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|Year : 2009 | Volume
| Issue : 1 | Page : 34--39
Desmoid tumors: Experience of 32 cases and review of the literature
V Kumar1, S Khanna2, AK Khanna2, R Khanna2,
1 Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005, UP, India
2 Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005, UP, India
Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005, UP
Background: Desmoids are infiltrative, locally destructive, soft tissue tumors. Although they do not metastasize, the incidence of local recurrence is quite high. Aim : Present study aimed at reporting the 10-year experience of 32 desmoid cases and reviewing some facts with symptoms, investigation, and treatment of the disease. Materials and Methods : Thirty two cases of desmoid tumors were reviewed over a 10-year span. Surgical resection and adjuvant radiotherapy were the treatments of choice whenever histological margins were positive . Results : Multiparous women in reproductive age were the most commonly afflicted. The commonest site of presentation was the abdominal wall. Ninety one percent (20/22) were infraumbilical. The tumors were found in the rectus sheath in 14 patients (64%) and were laterally situated in 8 patients (36%). Local infiltration was found in six patients and the urinary bladder was most commonly involved (3/6). Locally recurrent desmoids were seen in eight patients (25%). Conclusions : In our experience, 25% of the desmoid tumors (8/32) were recurrent and postoperative radiotherapy did not seem to influence the local recurrence rate. The most important predictor for recurrence was tumors of >5 cm.
|How to cite this article:|
Kumar V, Khanna S, Khanna A K, Khanna R. Desmoid tumors: Experience of 32 cases and review of the literature.Indian J Cancer 2009;46:34-39
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Kumar V, Khanna S, Khanna A K, Khanna R. Desmoid tumors: Experience of 32 cases and review of the literature. Indian J Cancer [serial online] 2009 [cited 2020 Apr 5 ];46:34-39
Available from: http://www.indianjcancer.com/text.asp?2009/46/1/34/48593
Desmoid tumors, also known as aggressive fibromatosis, are histologically benign neoplasms that arise from musculoaponeurotic structures. They differ from fibrosarcomas in the fact that desmoid tumors do not metastasize to other parts of the body. ,,, Desmoid tumors most commonly arise from the abdominal wall musculature, but can also be found in the tendons and ligaments of arms, legs, or even head and neck regions. Deep fibromatoses are aggressive tumors (hence, the term aggressive fibromatosis) and may cause serious clinical problems. , Retroperitoneal neoplasms are more common in familial polyposis coli and Gardner syndrome after abdominal surgery than in other conditions.  Clusters of cases in families without evidence of any associated syndromes have also been reported.  A history of trauma (often surgical) to the site of the tumor is elicited in one in four cases.  Peripheral desmoid tumors are firm, smooth, and mobile. They are often adherent to surrounding structures. The overlying skin is usually unaffected. The presence of such a soft tissue growth should alert the clinician to look more deeply into the family history for evidence of familial polyposis coli and Gardner syndrome. Intra-abdominal desmoid tumors remain asymptomatic until their growth and infiltration causes visceral compression. Symptoms of intestinal, vascular, ureteric, or neural involvement may be the initial manifestations. In this review, we have investigated the recently published papers on the abdominal wall desmoid tumors and have compared our 10-year experience of 32 cases.
Materials and Methods
Over a 10-year period from 1995-2004, 32 consecutive cases of desmoid tumors were reviewed retrospectively. All the cases were investigated with contrast enhanced CT scan [Figure 1]. Sixty eight percent (22) patients were women, of whom, 18 (81%) were in their reproductive age. Abdominal wall desmoid tumors accounted for 22 patients (68%). Recurrent desmoid tumors were seen in eight patients, of whom, three patients had a second recurrence. Patients with lesions of positive histological margins were treated with surgical resection and adjuvant radiotherapy. A Pubmed database search with keywords 'desmoid tumors', 'recurrence', 'surgery', and 'radiotherapy' aided in the investigation of published articles concerning abdominal wall desmoid tumors.
