A novel combined surgical approach to head and neck dermatofibrosarcoma protuberans

Head-and-neck dermatofibrosarcoma protuberans: Survival analysis and Clinically relevant immunohistochemical indicators

BACKGROUND

Head and neck dermatofibrosarcoma protuberans (HNDFSP) is extremely rare and not entirely understood.

OBJECTIVE

To investigate the clinicopathological features of HNDFSP and identify the expression of its clinically relevant indicators, with the expectation of improving the existing treatment strategies.

METHODS

A long-term follow-up of patients with HNDFSP who received treatment between 2000 and 2021 at Shanghai Ninth People's Hospital was conducted. The clinical, histological, and immunohistochemical data of the patients were retrieved and analyzed. The endpoint of the study was the incidence of significant disease-related clinical events (recurrences or metastasis).

RESULTS

A total of 49 patients with HNDFSP were included in the study, with males (92.7%) predominating than females (7.3%). Eighteen patients developed recurrent disease (36.8%) after surgery, and the median time of recurrence was 48 months (interquartile, 20-74 months). Metastasis occurred in two cases (4.1%). Two patients died during follow-up, both with local recurrence, and one of them with intestinal metastasis. Post-operation radiotherapy was administered to eight patients (16.3%) and the effect in local control was remarkable. Age, tumor size, and negative margins with sufficient safety width were the main independent factors affecting the disease-free survival. Several potential targeted therapeutic indicators, including EZH2 (80.0%), EGFR (91.4%), PDGF (97.1%), PD-L1 (77.1%), and VEGF (77.1%), were positively expressed in most tumor samples.

CONCLUSION

HNDFSP is rare, significantly challenging to control locally, and has a worse prognosis with current treatment strategies. Wide local excision and long-term follow-up are needed. Radiotherapy could improve the prognosis of patients with HNDFSP.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Negative Pressure Wound Therapy in the Head and Neck: A Summary of Uses and Application Techniques

Negative pressure wound therapy (NPWT) has had an expanded role in the management of complex wounds including its increasing use for complex wounds in the head and neck region. Challenges for use in the head and neck region include variations in surface topography and the proximity of sensitive mouth, nose, ear, eye, and tracheal openings. Despite these challenges, NPWT has been used in the head and neck immediately following free flap surgery, to prepare wounds for skin grafting or local flaps, to treat orocutaneous and pharyngocutaneous fistulas, to treat necrotizing and deep neck space infections, to temporize and palliate, and to treat chronic wounds with exposed bone and hardware among others. This review demonstrates the proven track record of successful uses of NPWT in the aforementioned scenarios, provides suggestions to improve efficacy, as well as an algorithm for use in certain clinical situations.

Double-layer biodegradable temporising matrix reconstruction for abdominal skin and soft-tissue reconstruction

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally invasive dermal sarcoma. The management is generally surgical, with wide local excision (WLE) forming the mainstay of treatment. Large abdominal wall defects are most aesthetically reconstructed using pedicled or free flaps; however, these require tumour-free surgical margins, and are off-set by donor site morbidity. We describe an alternative, aesthetic and low-morbidity technique for reconstruction of a subfascial defect following WLE of DFSP in a young woman in her early 20s, using two layers of a novel synthetic dermal matrix (NovoSorbBTM). To our knowledge, a double-layer reconstruction using an artificial dermal matrix has never been described for trunk reconstruction. We found that double-layer biodegradable temporising matrix can restore the inherent thickness and pliability of skin in a partial-thickness abdominal wall defect and offers improved durability and cosmesis compared with skin grafting or indeed single layer skin substitutes alone.

Role of a new acellular dermal matrix in a multistep combined treatment of dermatofibrosarcoma protuberans of the lumbar region: a case report

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare skin fibroblastic tumor, with a high rate of recurrence. The treatment of DFSP is generally surgical, and wide local excision is the mainstay of surgical treatment. Therefore, complete assessment of all surgical margins is fundamental before definitive reconstruction. The reconstruction is a challenge for plastic surgeons, especially in particular anatomical areas (for aesthetic or functional problems) or in patients who are not candidates for more complex surgical treatments. We describe an alternative approach for reconstructive treatment of the lumbar area after wide excision of DFSP (without fresh-frozen sections) in a young obese woman with a history of smoking, using a new type of acellular dermal matrix (ADM) in a combined management protocol. The benefits of ADM are numerous: immediate wound closure and prevention of infections and excessive drying; minimal donor site morbidity; and good functional and aesthetic outcomes. Moreover, it is a temporary cover while the anatomical specimen is histologically analyzed, without donor site morbidity or prevention of any future surgery (if the margins are not tumor-free) or radiotherapy.

