patients receiving surgical treatment, 16 (53%) recurred. Younger age ( p < 0.05) was a significant poor factor. According to RECIST for meloxicam treatment, CR was in one, PR in 10, SD in eight, PD in one evaluated at 2011. Older age ( p < 0.01) was significantly associated with good outcome for meloxicam treatment. Results of the previous study indicated that surgical treatment alone could not control desmoid tumors, even with negative surgical margin. Considering the functional impairment resulting from surgery with negative surgical margin, a conservative and effective treatment modality with fewer complications is desired. Conservative treatment with meloxicam is a promising novel modality for patients with extra-abdominal desmoid tumors.

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.

Limb salvage surgery in the excision of a massive fibromatosis

Fibromatosis is a rare fibroproliferative disorder with a tendency for local infiltrative and destructive growth. Local recurrence is frequent, despite apparent complete resection after radical excision. We present a case of a 22-year-old woman with massive recurrent thoracic fibromatosis extending into the neck and impairing the function of her right upper limb. This required a multidisciplinary approach to surgery to salvage the limb. The case highlights the fact that while every attempt should be made to achieve negative histologic margins, local recurrence is not uncommon. Therefore, if fibromatosis occurs adjacent to or involves vital structures, these should not be sacrificed to achieve negative margins. Function and structure preserving procedures are important as the primary goal, if not even more important.

Sarcoma and Skin Radiation Oncology

The goal of this review was to provide an overview of the use of radiotherapy in the management of sarcomas and skin cancer. Radiotherapy can be an important component of treatment in these patients. It can help optimize local control of the tumor and often allows preservation of organ function with excellent cosmesis.

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.

Multicentric extra-abdominal desmoid tumours

Despite their classification as benign, desmoid tumours are difficult to diagnose and manage. They are prone to recurrence and resection can be debilitating. Rarely, synchronous or metachronous multicentric desmoid tumours occur and may require further excision. Therefore, early detection of recurrence and multicentric tumours is vital. We present a case of metachronous desmoid tumours, and review the literature to propose a treatment pathway.

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.

Treatment of aggressive fibromatosis: a retrospective study of 72 patients followed for 1-27 years

We evaluated prognostic factors for local recurrence-free survival, including expression of estrogen receptors, after surgical treatment of aggressive fibromatosis in 72 patients (53 women) having primary tumors between 1970 and 1998. Their median age at diagnosis was 31(1 month-77 years) years. 50 patients had extraabdominal and 22 abdominal fibromatosis. Median tumor size was 4 (1-27) cm. 8 patients were treated with an intralesional resection, 32 with marginal, 31 with wide and with radical resection. They were followed for a median of 8 (1-27) years. The overall and local recurrence-free 5-year survival rates were 98% and 73%, respectively. Univariate analysis identified age, compartmentalization and tumor size as prognostic factors for local recurrence-free survival as well as radiotherapy in extraabdominal tumors. In the multivariate analysis, tumor size > 4 cm, extracompartmental location, inadequate margin and age < 32 years were independent negative prognostic factors for local recurrence. None of the tumors expressed estrogen receptors. In conclusion, aggressive fibromatosis as a high local recurrence rate, but a good prognosis, since almost no patients die of their tumor.

[Primary fibromatosis of the breast]

Primary fibromatosis of the breast is a very rare pathology which looks like a malignant tumor, clinically and radiologically. Fibromatosis of the breast is characterised by a local invasion and a risk of recurrence. Positive diagnosis is provided by histology and its treatment is surgical. The aim of this study was to report one case and to emphasize the difficulties encountered in the diagnosis and the treatment.

Treatment of extra-abdominal desmoid tumors with interferon-alpha with or without tretinoin

BACKGROUND AND OBJECTIVES

Surgery is the main treatment for extra-abdominal desmoid tumors, but the results of further management remain uncertain. Therefore, a retrospective analysis was undertaken to evaluate the toxicity and efficacy of treatment with interferon-alpha (IFN-alpha) +/- tretinoin in this setting.

METHODS

Thirteen patients with extra-abdominal desmoid tumors and a median age of 32 years (range, 15-73) received IFN-alpha. Seven of these patients received a combination of IFN-alpha and tretinoin in order to test further enhancement.

RESULTS

After a mean observation period of 27 +/- 15 months (mean +/- standard deviation) under treatment with IFN-alpha +/- tretinoin, local control was seen in 11 of 13 patients (85%). Seven patients had no evidence of disease at a mean disease-free interval of 22 +/- 18 months; in two patients progressive disease occurred after only 7 and 9 months, respectively, of observation. In another four patients, progression of the desmoid tumor was stabilized.

