Malignant fibrous histiocytoma (MFH) is a common soft tissue sarcoma usually involving limbs and retroperitoneum. MFH of the rectus abdominis muscle is extremely rare. Surgery in similar cases leads to large abdominal wall defects needing reconstruction. Biological and synthetic laminar absorbable prostheses are available for the repair of hernia defects in the abdominal wall. They share the important feature of being gradually degraded in the host, resulting the formation of a neotissue. We herein report the case of an 84-year-old man with MFH of the rectus abdominis muscle which was resected and the large abdominal wall defect was successfully repaired with a biological mesh.
Malignant fibrous histiocytoma (MFH) is a pleomorphic sarcoma. It was first described as malignant histiocytoma and fibrous xanthoma by Ozzello et al. [
The introduction of biological meshes (BMs) like Permacol (PM), Strattice, and Surgisis has opened new alternatives. BMs products have several potential advantages over other synthetic permanent materials in selected clinical situations. Indications for implantation of a BM in abdominal wall reconstruction include contaminated wounds, complex repairs at high risk for developing wound-healing problems, high likelihood of a cutaneous exposure, and unavoidable direct placement of mesh over bowel [
We herein report the case of an 84-year-old man with a MFH in the rectus abdominis muscle, treated by removal of the tumor and the muscle, which was reconstructed with BM.
An 84-year-old male was admitted complaining about abdominal pain and a palpable mass in the abdominal wall. His medical history included atrial fibrillation, chronic obstructive pulmonary disease, and open cholecystectomy performed 2 years ago. During the clinical examination, a large, immobile, and slightly painful mass was palpated at the level of the left rectus abdominis muscle. Abnormal laboratory findings included leukocytosis (14,323/mm³), Hb: 9 g/dL, and INR: 4.
Although the patient’s reported history of a two-month growing mass, spontaneous rectus abdominis rupture was initially suspected. The abdominal ultrasound (U/S) demonstrated a hyperechogenic mass limited to the abdominal wall. The abdominal computed tomography (CT) described a large mass of 11 × 7 cm in diameter, arising from the rectus abdominis muscle with sarcomatous characteristics (Figure
The abdominal CT demonstrates a 11 × 7 cm mass in diameter arisen from the rectus abdominis muscle.
Anemia and coagulation parameters were adjusted and the patient underwent surgery. Through a paramedian incision, en bloc resection of the tumor, the rectus abdominis, and the muscular sheath was performed (Figure
The en bloc resection of the tumor, the rectus abdominis, and the muscular sheath.
The biological mesh was directly posted over the intestinal loops; stay sutures were posted on the left ipsilateral internal oblique muscle and the posterior sheath-linea alba of the contralateral rectus abdominis muscle.
MFH generally refers to the group of tumors that originate from histiocytes and make their specific diagnosis difficult since these lesions have a variety of pathological types [
The most common symptoms are abdominal pain, fatigue, weight loss, and a palpable mass. Specifically, in the cases of abdominal and retroperitoneal MFH, hematuria, lower extremity pain, abdominal distension, varicose veins, and hernia could be observed [
The main treatment is extensive surgical resection in comparison with concurrent chemotherapy and radiation therapy to reduce the possibility of local recurrence and metastasis. It has been reported that the average 5-year survival rate of patients with MFH is 59% to 66.7% and the local recurrence rate is 16% to 31% [
Radical treatment often results in extended abdominal wall defects that need reconstruction. Various options of abdominal wall reconstruction exist. Primary closure does not always respect the principles of tension-free repair while it often results in an incisional hernia. Plastic surgery techniques such as pedicled or free myocutaneous flaps need advanced surgical skills and are time-consuming procedures that limit a wide application especially in patients with comorbidities.
On the other hand, surgery with permanent synthetic meshes (such as polyester, polypropylene, and expanded polytetrafluoroethylene) despite providing satisfactory results is often complicated by foreign body reaction, erosion of adjacent viscera, migration, intestinal obstruction, or fistula formation. BM structure is based on acellular porcine collagen or human cadaveric collagen. These meshes are not allergenic, incorporate easily into host tissue, do not cause a foreign body reaction, and present a rapid colonization of host tissue cells and blood vessels increasing resistance to infection. They also present a high tensile strength being at the same time soft and flexible. Less adhesion formation is a grade advantage considering the fact that it can be applied directly in contact with the abdominal viscera [
The advantage of using BMs is that the repair mechanisms approach optimal conditions. However, there may also be inconveniences, including adverse effects that have been described after implantation [
In the reported case, the abdominal defect was repaired using porcine acellular mesh. The mesh was directly posted over the intestinal loops while the external oblique muscle, the subcutaneous tissue, and the skin were closed over the mesh. Two suction drains were placed laterally between the mesh and the subcutaneous tissue while the patient’s postoperative course was uneventful.
MFH of the rectus abdominis is a rare but also existing abdominal wall tumor. BMs seem to offer a valid and rapid surgical option in similar cases where age and comorbidities limit complex reconstructions of the abdominal wall and where resections should always maintain a radical oncologic character. BM is an option for use in early closure of abdominal wall defects in potentially contaminated wounds, even when skin cover is not attainable at first, hence leaving the graft exposed. It allows earlier closure of the abdomen as well as earlier discharge of patients.
The authors declare that there is no conflict of interests regarding the publication of this paper.