Dermatofibrosarcoma protuberans: Wide local excision vs. Mohs micrographic surgery

Comparing Mohs micrographic surgery and wide local excision in the management of head and neck dermatofibrosarcoma protuberans: a scoping review

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive cutaneous sarcoma with a propensity for recurrence. Its management, particularly in the head and neck (H&N) region, presents unique challenges. This study aimed to evaluate the effectiveness of Mohs micrographic surgery (MMS) compared to wide local excision (WLE) in treating H&N DFSP and its impact on recurrence rates and tissue preservation. A comprehensive search was conducted in PubMed/MEDLINE, yielding 29 relevant studies. We included studies comparing MMS and WLE in adult patients with H&N DFSP and reporting local recurrence outcomes. Data were analyzed using random effects analysis, with a meta-analysis performed for comparative studies. Analysis of studies demonstrated a lower recurrence for MMS. Comparative analysis of five studies involving 117 patients showed a significantly lower recurrence rate in the MMS group (2%) compared to the WLE group (19%). Margin status varied between studies, with some achieving negative margins at shorter distances. In the management of H&N DFSP, MMS has emerged as a superior surgical technique, consistently associated with reduced recurrence rates and the potential for tissue preservation. The adoption of MMS should be considered for its capacity to achieve negative margins with fewer processing steps, particularly in anatomically complex regions like the H&N.

Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors

Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.

Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors

Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.

Do the Histological Differences of Soft Tissue Sarcomas Affect the Rate of Skin Defect Reconstruction?

BACKGROUND

In soft tissue sarcoma (STS) resection, flap reconstruction and/or skin grafting is frequently required. However, it is not clear whether the histological difference affects the rate of reconstruction. The present study aimed to investigate it.

METHODS

This study compared in 5 classifications (105 adipocytic tumors, 102 fibroblastic tumors, 39 muscle tumors, 31 peripheral nerve sheath tumors, and 178 tumors of uncertain differentiation). In addition, the reconstruction rates of detailed tumor sites were compared. The median and case number (percentage) were calculated.

RESULTS

Tumor size (adipocytic 112 mm vs fibroblastic 79 mm, muscle 72 mm, nerve 90 mm, uncertain 74 mm, P < 0.0001 in all comparisons), histological low-grade rates (adipocytic 43.8% vs uncertain 3.9%, P < 0.0001; fibroblastic 46.1% vs muscle 15.4%, P = 0.003; fibroblastic vs uncertain, P < 0.0001; nerve 19.4% vs uncertain, P = 0.003) and reconstruction rates (adipocytic 5.7% vs fibroblastic 42.2%, muscle 33.3%, nerve 32.3%, uncertain 25.8%, P < 0.0001 in all comparisons) were significantly different. In the region of lower extremity, the regions of thigh [adipocytic 1/62 (1.6%) vs fibroblastic 7/32 (21.9%), P = 0.002], and lower leg [adipocytic 1/16 (6.3%) vs fibroblastic 11/19 (57.9%), P = 0.002] were significantly different.

CONCLUSIONS

In adipocytic tumors, the tumor size was significantly large; however, the skin defect reconstruction rate was significantly lower than that of the other STS. Histologically, the reconstruction rate of STS derived from superficial tissue increases, whereas the reconstruction rate derived from deep tissue such as adipocytic tumor decreases.

Machine learning-based radiomics analysis for predicting local recurrence of primary dermatofibrosarcoma protuberans after surgical treatment

BACKGROUND AND PURPOSE

Dermatofibrosarcoma protuberans (DFSP) is characterized by locally invasive growth patterns and high local recurrence rates. Accurately identifying patients with high local recurrence risk may benefit patients during follow-up and has potential value for making treatment decisions. This study aimed to investigate whether machine learning-based radiomics models could accurately predict the local recurrence of primary DFSP after surgical treatment.

MATERIALS AND METHODS

This retrospective study included a total of 146 patients with DFSP who underwent MRI scans between 2010 and 2016 from two different institutions: institution 1 (n = 104) for the training set and institution 2 (n = 42) for the external test set. Three radiomics random survival forest (RSF) models were developed using MRI images. Additionally, the performance of the Ki67 index was compared with the three RSF models in the external validation set.

RESULTS

The average concordance index (C-index) scores of the RSF models based on fat-saturation T2W (FS-T2W) images, fat-saturation T1W with gadolinium contrast (FS-T1W + C) images, and both FS-T2W and FS-T1W + C images from 10-fold cross-validation in the training set were 0.855 (95% CI: 0.629, 1.00), 0.873 (95% CI: 0.711, 1.00), and 0.875 (95% CI: 0.688, 1.00), respectively. In the external validation set, the C-indexes of the three trained RSF models were higher than that of the Ki67 index (0.838, 0.754, and 0.866 vs. 0.601, respectively).

CONCLUSION

Random survival forest models developed using radiomics features derived from MRI images were proven helpful for accurate prediction of local recurrence of primary DFSP after surgical treatment and showed better predicting performance than the Ki67 index.

Dermatofibrosarcoma protuberans of the scalp: Surgical management in a multicentric series of 11 cases and systematic review of the literature

BACKGROUND

Dermatofibrosarcoma protuberans is a rare, slow-growing soft-tissue malignancy originating in the dermis that is characterized by an infiltrating growth pattern with a marked tendency of local recurrence. Complete surgical resection with pathological margin clearance must be achieved to reduce the risk of tumor recurrence. Resulting defects often require extensive reconstructive procedures. Dermatofibrosarcoma protuberans of the scalp poses particular challenges owing to the proximity to the face and brain. This study aims to evaluate treatment options and proposes an algorithm for management of scalp dermatofibrosarcoma protuberans based on a multicentric case series and systematic review of the literature.

METHODS

A retrospective multicentric chart analysis of 11 patients with scalp dermatofibrosarcoma protuberans who presented within the last 20 years was performed regarding demographic data, pathological tumor characteristics, and surgical management (resection and reconstruction). Additionally, a further 42 patients (44 cases) were identified through a systematic Preferred Reporting Systems for Systematic Reviews and Meta-Analysis-based review of the literature searching the Medline and Embase databases.

