Introduction
In 1924, Darier and Ferrand (1) first reported a case of progressive and
recurrent dermatofibroma. One year later, Hoffman (2) described the tendency of the
dermatofibroma tumor to develop into protruding nodules and termed
the condition dermatofibrosarcoma protuberans (DFSP). In 1962,
Taylor and Helwig (3) analyzed the
histological characteristics of DFSP and in 1992 it was discovered
that immunopositivity for CD34 correlated with negative
immunostaining for factor XIIIa (4,5). Then,
in 1997, Simon et al (6)
identified that a translocation between chromosome 17 and 22 was
the distinguishing cytogenetic alteration in neoplastic tissues
responsible for the development of DFSP.
DFSP is classified as a rare tumor, however, it may
be considered as the most common stromal tumor of cutaneous origin
(7). Numerous epidemiological
studies in the USA have reported a mean annual incidence rate
between 0.8 and 4.5 cases per million individuals (8–10).
Rutgers et al (11) reviewed
902 DFSP cases and identified a 3:2 incidence ratio of males to
females. However, Criscione and Weinstock (12) studied 9 population-based cancer
registries with a total of 2,885 DFSP cases and reported a higher
incidence in females. It has also been found that DFSP has a higher
incidence rate among individuals aged between 20 and 50 years
(13); however, several studies
have reported more than 160 pediatric cases of acquired DFSP and
more than 35 congenital cases (7,14–19).
In addition, it has been demonstrated that giant cell fibroblastoma
is the juvenile form of dermatofibroblastoma arising in childhood
(20).
Materials and methods
Patient data
A retrospective study was conducted in our
Department of Plastic and Reconstructive Surgery and all data were
collected from medical records of 59 DFSP patients within this
department from 1999 to 2011 (Table
I). The histopathological diagnosis and immunohistochemical
studies were conducted by the Department of Anatomical Pathology
within the same hospital. Each medical record included the age,
gender, tumor location and presentation, clinical features,
treatment modality, histopathological report, closure type and
prognosis of each patient. Informed consent was obtained from each
patient.
| Table ISummary of 59 cases of
dermatofibrosarcoma protuberans between 1999 and 2011. |
Table I
Summary of 59 cases of
dermatofibrosarcoma protuberans between 1999 and 2011.
Patient no. | Date of
diagnosis | Age (years) | Gender | Location | Presentation | Clinical
features | Surgical
modality |
Immunohistochemistry and cytogenetic
results | Closure type | Recurrence or
surgical revision |
---|
1 | 21/04/1999 | 20 | M | Back | On prior scars | Morphea-like | WE | CD34+
Vimentin+ | 1 closure | No |
2 | 19/05/2000 | 30 | F | Left arm | On apparently
normal cutis | Morphea-like | WE | CD34+ Actin
1A4-Vimentin+ | Local flap | Surgical
revision |
3 | 23/09/2000 | 30 | M | Abdomen | On apparently
normal cutis | Protruding | WE | CD34+
Vimentin+ | 1 closure | No |
4 | 03/10/2000 | 9 | F | Left ankle | On prior surgical
scar | Protruding
DFSP | WE | CD34+ | 1 closure | No |
5 | 03/10/2000 | 68 | F | Left shoulder | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | Local flap | No |
6 | 03/11/2000 | 54 | F | Forehead and root
of the nose | On prior
fronto-temporal | Morphea-like,
protruding DFSP fibrosarcoma | CE | CD34+
Vimentin+S100- | Local flap | Recurrence |
7 | 06/11/2000 | 60 | F | Right inguinal
region | On prior surgical
scar | Protruding
DFSP | WE | CD34+
Vimentin+CD68+ | 1 closure | No |
8 | 27/01/2001 | 57 | F | Right
supraclavicular region | On apparently
normal cutis | Protruding
DFSP | CE | CD34+ | 1 closure | Surgical
revision |
9 | 26/06/2001 | 36 | F | Right flank | On apparently
