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

Three-dimensional (3D)-printed custom-made titanium ribs for chest wall reconstruction post-desmoid fibromatosis resection

Desmoid fibromatosis (DF) is a rare low-grade benign myofibroblastic neoplasm that originates from fascia and muscle striae. For giant chest wall DF, surgical resection offer a radical form of treatment and the causing defects usually need repair and reconstruction, which can restore the structural integrity and rigidity of the thoracic cage. The past decade witnessed rapid advances in the application of various prosthetic material in thoracic surgery. However, three-dimensional (3D)-printed custom-made titanium ribs have never been reported for chest wall reconstruction post-DF resection. Here, we report a successful implantation of individualized 3D-printed titanium ribs to repair the chest wall defect in a patient with DF.

Impact and safety of pregnancy on desmoid fibromatosis management in the era of active surveillance. An international multicenter retrospective observational study

AIM

To evaluate desmoid fibromatosis (DF) progression and obstetric outcomes during and after pregnancy, providing evidence to inform clinical decision-making and counseling.

METHODS

This international, multicenter, retrospective observational study included data from 157 women with DF, contributing 177 pregnancies. Women were classified into three groups: DF diagnosed during pregnancy (Group A), pregnancy occurring after the diagnosis of DF (Group B: DF in situ during pregnancy), or pregnancy in previously resected DF (Group C). Logistic regression and tumor size trend analyses were conducted.

RESULTS

Among 177 pregnancies, Group A exhibited the highest rates of DF progression (68.7 % during pregnancy, 40.6 % postpartum), while Groups B and C had lower progression rates (9.5 % during pregnancy, 8.3 % postpartum). Active treatment was required in 5.6 % of cases. Spontaneous regression occurred in 23.7 % of pregnancies, particularly following progression. Obstetric complications were comparable to those in the general population.

CONCLUSION

Pregnancy is generally safe for women with DF, particularly after prolonged disease stability. Individualized counseling is essential for managing risks of progression and recurrence, supporting informed fertility decisions. Referral to specialized centers is recommended to optimize DF management during family planning and pregnancy.

Desmoid fibromatosis: interventional radiology (sometimes) to the rescue for an atypical disease

Desmoid fibromatosis (DF) is a rare locally aggressive soft tissue tumour that is characterized as benign as it cannot metastasize. It was managed until recently like sarcomas, that is, with radical surgical resection combined or not with radiotherapy. However, this approach was associated with a high rate of recurrence and significant morbidity. The management of this disease has progressively changed to a more conservative approach given the fact that DF may spontaneously stop to grow or even shrink in more than half of the cases. Should treatment be required, recent guidelines recommend choosing between systemic therapies, which include principally chemotherapy and tyrosine kinase inhibitors, and local treatments. And this is where the interventional radiologist may have an important role in treating the disease. Various ablation modalities have been reported in the literature to treat DF, notably high-intensity focused ultrasound and cryoablation. Results are promising and cryoablation is now mentioned in recent guidelines. The interventional radiologist should nevertheless apprehend the disease in its globality to understand the place of percutaneous treatments among the other therapeutic options. The goal of this review is therefore to present and discuss the role of interventional radiology in the management of DF.

The Desmoid Dilemma: Challenges and Opportunities in Assessing Tumor Burden and Therapeutic Response

Desmoid tumors are rare, locally invasive soft-tissue tumors with unpredictable clinical behavior. Imaging plays a crucial role in their diagnosis, measurement of disease burden, and assessment of treatment response. However, desmoid tumors' unique imaging features present challenges to conventional imaging metrics. The heterogeneous nature of these tumors, with a variable composition (fibrous, myxoid, or cellular), complicates accurate delineation of tumor boundaries and volumetric assessment. Furthermore, desmoid tumors can demonstrate prolonged stability or spontaneous regression, and biologic quiescence is often manifested by collagenization rather than bulk size reduction, making traditional size-based response criteria, such as Response Evaluation Criteria in Solid Tumors (RECIST), suboptimal. To overcome these limitations, advanced imaging techniques offer promising opportunities. Functional and parametric imaging methods, such as diffusion-weighted MRI, dynamic contrast-enhanced MRI, and T2 relaxometry, can provide insights into tumor cellularity and maturation. Radiomics and artificial intelligence approaches may enhance quantitative analysis by extracting and correlating complex imaging features with biological behavior. Moreover, imaging biomarkers could facilitate earlier detection of treatment efficacy or resistance, enabling tailored therapy. By integrating advanced imaging into clinical practice, it may be possible to refine the evaluation of disease burden and treatment response, ultimately improving the management and outcomes of patients with desmoid tumors.

Abdominal and intra-abdominal fibromatoses: Outcomes over time

OBJECTIVES

Abdominal wall and intra-abdominal fibromatoses are locally aggressive, nonmetastasizing neoplasms. Surgery has been the mainstay of local control, but new forms of therapy have been developed that may influence the clinical course and morbidity. We studied the clinical features and outcomes of patients with abdominal and intra-abdominal fibromatoses over time.

METHODS

Ninety-one patients-46 with abdominal wall and 45 with intra-abdominal fibromatosis-treated in our hospital systems between 2009 and 2023 were included. The patients were allocated to 1 of 2 groups based on the year of their initial treatment: before and including 2016 vs 2017-2023. Medical records and available histologic slides were reviewed.

RESULTS

Forty-six patients were treated between 2009 and 2016, and 45 patients were treated between 2017 and 2023. Patient ages ranged from 1 to 85 years (median, 39 years), and most patients (70%) were women (2:2 men to women). Patients self-reported as Hispanic (49%), followed by White (28%), Black (20%), and Asian (3%). A subset (21%) had familial adenomatous polyposis (FAP)/Gardner syndrome. Individuals with intra-abdominal fibromatoses (37%) were more likely to have FAP than individuals with abdominal wall fibromatosis (4%) (P < .0001). The most common initial treatment before and during vs after 2016 was surgical excision (78% and 51% respectively; P = .02), followed by active surveillance with other medical intervention (9% and 18%, respectively; P = .28) and use of tyrosine kinase inhibitors (0% and 18%, respectively; P = .014). The rate of multivisceral transplant in patients with FAP/Gardner syndrome was 47% vs 4% in patients with sporadic disease (P < .001); most transplants (92%) were performed before and during 2016. The overall tumor recurrence/persistence rate in patients who had undergone surgery was 31%. The recurrence/persistence rate in patients treated before and during 2016 was 39% (median follow-up, 24 months), which fell to 13% (median follow-up, 18 months) in individuals treated after 2016 (P = .032). The overall recurrence/persistence rate in patients with FAP/Gardner syndrome was 64% vs 21% in patients with sporadic disease (P = .002). In patients with sporadic disease, there were recurrences in 29% of patients treated before and during 2016 and in 9% of patients treated thereafter (P = .086). Intra-abdominal vs abdominal wall lesions in patients with FAP and in patients with sporadic disease were more likely to recur (26% vs 10% and 16% vs 5%), but this occurrence did not reach statistical significance (P = .15). Most recurrent tumors were treated by surgical re-excision in both groups.

CONCLUSIONS

Our data suggest that a combination of less morbid surgical approaches and the addition of nonsurgical approaches (active disease surveillance, use of tyrosine kinase inhibitors and other interventions) have resulted in substantially fewer surgical interventions over time for intra-abdominal and abdominal wall fibromatoses treated between 2009 and 2023. The overall probability of recurrences, however, in patients treated surgically remains similar.

Trends in Practice Patterns and Clinical Outcomes for Desmoid Tumors: A Large Single-Institutional Australian Cohort

BACKGROUND

Desmoid tumors (DT) are rare, locally aggressive neoplasms that affect a young population and have a tendency for recurrence. There is sparse contemporary real-world data to guide practice for DT. Here, we report on a large cohort of DT patients, describing patterns of care and clinical outcomes.

METHODS

Data on DT patients first seen between 2010 and 2021 were extracted from a prospective database and supplemented with a retrospective review of hospital records. Trends in treatment use were analyzed using the Cochran-Armitage test. Time-to-next intervention (TTNI) was estimated with the Kaplan-Meier method. Imaging response was categorized using the RECIST v1.1 criteria.

