Dermatofibrosarcoma protuberans: a population-based cancer registry descriptive study of 66 consecutive cases diagnosed between 1982 and 2002

A challenging diagnosis of dermatofibrosarcoma protuberans of the middle finger in an infant: A case report

INTRODUCTION

Dermatofibrosarcoma protuberans (DFSP) is a rare sarcoma, accounting for less than 0.1 % of tumors. While it predominantly occurs in adults, pediatric cases are unusual. This case report aims to highlight the diagnostic and therapeutic challenges posed by DFSP in infants due to its rarity and slow-growing nature, emphasizing the importance of early diagnosis and prompt intervention.

CASE PRESENTATION

We report the case of an 8-month-old infant presenting with a progressive finger mass, initially mistakenly diagnosed as a dermatofibroma. Local excision was done, but the tumor recurred after one year. Subsequent re-excision and skin grafting were performed, and histopathology confirmed DFSP. Despite middle finger amputation three weeks later, a new mass emerged on the adjacent ring finger after one year. This tested negative for DFSP. The fibrous mass has persisted for five years without significant changes.

CLINICAL DISCUSSION

DFSP is a rare sarcoma with a higher prevalence in adults. It typically presents as a painless, slow-growing mass and is usually diagnosed by biopsy and immunohistochemistry. Surgical excision with negative margins is the preferred treatment. The rarity and slow-growing nature of DFSP pose challenges in diagnosis and treatment.

CONCLUSION

Early diagnosis and prompt surgical intervention are crucial in managing DFSP, especially given its high recurrence potential. Maintaining a high index of suspicion is essential even in very young children. Aggressive resection with negative margins and diligent post-operative surveillance are key strategies to mitigate metastasis risk and improve prognosis in such challenging cases.

Enhancing Healthcare for Sarcoma Patients: Lessons from a Diagnostic Pathway Efficiency Analysis

Sarcomas, rare and with lower survival rates than common tumors, offer insights into healthcare efficiency via the analysis of the total interval of the diagnostic pathway, combining the patient interval (time between the first symptom and visit with a physician) and diagnostic interval (time between first physician visit and histological diagnosis). Switzerland's healthcare system, Europe's costliest, lacks research on treating rare conditions, like mesenchymal tumors. This study examines the total interval of the diagnostic pathway for optimization strategies. Analyzing a dataset of 1028 patients presented from 2018 to 2021 to the Swiss Sarcoma Board (MDT/SB-SSN), this retrospective analysis delves into bone sarcoma (BS), soft-tissue sarcoma (STS), and their benign counterparts. Demographic and treatment data were extracted from medical records. The patient interval accounted for the largest proportion of the total interval and secondary care interval for the largest proportion of the diagnostic interval. Age, grade, and localization could be elicited as influencing factors of the length of different components of the total interval. An increasing age and tumor size, as well as the axial localization, could be elicited as factors increasing the probability of sarcoma. The patient and secondary care interval (SCI) offer the greatest potential for optimization, with SCI being the bottleneck of the diagnostic interval. New organizational structures for care work-ups are needed, such as integrated practice units (IPU) as integral part of value-based healthcare (VBHC).

Dermatofibrosarcoma Protuberans: A Surgeon's Enigma

Dermatofibrosarcoma protuberans (DFSP) is a soft-tissue tumor arising from the dermis. It is a rare tumor, but the important point is that it has a higher incidence of local recurrence than other tumors. Management is primarily by wide local excision (WLE) with tumor negative margin (R0 resection) or Mohs micrographic surgery (MMS). In our case, a 57-year-old male patient presented with an anterior abdominal wall ulcerated mass. The patient had undergone surgery for the excision of the mass, twice before, at a different health-care facility. An incisional biopsy of the mass done at our hospital revealed it to be DFSP. The patient was treated by WLE with flap reconstruction. Post-operative histopathology examination (HPE) report confirmed DFSP with tumor-free margins (R0 resection). So if we fail to diagnose and manage DFSP correctly from the other commonly occurring tumors in the initial stages, there are very high chances of recurrence, and this causes significant morbidity to the patients.