RESULTS

In total, 30 cases were classified as primary and 20 cases as recurring scalp dermatofibrosarcoma protuberans (data from 5 cases were missing). The median tumor size was 24 cm2 (interquartile range 7.8-64), and the median defect size was 55.8 cm2 (interquartile range 48-112). Recurring scalp dermatofibrosarcoma protuberans was more often associated with invasion of deeper layers and required more extensive tumor resection to achieve negative margins. Within the subgroup that was managed with peripheral and deep en face margin assessment, no recurrence was observed. Most patients required local (41. 8%) or free flap (27.8%) reconstruction after dermatofibrosarcoma protuberans resection.

CONCLUSION

Whenever possible, peripheral and deep en face margin assessment-based techniques should be preferred for resection of scalp dermatofibrosarcoma protuberans because they provide superior oncological safety while preserving uninvolved tissue. Patients with locally advanced and recurring scalp dermatofibrosarcoma protuberans often require multidisciplinary treatment including neurosurgery, radiotherapy, and microvascular reconstructive surgery and should be referred to a specialized center.

[Micrographic controlled surgery in everyday dermatosurgery]

Micrographic controlled surgery (MCS) has become established in dermatosurgery in recent years and includes various methods to enable the histologically proven complete resection of malignant cutaneous tumors, while at the same time sparing tumor-free tissue in the immediate vicinity as much as possible. MCS is of great importance in the surgical treatment of cutaneous malignancies in so-called problem locations and aggressive tumor subtypes. Indications for MCS include basal cell carcinoma, cutaneous squamous cell carcinoma, Bowen's disease and Bowen's carcinoma, melanoma in chronic light-damaged skin with acral lentiginous melanoma, dermatofibrosarcoma protuberans (DFSP), and Merkel cell carcinoma. However, other tumor entities are also treated using MCS, such as extramammary Paget's disease and various cutaneous sarcomas. All procedures subsumed under MCS have in common the marking of the surgical specimen for topographical orientation, which provides assignment of remaining tumor remnants. Various methods of MCS (3D histology, the horizontal method or Mohs surgery) are presented in this article. Furthermore, this article aims to raise awareness of the possibilities and limitations of micrographically controlled surgery.

Wide local excision, Mohs micrographic surgery, and reconstructive options for treatment of dermatofibrosarcoma protuberans of the breast: A retrospective case series from Mayo Clinic

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) of the breast is a dermal fibroblastic neoplasm requiring wide excisional margins due to recurrence rates ranging from 26 to 60%. The current literature on reconstructive options and utility of Mohs micrographic surgery for DFSP of the breast is scarce. We describe surgical management of DFSP of the breast at our institution with the largest case series reported to date.

METHODS

A retrospective review was performed of women who underwent surgery for DFSP of the breast at our institution between 1990 and 2019. Continuous data was summarized using mean, median, and range; categorical data was summarized with frequency count and percentage. Preoperative lesion size and postoperative defect size were evaluated using 2-sided Fisher exact test, and p-values < 0.05 were considered statistically significant.

RESULTS

Nine patients underwent wide local excision (WLE) with reconstruction including pedicled latissimus dorsi flaps (n = 2), local flap advancement (n = 2), mastectomy with implant (n = 1), oncoplastic breast reduction (n = 1), and skin grafts (n = 3). Nine underwent Mohs micrographic surgery (MMS) with complex primary closure. Mean postoperative maximum wound defect size for WLE was 10.8 cm versus 7.0 cm for MMS with no statistical significance (p = 0.77). Mean preoperative maximum lesion size for WLE was 6.4 cm versus 3.3 cm for MMS with no statistical significance (p = 0.07). Complications with WLE included wound dehiscence in three patients and seroma in one patient. No complications were reported with MMS and primary closure. Recurrence was reported in one WLE patient, which was successfully detected despite flap coverage and resected without complications. Median follow-up for the patients without recurrence was 5.0 years, with two patients in MMS cohort lost to follow-up. Five-year overall survival was 100%.

CONCLUSIONS

MMS and WLE are both viable surgical options for managing DFSP of the breast. MMS could potentially minimize reconstructive needs due to smaller average defect size and result in fewer complications but may also result in asymmetry. Immediate flap reconstruction, especially in larger defects, can achieve excellent aesthetic outcomes for patients with DFSP of the breast without compromising detection of disease recurrence.

Recurrent Dermatofibrosarcoma Protuberans of the Head and Neck: a Case Series

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma that develops from dermal fibroblasts and spreads within the dermis and subcutaneous fat. It is locally aggressive, with a high local recurrence rate after excision but has extremely low metastatic potential. In the case of recurrent tumors, surgical excision with adequate margins is the gold standard treatment and may require adjuvant radiotherapy or chemotherapy in some cases. We conducted a retrospective analysis of individuals with dermatofibrosarcoma protuberance of the head and neck region that had treatment at our facility between 2016 and 2021. We gathered the data on the surgical techniques, reconstructive techniques used, histopathological features, adjuvant therapy, and outcomes. We treated three patients with head and neck dermatofibrosarcoma protuberance: one scalp lesion and two on the cheek. All three patients had recurrent tumors, two of whom were treated elsewhere for the primary lesion. One patient underwent surgery for a benign spindle cell tumor of the right cheek, but a final histopathological examination revealed dermatofibrosarcoma protuberance, and the tumor recurred within 3 months. The duration of recurrence is between 3 and 24 months. The size of the tumor ranges from 7.2 to 10.5 cm. The wide local excision margins range from 2 to 4 cm. Reconstruction ranges from split skin graft to regional flap. Inadequate margins raise the possibility of local recurrence in dermatofibrosarcoma protuberance.

Oncological efficiency of wide local excision in dermatofibrosarcoma protuberans

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a slow-growing, low- to intermediate-grade malignant sarcoma. Its optimal treatment is resection with wide margins; the likelihood of local control associated with this procedure exceeds 90%. The probability of regional or distant metastases is <5%.

OBJECTIVE

We examined the clinical, epidemiological, and pathological features, the treatment types, and outcomes of patients to investigate the width of safe surgical margins (SM) and how the width of SMs affected recurrence in DFSP.

METHODS

We retrospectively examined the records of 60 patients who were initially operated on with wide local excision for DFSP in the period 2008-2019. Optimal cutoff points for SMs were calculated with the receiver operating characteristic curve analysis and found as 1.925 cm histopathologically and 2.26 cm macroscopically.