RESULTS

A total of 135 patients, 265 treatment episodes were analyzed. Median follow-up was 4.3 years. The common tumor sites were abdominal wall (27%), upper limb (20%), lower limb (16%), and intra-abdominal (15%). Over time, the proportion of patients receiving no upfront treatment was stable (2010-2013: 31%, 2014-2017: 35%, 2018-2021: 29%; p = 0.5), but there was increasing first-line use of NSAID/tamoxifen (7%, 41%, 47%; p < 0.001), and decreasing first-line use of radiotherapy (35%, 14%, 4%; p < 0.001) and surgery (28%, 8%, 18%; p < 0.05). At 5 years, the proportion not requiring treatment switch was highest following surgery (72%), radiotherapy (66%), and no upfront therapy (52%). 12% and 5% of patients without treatment achieved partial and complete imaging responses at 2 years.

CONCLUSION

We highlight the heterogeneity and trends in DT management over a 12-year period, affirming the role of active surveillance, radiotherapy, and surgery in selected patients. Medical therapies are evolving and may significantly influence the DT management paradigm.

A Rare Case of Desmoid Fibromatosis in a Pediatric Patient: Surgical Management and Outcomes

Desmoid fibromatosis (DF) is a rare, locally aggressive tumor arising from the abdominal fascia or musculoaponeurosis, commonly affecting individuals between 15 and 60 years of age. We present a case of a 13-year-old boy with a 9-month history of progressive swelling in the left posterior thigh. Magnetic resonance imaging (MRI) revealed a soft tissue tumor encasing the sciatic nerve. A biopsy confirmed the diagnosis of DF, showing spindle cells arranged in fascicles. The patient underwent wide local excision of the tumor with preservation of the sciatic nerve. Postoperative recovery was smooth, and 1-year follow-up MRI showed no recurrence. Surgical excision remains the primary treatment, especially in symptomatic patients, although recurrence is common even with negative margins. This case underscores the importance of regular follow-up for DF and a multidisciplinary approach to optimize management and surveillance.

Clinical Challenges and Evolving Treatments in Desmoid Fibromatosis: A Single Institution Experience

Desmoid tumor (DT), also known as desmoid fibromatosis, is a rare, locally proliferative tumor characterized by an overgrowth of myofibroblastic cells. Due to the varied clinical presentation of DT, there are a multitude of treatment options. This study provides our institutional experience in characterizing and treating DT as well as patient outcomes. A retrospective review was performed for 49 patients diagnosed with DT. Patient demographics, tumor characteristics, treatment characteristics, and tumor recurrence were reported. We reported our institution's treatment trends over time, relative risk analysis for surgery, as well as univariate analysis for recurrence. Thirty-seven patients received surgery with an overall recurrence rate of 29.7% (11/37). In total, ten patients received medical therapy including tamoxifen/sulindac (n = 7), nirogacestat (n = 1), and sorafenib (n = 2). One patient has been followed with active surveillance. Relative risk for surgery and tumor recurrence was not significantly correlated with race, gender, location, or large tumor size > 5 cm. Four patients treated with medical therapy experienced tumor reduction and symptomatic improvement. Management of DT includes many surgical and non-surgical options. We noted a similar recurrence rate in patients who received surgical treatment to what has been reported in the literature roughly 33%. We also noted effective tumor control in patients receiving medical therapy. As such, surgery can be utilized in situations with well-demarcated DT which can be removed en bloc, while utilizing medical therapy for highly invasive tumors.

A methodology for determining dosing recommendations for anticancer drugs in patients with reduced kidney function

Reduced kidney function (or kidney dysfunction) is commonly an exclusion criterion for randomised controlled trials (RCTs) in cancer. Consequently, high quality evidence for anticancer drug dosing in reduced kidney function is limited and no internationally agreed guidelines exist to inform prescribing decisions in this population. A methodology for guideline development was applied which did not require availability of RCTs but used critical appraisal of existing observational literature and group consensus. An international multidisciplinary working group (n = 38) established consensus recommendations in two parts to form the International Consensus Guideline on Anticancer Drug Dosing in Kidney Dysfunction (ADDIKD). The approach enabled virtual participation worldwide. In Part 1 we developed a standardised approach for assessment and classification of kidney function in patients with cancer using global nephrology standards and working group expertise. Part 2 involved a comprehensive literature search of 59 anticancer drugs followed by a critical appraisal of the evidence certainty through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process and development of dosing recommendations in reduced kidney function. Key external stakeholders (n = 9) invited expert contributors (n = 25), and the working group participated in virtual interactive workshops to vote on the acceptability of these recommendations. The participants were provided with evaluation of the literature, and they engaged in several rounds of virtual discussion (involving robustness of the evidence behind recommendations and their real-world application) and anonymous consensus voting. Adapting the ADDIKD guideline development process to a virtual format enabled engagement with a very broad base of specialised international experts especially during the global pandemic. Combining GRADE methodology with consensus-building approaches was an effective method of producing recommendations (in an area lacking RCTs) by merging critical review of the literature with expert opinion and clinical practice.

Funding

Development of the ADDIKD guideline is funded by the Cancer Institute NSW as part of the NSW Government and received no funding from external commercial sources.

Gardner syndrome: When cervical-facial osteomas reveal the tip of the iceberg: A case report and literature review

Gardner syndrome is a subtype of familial adenomatous polyposis (FAP) characterized by colonic manifestations, multiple skull osteomas, dental abnormalities, benign soft tissue tumors, and a high risk of development of both colorectal cancer and papillary thyroid carcinoma. Many patients are incidentally diagnosed when presenting with craniofacial tumefactions related to osteomas. In such cases, further exploration of family history and other clinical manifestations often reveals positive findings. We report the case of a 34-year-old woman who presented with craniofacial tumefactions and recurrent orbital discomfort. A cranio-facial CT-scan revealed multiple osteomas, including one affecting the orbital region. Investigation of her family history, along with her clinical history, confirmed the presence of Gardner syndrome in her father and siblings, with colonic polyposis- under ongoing surveillance.

Desmoid fibromatosis of the breast

Desmoid-type fibromatosis (DTF) is a rare non-metastatic mesenchymal tumour that accounts for only 0.2% of all primary breast neoplasms. This locally aggressive tumour has a high recurrence rate and primarily affects women aged 20-40 years. DTF often presents with features mimicking breast carcinoma, posing diagnostic challenges and the risk of mismanagement. We report a case of a young woman with a left-sided breast mass and skin dimpling. Initial ultrasound and core needle biopsy findings suggested adenosis and intraductal papilloma. Due to the strong clinical suspicion of malignancy, a wide local excision was performed, which confirmed DTF. The patient is currently under surveillance with a regular MRI on follow-up. This case underscores the diagnostic difficulty of DTF, and due to its rarity and limited data, optimal management is debated. Current guidelines favour a conservative 'watch and wait' strategy, with surgery reserved for symptomatic cases. Close follow-up is crucial due to the high risk of recurrence.

Mandibular versus Maxillary Desmoplastic Fibroma: A Pooled Analysis of World Literature and Report of a New Case

The purpose of this study is to delineate differences between mandibular and maxillary desmoplastic fibroma (DF) via analysis of published cases. Details of cases were analyzed for distribution, demographics, presentation, treatment, and follow-up. Between 1961 and 2022, 195 cases were reported, averaged 2.7 annually. There were 159 (81.5%) mandibular and 36 (18.5%) maxillary cases. The posterior mandible was most commonly affected (91.2%; p < 0.05). Maxillary DF mostly involved the anterior region (53.1%; p < 0.05). The female:male ratio was 1:1.3 (1:2 mandibular and 1:4 maxillary), and the average age was 13.5 years (12.1 mandibular and 20.5 maxillary) with a peak frequency in both jaws in the first decade of life (p < 0.05). Mandibular cases mostly affected whites, and maxillary cases affected a higher percentage of Asians (p < 0.05). Maxillary cases caused more pain and intraoral ulceration (p < 0.05). The combined cure rate of all treatment modalities for mandibular and maxillary cases was 74.8 and 81.5%, respectively. The most effective single-modality treatment for DF of both jaws was surgery (p < 0.05). To the best of our knowledge, this review is the first to delineate difference between mandibular and maxillary DF. This work will aid attaining an improved management protocol of this uncommon disease.

