Dermatofibrosarcoma protuberans of the face: report of 2 cases and an overview of the recent literature

Darier-Ferrand dermatofibrosarcoma protuberans of the face: Case report and literature review

INTRODUCTION

Darier Ferrand Dermatofibrosarcoma (DFSP) is a rare skin tumor, characterized by its local aggressivity and high potential of recurrence. It affects mainly young and middle-aged adults. Its location in the head and neck region represents nearly 12.5 % of all DFSP.

CASE DESCRIPTION

We report a rare case of a 68-year-old patient who was treated for a DFSP of the cheek's lower part with reconstruction using a pectoralis major musculocutaneous flap. The postoperative course was uneventful and the aesthetic result was good.

DISCUSSION

DFSP is a tumor of intermediate malignancy. Its optimal management is based on complete surgical excision requiring various reconstruction procedures for large defects. The treatment of unresectable lesions remains difficult despite the targeted therapies proposed and the improvement of radiotherapy techniques.

CONCLUSION

The ideal management of a DFSP is based on surgical excision passing largely in healthy tissues. This situation requires early diagnosis and is the guarantee of disease-free survival without major sequelae in head and neck locations.

Giant dermatofibrosarcoma protuberans head and neck: a diagnostic dilemma

Dermatofibrosarcoma protuberans (DFSP) is rare, generally slow growing tumor, originating from dermal stem cell or undifferentiated mesenchymal cell. DFSP primarily occurs on the trunk and proximal extremities, with reported only 10-15% occurring in the head and neck region. There can be varied presentations of DFSP in atypical sites mimicking a benign appearance and history due to which diagnostic dilemmas can occur. The underlying malignancy needs to be unveiled by histopathology and immunohistochemistry which reveals bland spindle cells in sub epithelium arranged in whorled storiform pattern which was CD34+, suggestive of dermatofibrosarcoma protuberans. Surgical excision is the treatment of choice, wherever possible. We herein report two intriguing cases of DFSP in uncommon sites.

Dermatofibrosarcoma Protuberans of the Face

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive tumor with high rate of local recurrence but low metastatic potential. Its high-grade fibrosarcomatous variant and occurrence on the head and neck are rare findings associated with increased morbidity and mortality. The most significant prognostic feature of DFSP is obtaining tumor free surgical margins. As such, accurate recognition and proper management of this uncommon and locally aggressive malignancy is especially crucial in head and neck surgery.

Appearance of recurrent dermatofibrosarcoma protuberans in postoperative MRI follow-up

PURPOSE

To analyze the appearance of recurrent dermatofibrosarcoma protuberans (DFSP) in postoperative MRI follow-up and to assess the occurrence of postoperative soft tissue changes detected in MRI.

METHODS

A total of 464 MRI follow-up scans of 32 patients with histologically proven diagnosis of DFSP were analyzed. MR imaging was performed using a 1.5T MRI system. Recurrent DFSP was examined for signal intensity, contrast behavior, appearance, and extent in MRI.

RESULTS

The mean age of the patients was 44,5±17,1 years. Recurrences of DFSP occurred 26±23.3 months after primary tumor resection in the mean (Min.: 9, Max.: 60). In 25% of the patients (n = 8), recurrences of DFSP were detected. Recurrent DFSP most often showed a nodular and homogeneous configuration with well-defined borders and marked contrast enhancement, and a hyperintense signal in PD-weighted and turbo inversion recovery magnitude sequences. All recurrences were well detected in the follow-up MRIs regardless of the performed plastic surgery procedure. Lateral and depth margins had no significant impact on the local recurrence rate. In all, 88% of the patients developed subcutaneous tissue edema (p < 0.01), followed by muscle edema (34%, p = 0.02), and postoperative seroma (22%).

CONCLUSION

Recurrent DFSP mainly appear uniform and clearly delimitable on MRI as nodular, homogeneous, and well-defined lesions with marked contrast enhancement. Therefore, MRI is a valuable tool for postsurgical follow-up. Nearly all patients develop subcutaneous edema after the resection of DFSP.

