Microscopic margins and results of surgery for dermatofibrosarcoma protuberans

Novel role of fluorescent in situ hybridization technique (FISH) in recommended surgical margins of dermatofibrosarcoma protuberans: A preliminary study

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare skin tumor. There is no standard recommendation for its surgical management. The currently used histological analysis are HES (hematoxylin eosin saffron) staining and immunohistochemistry for CD34 expression in particular cases. Fluorescent in situ hybridization (FISH) technique is only used to qualify the DFSP as translocated or non-translocated and is not used as a diagnostic method. The aim of our study was to determine by FISH (as a diagnostic method) whether cancerous cells that could not be identified through HES staining±immunohistochemistry were present at the two-centimeter margins that were found to be tumor-free.

METHODS

Samples from patients who underwent surgery between 2010 and 2018 were collected. Intralesional and peripheral (at 2cm margins) paraffin slides were included. An average of 7.4 slides per specimen was analyzed. Firstly, the preselected slides were reread by a senior pathologist to confirm the absence of microscopic findings of DFSP at 2cm margins. Secondly a FISH analysis was used as a quantitative diagnostic approach, in order to find the t(17;22) translocation.

RESULTS

Among the seven specimens that included 2cm margins, two samples presented one or more translocations, which were not visible in standard morphology assessments at two centimeters tumor-free margins.

CONCLUSIONS

FISH analysis can have a new role in defining tumor-free margins. This would reduce the incidence of disease recurrence after resection and improve the post-operative complementary care.

Effective resection of dermatofibrosarcoma protuberans using the novel Saturn's rings technique

Dermatofibrosarcoma protuberans (DFSP) is a rare, low-grade sarcoma with locally infiltrative characteristics. A wide excision is made with a 5 cm gross margin. However, recently, Mohs micrographic surgery has emerged as an alternative. In this study, we evaluate a novel method (Saturn's Rings technique) for removing tumors that combines the advantages of wide excision and Mohs micrographic surgery. Between September 2001 and March 2020, 29 patients with DFSP, excluding the head and neck, were treated using Saturn's rings technique. Frozen biopsies were performed at regular intervals under various conditions and depths. If the biopsy was positive, a negative margin was obtained through an additional session. The depth and breadth of excision, reconstruction method, and postoperative recurrence were analyzed. The breadth of excision was evaluated at 1 cm intervals. Only 1 session was required in 12 cases, 2 sessions were needed in 13 cases, and 3 or more sessions were performed in 4 cases. In 24 cases, the depth of excision was limited to above the superficial fascia, with a negative biopsy of the superficial fascia. Local flaps were the most common reconstruction method (n = 21, 72.4%). No cases of recurrence were observed at follow-up (average, 45.7 months). Saturn's rings technique for DFSP maximized the preservation of normal tissue with minimal resection, was advantageous for reconstruction, and yielded good results without recurrence.

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).

Primary chest wall sarcoma; a single institution experience of 3 years

INTRODUCTION

Primary chest wall sarcoma is a rare entity. It can be classified based on its origin, as bone sarcomas or soft tissue sarcomas. Various prognostic factors have been studied in different case series like age, sex, tumor histology, grade, resection margin status, adjuvant treatment, and others. The present study aimed to analyze common histological types, their management by resection and reconstruction and prognosis, in cases presenting at a regional cancer center in western India.

MATERIAL AND METHOD

This was an observational study from a prospectively maintained database. 57 patients with chest wall sarcoma treated with curative intent between January 2016 till January 2019 with a minimum follow-up of 3 months were included in the study. The goals of surgical treatment were to obtain a wide resection margin of 3-4 cm, preserve the function of the chest wall and provide stability and rigidity to protect intrathoracic organs.

RESULTS

The median follow-up of the present patient's cohort was for 20.2 months. Overall two-year survival was 74.7%. Two-year OS and DFS of bone sarcoma were 62.3% and 35% and soft tissue sarcomas were 91% and 71.3%. Ewing's sarcoma had the worst two-year overall survival of 50.6% and chondrosarcoma and fibromatosis had 100% two-year overall survival.

