The surgical management of soft tissue tumours arising in the abdominal wall

doi:10.1016/j.ejso.2010.03.007

European Journal of Surgical Oncology (EJSO)

Volume 36, Issue 5, May 2010, Pages 489-495

https://doi.org/10.1016/j.ejso.2010.03.007 Get rights and content

Abstract

Background

Soft-tissue tumours can occur at almost any site, including the abdominal wall and represent a biologically diverse group of benign and malignant tumours.

Methods

A prospectively-kept database was searched to identify all patients with tumours resected that involved the abdominal wall. The histological diagnosis, complication rates and local recurrence rates were reported. Kaplan-Meier analysis of prognostic factors was determined for patients with primary abdominal wall sarcomas.

Results

Ninety-two patients underwent resection for tumours involving the abdominal wall. Desmoid tumours (n = 30) and primary soft-tissue sarcomas (n = 25) were the most common pathologies. Of 92 patients undergoing resection 87 required reconstruction of the abdominal wall defect with polypropelene mesh but only 2 patients required reconstruction of the overlying skin. There were no immediate surgical complications in patients who underwent isolated abdominal wall reconstruction and the long term incision hernia rate was 4%. Kaplan-Meier analysis for patients with primary abdominal wall sarcomas showed that local recurrence was higher in tumours > 10 cm (p = 0.0024) and in high grade tumours (p = 0.0021). Disease-specific survival was worst in high grade tumours (p = 0.0010) and tumours > 10 cm (p = 0.0042). Desmoid tumours did not recur in any patient after abdominal wall resection, irrespective of microscopic margins.

Conclusions

Tumours involving the abdominal wall exhibit a wide range of pathologies. Abdominal wall reconstruction can be achieved in the vast majority of cases with mesh reconstruction alone with little surgical morbidity. Sarcomas carry a significant risk of local recurrence. Abdominal wall fibromatosis carries a better prognosis than fibromatosis arising in the extremities.

Introduction

Soft-tissue tumours include a wide spectrum of pathologies, ranging from benign to high grade malignancies. Soft-tissue tumours can occur anywhere, but most often arise in the extremities.¹ When sarcomas at all sites are considered there is a high incidence of local recurrence (25%) and a five-year survival between 50% and 60%.² Local recurrence and disease-specific survival are closely related to tumour grade, size, depth, site and incomplete surgical resection margins.3, 4, 5, 6

Abdominal wall sarcomas account for between 1 and 5% of all soft-tissue sarcomas.⁷ Similar surgical principles apply to sarcomas in the abdominal wall namely complete surgical excision with negative histological margins. Fibromatosis or abdominal wall desmoids are benign, slow-growing tumours of myofibroblast origin with a propensity for local aggressive behaviour but with a lack of metastatic potential. In the extremities, fibromatosis has a reputation for local recurrence that can occur regardless of margin status.⁸ The aetiological link to familial adenomatous polyposis (FAP) has been well established. Other risk factors include oestrogen exposure and abdominal wall trauma.⁹ Primary abdominal wall sarcomas and abdominal wall desmoid tumours are the most common abdominal wall tumours, and preoperative histology is essential to distinguish them from less common pathologies which have similar clinical presentations. Endometriosis can occur in the abdominal wall as an implantation phenomenon.¹⁰ The abdominal wall can further be the site of metastatic carcinoma, either as an implantation¹¹ or by haematogenous spread. Other benign soft tissue tumours including intramuscular lipomas, schwannomas, haemangiomas can also rarely occur in the abdominal wall and cause local symptoms and concern. The purpose of this study is to report on the pathological spectrum of tumours resected at a single institute and to discuss the outcome after surgical resection and abdominal wall reconstruction in this diverse group of tumours.

Section snippets

Patients and methods

Patients with soft-tissue tumours resected from the abdominal wall from January 2000 until January 2009 were identified from a prospectively-kept database. The pathological and clinical records of these patients were reviewed.

The abdominal wall was defined as the region between the costal margins and the inguinal ligaments with the lateral aspect of the paravertebral muscles defining the lateral borders. Macroscopic margins were ascertained by the operating surgeon confirming either complete

Pathology and diagnosis

During the period January 2000 to Jan 2009, 92 patients underwent resection of tumours involving the abdominal wall. The patient demographics and pathological spectrum for the whole cohort is shown in Table 1. Pain was an infrequent presenting feature for all pathologies other than endometriosis, with most patients presenting with an asymptomatic abdominal mass.

The sex distribution was essentially equal for all pathologies other than abdominal wall desmoids and endometriosis where there was a

Discussion

Tumours involving the abdominal wall include a heterogeneous group of pathologies with a wide array of biological behaviour. Abdominal wall tumours can be divided into primary and secondary lesions. Primary lesions include sarcomas, desmoid tumours and other benign entities such as schwannomas, intramuscular lipomas or haemangiomas. Secondary lesions can be local recurrence or metastatic lesion (sarcoma, carcinoma or melanoma) or an implantation phenomenon such as endometriosis or port site,

Conclusion

Soft-tissue tumours of the abdominal wall exhibit a wide range of pathologies despite similar clinical presentation. Preoperative histological diagnosis is mandatory to plan appropriate surgical resection and to not compromise patient outcome. This can easily and accurately be accomplished by core-needle biopsy. Surgical resection should be planned according to preoperative histology and cross-section imaging. Abdominal wall sarcomas carry a significant risk of local recurrence especially for

Conflict of interest

The authors are not aware of any conflict of interest in relation to this manuscript.

Funding

No external funding was received during the preparation of this manuscript.

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^☆: Presented as a poster at the British Association of Surgical Oncology conference, London 2009. Abstract: Pencavel T, Strauss D, Thomas J, Hayes A. Abdominal Wall soft-tissue tumours: a large single-centre experience. EJSO 2009 (Nov);35(11):1212.

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The surgical management of soft tissue tumours arising in the abdominal wall☆