RESULTS

During the mean 89.6-month follow-up, local recurrence was seen in 36.7% and distant metastasis in 20% of the patients. Recurrences were significantly related to peripheral resection margins. Analysis by histopathologic cutoff points showed that the local recurrence rate was 84% when SM was ≤1.925 cm, but only 2.85% when >1.925 cm (p = 0.002). Recurrence-free survival was 40.92 months when SM was ≤1.925 cm and 225.75 months when s >1.925 cm (p<0.001). Analysis by macroscopic cutoff points showed that the local recurrence rate was 95.5% when SM was ≤2.26 cm, but only 4% when >2.26 cm (p = 0.001). Recurrence-free survival was 43 months when SM was ≤2.26 cm and 222 months when >2.26 cm (p<0.001). In metastatic patients, progression-free survival was 9 months with cytotoxic chemotherapy, whereas 38.4 months with tyrosine kinase inhibitor (imatinib) (p = 0.002).

CONCLUSION

This study showed SMs >2.5 cm to be sufficiently safe for WLE and optimized the balance among safe margin width, reconstruction need, and surgical morbidity. In metastatic DFSP patients, tyrosine kinase inhibitor imatinib is more effective than cytotoxic chemotherapy for progression-free survival.

Outcome After Surgical Treatment of Dermatofibrosarcoma Protuberans (DFSP): Does it Require Extensive Follow-up and What is an Adequate Resection Margin?

INTRODUCTION

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous tumour of indeterminate malignant potential. The mainstay treatment for DFSP is surgical resection. Given the reported high local recurrence rate, the ideal resection margin for DFSP is unclear. The purpose of this study was to ascertain the local recurrence and metastatic rate of DFSP and DFSP with fibrosarcomatous degeneration (FS-DFSP), with specific attention to margin status in an attempt to address the issue of margin adequacy.

METHODS

Patients treated for DFSP at a single sarcoma centre were identified from a prospective database. DFSP and FS-DFSP patients with and without prior surgery were included. Patients were followed after surgery to monitor complications, local recurrence and metastasis.

RESULTS

The study included 200 patients: 166 patients with DFSP and 34 patients with FS-DFSP. In the DFSP group, nine patients (5.4%) had positive margins, one case (0.6%) developed local recurrence (LR) and no patients developed distant metastases. In the FS-DFSP group, seven patients (20.6%) had positive margins, six patients (17.6%) developed local recurrence (LR) and eight patients (23.5%) developed distant metastases, of which three (37.5%) were in the lungs, one (12.5%) in bone and four (50%) in other soft tissue sites.

DISCUSSION AND CONCLUSION

Local recurrence and metastases are extremely rare in patients with DFSP. Achieving a negative as opposed to a wide surgical margin may be sufficient to avoid local recurrence of most DFSP. We suggest that no ongoing surveillance for local or systemic relapse is required for DFSP patients after negative margin resection. For FS-DFSP, we recommend the same surveillance schedule, based on tumour grade, as other soft tissue sarcoma.

Dermatofibrosarcoma protuberans in dermatological practice. Case report

Dermatofibrosarcoma protuberans (DFSP) is a mesenchymal neoplasm of fibrohistiocytic origin of moderate malignancy. The pathogenesis of DFSP involves chromosomal translocation, which leads to the formation of a fusion protein that promotes tumor growth due to increased production of platelet growth factor (PDGF). Clinically, it begins with an asymptomatic fibrous papule or firm plaques, which gradually over the course of several years become enlarged with the formation of asymmetrical multi-nodular structure of purple or red-brown color. The standards of diagnosis is a histological examination with the detection of a poor limited infiltrate indermis of a storiform architecture consisting of monomorphic spindle cells and diffuse CD34+ staining during immunohistochemistry. Complete surgical excision is considered the gold standard of treatment. Clinical case: female patient, 35 years old with a lesion in the form of a dense plaque in right subclavian area was examined by a dermatologist. The primary diagnosis was made as "morphea". In a year a slight growth of the lesion and the appearance of small firm nodules asymmetrically along the periphery were noted. According to the results of histological and immunohistochemistry studies the diagnosis of DFSP was made, the patient was referred to an oncologist for complete tumor removal.

Reconstruction options in recurrent dermatofibrosarcoma protuberans:A scoping review

Background

This review will outline the evaluation, diagnosis, and management of dermatofibrosarcoma protuberans and emphasizes multidisciplinary role of nurses, plastic surgeons and radiation oncologist in this recurrent metastatic lesion. It pinpoints affected population at risk, clinical features, and reconstruction options. No analytical research has been done in this area.

Material and Methods

A scoping review of patients of DFSP who underwent reconstruction after excision of tumors was performed in the Department of Burn and Plastic Surgery, AIIMS Rishikesh. It used a five framework approach. A review of 85 similar cases reported in the literature have been scrutinized in relation to the reconstruction options, sites of the tumor, margins of excision and recurrence.

Results

85 full length English studies were included out of the 445 cases found in Pubmed and related search engines to reveal various reconstructive options in reconstruction of DFSP defects. Present scoping review identifies free anterolateral thigh flap to be useful in 7 review articles followed by propeller flaps in 3 isolated case reports. 2 cases of free latissimus dorsi flap were used for reconstruction of abdominal defects.

Conclusion

All patients should undergo a strict screening protocol where the health personnel can play a crucial role by educating parents on the follow up and report new lesions as early as possible. All operated tumor patients can be given safety tips and education on care and risks after reconstruction with skin flaps or skin grafting. A multidisciplinary approach between the surgeon, nurse and radiation oncologist is needed for effective management of these lesions.

Evidence from Clinical Studies Related to Dermatologic Surgeries for Skin Cancer

Simple Summary

Although significant progress in pharmacotherapy for skin cancer has been made in the past several years, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgeries including lymph node dissection and skin graft can cause various complications, and these complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.

Abstract

Despite the significant progress made in the past several years in pharmacotherapies for skin cancer, such as BRAF/MEK inhibitors, immune checkpoint inhibitors, and Hedgehog pathway inhibitors, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In cases of lymph node metastases with clinically palpable lymphadenopathy, lymph node dissection (LND) is typically performed for most skin cancers. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgery can cause various complications. Although skin graft is frequently used for reconstruction of the surgical defect, extensive graft necrosis may develop if optimal stabilization of the graft is not obtained. LND also sometimes causes complications such as intraoperative or postoperative bleeding and postoperative lymphoceles. Moreover, as in other types of surgery, surgical site infection, intraoperative anxiety, and intraoperative and postoperative pain may also develop. These complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.