CONCLUSION

Chest wall sarcoma forms a heterogeneous group of tumors. In the present study, Ewing's sarcoma was the most common histology with the worst survival, since they presented in advanced stages. Management should be multidisciplinary and surgical resection should be aggressive to achieve an R0 resection. Reconstruction of chest wall should aim to provide structural and functional stability with minimal morbidity. Frozen section assessment should be utilized whenever in doubt.

Dermatofibrosarcoma protuberans of the breast: A case study

Dermatofibrosarcoma protuberans (DFSP) is a superficial mesenchymal neoplasm that originates from the dermal fibroblasts and tends to be locally aggressive. Although infrequent, it is one of the most common cutaneous sarcomas. It mainly affects young and middle-aged patients 20 to 50 years old. Any area of skin may be involved, but the most common sites of presentation are the trunk and extremities. DFSP of the breast is extremely rare. It classically presents as a nodular, exophytic, cutaneous mass, though initially it can manifest as a flat plague and can show persistent but slow growth for many years. Due to increased risk of local recurrence, the standard of care for localized disease is surgical excision with adequate margins. Wide local excision is the most common technique used, but as an alternative Mohs micrographic surgery has emerged as a procedure that offers lower local recurrence rates. Metastases are rare but have been previously reported. In such patients, treatment with imatinib or radiotherapy can be considered. The current case presents a 52-year-old lady with DFSP of the breast that was successfully managed by the Breast Unit of Athens Medical Center-Psychiko Clinic.

Dermatofibrosarcoma protuberans in children and adolescents: Primary and Relapsed disease-Experience of the Cooperative Weichteilsarkomstudiengruppe (CWS)

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare low-grade tumor. Little is known about best treatment of primary and relapsed disease (RD).

METHODS

Treatment and outcome of 40 patients with DFSP prospectively registered within the CWS-96 and -2002P trials and the registry SoTiSaR (1996-2016) were analysed.

RESULTS

Median age was 8 years (range, 0.64-17.77). Fluorescence in situ hybridization analysis to detect COL1A1-PDGFB fusion genes was positive in 86% (12/14) of evaluated patients. Primary resection was performed in all patients. Patients had IRS group I (n = 28), II (n = 9), and III (n = 2); not available (n = 1). To achieve complete remission (CR), a secondary resection was performed in 18 patients resulting in microscopically complete (R0, n = 34/40) and microscopically incomplete (R1, n = 5/40) resection. All patients achieved CR. The 5-year event-free survival (EFS) and overall survival was 86% (±12; CI, 95%) and 100% (±0; CI, 95%), respectively. R0 resection/IRS I was significantly favorable for the 5-year EFS. Local relapse occurred after a median time of 1.1 years (range, 0.04-5.1) in 15% (6/40) after CR. All patients with RD underwent resection and achieved CR. Three patients had fibrosarcomatous DFSP, two were alive after R0 resection.

CONCLUSION

Complete surgical resection is mandatory to prevent relapse of DFSP.

Dermatofibrosarcoma protuberans: A clinical analysis

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous tumor with a high incidence of misdiagnosis. DFSP has a high rate of recurrence but a low rate of metastasis. In the present study, retrospective analyses were performed on the clinical features, differential diagnosis and treatment of patients with DFSP to improve our understanding of the disease and allow more effective treatment measures to be implemented. The present study investigated the clinicopathological features of 70 pathologically confirmed cases of DFSP at the First Affiliated Hospital of Zhengzhou University (Zhengzhou, China) between March 2012 and 2017. The primary endpoint was recurrence rate. Three cases were analyzed in detail. The results revealed that 7 of the 41 primary patients (follow-up at 2.7 years) had recurrence (17.1%), compared with 11 (37.9%) of the 29 recurrent patients (follow-up at 2.0 years, P=0.049). Of the 59 patients with DFSP (follow-up at 2.6 years), 12 had recurrence (20.3%) compared with 6 (54.6%) of the 11 patients with fibrosarcomatous DFSP (FS-DFSP; follow-up at 2.1 years, P=0.045). DFSP requires diagnosis by pathological examination, and surgical resection is the main treatment. DFSP demonstrated a high recurrence rate, with the degree of malignancy increasing following multiple recurrences. FS-DFSP had a higher risk of local recurrence and distant metastasis, and a higher degree of malignancy than classic DFSP. These data may be useful to guide clinicians to improve decisions in the treatment of patients with DFSP.