Comprehensive RNA Sequencing Analysis Identifies Network Hub Genes and Biomarkers Differentiating Desmoid-type Fibromatosis From Reactive Fibrosis

Desmoid-type fibromatosis (DTF) is a benign but locally aggressive neoplasm characterized by persistent fibroblast activation, unlike reactive fibrosis (RF), where fibroblast activation is transient. Although the Wnt/β-catenin signaling pathway is known to play a role in DTF pathogenesis, the specific genetic drivers contributing to this abnormal fibroblast activation are not fully understood. To identify additional driver genes that underlie the persistent activation of fibroblasts in DTF, we conducted a comparative transcriptome analysis between 29 DTF and 14 RF tissue samples, identifying 4267 differentially expressed genes (DEGs) specific to DTF. These DTF-specific DEGs were significantly associated with pathways involved in embryonic limb morphogenesis and muscle contraction, whereas RF-specific DEGs were linked to immune response and apoptosis. Using weighted gene coexpression network analysis to further elucidate the key regulatory circuits associated with persistent activation of DTF fibroblasts, we identified a highly DTF-specific gene module comprising 120 genes. This module was also significantly enriched in other fibroproliferative conditions showing persistent fibroblast activation, such as keloid disease and idiopathic pulmonary fibrosis. Subsequent analyses identified 7 driver transcription factors (ZNF536, IRX5, TWIST2, NKD2, PAX9, SHOX2, and SALL4) within this DTF-specific module that may contribute to the sustained activation of DTF fibroblasts. We further assessed the utility of 5 key genes from this module (TWIST2, LRRC15, CTHRC1, SHOX2, and SALL4) as potential biomarkers to distinguish DTF from RF using immunohistochemistry. All markers demonstrated excellent diagnostic performance, with TWIST2 showing exceptionally high sensitivity and specificity, surpassing β-catenin, the current standard biomarker for DTF. In conclusion, our study identifies gene modules and driver transcription factors that are highly specific to DTF, offering new insights into the genetic underpinnings of abnormal fibroblast activation in DTF. We also propose novel biomarkers that could improve the diagnostic accuracy and clinical management of DTF.

Radiological features of desmoid-type fibromatosis: a two-institution retrospective study

OBJECTIVES

To characterize the radiological findings of desmoid-type fibromatosis (DF).

METHODS

This two-institution retrospective study included 152 patients with pathologically confirmed DF who underwent computed tomography (CT), magnetic resonance imaging (MRI), or 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT between January 2001 and February 2024. Two board-certified radiologists independently evaluated the CT, MRI, and FDG-PET/CT findings, and a third board-certified radiologist resolved discrepancies. Imaging was performed with and without contrast media: 70 patients underwent plain CT, 95 underwent contrast-enhanced (CE) CT, 115 patients underwent plain MRI examinations, 100 patients underwent CE-MRI, and 11 patients underwent FDG-PET/CT (most patients underwent several modalities).

RESULTS

The median age of the patients was 40 years, with a female predominance (male, 39.5% vs female, 60.5%). Swelling or palpable mass was the most frequent symptom (78/152, 51.3%). Gross total resection of DF was performed in 57 patients, with a recurrence rate of 38.6% (22/57). Tumors were most frequently observed in the extra-abdominal region (79/152, 51.6%). Characteristic radiological features included intermediate intensity on T2-weighted imaging (112/113, 99.1%), intermediate-to-high intensity on T1-weighted imaging (109/111, 98.2%), substantial enhancement in the late phase on MRI (100/100, 100%), moderate to strong enhancement in the late phase on CT (18/20, 90%), and arterial penetration sign on CE-CT (25/96, 26.0%). The mean apparent diffusion coefficient (ADC) of DFs was 1.46 × 10-3 mm2/s (range, 1.00-2.20).

CONCLUSION

This study highlights the unique imaging features of DF, including the arterial penetration sign and high mean ADC values, which can aid in differentiating DF from other soft tissue tumors. These findings may improve preoperative diagnostic accuracy and reduce the need for invasive procedures.

KEY POINTS

Question Imaging findings of DF are not well-documented in large-scale studies. Findings This study identifies unique imaging features of DF, such as the arterial penetration sign and high mean ADC values. Clinical relevance These distinctive imaging characteristics improve diagnostic accuracy for DF and lead to appropriate patient management, as DF requires distinct treatment strategies.

Cryotherapy in the Treatment of Extra-Abdominal Desmoid Tumors-A Review

The management of desmoid tumors (DTs) often poses challenges due to their variable clinical behavior, with treatment options including active surveillance, systemic therapy, and local therapies including surgery, ablation, and radiation. More recently, cryotherapy has emerged as a promising localized treatment for DTs. We aimed to conduct a review of the indications, techniques, and outcomes of cryotherapy in the treatment of extra-abdominal DTs. The review suggests that cryotherapy can be effectively used for both curative and debulking purposes, with a significant number of patients achieving symptom relief, disease stabilization, or regression. Although generally safe, cryotherapy is associated with potential risks, particularly when critical structures are in proximity. Overall, cryotherapy offers a viable, minimally invasive treatment option for DTs, with favorable outcomes in both symptom relief and tumor control.

Safety and efficacy analysis of ultrasound-guided microwave ablation for pediatric recurrent aggressive fibromatosis

BACKGROUND

The treatment of aggressive fibromatosis (AF) poses a challenge for physicians due to propensity for local recurrence and aggressive nature, with traditional surgical excision often resulting in recurrence. Ultrasound-guided ablation, offering minimal trauma and reusability, has emerged as a novel therapeutic option for invasive fibromas. We report our experience of microwave ablation (MWA) as a local and analgesic treatment for inoperable or recurring AF.

METHODS

This study includes 8 patients who underwent percutaneous MWA of 10 AF between November 2021 and November 2023. All patients underwent pain assessment using a visual analog scale (VAS) and preoperative imaging. Patients received clinical and radiological follow-up at 6 months post-procedure, with pain-rating and adverse events being recorded. A long-term follow-up was achieved until 1 November 2024.

RESULTS

In this study, the 10 tumors in 8 patients have a preoperative size ranging from 1.84 to 477.96 ml, with a mean of 71.90 ± 147.55 ml. Postoperatively, at 6 months, the lesion sizes ranged from 0 to 174.99 ml, with a mean of 24.97 ± 53.78 ml (P < 0.05). The mean volume reduction ratio (VRR) was 55.86% (range 15.48-100%), with an overall treatment effectiveness rate of 80% (8 out of 10). Long-term follow-up revealed 2 cases meeting complete response (CR) criteria, 4 cases achieving partial response (PR), and 2 cases meeting stable disease (SD) criteria. The average pre-treatment VAS score among the 8 patients was 6.38 (range 5-9), which decreased to 3.0 (range 0-6) after 1 month of treatment, demonstrating a significant average pain reduction of 3.38 (p < 0.05). The study reported an adverse reaction incidence of 12.5% (1/8) due to neural heat damage from ablation, with symptom improvement following supportive care.

CONCLUSION

MWA is an effective therapeutic option for the local treatment and for the analgesic management of AF.

Desmoid-type fibromatosis of the breast: a case report and literature review

Breast desmoid-type fibromatosis (BDF) is a rare tumor predominated by mesenchymal cells. It has a high recurrence rate, although distal metastasis is uncommon. It resembles breast cancer clinically, and histological pathology is the only approach to a confirmed diagnosis. Comprehensive and individualized treatments were recommended for BDF patients. Here, we presented a case of BDF secondary to primary breast carcinoma in our center. A 47-year-old female complained of a large mass in her left breast for 2.5 months. She has a past history of left breast carcinoma with a failure of surgical and systemic intervention. Despite an active re-operation, she still suffered from disease progression with a bad prognosis. After our report, the clinicopathological traits, differential diagnosis of BDF and current recommendation of management were discussed. This case report aimed to make a clear recognition of this rare and aggressive disease and elaborate up-to-date treatment recommendations. More effective drugs and larger sample clinical studies are encouraged for better management of refractory and progressive BDF.

Clinical Benefit of Pegylated Liposomal Doxorubicin and High Prevalence of Pre-Existing Psychiatric Conditions in Patients with Desmoid-Type Fibromatosis

Background/Objectives: Desmoid-type fibromatosis (DTF) is a locally invasive tumor composed of myofibroblast-like cells and collagen; it does not metastasize but can cause significant local morbidity. Most sporadic cases are associated with mutations in the CTNNB1 gene, which encodes beta-catenin. Various treatments have been used with differing efficacy and toxicity profiles. At our institution, pegylated liposomal doxorubicin (PLD) has become the preferred treatment for patients with DTF. We aim to describe our experience using PLD in patients with DTF who require treatment. Methods: A retrospective review of 61 DTF patients (41 females, 20 males) treated between 2000 and 2023 was conducted to assess the efficacy and toxicity of PLD. Results: Of the 26 patients treated with PLD, 23 had follow-up clinical data to assess benefit. Twenty-one showed clinical benefit, and only one progressed. Two patients did not benefit from PLD due to infusion reactions and chose alternative therapies. The primary side effect of PLD was hand-foot syndrome (HFS), but dose reduction and extended intervals allowed most patients to tolerate treatment. Other treatments, such as methotrexate, vinblastine/vinorelbine, and sorafenib, also showed activity but had significant toxicities, including severe HFS, malaise, and hypertension. Interestingly, 31 out of 61 patients had a pre-existing history of psychiatric conditions (primarily depression and anxiety), and 6 of 41 women had personal or family history of polycystic ovary syndrome (PCOS). Additionally, 15 patients had obesity, and 4 had hypothyroidism. Conclusions: PLD is an effective and well-tolerated treatment for DTF, with good clinical responses at lower, tolerable doses. The association of pre-existing psychiatric diagnoses, PCOS, and obesity warrants further investigation.

