Accelerated growth of dermatofibrosarcoma protuberans during pregnancy

A case report of abdominal metastatic dermatofibrosarcoma protuberans misdiagnosed as gastrointestinal stromal tumor

Dermatofibrosarcoma protuberans (DFSP) is a low-grade malignant soft-tissue tumor that originates from the skin. It has a slow onset in the early stages, non-specific clinical symptoms, low specificity, and can easily be overlooked, missed, or misdiagnosed by clinicians and pathologists. In addition, DFSP is prone to recurrence after local surgical treatment; however, distant metastasis, especially abdominal metastasis, is rare, which is also a challenge for the accurate diagnosis of DFSP when it progresses distantly. Now a case of abdominal metastasis of DFSP is reported. The patient has been treated with imatinib for ten years, and the lesion has shrunk, but because the patient has been receiving imatinib treatment, his abdominal lesion was once misdiagnosed as gastrointestinal stromal tumor. Therefore, we report on this case to enhance the understanding of the diagnosis and treatment of DFSP, and to provide reference for the pathological diagnosis and precise treatment of such patients.

Dermatofibrosarcoma protuberans of the breast in pregnancy

Dermatofibrosarcoma Protuberans (DFSP) is a rare, locally aggressive fibroblastic mesenchymal neoplasm, typically derived from the dermis, with the intramammary subtype being seen infrequently. We present a case of a 40-year-old woman whom was diagnosed with an intramammary DFSP during pregnancy, whom underwent successful surgical management during her second trimester. Our case demonstrates the importance of increased clinical awareness in the diagnosis and treatment of breast DFSP with careful multidisciplinary consideration.

Updates on the dermatopathology of pregnancy-associated skin conditions

Pathologists provide valuable input in the dermatological care of pregnant patients in various contexts. This article provides dermatopathology updates on cutaneous changes associated with pregnancy, organized based on the following classification system: physiological skin changes in pregnancy, specific dermatoses of pregnancy, dermatoses modified in pregnancy, and skin neoplasms in pregnancy. Awareness of the impact of pregnancy on the skin by pathologists is important, as this is an opportunity to contribute to diagnostic precision in this patient population.

Dermatofibrosarcoma protuberans in pregnancy: a case series and review of the literature

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma, which has been reported in pregnancy. This case series reports the clinical and histopathological findings of DFSP in pregnancy.

METHODS

Eighteen cases of DFSP, including six unreported cases and 12 cases from the literature, were identified. Age, anatomic location, tumor size, changes in tumor characteristics during pregnancy, histopathological features, and treatment were recorded. Follow-up data, when available, were noted.

RESULTS

The average age of the cohort was 30.6 years (range 19-38). Ten tumors (55.6%) were located on the trunk, four (22.2%) on the head and neck, three (16.7%) on the extremities, and one (5.6%) in the genitalia. Most tumors demonstrated features of conventional DFSP (12/18, 66.7%), while the remaining were identified as DFSP with fibrosarcomatous (FS) change (3/18, 16.7%), atrophic DFSP (2/18, 11.1%), and myxoid DFSP (1/18, 5.6%). Treatment was reported in 17 cases, at least nine of which were treated postpartum. Ten patients were treated with excision, while seven underwent Mohs micrographic surgery. Three patients recurred on follow-up, one with local recurrence and two with distant metastasis.

CONCLUSIONS

DFSP can undergo enlargement or change in size or color in pregnancy, possibly mediated by hormones. While the majority of cases in this series represented conventional DFSP, unusual clinical and histopathological variants were also present. Treatment in most cases can be safely delayed until after delivery, but recurrent or very large tumors may require treatment prepartum. Close monitoring for recurrence or metastasis is advised.

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.

Hormone receptor expression in patients with dermatofibrosarcoma protuberans

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma for which the exact etiology is unknown. Case reports exist of DFSP appearing and growing rapidly during pregnancy, suggesting a hormonal role.

OBJECTIVE

Our goal was to determine the expression of estrogen receptors (ERs) and progesterone receptors (PRs) in patients with DFSP.

