Dermatofibrosarcoma protuberans of the breast: mammographic, ultrasound, MRI and MRS features

Advances in non-invasive imaging for dermatofibrosarcoma protuberans: A review

Dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue sarcoma characterized by an asymmetric, infiltrative growth pattern and a high risk of local recurrence. This study aims to evaluate the effectiveness of various imaging modalities in the assessment and management of DFSP. Nine imaging modalities were reviewed including: Ultrasound (US), High-Frequency Doppler Ultrasound (HFUS), Computed tomography (CT), Positron emission tomography-computed tomography (PET-CT), and Magnetic Resonance Imaging (MRI), High-resolution-MRI (HR-MRI), Magnetic Resonance Spectroscopy (MRS), Optical Coherence Tomography (OCT), and Dermatoscopy. Imaging is mainly used for preoperative assessment and surgical planning, not routine diagnosis. US is effective for initial evaluations, demonstrating superior ability in detecting muscle invasion and defining tumour boundaries (sensitivity - 81.8%, specificity - 100%). MRI is valuable for preoperative evaluation, surgical planning, and monitoring DFSP recurrence. It more accurately assesses tumour depth than palpation, with a sensitivity of 67% and specificity of 100%, but was inferior when compared to US. CT is utilized in cases of suspected bone involvement or pulmonary metastasis. For advanced or recurrent DFSP, PET-CT helps manage treatment responses and imatinib therapy. Emerging technologies like MRS and OCT show potential in improving diagnostic accuracy and defining surgical margins, though more data are needed. US, MRI, and CT are the primary imaging modalities for DFSP. Emerging technologies like HR-MRI, PET-CT, MRS, and OCT hold promise for refining diagnostic and management strategies. Integrating multiple technologies could enhance management, particularly in atypical or aggressive cases. Further studies are required to refine imaging protocols and improve DFSP outcomes.

Conventional and contrast-enhanced ultrasound in the differential diagnosis of recurrent dermatofibrosarcoma protuberans and postoperative scar

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) has a high recurrence rate after resection. Because of the lack of specific manifestations, recurrent DFSP is easily misdiagnosed as post-resection scar. A few series have reported ultrasound findings of recurrent DFSP; moreover, the usefulness of contrast-enhanced ultrasound in differentiating recurrent DFSP has not been studied.

OBJECTIVE

We investigated conventional and contrast-enhanced ultrasound in the differential diagnosis of recurrent DFSP and post-resection scar.

METHODS

We retrospectively evaluated the findings of conventional and contrast-enhanced ultrasound in 34 cases of recurrent DFSP and 38 postoperative scars examined between January 2018 and December 2022.

RESULTS

The depth and vascular density of recurrent DFSP were greater than those of postoperative scars (P < 0.05). On gray-scale ultrasound, recurrent DFSP lesions were more commonly irregular, heterogeneous, and hypoechoic, with finger-like projections and ill-defined borders. Postoperative scar was more likely to appear as hypoechoic and homogeneous with well-defined borders (P < 0.05). On color Doppler ultrasound, recurrent DFSP was more likely to feature rich arterial and venous blood flow, and postoperative scar was more likely to display poor blood flow (P < 0.05). On contrast-enhanced ultrasound, recurrent DFSP was more likely to feature heterogeneous hyper-enhancement, and postoperative scar was more likely to display homogeneous iso-enhancement (P < 0.05). Recurrent DFSP presented a higher peak and sharpness than postoperative scar (P < 0.05).

CONCLUSION

Conventional and contrast-enhanced ultrasound produced distinct features of recurrent DFSP and post-resection scar, which could improve the accuracy of differential diagnosis.

Multimodal ultrasound for preoperative evaluation of dermatofibrosarcoma protuberans: a series of 40 cases

Background

Dermatofibrosarcoma protuberans (DFSP) is a rare, low to intermediate-grade sarcoma, which needs imaging examination. Small series of ultrasound findings in DFSP have been published; however, the usefulness of elastography and contrast-enhanced ultrasound (CEUS) in DFSP has not been studied. We aim to study multimodal ultrasound findings and report the correlation between imagings and tiny extension in DFSP for preoperative evaluation.

