Dermatofibrosarcoma protuberans of the breast: A case report

Wide local excision, Mohs micrographic surgery, and reconstructive options for treatment of dermatofibrosarcoma protuberans of the breast: A retrospective case series from Mayo Clinic

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) of the breast is a dermal fibroblastic neoplasm requiring wide excisional margins due to recurrence rates ranging from 26 to 60%. The current literature on reconstructive options and utility of Mohs micrographic surgery for DFSP of the breast is scarce. We describe surgical management of DFSP of the breast at our institution with the largest case series reported to date.

METHODS

A retrospective review was performed of women who underwent surgery for DFSP of the breast at our institution between 1990 and 2019. Continuous data was summarized using mean, median, and range; categorical data was summarized with frequency count and percentage. Preoperative lesion size and postoperative defect size were evaluated using 2-sided Fisher exact test, and p-values < 0.05 were considered statistically significant.

RESULTS

Nine patients underwent wide local excision (WLE) with reconstruction including pedicled latissimus dorsi flaps (n = 2), local flap advancement (n = 2), mastectomy with implant (n = 1), oncoplastic breast reduction (n = 1), and skin grafts (n = 3). Nine underwent Mohs micrographic surgery (MMS) with complex primary closure. Mean postoperative maximum wound defect size for WLE was 10.8 cm versus 7.0 cm for MMS with no statistical significance (p = 0.77). Mean preoperative maximum lesion size for WLE was 6.4 cm versus 3.3 cm for MMS with no statistical significance (p = 0.07). Complications with WLE included wound dehiscence in three patients and seroma in one patient. No complications were reported with MMS and primary closure. Recurrence was reported in one WLE patient, which was successfully detected despite flap coverage and resected without complications. Median follow-up for the patients without recurrence was 5.0 years, with two patients in MMS cohort lost to follow-up. Five-year overall survival was 100%.

CONCLUSIONS

MMS and WLE are both viable surgical options for managing DFSP of the breast. MMS could potentially minimize reconstructive needs due to smaller average defect size and result in fewer complications but may also result in asymmetry. Immediate flap reconstruction, especially in larger defects, can achieve excellent aesthetic outcomes for patients with DFSP of the breast without compromising detection of disease recurrence.

Dermatofibrosarcoma Protuberans Over Right Lumbar Region: A Case Report

Dermatofibrosarcoma protuberans is a rare, low-grade dermal soft-tissue tumor with a high propensity for recurrence but a low propensity for metastatic spread. It mostly affects the head, neck, proximal extremities, and trunk. We report a case of dermatofibrosarcoma protuberans over the right lumbar region. The patient presented with swelling in the right lumbar region measuring 3 cm × 3 cm. The local region ultrasonography (USG) revealed a well-defined hypoechoic lesion in the subcutaneous area. The patient was provisionally diagnosed with a peripheral nerve sheath tumor under evaluation. USG-guided fine needle aspiration cytology (FNAC) suggested a spindle cell tumor. Wide local excision of the tumor was performed. Monomorphic spindle cells in a storiform pattern were observed by histological evaluation. The neighboring adipose tissue was invaded by the tumor cells in a honeycomb-shaped pattern. The histological features were suggestive of Dermatofibrosarcoma Protuberans. Due to the high likelihood of recurrence, it is crucial to monitor these patients for an extended period of time.

Breast Imaging Findings in Dermatofibrosarcoma Protuberans: A Case Report and Review of Literature

Dermatofibrosarcoma protuberans (DFSP) is a rare, indolent, cutaneous sarcoma originating in the dermis, and although nearly half of cases occur on the trunk, DFSP of the breast is exceedingly rare, and imaging findings may resemble primary breast neoplasms. In this case report, a previously healthy, middle-aged female patient presented to the clinic with the complaint of abnormal growth in her left breast, which had been gradually increasing in size over the course of four years. Imaging of the left breast demonstrated a large, exophytic, partially intradermal mass with internal vascularity, raising concern for a primary breast neoplasm. Ultrasound-guided core needle biopsy revealed a diagnosis of DFSP. She underwent successful left skin- and nipple-sparing mastectomy with complete resection of the mass with negative margins confirmed on surgical pathology. Recognizing key features of DFSP on conventional breast imaging modalities, such as mammography and ultrasound, can be helpful in differentiating DFSP from primary breast neoplasms, but imaging findings alone may be nonspecific and biopsy is necessary for a definitive diagnosis. On mammography, DFSP typically presents as an exophytic, gently lobulated, non-calcified, and circumscribed mass. On sonographic examination, DFSP appears as a circumscribed, parallel-oriented mass that is hypoechoic relative to the surrounding fat, with intervening echogenic bands, posterior acoustic enhancement, and intralesional hypervascularity visualized on color Doppler. Although DFSP is slow-growing with a low incidence of metastatic disease, it has a high local recurrence rate and aggressive local resection is necessary to minimize the chance of recurrence.