METHODS

Archived formalin-fixed, paraffin-embedded tissue from patients with DFSP in the past 20 years at a single institution were analyzed for ER and PR using immunohistochemistry. A semiquantitative scoring method was used to evaluate the expression as positive or negative. Analysis was used to determine whether there was an association between receptor positivity and tumor site, age at diagnosis, sex, race, or disease recurrence.

RESULTS

Forty-four patients with DFSP were included in the study. Tumors were 22.7% ER⁺/PR⁺, 34.1% ER⁺/PR^-, 9.1% ER^-/PR⁺, and 34.1% ER^-/PR^-. There was no significant association between expression of ER and PR and sex, age at diagnosis, race, or tumor location. Loss of receptor expression was observed in all recurrent tumors.

LIMITATIONS

This study is limited by a lack of follow-up and a new scoring system.

CONCLUSIONS

The data presented warrant additional study to determine hormone receptor function and the potential efficacy of antihormone therapies for the treatment of patients with DFSP.

Risk of subsequent primary malignancies after dermatofibrosarcoma protuberans diagnosis: a national study

BACKGROUND

Patients frequently live many years after diagnosis of dermatofibrosarcoma protuberans (DFSP).

OBJECTIVE

We sought to determine the risk of subsequent primary malignancy (SPM) after DFSP diagnosis.

METHODS

Using the Surveillance, Epidemiology, and End Results database (1973-2008) for 3734 patients with DFSP, we compared the risk of developing 14 SPMs (12 most prevalent cancers in the United States plus other nonepithelial and soft tissue) relative to risk in the general population of same sex, race, and age and year of diagnosis.

RESULTS

Patients given the diagnosis of DFSP had an overall increased risk of SPM (observed:expected [O:E], 1.20; 95% confidence intervals [CI], 1.04-1.39), with much of the overall increased risk attributable to increased risk of nonepithelial skin cancer (O:E, 9.94; 95% CI, 3.38-22.30). Specifically, female patients with DFSP were at increased risk of other nonepithelial skin cancer (O:E, 14.50; 95% CI, 3.46-38.98), melanoma (O:E, 2.59; 95% CI, 1.02-5.35), and breast cancer (O:E, 1.44; 95% CI, 1.00-2.00). Male patients were not at increased overall risk (O:E, 1.18; 95% CI, 0.96-1.44) of SPM or at increased risk of any specific malignancy (P > .05) adjusted for multiplicity of t tests.

LIMITATIONS

Surveillance bias may have led to increased rates and earlier detection of primary malignances in patients with DFSP compared with the general population. Individual data that may reveal shared environmental causes of DFSP and SPM were unavailable.

CONCLUSIONS

Patients with DFSP are at increased risk of a number of SPMs.

A Primer of Mohs Micrographic Surgery: Uncommon Indications

Mohs micrographic surgery has been used for the treatment of tumors other than basal and squamous cell carcinomas. Parameters to be considered when deciding on a treatment include location, size, growth pattern, and recurrence rates. It is important to consider that sometimes the high-risk nature of the tumor is more significant than the need for tissue sparing. Modifications to the Mohs micrographic surgery technique may be used to ensure diagnostic accuracy and confirm complete removal of the lesion (e.g., immunohistochemical staining and paraffin-embedded sections).

Sarcomas cutâneos primários

Os sarcomas com apresentação cutânea primária são tumores raros e de grande heterogeneidade histológica. Com a evolução da oncologia cutânea e da cirurgia dermatológica, os dermatologistas têm sido cada vez mais requisitados para o diagnóstico e orientação terapêutica de tumores menos freqüentes. Este artigo de revisão analisa os sarcomas cutâneos primários observando suas características clínicas, etiopatogênicas e histológicas, bem como aspectos do tratamento e evolução. Enfatiza os sarcomas de maior relevância para o dermatologista, como angiossarcoma, dermatofibrossarcoma protuberans, fibroxantoma atípico, leiomiossarcoma, lipossarcoma, tumor maligno de bainha de nervo periférico e sarcoma epitelióide. O sarcoma de Kaposi não é abordado devido a suas características individuais específicas.

