Large desmoid tumour of the small bowel mesentery

A 74-year-old man was being investigated for a pancreatic insulinoma when an incidental mesenteric mass measuring 2.6 cm x 2.5 cm was noticed on CT imaging. A wait-and-see approach was decided on. Thirty-nine months later, the patient presented with symptoms of abdominal obstruction. CT images revealed the mesenteric mass filled majority of the abdominal cavity and measured 29 cm x 26 cm x 16 cm. The patient underwent an open bypass gastrojejunostomy which stopped working a few weeks later due to further compression by the tumour. A debulking surgery was performed: a right hemicolectomy and small bowel resection with excision of the desmoid tumour and bypass gastrojejunostomy. The tumour measured 12.6 kg and was macroscopically visualised to have a white cut surface with a focal translucent area. Microscopic analysis revealed bland spindle cells with pale eosinophilic cytoplasm showing no cytological atypia, in keeping with a mesenteric desmoid tumour. Currently, two and a half years from the debulking surgery, the patient remains well and in remission with planned surveillance.

Familial adenomatous polyposis associated with desmoid tumors presenting with abdominal abscess: A case report and literature review

RATIONALE

Familial adenomatous polyposis (FAP) associated with desmoids tumors (DTs) complicated by abscess formation is rare. The management is not easy and the choice of the best treatment may be controversial.

PATIENT CONCERNS

A 33-year-old man was admitted to our hospital for abdominal pain, fever, chills, nausea, and vomiting. He had a family history of FAP, and history of abdominal surgery.

DIAGNOSES

An abdominal enhanced chest computed tomography (CT) scan revealed a soft tissue mass in the abdominal wall and an irregular mesenteric soft tissue mass with internal fistula and intra-abdominal abscess. A CT-guided biopsy of the abdominal wall mass revealed DTs.

INTERVENTIONS

The patient was given oral antibiotics for 6 months, and ultimately underwent surgery.

OUTCOMES

The patient had no evidence of recurrence on follow-up at 10 months.

LESSONS

This case indicates that for patients with FAP who have a history of abdominal surgery and a progressively enlarging mass and abscess in the abdomen, it is necessary to consider the possibility of DTs. FAP-related DTs are rarely complicated by abscess formation. Antibiotic therapy plus surgical resection of the tumor may be effective and make good prognosis.

Surgical management of a giant abdominal wall desmoid tumour

Desmoid tumours are clonal fibroblastic proliferations in soft tissues, characterised by infiltrative growth and local recurrence, but not metastasis. Various treatment strategies for desmoid tumours exist, varying from observation, medical and systemic therapy to radiotherapy and surgery. A 25-year-old woman with a background of familial adenomatous polyposis was referred with an enlarging abdominal desmoid tumour measuring 40×40×40 cm despite repeated radiofrequency ablation, surgical debulking and hormone therapy. The patient had a two-stage operation. The first stage involved excision of the desmoid tumour with full-thickness abdominal wall. The abdominal wall was not closed, and a topical negative pressure seal was applied. After 2 days, she underwent the second stage: reconstruction of the abdominal wall defect with a large porcine mesh which was covered with anterolateral thigh flaps. Postoperative complications included ileus and a fall which required further surgery. The patient was discharged 1 month after the first operation. Abdominal MRI scans were performed at 3 and 7 months postdischarge and showed no recurrence of diseaseBackground.

Retroperitoneal fibromatosis presenting as a mesenteric mass: A case report

RATIONALE

Fibromatoses or desmoid tumors are relatively rare tumors derived from the musculoaponeurotic system. This tumor has no specific clinical symptoms and it is sometimes misdiagnosed as other diseases such as gastrointestinal stromal tumors (GISTs).

PATIENT CONCERNS

A 28-year-old man visited Peking Union Medical College for a tangible abdominal mass without abdominal pain or distention.

DIAGNOSES

Considering the imaging characteristics and clinical manifestation, this mass was primarily diagnosed as GIST before surgery. During the surgery, the occupancy was found under the ileocecal mesentery, with grayish white appearance, tough texture, and poor mobility, which was not consistent with the character of the GIST. After the surgery, pathological examination and individual immunohistochemistry results demonstrated that the lesion was compatible with the diagnosis of retroperitoneal fibromatosis with purulent inflammation of chronic lymphadenitis.

INTERVENTIONS

Therefore, we decided to perform tumor mass resection, right colon resection, partial duodenum resection, and intestinal anastomosis on laparotomy, but the right ureter was retained. After excision of the tumor, the ends of the intestine segment were continuously sutured.

OUTCOMES

The patient experienced no intraoperative or postoperative complications, and was discharged 3 days after surgery. Periodic follow-up physical examinations such as the abdominal ultrasound and computed tomography were performed each 3 months, and no evidence of recurrence was observed during the whole 12 months.

