Dermatofibrosarcome de Darier Ferrand : traitement par chirurgie micrographique de Mohs avec inclusion en paraffine

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.

Wide local excision vs. Mohs Tübingen technique in the treatment of dermatofibrosarcoma protuberans: a two-centre retrospective study and literature review

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare, low-grade mesenchymal skin tumour, characterized by slow infiltrative growth and common local recurrence, with infrequent distant metastases.

OBJECTIVE

The aim of this study is to better clarify clinicopathological characteristics of this tumour and to evaluate the cure rates of Mohs Tübingen technique (MTT) and wide local excision (WLE). Eventually, we perform a literature review to compare our experience with published data.

METHODS

A retrospective review was conducted on 135 patients diagnosed, treated and followed up between 1997 and 2014 at two different institutions. Sixty-two patients underwent to WLE and 73 to MTT. The primary end-points were the following: percentage of recurrences, time to progression and recurrence annual risk rate. Then, the PubMed database was searched for DFSP case series treated with standard surgical resection (SSR), WLE, Mohs' micrographic surgery (MMS) and MTT. The annual risk rate of recurrence calculated and reported for the four separate procedures was pooled to compare them.

RESULTS

Five of the 62 patients with WLE (8.1%) experienced recurrences after a mean follow-up of 4.7 years; the percentage of recurred patients 9 years after MTT was 5.5%, and the annual recurrence risk rate of 0.6%. Pooling these data with those from literature, the recurrence rate varies from 26% to 60% for SSR, from 0% and 41% for WLE, from 0% and 8.3% for MMS and from 0% to 5.5% for MTT. The lowest annual recurrence risk rate was found for MTT.

CONCLUSION

Significantly lower recurrence rates were recorded in patients treated with classic or Tübingen Mohs' technique. To the best of our knowledge, our case series is the widest treated with MTT ever described in the literature; these data may be useful to guide clinicians in the choice of the gold standard treatment for Dermatofibrosarcoma protuberans.

Histologic Features Associated with Deep Invasion in Dermatofibrosarcoma Protuberans

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing cutaneous tumor that can invade the subcutaneous tissue, muscle tissue, and even bone.

OBJECTIVE

To identify histologic features associated with greater depth of invasion, i.e., local aggressiveness, in DFSP.

MATERIAL AND METHODS

We analyzed associations between histologic features of DFSP (e.g., type of subcutaneous invasion, histologic pattern, cell type, areas of fibrosarcoma) and the presence and absence of muscle fascia involvement.

RESULTS

We studied 155 cases of DFSP. The following histologic characteristics were significantly associated with involvement of the muscle fascia: the presence of a sheetlike pattern, a high degree of cellular pleomorphism, and more than 1 mitotic figure. The tumor did not extend beyond the subcutaneous tissue in the majority of cases (62.6%), but there was involvement of the fascia or galea aponeurotica in 17 cases (11%) and of the muscle tissue in 36 cases (23.2%).

CONCLUSIONS

Histologic patterns, degree of pleomorphism, and number of mitotic figures are important predictors of deep invasion (fascia or muscle) in DFSP; these layers can be involved in up to 30% of cases.

[Mohs micrographic surgery in two children with dermatofibrosarcoma protuberans]

Dermatofibrosarcoma protuberans is a rare low-grade malignant tumor. The pseudopodia structure of the tumor requires 3-5 cm surgical margins. Mohs micrographic surgery (MMC) can reduce these margins to 1.3 cm while controlling all the histological excision margins. Children seem to be a good indication for this technique because it reduces the amount of skin removed. We report 2 cases of pediatric DFS treated with CMM to illustrate the usefulness of this technique in pediatrics. Two girls, aged 12 and 13 years, had a dermatofibrosarcoma located on the breast and sternum, respectively. CMM was proposed. One operative session was needed with direct closure in a second phase. MMS is a useful surgical technique for childhood tumors. If dermatofibrosarcoma is a very good indication in children, other skin tumors could benefit from this approach.

