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Desmoid tumors (DT) are rare fibroblastic neoplasms characterized by local aggressiveness, absence of metastatic potential, and heterogeneous clinical behavior. During the last decade, management has shifted from routine upfront surgery toward active surveillance and selective systemic therapy. We evaluated temporal changes in management and surgical outcomes within a multicenter real-world cohort.

We retrospectively reviewed consecutive patients with histologically confirmed DT managed between January 2015 and January 2026 across four tertiary hospitals in Madrid, Spain. Treatment-era analyses compared 2015-2019 with 2020-2026. Local recurrence-free survival (RFS) after surgery was estimated using the Kaplan-Meier method.

Eighty-two patients were included. Initial management was available for 79 patients: surgery in 48, active surveillance in 17, and systemic therapy in 14. Among 77 patients with an assignable treatment era, upfront surgery decreased from 24/30 (80.0%) in 2015-2019 to 24/47 (51.1%) in 2020-2026 (Fisher p = 0.015), while active surveillance and systemic therapy increased. Fifty-three patients underwent surgery during follow-up. Local recurrence occurred in 11/51 patients with evaluable postoperative follow-up. R1 resection was associated with a higher unadjusted risk of local recurrence than R0 resection (40.0% vs 3.8%; conditional OR 15.84, exact 95% CI 1.92-751.38; Fisher p = 0.002).

Contemporary recommendations have been progressively incorporated into routine practice, with reduced reliance on upfront surgery. Surgery remains important in selected patients. The observed association between R1 margins and local recurrence is unadjusted and should be interpreted cautiously given the limited number of events and potential residual confounding.