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Desmoid of the anterior chest wall
DESMOID OF THE ANTERIOR MAJOR
THOMAS
B. WIPER
AND
CHEST WALL
MAJOR
JOSEPH M.
MILLER
MEDICAL CORPS, ARMY OF THE UNITED STATES
D
ESMOIDS or frbromas are infrequentIy occurring tumors of the muscuIofascia1 structures usuaIIv appearing on the anterior abdomina1 waII. Their presence at other sites has been noted aIthough their appearance eIsewhere than upon the abdomina1 waI1 is distinctIy in the minority. Pearman and Mayo have reviewed the Iiterature rather carefuIIy and have reported the details of seventyseven patients with desmoids who were treated at the Mayo CIinic. In twenty-two instances in their series, the tumor was Iocated in the skeIeta1 muscIe system’ removed from the anterior abdomina1 waI1. The incidence in females in these twenty-two cases was greater than that among maIes, as is usua1 with this particular tumor at any site. The casua1 factors underIying the appearance of these tumors are unknown. However, a history of trauma is frequentIy obtained and was noted in 60 per cent of the seventy-s.even cases reported by Pearman and Mayo. The pathoIogic characteristics of these tumors are somewhat reminiscent of a Ieiomyoma of the uterus. The structure is tough, grates under the knife and the cut surface buIges. The interIacing bundIes are cIearIy visua1 to gross inspection. The histoIogic structure is that of a rather cclIuIar frbroma which is not encapsuIated. The surrounding and infiItrated muscIe fibers are attenuated and foreign bodyIike giant ceIIs of muscuIar origin are visibIe. The tumors do not undergo metastasis. They may, however, recur IocaIIy if incompIeteIy removed. The patient whose case report foIIows is of interest because he is a maIe, a debnite history of trauma was present, and the tumor was found in the upper
anterior portion of the chest waI1 intimately connected with the pectoraIis major muscIe. CASE
REPORT
The patient is a twenty-three year oId white maIe who incurred a wound of the right thorax from a she11 fragment. He suffered a fracture of the right humerus, a Iaceration of the right lung and a fracture of the right coracoid process. SeveraI thoracenteses were done and Iater a thoracotomy with remova of the foreign body was performed. Two months after injury, the patient noted a smaI1 mass in the right infracIavicuIar region. GraduaI growth was noted. The mass was tender and pain at the site of the tumor was noted upon exercise. Physical examination was not noteworthy with the exception of the presence of the tumor. A firm, rounded mass measuring about 5 by 3 cm. was found in the right infraclavicular region over the first rib. (Fig. I.) The skin was freeIy movabIe over the tumor which was firmly attached to the deeper structures. Other tumors were not found during the examination. Various Iaboratory procedures incIuding determinations of the bIood calcium, phosphorus and phosphotase were done as we felt a tumor of bony origin might be present. These determinations were a11 found to be within norma limits. Likewise the roentgenograms of the chest and the skeIeton did not revea1 a bone tumor or tumors to be present. We were thus confronted with a firm tumor apparentIy not of osseous origin but which was firmiy attached to the deep structures in the right infracIavicuIar area. Photographs of the patient using the infrared technic did not show any dilated venous channeIs about the tumor. Some idea as to the depth to which the mass extended was obtained from a phIebogram of the right upper extremity. Twenty-five cc. of diodrast were injected into a vein in the Iower right forearm with a tourniquet about the mid-arm. A pressure of 30 mm. of mercury was maintained during the injection. A visualization of the right brachia1, subcIavian and innominate veins was obtained
556
and no perceptible in size or position noted.
deviation from the normal of these blood vessels was
mass of intermingled broad connective tissue fibers among which were numerous capillaries and foreign body giant cells. Infiltration of the
FIG. 2. Cross-section
of the tumor.
surrounding muscle by the connective tissues tibers was noted. Numerous areas of hemorrhage and foreign body giant ceIIs were seen at the periphery of the lesion. The intermingling of the fibrous core, the giant ceI1 reaction and the apparent infiItrative character of the tumor classified it as a desmoid. FIG.
I. Right infracIavicular tumor. SUMMARY
Surgical exploration was the next procedure as all attempts to establish a diagnosis were without avail. A curvilinear incision over the tumor was made. The mass was of firm fibrous consistency without definite encapsulation, infiltrating the pectoralis major muscle and IirmIy attached to the fibrous tissue over the sternoclavicular joint. A wide block resection of the tumor and adjacent muscIe was done. The postoperative period was without incident. The wound healed quickly and firmly. The tumor was 3 cm. in diameter and upon cut section presented a mass of coarsely reticulated fibrous tissue flecked with vellowportions of ish areas. (Fig. 2.) The peripheral the tumor were hemorrhagic and stained yellowish-brown. MicroscopicaIIy, the specimen consisted of a
The tumor is of interest for severa reasons. It occurs in maIes but in a minority of cases. Likewise it usuaIIy is found in connection with the musculo-aponeurotic structures of the anterior abdomina1 waI1 and only occasionaIIy in other sites. A definite history of trauma was obtained from the patient which gives further support to the theory of traumatic origin in connection with individual predisposition as a cause for the appearance of these tumors. REFERENCE I. PEARMAN, R. 0. and MAYO, C. W. Desmoid
clinical and pathoIogic ‘25,
1942.
tumors: study. Surgerlr, I I 5: I 14-
THOMAS
B. WIPER
AND
CHEST WALL
MAJOR
JOSEPH M.