[Dermatofibrosarcoma protuberans in children]

Dermatofibrosarcoma protuberans (DFSP) is a relatively rare skin neoplasm. Usually affecting adults, the incidence in children is even less frequent. Through a report of three pediatric cases of DFSP, we describe the particularities of this tumor in children. Three boys aged 8, 9, and 15 years presented with a firm nodular skin lesion of the trunk, varying in size from 1 to 5 cm. No previous trauma event had occurred. Diagnosis was confirmed in all cases by immunohistological study. Surgical excision was performed in all cases. No recurrence was evident during the follow-up period of, respectively, 15, 36, and 49 months. The DFSP is an infiltrative tumor of intermediate malignancy, with a limited potential for metastasis (<5%) but a high rate of local recurrence (≥ 50%). The incidence in children is even less frequent. In children, its seemingly benign clinical appearance may explain delays in diagnosis; the majority of lesions affect the extremities, suggesting a potential role-played by injury. In our observations, however, as in adults, the trunk was the site of occurrence. Despite the uncertain pathogenesis of this tumor, the finding of certain characteristic histopathological features helps establish an accurate diagnosis. As in adults, surgical treatment with large surgical margins remains the best practice for children with DFSP, directly affecting the prognosis.

[Dermatofibrosarcoma protuberans: surgical treatment using the Tübingen technique (31 cases)]

BACKGROUND

Dermatofibrosarcoma protuberans is a rare cutaneous sarcoma that progresses slowly. Although it exhibits pronounced local aggressiveness, it rarely metastasises. The condition is difficult to treat on account of asymmetric and unpredictable growth as well as the frequency of relapse. Treatment is primarily surgical.

PATIENTS AND METHODS

We report 31 cases of dermatofibrosarcoma protuberans operated at the Dermatology Clinic of Novara between 1997 and 2004 using the Tübingen technique. An immunohistochimical study was performed and screening was carried out for possible extension of the neoplasm into muscle.

RESULTS

Muscular involvement was seen in 4 cases. No relapses were seen over a median survival period of 3 years and no patients were lost to follow-up.

DISCUSSION

The Mohs technique is the surgical method of reference and allows tumour eradication with sparing of healthy tissue. The Tübingen method constitutes an alternative approach requiring fewer histological sections. The results obtained in our series were good and no relapses were seen over a median survival period of 3 years.

Histologie 3D : une technique de chirurgie micrographique adaptée aux dermatologues et pathologistes hospitaliers et libéraux

We present 2 techniques of micrographic surgery (3D-histology) useful to control lateral and deep limits of cutaneous tumors. We have adapted the protocol created in Germany, at the University of Tuebingen, for French pathologists and dermatologists.

[Childhood-onset multifocal atrophic dermatofibrosarcoma]

BACKGROUND

Atrophic dermatofibrosarcoma is a rare clinical variant of dermatofibrosarcoma protuberans (or Darier-Ferrand tumor) preferentially observed in childhood and early adulthood.

OBSERVATION

We report a case of multifocal atrophic dermatofibrosarcoma protuberans of childhood onset only diagnosed when the patient was 29 years old. The clinical presentation was an asymptomatic macular brown plaque on the right thigh measuring 10 cm. Initially, because of the large size of the lesion, treatment consisted of limited surgical excision.

DISCUSSION

Diagnosis of the atrophic variant of dermatofibrosarcoma in childhood is difficult, and is usually made several years later in early adulthood because of its slow development, lack of symptoms and generally benign appearance. Histological tests and immunohistochemical staining may confirm clinically suspected diagnosis, and in complex cases, cytogenetic studies can help confirm a diagnosis of dermatofibrosarcoma through detection of reciprocal translocation t (17,22), which fuses collagen type Ialpha1 (COLIA1) and platelet-derived growth factor (PDGDFbeta), and which is highly characteristic of dermatofibrosarcoma protuberans. Conventional treatment of dermatofibrosarcoma protuberans consists of extensive surgical excision, but Mohs micrographic surgery is also advocated for removal of certain dermatofibrosarcoma protuberans, while use of tyrosine kinase PDGF receptor inhibitors such as imatinib mesylate (Glivec) is limited to distant metastases.