International Journal of Urology
Blackwell Publishing AsiaMelbourne, AustraliaIJUInternational Journal of Urology0919-81722005 Blackwell Publishing Asia Pty LtdJanuary 20061318486Case Report
Desmoid tumor after testis cancer treatment
Correspondence: Peter Langenstroer
consin Ave., Medical College of Wisconsin, Milwaukee, WI
53226, USA. Email: firstname.lastname@example.org
Received 15 October 2004; accepted 15 March 2005.
, 9200 West Wis-
Intra-abdominal desmoid tumor following retroperitoneal lymph
node dissection for testicular germ cell tumor
ERIC J LAWATSCH,
NANCY B DAVIS
Departments of Urology,
College of Wisconsin, Milwaukee, Wisconsin, USA
MILTON W DATTA,
AND PETER LANGENSTROER
PETER VAN TUINEN,
GARY S SUDAKOFF,
Neoplastic Diseases and Related Disorders, Medical
including recurrent germ cell tumor, residual mature teratoma, or sarcomatoid degeneration. We report the case of a 27-year-old
man with a large abdominal mass occurring in the setting of a mixed germ cell tumor after radical orchiectomy with primary
chemotherapy followed by retroperitoneal lymph node dissection. Surgical excision of this mass followed by pathological review
revealed an intra-abdominal desmoid tumor. Fluorescence
strate a germ cell tumor origin. This is the fourth such case of an intra-abdominal desmoid tumor after retroperitoneal lymph node
dissection for testicular cancer in the urologic literature. This case highlights the need for careful consideration of a desmoid
tumor when a rapidly growing spindle cell tumor is encountered in a post-treatment testis cancer patient.
In the testicular cancer post-treatment setting a rapidly growing retroperitoneal mass leads to a differential diagnosis
hybridization (FISH) for isochromosome 12p failed to demon-
retroperitoneal lymph node dissection, testicular cancer.
desmoid tumor, non-seminomatous germ cell tumor, postchemotherapy retroperitoneal lymph node dissection,
In the testicular cancer postchemotherapy setting, a rapidly
growing retroperitoneal mass leads to a differential diag-
nosis including recurrent germ cell tumor, residual mature
teratoma, or sarcomatoid degeneration. Here we present a
rare case of a post-treatment intra-abdominal desmoid
The patient is a 27-year-old man who underwent right
radical orchiectomy for a testicular germ cell tumor in June
2001. The testicular pathology revealed a mixed germ cell
tumor composed of yolk sac tumor (40%), mature and
immature teratoma (40%), embryonal carcinoma (15%),
and choriocarcinoma (5%). He subsequently received four
cycles of chemotherapy with bleomycin, etoposide and
cisplatin, and a full bilateral postchemotherapy retroperi-
toneal lymph node dissection (RPLND) revealed only
residual mature teratoma. In January 2004 the patient was
noted to have a 7-cm intra-abdominal mass on a routine
surveillance computed tomography (CT) scan (Fig. 1) that
was not present 4 months previously. Tumor markers at
that time were normal. In March 2004, the patient under-
went exploratory laparotomy and excision of a 1 kg,
including portions of the mesentery, terminal ileum, and
right colon. Pathologic examination revealed a desmoid
tumor composed of bland spindled cells involving the
mesentery and invading into the muscularis propria of the
small bowel (Fig. 2). Subsequent fluorescence
hybridization (FISH) for chromosome 12p failed to iden-
tify isochromosome 12p elements in the tumor cells. No
additional treatment was given and the patient remains
without evidence of disease 10 months after surgery.
8.5 cm red-tan retroperitoneal mass
Desmoid tumors are considered to be a benign, locally
aggressive, reactive fibroblastic proliferation. While they
are exceedingly rare in the general population, they are the
second most common cause of morbidity and even mortal-
ity in patients with familial adenomatous polyposis who
have undergone surgery or trauma.
appearance histologically and lack of distant metastases,
desmoid tumors can aggressively infiltrate local structures,
often leading to bowel or urinary tract obstruction.
cal treatment has been attempted, but typical recurrence
rates average around 40%. Recent use of agents such as
sulindac may offer an alternative medical management of
these tumors. While extremely rare in patients with a
history of testis cancer, they have been described at least
three times previously in the biomedical literature
In the setting of a postchemotherapy and post-RPLND
germ cell tumor, abdominal CT imaging is an important
Despite their benign
Desmoid tumor after testis cancer treatment 85
screening study for recurrent retroperitoneal disease. In a
study by Einstein
., the contrast enhanced CT appear-
ance of 34 intra-abdominal desmoid tumors in 25 patients
was retrospectively reviewed.