A Comparison of Mohs Micrographic Surgery and Wide Local Excision for Treatment of Dermatofibrosarcoma Protuberans With Long-Term Follow-up: The Mayo Clinic Experience

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a soft tissue tumor with slow infiltrative growth and local recurrence if inadequately excised.

OBJECTIVE

To compare long-term outcomes after Mohs micrographic surgery (MMS) and wide local excision (WLE).

MATERIALS AND METHODS

Records of patients with DFSP surgically treated with WLE or MMS from January 1955 through March 2012 were retrospectively reviewed.

RESULTS

Mean follow-up for patients treated with MMS (n = 67) and WLE (n = 91) was 4.8 and 5.7 years, respectively. Twenty-eight patients (30.8%) with WLE had recurrence (mean, 4.4 years), whereas only 2 (3.0%) with MMS had recurrence (1.0 and 2.6 years). Recurrence-free survival rates at 1, 5, 10, and 15 years were significantly higher with MMS (p < .001). Mean preoperative lesion sizes were similar (5-6 cm) between the 2 groups, whereas mean (standard deviation) postoperative defect sizes were 10.7 (4.3) cm and 8.8 (5.5) cm for WLE and MMS, respectively (p = .004). Primary closure was used for 73% of MMS cases, whereas WLE more commonly used flaps, grafts, or other closures (52%). Two Mohs layers typically were required for margin control.

CONCLUSION

Surgical excision with meticulous histologic evaluation of all surgical margins is needed for DFSP treatment to achieve long-term high cure rates and low morbidity.

Dermatofibrosarcoma Protuberans: Wide Local Excision Versus Mohs Micrographic Surgery

Dermatofibrosarcoma protuberans (DFSP) is a rare dermal soft tissue sarcoma characterized by a typically indolent clinical course. The greatest clinical challenge in management of DFSP is achieving local control. There is vigorous debate in the literature as to the optimal surgical approach to these tumors. The choice between wide local excision and Mohs micrographic surgery for DFSP should be governed by the attainment of three goals: (1) to completely excise the tumor with negative margins, tantamount to cure; (2) to preserve function, optimize cosmesis, and minimize morbidity of resection; and (3) to minimize cost and inconvenience to the patient and the health care system at large.

Wide Local Excision for Dermatofibrosarcoma Protuberans: A Single-Center Series of 90 Patients

Background. Dermatofibrosarcoma protuberans (DFSP), a rare low-grade sarcoma of fibroblast origin, tends to extend in a finger-like fashion beyond macroscopic tumor margins. Therefore, incomplete removal and subsequent recurrence are common. This study aimed to determine the efficacy of wide local excision (WLE) for controlling local recurrence of DFSP. Methods. The medical records of 90 DFSP patients who received WLE at our hospital between June 1992 and January 2015 were retrospectively reviewed. WLE was conducted including a 3 cm (range, 1 to 5 cm) safety margin according to tumor size, location, and recurrence status. Clinical and tumor characteristics and surgical methods were evaluated for risk factor analysis and local recurrence-free survival. Results. DFSP occurred most often in patients in their 30s (30%) and on the trunk (51.1%). Five patients (5.5%) experienced local recurrence during the 43.4-month follow-up period. Recurrence was found at a mean of 10.8 months after WLE. Although no factors were significantly associated with recurrence, recurrences were more frequent in head and neck. Recurrence-free survival was 87% in 6 years and 77% in 7 years. Conclusions. WLE with adequate lateral and deep margins can effectively control local recurrence rate and is a simple and effective method to treat DFSP.

[Dermatofibrosarcoma protuberans, particular skin tumor: report of 32 cases and review of the literature]