LESSONS

To sum up, intra-abdominal fibromatosis is an extremely rare tumor that must be differentiated from other tumors of the digestive tract, and pathological and immunohistochemical examination is a critical part of the diagnosis. Early diagnosis of fibromatosis is essential for the outcome. Extensive resection of the mass minimizes the risk of relapse.

A giant mesenteric fibromatosis involving the muscular layer of the colon wall: A case report

RATIONALE

Mesenteric fibromatosis (MF) is a rare tumor whose biological behavior is intermediate between benign fibrous neoplasms and fibrosarcomas, and the characteristic of these tumors are local aggressive lesions which is prone to local recurrence but non-metastasizing. The common symptom is abdominal distention or painless mass. We report a case of giant MF in abdominal cavity with abdominal distention as the main symptom.

PATIENT CONCERNS

A 26-year-old male presented with 2-month history of abdominal distention, lack of appetite, and symptoms grew progressively more debilitating with time.

DIAGNOSES

This patient underwent a contrast-enhanced computed tomography scan which showed a giant (37 × 25 × 13 cm), inhomogeneous enhancing, well-defined, and soft tissue density mass in abdominal cavity, possibly arising in mesocolon, which suggested a high possibility of MF. The postoperative pathology showed that the tumor cells to be positive for β-catenin, vimentin, negative for CD34, CD117, DOG-1, S-100, Desmin, which confirmed the diagnosis of MF.

INTERVENTIONS

Exploratory laparotomy was performed, which revealed a large mass involving the transverse colon wall, the root of mesocolon, and encasing the middle colic vessels and the 1st branch of jejunal arteries. The complete surgical resection was performed and the mass weighted 10 kilograms (kg).

OUTCOMES

The patient recovered uneventfully and was discharged 9 days after surgery. Three-month, 6-month, 12-month and 18-month on follow-up after surgery, showed no evidence of recurrence.

LESSONS

The MF is a very rare tumor, especially a giant tumor (10 kg) involving the muscular layer of colon wall. In addition, treatment of giant MF still remains a challenge. We consider that surgical resection with negative margins is the goal but not at the expense of damaging the function of vital organs. Specific measures should be considered based on the individual patient in order to relieve symptoms and improve quality of life.

New intra-abdominal mass after operation for colorectal cancer: desmoid tumor versus peritoneal seeding

PURPOSE

To identify differential clinical and imaging findings between intra-abdominal desmoid tumors and peritoneal seeding that developed after surgery for colorectal cancer.

METHODS

8 patients (9 desmoid tumors) and 11 patients (13 peritoneal seeding masses) were enrolled in our retrospective study. Patients with three or more tumors were excluded. Clinical findings including location of initial tumors, type of surgery, T- and N-stages of initial tumors, time interval between initial surgery and development of intra-abdominal tumors, and level of carcinoembryonic antigen (CEA) were evaluated. Imaging findings of intra-abdominal tumors including size, number, growth rate, location, shape, homogeneity, relative enhancement, and maximum standardized uptake value were evaluated. The Mann-Whitney U test and Fisher's exact test were used to compare clinical and imaging findings between desmoid tumors and peritoneal seeding.

RESULTS

In patients with a desmoid tumor, initial T-stage, initial N-stage, and level of CEA at the time of surgery for intra-abdominal tumor were lower than in patients with peritoneal seeding (p = 0.027, p = 0.033, and p = 0.017). The desmoid tumors were frequently located in the small bowel mesentery (p = 0.018) and were larger at detection (p = 0.041). Round or ovoid shapes on CT images were more frequently observed with the desmoid tumors (p = 0.035).

CONCLUSIONS

Stage of colorectal cancer, CEA level, and location, size, and shape of new intra-abdominal tumors can be helpful for differentiating between intra-abdominal desmoid tumors and peritoneal seeding in patients with a history of colorectal cancer surgery.

Duodenum-derived fibromatosis that invaded the muscular layer of intestinal wall: A rare case report

RATIONALE

Intraabdominal fibromatosis is a rare benign tumor that often affects the mesentery or retroperitoneum, and can infiltrate adjacent organs. However, it is rare for fibromatosis to arise from the small intestinal wall.

PATIENT CONCERNS

A 27-year-old female with a tangible abdominal tumor is described.

DIAGNOSES

The computed tomography (CT) scan revealed a 7.5 cm, small intestine-associated tumor in the right abdomen.

INTERVENTIONS

The patient received tumor resection and intestinal anastomosis.

OUTCOMES

Further pathological examination confirmed the tumor as a duodenal fibromatosis that infiltrated the intestinal wall. To the best of our knowledge, this is the first report of a duodenum-derived fibromatosis that invaded the muscular layer of the intestine.