Dermatofibrosarcoma Protuberans Recurrence After Wide Local Excision Versus Mohs Micrographic Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Local recurrence (LR) rates of dermatofibrosarcoma protuberans (DFSP) treated with different surgical modalities are unknown.

OBJECTIVE

To evaluate the differences in LR rates of DFSP treated with wide local excision (WLE) versus Mohs micrographic surgery (MMS).

MATERIALS AND METHODS

Pertinent studies of DFSP treated with either WLE or MMS were identified through a search of multiple databases, including Ovid MEDLINE (1946-2018), Embase (1988-2018), Web of Science (1975-2018), and Scopus (1970-2018). Comparative 2-arm and noncomparative single-arm studies were assessed through meta-analyses.

RESULTS

Of the 517 studies identified, 88 met inclusion criteria (12 comparative studies; 76 single-arm studies). In the 12 comparative studies, 352 patients with DFSP underwent MMS and 777 patients with DFSP underwent WLE. The LR rate was 1.7% after MMS and 3.7% after WLE (odds ratio, 1.549; 95% CI, 0.710-3.381; p = .27). In the 76 noncomparative studies, 980 patients underwent MMS (LR rate, 1.5%; 95% CI, 0.9%-2.1%; p < .001), and 2,215 patients underwent WLE (LR rate, 9.4%; 95% CI, 7.5%-11.3%; p < .001).

CONCLUSION

The LR rate of DFSP in patients treated with MMS is lower than in patients treated with WLE. Because of high rates of postoperative DFSP LR, MMS should be strongly considered when available.

A review of Mohs Micrographic Surgery for skin cancer: Part 1 - melanoma and rare skin cancers

Mohs micrographic surgery is a precise and effective method commonly used to treat high risk basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) on the head and neck. Whilst the majority of evidence for Mohs relates to keratinocyte cancers, there is published evidence for other types of skin cancer. This review aims to discuss the evidence for using MMS to treat six different types of skin cancer, including melanoma, lentigo maligna, dermatofibrosarcoma protuberans, atypical fibroxanthoma, microcystic adnexal carcinoma and pleomorphic dermal sarcoma, particularly in the context of survival rates and cancer recurrence. These cancers were chosen as there was sufficient literature for inclusion and given MMS is most useful when cancers are contiguous, rather than for cancers with marked metastatic potential such as angiosarcoma or merkel cell carcinoma. We searched Medline, Pubmed and Embase using the keywords: 'melanoma', 'mohs micrographic surgery', 'lentigo maligna', 'dermatofibrosarcoma protuberans', 'atypical fibroxanthoma', 'microcystic adnexal carcinoma' and 'pleomorphic dermal sarcoma' along with their appropriate synonyms, to identify the relevant English-language articles from the year 2000 onwards given that literature for Mohs on non-keratinocyte is sparse prior to this date. A MeaSurement Tool to Assess systematic Reviews (AMSTAR) was used to assess the validity of systematic reviews. Further high-quality, multi-centre randomised trials are necessary to establish the indications and efficacy of MMS for rarer cancers, particularly for AFX and PDS, where limited studies were identified.

Assessing the Safety and Utility of Wound VAC Temporization of the Sarcoma or Benign Aggressive Tumor Bed Until Final Margins Are Achieved

BACKGROUND

Local recurrence of microinvasive sarcoma or benign aggressive pathologies can be limb- and life-threatening. Although frozen pathology is reliable, tumor microinvasion can be subtle or missed, having an impact on surgical margins and postoperative radiation planning. The authors' service has begun to temporize the tumor bed after primary tumor excision with a wound vacuum-assisted closure (VAC) pending formal margin analysis, with coverage performed in the setting of final negative margins.

METHODS

This retrospective analysis included all patients managed at a tertiary referral cancer center with VAC temporization after soft tissue sarcoma or benign aggressive tumor excision from 1 January 2000 to 1 January 2019 and at least 2 years of oncologic follow-up evaluation. The primary outcome was local recurrence. The secondary outcomes were distant recurrence, unplanned return to the operating room for wound/infectious indications, thromboembolic events, and tumor-related deaths.

RESULTS

For 62 patients, VAC temporization was performed. The mean age of the patients was 62.2 ± 22.3 years (median 66.5 years; 95% confidence interval [CI] 61.7-72.5 years), and the mean age-adjusted Charlson Comorbidity Index was 5.3 ± 1.9. The most common tumor histology was myxofibrosarcoma (51.6%, 32/62). The mean volume was 124.8 ± 324.1 cm³, and 35.5% (22/62) of the cases were subfascial. Local recurrences occurred for 8.1% (5/62) of the patients. Three of these five patients had planned positive margins, and 17.7% (11/62) of the patients had an unplanned return to the operating room. No demographic or tumor factors were associated with unplanned surgery.

CONCLUSIONS

The findings showed that VAC-temporized management of microinvasive sarcoma and benign aggressive pathologies yields favorable local recurrence and unplanned operating room rates suggestive of oncologic and technical safety. These findings will need validation in a future randomized controlled trial.

Management of dermatofibrosarcoma protuberans

PURPOSE OF REVIEW

Provide an up to date review of the diagnosis, workup and treatment of dermatofibrosarcoma protuberans (DFSP). DFSP can be a challenging disease to manage and adequate understanding of the most up to date literature can help provide comprehensive treatment strategies.

RECENT FINDINGS

DFSP is an infiltrative cutaneous sarcoma. It tends to have deep local invasion with a high risk of local recurrence, but a low risk of distant metastasis. It presents typically as a slow growing, asymptomatic skin lesion. It presents rarely in the head and neck, only 15% of the time. Recent data has discussed the role of wide local excision (WLE) vs. Mohs surgery. In addition, for unresectable disease the role of systemic therapy and immunomodulatory agents such as Imatinib has shown success.

SUMMARY

Typically, surgical management is the first line for DFSP, however the risk for local recurrence still remains high with negative margins. Due to this risk, lifelong surveillance is required after initial diagnosis and management. Similar to other head and neck tumors, most recurrences happen within the first 3 years after treatment. DFSP can be treated with WLE or Mohs. For aggressive disease that is considered unresectable systemic therapy does exist, including molecular targeted therapies.

[Mohs micrographic surgery for skin cancers: A 10 year - single-center series of 548 patients treated by formalin-fixed tissue Mohs surgery assessing the impact of reduced margins]

AIM

Only few robust studies specify the indications of Mohs Surgery techniques in skin tumors. The aim of this work was to carry out a review of almost 10 years of experience, assessing the impact of reduced margins on reconstruction, and proposing a management algorithm in the light of the literature.