A family history of desmoid tumors was found in four patients, all of whom had abdominal wall desmoid tumors. Associated familial adenomatous polyposis (FAP) was found in one patient. This patient had an extremity desmoid tumor in relation to the tendon of biceps brachii. Among the 22 abdominal wall desmoids, 19 were present in reproductive aged women (15-45 years), of whom 16 were multiparous with one or more children each. There was a history of abdominal surgery in six patients (27%), of these five had undergone a LSCS and one had an appendectomy. Among the five patients who had a LSCS, three had a lower middle incision and two had a pfannenstiel's incision.
Among abdominal wall desmoids, the tumor was present in the infraumbilical portion of the abdomen in 20 patients (90%) and in above the umbilicus in 2 (10%). The tumor was found to arise from the rectus sheath and muscle in 14 patients [Figure 2] (64%) while in 8 patients (36%) it was from the muscles and fascia lateral to the rectus muscle. Extremity desmoid was found in 10 patients of whom 4 had it on the tendo Achilles. None of our patients had distant metastasis but local infiltration was seen in six patients (27%). Infiltration into the urinary bladder was seen in three and histological positive margin was found in six patients. Postoperatively, histological positive margins were found in six patients and they were subjected to radiotherapy. On follow up for periods ranging from 1-10 years, eight patients returned with recurrence of their tumors. They were subjected to re-excision and adjuvant radiotherapy. All the 32 patients were symptomatic complaining of heaviness because of bulkier size, pain, or infiltrating of the tumor to the nearby structures (in three patients infiltration to urinary bladder occured). No conservative management was done.
Excision of abdominal wall desmoid was followed by prolene mesh repair [Figure 3] in 12 patients while direct primary repair was achieved is 10 patients. Mesh repair was more often required in laterally originating desmoid (6/8, 75%) compared with those arising from rectus sheath (6/14, 43%).
Desmoid tumors account for 0.03% of all neoplasms.  They can occur throughout the body in any skeletal muscle, but are most commonly seen to arise from rectus abdominis in postpartum women. Desmoid tumor arises from myofibroblast, lacks a true capsule, and usually infiltrates into adjacent muscle bundles. The telomerase length and activity is normal,  nuclei are small and regular, and mitoses are infrequent - all of which support its histologically benign nature. Grossly, the desmoid tumors are morselized because of the incomplete excision and cutting through it had a firm gritty cut with vaguely fascicular white tan surface [Figure 4]. Despite the benign histologic character, their biological behavior is more 'malignant', since the infiltrative pattern of growth can ultimately lead to life-threatening visceral involvement and even cause death. 
Surgical trauma has been intimated in 68-86% of abdominal and intra-abdominal desmoids. , In our series, surgical intervention has been found in six patients (27%). It has been suggested that trauma might have caused some precursor lesions that have progressed to true lesions, but results are still to be proven. 
Role of an endocrine etiology in the occurrence of desmoid tumor has also been suggested. These tumors occur twice as commonly among women. The commonest groups associated are young women during or after pregnancy. In our series, among 22 abdominal desmoids, 18 (81%) were among the women of child bearing age group. The fibroblast has been shown to exhibit a proliferative response to estrogen.  Additionally, desmoids regress on tamoxifen and oral estrogen therapy. Women with desmoid tumor have regression of their lesions after attaining menopause.