normal cutis | Morphea-like | CE | CD34+ CD68- | 1 closure | Recurrence |
10 | 04/07/2001 | 34 | M | Left thigh | On apparently
normal cutis | Protruding
DFSP | WE | CD34- | Graft | No |
11 | 29/10/2001 | 14 | F | Left leg | On apparently
normal cutis | Morphea-like | WE | CD34+ | 1 closure | No |
12 | 09/05/2002 | 27 | F | Left shoulder | On apparently
normal cutis |
Atrophoderma-like | CE | CD34+ | 1 closure | Surgical
revision |
13 | 30/09/2002 | 32 | F | Back | On prior surgical
scar | Protruding
DFSP | WE | CD34+
S-100+ | 1 closure | No |
14 | 10/12/2002 | 66 | M | Scalp | On prior actinic
keratosis |
Atrophoderma-like | WE | CD34+ Actin
1A4+ | 1 closure | No |
15 | 28/12/2002 | 34 | | Right
supraclavicular region | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ CD68- | Local flap | No |
16 | 10/01/2003 | 24 | M | Right cheek | On apparently
normal cutis | Protruding
DFSP | CE | CD34+
Vimentin+ | Local flap | No |
17 | 03/02/2003 | 57 | M | Nape | On apparently
normal cutis | Protruding
DFSP | WE | CD34+
Vimentin+Actin 1A4-EMA-CD31+ Factor VIII+CD99+ Bcl-2+ | 1 closure | No |
18 | 21/03/2003 | 64 | F | Right leg | On prior blue nevus
and lentigo simplex | Pigmented DFSP | WE | Hemosiderin+
CD34+S-100− | 1 closure | No |
19 | 07/04/2003 | 67 | M | Right foot | On apparently
normal cutis | Morphea-like | WE | CD34+ | 1 closure | No |
20 | 28/04/2003 | 28 | F | Left breast | On apparently
normal cutis | Pigmented DFSP | WE | CD34+ Actin
1A4+S-100- | Local flap | No |
21 | 06/05/2003 | 54 | F | Left breast | On apparently
normal cutis | Protruding
DFSP | WE | CD34+
S-100− | Local flap | No |
22 | 16/06/2003 | 14 | F | Left shoulder | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | No |
23 | 23/06/2003 | 26 | F | Left arm | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | No |
24 | 03/07/2003 | 21 | F | Right thigh | On apparently
normal cutis | Pigmented DFSP | WE | CD34+ | Graft | No |
25 | 21/07/2003 | 26 | F | Left shoulder | On apparently
normal cutis | Protruding
DFSP | WE | CD34+
Vimentin+ | Local flap | No |
26 | 11/08/2003 | 18 | M | Right forearm | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | No |
27 | 17/09/2003 | 24 | M | Right arm | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ Actin
1A4+Desmin, CK- | 1 closure | No |
28 | 27/10/2003 | 39 | F | Abdomen | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | No |
29 | 24/03/2004 | 19 | F | Right arm | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | No |
30 | 05/08/2004 | 28 | M | Chest | On apparently
normal cutis | Morphea-like | WE | CD34+ | 1 closure | Surgical
revision |
31 | 18/09/2004 | 25 | M | Left leg | On apparently
normal cutis | Ulcerated
protruding DFSP | WE | CD34+Actin 1A4+
Bcl-2+ | 1 closure | No |
32 | 21/10/2004 | 19 | F | Scalp | On prior surgical
scar | Ulcerated
protruding DFSP | WE | CD34+ Actin
1A4-S-100- | 1 closure | No |
33 | 12/05/2004 | 19 | F | Left shoulder | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | No |
34 | 05/01/2005 | 23 | F | Chest | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | Surgical
revision |
35 | 08/04/2005 | 52 | F | Left laterocervical
region | On apparently
normal cutis | Protruding
DFSP | CE | CD34+ | 1 closure | Surgical
revision |
36 | 12/04/2005 | 43 | F | Left inguinal
region | On prior surgical
scar | Protruding
DFSP | WE | CD34+ | Local flap | No |
37 | 10/05/2005 | 37 | M | Left shoulder | On apparently
normal cutis | Morphea-like | CE | CD34+ | 1 closure | Surgical
revision |
38 | 14/10/2005 | 31 | M | Right inguinal
region | On apparently
normal cutis | Morphea-like | CE | CD34+ | 1 closure | Surgical
revision |
39 | 11/02/2006 | 56 | F | Abdomen | On apparently
normal cutis | Morphea-like | WE | CD34+ | 1 closure | No |