DFSP of the Breast: Histomorphological, Immunohistochemical, and Molecular Features of a Rare Case in an Unusual Location

We present a case of a 21-year-old female with a vague nontender mass in the lower inner quadrant of the left breast discovered incidentally on chest imaging following trauma. A breast ultrasound demonstrated an 8×6×8 mm irregular hyperechoic mass at the 7 o'clock position of the left breast, 9 cm from the nipple. The mass was graded Breast Imaging Reporting and Data System (BI-RADS) category 4 (suspicious finding). An ultrasound-guided biopsy of the mass showed a proliferation of monotonous spindled cells in a storiform pattern with tapered nuclei with infiltration into the adipose tissue. No normal breast elements were identified in the biopsy. Myofibroblastoma was the first differential diagnosis; however, the characteristic infiltrative pattern of the tumor mandated additional tests including fluorescence in situ hybridization to rule out a dermatofibrosarcoma protruberance (DFSP). Immunohistochemical staining showed positive staining for CD34, which can be positive in myofibroblastoma also. However, fluorescence in situ hybridization demonstrated a platelet-derived growth factor B (22q13.1) gene rearrangement confirming a diagnosis of DFSP. The patient underwent a wide local excision of the DFSP for definitive treatment. She is doing well with no recurrence reported so far, after 15 months of follow-up. Conventional DFSP does not metastasize but is prone to recurrence making wide margins imperative for definitive treatment.

Dermatofibrosarcoma protuberans of the breast: A case study

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

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 Mimicking Primary Breast Neoplasm: A case report and literature review

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing mesenchymal neoplasm of the dermis and subcutaneous tissues that has a low-to intermediate-grade malignancy. DFSP commonly involves the trunk and extremities, and very rarely the breast skin, mimicking a primary breast neoplasm with few reported cases in the literature. We report a 35-year old female patient who was referred to the Royal Hospital, Muscat, Oman in 2017, with a two-year history of a slow growing left breast lump. Assessment of the breasts with mammography revealed a lobulated lesion in the left-upper-inner quadrant with neither microcalcification nor architectural distortion, mimicking a benign lesion. However, on ultrasound, the lesion had suspicious features with increased vascularity and hence, it was categorised as breast imaging reporting and data system (BIRAD) IV. The patient underwent left breast wide local excision and the histopathological diagnosis was dermatofibrosarcoma protuberans.

COL1A1-PDGFB fusion uterine fibrosarcoma: A case report with treatment implication

COL1A1-PDGFB gene fusion associated uterine sarcoma, so called dermatofibrosarcoma-like tumor, a recently reported entity in the uterine corpus, morphologically appears as high grade sarcoma with some features of dermatofibrosarcoma. So far only one other case has been reported in the uterine corpus and two in the uterine cervix. Identification of this gene fusion allows greater choice of targeted therapy in these patients. All the reported cases in the mullerian system are found to be CD34 positive by immunohistochemistry, a commonly used antibody in most immunohistochemistry laboratories. We would, therefore, propose routine CD34 immunohistochemical staining in all high grade uterine sarcomas which have failed other common immunohistochemical markers.

Dermatofibrosarcoma of The Breast - Case Report and Review of Literature

Dermatofibrosarcoma protuberans is a rare form of soft tissue sarcoma that tends to invade and recur locally. The most common site of this disease is head, neck and extremities; however, the involvement of the breast has been reported. We present a case with a dermatofibrosarcoma of the breast that is composed of low-grade spindle cells which are positive for CD43. She was treated by wide surgical excision followed by adjuvant external beam irradiation at a dose of 60 Gray. After a follow-up of 24 months, no local-regional or distant recurrence was detected.