Dermatofibrosarcoma protuberans: report of a case with a variant ring chromosome and metastases following pregnancy

BACKGROUND

The most frequent molecular abnormality observed in dermatofibrosarcoma protuberans (DFSP) is the formation of a supernumerary ring chromosome or translocation resulting in fusion of the gene encoding the alpha-chain of type 1 collagen, COL1A1 from 17q22, to the platelet-derived growth factor beta-chain, PDGFB gene from 22q13. Rare cases documenting variant ring or marker chromosomes involving regions other than 17q22 and 22q13 have been reported. Further analysis in three of these cases demonstrated the presence of the COL1A1 and PDGFB genes.

METHODS

We report a further case of DFSP with a rare variant ring chromosome. The tumor appeared to undergo accelerated growth during pregnancy, then metastasized following pregnancy. We describe the clinical, histological, immunohistochemical, and cytogenetic features.

RESULTS

The metastatic tumor showed a variant r(17;?) chromosome. A locus-specific probe was required to demonstrate presence of the PDGFB gene within the ring, indicating cryptic molecular rearrangement between chromosomes 17 and 22, and recombination with an unknown chromosome.

CONCLUSIONS

Cryptic rearrangement of chromosomes 17 and 22 should be suspected in variant ring chromosomes and translocations. Pregnancy may contribute to accelerated growth of DFSP, and delay in surgical resection should be avoided.

Late recurrence of dermatofibrosarcoma protuberans in the female breast: a case report

The case presented is of a 39-year-old female who, at the age of 13 years, had had a "dermatofibroma" excised from her left breast. Twenty-six years later she developed an unsightly "stretched scar". Excision biopsy demonstrated a dermatofibrosarcoma protuberans (DFSP). This was managed by wide local excision, preservation of the nipple-areolar complex, and immediate reconstruction with a pedicled latissimus dorsi flap. Review of the original histology confirmed the presence of DFSP, revising the original diagnosis. Most DFSPs recur within 3 years of primary excision. Such prolonged latency prior to recurrence has not been previously described. This reinforces the need to educate patients regarding the importance of long-term scar surveillance following skin tumour excision.

Giant-cell tumors of bone and progesterone receptors

Estrogen receptors, progesterone receptors, and cathepsin D were determined in 10 patients with giant-cell bone tumor. Progesterone receptors were expressed in 5 of 10 patients tested, whereas low levels of estrogen receptors were found in 1 patient. Cathepsin D levels were elevated in 5 of 5 samples studied. High values of progesterone receptors correlated with low tumor grade. Cathepsin D levels correlated negatively with tumor grade but positively with local tumor expansion. Giant-cell bone tumor expressing progesterone receptors may manifest benign behavior. Cathepsin D may be involved in tumor expansion, possibly through its effect on bone resorption.

Giant fibrosarcoma arising in dermatofibrosarcoma protuberans on the scalp during pregnancy

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a low-grade malignant soft tissue tumor of subcutaneous tissues that has a propensity for local recurrence; however, it seldom metastasizes. Most lesions occur over the trunk or proximal extremities, and there is slight male preponderance. DFSP is rare on the head and neck. Less than 5% tumors are located on the scalp.

OBJECTIVE

To describe a case of giant fibrosarcoma arising in DFSP on the scalp during pregnancy.

METHOD

In our patient, the tumor was on scalp and measured 15 x 11 x 7 cm. The recurrent tumor that developed in the same region was measured 33 x 30 x 15 cm. Histopathologic examination of this mass revealed fibrosarcoma. The mass was excised from the subperiosteal plane with a 3-cm free margin. Because of the high possibility of recurrence, the defect site was reconstructed with a split-thickness skin graft.

RESULTS

After 1 year of follow-up, no recurrence or metastasis was detected.

CONCLUSION

We present a unique case in which the person has a giant fibrosarcoma on her scalp arising from DFSP with fibrosarcomatous change during pregnancy.