Five principles to prioritise in small-scale surgical quality improvement: a qualitative study of the views of surgical improvement leaders

OBJECTIVE

Variations in the quality and safety of surgical care remain persistent. Efforts to improve are needed, but are themselves variably effective, with often disappointing impacts. When compared with large-scale, multisite and better resourced improvement efforts, the evidence base for small-scale quality improvement (QI) has remained under-developed and lacking in clarity on good practice. We aimed to identify experienced leaders' views on the principles that should guide small-scale QI projects in surgery.

METHODS

Two rounds of virtual focus groups were conducted with 10 QI leaders, comprising surgeons, anaesthetists and nurses from three countries (Ireland, the UK and the USA). All participants had formal training in improvement techniques and at least 10 years' experience leading small-scale QI efforts in surgery. Analysis was informed by the principles of the constant comparative method together with content analysis.

RESULTS

Analysis of the focus groups identified five principles to prioritise for small-scale surgical QI: ensure high-quality planning before project launch; understand the problem to be solved to define focused project aims; ensure improvement efforts are sensitive to time, capacity and local context; assemble the right improvement team and engage the relevant stakeholders; and use of a clear, structured framework to guide QI is likely to be very helpful.

CONCLUSIONS

This study identifies five principles likely to be useful in guiding better surgical QI in frontline settings. These principles can help inform a structured framework to support small-scale surgical improvement efforts.

Enhancing rare cancer care in developing countries through patient advocacy: insights from the Desmoid Tumor Brazilian Association

Introduction

Desmoid tumors are soft-tissue neoplasms that can have profound impacts on the lives of people living with such diseases. As they are rare tumors, patients often have difficulty finding teams specialized in sarcomas and support networks. In low- and middle-income countries, the challenges are exacerbated due to a need for established networks and medication access.

Discussion

In this setting, patient advocacy groups are important in supporting affected people. To this end, the Desmoid Tumor Brazilian Association (DTBA) was established to help mitigate those challenges. This paper highlights the perspectives of patients with desmoid tumors living in Brazil, obtained in a nationwide survey, and discusses aspects related to access to specialists, medications, education, and awareness in Brazil.

Conclusions

The most commonly reported challenges in Brazil are access to educational material and specialists. The DTA continues to strive to improve support for people living in Brazil through initiatives such as Scientific and Educational Meetings, improving awareness, fostering science, and working on methods to facilitate access to medication and specialists.

Desmoid tumors: Old and new drugs for a rare and challenging disease

There has been a paradigm shift in the treatment strategy for patients with desmoid tumor toward less invasive management using systemic therapies. In addition to older drugs, such as conventional chemotherapy and tyrosine kinase inhibitors, the newest class of medical agents—the gamma secretase inhibitors—have been included in the treatment armamentarium for patients with desmoid tumor, as nicely depicted in the latest consensus guideline from The Desmoid Tumor Working Group.

UK guidelines for the management of soft tissue sarcomas

Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location, means that developing evidence-based guidelines is complicated by the limitations of the data available. This makes it more important that STS are managed by expert multidisciplinary teams, to ensure consistent and optimal treatment, recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous versions published in 2010 and 2016 [1, 2]. The original guidelines were drawn up by a panel of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This iteration of the guidance, as well as updating the general multidisciplinary management of soft tissue sarcoma, includes specific sections relating to the management of sarcomas at defined anatomical sites: gynaecological sarcomas, retroperitoneal sarcomas, breast sarcomas, and skin sarcomas. These are generally managed collaboratively by site specific multidisciplinary teams linked to the regional sarcoma specialist team, as stipulated in the recently published sarcoma service specification [3]. In the UK, any patient with a suspected soft tissue sarcoma should be referred to a specialist regional soft tissues sarcoma service, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging and a tissue biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon, combined with pre- or post-operative radiotherapy for tumours at higher risk for local recurrence. Systemic anti-cancer therapy (SACT) may be utilised in cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late effects of treatment.

Sorafenib or anthracycline-based chemotherapy for progressive desmoid tumors

BACKGROUND

Desmoid tumors can cause morbidity due to local invasion, potentially being fatal when fast growth compromises vital structures. In this context, a timely treatment response is required. This study aims to compare the activity of sorafenib and anthracycline-containing regimens during the first year of treatment.

METHODS

The authors conducted a multi-institutional retrospective analysis of desmoid tumor patients treated with either sorafenib or an anthracycline-containing regimen over 1 year. The primary end point was the overall response rate (ORR). The secondary end points were time to response (TTR), progression-free survival (PFS), and adverse events.

RESULTS

From 2005 to 2022, 80 patients received sorafenib and 51 received an anthracycline-containing regimen with similar baseline characteristics. The 1-year ORR was 37% for anthracycline and 13% for sorafenib (p = .016). Median best response was -9% (range, -73 to 51) for anthracycline and -4% (range, -69 to 126) for sorafenib. Median TTR was 5.6 months (95% confidence interval [CI], 3.4-7.8) for anthracycline and 8.7 months (95% CI, 6.3-11.1) for sorafenib (p = .2). One-year PFS was 73% (95% CI, 60-86) for anthracycline and 59% (95% CI, 47-71) for sorafenib (p = .3). Common grade 1-2 adverse events for sorafenib were hand-foot syndrome (40%), diarrhea (25%), and fatigue (22%); for anthracycline, they were nausea (31%), fatigue (16%), and rash (14%). Grade 3 events were higher in the anthracycline group, 27% versus 14% (p < .05).

CONCLUSION

Anthracycline-based therapy provided a greater 1-year response rate than sorafenib but was associated with a higher rate of serious adverse events. Higher-risk desmoid tumors, which need a more timely response, might benefit from anthracycline-based therapies, whereas average-risk tumors could benefit from sorafenib.

Hemorrhagic Shock Caused by an Aggressive Fibromatosis in the Gastropancreatic Region: A Case Report

Introduction

Aggressive fibromatosis (AF), also known as desmoid tumor, is a rare condition characterized by the proliferation of monoclonal fibroblasts, primarily originating from connective tissue. Despite being histologically benign, AF exhibits malignant-like behavior, including local invasion and a high recurrence rate. AF can be classified based on its location into extra-abdominal, abdominal wall, and intra-abdominal types. Intra-abdominal AF (IAF), though least common, has the worst prognosis and highest mortality rate. Traditionally, complete surgical resection (R0) was the preferred treatment, but recent strategies favor conservative management, especially for asymptomatic patients. Emergency surgery is reserved for complications like bleeding, perforation, or obstruction.

Case Presentation

This report details a rare case of IAF in the retroperitoneum of a 39-year-old woman presenting with hemorrhagic shock. Emergency surgery, including partial distal pancreatectomy and partial gastrectomy, was performed. The tumor was β-catenin positive, confirming the diagnosis of IAF. Postoperatively, the patient recovered well and showed no recurrence after 2 years without additional therapy.

Conclusion

In summary, IAF presents significant diagnostic and therapeutic challenges. Effective management relies on a multidisciplinary approach, combining various diagnostic tools to improve early detection and patient outcomes. Continued research is essential to understand the pathogenesis of AF and to develop less invasive treatment options.

Lymphoid enhancer-binding factor 1 (LEF1) immunostaining as a surrogate for β-catenin (CTNNB1) mutations

AIMS

Mutations affecting exon 3 of the β-catenin (CTNNB1) gene result in constitutive activation of WNT signalling and are a diagnostic hallmark of several tumour entities including desmoid-type fibromatosis. They also define clinically relevant tumour subtypes within certain entities, such as endometrioid carcinoma. In diagnostics, β-catenin immunohistochemistry is widely used as a surrogate for CTNNB1 mutations. Yet, it is often difficult to assess in practice, given that the characteristic nuclear translocation may be focal or hard to distinguish from the spillover of the normal membranous staining.