LESSONS

Our study demonstrated that an unexplained abdominal mass should be noteworthy and properly treated.

High-intensity focused ultrasound treatment for intra-abdominal desmoid tumors: a report of four cases

Desmoid tumors are rare clonal fibroblastic proliferations that can arise at abdominal or extra-abdominal sites. Complete surgical resection is the primary treatment for resectable desmoid tumors, but a high rate of local recurrence has been reported even after complete resection. For patients with a recurrent tumor, the goals of treatment are to control the recurrence, maintain quality of life, and prolong survival. Radiofrequency ablation, radiotherapy, chemotherapy, and other medical therapies can be used as alternative methods, but there are considerable controversies over the roles of these methods in the management of desmoid tumors. High-intensity focused ultrasound (HIFU) is a minimally invasive and effective method for treatment of solid tumors. We used HIFU to treat four patients with intra-abdominal desmoid tumors from June 2011 to September 2013. Post-procedural pain was seen in all patients. One patient had an intra-abdominal abscess and another suffered a slight injury to the femoral nerve. The patients were followed up for 19-46 months (mean 34 months) until April 2015. The tumor in one patient disappeared, and no tumor progression was observed in the other patients.

Intra-abdominal fibromatosis: differentiation from gastrointestinal stromal tumour based on biphasic contrast-enhanced CT findings

AIM

To identify the computed tomography (CT) criteria that differentiate intra-abdominal fibromatosis (IAF) from gastrointestinal stromal tumour (GIST).

MATERIALS AND METHODS

CT images of 34 pathologically proven cases of IAF (n = 15) and GIST (n = 19) were retrospectively reviewed. Location, contour, border, enhancement pattern, presence of necrosis, vessels, and air within the lesion were analysed. Long diameter (LD), short diameter (SD), LD/SD ratio, degree of enhancement, and lesion/aorta (L/A) CT attenuation ratio were measured and calculated. Significant CT criteria were identified using Fisher's exact test, grouped t-test, and receiver operating characteristic (ROC) curve. Sensitivity and specificity values were calculated when single or multiple CT criteria were used.

RESULTS

Extra-gastrointestinal location, ovoid or irregular contour, homogeneous enhancement, absence of intra-lesional necrosis, lower degree of enhancement, and L/A CT attenuation ratio differentiated IAF from GIST (p < 0.05). When any three of these eight criteria were combined, the sensitivity and specificity for diagnosing IAF were 100% (15 of 15) and 89.5% (17 of 19), respectively.

CONCLUSION

The following eight CT criteria are helpful to differentiate IAF from GIST: extra-gastrointestinal location, ovoid or irregular contour, homogeneous enhancement, absence of intra-lesional necrosis, a degree of enhancement of less than 40.5 HU in the arterial phase versus 46.5 HU in the portal venous phase, and an L/A CT attenuation ratio <0.315 in the arterial phase versus 0.525 in the portal phase.

Desmoid tumorsA clinical review of 30 patients with more than 20 years’ follow-up

We retrospectively studied the outcome in a consecutive series of 30 patients with desmoid tumors who were followed for more than 20 years after treatment (surgery in 29 patients). A local recurrence occurred in 12 patients and more than 1 recurrence occurred in 8. 3 patients had spontaneous complete regression of the tumor. At follow-up after mean 28 (20-54) years, all patients were tumor-free except 1 who had had a stable tumor for at least 11 years. Symptoms were related more to treatment than to the tumor. We conclude that desmoid tumors may have a high capacity for self-limitation and that conservative therapy should be considered in symptom-free patients.

Uptake characteristics of fluorodeoxyglucose (FDG) in deep fibromatosis and abdominal desmoids: potential clinical role of FDG-PET in the management

In this preliminary report, we explore the uptake pattern of fluorodeoxyglucose (FDG) in fibromatosis and hypothesize the potential clinical role of FDG-positron emission tomography (PET) in the management of this benign but locally aggressive heterogeneous group of soft-tissue tumours. Five patients were studied (two men and three women, age range 23-35 years), among whom were three cases of deep musculoskeletal fibromatosis, one of abdominal fibromatosis (abdominal desmoid) associated with familial adenomatous polyposis (Gardner's syndrome) and one case of both deep musculoskeletal fibromatosis and abdominal desmoid. The FDG uptake in the lesions was heterogeneous in four cases and relatively homogeneous in one case. The uptake ranged from low to moderate grade with areas or foci of relatively avid FDG uptake. The maximum standardized uptake value (SUV(max)) observed was up to 4.7; the avidity probably related to the biological aggressiveness and tendency for recurrence, characteristic of fibromatosis. A dual-point FDG-PET carried out over four active foci in two cases registered an increase in SUV ranging from 6.93% to 25.85% (mean 19.28%). Treatment monitoring with chemotherapy was carried out in two cases: the reduction in FDG uptake was consistent with the histological evidence of fibrosis and reduction in mitosis. Hence, a baseline FDG-PET can serve a valuable role in monitoring the effect of systemic pharmacotherapy in patients with recurrent progressive disease after unsuccessful local-regional treatment. The findings in this report can be extrapolated and have implications for studying the utility of FDG-PET in defining aggressiveness, guiding biopsy and defining excision site in a large tumour and in monitoring therapy in fibromatosis.