Methods

Two-D ultrasound, 3-D color ultrasound, elastography, and CEUS findings were retrospectively evaluated. Forty histopathologically confirmed DFSPs were studied.

Results

On 2-D ultrasound, 26(65%) appeared as mostly hypoechoic lesions with occasional hyperechoic dots within the tumor matrix and lobulated lateral borders. Eight (20%) lesions were multilayered. Ninety-five percent of lesions showed increased vascularity. On 3-D ultrasound, DFSPs showed branch-shaped, striped, and wrapped color patterns. Power Doppler showed mainly artery of a moderate arterial peak systolic blood flow and low resistance index. DFSP is hard on elastography. On CEUS, DFSPs showed a long peak time, low peak and a small amount of perfusion around the tumor, 73.7% (14/19) of lesions showed a heterogeneous contrast enhancement and 89.5% (17/19) of lesions showed hyper-enhancement. CEUS showed better concordance than US with histology on the maximum diameter and depth (P < 0.05).

Conclusions

Multimodal ultrasound showed significant characteristics in DFSP, which would improve diagnostic accuracy. CEUS could be an effective tool to determine tiny tumor extension.

Chemotherapy and targeted treatments of breast sarcoma by histologic subtype

Introduction: Breast sarcomas (BS) are uncommon and often present both diagnostic and therapeutic challenges. Historically, radical surgery has been the mainstay of treatment for localized breast sarcomas. On the other hand, in advanced disease, since they are a heterogeneous group of neoplasms consisting of several different subtypes including angiosarcoma, phyllodes tumor, and pleomorphic undifferentiated sarcoma, there is a lack of proven specific therapy. As a result, their treatment is based on the soft tissue sarcoma (STS) paradigm, whereas histotype-tailored approaches apply to specific subtypes like dermatofibrosarcoma protuberans. To date, advanced stages constitute an incurable form of disease and chemotherapy remains the cornerstone of treatment with the aim of palliation of symptoms and increase in survival.Areas covered: In this manuscript, we review the clinicopathologic characteristics of the most common subtypes of BS, as well as the current treatment landscape of BS, with a particular focus on opportunities and challenges provided by new targeted molecules and immunotherapy.Expert opinion: The treatment approach of advanced BS is based on the pathologic subtype. A true breakthrough has still to be obtained, as the development of new agents in BS suffers from the same weaknesses as in other STS.

Usefulness of ultrasound in dermatofibrosarcoma protuberans and correlation with histopathological findings: A series of 30 cases

BACKGROUND

Small series of ultrasound findings in dermatofibrosarcoma protuberans (DFSP) have been published, but the usefulness of this technique as a preoperative planning tool for tumor resection has not been studied.

MATERIALS AND METHODS

We retrospectively reviewed patients with DFSP at our hospital that underwent ultrasound examination. Depth of invasion was evaluated by ultrasound and histopathology. Accuracy of ultrasound for assessing depth of tumor invasion was estimated.

RESULTS

Thirty histopathologically confirmed DFSPs were studied. Classic finger-like projections were observed in 73.3% of cases. A posterior hyperechoic area extending deep into the subcutaneous tissue correlated with the honeycomb DFSP pattern and was observed in 53.3% of patients. Concordance between ultrasound and histopathologic depth measurements was excellent. Lateral tumor extension and Doppler activity were not evaluated in our series.

CONCLUSION

Ultrasound showed excellent prediction of depth of invasion. Further studies are required to define the usefulness of ultrasound for determining lateral tumor extension.