METHODS

We therefore examined lymphoid enhancer-binding factor 1 (LEF1) immunostaining, a nuclear marker of WNT activation that serves as a potential surrogate for CTNNB1 mutations.

RESULTS

In a cohort of endometrial carcinomas with known mutation status (n=130) LEF1 was 85% accurate in predicting CTNNB1 mutation status (64% sensitivity, 90% specificity) while β-catenin was 76% accurate (72% sensitivity; 77% specificity). Across a variety of entities characterised by CTNNB1 mutations as putative drivers, we found diffuse and strong expression of LEF1 in 77% of cases. LEF1 immunostaining proved easier to interpret than β-catenin immunostaining in 54% of cases, more difficult in 1% of cases and comparable in the remaining cases.

CONCLUSION

We conclude that LEF1 immunostaining is a useful surrogate marker for CTNNB1 mutations. It favourably complements β-catenin immunohistochemistry and outperforms the latter as a single marker.

Circulating Tumor DNA in Patients with Desmoid Fibromatosis during Active Surveillance

BACKGROUND

Sporadic desmoid fibromatosis (DF) is a rare locally aggressive tumor characterized by mutation in exon 3 of CTNNB1 (T41A, S45F, and S45P). Standard of care is active surveillance (AS), but 30% require treatment. DF clinical course is unpredictable and identification of prognostic markers is needed to tailor strategy. In this prospective study, we investigated the consistency between mutation detected in tumor biopsies with that detected in plasma by digital droplet PCR (ddPCR) and the association between circulating tumor DNA (ctDNA) abundancy with clinical outcome.

PATIENTS AND METHODS

A total of 56 patients and 10 healthy donors were included. CTNNB1 mutation status of DF biopsies was determined by Sanger and in case of WT CTNNB1 with NGS. In matched plasma samples at enrollment and during AS at specific timepoints, we evaluated cfDNA quantity and ctDNA.

RESULTS

ctDNA levels were measured in 46 patients with CTNNB1 mutation. Detection rate for T41A, S45F and S45P was 68%, 42% and 100%, respectively. S45P variant has been detected in all patients with S45P mutation. Longitudinal assessment of ctDNA during AS in nine patients (four with regression and five with progression as first event according to RECIST) showed a concordance between the event and ctDNA level change in six out of nine patients tested (4/5 with progression and 2/4 with regression).

CONCLUSIONS

Results of ctDNA analysis support its potential clinical implementation as diagnostic tool in specific clinical scenarios where biopsy can be challenging. A prospective clinical trial needs to be performed to evaluate the potential role of ctDNA as predictive biomarker.

Desmoid-type fibromatosis in an uncommon location: A case report of shoulder involvement misdiagnosed as rhabdomyosarcoma

INTRODUCTION AND IMPORTANCE

Desmoid-type fibromatosis is an uncommon tumor characterized by its local invasiveness, with shoulder involvement being notably infrequent. The optimal treatment strategy for this tumor remains a topic of ongoing debate.

CASE PRESENTATION

A 47-year-old Tunisian woman with a history of hypothyroidism, presented with pain and swelling in her left shoulder for a year. Examination revealed a firm, painful 4 cm mass, and MRI showed a poorly defined intramuscular tumor in the deltoid muscle, initially suspected to be rhabdomyosarcoma. However, surgical biopsy confirmed desmoid-type fibromatosis of the shoulder. The patient underwent surgical wide en-bloc resection of the tumor. The patient's recovery was uneventful, and she received physical therapy. At the three-year follow-up, she reported residual shoulder pain after heavy lifting, improving with analgesics. Examination showed no neurological deficits and a Constant score of 83 out of 100.

CLINICAL DISCUSSION

Due to their deep-seated nature and infiltrative growth patterns into neighboring subcutaneous tissues or muscles, along with the presence of myxoid or fibrotic components, desmoid-type fibromatosis can present challenges in distinguishing them from malignant soft tissue neoplasms based on imaging characteristics.

CONCLUSIONS

While radiologic evaluations may indicate characteristics suggestive of a malignant soft tissue tumor, histological confirmation is imperative prior to initiating surgical intervention. Continued research into the optimal treatment approaches for desmoid-type fibromatosis is essential for improving future patient outcomes and quality of life.

Aggressive Fibromatosis in the Abdominal Wall: A Rare Case of Intramuscular Desmoid Tumor

Desmoid tumors are uncommon soft tissue neoplasms that do not metastasize but are locally aggressive, often causing recurrence due to their infiltrative nature. This report discusses a case involving a symptomatic desmoid tumor in the right upper abdomen of a 23-year-old female patient. The diagnosis was established through clinical examination, ultrasonography, and computed tomography. A complete resection with a 2 cm margin followed by mesh placement for parietal reconstruction was carried out. Histopathological analysis confirmed the diagnosis of desmoid tumor. The patient was discharged on the fifth postoperative day and is recovering well. The "wait and watch" approach is suitable for asymptomatic patients, while surgical and systemic therapies are recommended for symptomatic individuals. Complete surgical excision with sufficient safety margins followed by parietal reconstruction using prosthetic reinforcement is advised when necessary.

Uncommon Fibroinflammatory Sinonasal Tract Lesions: Granulomatosis with Polyangiitis, Eosinophilic Angiocentric Fibrosis, and Rosai-Dorfman Disease

Fibroinflammatory lesions of the sinonasal tract include inflammatory polyps (chronic rhinosinusitis), various infectious, sarcoidosis, and NK/T-cell lymphoma as examples of the most commonly encountered lesions. However, the differential diagnosis includes several less frequently encountered entities, such as granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis (Churg-Strauss), eosinophilic angiocentric fibrosis considered part of IgG4-related disease, and Rosai-Dorfman disease. This review focuses on these latter entities providing an update on clinical, laboratory, imaging, histology, and ancillary testing employed to reach an actionable diagnosis.

Multiple maxillofacial desmoid tumours: a case report

Desmoid tumors (DTs) are rare benign neoplasms but cause significant mortality due to their locally infiltrative nature and propensity to recur. Most DTs occur in the extremities and trunk. Head and neck DTs are uncommon but can have a significant impact on a patient's facial appearance. However, there is limited information available about the diagnosis and treatment for multiple DTs located in head and neck. We report the first case of multiple maxillofacial DTs in a 14-year-old boy. He had painless submandibular masses for three months and MRI imaging reveals abnormal high signals on the submandibular and bilateral zygomatic regions. Considering facial aesthetics, via intraoral incision we obtained a biopsy from the largest mass. Pathological examination confirmed a diagnosis of DT. We selected the wait-and-see strategy and clinically monitored the rest of the masses. During the subsequent 1-year follow-up, the masses were stagnant and appeared to involute. According to the development and outcome of this case, a conservative treatment for craniofacial DTs is suggested; however, greater clarity concerning management and prognosis could derive from prospective study of a larger patient cohort in the future.

Evolution of Initial Treatment for Desmoid Tumors

INTRODUCTION

Desmoid tumors (DTs) are rare, fibroblastic cell proliferations that can exhibit locally aggressive behavior but lack metastatic potential. Initial management has traditionally involved upfront resection; however, contemporary guidelines and expert panels have increasingly advocated for prioritizing active surveillance strategies.

METHODS

A single-institution, retrospective chart review identified all patients diagnosed with a primary DT at any site from 2007 to 2020. The primary outcome was the initial management strategy over time. Secondary outcomes included treatment-free survival (TFS) and time to treatment (TTT) for those undergoing active surveillance, as well as recurrence-free survival (RFS) and time to recurrence for those undergoing resection.

RESULTS

Overall, 103 patients were included, with 68% female and a median follow-up of 44 months [24-74]. The most common tumor locations included the abdominal wall (27%), intra-abdominal/mesenteric (25%), chest wall (19%), and extremity (10%). Initial management included resection (60%), systemic therapy (20%), active surveillance (18%), and cryoablation (2%). Rates of surgical resection significantly decreased (p < 0.001) over time, from 69.6% prior to 2018 to 29.2% after 2018. For those treated with upfront resection, 5-year RFS was 41.2%, and for patients undergoing initial active surveillance, TFS was 66.7% at 2 years, with a median TTT of 4 months [4-10].