CONCLUSIONS

The data of this retrospective, nonrandomized study on therapy with IFN-alpha +/- tretinoin suggest that such treatment may be effective in prolonging the disease-free interval of patients after intralesional or marginal surgery. Because of the encouraging response rate, this regimen appears to be another nonsurgical treatment alternative.

Modification of growth of desmoid tumours in tissue culture by anti-oestrogenic substances: a preliminary report

BACKGROUND

Tamoxifen and toremifene have been used in patients with advanced desmoid tumours with response rates of 51%.

METHODS

We developed an experimental model of desmoid tumour cells in tissue culture to study their effect. Four cell lines were established in tissue culture. All native and corresponding cultured tumours were oestrogen receptor negative. Tumour 1 was from a 22 year old with familial adenomatous polyposis (FAP) and recurrent abdominal wall desmoid tumours. She remains disease free on tamoxifen 4 years following surgery. Both her mother and sister also have shown regression of their FAP-associated desmoid tumours at the menopause and on tamoxifen, respectively. We assessed the effect of tamoxifen on desmoid tumours in tissue culture at 780 ng/mL. The results were assessed by cell density counting.

RESULTS

Tumours 1 and 2 have responded with an approximately. 50% reduction in growth to tamoxifen at 780 ng/mL.

CONCLUSIONS

This apparent growth inhibitory effect of tamoxifen on two desmoid tumour cell lines appears to be independent of oestrogen and correlates with the in vivo effect of tamoxifen on three desmoid tumours in an FAP family.

Regression of large pelvic desmoid tumor by tamoxifen and sulindac

A 54-year-old man was evaluated for symptoms of bladder outlet obstruction. Evaluation revealed a 10 by 9.8-cm tumor composed of bland, fibroblastic, poorly cellular material adjacent to the prostate. Administration of a course of antiestrogen (tamoxifen) and a nonsteroidal anti-inflammatory agent (sulindac) resulted in prompt relief of symptoms and a slow decrease in the size of the tumor as measured by computed tomography. After 54 months of therapy, the tumor was undetectable clinically and dramatically reduced in size as seen on computed tomography. Data on the natural history of desmoid tumors and the efficacy of various therapeutic strategies are reviewed.

Extraabdominal desmoid tumor

An extraabdominal desmoid tumor of the shoulder occurring in a middle-aged woman without Gardner's syndrome is described. Two punch biopsy specimens from the tumor were initially interpreted as representing scar tissue; a third incisional biopsy specimen demonstrated the characteristic features of a desmoid tumor. Because desmoid tumors are locally aggressive, early diagnosis and treatment are crucial to minimize morbidity and mortality. Typical clinical and histologic findings characteristic of an extraabdominal desmoid tumor are described, and treatment options are reviewed.

Cervical paraspinous desmoid tumor in a child: case report

Desmoid tumors are uncommon fibroblastic proliferative lesions usually occurring in the abdominal wall of adults. We report an unusual case of such a tumor presenting as a rapidly growing cervical paraspinous mass in a 19-month-old girl. After surgical resection without adjuvant therapy, the child is recurrence free after 17 months. The primary treatment of these lesions is surgical resection. We found magnetic resonance imaging to be the best imaging method for evaluation, because it was able to distinguish the tumor from the surrounding muscle. Careful postoperative surveillance is warranted, because these tumors have a high rate of recurrence. Although rare, desmoid tumor should be considered in the differential diagnosis of a paraspinous soft tissue tumor in a pediatric patient.

Musculoaponeurotic fibromatosis (extraabdominal desmoid tumor) in a child with idiopathic multicentric osteolysis

The fibromatoses are a group of benign proliferations of fibrous tissue with clinical behavior ranging from that of truly malignant tumors to that of benign reactive fibrous proliferations. Some of the superficial fibromatoses are fairly common, but the deep ones, also known as desmoid tumors or musculoaponeurotic fibromatoses, are rare. Idiopathic multicentric osteolysis is a rare skeletal disorder of childhood that causes progressive destruction of bones and renal failure. We recently saw a young girl with both extraabdominal musculoaponeurotic fibromatosis and idiopathic multicentric osteolysis. The classification, diagnosis, and treatment of the deep fibromatoses are reviewed, and the possible association between the minor bone changes occasionally reported in musculoaponeurotic fibromatosis and idiopathic multicentric osteolysis is discussed.