Epidemiological trends and survival outcomes for dermatofibrosarcoma protuberans of the head and neck region

BACKGROUND

Given the rarity of dermatofibrosarcoma protuberans (DFSP) of the head and neck, the incidence and prognosis specific to this region are poorly defined. The purpose of this study was to determine epidemiology, clinicopathological characteristics, and prognostic factors of patients with DFSP of the head and neck region, using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

A cohort analysis was performed for primary head and neck DFSP reported to the SEER database between 2000 and 2018. Overall survival was determined using Kaplan-Meier analysis while Cox regression modeling was used to examine predictive factors.

RESULTS

A total of 681 cases were reported to the SEER database between 2000 and 2018. Incidence rates decreased over time. Overall survival was 94%, and disease-specific survival was 99% at 5 years. Cases of head and neck DFSP were found to occur more frequently in males. There was no difference in incidence rates between White patients and Black patients. Age ≥ 60 years old, tumor size, and living location were the most significant predictors of overall survival.

CONCLUSIONS

This analysis of DFSP of the head and neck demonstrates a downward trend in incidence, higher age-standardized incidence in males, and similar race-based incidences, which differs from data reported on DFSP of other anatomic locations.

Mesenchymal Tumors of the Breast: Fibroblastic/Myofibroblastic Lesions and Other Lesions

Mesenchymal breast tumors are a rare and diverse group of tumors that present some of the most challenging cases for multidisciplinary breast cancer teams. As a result of overlapping morphologies and a lack of large-scale studies on these tumors, practices are often heterogeneous and slow to evolve. Herein, we present a non-systematic review that focuses on progress, or lack thereof, in the field of mesenchymal breast tumors. We focus on tumors originating from fibroblastic/myofibroblastic cells and tumors originating from less common cellular origins (smooth muscle, neural tissue, adipose tissue, vascular tissue, etc.).

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.

Dermatofibrosarcoma protuberans surgery: Experiences of four African surgical oncology units and literature review

BACKGROUND AND OBJECTIVES

Dermatofibrosarcoma is a locally malignant tumor. This gives surgery a place of choice. The advent of imatinib has improved outcomes. Our aim is to describe the indications, techniques and results of surgery.

METHODS

A retrospective, multicenter, descriptive study conducted in four West African surgical oncology units. It covers dermatofibrosarcoma surgery performed between January 1, 1988 and December 31, 2020. We took into account the surgical procedure, the mode of skin coverage, adjuvant treatments and survival. Comparisons were possible using Student's t-test and Pearson's χ² .

RESULTS

We recorded 81 cases of dermatofibrosarcoma. Surgery was effective in 90.1% of cases. Wide resection was the principle with a mean resection margin of 3.8 ± 1.9 cm. healing by primary intention, flaps and healing by secondary intention were the methods of skin coverage in 30.1%, 24.7% and 41.1% respectively. The type of skin coverage was related to the topography and size of the tumor (p < 0.0001). The healing time is associated with the type of skin cover. The recurrence rate was not related to the type of skin coverage (p = 0.8).

CONCLUSIONS

Wide and deep resection in the absence of Mohs micrographic surgery ensures healthy margins. Oncoplasty reduces the healing time without increasing the risk of recurrence.

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.

Surgical Outcomes of Primary Dermatofibrosarcoma Protuberans: A Retrospective, Multicenter Study

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive tumor with a low rate of metastatic disease. Previous series have shown a superiority of Mohs micrographic surgery (MMS) compared with wide local excision (WLE). Likewise, there is paucity of data examining the long-term follow-up of patients.

OBJECTIVE

The purpose of the current study was to examine the outcome of surgical treatment of primary DFSP of the trunk and extremities.

METHODS

We reviewed 236 patients (115 females, 121 males, mean age 41 ± 15 years) undergoing MMS (n = 81, 34%) or WLE (n = 155, 66%) to treat a primary DFSP. Mean tumor size and follow-up was 4 ± 2 cm and 7 years, respectively. Final margins were negative in 230 (97%) patients.