Reconstructive strategies for dermatofibrosarcomas of the face: role of regenerative dermal templates

BACKGROUND

Dermatofibrosarcomas protuberans is a challenging cutaneous tumor from an oncologic and reconstructive surgical point of view. Involvement of functionally and aesthetically sensitive areas, such as facial units, in young patients accounts for more demanding cases. An updated evaluation of most beneficial excisional/reconstructive strategies in these cases is still lacking.

METHODS

We investigated the potential of regenerative dermal templates in staged postoncologic reconstructive management of a young woman affected by a dermatofibrosarcomas protuberans of the forehead involving the frontal bone.

RESULTS

Final result was optimal in terms of cosmetic and functional recovery, obtaining a pliability, softness, and color similar to surrounding healthy skin.

CONCLUSION

In facial dermatofibrosarcomas protuberans, staged reconstruction with regenerative dermal templates provides a conservative yet safe and effective management, achieving optimal aesthetic outcomes. We suggest its adoption as first-line treatment in facial dermatofibrosarcomas protuberans that cannot be repaired by direct suture and in equivalent benign yet challenging cases.

Imaging findings of head and neck dermatofibrosarcoma protuberans

BACKGROUND AND PURPOSE

Dermatofibrosarcoma protuberans is a rare, locally aggressive sarcoma of the skin in children and adults, usually involving the trunk and extremities and less commonly the head and neck. Despite clinical reports in the literature on the management of dermatofibrosarcoma protuberans, there are limited articles describing its imaging features.

MATERIALS AND METHODS

We retrospectively reviewed the demographics and imaging findings in all 24 patients with pathologically proven dermatofibrosarcoma protuberans of the head and neck seen at a tertiary cancer center between 2001 and 2010.

RESULTS

Twenty-two of the 24 lesions were nodular and well circumscribed; 19 of the 24 were located on the scalp. On imaging, all 24 lesions involved subcutaneous tissues. The lesions ranged in size from 0.6-9.5 cm (mean, 3.7 cm; standard deviation, 2.3 cm). Twelve lesions involved the soft tissues either at or extending directly to the midline. Thirteen lesions were associated with bulging of the skin surface. Fourteen lesions were imaged with CT and 14 with MR imaging. Whereas variable enhancement patterns were noted on CT and MR imaging, dermatofibrosarcoma protuberans was usually T2-hyperintense and demonstrated marked enhancement. None of the lesions was associated with bone invasion, perineural spread, or nodal/distant metastasis.

CONCLUSIONS

Knowledge of the imaging characteristics of dermatofibrosarcoma protuberans may alert neuroradiologists to include dermatofibrosarcoma protuberans in the differential diagnosis of lesions about the head and neck with similar imaging characteristics.

Half forehead reconstruction with a single rotational scalp flap for dermatofibrosarcoma protuberans treatment

Background

Dermatofibrosarcoma protuberans (DFSP) is a soft tissue neoplasm of intermediate to low-grade malignancy. Although metastasis rarely occurs, DFSP has a locally aggressive behavior with a high recurrence rate. In the head and neck area, resection involving a wide margin of healthy tissue can be difficult because of functional and cosmetic considerations. We describe a novel reconstructive method for half forehead defects with an innovative single local wide scalp flap following excision of DFSP with a 3 cm margin of healthy tissue.

Methods

Two patients underwent wide resection of forehead DFSP and reconstruction with a single rotational scalp flap. The scalp flap blood supply was provided from three main vessels: the superficial temporal artery, occipital artery and posterior auricular artery.

Results

No early or late complications were observed in either patient with no local recurrence after 18 months of follow-up. The donor area could be closed primarily in both cases and the flaps survived completely.

Conclusion

This innovative technique allowed a radical excision of forehead DFSP with sufficient healthy margins, thus potentially decreasing tumor recurrence rate. Reconstruction was achieved avoiding microsurgery, skin expanders and large skin grafts. Moreover, all main reconstructive criteria, such as functional and cosmetic tissue characteristics, were completely fulfilled.