A Rare Malignant Disease, Dermatofibrosarcoma Protuberans of the Breast: A Retrospective Analysis and Review of Literature

Dermatofibrosarcoma protuberans (DFSP) is a rare low-grade fibroblastic mesenchymal tumor derived from the dermis. The aim of this retrospective analysis was to summarize the clinicopathological data from our cases and published cases to offer more evidence for the recognition of dermatofibrosarcoma protuberans (DFSP). A total of 6 breast DFSP patients who had received treatment in our hospital were retrospectively enrolled, and detailed clinicopathological data were gathered for analysis. The median age was 29.5 years (ranging from 17 to 42 years). Most cases presented a red or brown-red, mobile, well-circumscribed, protruding, breast mass (ranging from 1 to 3 cm). For histopathology, all cases (6/6) showed a storiform pattern of spindle cells that were positive for CD34 (6/6) and Vimentin (5/6) and negative for smooth muscle actin (0/6) and S-100 protein (0/6). The majority of patients (5/6) underwent wide local excision, with 2 cases treated with radiotherapy. With a median follow-up of 36 months, all 6 patients survived without recurrence or metastasis. The PubMed database was used to search for similar cases. Eventually, 36 cases were included in this review, while cases without detailed clinical information or not reported in English were excluded from the analysis. To summarize, DFSP of the breast is an extremely rare malignancy characterized by spindle tumor cells arranged in a storiform pattern and positivity for CD34. The core needle biopsy is one of the crucial methods for its preoperative diagnosis. Management of DFSP is mainly based on surgical excision. It is prone to local recurrence, so long-term follow-up is required.

Dermatofibrosarcoma Protuberans Mimicking Primary Breast Neoplasm: A case report and literature review

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing mesenchymal neoplasm of the dermis and subcutaneous tissues that has a low-to intermediate-grade malignancy. DFSP commonly involves the trunk and extremities, and very rarely the breast skin, mimicking a primary breast neoplasm with few reported cases in the literature. We report a 35-year old female patient who was referred to the Royal Hospital, Muscat, Oman in 2017, with a two-year history of a slow growing left breast lump. Assessment of the breasts with mammography revealed a lobulated lesion in the left-upper-inner quadrant with neither microcalcification nor architectural distortion, mimicking a benign lesion. However, on ultrasound, the lesion had suspicious features with increased vascularity and hence, it was categorised as breast imaging reporting and data system (BIRAD) IV. The patient underwent left breast wide local excision and the histopathological diagnosis was dermatofibrosarcoma protuberans.

Review of the pathophysiology, diagnosis, and therapy of vulvar leiomyoma, a rare gynecological tumor

The objective of this article is to discuss the pathophysiology, diagnosis, differential diagnosis, and therapy of vulvar leiomyoma. We performed a review of all English-language reports of vulvar leiomyoma published in PubMed from 1978 to 2015 using the following search terms: "vulval leiomyoma," "vulvar leiomyoma," "vulval smooth muscle tumor," and "external genitalia smooth muscle tumor." Vulvar leiomyomas, which are rare benign monoclonal tumors, most commonly occur in the fourth and fifth decades of life. The genetics of vulvar leiomyoma remain undefined. Three principal histological patterns have been identified: spindled, epithelioid, and myxoid. Imaging tests such as ultrasound, endoscopic ultrasound, and magnetic resonance imaging are used in diagnosis. Surgical excision is the only curative treatment for vulvar leiomyomas. Establishment of a full differential diagnosis list and correct final diagnosis before surgery are essential for optimal clinical management. Although recurrence of vulvar leiomyoma is extremely rare, long-term follow-up of all cases is advisable.

Dermatofibrosarcoma Protuberance of the Breast: a Diagnostic Challenge

Dermatofibrosarcoma protuberans (DFSP) is an uncommon slow growing neoplasm of the dermis with tendency to invade the subcutaneous tissues. It presents during the third to fourth decade of life and is commonly seen over the trunk, extremities and head and neck. DFSP presenting as a breast lump is rare but few cases have been reported in the literature. Pre-operative diagnosis with mammography, ultrasonography and FNAC is challenging. We report a case of a DFSP of the right breast in a middle aged lady with history of recurrent breast lumps excised and diagnosed in the past as benign. She presented with progressively increasing right breast lump of 2 months duration. She underwent wide local excision and histology revealed dermatofibrosarcoma protuberans. In view of its local aggressiveness with incomplete surgical margin, mastectomy was performed.

