Fibrosarcomatous dermatofibrosarcoma protuberans: a rapidly growing 30 cm mass on the posterior scalp

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing sarcoma of the skin and subcutaneous tissue, accounting for around 5 cases per million per year. Fibrosarcomatous transformation of DFSP occurs in 10%-15% of DFSP cases, with a higher risk of local recurrence, metastasis, and death. We present a case of a male in his 30s with a complaint of rapidly progressive mass in the occipital region of the head. Within 1 year, the mass enlarged by >30 cm. Physical examination revealed a skin-colored 40×30 cm mass with an overlying skin necrosis at the posterior scalp. Brain, neck, and chest computed tomography (CT) scans were performed. The mass was surgically excised by wide excision with a 2 cm margin. Pathological report confirmed fibrosarcomatous DFSP Grade 3 with decreased CD34 expression. Delayed reconstruction of free flap and split-thickness skin graft were subsequently performed. No recurrence was detected 3 months postoperatively.

3D-printed Model and guide plate for accurate resection of advanced cutaneous squamous cell carcinomas

Purpose

Advanced cutaneous squamous cell carcinomas (cSCC) can have unclear borders, and simple expanded resection may not only destroy surrounding normal tissues unnecessarily, but can also leave residual tumor cells behind. In this article, we describe a new method for resection and evaluate its accuracy.

Methods

The magnetic resonance imaging (MRI) data of 12 patients with advanced cSCC were reconstructed to obtain three-dimensional (3D) tumor models and guide plates for surgeries. Thirty-eight patients with the same cSCC stage, who underwent expanded resection, were included. The distances between the upper, lower, left and right horizontal margins and tumor pathological boundaries were classified as "positive", "close" (0-6 mm), "adequate" (6-12 mm) or "excessive" (>12 mm). The positive margin rate and margin distance were compared between the groups.

Results

The 3D tumor models of 12 patients were all successfully reconstructed. The positive rate of 48 surgical margins in the guide plate group was 2.1%, and the proportion of "adequate" margins was 70.8%. A total of 152 margins of 38 patients were included in the extended resection group, for which the positive rate was 13.8%; this was higher than that of the guide plate group (P = 0.045). The proportion of "adequate" margins was 27.6%, with group differences seen in the distance distribution (P < 0.01).

Conclusions

In surgical resection of advanced cSCC, compared with simple expanded resection, surgical planning using a 3D tumor model and guide plate can reduce the rate of horizontal surgical margins, and the probability of under- or over-resection.Clinical Trial Registration: http://www.chictr.org.cn, Identifier [No. ChiCTR2100050174].

Dermatofibrosarcoma protuberans in dermatological practice. Case report

Dermatofibrosarcoma protuberans (DFSP) is a mesenchymal neoplasm of fibrohistiocytic origin of moderate malignancy. The pathogenesis of DFSP involves chromosomal translocation, which leads to the formation of a fusion protein that promotes tumor growth due to increased production of platelet growth factor (PDGF). Clinically, it begins with an asymptomatic fibrous papule or firm plaques, which gradually over the course of several years become enlarged with the formation of asymmetrical multi-nodular structure of purple or red-brown color. The standards of diagnosis is a histological examination with the detection of a poor limited infiltrate indermis of a storiform architecture consisting of monomorphic spindle cells and diffuse CD34+ staining during immunohistochemistry. Complete surgical excision is considered the gold standard of treatment. Clinical case: female patient, 35 years old with a lesion in the form of a dense plaque in right subclavian area was examined by a dermatologist. The primary diagnosis was made as "morphea". In a year a slight growth of the lesion and the appearance of small firm nodules asymmetrically along the periphery were noted. According to the results of histological and immunohistochemistry studies the diagnosis of DFSP was made, the patient was referred to an oncologist for complete tumor removal.

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.

Imaging in Soft Tissue Sarcomas: Current Updates

Soft tissue sarcomas (STS) are heterogeneous malignant tumors that have nonspecific imaging features. A combination of clinical, demographic, and imaging characteristics can aid in the diagnosis. Imaging provides important information regarding the tumor extent, pretreatment planning, and surveillance of patients with STS. In this article, we illustrate the pertinent imaging characteristics of the commonly occurring STS and some uncommon sarcomas with unique imaging characteristics.

A rare case of dermatofibrosarcoma protuberans of the forefoot

Dermatofibrosarcoma protuberans is an extremely rare, potentially malignant tumor type that usually presents on the trunk or proximal extremities. The clinical presentation includes a gradually enlarging painless plaque-like or nodular lesion of the skin with surrounding red to blue discoloration. The diagnosis is based on clinical presentation, computed tomography or magnetic resonance imaging, and biopsy with histologic analysis. An early and timely diagnosis improves chances of complete surgical resection thus improving prognosis. Herein, we present a rare case of dermatofibrosarcoma protuberans with the hopes that its addition to the literature will aid in the earlier recognition of future patients and help prevent this potentially curable disease from becoming deadly.