Le dermatofibrosarcome (DFS) est une tumeur fibreuse de la peau, de croissance lente, à très haut risque de récidive locale, mais à potentiel métastatique faible. A partir d'une étude rétrospective étalée sur une période de 5 ans (décembre 2008 - décembre 2013), nous avons analysé les caractéristiques épidémiologiques et cliniques, le délai de diagnostic, le type de thérapeutique et le devenir de 32 patients présentant des tumeurs de Darier et Ferrand histologiquement prouvées. Parmi les 32 patients, 10 se sont présentés initialement au service pour une récidive tumorale. Une discrète prédominance masculine a été notée. Les DFS touchent préférentiellement l'adulte jeune. Le délai diagnostique observé est en moyenne de 4 ans. Le tronc est la localisation préférentielle (60%), suivi par les extrémités proximales (30%). Les 32 patients ont été traités par exérèse chirurgicale avec une marge de 5cm en surface, emportant en profondeur une barrière anatomique saine. La couverture de la perte de substance (PDS) a été réalisée après confirmation anatomopathologique du caractère carcinologique de l'exérèse, et a fait appel à différents moyens allant de la greffe cutanée aux lambeaux musculo –cutanés libres. L’évolution a été marquée par la survenue d'une récidive tumorale chez 8 patients (3 cas parmi les tumeurs vues en première intention et 5 cas parmi les tumeurs vues en récidive) et les résultats ont été jugés satisfaisants sur le plan esthétique et fonctionnel. Le DFS de Darier et Ferrand est une tumeur dont le pronostic et le risque évolutif sont principalement liés au délai diagnostic et la qualité de la première exérèse. Le diagnostic tardif, rend difficile la chirurgie d'exérèse et de reconstruction Les possibilités de guérison en cas de chirurgie primaire bien conduite sont significativement supérieures à celles d'une chirurgie de rattrapage. L'amélioration du pronostic passe par une prise en charge multidisciplinaire précoce et codifiée d'où l'intérêt de la sensibilisation et de l'information du médecin généraliste pour le diagnostic précoce et l'orientation correcte de ces malades vers des centres spécialisés.

Abdominoplasty and thoraco-epigastric flaps for large anterior trunk defects after dermatofibrosarcoma protuberans wide resection: Two illustrative cases

INTRODUCTION

Excision of large dermatofibrosarcoma protuberans in the anterior aspect of the trunk often results in large surgical defects that frequently dictate the need for microsurgical reconstruction. However, this option is not always available.

PRESENTATION OF CASE

The authors describe two patients with very large anterior trunk dermatofibrosarcoma protuberans: one in the epigastric region and the other in the hypogastric region. In the patient with the hypogastric tumor, a classical abdominoplasty flap associated with umbilical transposition was used to cover the skin defect after muscle and fascial plication, and placement of a polypropylene mesh. In the patient with the epigastric tumor, a synthetic mesh was also placed, and the skin and subcutaneous defect was reconstructed with a reverse abdominoplasty flap and two thoraco-epigastric flaps. In both cases, complete closure was possible without immediate or late complications.

DISCUSSION

The local options described in this paper present several potential advantages compared to microsurgical reconstruction, namely they are easier and faster to perform and teach; they provide a good skin color and texture match; they are not associated with distant donor site morbidity; follow-up is usually less cumbersome; the post-operative hospital stay tends to be shorter; they are less costly; they are less prone to complete failure.

CONCLUSION

The authors believe that these two patients clearly show that local flaps, although frequently neglected, continue to be valid options for reconstructing large anterior trunk defects, even in the current era of microsurgery enthusiasm.

Dermatofibrosarcoma protuberans: clinical diagnoses and treatment results of 260 cases in China

BACKGROUND AND OBJECTIVES

Dermatofibrosarcoma protuberans (DFSP) is a low-grade malignant tumor but has high local recurrence rate. The objectives of this study were to analyze their clinicopathologic factors and review the experience of multidisciplinary treatments.

METHODS

A total of 260 patients who were treated between 1985 and 2006 in Fudan University Shanghai Cancer Center were evaluated. Outcomes were compared focusing on recurrence and survival. Classical DFSP and transformed DFSP were the two subtypes.

RESULTS

After local excision, 50.2% of the patients were found to have residual tumors. The recurrence rate after local excision was significantly higher than that after wide excision (45.0% vs. 8.5%, P < 0.0001). Patients undergoing wide excision with margins ≥3 cm were found to have lower recurrence rate compared with those margins 1.5-2.5 cm (5.7% vs. 13.6%, P = 0.043). Compared with classical DFSPs, transformed DFSPs had significantly higher recurrence rate (34.5% vs. 6.3%, P < 0.0001), higher metastatic rate (23.5% vs. 0.4%, P < 0.0001), and worse prognosis (10-year survival rate 66.0% vs. 98.6%, P < 0.0001).