RESULTS

There was no difference (p > 0.05) in patient age, sex, tumor size, negative margin excision, or history of a previous inadvertent excision between patients who underwent WLE and those undergoing MMS. There were two cases of local recurrence and two cases of metastasis, with no difference in the 5-year local recurrence-free survival (98% vs. 99%, p = 0.69) or metastatic-free survival (98% vs. 100%, p= 0.27) between WLE and MMS.

CONCLUSION

There was no difference in oncologic outcome comparing MMS with WLE for DFSP outside the head and neck. The goal of treatment for DFSP is to achieve a negative margin, regardless of surgical treatment modalities. A 'less is more' approach to follow-up can likely be taken for patients with completely resected DFSP in easy-to-examine anatomical areas. In these patients, no formal follow-up should be required.

Myxoid Dermatofibrosarcoma Protuberans of the Scrotum: Rare Tumor in an Uncommon Location

Background

Case Presentation

Conclusion

Natural speed of growth of untreated soft-tissue sarcomas: A dimension-based imaging analysis

PURPOSE

The interval from first symptoms to diagnosis, staging and referral to reference center can last months for soft-tissue sarcoma (STS) patients. Meanwhile, patients can undergo different imaging that capture the 'natural' tumor changes, before medical intervention. Aim was to depict these 'natural' dimensional variations and to correlate them with patients' outcome.

METHODS

Single-center retrospective study including all consecutive adults with newly-diagnosed STS, ≥2 pre-treatment imaging (CT-scan or MRI) on the tumor (Exam-0 and Exam-1), and managed in reference center between 2007 and 2018. Longest diameter (LD) and volume were calculated on both examinations to obtain the naïve dimensional growth before any intervention. SARCULATOR nomogram was applied on data at Exam-0 and Exam-1. Correlations with overall, metastatic and local relapse-free survivals (OS, MFS and LFS), and with pre-treatment pathological features were performed.

RESULTS

137 patients were included (median age: 65 years). Average naïve growth was +39.4% in LD and +503% in volume during an average Exam-0-to-Exam-1 interval of 130 days. The 10-year distant metastasis and OS predictions were different at Exam-0 and Exam-1 (P < 0.0001 for both). All the changes in radiological measurements significantly correlated with pre-treatment number of mitosis, grade and complex genomic (P-value range: <0.0001-0.0481). Multivariate Cox modeling identified the relative change in LD/month and absolute change in LD/month as independent predictors for OS and LFS, respectively (P = 0.0003 and 0.0001, respectively).

CONCLUSION

When available, the natural speed of growth on pre-treatment imaging should be evaluated to improve the estimation of pre-treatment histological grade and patients' OS and LFS.

Dermatofibrosarcoma- An uncommon entity, commonly mismanaged: a case report

Introduction & importance

Dermatofibrosarcoma protuberans (DFS) is a slow-growing, recurrent, cutaneous soft tissue sarcoma with low metastatic potential. It is not uncommon for DFS to get misdiagnosed and treated like commoner parietal wall swellings, viz., epidermal cysts, lipomas and fibromas. Suboptimal management often leads to recurrence, which may be difficult to manage.

Case report

A 33-year male was referred to us with a lump in his lower abdomen for 15 years, without any symptoms. The patient underwent medical management for 6 years, followed by excision. The swelling recurred four years later and progressed in size till the next 5 years. At our centre, the patient underwent imaging and aspiration cytology, which established diagnosis of DFS, followed by wide local excision. Biopsy was conclusive and margins negative.

Discussion

DFS presents commonly as an asymptomatic indurated plaque that slowly enlarges over months to years. Untreated, DFS can attain massive dimensions, producing the large “protuberant” nodules, and hence the name. In the current report, 15 years elapsed before the correct diagnosis was established. In this case, recurrence first appeared after four years of excision. The possibility of primary wound closure after wide excision decreases with every subsequent excision, and reconstructive options may not be readily available.

Conclusion

The current report highlights a diagnostic delay of 15 years in a case of DFS. Asymptomatic, indolent nature combined with low awareness among community doctors contribute to delay in timely diagnosis. Community doctors should consider DFS as a differential in any long-standing, indolent, asymptomatic parietal wall swelling, especially with a history of recurrence.