Mesenteric fibromatosis with involvement of the gastrointestinal tract

Primary mesenteric fibromatosis is a rare condition. The aggressive nature of these tumors and the potential for major morbidity secondary to resection makes it a challenging disease for the surgeon. We report a case of mesenteric fibromatosis with involvement of small bowel.

Spontaneous isolated mesenteric fibromatosis: sonographic and computed tomographic findings with pathologic correlation

Eight cases of spontaneous isolated mesenteric fibromatosis (SIMF) were retrospectively reviewed. Clinical presentations included palpable abdominal mass (n = 6), abdominal pain (n = 4), gastrointestinal bleeding (n = 2) and acute abdomen (n = 1). On sonography and computed tomography (CT), eight SIMFs (size range 3 to 24 cm, mean 14.8 cm) were categorized into four morphologic patterns: well-defined inhomogeneous, well-defined homogeneous, well-defined cystic or infiltrative mesenteric mass patterns. Well-defined inhomogeneous SIMF (n = 3) was correlated with the histopathologic finding of bundles of fibroblasts with unevenly intermingled hyaline and/or myxoid degeneration areas, whereas well-defined homogeneous SIMF (n = 2) showed scarce degenerative changes. Well-defined cystic SIMF (n = 2) were ascribed to the presence of large areas of myxoid and cystic degenerations. One SIMF presented as an infiltrative mesenteric mass and the patient died 10 months after diagnosis. Both cases of cystic SIMFs showed tumor recurrences and one patient died after 84 months. The other five patients were cured by radical tumor resection. In summary, sonography, similar to CT, is also useful for evaluating SIMF with protean morphologic features, ascribing to the underlying histopathologic changes with varied degrees of hyaline, myxoid or cystic degenerations.

Giant mesenteric fibromatosis presenting as small bowel obstruction

Mesenteric fibromatosis is a proliferative fibroblastic neoplasia of the small intestine mesentery that may occur as a unique or multiple formation. Mesenteric fibromatosis is a rare, locally aggressive neoplasm and may present with abdominal discomfort, abdominal pain, weight loss, or symptoms of ureteral obstruction, mesenteric ischemia, or intestinal obstruction. It is of the utmost importance to distinguish mesenteric fibromatosis from gastrointestinal stromal tumors. Histopathology accurately differentiates between these two distinct entities. The preferred treatment is local surgical excision with a margin of uninvolved tissue. The involvement of important structures like the superior mesenteric artery and the superior mesenteric vein may pose a challenge during resection, but these tumors can be excised and the vessels repaired primarily.

Inoperable aggressive mesenteric fibromatosis with ureteric fistula. Case report and literature review

The purpose of our report is to illustrate an aggressive case of mesenteric fibromatosis in a 17-year-old girl with a ureteric fistula and to review imaging and pathological features, natural history and treatment options of this disease. Our patient underwent computed tomography that revealed a widespread intra-abdominal mass. The necrotic centre of this mass had a fistulous communication with the right ureter. Fibromatoses represent a spectrum of uncommon benign conditions characterised by proliferating fibrous tissue. The deep intra-abdominal form of mesenteric fibromatosis (MF), one of the rare subtypes of the 'fibromatoses' or 'desmoid tumours', grows rapidly and may become extensive. Surgery provides good results in limited disease and non-surgical modalities in cases of unresectable and residual disease.

Aggressive intra-abdominal fibromatosis in children and response to chemotherapy

Intra-abdominal fibromatosis (IAF) is a rare benign neoplasm arising from the abdominal fibrous tissue, mostly in the mesentery. IAF is characterized by a tendency to infiltrate the surrounding vessels and vital structures and recurrence after usually incomplete surgical removal. Accordingly, IAF is associated with considerable morbidity and mortality. The authors report on a boy who presented with a large IAF at the age of 5 years. Within 6 months after initial presentation, he underwent 4 subsequent abdominal explorations for diagnosis, tumor reduction, and intestinal obstructions. IAF was confirmed by the presence of vimentin and absence of other biological cell markers. Due to accelerated tumor growth and deteriorated general condition, as a last resort, a chemotherapy trial with vincristin and methotrexate was carried out. This regimen proved to be effective in reducing the tumor burden and improving the patient's general condition. Outcome of IAF depends on early diagnosis and complete tumor resection, and, if indicated, timely employment of neo/adjuvant chemotherapy. Radiotherapy must be considered in life-threatening conditions as the last resort in a growing child [2-4].