Primary cutaneous malignancies in sub-Saharan Africa

Cutaneous malignancies are the most common malignancies in Whites; traditionally considered rare among Blacks, their occurrence in sub-Saharan Africa is yet to be fully characterized.Data on specimens submitted between 1992 and April 2008 on all histologically proven primary cutaneous malignancies were collected from the Pathology Department, including patient age, sex, anatomic site of malignancy, and histologic diagnosis. There were 1900 patients with primary cutaneous malignancies, aged between 8 months and 110 years, with a mean age of 49 years. There were 14 different types of malignancies found, with squamous cell carcinoma representing 45% of the total. A number of the rarer types have not been reported previously, from this region.Cutaneous malignancies in Africa present a number of management challenges including the following: difficulties in early diagnosis in the dark skin, late presentation, access to treatment, and the ability to pay for the appropriate treatment. The current human immunodeficiency virus/acquired immune deficiency syndrome scourge on the continent may lead a significant increase in cutaneous malignancies, posing even bigger challenges.

Dermatofibrosarcoma protuberans with fibrosarcomatous transformation of the head and neck

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous neoplasm associated with a high cure rate. We present a case of aggressive DFSP with fibrosarcomatous areas in the head and neck. A 28-year-old Mediterranean female presented with a 45-day history of rapidly growing cutaneous lesion of the face. Surgical biopsy confirmed the diagnosis of DFSP. Subsequently, the patient underwent wide local surgical resection, followed by reconstruction. Histopathology report revealed fibrosarcomatous transformation and the patient underwent adjuvant radiotherapy. The patient continues to be disease free at the 35-month follow-up.

Although DFSP behave as non-aggressive malignancy, surgery with complete removal of the affected area is the intervention of choice. Moreover, adjuvant treatment and follow-up of the patient is essential in order to prevent recurrence.

Dermatofibrosarcoma protuberans with contiguous infiltration of the underlying bone

Dermatofibrosarcoma protuberans (DFSP) is a rare, low-grade, cutaneous neoplasm with pronounced tendency for local recurrence. A case of DFSP that showed direct infiltration into the underlying bone marrow is described. To the best of our knowledge, such direct bony involvement by dermatofibrosarcoma has not been reported in the English literature to date. The role of imaging is also discussed for planning adequate initial treatment, which will result in a lower recurrence rate and improved clinical outcome.

Recurrent craniofacial dermatofibrosarcoma protuberans: long-term prognosis after close surgical removal

Dermatofibrosarcoma protuberans (DFSP) is a low-grade malignant neoplasm of the dermis that rarely manifests in the craniofacial area. In this retrospective analysis, we investigated the long-term survival of 7 patients with recurrent craniofacial DFSP. This study includes all patients in our department with recurrences of DFSP between 1989 and 2006. All patients were treated by radical surgery with 1-cm free safety margin in every direction and remained in routine long-term follow-up for tumor patients. Two of the 7 patients showed a local recurrence, which was again successfully treated surgically with the same technique. Advanced reconstruction with free full-thickness skin transfers, regional flaps, and forearm flaps, respectively, was required in 5 of the 7 patients. The other 2 patients were reconstructed locally. The long-term prognosis of craniofacial DFSP can be assessed optimistically even if the tumor already reoccurred. All 7 patients included in this study are still alive and so far not suffering from local recurrence. Advanced reconstructive techniques are often required in the management of reoccurring craniofacial DFSP. Late recurrences have been reported; therefore, a long-term follow-up for these patients should be considered.

[Skin tumours of the facial area]

Almost the complete spectrum of skin tumours can occur within the facial area, ranging from benign tumours of infancy to typical malignancies of old age. This spectrum is quiet heterogeneous and comprises every cell type within the skin as a possible origin for tumour growth. Among these are cells derived from the epidermis; adnexal structures; connective, fatty, and vascular tissue; muscle; nerves; melanocytes; and skin-infiltrating inflammatory cells. Due to this diversity, a correct assessment of the clinical findings compared with a histopathologic appraisal in cases of uncertainty is mandatory in order to recommend appropriate therapy. The present overview aims to summarise the basics of the most frequent and most important skin tumours occurring on the face.