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It is not uncommon for DFS to get misdiagnosed .

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Suboptimal management often leads to recurrence, which may be difficult to manage.

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We report a case that highlights a diagnostic delay of 15 years in the case of DFS.

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Indolent nature low awareness among doctors contribute to delay in the diagnosis.

The sarcoma diagnostic interval: a systematic review on length, contributing factors and patient outcomes

Sarcomas are rare and heterogeneous mesenchymal tumours of soft tissue or bone, making them prone to late diagnosis. In other malignancies, early diagnosis has an impact on stage of disease, complexity of therapeutic procedures, survival and health-related quality of life (HRQoL). Little is known about what length of diagnostic interval should be considered as delay in patients with bone (BS) or soft tissue sarcomas (STS). To quantify total interval (defined as time from first symptom to histological diagnosis) and its components, identify contributing factors to its length and determine the impact on patients’ outcome in terms of mortality and HRQoL. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seventy-six articles out of 2310 met the predefined inclusion criteria. Total intervals, varied broadly; 9–120.4 weeks for BS and 4.3–614.9 weeks for STS. Older age and no initial radiological examinations were contributing factors for a long interval in BS, while in STS results were conflicting. The impact of length of total interval on clinical outcomes in terms of survival and morbidity remains ambiguous; no clear relation could be identified for both BS and STS. No study examined the impact on HRQoL. The length of total interval is variable in BS as well as STS. Its effect on outcomes is contradictory. There is no definition of a clinically relevant cut-off point that discriminates between a short or long total interval. Prospero: CRD42017062492.

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 in the breast: Case report

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The occurrence of dermatofibrosarcoma protuberans in the breasts is rare.

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Histological examination is helpful for identifying dermatofibrosarcoma protuberans.

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Treatment of dermatofibrosarcoma protuberans; surgical resection.

Introduction and importance

Dermatofibrosarcoma protuberans (DFSP) represents about 1% of soft tissue sarcomas with an estimated incidence of 0.8–5.0 cases per million per year. The involvement of DFSP in breast is very rare and very few cases have been reported in the literature. DFSP was recurred in situ, not spread to distant site. The complete surgical excision with wide, pathologically negative margins of 3 cms is the optimal treatment for primary or recurrent tumor.

Presentation of case

A 46-year-old woman presented with palpable lump in the in the right breast. On ultrasonography, a lesion appeared as hypoechoic, circumscribed mass of approximately 37 mm × 30 mm in diameter in the upper central part of the right breast. The mass of right breast was demonstrated DFPS by pathologic examination. Chest computerized tomography (CT) scan and 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG) positron-emission tomography (PET) showed only primary lesion in subcutaneous layer and no enlarged lymph node. The patient underwent excision of the tumor widely. There was no evidence of DFSP local recurrence after five years of follow-up of the patient.

Discussion

DFSP is a rare tumor arising from dermis and subcutaneous mesenchymal tissue. Whereas, characteristic imaging feature of DFSP in the breast are not well-defined. The primary treatment for DFSP is considered to be surgical excision.

Conclusion

DFSP in breast is extremely uncommon and can mimic a primary breast tumor. Surgical excision with adequate resection margins is recommended to ensure local control of the disease.

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

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

Dermatofibrosarcoma protuberans associated with trauma: A case report

A case of dermatofibrosarcoma protuberans (DFSP) in a 22-year old female associated with blunt trauma of the mid-upper back is presented in the current study with a review of the literature. DFSP is a rare slow growing sarcoma of the soft tissue most commonly seen on the trunk and upper extremities with a low to intermediate grade malignant potential, high chance of local invasion and a high local recurrence rate. The literature search revealed that both non-congenital mutation as well as trauma serve a role in the development of this dermal neoplasm, but the exact mechanism by which trauma may predispose to development of DFSP is unknown. However, it seems intuitive that chronic inflammation and stimulation of the immune system at a local level may trigger the immunopathologic changes that could lead to the malignant transformation of dermal cells. Future research into the relationship between trauma and DFSP on a cellular level is required, as there appears to be a direct link present.

