Aggressive fibrous tissue lesions in the upper extremity: treatment and results

Desmoid tumor of the forearm. Reconstructive surgery and functional result

Functional results after resection-reconstruction operated at the same time. Desmoid tumors, also known as aggressive fibromatosis, are benign locally aggressive tumors with a high rate of recurrence. Most authors recommend surgical treatment with wide-free margin. Achieving margins of normal tissue around an upper extremity lesion without creating significant functional compromise is frequently difficult. Therefore, functional reconstructive surgery is important, considering that for most patients treated for these tumors, the life expectancy is high and considering also that wide resection can affect the function and the aesthetics as well. We present a case of aggressive fibromatosis in the proximal third of the forearm treated by wide resection and reconstructive surgery in one single procedure, with an acceptable functional result with no evidence of recurrence at 3 years of follow-up.

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.

Desmoid tumor: prognostic factors and outcome after surgery, radiation therapy, or combined surgery and radiation therapy

PURPOSE

To evaluate the therapeutic value of resection and the potential benefits of and indications for adjuvant and definitive radiation therapy for desmoid tumors.

MATERIALS AND METHODS

We performed a retrospective review of 189 consecutive cases of desmoid tumor treated with surgical resection, resection and radiation therapy, or radiation therapy alone. Treatment was surgery alone in 122 cases, surgery and radiation therapy in 46, and radiation therapy alone in 21. Median follow-up was 9.4 years.

RESULTS

Overall, 5- and 10-year actuarial relapse rates were 30% and 33%, respectively. Uncorrected survival rates were 96%, 92%, and 87% at 5, 10, and 15 years, respectively. For the patients treated with surgery, the actuarial relapse rates were 34% and 38% at 5 and 10 years, respectively. Among 78 patients with negative margins, the 10-year recurrence rate was 27%, whereas 40 margin-positive patients had a 10-year relapse rate of 54% (P = .003). Tumors located in an extremity also had a poorer prognosis than did those in the trunk. For patients treated with radiation therapy for gross disease, the 10-year actuarial relapse rate was 24%. For patients treated with combined resection and radiation therapy, the 10-year actuarial relapse rate was 25%. The addition of radiation therapy offset the adverse impact of positive margins seen in the surgical group.

CONCLUSION

Wide local excision with negative pathologic margins is the treatment of choice for most desmoid tumors. Function-sparing resection is appropriate because adjuvant radiation therapy can offset the adverse impact of positive margins. Unresectable disease should be treated with definitive radiation therapy.

Radiation therapy in the management of desmoid tumors

PURPOSE

To evaluate the outcome of patients with extra-mesenteric desmoid tumors treated with radiation therapy, with or without surgery.

METHODS AND MATERIALS

The outcome for 75 patients receiving radiation for desmoid tumor with or without complete gross resection between 1965 and 1994 was retrospectively reviewed utilizing univariate and multivariate statistical methods.

RESULTS

With a median follow-up of 7.5 years, the overall freedom from relapse was 78% and 75% at 5 and 10 years, respectively. Of the total, 23 patients received radiation for gross disease because it was not resectable. Of these 23 patients, 7 sustained local recurrence, yielding a 31% actuarial relapse rate at 5 years. Radiation dose was the only significant determinant of disease control in this group. A dose of 50 Gy was associated with a 60% relapse rate, whereas higher doses yielded a 23% relapse rate (p < 0.05). The other 52 patients received radiation in conjunction with gross total resection of tumor. The 5- and 10-year relapse rates were 18% and 23%, respectively. No factor correlated significantly with disease outcome. There was no evidence that radiation doses exceeding 50 Gy improved outcome. Positive resection margins were not significantly deleterious in this group of irradiated patients. For all 75 patients, there was no evidence that radiation margins exceeding 5 cm beyond the tumor or surgical field improved local-regional control. Ultimately, 72 of the 75 patients were rendered disease-free, but 3 required extensive surgery (amputation, hemipelvectomy) to achieve this status. Significant radiation complications were seen in 13 patients. Radiation dose correlated with the incidence of complications. Doses of 56 Gy or less produced a 5% 15-year complication rate, compared to a 30% incidence with higher doses (p < 0.05).

CONCLUSIONS

Radiation is an effective modality for desmoid tumors, either alone or as an adjuvant to resection. For patients with negative resection margins, postoperative radiation is not recommended. Patients with positive margins should almost always receive 50 Gy of postoperative radiation. Unresectable tumors should be irradiated to a dose of approximately 56 Gy, with a 75% expectation of local control.

Function-sparing surgery for desmoid tumors and other low-grade fibrosarcomas involving the brachial plexus

OBJECTIVE

Low-grade fibrosarcomas and desmoid tumors present a surgical challenge in that they have a strong tendency for local invasion, surgical margins are poorly delineated, and complete resections are difficult. Nowhere is this more evident than in those lesions involving the brachial plexus. We review our experience with these difficult lesions.

METHODS

From a prospective database of 2900 patients admitted for treatment of sarcoma between 1982 and 1996, we identified 15 patients with involvement of the brachial plexus by a low-grade fibrosarcoma or desmoid tumor. All patients underwent resection, with 13 of 15 receiving adjuvant radiotherapy. The 15 patients had a mean age at initial operation of 47 years. The male-to-female ratio was 8:7. The mean follow-up period was 65 months (median, 53 mo).

RESULTS

Gross total resection was achieved in 12 patients (80%), although 11 of these patients had positive surgical margins. Overall, 64% of the tumors have recurred locally. There were no distant metastases, and no patients died as a result of their disease. One patient died as a result of unrelated cancer. An assessment of the functional outcomes revealed seven patients with normal function or mild neurological deficits and eight who were suffering from significant weakness, debilitation, or chronic pain. One patient required forequarter amputation.

CONCLUSION

Surgical resection plus postoperative radiotherapy is the treatment of choice for low-grade fibrosarcomas and desmoid tumors involving the brachial plexus. However, aggressive surgical management with the goal of achieving a gross total resection with negative histological margins can produce unnecessary morbidity. Preserving function should be a primary goal of the operations, although this will be associated with residual disease and will risk local recurrence but rarely death resulting from the disease.