Multifocal desmoid tumor in childhood: report of two cases and review of the literature

Desmoid tumors in the pediatric population

Desmoid tumors are benign soft tissue tumors associated with locally aggressive growth and high rates of morbidity, but they do not metastasize via lymphatic or hematogenous routes. While most of the data on desmoid tumors originates in the adult literature, many of the findings have been applied to the management of pediatric patients. This article discusses the epidemiology, etiology, clinical presentation, pathology, and treatment of this rare tumor in the pediatric population and includes a literature review of the most recent large series of pediatric patients with desmoid tumors.

A prospective phase II trial of vinblastine and methotrexate in multivessel intraluminal pulmonary vein stenosis in infants and children

OBJECTIVE

To determine the safety and efficacy of the chemotherapeutic agents vinblastine and methotrexate in the treatment of children with progressive multivessel intraluminal pulmonary vein stenosis (PVS).

METHODS

Children received weekly vinblastine and methotrexate for a period of 1 year. Outcomes (for patients receiving ≥1 month of chemotherapy) were classified separately for patients with isolated PVS and PVS with congenital heart disease (CHD). Primary efficacy outcome was "response to treatment" categorized by echocardiographic criteria of response. Survival to 1 year was also evaluated. All adverse events were classified according to Cancer Therapy Evaluation Program, Common Terminology Criteria version 3.0. Events were further classified as related to chemotherapy, cardiac, or other causes.

RESULTS

Among 29 patients enrolled, 28 received at least one dose of chemotherapy and were evaluable for toxicity, while 23 were evaluable for response (21 CHD, 2 isolated). Both patients in the isolated group had progressive disease and died. Overall, 33% (7/21) of patients with PVS and CHD had stable disease; 1-year survival of 38%; and four patients continue in remission (93, 96, 124, and 125 months after treatment initiation). While both cardiac-related (19%) and chemotherapy-related (53%) toxicities were common, most were asymptomatic laboratory changes. Grade 3 (13%) and grade 4 (4%) toxicities were reversible, and no treatment-related grade 5 toxicities were observed.

CONCLUSION

We report on the first prospective trial of chemotherapy for infants and children targeting the presence of myofibroblastic cells within the lesions of PVS based on myofibroblastic proliferation associated with desmoid tumors of infancy. The toxicity profile resulted in numerous treatment delays and interruptions that, combined with limited information on the natural history of PVS in this patient population, hampered our ability to determine the true efficacy of this approach. These results will be important as a baseline for clinical trials in this patient population.

[Desmoid tumor of the breast in a 9 years old little girl]

Aggressive fibromatosis (desmoid tumour) of the breast is a rare tumour that accounts only for 0.2% of primary breast tumours. This is a benign mesenchymal tumour that develops from muscular fasciae and aponeuroses. It is characterized by its local evolution and its tendency to relapse without metastasizing. Wide radical resection should be attempted whenever possible. Positive margins at resection and reoperation are associated with a high risk of local recurrence. The role of radiotherapy and of medical treatments- especially anti-estrogens - remains unclear. We report here the case of desmoid tumour of the breast arising in a 9-year-old little girl.

Multicentric extra-abdominal desmoid tumors arising in bilateral lower limbs

Extra-abdominal desmoid tumors preferentially affect the shoulders, arms, backs, buttocks, and thighs of young adults. Multicentric occurrence is rather rare but seems to be another distinctive feature of extra-abdominal desmoid tumors. In this article we report a rare case of multicentric extra-abdominal desmoid tumors arising in bilateral lower limbs.

Multicentric extra-abdominal desmoid tumours

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

Extra-abdominal desmoid tumour of the breast: review of the primary management and the implications for breast reconstruction

This case report illustrates the presentation and management of an extra-abdominal desmoid tumour of the breast. A review of the literature describing the aetiology, pathology and risk of recurrence was undertaken to determine how current understanding of this rare tumour may affect the management of patients, should they require breast reconstruction after radical excision of the primary tumour. The natural progression of the disease is variable and there are no markers predictive of recurrence or regression. Primary lesions should be assessed with respect to their anatomical site of origin (i.e. whether they arise within the breast or invade the breast from the underlying musculo-aponeurotic tissue) and the extent of local invasion. Radical excision of the tumour with clear histological margins decreases the likelihood of recurrence. Tumours arising from the musculo-aponeurotic system have increased risks of recurrence and of developing multifocal primary tumours in specific anatomical territories. Local recurrences should be assessed for extent and anatomical distribution, and radical excision performed as for a primary tumour. Radiotherapy can be used as an alternative treatment if radical excision of a primary or recurrent tumour would cause severe functional loss or mutilation. Radiotherapy can be used for positive histological margins following tumour excision. There is a higher risk of recurrence in the first 3 years after primary excision, and breast reconstruction may be best delayed for this period. Surgical trauma has been implicated in the aetiology of recurrence and the patient should be informed of this prior to breast reconstruction.