40 | 01/04/2006 | 32 | M | Right arm | On apparently
normal cutis | Protruding
DFSP | WE | CD34+
Vimentin+CD163-Actin 1A4- | 1 closure | No |
41 | 20/12/2006 | 29 | M | Abdomen | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | No |
42 | 06/02/2007 | 28 | F | Left arm | On apparently
normal cutis | Pigmented DFSP | WE | CD34+ | 1 closure | No |
43 | 12/03/2007 | 52 | F | Left scapular
region | On apparently
normal cutis | Morphea-like | CE | CD34+
S-100− | 1 closure | Surgical
revision |
44 | 26/06/2007 | 63 | M | Left arm | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | No |
45 | 16/11/2007 | 37 | M | Abdomen | On apparently
normal cutis | Morphea-like | WE | CD34+ | 1 closure | No |
46 | 09/01/2008 | 37 | F | Left arm | On apparently
normal cutis |
Atrophoderma-like | WE | CD34+ | 1 closure | No |
47 | 29/02/2008 | 37 | F | Right arm | On pigmented
cutis | Pigmented DFSP | WE | CD34+ | Graft | No |
48 | 19/03/2008 | 69 | F | Right shoulder | On apparently
normal cutis | Protruding
DFSP | WE | CD34+
S-100−Actin 1A4− | 1 closure | No |
49 | 30/03/2009 | 53 | M | Right thigh | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | Graft | No |
50 | 28/07/2009 | 57 | M | Scalp | On apparently
normal cutis | Protruding
DFSP | WE | CD34+
CD31-Desmin- | 1 closure | No |
51 | 04/12/2009 | 29 | M | Left cheek | On apparently
normal cutis | Protruding
DFSP | CE | CD34+
CD117+CD31-CD68-CD163- | Local flap | Surgical
revision |
52 | 23/12/2009 | 35 | F | Vulva | On apparently
normal cutis | Protruding
DFSP | CE | CD34+ | 1 closure | No |
53 | 29/04/2010 | 33 | F | Palpebral
commissure | On apparently
normal cutis | Protruding
DFSP | CE | CD34+ | Local flap | No |
54 | 20/07/2010 | 43 | F | Left thigh | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ CD68+ | Graft | No |
55 | 24/12/2010 | 42 | M | Left arm | On apparently
normal cutis | Pigmented DFSP | WE | CD34+ | 1 closure | No |
56 | 15/03/2011 | 32 | F | Gluteus | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | Local flap | No |
57 | 20/05/2011 | 1 | F | Left flank | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | Surgical
revision |
58 | 04/08/2011 | 47 | M | Temporal
region | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | Local flap | No |
59 | 04/10/2011 | 64 | M | Left shoulder | On apparently
normal cutis | Protruding
DFSP | WE | CD34+ | 1 closure | No |
Methods
Surgical treatment was achieved by performing
conventional and wide excision. Conventional surgery was adopted in
areas where wide excision would have been difficult to perform,
including the root of the nose, vulva, cheek and palpebral
commissure. The mean margin used in this type of treatment was 1.07
cm. The majority of cases treated were subjected to wide excision
with a mean margin of 3.4 cm. Both surgical options were performed
by removing the skin, subcutaneous tissue and superficial
fascia.
All specimens excised were subjected to formalin
fixation and sectioning to confirm the tumor-free margins and
histopathological positivity. The immunohistochemical stainings
adopted in this study included: CD34 antigen (clone, QBEnd/10, NCL;
Novacastra), Vimentin (clone, V9; Thermo Scientific), ACTML, Van
Gieson, hematoxylin and eosin, Protein S100 (clone, 4C4.9; Thermo),
CD68 (clone, KP1; NCL) and Perl's iron staining.
Follow up
Patient follow-up for recurrences ranged from 3 to
120 months with a mean follow-up time of 62 months. A variety of
surgical techniques were adopted for the most suitable wound
closure, including primary intention, local flaps or grafting.
No patient within this study had been treated with
chemotherapy or radiation prior to treatment at our institution,
and no additional adjuvant treatments were performed.