PATIENT AND METHODS

All the records of patients having benefited from a Mohs technique in our center were retrospectively compiled from January 2011 until January 2020. A formalin-fixed tissue Mohs surgery was used. An impact assessment of reduced margins was made both on the excisional surface but also on the improvement of the reconstruction.

RESULTS

548 patients were included. Complete tumour clearance was achieved with one surgical stage in 71% of cases. The excisional surface of tumours located in the periorbital and nasal areas was significantly more often reduced compared to other areas (P=0,020). The improvement of the reconstruction was deemed significant in the periorbital and nasal areas; as well as for tumours located on limbs and trunk linked with Dermatofibrosarcoma management.

CONCLUSION

This study underlines the interest of assessing the clinical relevance of reducing margins depending on the tumor location. Our single-center experience feedback on a large series allows to clarify Mohs technique indications by means of a literature review.

Local Recurrence Rates of Skin Tumors After Resection With Complete Circumferential Peripheral and Deep Margin Assessment-Identification of High-Risk Entities

BACKGROUND

The local recurrence rates of malignant skin tumors after micrographic controlled surgery using complete circumferential peripheral and deep margin assessment (CCPDMA) are reported to be low. However, in daily practice, tumor entities with a significantly higher recurrence rate are found.

OBJECTIVE

The aim of the investigation was to identify these high-risk tumors to develop approaches for risk stratification.

PATIENTS AND METHODS

We included different malignant tumors that were surgically treated and examined with CCPDMA using paraffin sections and H&E staining. Re-excisions were performed until the tumor was completely removed.

RESULTS

Ninety-nine thousand three hundred seventy-two tumors were included in the study; the follow-up period was 4 years (median). Eight tumor entities were identified as high-risk entities, showing a significantly higher local recurrence rate of over 20%: desmoplastic squamous cell carcinoma, desmoplastic melanoma, Merkel cell carcinoma, microcystic adnexal carcinoma, pleomorphic sarcoma, liposarcoma as well as angiosarcoma, and extramammary Paget's disease.

CONCLUSION

Complete circumferential peripheral and deep margin assessment allows complete control of the resection margins and enables skin-sparing resections with low recurrence rates for basal cell carcinomas, nondesmoplastic squamous cell carcinomas, lentiginous melanomas, and dermatofibrosarcoma protuberans. However, other tumors show significantly higher recurrence rates and therefore need to be classified as high-risk tumors.

Dermatofibrosarcoma Protuberans: A Clinicopathologic and Therapeutic Analysis of 254 Cases at a Single Institution

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare low-grade tumor that typically does not metastasize but often recurs. Fibrosarcomatous DFSP (FS-DFSP) is associated with a substantially higher rate of metastasis and a poorer prognosis.

OBJECTIVE

This study sought to investigate the epidemiological, histopathological, and clinical characteristics of DFSP, especially with a particular focus on FS-DFSP.

MATERIALS AND METHODS

Clinical data from 254 patients treated between January 1999 and July 2018 were retrospectively reviewed. Endpoints of the study were the incidence of significant disease-related clinical events.

RESULTS

Follow-up data from 211 patients were available for analysis, with a median follow-up time of 38 months (range: 1-196 months). The 5-year recurrence-free survival rate of patients underwent wide-local excision (WLE) was 97.1%. Patients underwent WLE exhibited a significantly decreased recurrence rate relative to patients treated through local excision (2.9% vs 37.7%; p < .001). Fibrosarcomatous DFSP had significantly higher rates of distant metastasis (66.7% [n = 4] vs 2.0% [n = 4]; p < .001) and long-term mortality (50.0% [n = 3] vs 1.5% [n = 3]; p < .001), compared with classical DFSP (C-DFSP).

CONCLUSION

Wide-local excision is an effective means of reducing DFSP recurrence. Rates of metastasis are higher for FS-DFSP than for C-DFSP, with the former having significantly poorer outcomes.

Association between surgical excision margins and outcomes in patients with dermatofibrosarcoma protuberans: A meta-analysis

Dermatofibrosarcoma protuberans (DFSP) is a tumor with low-grade malignancy and high recurrence rates. Wide local excision (WLE) is essential for DFSP, but its surgical excision margin is controversial. This study aimed to examine whether resection margin is associated with the prognosis of patients with DFSP by systematically reviewing related literature. Studies that evaluated the relationship between excision margins and outcomes after WLE were retrieved from the Cochrane Library, PubMed, Embase, and Web of Science databases. Relative risk (RR) estimates and 95% confidence intervals (CIs) were measured via a random-effect model to evaluate the subsequent outcomes: recurrence rate, mortality, and positive surgical margin rate. Sensitivity and subgroup analyses were simultaneously carried out. The meta-analysis of eight observational literatures demonstrated a significant positive correlation of ≥3 cm margin with the recurrence rate (RR = 0.17, 95% CI 0.09-0.31) and the positive surgical margin rate (RR = 0.09, 95% CI 0.02-0.46). The same result was observed in the recurrence rate in all subgroups. The stability of the above outcomes was authenticated via sensitivity analyses. Our meta-analysis illustrated that excision with <3 cm surgical margin exhibited an increased risk of poor DFSP prognosis (high recurrence rate and increasing positive margin rate).

[Dermatofibrosarcoma protuberans (Darier-Ferrand) of the abdomen: a case report]

Dermatofibrosarcoma is a rare skin tumor. Morphological characteristics can be misleading and unknown to most of physicians. Diagnostic delay may affect patient´s management and prognosis. We here report the case of a young patient with lesions protruding from the abdominal wall mistaken for benign cysts. X-ray examination revealed subcutaneous adipose tissue mass. This was suspected of being a fibrosarcoma. The mass was resected with a macroscopic safety margin. The anatomo-pathological study confirmed the diagnosis of dermatofibrosarcoma. Clinical and radiological follow-up examinations didn´t show any recurrence. This study highlights the importance of suspecting this rare tumor requiring specialist treatment.