An unusual case of ureteric obstruction

We report a case of a 33-year-old female presenting with right sided abdominal pain, a right iliac fossa mass and right hydronephrosis. The mass was subsequently shown to represent an isolated desmoid tumour compromising the adjacent ureter. The patient had no predisposing factors for this pathology. This is an uncommon occurrence and we discuss the imaging features and differential diagnosis.

Diffuse intra-abdominal fibromatosis-report of a new entity with review of literature

Fibromatosis, arare non-neoplastic spindle cell proliferation of unknown aetiology, can occur anywhere in the body. Though extra-abdominal sites are commonly involved, intra-abdominal fibromatosis has also been described. Described herein is an unusual case of diffuse intra-abdominal fibromatosis in a 9-year-old boy, who could not be salvaged despite extensive medical management.

Response of Estrogen Receptor–Positive Intraabdominal Fibromatosis to Aromatase Inhibitor Therapy

BACKGROUND

Intraabdominal fibromatosis is a rare tumor-like lesion of uncertain etiology.

CASE

A 49-year-old woman underwent abdominal hysterectomy and bilateral salpingooophorectomy in 1997 to treat uterine leiomyomata and ovarian fibromatosis. Postoperatively, she received estradiol 2 mg daily as hormone replacement therapy (HRT). In 2000, laparotomy performed for a large pelvic tumor revealed inoperable intraabdominal fibromatosis. The tumor, which was positive for estrogen and progesterone receptors, resolved during aromatase inhibitor therapy. The first follow-up computed tomographic (CT) scan revealed that the tumor masses were significantly reduced in size, and successive CT scans revealed stable disease.

CONCLUSION

Intraabdominal fibromatosis that expresses estrogen and progesterone receptors may respond favorably to treatment with aromatase inhibitors.

Sporadic hereditary pancreatic desmoid tumor: a new entity?

Deeply seated aggressive fibromatosis also termed as desmoid tumors are rare tumors that invade surrounding structures. Although they never metastasize mortality rate may be as high as 10% due to their aggressive local behavior. Intraabdominal desmoid tumors are usually associated with familial poliposis coli and have a high recurrence rate regardless of the therapy instituted. Sporadic cases are very rare and generous surgical excision may be of benefit. We hereby report 2 siblings with sporadic pancreatic desmoid tumors who also harbor additional fibrotic masses in the pelvis. Although in previously reported cases there is usually a triggering event such as trauma, in the present cases there was no inciting event. Furthermore, the cases are without an associated FAP history, which provides the first clinical clue of a possible genetic determinant in this rare disorder.

Stepwise progression of familial adenomatous polyposis-associated desmoid precursor lesions demonstrated by a novel CT scoring system

INTRODUCTION

Desmoids are rare, locally aggressive but nonmetastasizing clonal proliferations of fibroblasts that occur both sporadically and in association with familial adenomatous polyposis. Most occur in intra-abdominal sites, where they may lead to major morbidity and mortality. A proposed desmoid precursor lesion occurs in the mesentery of one-third of patients with familial adenomatous polyposis, and postoperative mesenteric fibromatosis has been identified in 20 percent of such patients. True desmoids occur in 10 percent, which suggests a model of development in which the phenotype becomes increasingly severe in a manner analogous to the adenoma-carcinoma sequence. This work aimed to confirm such a progression.

METHODS

A five-point CT scoring system for mesenteric fibromatosis and desmoids was devised and validated, and in doing so, their incidence was observed. In the second part of the study, seven patients known to have a precursor lesion underwent abdominal CT a median of 27.5 months after the surgery that identified the lesion. Scans were assessed by the scoring system and compared with those of a matched control group of familial adenomatous polyposis patients.

RESULTS

The CT scoring system was reliable and reproducible. Of 103 scans of asymptomatic patients with familial adenomatous polyposis, mesenteric fibromatosis and desmoid tumors were identified in 21 and 2 percent, respectively. In the follow-up of patients with desmoid precursor lesions, those in the precursor lesion group had a significantly greater degree of mesenteric fibromatosis and desmoid formation than their corresponding controls (P = 0.009, Mann-Whitney U test).

CONCLUSION

A reliable CT scoring system for mesenteric fibromatosis and desmoid tumors in familial adenomatous polyposis is presented. Results with this system provide further evidence for a stepwise progression in the development of desmoids.