Results
Clinical and surgical data are presented in Tables I–III. As demonstrated in Table II, the mean patient age at time of
diagnosis was 37 years (71% of cases were <50-years-old and 29%
of cases were >50-years-old), and the majority of cases
presented were female (61%). The tumor was located on the trunk,
upper extremities, lower extremities and head and neck region in
49, 20, 15 and 16% of cases, respectively. The protruding form of
DFSP was the most frequent clinical variety presented, occurring in
66% of all cases. Notably, 17% of patients reported a prior
alteration of the cutis, including previous wounds, surgical scars,
actinic keratosis, blue nevus and lentigo simplex. Additionally, no
cases presented were recurrent at the time of their initial
diagnosis.
| Table IIICorrelation between excision modality
and prognosis. |
Table III
Correlation between excision modality
and prognosis.
| No. of cases
treated
| |
---|
Prognosis | Conventional
excision (%) | Wide excision
(%) | Total (%) |
---|
Tumor free | 3 (5) | 43 (73) | 46 (78) |
Surgical
revision | 8 (14) | 3 (5) | 11 (19) |
Tumor
recurrence | 2 (3) | 0 (0) | 2 (3) |
Total | 13 (22) | 46 (78) | 59 (100) |
| Table IIClinical features of 59 DFSP
patients. |
Table II
Clinical features of 59 DFSP
patients.
Clinical
features | No. of cases | Total cases
(%) |
---|
Gender | | |
Male | 23 | 39 |
Female | 36 | 61 |
Age at
diagnosis | | |
Mean age
(years) | 37 | - |
<50-years-old | 42 | 71 |
>50-years-old | 17 | 29 |
Clinical
presentation | | |
Morphea-like | 11 | 19 |
Atrophoderma-like | 3 | 5 |
Angioma-like | 0 | 0 |
Protruding
DFSP | 39 | 66 |
Pigmented
DFSP | 6 | 10 |
Location | | |
Trunk | 29 | 49 |
Upper
extremities | 11 | 20 |
Lower
extremities | 9 | 15 |
Head and neck
region | 10 | 16 |
Presentation | | |
On apparently
normal cutis | 49 | 83 |
On
pigmented/prior altered cutis | 10 | 17 |
A total of 13 of 59 (22%) cases were treated with
conventional excision due to the difficult location of the tumor
(Table III). Following surgery, 3
(5%) cases had tumor-free margins, 8 (14%) cases required surgical
revision and 2 (3%)cases lead to recurrence. Although conventional
excision may lead to a higher recurrence rate (as demonstrated by
this study), in certain cases prognosis may be positively affected
by this treatment option. The remaining 46 (78%) cases were treated
with wide excision. No patient developed recurrences and only 3
(5%) cases required surgical revision. Additionally, no patient
referred to in Tables I–III presented metastatic disease.
Discussion
The main etiological factor in the development of
DFSP is the presentation of several prior traumas, including
surgical scars (21), trauma scars
(22), burns (23), radiodermatitis (24), vaccination sites (25), sites of central venous lines
(26) and insect bites (27).
The most common anatomical site affected by DFSP is
the trunk (42–72%), with the majority of cases found on the chest
and trunk. A total of 16 to 30% of DFSP cases are located on the
proximal extremities (particularly on the legs) and up to 16% of
cases affect the head and neck areas (7,13).
Clinically, DFSP behaves as a slow-growing
asymptomatic plaque and consequently, the majority of patients
consult their doctors at a late stage (13). Initially, the neoplasm presents as a
violaceous reddish-brown or pink indolent plaque with a hard
consistency; at this stage the lesion may be misinterpreted as a
hypertrophic scar. Over time, the tumor diffusely infiltrates the
deep layers of the skin and the dermis, which leads to the
development of several multiple nodules, which are indurated to
palpation and adherent to the surrounding tissues, including the
subcutaneous fat, fascia, muscle, periosteum and bone.
Martin et al (28) distinguished three clinical forms of
non-protruding DFSP: morphea-like, atrophoderma-like and
angioma-like (Table IV). However,
the most frequent presentation described in adults is a large
plaque presenting multiple nodules on its surface.
| Table IVClinical variants of the
preprotuberant stage of DFSP as described by Martin et al
(25). |
Table IV
Clinical variants of the
preprotuberant stage of DFSP as described by Martin et al
(25).
Variant | Clinical
features | Onset |
---|
Morphea-like | White or brown
indurated plaque appearing as a scar, morphea, morpheaform basal
cell carcinoma or dermatofibroma plaque | Childhood |
Atrophoderma-like | Soft depressed
white or brown plaque similar to atrophoderma or anetoderma | Congenital |
Angioma-like | Indurated red or
violaceous plaques with clinical appearance similar to vascular
malformations or angiomas | Uncommon |
DFSP is characterized by a low rate of metastasis
and an eccentric growth rate, which may determine a high level of
local invasion. It was found that conventional surgery leads to
local recurrence in up to 30% of cases (13).