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.

Presentation and Management of Dermatofibrosarcoma Protuberans: a Single Center Protocol

Dermatofibrosarcoma protuberans (DFSP) is a slow growing dermal tumor with a very low metastatic potential but with significant subclinical extension and capacity for local destruction with local recurrence rates ranging from 0 to 50%. Controversy exists regarding margin width and excision techniques, with some advocating Mohs surgery and others wide excision. We reviewed the excision technique along with the recurrence rates at a tertiary care center in eastern India. This study is a retrospective review of patients with DFSP from June 2011 to September 2018. Patients had initial wide excision using 2-3 cm margins with primary closure or reconstructive procedure; re-excision was done for positive margins. Pathologic analysis included en face sectioning. We evaluated margin width, number of excisions, reconstruction methods, radiation, and outcomes. A total of 31 patients with DFSP (15 males, 16 females), median age 41 years (range 14-82), were treated. Locations were extremities (13), trunk (12), and head and neck (06). The median number of excisions to achieve negative margins was 1 (range 1-3). Closure techniques included primary closure (13; 42%), tissue flaps (13; 42%), and skin grafting (05; 16%). There were 11 patients who received postoperative radiation, 4 for positive margins after maximal surgical excision. At a median follow-up of 24 months (range 1-72), 2 patients (6.5%) recurred locally, and 1 patient (3.2%) had lung metastasis. Using a standardized surgical approach including meticulous pathologic evaluation of margins, low recurrence rate (10%) was achieved with adequate margins (2-3 cm).

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.

Mimickers of Infantile Hemangiomas

Infantile hemangiomas (IHs) are the most common tumors of infancy and usually follow a typical course of growth and involution. We report four soft tissue tumors that were referred to the pediatric dermatology clinic as IHs and the process by which they were diagnosed and treated. Clinicians should be aware of presentations of these uncommon, but serious soft tissue tumors. Many of these mimickers have a vastly different clinical prognosis, and early intervention to limit sequelae is crucial. Biopsy of atypical lesions should be considered early in the diagnostic process since they have varied prognosis and treatment strategies.

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

Dermatofibrosarcoma protuberans (DFSP) is a rare superficial soft tissue sarcoma. Its rarity precludes large prospective studies. Clinical diagnosis requires an high index of suspicion. Effective management requires an appreciation of tumor biology and the nature of the characteristic infiltrative growth pattern. DFSP tends to recur locally, with a low risk of dissemination. Aggressive surgical resection with widely negative margins is essential to management. Radiotherapy may be indicated in special circumstances. Understanding the molecular pathogenesis has resulted in use of tyrosine kinase inhibitor therapy for patients with locally advanced disease or in metastatic disease. DFSP patients require long-term follow-up.

A single-institutional review of 68 patients with dermatofibrosarcoma protuberans: wide re-excision after inadequate previous surgery results in a high rate of local control

Background

Dermatofibrosarcoma protuberans (DFSP) is a cutaneous soft tissue sarcoma characterized by an indolent but aggressive local growth. Unplanned excisions with positive margins are common, and the prognostic impact of radical re-excisions is still unclear. The aim of the present study was to identify prognostic indicators of recurrence-free survival (RFS) in patients with DFSP through a long-term follow-up. We tried particularly to determine the prognostic impact of surgical margins and re-excisions in patients after earlier inadequate surgery.

Methods

Seventy-five patients with DFSP were treated surgically at our institution between 1999 and 2015. Analyses were restricted to 68 participants with available information on surgical margins. The median follow-up was 5.4 years.

Results

Fifty-four patients (79.4%) had low-grade DFSP and 14 patients (20.6%) intermediate-grade FS-DFSP. The 5-year RFS rates were estimated to be 93.5% (95% CI 81.2–97.9) for low-grade DFSP and 39.7% (95% CI 13.0–65.8) for FS-DFSP (P < 0.0001). Re-excisions were performed in 55 patients (80.9%) following R1 or marginal R0 resections. Negative margins could be attained in a total of 65 patients (95.6%). Negative margin widths >1 cm led to the best local outcome within the R0 subgroup. Significant adverse prognostic features in the multivariate analysis included histologic grade and close margins.