CONCLUSIONS

This single-institution cohort at a tertiary medical center spanning over a decade demonstrates the transition to active surveillance for initial management of DTs, and highlights salient metrics in the era of surveillance. This trend mirrors recommended treatment strategies by expert panels and consensus guidelines.

A real-world study on the clinicopathological profile, treatment outcomes and health-related quality of life, anxiety and depression among patients with desmoid tumor at two tertiary care centers in India

Background

The medical management of DT comprises tyrosine kinase inhibitors (TKIs), hormonal agents, anti-inflammatory drugs with the recently approved gamma secretase inhibitor nirogacestat being the current standard of care. Real-world data on evolving treatment landscapes of DT remains scarce.

Methods

This is a retrospective study of patients with DT registered between 1995 and 2020 at All India Institute of Medical Sciences, New Delhi and Tata Medical Center, Kolkata. Baseline characteristics were analyzed in form of median values and interquartile range. Categorical and continuous variables were compared by chi square and independent samples T- tests respectively. Anxiety, depression and QoL were prospectively measured among 30 patients using Hospital Anxiety and Depression (HADS) and Functional Assessment of Cancer Therapy-General (FACT-G) scales respectively between 2022 to 2023.

Results

200 patients were included with a male-predominant (n=111, 55.5%) population and median age 26.5 (2.5-75) years. Extremity (n=100, 50%) and abdomen (n=65, 32.5%) were commonest primary sites and median of 2 (1-4) lines of treatment were received. First-line included surgery (n=116, 58%), systemic therapy (n=67, 33.5%), radiotherapy (10, n=5%) and active surveillance (n=7, 3.5%). First-line systemic agents included tamoxifen (n=55, 27.5%), imatinib (n=7, 3.5%), sorafenib (n=1, 0.5%) and chemotherapy (n=4, 2%). 2019 onward, 3% and 63% underwent active surveillance and surgery respectively. Best radiological response obtained with tamoxifen was stable disease (SD) (n=76, 59%) and partial response (PR) (n=31, 24.2%). Best radiological response obtained with sorafenib was PR (n=17, 60.7%) and SD (n=9, 32.1%). Thirty patients underwent HADS and FACT-G scale assessment. Mean HADS-Anxiety subscale score was 3.6 (+/-3.9 SD) and HADS-Depression sub-scale score was 2.6 (+/-3.5 SD) with clinically significant anxiety and depression in 2 (6.7%) patients each. The overall mean FACT-G score was 87.5 (+/-12.6 SD) and lower mean physical well-being (p=0.006) and emotional well-being (0.017) scores were significantly associated with higher HADS-anxiety (>/=8) scores.

Conclusions

Assessment of anxiety, depression and QoL are paramount to gauge the psychological impact of DT. This study gives an overview of clinical and management profile of patients with DT in India, with limitations of selection bias, heterogeneous population and small sample size for QoL assessment.

Adenomatous Polyposis Coli Gene Mutations, Risk Factors, and Long-term Outcomes Associated With Desmoid Tumors in Patients With Familial Adenomatous Polyposis After Colectomy in Japan

GOALS

To clarify the characteristics of desmoid tumors in Japanese patients with familial adenomatous polyposis after colectomy.

BACKGROUND

Few comprehensive reports have been published on desmoid tumors in Asian patients with familial adenomatous polyposis.

STUDY

This retrospective study included the data of 81 patients with familial adenomatous polyposis who underwent surgery between 1978 and 2021. The adenomatous polyposis coli gene mutation sites, risk factors, and long-term outcomes associated with desmoid tumors in Japanese patients with familial adenomatous polyposis after colectomy were analyzed.

RESULTS

No association was observed between the gene mutation sites and desmoid tumor development in 40 patients who underwent genetic analyses. The rate of desmoid tumor development was 30.3% in 66 patients. Multivariate analysis revealed that age below 32 years at colectomy (hazard ratio = 5.491, 95% confidence interval 1.820-16.50, P < 0.001) and familial adenomatous polyposis-related malignancies other than colorectal cancer (hazard ratio = 5.574, 95% confidence interval 2.075-14.98, P < 0.001) were independent risk factors for desmoid tumor development following colectomy. The 10-year disease-specific survival and overall survival rates for desmoid tumors were 92.9% and 76.9%, respectively. The median surveillance duration was 90 months.

CONCLUSIONS

Adenomatous polyposis coli gene mutation sites alone were not considered a factor for delaying or avoiding colectomy to prevent desmoid tumors in Japanese patients with familial adenomatous polyposis. The timing of colectomy and careful surveillance should be considered for managing patients at a high risk of developing desmoid tumors. Desmoid tumors in patients with familial adenomatous polyposis did not significantly impact prognosis, and pharmacological treatments are important for disease control.

Efficacy and Safety of Auranofin for Progressive Desmoid-Type Fibromatosis: The Study Protocol of an Open-Label Phase II Trial

Background As desmoid-type fibromatosis (DF) exhibits a high recurrence rate after surgery, initial active surveillance followed by medical therapy is the mainstay of the treatment. However, there are few effective drugs with acceptable side effects. Methodology Among drugs that have been used for a long period and possess a known safety profile, auranofin was observed to be effective in suppressing DF using the drug repositioning method in our laboratory. This clinical study has been designed to examine the efficacy and safety of auranofin, an approved anti-rheumatic drug, in patients with progressive DF. Results This study is conducted as a single-center, single-arm, open-label study. Auranofin 3 mg tablets will be administered twice daily to DF patients with progressive disease. The primary endpoint is progression-free survival at 26 weeks after starting treatment. Secondary endpoints include response rate, T2-weighted MRI evaluation, pain intensity, quality of life (QOL), and safety assessment. Conclusions This is the first clinical trial of auranofin in patients with aggressive DF. The study will allow an in-depth understanding of the efficacy of auranofin for response rate as well as for changes in MRI findings, pain, and QOL in patients with aggressive DF.

Complex Surgical Management of Extensive Chest-Wall Desmoid Fibromatosis

Desmoid fibromatosis (DF) is a rare tumor that arises from fibroblasts and myofibroblasts and typically presents on the trunk and limbs. While metastasis of fibromatosis is exceedingly uncommon, DF can spread rapidly to adjacent tissue. Its aggressive nature and frequent recurrence pose challenges for treatment, often requiring a multidisciplinary approach. This case represents the multidisciplinary workup for the identification and management of a rare presentation of desmoid fibromatosis involving the breast. It also discusses the post-surgical follow-up of the patient after a complex resection and reconstruction. We report a case of a patient treated at George Washington University Hospital, Washington, DC. A 26-year-old woman presented with left chest pain. Physical examination revealed an approximately 12-13 cm, ill-defined, immobile mass arising from the left breast. An MRI demonstrated a 9.5 cm spiculated mass involving the left pectoralis major muscle and underlying costal cartilage junctions. The tumor extended deep to the rib margin and along the anterior margin of the pleura. The mass was resected en bloc in a joint case with thoracic and general surgery and reconstructed with a bilateral bi-pedicled, muscle-sparing, transverse rectus abdominis myocutaneous free flap with plastic surgery. Pathology demonstrated desmoid fibromatosis. In conclusion, desmoid tumors of the breast represent a very rare breast neoplasm that can imitate other breast masses, both benign and malignant. Surgery remains an important treatment option and may require coordination and complex surgical planning between various surgical subspecialties.

Transarterial doxorubicin-eluting beads embolization for the treatment of desmoid fibromatosis in the pubic region

Desmoid fibromatosis (DFs) is rare, low-grade neoplasm. Although it poses no risk of metastasis, DFs exhibits a range of clinical manifestations characterized by local infiltrative growth tendencies and a propensity for recurrence. Despite its nonmalignant nature, DFs can be highly debilitating and occasionally life-threatening, causing severe pain and functional limitations. Traditionally, surgery served as the conventional primary treatment approach; nevertheless, a recent shift in paradigm towards a more conservative management has emerged, accompanied by efforts to standardize the strategy among clinicians. Systemic doxorubicin has been demonstrated to be effective in treating DFs; however, it carries potential risks of adverse effects on the cardiovascular, digestive, and hematologic systems. The novel intravascular intervention employing drug-eluting beads loaded with doxorubicin represents an effective treatment for DFs, optimizing drug delivery to the target lesion and reducing systemic toxicity. In this article, we present a rare case of DFs in the right pubic region treated with transarterial doxorubicin-eluting beads embolization.