[Desmoid tumor of rectus muscle of abdomen in a young woman]

The paper presents a case of 28-year-old woman operated at the Department of General Surgery University School of Medicine in Poznań because of desmoid tumor of rectus muscle of abdomen. The patient was incorrectly diagnosed a year earlier. The authors emphasize diagnostic problems leading to a delayed diagnosis.

Successful treatment of recurrent pelvic desmoid tumour with tamoxifen: case report

The case report of a young woman with recurrent pelvic desmoid tumour successfully treated with tamoxifen is described. The desmoid tumour recurred within 6 months after the initial exploratory laparotomy. Tamoxifen therapy led to complete relief of ascites within 2 months and complete tumour regression by the end of the fourth month, and the patient has remained stable for 6 years. Without sacrificing pelvic organs or major vessels and preserving reproductive ability, tamoxifen should be considered as the first drug of choice in such a recurrent condition.

Mediastinal fibromatosis presenting with superior vena cava syndrome

We encountered a fatal case of mediastinal fibromatosis in a 67-year-old female in whom there was aggressive infiltration into the large vessels, nerves and pericardium. She presented with the superior vena cava syndrome, Horner's syndrome, paralysis of bilateral vocal cords and diaphragm and heart failure. Mediastinoscopical examination revealed an extremely firm tumor adhering to the sternum, trachea and brachiocephalic artery. She died of severe heart failure due to the disturbed dilatation of the heart and ventilatory insufficiency. Although mediastinal fibromatosis is very uncommon and sometimes difficult to diagnose at an early stage, physicians should be aware of this disease for the differential diagnosis of mediastinal tumors.

Treatment of mesenteric desmoid tumours with the anti-oestrogenic agent toremifene: case histories and an overview of the literature

Desmoid tumours are histologically benign but due to their infiltration and compression of surrounding structures potentially life-threatening fibromatous lesions of unknown aetiology. The annual incidence rate is 2-4 per million people. The mesenteric variant constitutes about 10% of all desmoid tumours, although in familial adenomatous polyposis (FAP) patients this may be up to 70%. Due to the small number of patients with mesenteric desmoids the therapy is mainly empirical. This report describes the rationale as well as the value of the short- and long-term treatment (up to 6 years) with the anti-oestrogenic agent toremifene in combination with sulindac in two patients suffering from such a mesenteric desmoid tumour. These patients did not respond to sulindac alone and previous treatment with tamoxifen together with this non-steroidal anti-inflammatory drug had also failed. An overview of the literature on the management of these dismal tumours is presented.

Abdominal wall closure after selective aponeurotic incision and undermining

The tension required to pull the anterior and the posterior rectus sheaths toward the midline was studied in 20 fresh cadavers at two levels: 3 cm above and 2 cm below the umbilicus. The quotient of the force used to mobilize the aponeurotic site to the midline and its resulting displacement was called the traction index. These indices were compared in three situations: (1) prior to any aponeurotic undermining, (2) after the incision of the anterior rectus sheath and the undermining of the rectus muscle from its posterior sheath, and (3) after additionally releasing and undermining the external oblique muscle. A significant decrease in aponeurotic resistance was observed after each dissection. The anterior sheath showed higher resistance to traction compared with the posterior sheath on both levels. No statistical difference was noted in the comparison of the values of the aponeurosis above and below the umbilicus. These results suggest that these procedures are effective in assisting in the closure of abdominal wall defects because these maneuvers decrease substantially the tension required for advancement of the aponeurotic edges.

Clinical, ultrasonographic and tomographic features on the natural evolution of primary mesenteric fibromatosis: a case report

Primary mesenteric fibromatosis is a rare, histologically benign, pathology which is characterized by fibrous proliferation in the mesentery and made more serious by biological malignancy as it has a high inclination towards involving the visceral abdominal structures in its growth. While the cases reported in the literature describe the attempts to cure and reduce the tumor growth, this report describes the clinical, ultrasonographic and tomographic features during the natural growth rate of a case of inoperable primary mesenteric fibromatosis during a 20 month follow-up.

MR appearances of desmoid tumors in familial adenomatous polyposis

OBJECTIVE

The purpose of this study was to investigate the ability of MR imaging to show desmoid tumors in patients with familial adenomatous polyposis, to document the appearances of these tumors, and to identify possible predictors of growth.

SUBJECTS AND METHODS

CT and MR imaging of 15 patients with familial adenomatous polyposis and known abdominal wall or intraabdominal desmoid tumors were performed. Nine patients underwent follow-up CT and MR imaging, and four patients had undergone CT within the previous 12 months. Unenhanced and gadolinium-enhanced T1-weighted MR imaging sequences and T2-weighted MR imaging sequences were performed, as was unenhanced and IV contrast-enhanced helical CT. The CT and MR images were independently assessed.