Conclusions

The data from this study underscore the long-term benefit of negative margins. In our analysis, re-excisions were an effective method to achieve a high rate of local control in patients who presented after R1 or marginal R0 resection. To ensure the best outcome, re-excisions should aim at negative margin widths of more than 1 cm in the histologic specimen.

Dermatofibrosarcoma protuberans post basal cell carcinoma excision: A case report

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A link between dermatofibrosarcoma protuberans and basal cell carcinoma is proposed.

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1 case suggesting a link has been reported in the literature previously.

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Few healthcare providers are aware of dermatofibrosarcoma protuberans.

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Increased awareness of this tumor and its management is needed.

Introduction

Dermatofibrosarcoma protuberans (DFSP) is a rare, malignant, soft tissue neoplasm of the dermis. Tumor recurrence is common following resection, and can be locally devastating if not identified in a timely manner.

We report a unique case of this rare tumor. This case poses the question of an association between basal cell carcinoma (BCC) and DFSP, and presents the possible need for increased awareness of DFSP for healthcare providers and patients with a history of non-melanoma skin cancers as well as surgical or burn scars.

Presentation of case

A 77-year-old male with a history of surgical excision of BCC presented with several palpable lesions in the superficial cutaneous tissue of the right anterior abdominal wall. Most of the lesions were consistent with lipoma; however, one lesion near the excision site of the BCC was more solid in consistency. The mass was removed with wide local excision encompassing all layers down to the abdominal fascia. Subsequent pathology findings included CD34 positive spindle cells in a whorled pattern consistent with DFSP. Resection margins were positive and a wide re-excision was performed with margins being negative.

Discussion

DFSP comprises approximately 0.01% of all malignant tumors. There are no known precipitating factors of DFSP, but its presence in surgical and burn scars is not uncommon.

An association between DFSP and basal cell carcinoma has been suggested in the literature. Dermatofibroma and rarely DFSP may demonstrate basaloid proliferation of the overlying epidermis with characteristics of BCC. One case reporting coexistent DFSP and BCC located to the ear also suggested an association, but concluded that the finding was likely incidental due to sun exposure. In our case, the lesion’s location is less routinely subjected to sun exposure and points more towards a possible association.

The mainstay of treatment for local DFSP is wide local excision. Negative margins with the removal of fascia and muscle tissue as necessary is essential and the most significant prognostic factor. Three-dimensional reconstructions of DFSP have shown villous finger like projections of primary tumors, which is believed to be responsible for local recurrence. Recurrence can be devastating, as several cases have demonstrated rapid growth of remaining cells with increased morbidity following further resection.

Conclusion

Based on this case and those found in the literature, we believe an association may exist between DFSP and BCC and further study of this association is needed. DFSP is a rare malignancy unknown to many healthcare providers, but in the presence of increased awareness and physician vigilance in surgical resection and follow up, the potential morbidity of DFSP may be prevented.

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.

Usefulness of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in dermatofibrosarcoma protuberans on treatment with imatinib

Dermatofibrosarcoma protuberans (DFSP) is a rare locally aggressive tumor with distant metastases being unusual. We present a case of metastatic DFSP treated with imatinib showing complete metabolic response to treatment.

Transformation of Dermatofibrosarcoma Protuberans into a Fibrosarcoma

Dermatofibrosarcoma protuberans is a rare cutaneous mesenchymal tumor characterized by a low potential of malignancy with a very low rate of metastasis but an important rate of local recurrence. Its transformation into a fibrosarcoma is exceptional, responsible for a higher metastatic potential. This transformation implies a closer surveillance. Through a case report and literature review, we will try to expose epidemiological, clinical, histological, therapeutic, and outcome particularities of this entity.

Incidence and Survival of Primary Dermatofibrosarcoma Protuberans in the United States

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma for which data on risk factors, incidence, and survival are limited.