Soft-Tissue Sarcomas: An Update for Radiologists Based on the Revised 2013 World Health Organization Classification

OBJECTIVE

Soft-tissue sarcomas are a diverse group of malignancies, and our rapidly improving understanding of their molecular pathogenesis and treatment is leading to better clinical outcomes. The revised 2013 World Health Organization (WHO) classification of soft-tissue sarcomas introduced several important changes. We provide a comprehensive overview of the relevant changes for radiologists.

CONCLUSION

Rapid advances in the understanding of the pathogenesis and molecular biology of soft-tissue sarcomas led to major revisions in the 2013 WHO classification. To provide optimal multidisciplinary patient care, radiologists must remain up-to-date with the latest developments in the field of soft-tissue sarcomas to best correlate the histologic and imaging features of the various types of tumors and understand the unique patterns of treatment response and disease recurrence.

An introduction to primary skin imaging

Dermatology is a field in which clinical examination is heavily relied upon for diagnosis. When required, a tissue biopsy may also be performed to confirm the diagnosis. Recent advances in imaging techniques have been applied to cutaneous lesions to improve diagnostic accuracy without the need for biopsy. These new imaging techniques are reviewed for their developing role in dermatology.

Computed tomographic and pathological findings of dermatofibrosarcoma protuberans

OBJECTIVE

The aim of the study was to investigate the computed tomographic (CT) and pathological findings of dermatofibrosarcoma protuberans to improve the awareness and understanding of the tumors from aspect of CT images.

METHODS

The CT findings of 16 cases (17 tumors) with dermatofibrosarcoma protuberans confirmed by pathological findings were retrospectively selected. Fourteen cases were primary dermatofibrosarcoma protuberans, 2 cases were recurrent tumors. Thirteen patients had CT plain and enhanced scans, 1 patient had direct enhanced CT scan, 2 patients had only unenhanced scan. Images of the tumors were analyzed and compared with pathological results.

RESULTS

Of the 16 cases (17 tumors total), 9 cases were on the trunk, 7 cases were on the head and the neck; 15 cases appeared as solitary isohypodense, ovoid, or round mass at the cutaneous and subcutaneous tissue, 1 case demonstrated 2 isodense masses on unenhanced CT images. The mean diameter of tumors was 4.0 cm, and the depth was 1.7 cm. The margin was well defined (n = 15 [88.2%]) or ill defined (n = 2 [11.8%]). Fifteen tumors revealed moderate or marked homogeneous (n = 12 [80%], smaller lesion, diameter <5 cm) or heterogeneous (n = 3 [20%], larger lesion, diameter ≥5 cm) enhancement on enhanced CT with intratumoral nonenhancement areas, which indicated intratumoral necrotic and cystic degeneration areas. No calcifications and metastasis were found. The histological examinations revealed large amounts of uniform spindle cells, which were arranged in "storiform" pattern. Immunohistochemical analysis revealed samples positive for CD34 and vimentin.

CONCLUSION

The common imaging findings of dermatofibrosarcoma protuberans include a solitary, superficial, subcutaneous solid mass, various homogenous or heterogeneous enhancements due to degenerative areas. Computed tomographic scan is helpful to detect the size, location, depth and range of this tumor.

Correlation between preoperative magnetic resonance imaging and surgical margins with modified Mohs for dermatofibrosarcoma protuberans

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is characterized by asymmetrical and poorly defined growth. Magnetic resonance imaging (MRI) has been proposed for the delimitation of this tumor.

OBJECTIVES

To study the utility of MRI in evaluating the depth of infiltration in DFSP and to compare the efficiency of clinical palpation with that of MRI in delimiting the invasiveness of DFSP.

METHODS

Observational, prospective study of DFSP cases. The MRI scans for all cases were compared with the exact histological infiltration plane obtained using modified Mohs micrographic surgery (MMS).

RESULTS

Forty-three DFSPs were included: 22 primary, nine recurrent, and 12 extirpated with positive margins. Sensitivity for detecting deep invasion was 58% on examination using palpation and 67% using MRI.

CONCLUSIONS

We present the largest series of DFSP cases studied using MRI published to date. In primary cases, MRI has greater sensitivity than palpation for detecting depth of infiltration (67% vs 58%). MRI seems to be useful in primary DFSP in locations other than the head, neck, and upper part of the thorax. MRI is not useful for confirming tumor persistence in extirpated DFSP with positive margins or for studying lateral extension in primary DFSP.