Mohs micrographic surgery for dermatofibrosarcoma protuberans: University of Miami and NYU experience

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a relatively rare cutaneous malignancy with the potential for significant local destruction and morbidity. This neoplasm has a tendency for recurrence following excision due to its infiltrative nature. Surgical excision with wide margins has been considered the standard therapy for DFSP but has had reported recurrence rates of up to 60%.

OBJECTIVE

The results of 20 patients with DFSP treated with Mohs micrographic surgery (MMS) are reported. We also reviewed the world literature on the role of MMS for treatment of this tumor.

METHODS

Twenty patients between the ages of 20 and 82 years with DFSP were treated with MMS. The patients were followed for recurrences between 4 and 216 months (mean 56.4 months).

RESULTS

None of the 20 patients had a recurrence of DFSP following MMS. Of 221 DFSP patients in our review of the world literature treated with MMS, only 5 (2.3%) had a recurrence.

CONCLUSION

MMS is an effective treatment of DFSP.

Steroid hormone receptor in pleural solitary fibrous tumours and CD34+ progenitor stromal cells

Solitary fibrous tumours (SFT), originally described in the pleura, were subsequently recognized in numerous extrapleural sites. This suggests that a common stem cell, present in various organs and tissues, may be at the origin of SFT and that specific factors may be involved in the proliferation of such cells. Recently it has been described that steroid hormone receptors, progesterone receptors in particular, are expressed by extrapleural SFT. In addition, progesterone may participate as growth factor in many CD34(+) stromal neoplasms, which express low levels of the hormone receptors. The present study analysed the expression of androgen (AR), oestrogen (ER) and progesterone (PR) receptors in a series of 32 pleural SFT, 10 mesotheliomas and in reactive tissue of chronic pleuritis. ER and AR were never expressed by SFT or by chronic pleuritis, whereas PR were demonstrated in 2/16 "large" (>8 cm) and in 6/16 "small" (< or =8 cm) pleural SFT (all expressing CD34, bcl-2 and CD99). PR(+) SFT had a significantly higher proliferative activity (p = 0.04) (Ki-67 mean value 6.5%) and lower p27(kip1) (mean value 51.5%) expression than the PR(-) cases (Ki-67 mean value 3.81% and p27(kip1) mean value 57.86%). One of the cases expressing a high level of PR (80%) recurred 1 year after first surgery and the recurrence was PR(+) as well, but with a lower percentage of nuclear receptor expression (12%). In addition, in chronically inflamed subserosal tissue, a subpopulation of CD34(+) endothelial and interstitial dendritic cells was identified, which also expressed PR. These findings suggest that the CD34(+) submesothelial interstitial dendritic cells, activated during reactive processes, may be the stem cells that give rise to SFT, and that progesterone might participate in the growth of SFT through modulation of its specific receptors.

The skin in pregnancy

BACKGROUND

Physiologic skin changes are common during pregnancy due to a temporary shift in hormonal, metabolic, and immunologic factors. Physicians may mistake normal skin changes in pregnancy as pathologic change within the skin, and so an appreciation of the common and less common skin manifestations will assist in appropriate patient care.

OBJECTIVE

This review highlights the normal physiologic skin changes in pregnancy, which include pigmentary changes, changes to the hair and nails, alterations in glandular activity, vascular and hematological changes, cutaneous tumors, and mucous membrane changes.

CONCLUSION

Physiologic changes to the skin in pregnancy can be complex and confusing. Pregnancy can be a stressful time for women so it is imperative that physicians be aware of the normal skin changes during pregnancy in order to prevent unnecessary investigations and treatments.

Dermatoses of pregnancy

The dermatoses of pregnancy can be classified into the following 3 groups: physiologic skin changes in pregnancy, dermatoses and cutaneous tumors affected by pregnancy, and specific dermatoses of pregnancy. Correct diagnosis and classification are essential for the treatment of these disorders, when necessary. Laboratory investigations are required when the diagnosis remains in question despite a careful history and thorough physical examination. A discussion with the pregnant woman about the nature of her skin condition, and the possible fetal risks associated with it, is imperative.