OBJECTIVE

The authors sought to establish a comprehensive report on the incidence of and survival from primary DFSP.

METHODS

The authors used data from the 18 registries of the Surveillance, Epidemiology, and End Results Program from 2000 to 2010.

RESULTS

Overall incidence was 4.1 per million person-years and steady over the decade. Trunk was the most common anatomic site except in older men. Incidence among women was 1.14 times higher than men (95% confidence interval [CI] of rate ratio: 1.07-1.22). Incidence among blacks was almost 2 times the rate among whites (95% CI of rate ratio: 1.8-2.1). Ten-year relative survival of DFSP was 99.1% (95% CI: 97.6-99.7). Increased age, male sex, black race, and anatomic location of the limbs and head as compared with the trunk were associated with higher all-cause mortality.

CONCLUSION

This is the largest population-based study of DFSP derived from a cohort of almost 7,000 patients. The epidemiologic profile of DFSP differs from most skin cancers. Incidence is stable and highest among women and blacks. Worse survival is associated with increased age, male sex, black race, and anatomic location of the limbs and head.

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.

Pediatric dermatofibrosarcoma protuberans in Madrid, Spain: multi-institutional outcomes

Little is known about the incidence and management of dermatofibrosarcoma protuberans (DFSP) in children. We conducted a retrospective review of all patients younger than 18 years of age treated for DFSP over a period of 11 years (2000-2011) in Madrid, Spain. The sample consisted of 13 children. The average annual incidence of DFSP in the pediatric population corresponded to 1.02 cases per million person-years (95% confidence interval 0.55, 1.73). Sites of involvement were diverse, with 15.3% of tumors found in acral locations. The median tumor size was 3.5 cm × 3 cm and the median time from apparent onset to diagnosis was 36 months. Histopathologic examination revealed conventional (77.0%), pigmented (15.4%), and myxoid (7.6%) variants. The mitotic index was consistently <5 per 10 high-power fields. All lesions were removed using surgical excision. One patient developed a local recurrence because of initial affected margins; none developed metastases. The median duration of clinical follow-up was 70.5 months. This study estimated the average annual incidence rate of DFSP in a population of patients younger than 18 years and reviewed the experience of several hospitals in the management of this tumor.

A systematic review of outcome data for dermatofibrosarcoma protuberans with and without fibrosarcomatous change

BACKGROUND

To our knowledge, no systematic review of dermatofibrosarcoma protuberans (DFSP) outcomes based on the presence or absence of fibrosarcomatous (FS) change has been performed.

OBJECTIVE

We sought to compare available outcome data for DFSP versus DFSP-FS.

METHODS

The literature was searched for DFSP and DFSP-FS reports with outcome data (local recurrence, metastasis, or death from disease). Chi-square tests were calculated to determine whether DFSP and DFSP-FS significantly differed in risk of local recurrence, metastasis, and death from disease.

RESULTS

In all, 24 reports containing 1422 patients with DFSP and 225 with DFSP-FS are summarized. Risk of local recurrence, metastasis, and death from disease in DFSP-FS was significantly higher as compared with DFSP (local recurrence 29.8% vs 13.7%, risk ratio 2.2 [95% confidence interval 1.7-2.9]; metastasis 14.4% vs 1.1%, risk ratio 5.5 [95% confidence interval 4.3-7.0]; and death from disease 14.7% vs 0.8%, risk ratio 6.2 [95% confidence interval 5.0-7.8]). There was no significant difference in DFSP-FS outcomes based on proportion of FS change within tumors.

LIMITATIONS

This study is based on previously reported data from different hospitals with no uniform process for reporting FS change. The impact of confounders (age, immune status, tumor location, treatment) could not be evaluated because of limited data.

CONCLUSION

Based on available retrospective data, risk of metastasis and death is elevated in DFSP-FS as compared with DFSP. Even a low degree of FS involvement portends worse outcomes.