Cutaneous mesenchymal tumors treated with Mohs micrographic surgery: a comprehensive review

Cutaneous mesenchymal tumors (CMT) are rare tumors with wide clinicopathologic heterogeneity. Treatment of malignant cutaneous mesenchymal tumors traditionally includes wide local excision (WLE), though Mohs micrographic surgery (MMS) has been increasingly used. A PubMed literature review of articles from inception until September 2019 related to malignant CMT and surgical treatment with MMS or WLE was completed. Dermatofibrosarcoma protuberans treated with MMS recurred in 1.2% of patients with no reported metastasis. Atypical fibroxanthoma treated with MMS recurred and metastasized in 2.7 and 2.5%, respectively. Undifferentiated pleomorphic sarcoma treated with MMS recurred in 32% with an unknown metastatic rate. Superficial leiomyosarcoma treated with MMS recurred in 3.8% with no reported metastasis. Cutaneous angiosarcoma and myofibrosarcoma treated with MMS have shown no recurrence or metastatic disease, but literature is sparse. The rarity of malignant CMT and the lack of comparative data on treatment make conclusive treatment recommendations difficult. However, recent literature suggests MMS is a useful option and potentially a superior treatment for primary cutaneous mesenchymal tumors.

Mohs micrographic surgery in dermatofibrosarcoma protuberans: Rate and risk factors for recurrence in a prospective cohort study from the Spanish Registry of Mohs Surgery (REGESMOHS) and review of the literature

Characterization of patients, surgery procedures and the risk factors for dermatofibrosarcoma protuberans (DFSP) recurrences is poorly defined. In this study, we aimed to describe the demographics, tumor characteristics and interventions of DFSP treated with Mohs micrographic surgery (MSS) to determine the rate and risk factors for recurrence. Data were collected from REGESMOHS, a nationwide prospective cohort study of patients treated with MMS in Spain. From July 2013 to February 2020, 163 patients with DFSP who underwent MMS were included. DFSP was mostly located on trunk and extremities. Recurrent tumors had deeper tumor invasion and required higher number of MMS stages. Paraffin MMS was the most frequently used technique. Overall recurrence rate was 0.97 cases/100 person-years (95% IC = 0.36-2.57). No differences were found in epidemiological, tumor, surgery characteristics or surgical technique (frozen or paraffin MMS [p = 0.6641]) in terms of recurrence. Median follow-up time was 28.6 months with 414 patient-years of follow-up. In conclusion, we found an overall low recurrence rate of DFSP treated with MMS. None of the studied risk factors, including MMS techniques, was associated with higher risk for recurrence.

Clinicopathological features of fibrosarcomatous dermatofibrosarcoma protuberans and the construction of a back-propagation neural network recognition model

BACKGROUND

Fibrosarcomatous dermatofibrosarcoma protuberans (FS-DFSP) is a form of tumor progression of dermatofibrosarcoma protuberans (DFSP) with an increased risk of metastasis and recurrence. Few studies have compared the clinicopathological features of FS-DFSP and conventional DFSP (C-DFSP).

OBJECTIVES

To better understand the epidemiological and clinicopathological characteristics of FS-DFSP.

METHODS

We conducted a cohort study of 221 patients diagnosed with DFSP and built a recognition model with a back-propagation (BP) neural network for FS-DFSP.

RESULTS

Twenty-six patients with FS-DFSP and 195 patients with C-DFSP were included. There were no differences between FS-DFSP and C-DFSP regarding age at presentation, age at diagnosis, sex, size at diagnosis, size at presentation, and tumor growth. The negative ratio of CD34 in FS-DFSP (11.5%) was significantly lower than that in C-DFSP (5.1%) (P = 0.005). The average Ki-67 index of FS-DFSP (18.1%) cases was significantly higher than that of C-DFSP (8.1%) cases (P < 0.001). The classification accuracy of the BP neural network model training samples was 100%. The correct rates of classification and misdiagnosis were 84.1% and 15.9%.

CONCLUSIONS

The clinical manifestations of FS-DFSP and C-DFSP are similar but have large differences in immunohistochemistry. The classification accuracy and feasibility of the BP neural network model are high in FS-DFSP.

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.

Treatment of dermatofibrosarcoma of the head and neck with Mohs surgery with paraffin sections

INTRODUCTION

Dermatofibrosarcoma protuberans (DFSP) is a rare, low-grade mesenchymal skin tumor. Complete surgical excision remains the mainstay of treatment. Head and neck (HN) DFSP features high local recurrence (LR) rates with wide local excision (WLE) due to both anatomical limitations and functional and cosmetic concerns. Mohs micrographic surgery (MMS) allows complete margin control and is particularly suitable for HN-DFSPs.

PATIENTS AND METHODS

Between 2000 and 2018, 103 DFSP were managed with MMS; 41 (39.8%) were in the HN. Our case series included 23 females (56.1%); mean age: 44.5 yrs. The most frequent sites were the supraclavicular area (10) and forehead (9). Mean size: 5.1 cm (6-16). Previous surgery: 43.9%. We have used permanent-tissue MMS (27 cases) since 2006.

RESULTS

Mean first layer lateral margin: 1.6 cm. Negative margins after first and second stage: 51.2% and 92.7%, respectively. Mean follow-up: 92.6 months (16-225). LR: 1(2.4%). We observed no regional or distant metastasis.

DISCUSSION

We conducted a literature search in PubMed for HN-DFSP and found that this seems to be the largest published series to date. In terms of LR, a substantial difference between WLE 62.5% (9-73%) and MMS 0.8% (0-2.4%) was seen. Forty-one HN-DFSP with unfavorable prognostic factors (mean size: 5.1 cm, previous treatment: 43.9%) were treated. LR: 1(2.4%). Mean follow-up: 92.6 months. Randomized controlled trials are needed, though not likely to be conducted, mainly because of the rarity of HN-DFSP, the need for a long follow-up, and the lack of MMS availability in some institutions. We consider MMS to be the standard treatment for HN-DFSP due to its high cure rate and tissue sparing. Modified WLE with complete margin control appears to be a comparable strategy.

A 10-year review of surgical management of dermatofibrosarcoma protuberans

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare skin cancer. Standard treatment in the UK is either wide local excision (WLE) or Mohs micrographic surgery (MMS). It is unclear which approach has the lower recurrence rate.

OBJECTIVES

We undertook a retrospective comparative review of surgical management of DFSP in the UK National Health Service in order to define (i) current surgical practice for primary and recurrent DFSP, (ii) local recurrence rates for primary DFSP and (iii) survival outcomes for DFSP.

METHODS

A retrospective clinical case-note review of patients with histologically confirmed DFSP (January 2004 to December 2013) who have undergone surgical treatment.