Different Shades of Desmoid-Type Fibromatosis (DTF): Detection of Noval Mutations in the Clinicopathologic Analysis of 32 Cases

BACKGROUND

Desmoid-type fibromatosis (DTF) is a locally aggressive myofibroblastic/fibroblastic neoplasm with a high risk of local recurrence. It has a variety of histologic features that might confuse diagnosis, especially when detected during core needle biopsy. The Wnt/β-catenin pathway is strongly linked to the pathogenesis of DT fibromatosis.

METHOD

This study examined 33 desmoid-type fibromatoses (DTFs) from 32 patients, analyzing its clinical characteristics, histologic patterns, occurrence rates, relationship with clinical outcomes, immunohistochemical and molecular findings.

RESULTS

The DTFs exhibit a range of 1 to 7 histologic patterns per tumor, including conventional, hypercellular, myxoid, hyalinized/hypocellular, staghorn/hemangiopericytomatous blood vessels pattern, nodular fasciitis-like, and keloid-like morphology. No substantial association was found between the existence of different histologic patterns and the clinical outcome. All thirty-three (100%) samples of DTF had a variable percentage of cells that were nuclear positive for β-catenin. An NGS analysis detected novel non-CTNNB1 mutations in two DTFs, including BCL10, MPL, and RBM10 gene mutations.

CONCLUSIONS

This study reveals a diverse morphology of DTFs that could result in misdiagnosis. Therefore, surgical pathologists must comprehend this thoroughly. Also, the importance of the newly identified non-CTNNB1 gene mutations is still unclear. More research and analyses are needed to completely grasp the clinical implications of these mutations.

Phase II basket trial of dual anti-CTLA-4 and anti-PD-1 blockade in rare tumors (DART) SWOG S1609: the desmoid tumors

BACKGROUND

Dual inhibition using anti-programmed death-1 (PD-1) and anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4) checkpoint inhibitors has proven effective in many cancers. However, its efficacy in rare solid cancers remains unclear. Desmoid tumors are ultrarare soft-tissue tumors, traditionally treated with surgery. This study reviews the first results of using ipilimumab and nivolumab in the desmoid tumor cohort of the SWOG S1609 Dual Anti-CTLA-4 & Anti-PD-1 blockade in Rare Tumors (DART) trial.

METHODS

DART is a prospective/open-label/multicenter (1,016 US sites)/multicohort phase II trial of ipilimumab (1 mg/kg intravenously every 6 weeks) plus nivolumab (240 mg intravenously every 2 weeks) that opened at 1,016 US sites. The primary endpoint included overall response rate (ORR) defined as confirmed complete (CR) and partial responses (PR) based on Response Evaluation Criteria in Solid Tumors (RECIST) v.1.1. Secondary endpoints include progression-free survival (PFS), overall survival (OS), clinical benefit rate (CBR; stable disease (SD) ≥6 months plus CR and PR) and toxicity.

RESULTS

Sixteen evaluable patients (median age: 37) with desmoid tumors and a median of 1.5 prior therapies (with no prior exposure to immunotherapy) were analyzed. The tumors varied in location (eight abdomen, three lower limb, two upper limb, two pelvis, and one neck). ORR was 18.8% (3/16; 3 confirmed PR): 40% regression (PFS 30+ months), 83% regression (PFS 16 months) and 71% regression (PFS 8.4 months). Seven additional patients (43.8%) had prolonged SD over 6 months (PFS: 16.5, 22.4+, 22.6, 30.1, 38.2+, 48.3+ and 60.7+ months). Overall CBR was 62.5% (10/16). Median PFS was 19.4 months, with 6-month PFS of 73% and 1-year PFS of 67%. All patients were alive at 1 year; median OS was not assessable, as 13 patients were alive at analysis. Common adverse events included fatigue, nausea and hypothyroidism, with 50% experiencing grade 3-4 events. There were no grade 5 events.

CONCLUSION

Treatment with ipilimumab and nivolumab in desmoid tumors yielded an ORR of 18.8% and a CBR of 62.5% with durable responses seen. This is the first prospective study exploring the efficacy of this combination in this rare disease. Ongoing studies aim to identify markers for response and resistance. Expanded trials are necessary.

TRIAL REGISTRATION NUMBER

NCT02834013.

Clinical, mechanistic, and therapeutic landscape of cutaneous fibrosis

When dysregulated, skin fibrosis can lead to a multitude of pathologies. We provide a framework for understanding the wide clinical spectrum, mechanisms, and management of cutaneous fibrosis encompassing a variety of matrix disorders, fibrohistiocytic neoplasms, injury-induced scarring, and autoimmune scleroses. Underlying such entities are common mechanistic pathways that leverage morphogenic signaling, immune activation, and mechanotransduction to modulate fibroblast function. In light of the limited array of available treatments for cutaneous fibrosis, scientific insights have opened new therapeutic and investigative avenues for conditions that still lack effective interventions.

Prognostic impact of tumor location and gene expression profile in sporadic desmoid tumor

PURPOSE

Prognostic biomarkers remain necessary in sporadic desmoid tumor (DT) because the clinical course is unpredictable. DT location along with gene expression between thoracic and abdominal wall locations was analyzed.

METHOD

Sporadic DT patients (GEIS Registry) diagnosed between 1982 and 2018 who underwent upfront surgery were enrolled retrospectively in this study. The primary endpoint was relapse-free survival (RFS). Additionally, the gene expression profile was analyzed in DT localized in the thoracic or abdominal wall, harboring the most frequent CTNNB1 T41A mutation.

RESULTS

From a total of 454 DT patients, 197 patients with sporadic DT were selected. The median age was 38.2 years (1.8-89.1) with a male/female distribution of 33.5/66.5. Most of them harbored the CTNNB1 T41A mutation (71.6 %), followed by S45F (17.8 %) and S45P (4.1 %). A significant worse median RFS was associated with males (p = 0.019), tumor size ≥ 6 cm (p = 0.001), extra-abdominal DT location (p < 0.001) and the presence of CTNNB1 S45F mutation (p = 0.013). In the multivariate analysis, extra-abdominal DT location, CTNNB1 S45F mutation and tumor size were independent prognostic biomarkers for worse RFS. DTs harboring the CTNNB1 T41A mutation showed overexpression of DUSP1, SOCS1, EGR1, FOS, LIF, MYC, SGK1, SLC2A3, and IER3, and underexpression of BMP4, PMS2, HOXA9, and WISP1 in thoracic versus abdominal wall locations.

CONCLUSION

Sporadic DT location exhibits a different prognosis in terms of RFS favoring the abdominal wall compared to extra-abdominal sites. A differential gene expression profile under the same CTNNB1 T41A mutation is observed in the abdominal wall versus the thoracic wall, mainly affecting the Wnt/β-catenin, TGFβ, IFN, and TNF pathways.

Aggressive fibromatosis of the sigmoid colon: A case report

BACKGROUND

Aggressive fibromatosis (AF), also known as desmoid tumor or desmoid-type fibromatosis, is a rare soft tissue neoplasm that can occur in almost any part of the body. Although it is a benign disease, AF is aggressive and infiltrative and has a high recurrence rate after surgery. Common sites for intra-abdominal AF are the small bowel mesentery, retroperitoneum, and pelvis. AF in the colon is extremely rare.

CASE SUMMARY

Here, we report the first case of sigmoid colon AF, which was accidentally discovered in a 27-year-old woman during laparoscopic myomectomy. Computed tomography confirmed a slightly enhanced mass in the sigmoid colon. Subsequent colonoscopy did not reveal a mass in the colonic lumen, but a suspected external compress was found in the sigmoid colon. Surgical disease involving a gastrointestinal stromal tumor was suspected. The patient underwent laparoscopic exploration, and sigmoidectomy with a negative margin was performed to excise the mass. Postoperative immunohistochemistry revealed that the mass was an AF. The patient recovered well and was recurrence-free at the 30-month follow-up without adjuvant therapy.

CONCLUSION

AF should be considered in the differential diagnosis of subepithelial colon masses. Radical resection alone can achieve good outcomes.

Setting the international research agenda for sarcomas with patients and carers: results of phase II of the Sarcoma Patient Advocacy Global Network (SPAGN) priority setting partnership

BACKGROUND

Typically, researchers and clinicians determine the agenda in sarcoma research. However, patient involvement can have a meaningful impact on research. Therefore, the Patient-Powered Research Network (PPRN) of the Sarcoma Patient Advocacy Global Network (SPAGN) set up a Priority Setting Partnership (PSP). The primary objective of this partnership is to identify priorities for research and patient advocacy topics.