Imaging Features of Breast Dermatofibrosarcoma Protuberans in Various Modalities Including FDG-PET CT

Dermatofibrosarcoma protuberans is an uncommon malignant mesenchymal tumor of the dermis, which most commonly appears on the body and extremities. A preoperative diagnosis of dermatofibrosarcoma protuberans is extremely difficult, because it is a very rare entity and its appearance is often similar to that of benign breast lesion. Here, we presented a case of breast dermatofibrosarcoma protuberans with associated radiological mammography, ultrasound, magnetic resonance imaging and fludeoxyglucose-positron emission tomography computerized tomography (FDG-PET CT) features. To our knowledge, our case is the first report of PET-CT findings of breast dermatofibrosarcoma protuberans. Furthermore, we reviewed characteristic radiologic features of this rare entity, which are helpful for differentiating it from other primary benign breast lesions.

A Rare Breast Tumor: Dermatofibrosarcoma Protuberans

Dermatofibrosarcoma protuberans is a slow-growing, local aggressive fibrous tumor of the subcutaneous tissue, frequently seen in the proximal extremities and the trunk. Its occurrence in the breast is very rare. Herein, we present a female who presented with a breast mass, and aim to discuss pathological features and differential diagnosis of dermatofibrosarcoma protuberans. A 44-year-old female presented to our clinic with a mass on her breast. Physical examination revealed a 8×5.5 cm mass with multilobular nodules on the skin in the lower inner quadrant of her right breast. Her mammography revealed a hyperdense, 7.5×6.5 cm, well-demarcated, lobulated mass in the right breast, which caused nodules on the lower para-areolar portion of the breast skin. There was no axillary lymphadenopathy on both clinical and radiologic examinations. A core needle biopsy had been performed prior to her referral to our center, which revealed a 'spindle cell lesion'. The patient underwent simple mastectomy. On macroscopic examination; the skin over the lesion appeared ulcerated, and there was a well-defined solid mass, which was pale white-tan on the cut surface. Microscopic examination revealed monotonous spindle cell proliferation arranged in storiform pattern within the collagenous stroma with irregular extensions into deep adipose tissue. There were no necrosis or nuclear pleomorphism. The mitotic rate was 2-3/10 HPF. Immunohistochemically tumor cells showed diffuse CD34 positivity, and S100, EMA and SMA negativity. Based on histopathological and immunohistochemical findings, the lesion was diagnosed as dermatofibrosarcoma protuberans. Local recurrence is expected in 20-50% of these cases. Its treatment requires complete surgical excision with wide margins. Distant metastases, although rare, have been reported.

Dermatofibrosarcoma Protuberans: Computed Tomography and Magnetic Resonance Imaging Findings

The aim of this study was to analyze the computed tomography (CT) and magnetic resonance imaging (MRI) findings of dermatofibrosarcoma protuberans (DFSP), with a view to improving the diagnosis of this kind of tumor. A total of 27 cases of histopathologically confirmed DFSP were analyzed retrospectively. Of these, 18 patients underwent a CT scan and 9 patients underwent an MRI. All patients underwent unenhanced and contrast-enhanced examinations; 1 patient underwent multiphrase CT enhancement examination. Imaging characteristics, including location, shape, size, number, edge, and attenuation or intensity of each lesion, both unenhanced and contrast enhanced, were analyzed. Of the 27 cases, 24 were solitary, 2 had 2 nodules, and 1 had multiple confluent tumors. The lesion with multiple confluent tumors was ill defined and irregular; the other lesions were oval or round, well-defined nodules or masses. The unenhanced CT images showed 19 homogenous isodense lesions. There was no calcification in any of the patients. The contrast-enhanced CT images showed intermediate and marked nonhomogeneous enhancement in 13 lesions, intermediate homogeneous enhancement in 4 lesions, and a mild heterogeneous enhancement in 2 lesions. MR T1-weighted images revealed 1 ill-defined and 9 well-defined homogeneous isointense lesions. T2-weighted images showed homogeneous hyperintensity to the muscles in 6 lesions, 3 mild hyperintense lesions with hypointense lesions, and 1 mixed, mild hyperintense and isointense lesion. Contrast-enhanced T1-weighted images demonstrated intermediate and marked nonhomogeneous enhancement in 9 lesions and intermediate homogeneous enhancement in 1 lesion. DFSP is characterized by a subcutaneous well-defined soft tissue nodule or mass on plain CT/MR scans, and shows intermediate-to-marked enhancement on contrast-enhanced CT/MR scans. The imaging findings for DFSP are nonspecific, but may help to define the diagnosis in an appropriate clinical setting.