RESULTS

CT revealed 35 desmoid tumors: 22 were intraabdominal and 13 were in the abdominal wall. MR imaging revealed 21 of the 22 intraabdominal desmoid tumors and 13 of the 13 abdominal wall desmoid tumors. MR imaging and CT findings agreed precisely on the site and margin of the intraabdominal and abdominal wall desmoid tumors. CT was more effective in revealing their relationship to the bowel. Contrast enhancement was more easily identified on MR images than on CT scans, especially when enhancement was inhomogeneous. High signal intensity on T2-weighted images was seen in eight desmoid tumors, all of which showed significant growth on follow-up scans.

CONCLUSION

MR imaging can show both intraabdominal and abdominal wall desmoid tumors in patients with familial adenomatous polyposis. High signal intensity on T2-weighted images was seen from desmoid tumors that had shown marked growth on follow-up imaging.

Chemotherapy for desmoid tumors in association with familial adenomatous polyposis

PURPOSE

This study was designed to assess the effect of chemotherapy on complex desmoid tumors associated with familial adenomatous polyposis.

METHODS

Five patients (3 males, 2 females; age range, 29-45 years) had symptomatic, unresectable intra-abdominal desmoid tumors in association with familial adenomatous polyposis that were unresponsive to conventional medical therapy. Each patient was treated with a cytotoxic chemotherapeutic regimen consisting of doxorubicin and dacarbazine followed by carboplatin and dacarbazine. Response to treatment was assessed by measurement of tumor size using computerized tomography. Follow-up has been for a mean of 22 (range, 10-30) months.

RESULTS

One patient has had a complete response, and three patients have had a partial response, with a reduction in tumor volume of at least 50 percent. One patient had a minimum response to treatment and developed a rapid increase in tumor size on cessation of therapy. Complications of treatment included febrile neutropenia, severe epistaxis, and subclavian vein thrombosis.

CONCLUSIONS

The cytotoxic chemotherapeutic regimen described is effective in the treatment of selected unresectable desmoid tumors associated with familial adenomatous polyposis and should be considered in symptomatic patients who do not respond to conventional medical therapy.

[Malignant desmoplastic tumor with divergent differentiation]

Malignant desmoplastic tumor with divergent differentiation is an extremely rare, but well-defined tumor entity. The case of a 15-year-old boy with this tumor and the differential diagnosis are discussed in the present article.

Diffuse abdominal uptake of technetium-99m-HDP after colectomy in Gardner's syndrome

A 37-yr-old man presented with increasing abdominal girth and multiple palpable intra-abdominal masses 3 yr after colectomy for polyposis coli. Whole-body skeletal scintigraphy performed prior to laparotomy demonstrated diffuse abdominal uptake of 99mTc-HDP consistent with mesenteric fibromatosis confirmed at surgery. When diffuse abdominal uptake of skeletal imaging agents occurs in patients with prior colectomy for polyposis coli, mesenteric fibromatosis as a manifestation of Gardner's syndrome should be suspected. This case illustrates another cause of diffuse abdominal uptake of skeletal imaging agents.

CT appearances of desmoid tumours in familial adenomatous polyposis: further observations

Intra-abdominal desmoid tumours represent a major cause of morbidity and mortality in patients with familial adenomatous polyposis (FAP), and such patients are also liable to develop musculoskeletal desmoids. We have reviewed the CT appearances of 44 desmoid lesions (28 intra-abdominal and 16 musculoskeletal) in 20 patients with FAP. We found a considerable heterogeneity in the CT appearance of musculoskeletal and intraabdominal desmoids, with respect to their density, definition and change in size or density on follow-up, not only between different patients but also in patients with multiple lesions, who rarely showed identical appearances of all lesions. In some cases, mesenteric tumours may initially present as ill-defined soft tissue infiltration of mesenteric fat, becoming larger and more mass-like with time. On medical treatment, shrinkage was seen infrequently in musculoskeletal desmoids, and not at all with mesenteric lesions. CT evidence of bowel involvement by intra-abdominal lesions was frequent, most commonly appearing as 'tethering' or encasement of bowel loops. The presence of a large mesenteric mass (> 10 cm diam.), multiple mesenteric masses, extensive small bowel involvement and/or bilateral hydronephrosis were associated with ultimate death.