METHODS

In the first phase of this PSP, including 264 sarcoma patients and carers from all over the world, 23 research topics regarding sarcomas and 15 patient advocacy topics were identified using an online survey. In the second phase, participants were asked to fill in a top five and a top three of research and patient advocacy topics, respectively. Additionally, sociodemographic characteristics and sarcoma characteristics were collected. Social media channels, local national patient advocacy groups and the SPAGN website were used to distribute the survey.

RESULTS

In total, 671 patients (75%) and carers (25%) participated in this survey. The five highest ranked research topics were related to causes of sarcoma (43%), prognosis and risk of recurrence (40%), specific subtypes of sarcoma (33%), the role of immunotherapy, targeted therapy and combined therapy (30%), and hereditary aspects (30%). The three highest ranked patient advocacy topics were improving the diagnostic process of sarcoma (39%), access to tumor DNA analysis (37%) and establishing an international sarcoma registry (37%).

CONCLUSIONS

This sarcoma PSP has identified priorities for research and patient advocacy, offering guidance for researchers, assisting funding agencies with assessing project relevance and empowering patient advocates to represent the needs of patients and carers.

First Description of the Clinical Activity of Avapritinib in Sporadic Mesenteric Desmoid Tumor

Desmoid tumors (DTs) are rare and locally aggressive with a high rate of local recurrence even with optimal surgical resection. Systemic treatments are often utilized for desmoid cases with high risk of surgical morbidity or for local and symptomatic control of recurrent disease. However, the systemic treatment options for DTs are limited with limited responses. Avapritinib is a tyrosine kinase inhibitor (TKI) approved in 2020 for adults with unresectable or metastatic gastrointestinal (GI) stromal tumors (GISTs) harboring a platelet-derived growth factor receptor alpha (PDGFRA) Exon 18 mutation, including D842V mutations. In this case report, we describe a 55-year-old man with a history of D842V-mutant gastric GIST who presented several years after complete resection of the GIST with an enlarging soft tissue mass in the small intestine. After a nondiagnostic biopsy, the patient was started on avapritinib due to concerns for recurrent D842V-mutant GIST. The tumor had a partial response to treatment by RECIST 1.1 criteria, and the patient underwent surgical resection. The final pathology report revealed a sporadic DT. To our knowledge, this is the first known description of the activity of avapritinib in the treatment of a sporadic mesenteric DT, which is relevant given the limited treatment options for patients with this diagnosis. This clinical finding may be worth exploring in a dedicated clinical trial.

Real-life experience with sorafenib for advanced and refractory desmoid-type fibromatosis

BACKGROUND

In recent years, there has been a change in the therapeutic landscape of desmoid-type fibromatosis (DF). Watchful waiting is now preferred over initial local treatments such as surgery and radiotherapy. Systemic treatment is considered for progressive or symptomatic disease. The aim of this study is to review real-life data on the use of sorafenib in DF.

METHODS

We established a retrospective dataset of patients treated with sorafenib in our centre, Ghent University Hospital, for progressive DF. Patient demographics, disease characteristics, response to therapy using Response Evaluation Criteria in Solid Tumours 1.1 criteria and toxicity according to CTCAE v5.0 were assessed.

RESULTS

Eleven patients with DF were treated with sorafenib between 2020 and 2024. Median treatment duration was 20.4 months (95% confidence interval [CI], 10.0-NR). 36.4% achieved partial response, 54.5% stable disease and 9.1% progressive disease. For three patients, the treatment is ongoing. The median time to objective response rate is 15.0 months (95% CI, 8.8-NR). The majority (81.8%) experienced grade 2 toxicity, and one third of patients grade 3 toxicity (36.4%). The most common all-grade adverse event was skin toxicity (hand-foot syndrome, pruritus and rash) (90.9%). Nine patients (81.8%) needed dose reduction with a median time to first reduction of 1.1 months (95% CI, 0.5-NR). One patient stopped treatment due to toxicity.

INTERPRETATION

Real-life data on the use of sorafenib in the treatment of DF is consistent with published data in clinical trial setting. Sorafenib is an effective treatment option for progressive DF although associated with significant toxicity and the need for rapid dose reduction.

Current Management of Desmoid Tumors: A Review

Importance

Desmoid tumor (DT) is a rare and locally aggressive monoclonal, fibroblastic proliferation characterized by a variable and often unpredictable clinical course. Previously, surgery was the standard primary treatment modality; however, within the past decade, a paradigm shift toward less-invasive management has been introduced and an effort to harmonize the strategy among clinicians has been made. To update the 2020 global evidence-based consensus guideline on the management of patients with DT, the Desmoid Tumor Working Group convened a 1-day consensus meeting in Milan, Italy, on June 30, 2023, under the auspices of the European Reference Network on Rare Adult Solid Cancers and Sarcoma Patient Advocacy Global Network, the Desmoid Foundation Italy, and the Desmoid Tumor Research Foundation. The meeting brought together over 90 adult and pediatric sarcoma experts from different disciplines as well as patients and patient advocates from around the world.

Observations

The 2023 update of the global evidence-based consensus guideline focused on the positioning of local therapies alongside surgery and radiotherapy in the treatment algorithm as well as the positioning of the newest class of medical agents, such as γ-secretase inhibitors. Literature searches of MEDLINE and Embase databases were performed for English-language randomized clinical trials (RCTs) of systemic therapies to obtain data to support the consensus recommendations. Of the 18 full-text articles retrieved, only 4 articles met the inclusion criteria. The 2023 consensus guideline is informed by a number of new aspects, including data for local ablative therapies such as cryotherapy; other indications for surgery; and the γ-secretase inhibitor nirogacestat, the first representative of the newest class of medical agents and first approved drug for DT. Management of DT is complex and should be carried out exclusively in designated DT referral centers equipped with a multidisciplinary tumor board. Selection of the appropriate strategy should consider DT-related symptoms, associated risks, tumor location, disease morbidities, available treatment options, and preferences of individual patients.

Conclusions and Relevance

The therapeutic armamentarium of DT therapy is continually expanding. It is imperative to carefully select the management strategy for each patient with DT to optimize tumor control and enhance quality of life.

Desmoid Tumor after Sleeve Gastrectomy: Case Report and Literature Review

Desmoid tumor is a rare mesenchymal neoplasm of unknown etiology. Despite rare, the diagnosis of desmoid tumors after bariatric surgery is increased over the last few years. We report a case of a 26-year-old male with complains of abdominal pain and postprandial fullness, diagnosed with a locally advanced large intra-abdominal mass (40 × 21 × 11.7 cm) centered in the mesentery, developed 3 years after sleeve gastrectomy. Percutaneous biopsy was suggestive of a mesenquimatous tumor and the patient underwent surgery. R0 surgical resection was achieved, despite intimal contact and common vascularization with a jejunal loop. Histopathology examination of the surgical specimen revealed fusiform to stellate cells with mild atypia, thin-walled vessels, and diffuse beta-catenin expression (negative for DOG-1, CD117, CD34, S100, desmin, and alpha-actin). The diagnosis of a desmoid tumor was made. The patient remained asymptomatic, and no recurrence occurred over a 4-year follow-up. With the increasing number of bariatric surgeries, owing to the alarming growing incidence of obesity and related conditions, it is expected that desmoid tumors reports will gradually increase over the next few years. Thus, both gastroenterologists and surgeons should be aware of the potential for desmoid tumor development shortly after surgery, to offer a prompt diagnosis and treatment.

[Recurrence of a Desmoid Tumour in a Scar at the Donor Site of a Latissimus Dorsi Flap]

A desmoid tumour, also known as aggressive fibrous tumour or desmoid fibromatosis, is a rare, benign tumour originating from connective tissue cells. Desmoid tumours account for approximately 0.03+% of all neoplasms and less than 3+% of all soft tissue tumours. The estimated incidence in the general population is 2 to 4 cases per million people per year [1]. Desmoid tumours are characterised by aggressive growth but typically do not metastasize. They often occur in young adults and preferably affect specific body regions such as the abdomen, shoulder, chest, or extremities. The exact cause of the condition is not fully understood, but genetic changes and hormonal factors may play a role. Symptoms of a desmoid tumour depend on its location and size, with pain, swelling, or restricted movement commonly occurring. A diagnosis is typically made through a tissue sample (biopsy) and imaging techniques such as MRI or CT [2]. To our knowledge, this is the first documented case of recurrence of a desmoid tumour in the scar at the donor site of a latissimus dorsi flap previously used for the reconstruction of desmoid resection in the lower leg.