tumors were described as isodense (47%) or hyperdense
(41%) when compared to muscle. Also, the majority of
desmoid tumors (68%) were described as spherical with
sharp contours as opposed to an infiltrative margin. Unfor-
tunately, the appearance of desmoid tumors on contrast
enhanced CT is not specific, and similar appearances can
be seen in vascular neoplastic and inflammatory masses as
well as malignant neoplasms containing desmoplastic
components. The appearance of desmoid tumors using
magnetic resonance imaging (MRI) is also non-specific.
In a study by Quinn
. the MRI appearance of desmoid
In this study, desmoid
tumors was similar to that of other soft-tissue lesions. Fur-
thermore, while the MRI appearances of most lesions were
judged to be well demarcated, microscopic examination
revealed that all lesions invaded adjacent structures. There-
fore, while helpful from a screening standpoint, the CT and
MRI appearance of desmoid tumors is non-specific, and
histological diagnosis is necessary.
The identification of an abdominal tumor mass in a
patient previously treated for germ cell tumor raises a
differential diagnosis that includes recurrent tumor, resid-
ual mature teratoma, or sarcomatoid degeneration arising
from residual tumor. This broad differential also elicits a
range of potential treatment options ranging from salvage
chemotherapy and/or bone marrow transplant for residual
tumor to aggressive surgical re-excision for sarcomatous
abdomen demonstrating retroperitoneal mass (outlined by
white arrows) prior to surgery.
Non-contrast enhanced computed tomography of
tan mass. (b) Histologic examination revealed homogeneous
spindled cells without pleomorphism, necrosis, or increased
Desmoid tumor. (a) Gross appearance of a uniform
Summary of intra-abdominal desmoid tumors after testis cancer
Time to occurrence
of desmoid tumor
after therapy (years)
34 embryonal orchiectomy,
Current study27 mixed
†Three courses of actinomycin D, vinblastine, cyclophosphamide and cisplatin. ‡Teratoma and yolk sac elements. §Two cycles
of vinblastine, bleomycin, etoposide, and cisplatin as well as one course of cisplatin, etoposide and bleomycin. ¶Retroperitoneal,
mediastinal, and subclavian nodes (400, 400, 300 Gy, respectively).
choriocarcinoma. RPLND, retroperitoneal lymph node dissection.
yolk sac, mature and immature teratoma, embryonal, and
moid tumor, coupled with the FISH studies confirming the
lack of origin from germ cell tumor elements, eliminated
the diagnosis of sarcomatous degeneration (which tend to
retain isochromosome 12p),
aggressive surgery or salvage chemotherapy. This case
highlights the need for careful consideration of a desmoid
tumor when a rapidly growing spindle cell tumor is
encountered in a post-treatment testis cancer patient.
In this case, the correct diagnosis of des-
and avoided the need for
The authors would like to thank Dr R. S. Foster and Dr N.
Vogelsang for their helpful discussions regarding desmoid
tumors in testicular cancer patients.
1Jones IT, Jagelman DG, Fazio VW, Lavery IC, Weakley
FL, McGannon E. Desmoid tumors in familial polyposis
2 Shields CJ, Winter DC, Kirwan WO, Redmond HP. Des-
Eur. J. Surg. Oncol.
Gianis TJ, Carey PM, Bracken RB. Giant desmoid tumor
of the abdominal wall masquerading as recurrent testicular
Little JS Jr, Foster RS. Intra-abdominal desmoid tumor: an
unusual case of recurrent tumor in a testis cancer patient.
Wegner HE, Fleige B, Dieckman KP. Mesenteric desmoid
tumor 19 years after radiation therapy for testicular cancer.
Einstein DM, Tagliabue JR, Desai RK. Abdominal des-
moids: CT findings in 25 patients.
Quinn SF, Erickson SJ, Dee PM
fibromatosis: results in 26 patients with pathologic correla-
Am. J. Roentgenol.
Motzer RJ, Amsterdam A, Prieto V
malignant transformation: diverse malignant histologies
arising in men with germ cell tumors.
Am. J. Roentgenol.
MR imaging in