A 59-year-old man comes to the office complaining of a vague upper abdominal discomfort. The pain has been present for most of the past 3 months but has never been severe enough to make him seek immediate medical attention. The discomfort is not associated with eating or performing any activities. He has no other medical problems. His blood pressure is 120/60 mm Hg, pulse is 84/min, and respirations are 14/min. Abdominal examination reveals the presence of multiple scars from previous surgical procedures around the epigastric area. A 3 x 5-cm, oblong-shaped, firm, and deeply seated mass is palpable in the epigastric area. There is no tenderness on direct palpation of the mass and surrounding epigastric area. The patient says that he previously had similar "things" in the same area "but they were taken out." Which of the following is the most likely diagnosis?

Question

A 59-year-old man comes to the office complaining of a vague upper abdominal discomfort.  The pain has been present for most of the past 3 months but has never been severe enough to make him seek immediate medical attention.  The discomfort is not associated with eating or performing any activities.  He has no other medical problems.  His blood pressure is 120/60 mm Hg, pulse is 84/min, and respirations are 14/min.  Abdominal examination reveals the presence of multiple scars from previous surgical procedures around the epigastric area.  A 3 x 5-cm, oblong-shaped, firm, and deeply seated mass is palpable in the epigastric area.  There is no tenderness on direct palpation of the mass and surrounding epigastric area.  The patient says that he previously had similar "things" in the same area "but they were taken out."  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: This patient presents with an abdominal mass and mild pain consistent with a likely desmoid tumor, which is a locally aggressive benign tumor arising from fibroplastic elements within the muscle or fascial planes with very low potential for metastasis or differentiation. Desmoid tumors are rare but increased in patients with familial adenomatosis polyposis (i.e., Gardner syndrome) and thought to be due to abnormal wound healing or clonal chromosomal abnormalities causing a neoplastic behavior. This tumor has a variable clinical course, can range from slow to rapid growth, and has varying sizes. Desmoid tumors typically present as deeply seated painless or sometimes painful masses in the trunk/extremity, intraabdominal bowel and mesentery, and abdominal wall. They can cause intestinal obstruction and bowel ischemia and have a high rate of recurrence, even after aggressive surgery (as in this patient). Computed tomography scan or MRI should be done to evaluate the size of the mass, with biopsy for histologic diagnosis. Surgery is the definitive therapy for desmoid tumors that are symptomatic, cause risk to adjacent structures or cosmetic issues for the patient, or are recurrent. Patients who are not surgical candidates can be treated with radiation therapy. Close observation is an alternative strategy in patients who are asymptomatic, have stable masses, or have intraabdominal masses seen in Gardner syndrome. This mildly symptomatic patient has had multiple surgeries to remove his likely recurrent desmoid tumor and can be treated with close observation, another surgery, or possibly radiation therapy, depending on his preference and surgical risk. (Choice A) A dermatofibroma is a benign proliferation of fibroblasts that usually occurs after trauma or insect bite and can also be idiopathic. It is usually a firm hyperpigmented nodule located on the lower extremities rather than the abdomen. (Choice C) An epidermoid cyst is a discrete nodule that is usually located on the skin and a result of the normal epidermal keratin becoming lodged in the dermis. Epidermoid cysts can be seen in Gardner syndrome but are usually located on the extremities rather than the trunk or abdomen and resolve spontaneously without treatment. (Choice D) A lipoma is an asymptomatic and benign subcutaneous collection of fat cells. It is usually soft without rapid enlargement or recurrence after resection, making it less likely in this patient. (Choice E) A pyogenic granuloma (granuloma telangiectaticum) is caused by capillary proliferation after trauma and usually presents as a dome-shaped papule with recurrent bleeding. It is more commonly seen in pregnant women and a less likely cause in this patient. Educational objective: Desmoid tumors are slow-growing and locally aggressive benign neoplasms with a high rate of local recurrence, even after surgical excision. References: The enigma of desmoid tumors. (http://www.ncbi.nlm.nih.gov/pubmed/10363901) Desmoid tumor: from surgical extirpation to molecular dissection (http://www.ncbi.nlm.nih.gov/pubmed/19436199)

A 59-Year-Old Man Comes to the Office Complaining of a Vague