Computed tomographic and pathological findings of dermatofibrosarcoma protuberans

OBJECTIVE

The aim of the study was to investigate the computed tomographic (CT) and pathological findings of dermatofibrosarcoma protuberans to improve the awareness and understanding of the tumors from aspect of CT images.

METHODS

The CT findings of 16 cases (17 tumors) with dermatofibrosarcoma protuberans confirmed by pathological findings were retrospectively selected. Fourteen cases were primary dermatofibrosarcoma protuberans, 2 cases were recurrent tumors. Thirteen patients had CT plain and enhanced scans, 1 patient had direct enhanced CT scan, 2 patients had only unenhanced scan. Images of the tumors were analyzed and compared with pathological results.

RESULTS

Of the 16 cases (17 tumors total), 9 cases were on the trunk, 7 cases were on the head and the neck; 15 cases appeared as solitary isohypodense, ovoid, or round mass at the cutaneous and subcutaneous tissue, 1 case demonstrated 2 isodense masses on unenhanced CT images. The mean diameter of tumors was 4.0 cm, and the depth was 1.7 cm. The margin was well defined (n = 15 [88.2%]) or ill defined (n = 2 [11.8%]). Fifteen tumors revealed moderate or marked homogeneous (n = 12 [80%], smaller lesion, diameter <5 cm) or heterogeneous (n = 3 [20%], larger lesion, diameter ≥5 cm) enhancement on enhanced CT with intratumoral nonenhancement areas, which indicated intratumoral necrotic and cystic degeneration areas. No calcifications and metastasis were found. The histological examinations revealed large amounts of uniform spindle cells, which were arranged in "storiform" pattern. Immunohistochemical analysis revealed samples positive for CD34 and vimentin.

CONCLUSION

The common imaging findings of dermatofibrosarcoma protuberans include a solitary, superficial, subcutaneous solid mass, various homogenous or heterogeneous enhancements due to degenerative areas. Computed tomographic scan is helpful to detect the size, location, depth and range of this tumor.

Recurrent bilateral dermatofibrosarcoma protuberans of eyelids

A 26-year-old man had a history of multiple nodules involving the upper and lower eyelids bilaterally, for which he had undergone wide local excision along with eyelid reconstruction. Three years later, he presented to the authors with recurrence of the tumor masses. Tumor debulking surgery was performed bilaterally, with eyelid reconstructive surgery. Histopathology of the excised mass showed spindle-shaped cells in the dermis, which were arranged in a storiform pattern. Immunohistochemically, the tumor expressed vimentin diffusely and CD-34 focally. Histopathologic findings of storiform pattern of tumor cells and positive immunohistochemical stains for CD-34 led to the diagnosis of dermatofibrosarcoma protuberans. The clinical course was marked by repeated local recurrences following multiple debulking procedures. Local control could not be achieved in this case and at last follow up, the tumor was surgically unresectable.

Late local recurrence of dermatofibrosarcoma protuberans in the skin of female breast

Dermatofibrosarcoma protuberans (DFSP) of the breast is exceptionally obscure and late local recurrence of this entity on this site is even more uncommon. We describe such a case in a 48-year-old woman, who at the age of 35 had a DFSP excised from her right breast. Thirteen years later, she developed an ovoid mass in her right breast over the postsurgical scar area. Wide local excision of the tumor with generous tissue margin was performed and microscopic and immunohistochemical findings established the diagnosis of recurrent DFSP. No further treatment was administered and she remains well 18 months later, without tumor recurrence. We report an exceptionally rare case of local recurrence of DFSP in the female breast and discuss in detail the diagnostic and therapeutic implications of this pathology.