RESULTS

The surgical management of 483 primary and 64 recurrent DFSP in 11 plastic surgery and 15 dermatology departments was analysed. Almost 75% of primary DFSP (n = 362) were treated with WLE and 20% (n = 97) with MMS. For recurrent DFSP, 69% (n = 44) and 23% (n = 15) of patients underwent WLE and MMS, respectively. Recurrent primary DFSP occurred in six patients after WLE and none after MMS. The median follow-up time was 25·5 months (interquartile range 6·8-45·1) for new and 19·8 (IQR 4·5-44·5) for recurrent DFSP [Correction added on 1 Feb 2021, after first online publication: 4.8 years (interquartile range 3.5-5.8) was incorrect], with eight reported deaths during the follow-up analysis period (one confirmed to be DFSP related).

CONCLUSIONS

WLE was the most common surgical modality used to treat DFSP across the UK. The local recurrence rate was very low, occurring only after WLE. Although a prospective randomized controlled trial may provide more definitive outcomes, in the absence of a clearly superior surgical modality, treatment decisions should be based on patient preference, clinical expertise and cost.

Adequate surgical margins for dermatofibrosarcoma protuberans - A multi-centre analysis

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive tumour. Adequate margins have a positive impact on recurrence rates. The aim of this study is to assess how adequate margins are achieved and secondly which additional treatment modalities might be necessary to achieve adequate margins.

MATERIAL & METHODS

Patients with DFSP treated between 1991 and 2016 at three tertiary centres were included. Patient- and tumour characteristics were obtained from a prospectively held database and patient files.

RESULTS

A total of 279 patients with a median age of 39 (Interquartile range [IQ], 31-50) years and a median follow-up of 50 (IQ, 18-96) months were included. When DFSP was preoperatively confirmed by biopsy and resected with an oncological operation in a tertiary centre, in 86% was had clear pathological margins after one excision. Wider resection margins were significantly correlated with more reconstructions (p = 0.002). A substantial discrepancy between the primary surgical macroscopic and the pathological margins was found with a median difference of 22 (range, 10-46) mm (Fig. 1). There was no significant influence of the width of the pathological clear margins (if > 1 mm) and the recurrence rate (p = 0.710).

CONCLUSION

The wider the resection margins, the more likely it is to obtain clear pathological margins, but the more likely patients will need any form of reconstruction after resection. The aim of the primary excision should be wide surgical resection, where the width of the margin should be balanced against the need for reconstructions and surgical morbidity.

Dermatofibrosarcoma Protuberans: Update on the Diagnosis and Treatment

Dermatofibrosarcoma protuberans (DFSP) is a slow growing, low- to intermediate-grade dermal soft-tissue tumor. It has a high local recurrence rate but low metastatic potential. It is characterized by a uniform spindle cell arrangement, classically with a storiform pattern and CD34 immunoreactivity. The histomorphology and immunophenotype overlap with a broad range of other neoplasms. The standard treatment is complete surgical excision. The surgical procedures include wide local excision (WLE) with tumor free margins, Mohs micrographic surgery (MMS) and amputation. Unresectable DFSPs are treated with radiation therapy and/or targeted therapy. DFSP has characteristic t(17; 22) (q22; q13), resulting in a COL1A1- PDGFB fusion transcripts in more than 90% of DFSPs. Molecular detection of the gene rearrangement or fusion transcripts is helpful for the diagnosis of patients with atypical morphology and for screening candidates for targeted therapy with tyrosine kinase inhibitors. The aims of the present review are to update the clinical presentation, tumorigenesis and histopathology of DFSP and its variants for diagnosis and differential diagnosis from other benign and malignant tumors, to compare the advantages and drawbacks of WLE and MMS, to propose the baseline for selecting surgical procedure based on tumor’s location, size, stage and relationship with surrounding soft tissue and bone structures, and to provide a biologic rationale for the systemic therapy. We further propose a modified clinical staging system of DFSP and a surveillance program for the patients after surgical excision.

Darier and Ferrand's dermatofibrosarcoma: A carcinologic and cosmetologic challenge in a low-income country

INTRODUCTION

Dermatofibrosarcoma (DFS) is a common dermic sarcoma. It is a local malignant tumor occurring in young adults. The recurrence potential justifies an R0-type surgery with a three centimeters margin. We report our experience of the management of locally advanced DFS by resection and reconstructive surgery.

METHODS

It is an ongoing descriptive study spanned from June 2005 to December 2018. We included all DFS cases treated by curative resection and reconstruction. A total of eight cases of DFS among 108 soft tissue sarcomas were studied. All patients were males. The mean age was 41.8 years [32-60]. Carcinologic results, cosmetic results, and outcomes were analyzed.

RESULTS

R0-type resection was performed in six cases. In two cases, the resection was R1-type and resulted in amputation. In four cases, it was an iterative surgery. Average desease duration was 4 years [1-8]. Reconstructive surgery was needed for wound closure in six cases. Wounds healed in 28 days [18-90]. Outcomes showed hyperchromic keloid scars (N=2) at the trunk localization.

CONCLUSION

DFS is a common cancer with a good outcome if managed earliest. Delayed diagnoses and inadequate first-time surgery led to tumor extension and recurrences. Locally advanced tumors management needs extensive resections and reconstructive surgery. In addition to surgery, Imatinib and radiotherapy improve outcomes, but are not available in our context.

Dermatofibrosarcoma Protuberans

Dermatofibrosarcoma protuberans (DFSP) is an uncommon dermal neoplasm that exhibits a high rate of local recurrence and infiltrative behavior, but has a low risk of metastasis. It arises as a slowly progressive, painless pink or violet plaque. Histologically, DFSP is characterized by a monomorphous spindle cell proliferation in a storiform pattern. The gold standard of treatment is surgical resection with negative margins. In cases where obtaining clear margins is not possible, radiation and systemic therapy with tyrosine kinase inhibitors, such as imatinib mesylate, has been shown to be effective.