CONCLUSIONS

Performing adequate initial resection is important for patients with DFSP. Once DFSP was diagnosed, wide excision with a best margin of ≥3 cm is necessary. Transformed DFSPs are more aggressive tumors which need more energetic treatments.

Dermatofibrosarcoma protuberans (DFSP): predictors of recurrence and the use of systemic therapy

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft tissue malignancy that typically presents with local invasion but rarely metastasizes. We examine clinicopathologic factors associated with disease-free survival (DFS) in patients with primary and recurrent DFSP and evaluate responses to multimodality therapy.

MATERIALS AND METHODS

Patients treated for DFSP were identified in a prospectively maintained database. Clinicopathologic factors associated with DFS were analyzed using univariate and multivariate analysis.

RESULTS

A total of 244 patients with DFSP were identified. Median follow-up was 50 months. A total of 14 patients had local recurrence (LR), and 2 patients had distant recurrence (DR), with a median time to recurrence of 35 months. At time of last follow-up, 70% and 47% of patients showed no evidence of disease (NED) in the primary (n = 197) and recurrent groups (n = 47), respectively. On univariate analysis, tumor location and depth were associated with DFS in the primary group, while margin status (R1 vs. R0) was associated with DFS in the LR group. On multivariate analysis, only depth (primary group) and margin status (LR group), remained significant. Also, 22 patients had therapy other than surgical resection: 14 radiotherapy, 4 tyrosine kinase inhibitor (TKI) only, 2 conventional chemotherapy only, and 2 chemotherapy plus TKI. Responses to other therapies were variable.

CONCLUSIONS

DFS after treatment for DFSP is strongly predicted by tumor depth in the primary setting and margin status in recurrent tumors. The treatment for DFSP in the primary or recurrent setting is excision with negative margins, resulting in low recurrence rates and infrequent metastatic spread. Multimodality treatment, especially TKI use, can be effective, but is not curative.

[Vulvar Darier-Ferrand dermatofibrosarcoma: Unusual localization of a rare tumour (about one case and a review of the literature)]

First described by Darier and Ferrand in 1984, the dermatofibrosarcoma is a fibrous tumour of the skin with high local malignancy, progressive evolution and great opportunity of recidivism. We report unusual case of Darier-Ferrand dermatofibrosarcoma relapsing of the vulva in a 76-year-old female patient. The clinical examination showed a big, rounded mass with fixed consistence. The surgical resection was complete, passing to 3 cm laterally with economy of healthy tissues that leaves the least of functional and esthetical sequelae. The histological examination of the operative piece confirmed the diagnosis. This case shows the huge nature of the mass, the local aggressiveness of the tumour and the possible difficulties of the complete exeresis of the lesion in significant anatomic region.

Dermatofibrosarcoma protuberans: A case report of a rare, bulky tumor that was managed with surgical therapy

We report a case of this rare tumor and describe the surgical approach that we adopted and the clinical outcome; we also report his condition at 24 months' follow-up. Although treatment was with radical surgery, sufficient shoulder function could be obtained in our patient. We also describe the interesting MR findings of this tumor which correlated well with the histopathologic findings.

[Skin cancer: what's new in clinical research?]

Every year skin cancer is the subject of many publications. In this review of the recent literature, we selected epidemiological, clinical, and therapeutic data published between October 2006 and September 2007. Some of the studies presented in conferences in 2007 are also mentioned. New epidemiological data have been provided regarding the incidence of different types of skin cancers, the effect of certain risk factors or drug or food protective factors, the overall improvement of survival in melanoma, the epidemiological, clinical, and/or therapeutic particularities of rapidely growing melanomas and thick melanomas, and the relations between sun exposure, skin cancers, and other solid tumors. New prognostic studies in melanoma have improved the evaluation of prognosis in specific situations such as thin melanoma, acrolentiginous melanoma, and melanoma with positive sentinel lymph nodes (depending on the type of positivity) or negative sentinel lymph nodes. Important results on adjuvant interferon in melanoma have been presented. Clinical trials evaluating new therapeutic approaches in stage III and IV melanoma are going on. Several studies confirmed the clinical benefit of adjuvant irradiation on the tumor site in Merkel cell carcinoma. New treatments are being studied or have been approved in refractory forms of cutaneous T-cell lymphoma and in inoperable forms of squamous cell carcinoma and dermatofibrosarcoma protuberans.