Dermatofibrosarcoma protuberans in a 10-year-old child

BACKGROUND

Dermatofibrosarcoma protuberans is a rare mesenchymal malignancy in childhood and adolescence. The tumor is characterized by dermal spindle cell proliferation with infiltration of subcutaneous tissue, expression of CD34, and a specific fusion of the platelet-derived growth factor beta with the collagen type 1alpha1 gene.

MAIN OBSERVATION

We observed a 10-year-old girl with a medaillon-like, asymptomatic plaque on the chest that was diagnosed as DSFP. The tumor was completely removed by delayed Mohs surgery. Follow-up so far has shown a complete response.

CONCLUSIONS

The prognosis of dermatofibrosarcoma protuberans in children is excellent as long as early diagnosis is followed by complete excision with Mohs surgery as a golden standard.

Dermatofibrosarcoma protuberans in childhood treated with slow Mohs micrographic surgery

Dermatofibrosarcoma protuberans (DFSP) in childhood is a rare tumor with high recurrence rates. Wide local excision can result in disfiguring mutilation, whereas Mohs micrographic surgery (MMS) reduces surgical margins. MMS in children is not performed routinely, as the required infrastructures such as a histopathology lab in close proximity to the operating room is often lacking. We retrospectively reviewed children diagnosed with DFSP treated at our hospital over 2 years. We recorded surgical treatment details, including margins, duration of inpatient stay, outcome, follow-up, and molecular genetic tumor tissue analysis. Four children with a median age of 6.8 years (range 6.0-8.8 years) were identified who had a diagnostic delay of a median of 2.5 years (range 0.5-4.0 years); all underwent complete tumor excision using the slow MMS technique using vacuum-assisted closure systems between repeated excisions and before wound closure. The median maximal safety margins were 1.5 cm (range 1.0-3.0 cm). By using vacuum-assisted closure systems, no dressing changes were needed, pain was limited, and full mobility was maintained in all children. The median total time in the hospital was 11 days (range 10-14 days). No relapses occurred during a median follow-up of 25.8 months (range 11.3-32.6 months). Collagen 1A1/platelet-derived growth factor B (COL1A1/PDGFB) translocation on chromosomes 17 and 22 was detected in all three analyzable specimens. Lesions suspected of being DFSP warrant prompt histologic evaluation; interdisciplinary management is mandatory in particular for children. Micrographic surgery allows smaller surgical margins than wide excision and should be considered as the treatment of choice in children with DFSP. The interim usage of vacuum-assisted closure systems increases patient comfort. Translocations in the COL1A1/PDGFB gene imply susceptibility to targeted treatment modalities for therapy-resistant cases.

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.

Intratumoral mast cell number is negatively correlated with tumor size and mitosis in dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous tumor with intermediate malignancy. The purpose of this study was to evaluate the utility of p53, smooth muscle actin (SMA) and c-kit as immunohistochemical markers and toluidine blue staining for mast cell that can correlate with the clinical outcome and clarify role of mast cells in pathogenesis of tumor. We analysed data for 32 lesions from 31 patients. Fibrosarcomatous type DFSP showed high immunoreactivity for SMA compared with other subtypes (P = 0.026). No differences in p53 immunoreactivity were observed between subtypes. None of tumor cells were immunoreactive with c-kit. The mast cell counts showed a negative correlation with mitosis and tumor size (P < 0.05), implying that mast cells do not have a causative primary role in tumorigenesis but rather play a secondary role.

Dermatofibrosarcoma protuberans in childhood

Dermatofibrosarcoma protuberans (DFSP) is a fibrohistiocytic tumor of intermediate malignancy that is very rare in childhood. Only 6% of these tumors present in children. Clinical diagnosis is very difficult in the early stages of disease, but to ensure appropriate treatment it is important to identify DFSP as early as possible and rule out benign conditions that are more common at this age. The clinical presentation and histopathologic and molecular characteristics of DFSP are similar in children and adults. Clinical diagnosis is, however, more difficult in children and requires a high degree of suspicion. The absence of characteristic features and the rarity of this tumor explain why diagnosis is often delayed. Complete surgical excision of the tumor is very important to reduce the risk of recurrence. This article presents a review of current knowledge about the management of DFSP in children and examines the latest treatment options.