CASE PRESENTATION

In October 2019, a 34-year old obese Caucasian Woman with a history of smoking came to our institute for a multinodular growing polypoid mass in her lumbar region. An incisional biopsy diagnosed DFSP. The patient underwent proper staging. A wide local excision with 3 cm clinically healthy tissue margins down to the muscle fascia was performed and the defect was repaired using a combined approach with a new artificial bilaminar dermal template (Pelnac®, Gunze Ltd., Osaka, Japan) and a negative-pressure wound therapy system (V.A.C.®, KCI, San Antonio, USA). After the final histological examination revealed tumor-free margins, a split-thickness graft was harvested from the right gluteus and fixed to the new derma with negative-pressure wound therapy. Postoperative radiotherapy was not necessary. After 15 days, the wound had healed without complications, with satisfactory aesthetic outcome and with no limitation of back motion or pain. After 6 months of follow-up, the patient was free from disease.

CONCLUSIONS

This is the first reported case of Pelnac® use in DFSP reconstruction of the lumbar region. We believe that the multistep approach described herein may be a good alternative approach in selected patients with wide resections in particular anatomical areas, especially when frozen sections (with Mohs micrographic surgery) are not available.

Multidisciplinary surgical treatment approach for dermatofibrosarcoma protuberans: an update

Dermatofibrosarcoma protuberans (DFSP) is a cutaneous sarcoma that has remained a challenge for oncologic and reconstructive surgeons due to a high rate of local recurrence. The objective of this study is to investigate the oncologic and reconstructive benefits of employing a multidisciplinary two-step approach to the treatment of DFSP. A retrospective review was conducted using a prospectively collected database of all patients who underwent resection and reconstruction of large DFSPs by a multidisciplinary team, including a Mohs micrographic surgeon, surgical oncologist, dermatopathologist, and plastic and reconstructive surgeon, at one academic institution from 1998-2018. Each patient underwent Mohs micrographic surgery for peripheral margin clearance (Step 1) followed by wide local excision (WLE) of the deep margin by surgical oncology and immediate reconstruction by plastic surgery (Step 2). 57 patients met inclusion criteria. Average defect size after WLE (Step 2): 87.3 cm² (range 8.5-1073.5 cm²). Mean follow-up time was 37 months (range 0-138 months). There were no cases of recurrence. A two-step multidisciplinary surgical treatment approach for DFSP minimizes risk of recurrence, decreases patient discomfort, and allows immediate reconstruction after deep margin clearance.

Clinical and pathological analysis of dermatofibrosarcoma protuberans with long-term follow-up

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare dermal sarcoma characterised by low-grade malignancy, slow infiltrative growth, local recurrence and rare distant metastases.

OBJECTIVE

Many international studies exist on DFSP, but limited data on Asian patients are available. This article fills this gap.

METHODS

A retrospective and observational patient series based on records of 99 patients diagnosed with DFSP and treated with wide local excision and assessments of complete circumferential peripheral and deep margin from 2002 to 2018. The margin width, pathological characteristics and surgical methods of 99 patients were described. Follow-up outcomes of 43 patients were evaluated.

RESULTS

In total, 106 DFSP resections were performed in 99 Asian patients (mean age: 44 years, SD: 14 years). Locations of DFSP are the trunk (63%), extremities (23%), head and neck (9%) and groin (5%). The average margin width was 3.5 ± 0.5 (SD) cm. CD34, vimentin and AOPD positivity was found in 98%, 100% and 86% of specimens, respectively. The median value of Ki67 expression was 5% + (range 1% + ∼ 50% +). Primary closure was used for 69% of all excisions, while flaps, grafts or other closures were used for the other excision procedures. A total of 43 patients were followed up for a mean duration of 53±36 (SD) months. Six patients exhibited recurrence. The eight-year recurrence-free survival rate was 94%.

CONCLUSION

Wide local excision and margin assessments can remove DFSP tumours and control recurrence.

Pediatric head and neck fibrosarcomas: A demographical, treatment, and survival analysis and review of a rare case

OBJECTIVE

To examine pediatric head and neck fibrosarcoma cases and review the demographics, management, and survival for these patients.

METHODS

Pediatric patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1973 to 2014 based on a diagnosis of a head and neck fibrosarcoma using ICD-O-3 head and neck primary sites and histology codes. Patients were included from birth-18 years of age. Additionally, a pediatric case of a head and neck infantile fibrosarcoma treated at the Nemours Children's hospital in Orlando, Florida is presented.

RESULTS

One hundred-thirteen pediatric head and neck fibrosarcomas were identified within the SEER database over the study period. The mean age at diagnosis was 9.8 years (SD: 6.2, range: 0.0-18.0). The mean age at diagnosis for infantile fibrosarcomas was 1.7 years (SD: 3.2, range: 0.0-12.0). Fifty-one (45.1%) patients were female. A majority (N = 67, 59.3%) of patients had dermatofibrosarcoma followed by 18 (15.9%) who had infantile fibrosarcomas. Nearly all patients (N = 107, 94.7%) received surgical intervention. 27.8% of patients with an infantile fibrosarcoma received chemotherapy as a part of their care compared to 1.5% of patients with a dermatofibrosaroma (p = .004). The 5-year disease-specific survival was 97%.