Triple-phase bone scan findings in aggressive fibromatosis. Before and after radiation therapy

The authors present comparative triple-phase bone scan findings in three cases of histologically proven aggressive fibromatosis both before (initial evaluation) and after radiation therapy. The purpose of the study was to compare triple-phase bone scan findings in aggressive fibromatosis both before and after radiation therapy and to determine whether any additional physiological information could be obtained. Before radiation therapy, the triple-phase bone scintigraphy demonstrated increased flow and radiotracer pooling in the areas of tumors on dynamic flow and immediate blood pool images, respectively. However, the delayed static images demonstrated variable radiotracer uptake. When compared to preradiation therapy triple-phase bone scan, decreased vascularity was well demonstrated in all three patients after radiation therapy. In addition, it also provided information regarding the changes in the size and extent of tumor, noninvaded underlying bone, and remainder of the skeleton. This additional information can be particularly useful in patients with equivocal or questionable histologic diagnosis especially from small, unrepresentative biopsies.

CT of intraabdominal desmoid tumors: is the tumor different in patients with Gardner's disease?

OBJECTIVE

A retrospective study of abdominal CT scans of patients with proved intraabdominal desmoid tumors was done to determine if any objective characteristics exist to differentiate desmoids related to Gardner's syndrome from isolated desmoids. Because the desmoid tumors of Gardner's syndrome can predate the diagnosis of Gardner's syndrome, it would be helpful to know which patients with desmoids need careful follow-up studies as well as initial workup for Gardner's syndrome and all its ramifications. Also, it would be important to differentiate benign from malignant desmoids associated with Gardner's syndrome. It was hoped that the location, enhancement characteristics, and/or the presence or absence of infiltration might be of value. We were interested in noting if, over time, the growth characteristics of desmoids found in Gardner's syndrome were different from those of isolated desmoids.

MATERIALS AND METHODS

We reviewed 101 abdominal CT scans obtained in 23 patients during a 13-year period. Forty desmoid tumors were intraabdominal, including 30 lesions associated with Gardner's syndrome in 13 patients and 10 desmoids of the idiopathic form in 10 patients. These tumors were studied to define location; whether they were single or multiple; and whether they had any specific CT characteristics regarding margins, attenuation numbers, or contrast enhancement.

RESULTS

Desmoid tumors associated with Gardner's syndrome were more likely to be multiple (38%, five of 13 patients) and to involve the mesentery (60%, 18 of 30 tumors) and the abdominal wall (40%, 12 of 30 tumors), whereas isolated desmoid tumors were singular (all 10 patients) and were located in the retroperitoneum (six cases), pelvis (three), and anterior wall (one). Desmoids related to Gardner's syndrome also tended to be smaller (mean diameter, 4.8 cm) than idiopathic desmoids (mean diameter, 13.8 cm). No differentiating CT characteristics regarding margins, attenuation numbers, or response to contrast material were ascertained. Ten new lesions (seven intraabdominal, three mesenteric) developed in three patients with Gardner's syndrome, whereas no new intraabdominal lesions developed in patients with idiopathic desmoids. Follow-up data on 16 surgically resected desmoids in nine patients (seven with Gardner's syndrome and two with isolated desmoids) revealed seven local recurrences (two in the two patients with isolated desmoids and five in two patients with Gardner's syndrome).

CONCLUSION

No CT characteristics, such as attenuation values, margins, and response to the contrast material, were found that would enable differentiation between isolated intraabdominal desmoids and those associated with Gardner's disease. Desmoid tumors associated with Gardner's syndrome tend to occur in the mesentery and abdominal wall, whereas isolated desmoids involve the retroperitoneum and pelvis. When studying CT scans obtained over time, new lesions were noted to develop in a few of the patients with Gardner's syndrome (three of 13), whereas no new lesions were found in patients with isolated desmoids.

Abdominal wall desmoid mimicking intra-abdominal mass: MR features

A case of abdominal wall desmoid which enlarged toward the liver and mimicked an intra-abdominal tumor is presented. T*2-weighted MR images clearly demonstrated the tumor's continuity with the rectus abdominis muscle. The case presented suggests MRI may provide more valuable information concerning the origin of a right-upper-quadrant mass than CT does. However, the nature of the signals and attachment which this case showed were so unusual for desmoids that this case has not been diagnosed accurately.

Diffuse intra-abdominal fibromatosis in association with bilateral ovarian fibromatosis and oedema

A case of bilateral ovarian enlargement secondary to massive ovarian oedema with underlying intra-abdominal and pelvic fibromatosis is presented. Bilateral salpingo-oophorectomy and hysterectomy led to rapid progression of the intra-abdominal and pelvic fibromatosis, which was previously unsuspected. The case highlights the importance of recognizing massive oedema of the ovary as a distinct entity as it is a benign condition affecting young females and can be confused with ovarian neoplasm. In this case, the major morbidity was from the underlying diffuse intra-abdominal fibromatosis. Conservative management with prolonged bowel rest, total parenteral nutrition, and intravenous steroid and Tamoxifen successfully led to complete resolution of bowel obstruction from diffuse fibromatosis.