Kim (29) described
seven histological DFSP subtypes of which 90% of cases are
represented by ‘classic’ DFSP (Table
V). Histologically, the ‘classic’ subtype of DFSP appears as a
well-differentiated fibrosarcoma initially located on the dermis.
The neoplasm is composed of a poor stroma with a dense growth of
monomorphous fusiform cells and a large elongated nucleus
characterized by little pleomorphism and a low mitotic index. In
addition, spindle cells are irregularly organized in linked
fascicles with a storiform arrangement. Taylor and Helwig (3) reported a typical diagnostic pattern of
DFSP, which is represented by a cartwheel arrangement where cells
are arranged radially around a central acellular collagenous
area.
| Table VHistological subtypes of DFSP as
described by Kim (29). |
Table V
Histological subtypes of DFSP as
described by Kim (29).
Subtype | Histological
characteristics | Clinical
features |
---|
‘Classic’ DFSP | Monomorphous
fusiform cells (spindle cells) with large elongated nucleus and
poor cytoplasm, low mitotic index | Most common subtype
(90%)
Rare metastasis (≤0.5%) |
Giant cell
fibroblastoma | Giant
multinucleated cells, sinusoidal vessels, myxoid stroma | Frequently observed
in childhood |
Bednar tumor | Melanocytes and
deposits of melanin | Observed in African
and American patients |
Sclerotic DFSP | Abundant stroma
with several layers of collagen and areas of denser
cellularity | Rare subtype |
Myxoid DFSP | Spindle cells
grouped in nodules with eosinophilic cytoplasm | Rare subtype |
Atrophic DFSP | Atrophic mid-dermis
with subcutaneous tissue close to the epidermis | Frequently observed
in childhood |
Fibrosarcomatous
DFSP | High mitotic index
with high cellularity and marked nuclear pleomorphism | Subtype with the
highest recurrence rate and metastatic potential, most aggressive
variant |
DFSP has the tendency to expand from the central
focus and invade the surrounding tissues. The tentacle-like
projections invade the septa and fat lobules and adopt a honeycomb
(30%) or multilayered (70%) subcutaneous pattern (30,31).
In both patterns, tentacle-like projections can be inadvertently
omitted during wide excision, determining a possible cause of tumor
recurrence followed by fascia, muscle and bone invasion.
The first immunohistochemical marker identified for
DFSP was the CD34 antigen. It is expressed in up to 90% of cases,
differentiating DFSP from other fibrohistiocytic tumors (32,33)
(Table VI). Previous studies have
revealed that CD34 is also expressed by other sarcomas and benign
fibrohistiocytic lesions, including solitary fibrous tumor
(34), sclerotic fibroma (35), superficial acral fibromyxoma
(36), cellular digital fibromas
(37), dermatofibromas (38) and nuchal-type fibroma (39). Consequently, CD34 may be considered
as a non-specific marker for DFSP. Other immunohistochemical
markers, including factor XIIIa, stromelysin III, apolipoprotein D
and CD163, have been found to be positive in dermatofibromas and
negative in DFSP (13,39–41).
Bandarchi et al (42) also
reported that D2-40 may be used as a marker for the differential
diagnosis between DFSP and dermatofibroma (Table VI).
| Table VIImmunohistochemical markers used for
differential diagnosis of DFSP. |
Table VI
Immunohistochemical markers used for
differential diagnosis of DFSP.