Family history of the desmoid tumor was found in four patients with one patient having associated FAP. The prevalence of desmoid tumor in FAP is 10-25%. ,,, There has been well-documented evidence that these FAP-associated desmoids have been associated with adematous polyposis coli ( APC ) germline mutation. There has also been good evidence that the position of the APC germline mutation affects the likelihood of developing desmoids. , The association between a distal (or 3˘) germline mutation and an increased propensity to desmoids was first noted by Caspari et al ,.  and Davies et al ,.  in 1995 and supported by many other studies. Caspari originally stated that it was patients with a germline mutation 3´ of codon 1444 who had a greater likelihood of developing desmoids. The more distal to the 3´ end of the gene the mutation is located, the desmoid phenotype becomes more severe and the risk of any affected patient developing desmoids becomes higher tumors increase in number, and the age of onset is younger.  The role of other modifier gene has also been proposed to explain the differences in the phenotype of the individual having the same germline mutation. , Bertario et al .  and a recent study at St Mark's  indicated that family history is a risk factor independent of germline APC mutation and that families do exist with 5´ germline mutations and a high proportion of members affected with desmoids. These phenomena explain the involvement of modifier genes and provide a platform for future target gene therapy. 3´ germline mutation has been associated with low density colonic phenotype with very high penetrance. , Individuals in this group are managed with close colonoscopic surveillance and perhaps celecoxib prophylaxis against the development of colorectal polyps, with colectomy being delayed. Patient with 5´ germline mutation have a classical colonic phenotype and in these people surgery cannot be delayed. Desmoids which are monoclonal proliferation of cells progress through well-defined precursor lesions before becoming mature tumors.  Desmoid precursor lesion and mesenteric fibrosis has been identified as the intermediate stage lesion before the development of the tumor. The role of beta catenin has also been implicated; the loss of APC gene allows this cytosolic protein to travel to the nuclei and increases the cellular component of cell cycle. Many authors have examined the role of beta catenin and assigned it as a marker to distinguish desmoid from other histologically similar
tumor. ,, It has been proven that genetic deletion of receptor for hyaluronan-mediated motility (Rhamm) attenuates the formation of desmoids. Rhamm, a protein with an important role in wound healing and neoplastic progression, is also expressed at high levels in aggressive fibromatosis.  Genetic testing for APC gene mutation is also advocated for patients with desmoid tumors and with positive family history lately. ,, This may help in screening of individuals who should undergo continuous surveillance of their colorectal and upper GI tract lesions.
The clinical features of desmoid tumors in our patients were consistent with those generally reported. This disease is more common among women than men, it can occur at any age, and it can arise in a variety of sites, but it most frequently occurs in the limb girdles. The lesion tends to be bulky at presentation. It is necessary to follow these patients for a prolonged time because occasional relapses will first become evident after five years. However, in some series there have been occasional desmoid-related mortality and the clinical course was rough at times. Desmoids can be divided into four groups, as reported in a study by Church.  He has described in his series that 10% of tumors resolve spontaneously, 30% undergo cycles of progression and resolution, 50% remain stable after diagnosis, and 10% progress rapidly. This natural history should be borne in mind while assessing the efficacy of therapy.
Wide local resection, advocated nearly 100-years ago, remains the treatment of choice for most patients with desmoid tumors. Nevertheless, there are little data and agreement with regard to what constitutes an adequate wide margin. Typically, these tumors lack pseudoencapsulation and have nonpalpable extensions along muscle bundles and fascial planes, precluding reliable intraoperative clinical estimation of their extent. Despite this, attempts have been made in a number of reports to define the optimal operative procedure by evaluating outcome according to the type of resection - designated variously as simple excision, local excision, wide excision, adequate resection, inadequate resection, radical local excision, and so on - without evaluating the actual pathologic margin. Recurrence rates for margin-positive versus margin-negative resections have been reported as 43 vs. 15%, 47 vs. 15%, 68 vs. 12%, and 42 vs. 22. One study, however, found that when tumors with negative margins were subdivided into those with close (1 mm) margins, there was no difference in outcome.  Thus, it seems that an appropriate resection for desmoid tumors is one that achieves negative, even if close, microscopic surgical margin.
Unfortunately, the achievement of histopathological negative margins does not assure eradication of this disease. In one series the recurrence rate after margin-negative resection was 27%. Another recent study found a 22% recurrence rate after margin-negative resection.  Recurrence rates as high as 68% have been reported in this circumstance.  Clearly, occult tumor clonogens are left in situ in a significant proportion of margin-negative tumor beds. Determinants of local recurrence other than margin status have been poorly studied and reports are conflicting. In our series, a major prognostic factor was tumor location and size and whereas some studies  have not found anatomic site to be a determinant of outcome, at least three other studies have found a preponderance of recurrences among extremity lesions.  The reasons for this phenomenon are unclear, but it was not evident among patients receiving radiation therapy which suggests a particular difficulty in achieving adequate resection for extremity desmoid tumors. Despite wide surgical margins, a local recurrence rate of 24-77% at 10 years is reported. The time from surgery to first recurrence has been reported to vary from 4-106 months with a median of 15 months. The disease-free survival at five years has been reported to be 73% and at 10 years 70%. Metastatic disease has not been reported with desmoid tumor.