MILLER
MEDICAL CORPS, ARMY OF THE UNITED STATES
D
ESMOIDS or frbromas are infrequentIy occurring tumors of the muscuIofascia1 structures usuaIIv appearing on the anterior abdomina1 waII. Their presence at other sites has been noted aIthough their appearance eIsewhere than upon the abdomina1 waI1 is distinctIy in the minority. Pearman and Mayo have reviewed the Iiterature rather carefuIIy and have reported the details of seventyseven patients with desmoids who were treated at the Mayo CIinic. In twenty-two instances in their series, the tumor was Iocated in the skeIeta1 muscIe system’ removed from the anterior abdomina1 waI1. The incidence in females in these twenty-two cases was greater than that among maIes, as is usua1 with this particular tumor at any site. The casua1 factors underIying the appearance of these tumors are unknown. However, a history of trauma is frequentIy obtained and was noted in 60 per cent of the seventy-s.even cases reported by Pearman and Mayo. The pathoIogic characteristics of these tumors are somewhat reminiscent of a Ieiomyoma of the uterus. The structure is tough, grates under the knife and the cut surface buIges. The interIacing bundIes are cIearIy visua1 to gross inspection. The histoIogic structure is that of a rather cclIuIar frbroma which is not encapsuIated. The surrounding and infiItrated muscIe fibers are attenuated and foreign bodyIike giant ceIIs of muscuIar origin are visibIe. The tumors do not undergo metastasis. They may, however, recur IocaIIy if incompIeteIy removed. The patient whose case report foIIows is of interest because he is a maIe, a debnite history of trauma was present, and the tumor was found in the upper
anterior portion of the chest waI1 intimately connected with the pectoraIis major muscIe. CASE
REPORT
The patient is a twenty-three year oId white maIe who incurred a wound of the right thorax from a she11 fragment. He suffered a fracture of the right humerus, a Iaceration of the right lung and a fracture of the right coracoid process. SeveraI thoracenteses were done and Iater a thoracotomy with remova of the foreign body was performed. Two months after injury, the patient noted a smaI1 mass in the right infracIavicuIar region. GraduaI growth was noted. The mass was tender and pain at the site of the tumor was noted upon exercise. Physical examination was not noteworthy with the exception of the presence of the tumor. A firm, rounded mass measuring about 5 by 3 cm. was found in the right infraclavicular region over the first rib. (Fig. I.) The skin was freeIy movabIe over the tumor which was firmly attached to the deeper structures. Other tumors were not found during the examination. Various Iaboratory procedures incIuding determinations of the bIood calcium, phosphorus and phosphotase were done as we felt a tumor of bony origin might be present. These determinations were a11 found to be within norma limits. Likewise the roentgenograms of the chest and the skeIeton did not revea1 a bone tumor or tumors to be present. We were thus confronted with a firm tumor apparentIy not of osseous origin but which was firmiy attached to the deep structures in the right infracIavicuIar area. Photographs of the patient using the infrared technic did not show any dilated venous channeIs about the tumor. Some idea as to the depth to which the mass extended was obtained from a phIebogram of the right upper extremity. Twenty-five cc. of diodrast were injected into a vein in the Iower right forearm with a tourniquet about the mid-arm. A pressure of 30 mm. of mercury was maintained during the injection. A visualization of the right brachia1, subcIavian and innominate veins was obtained
556
and no perceptible in size or position noted.
deviation from the normal of these blood vessels was
mass of intermingled broad connective tissue fibers among which were numerous capillaries and foreign body giant cells. Infiltration of the
FIG. 2. Cross-section
of the tumor.
surrounding muscle by the connective tissues tibers was noted. Numerous areas of hemorrhage and foreign body giant ceIIs were seen at the periphery of the lesion. The intermingling of the fibrous core, the giant ceI1 reaction and the apparent infiItrative character of the tumor classified it as a desmoid. FIG.
I. Right infracIavicular tumor. SUMMARY
Surgical exploration was the next procedure as all attempts to establish a diagnosis were without avail. A curvilinear incision over the tumor was made. The mass was of firm fibrous consistency without definite encapsulation, infiltrating the pectoralis major muscle and IirmIy attached to the fibrous tissue over the sternoclavicular joint. A wide block resection of the tumor and adjacent muscIe was done. The postoperative period was without incident. The wound healed quickly and firmly. The tumor was 3 cm. in diameter and upon cut section presented a mass of coarsely reticulated fibrous tissue flecked with vellowportions of ish areas. (Fig. 2.) The peripheral the tumor were hemorrhagic and stained yellowish-brown. MicroscopicaIIy, the specimen consisted of a
The tumor is of interest for severa reasons. It occurs in maIes but in a minority of cases. Likewise it usuaIIy is found in connection with the musculo-aponeurotic structures of the anterior abdomina1 waI1 and only occasionaIIy in other sites. A definite history of trauma was obtained from the patient which gives further support to the theory of traumatic origin in connection with individual predisposition as a cause for the appearance of these tumors. REFERENCE I. PEARMAN, R. 0. and MAYO, C. W. Desmoid
clinical and pathoIogic ‘25,
1942.
tumors: study. Surgerlr, I I 5: I 14-