CONCLUSIONS

Pediatric patients with head and neck fibrosarcomas are most likely to present in Caucasian males or females during late childhood or early adolescence. Infantile fibrosarcomas present in pediatric patients at a much earlier age. Surgical management is common for pediatric head and neck fibrosarcomas. Additionally, chemotherapy may be used for infantile fibrosarcomas of the head and neck. Survival rates for pediatric patients with a head and neck fibrosarcoma are excellent.

Skin cancers and dermal substitutes: Is it safe? Review of the literature and presentation of a 2-stage surgical protocol for the treatment of non-melanoma skin cancers of the head in fragile patients

Non-melanoma skin cancers (NMSC) represent the most common skin tumours of the head region. We describe the use of dermal substitute in a 2-stage surgery protocol for selected fragile patients to remove NMSC of the head region. A review of the literature focusing on dermal substitutes' safety after skin tumours excision is provided. A total of 45 fragile patients with NMSC in the head region were selected and scheduled for the 2-stage surgical protocol. The first stage consisted of traditional surgical excision and immediate coverage with Hyalomatrix (Fidia Advanced Biopolymers, Abano Terme, Italy). After histology confirmed diagnosis and clearance of the margins, full-thickness skin autografts were performed. All of the patients reached complete tumour excision and wound healing. No local recurrences were registered during 24 months follow up. The 2-stage surgical therapeutic-diagnostic-reconstructive approach represents a less stressful and oncologically safe surgical protocol in selected fragile patients. When patients cannot tolerate invasive and long surgical procedures, general anaesthesia, and long hospitalisation, skin grafting following temporary skin substitute coverage can achieve oncological clearance and provide good functional and aesthetic results. The use of dermal substitutes represents a valid alternative surgical option in cases of ASA III, fragile patients non-eligible for complex reconstructive surgery. To our knowledge, this is the first paper reviewing literature focusing on dermal substitutes' applications and safety after skin tumour excision.

The Use of Integra Dermal Regeneration Template Versus Flaps for Reconstruction of Full-Thickness Scalp Defects Involving the Calvaria: A Cost-Benefit Analysis

Background

INTEGRA^® Dermal Regeneration Template is a well-known and widely used acellular dermal matrix. Although it helps to solve many challenging problems in reconstructive surgery, the product cost may make it an expensive alternative compared to other reconstruction procedures. This retrospective study aims at comparing INTEGRA-based treatment to flap surgery in terms of cost and benefit.

Patients and Methods

We considered only patients treated for scalp defects with bone exposure in order to obtain two groups as homogeneous as possible. We identified two groups of patients: 17 patients treated with INTEGRA and 18 patients treated with flaps. All patients were admitted in our institution between 2004 and 2010, and presented a defect of the scalp following trauma or surgery for cancer, causing a loss of the soft tissues of the scalp with bone exposure without pericranium. To calculate the cost in constant euros of each treatment, three parameters were evaluated for each patient: cost of the surgical procedure (number of doctors and nurses involved, surgery duration, anesthesia, material used for surgery), hospitalization cost (hospitalization duration, dressings, drugs, topical agents), and outpatient cost (number of dressing changes, personnel cost, dressings type, anti-infective agents). The statistical test used in this study was the Wilcoxon Mann–Whitney (α = 0.05).

Results

No significant difference was characterized between the two groups for gender, age, presence of diabetes, mean defect size, and number of surgical procedures. All patients healed with good quality and durable closure. The median total cost per patient was €11,121 (interquartile range (IQR) 8327–15,571) for the INTEGRA group and €7259 (IQR 1852–24,443) for the flap group (p = 0.34). A subgroup of patients (six patients in the INTEGRA group and five patients in the flap group) showing defects larger than 100 cm² were considered in a second analysis. Median total cost was €11,825 (IQR 10,695–15,751) for the INTEGRA group and €23,244 (IQR 17,348–26,942) for the flap group.

Conclusion

Both treatments led to a good healing of the lesions with formation of soft and resistant tissue. No significant difference was characterized between the two groups for days of hospitalization and costs. In cases of patients with defects larger than 100 cm² for whom major surgery is needed, the treatment with INTEGRA seemed to be less expensive than the treatment with free flaps or pedicle flaps.

Level of Evidence V

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Surgical Treatment of Enormous Recurrent Dermatofibrosarcoma Protuberans

A patient with enormous recurrent dermatofibrosarcoma protuberans underwent modified three-dimensional histology surgery. Frozen-section examination was used to identify the margins. The patient had a normal postoperative course.