Multimodality treatment in the control of deep musculoaponeurotic fibromatosis

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

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

Fibromatosis presenting as a sacrococcygeal mass

Most children older than a year who present with a sacrococcygeal mass have a malignant tumor. We describe an 8-year-old child with of a sacrococcygeal soft tissue mass that was completely resected with histologic findings consistent with fibromatosis. Fibromatosis is a deep-seated, musculoaponeurotic, borderline tumor that is rare in childhood and has a high incidence of local recurrence even after margin-free resection. We review and discuss management strategies for treatment of fibromatosis in children. This case represents the first report of fibromatosis presenting as a sacrococcygeal mass.

Aggressive fibromatosis: MRI features with pathologic correlation

OBJECTIVE

We present the MRI features with pathologic correlation of aggressive fibromatosis, incorporating 203 cases over a 5-year period from the Royal Marsden Hospital Sarcoma Unit database.

MATERIALS AND METHODS

Sixty patients had imaging available for retrospective review of which 29 had preoperative MRI and final histopathologic diagnosis of aggressive fibromatosis.

RESULTS

The average age at diagnosis was 41.3 years with a female-to-male sex ratio of 1.2:1. Twenty lesions were extraabdominal; six, intraabdominal; and three, in the abdominal wall (classic desmoid). The average tumor size was 6.4 cm (range, 2.2-13.7 cm). Intraabdominal aggressive fibromatosis produced the largest tumors, averaging 9.5 cm. Most lesions were ovoid (52%) or infiltrative (34.5%) in outline with an irregular or lobulated contour (76%). The lesions crossed major fascial boundaries in 31% of cases overall and in 66% of patients referred for recurrent disease. On MRI, homogeneous isointensity or mild hyperintensity on T1-weighted images and heterogenous high signal on T2-weighted or STIR images were seen. All lesions enhanced after IV gadolinium, usually avidly. In contrast to previous reports, 38% of cases failed to show low signal on all pulse sequences and no abnormalities were seen in local bone structures. Histology showed sheets of bland spindle cells in dense collagen and did not vary with the MRI signal characteristics of the lesion. Patients referred for recurrent disease were most likely to have a recurrence after surgery. MRI and pathology findings did not predict recurrence.

CONCLUSION

Accurate diagnosis and staging of aggressive fibromatosis by MRI have important treatment and prognostic implications.

Aggressive fibromatosis of the abdominal wall, limbs and limb girdles

Background

Aggressive fibromatosis (AF) is a rare soft-tissue tumour. It is histologically benign but locally aggressive and destructive. Surgery is the mainstay of treatment. This was a review of patients treated at the Royal Marsden Hospital between 1986 and 2003.

Methods

Records of patients with abdominal wall (23) and limb or limb girdle (86) AF were studied to determine patient, tumour and treatment characteristics and outcome. Children and patients with intra-abdominal AF were excluded. The data were analysed by Cox regression to calculate univariate hazard ratios.

Results

Twenty-one (19·3 per cent) of 109 patients developed recurrence after a median follow-up of 39 months. Recurrence did not correlate with surgical margin or any other variable.

Conclusion

Wide excisional, function-preserving surgery is the goal in treatment of AF. Surgery for recurrent disease is often curative. Tumours are frequently irresectable at presentation and an initial period of expectant observation is advisable because growth arrest is a common feature of the disease.

Quality of surgery and outcome in extra-abdominal aggressive fibromatosis: a series of patients surgically treated at a single institution

PURPOSE

To explore prognostic factors in surgically treated aggressive fibromatosis (extra-abdominal desmoid tumor).

PATIENTS AND METHODS

A total of 203 consecutive patients treated with surgery over a 35-year period at a single referral center were retrospectively reviewed. One hundred twenty-eight were first seen at our institution with primary disease, whereas 75 had a recurrent tumor. All patients underwent macroscopically complete resection. Margins were rated as negative in 146 (97 with primary tumors, 49 with recurrences) and positive in 57 (31 in primary, 26 in recurrences) patients. Median follow-up was 135 months.

RESULTS

Patients with primary disease had a better disease-free survival rate than those with recurrence (76% v 59% at 10 years). Presenting with a recurrence was also the strongest predictor of local failure in the multivariate analysis. In patients first treated for primary disease, size and site had prognostic significance, whereas microscopically positive surgical margins did not. In contrast, in patients with recurrence, there was a trend toward better prognosis if margins were negative (although this was not significant at multivariate analysis).

CONCLUSION

Presence of microscopic disease does not necessarily affect long-term disease-free survival in patients with primary presentation of extra-abdominal desmoid tumors. Thus, function-sparing surgery may be a reasonable choice when feasible without leaving macroscopic residual disease. In patients with recurrences, positive margins may more clearly affect prognosis, potentially necessitating adjuvant radiation in selected cases.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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