Radiation therapy is effective in controlling gross desmoid tumor. The long-term control rate, in one series, of (76%)  is consistent with that in other reports. , In the absence of randomized data, it is difficult to evaluate precisely the potential benefits of adjuvant treatment. However, the adverse impact of positive resection margins was largely offset by the addition of radiation therapy to surgery.
A variety of systemic agents - including tamoxifen, nonsteroidal and steroidal anti-inflammatory agents, testolactone, and cytotoxic chemotherapeutic agents - have been reported to produce partial or complete tumor responses. However, the numbers of patients treated with these agents have been small, the durability of the responses has been poorly documented, and the response rates have not approached those of conventional surgery and radiation therapy. Use of such systemic treatments remains experimental or applicable to situations in which the more conventional modalities have already been tried. Surgery remains the treatment of choice.
In our experience, 25% of the desmoid tumors (8/32) was recurrent. The addition of postoperative radiotherapy did not seem to influence the local recurrence rate. The most important predictor for recurrence was the tumor size >5 cm. The site of tumor (extremity or abdominal wall) and the marginal status at the time of primary surgery were not found to be significant prognostic factors with respect to local recurrence. The other clear correlation for risk of recurrence was whether surgery was undertaken for primary or recurrent disease. Most authors agree that a positive resection margin is the most important independent predictive factor for local recurrence. Other authors believe that recurrence rate is more dependent on the inherent characteristics of the disease. Microscopically positive margin in their experience do not differ substantially from microscopically negative margins in primary lesion with regards to local recurrence. 
In a review of series of 106 cases Stoeckle et al, have reported that desmoid tumors evolved actively over a median period of three years and stabilized. Recurrences or progression most commonly occurred between 14-17 months thereafter. Risk factors for recurrence were presentation (primary vs. recurrent), gender, tumor location, and resection margins. However, survival was independent from these factors, with equivalent survival whether resection had been performed or not. Tumor control and functional outcome depended on location and presentation. Recurrences were observed in 12/23 patients after radiotherapy.  They concluded that desmoids tumors have little or no pain, are inactive or relatively benign, and should be dealt with a perspective other than sarcoma. Since no difference is found in the local recurrence rate after wide excision with positive or negative margins these tumors have become highly unpredictable and mysterious in their response. With its behavior Rock et al,  have managed desmoid with observation only in 68 patients.
The present study showed that natural history of desmoid tumor is not consistent. We have observed that there can be periods of partial regression as well as rapid growth. There can also be long periods of stable disease with neither progression nor regression. But the most characteristic feature was that of a slow locally invasive growth. These variations in the tumor growth are said to be independent of any medical treatment. Desmoid tumors are puzzling, ambiguous, and inexplicable. All the endeavors should be directed toward achieving negative margins during resection even if gross or microscopic residual disease has not been proven to influence the survival rate. Adjuvant radiation has been suggested to diminish local recurrence and should be used selectively, especially in margin-positive tumors. It is undetermined why some tumors continue to grow and others can be followed for long periods without any subsequent problems. 
We, at our centre, generally asses the resectability with CECT and if the tumor is safely resectable, we do the wide excision with function and structure preserving procedure followed by adjuvant radiotherapy if margin is positive. If the tumor is irresectable, we use sulindac 150 mg twice daily for six months in combination with tamoxifen 120 mg daily for six months and resectability is reassessed. If there is no tumor progression same regimen is continued. If there is tumor progression and the tumor is operable then surgery is done, and if inoperable, the patient is shifted to palliative chemotherapy and radiotherapy. Aggressive attempt of obtaining wide margin is generally avoided.
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