The efficacy of Mohs micrographic surgery over the traditional wide local excision surgery in the cure of dermatofibrosarcoma protuberans

Usually most patients with dermatofibrosarcoma protuberans (DFSP) may present rather late when the tumor is in protuberant phase due to its rarity and indolent onset. It has a high propensity for local recurrence and destructive nature. Management of DFSP requires a biopsychosocial and Multidisplinary approach regardless of the clinical or immunohistochemical variant. Surgery is the Gold standard management of localized disease. DFSP rarely exhibits any lymphatic or hematogenous dissemination. It is because of its high recurrence rate associated with Wide Local Excision (WLE), the introduction of Mohs micrographic surgery (MMS) has really helped in reducing the rates of recurrence of DFSP. Thus, the aim of this meta-analysis and systemic review is to advocate for MMS over WLE for DFSP and other cutaneous malignancies using DFSP as a prototype. The objective of this study were to conduct a meta-analysis on comparative surgical methods used in the cure of DFSP with regards to WLE verses MMS, to evaluate the cure rates with relation to recurrence rates, offer a recommendation on the various treatment modalities based on the location of lesion, and use of adjuvant therapy in different clinical-medical setups. A comprehensive retrospective analysis search in EMBASE, Google Scholar and Medline (PubMed) for studies published from 2008 to 2018 containing the surgical management of DFSP with WLE verses MMS were reviewed. Five studies of moderate-quality evidence (level B) with a pooled patient load of 684 was analyzed and found for recurrence of DFSP after WLE and MMS to be 9.10% and 2.72% respectively after an average follow-up time for both groups of 5.32 years with a female predominance of 1.58. The trunk is the commonest site for the DFSP lesion which was at 52.80% then the upper and lower extremities zones and the head and neck zones at 31.75% and 15.45% respectively. The pooled adjusted odds ratio (OR) analysis indicated that there was a direct relationship with regards the reduced recurrence rate of DFSP in the MMS group compared to the WLE group (OR:0.31;95%; CI :0.17-0.56). Furthermore, there was significant association between the reduced recurrence rate with the MMS in DFSP patients with a statistical P-value of 0.0001 at 95% CI. The expected increased recurrence rate by zones was in WLE head and neck zone at 38.19% then trunk and extremities zone at 13.34%. In the MMS group it was at of 23.4% as compared to 16.0% in the head and neck zone. Mohs Micrographic Surgery (MMS) is more efficacious in the cure rate and recurrence reduction of DFSP and should be advocated for as first line therapy especially in high recurrence prone zones.

Ophthalmologic aspects of Dermatofibrosarcoma Protuberans: A systematic review in the context of a rare case of primary orbital involvement

OBJECTIVE

To provide a systematic review on ophthalmologic presentations of dermatofibrosarcoma protuberans (DFSP) in conjunction with a case report of primary orbital involvement by this tumor.

METHODS

A thorough electronic search on PubMed, Medline, Scopus, EMBASE and web of science databases was performed. All available data from reported cases along with our described case were extracted and analyzed.

RESULTS

We describe a 66-year-old male with primary orbital DFSP who was managed by total excision of the tumor without recurrence after 18 months of follow-up. In the literature, 14 studies reporting 15 cases were identified and reviewed. Our review topics included epidemiology, clinical presentations, pathologic features, differential diagnosis, imaging, treatment and prognosis.

CONCLUSION

Rarely, but crucially, ophthalmologists may encounter DFSP in the orbital or periorbital area. They should be familiar with the pathologic nature and treatment options for this tumor. This diagnosis should be kept in mind when approaching a case with a non-tender, nodular, firm, mass or more rarely an indenting orbital mass.

Patient indications for Mohs micrographic surgery: a clinical practice guideline

Objective

The purpose of the present work was to develop evidence-based indications for Mohs micrographic surgery in patients with a diagnosis of skin cancer.

Methods

The guideline was developed by Cancer Care Ontario's Program in Evidence-Based Care, together with the Melanoma Disease Site Group and the Surgical Oncology Program, through a systematic review of relevant literature, patient- and caregiver-specific consultation, and internal and external reviews.

Recommendation 1

Given a lack of high-quality, comparative evidence, surgery (with postoperative or intraoperative margin assessment) or radiation (for those who are ineligible for surgery) should remain the standard of care for patients with skin cancer.

Recommendation 2

Mohs micrographic surgery is recommended for patients with histologically confirmed recurrent basal cell carcinoma of the face and is appropriate for primary basal cell carcinomas of the face that are larger than 1 cm, have aggressive histology, or are located on the H zone of the face.

Recommendation 3

Mohs micrographic surgery should be performed by physicians who have completed a degree in medicine or equivalent, including a Royal College of Physicians and Surgeons of Canada Specialist Certificate or equivalent, and have received advanced training in Mohs micrographic surgery.

Dermatofibrosarcoma protuberans: A rare and devastating tumor of the vulva

•

Biopsies of a large mass are prone to sampling errors and may lead to an incorrect diagnosis.

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MRI imaging of vulvar tumors can aid in surgical planning.

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Large sarcomas of the vulva require a multi-disciplinary approach.

Dermatofibrosarcoma protuberans (DFSP) arising from a keloid scar - A case report

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma with an indolent early course that may be misdiagnosed for benign skin pathology. In this case-report we highlight an instance of DFSP arising from a keloid scar de novo and present a reconstruction with a local pedicled LD flap. We subsequently appraise the related literature and discuss the diagnostic challenges.

Patient Indications for Mohs Micrographic Surgery: A Systematic Review

The purpose of the present review was to describe evidence-based indications for Mohs micrographic surgery (MMS) in patients with a diagnosis of skin cancer. Relevant studies were identified from a systematic MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews search of studies published from 1970 to 2017. Randomized controlled trials (RCTs), prospective and retrospective comparative studies with greater than 30 patients, and single-arm retrospective studies with multivariate analyses were included. A total of 2 RCTs, 3 prospective studies, and 16 retrospective studies (14 comparative and 2 single-arm) were included. Data on recurrence rate, cure rate, complications, cosmesis, and quality of life were extracted. Surgery (with postoperative or intraoperative marginal assessment) or radiation for those who are ineligible for surgery should remain the standard of care for patients with skin cancer given the lack of high-quality, comparative evidence. MMS is recommended for those with histologically confirmed recurrent basal cell carcinoma (BCC) of the face and is appropriate for primary BCCs of the face that are >1 cm, have aggressive histology, or are located on the H zone of the face. The available evidence is difficult to generalize to all patients with skin cancer because the evidence did not adequately cover non-BCC skin cancers; however, those skin cancers can be considered on a case-by-case basis for MMS. MMS should be performed by physicians who have completed a degree in medicine or equivalent, including a Royal College of Physicians and Surgeons of Canada Specialist Certificate or equivalent, and have received advanced training in MMS.