Marker | Expressed | Not expressed |
---|
CD34 | DFSP, inflammatory
fibrosarcoma, myofibrosarcoma, angiosarcoma, epithelioid
sarcoma | Dermatofibroma,
malignant fibrous histiocytoma, pediatric myofibromatosis,
fibrosarcoma, hypertrophic scars or keloids |
Factor XIIIa | Dermatofibroma | DFSP |
Stromelysin
III | Dermatofibroma | DFSP |
Apolipoprotein
D | Dermatofibroma | DFSP |
CD163 | Dermatofibroma | DFSP |
D2-40 | Dermatofibroma | DFSP |
Molecular biology techniques, including
reverse-transcriptase polymerase chain reaction and fluorescent
in situ hybridization, have revealed that DFSP is
characterized by supernumerary ring chromosomes or a reciprocal
translocation between chromosome 17 and chromosome 22 t(17;22)
(q22;q13) (6,43). This translocation involves the
collagen type 1 α 1 (COL1α1) gene located on chromosome 17 and the
PDGFβ gene located on chromosome 22. In DFSP, COL1α1 is highly
expressed and acts as an inducer of gene transcription (44). COL1α1-PDGFβ fusion leads to the
transcription of a fully active PDGFβ protein, which triggers
mitosis through the activation of the PDGFβ receptor (PDGFβR) via
auto-crine and paracrine stimulation of its functional ligand
(45). The PDGFβR is composed of
three structural domains: an extracellular binding, a transmembrane
and a cytoplasmic domain with tyrosine kinase activity. The
tyrosine kinase activates an intracellular signaling cascade that
affects physiological cell processes, including chemotaxis,
proliferation and apoptosis (13).
Primary treatment of DFSP consisted of complete
surgical excision of the lesion. It has been reported (46) that standard surgical resection leads
to a local recurrence rate of up to 60%, which is due to the occult
spreading of the tentacle-like projections beneath the clinically
normal-appearing skin margins.
The main challenge in DFSP surgery is to achieve
satisfactory local control. To obtain the lowest recurrence rate,
two surgical treatments may be performed: wide local excision and
Mohs micrographic surgery (MMS). In addition to surgical methods
(recurrent and metastatic lesions), molecular targeted therapy with
imatinib mesylate may be considered as a suitable alternative or
additional treatment option for DFSP.
Several studies have demonstrated a significant
correlation between wide excisions and low recurrence rates
(46–48) (Table
VII). According to previous studies, it is recommended that
surgical excisions be performed at least 2–3 cm away from the gross
margin. Furthermore, it is important to perform a three dimensional
en bloc removal of the tumor, including skin, subcutaneous tissue
and fascia. If the underlying bone structures are affected it is
necessary to perform a wide resection of the periosteum and bone
(7).
| Table VIICorrelation between surgical margins
and local recurrence rate in DFSP wide local excision. |
Table VII
Correlation between surgical margins
and local recurrence rate in DFSP wide local excision.
Author (Refs.) | Surgical margin
(cm) | Recurrence rate
(%) |
---|
Chang et al
(46) | 5 | <5 |
Fiore et al
(47) | 3 | 20 |
Gloster et
al (48) | <2 | 40 |
MMS can be used to produce a local control that is
more effective. MMS is a surgical procedure characterized by
precise histological resection margin control. According to
Dim-Jamora and Perone (49), MMS
should be the first choice for DFSP treatment. The most important
technical aspect in MMS is continual sequential horizontal
sectioning (5–7 μm) with immediate microscopic examination of the
frozen sections of the resected tissue until a clear margin is
obtained. Guillen and Cockerell (50) revealed through MMS that
tentacle-like formations can extend beyond 3 cm in the horizontal
direction. Loss and Zeitouni (51)
consider MMS as the treatment of choice in anatomically challenging
areas, including the head or neck. Although the efficacy of MMS is
highly recognized, this technique is also considered to be
elaborate, time-consuming and labor-intensive (7).
According to the cytogenetic role of PDGFβR in the
pathogenesis of DFSP, several studies have focused on the most
suitable strategy to inhibit the mitogen process. Imatinib competes
with adenosine triphosphate and prevents tyrosine kinase receptor
autophosphorylation. This leads to inhibition of the aberrant
signal transduction pathway and a partial restoration of
intracellular signaling.
Data in the present study demonstrate the
controversy surrounding the adoption of general guidelines
regarding safe margins. However, we are confident to use the
guidelines proposed by Chang et al (46), Fiore et al (47) and Gloster et al (48). Future treatments for DFSP may adopt
other parameters, including the cytogenetical study of surgical
margins, since margins that are phenotypically recognized to be
tumor-free, may hide the genetical translocation t(17;22)
(q22;q13). Further studies should investigate the possibility of
obtaining genotypically altered margins from margins that may
appear phenotypically healthy. This may improve the accuracy of
tumor excision and the predictability of further possible
recurrences.
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