Reconstructive challenge of dermatofibrosarcoma protuberans in the female breast
© Park et al; licensee BioMed Central Ltd. 2011
Received: 26 August 2010
Accepted: 7 January 2011
Published: 7 January 2011
Dermatofibrosarcoma protuberans is an uncommon locally aggressive malignant neoplasm that most frequently appears in the trunk, followed by the extremities, head, and neck. But occurrence in the breast is extremely rare. We present a case of a 28-year-old woman, who had a history of trauma 5 years previously and excision 1 year before presentation at our clinic. We performed wide excision, together with microscopic and immunohistochemical analysis. No postoperative oncologic treatment was used and she remains disease-free 1 year after the surgery without any tumor recurrence. Here, we report a case of dermatofibrosarcoma protuberans in the female breast and present a detailed discussion of the diagnosis and treatment with reference to available literatures.
Dermatofibrosarcoma protuberans (DFSP) is an uncommon, slow-growing, low-grade sarcoma of putative dermal fibroblastic origin. DFSP was first described by Darier and Ferrand in 1924 and was referred to as a progressive and recurrent dermatofibroma. It was later officially termed "dermatofibrosarcoma protuberans" by Hoffmann in 1925.
DFSP is a clinically challenging neoplasm because it is characterized by a high recurrence rate with a high propensity for local invasion. In addition, it is difficult to make a correct preoperative diagnosis because DFSP is often left untreated for several years, probably due to its benign appearance and initial indolent behaviour.
Our case highlights two specific features. First, understanding the natural history of this entity is crucial even though there are potential difficulties in the diagnosis of DFSP owing to its rarity. Second, reconstruction for aesthetic purpose can be delayed since the presence of a flap after immediate reconstruction may prevent detection of the local recurrence and better aesthetic outcomes can be achieved with delayed procedure.
We performed a wide excision of the breast lesion with a 3 cm margin and a frozen section under general anesthesia and the defect was closed primarily.
DFSP accounts for approximately 6% of all soft tissue sarcomas with an estimated incidence of 0.8 cases per million per year .
DFSP occurs most frequently between the second to fourth decades of life and males are more frequently affected. Most cases of DFSP present as a plaque-like cutaneous thickening and generally increase in size at a slow rate for a considerable period of time, thus they are often regarded as a benign tumor before more rapid growth ensues. For this reason, it is usually regarded lightly by patients as well as physicians leading to delayed and often 'wait and watch' approach. Differential diagnoses include dermatofibromas, keloid, or morphea in early lesions, or cutaneous metastasis, malignant lymphoma, and Kaposi sarcoma in advanced states .
Tohru et al. and Hisaki et el. place a small value on mammography and ultrasonography in preoperative diagnosis of DFSP in the breast. MRI can give information about the deep tissue involvement, especially in patients with large recurrent tumors, whereas, CT has limited value except defining bone involvement. Fine-needle aspiration(FNA) may be useful in establishing a nonspecific pathology in patients with previously treated tumors. However, FNA is not always feasible because obtaining sufficient tissue is difficult for most untreated tumors. Large core needle biopsy or excisional biopsy can help to provide a correct diagnosis. The characteristic findings are interlacing spindle-shaped tumor cells in the dermis and subcutaneous fat layer that form definite bands that interweave or radiate like spokes of a wheel, forming a so-called 'cartwheel' or 'storiform' pattern.
Immunohistochemical markers are highly sensitive for DFSP. In particular, CD34 is a useful marker that allows differentiation of DFSP tumor cells from normal stroma cells. DFSP generally stains positive for CD34 and negative for S-100 protein, factor XIIIa.
Many authors share the same opinion that complete surgical excision with wide, pathologically negative margins is the optimal treatment for primary or recurrent DFSP. Traditionally, the recommended treatment has been wide surgical excision with gross margins of at least 3 cm [4, 9, 10]. In 1967, McPeak et al concluded that even with this margin the recurrence rate was 10% (8 of 82). As many authors believe that the risk of metastasis is increased in cases with several incompletely excised recurrent tumors, surgeons should focus on complete tumor excision to prevent local recurrence, metastasis, and reoperations. Since wide excision usually causes noteworthy distortion and leaves patients with significant cosmetic problems, especially in the female breast, reconstructive procedure is required in almost every instances. In cases in which wide excision and primary flap reconstructions are performed simultaneously, there should be no doubt as to the adequacy of the excision, because the presence of a flap may prevent detection of the local recurrence. In general, the reconstructive challenge in DFSP such as in the trunk, extremities, head and neck comprises of large tissue defects which need covering when vital structures are exposed. In cases of the breast, however, the challenge lay in being able to create a near-normal-looking breasts with good symmetry and color match.
Mohs microscopic surgery (MMS) has emerged as an alternative approach allowing immediate microscopic examination of the margins. However, MMS requires considerable training, a specialized team, multiple stages.
Adjuvant radiation therapy can be administered if margins are positive or very close to the tumor after maximal resection.
Recently, the tyrosine kinase inhibitor Imatinib, was shown to induce regression of advanced DFSP when it is impossible to obtain surgical margins. According to a review of Mizutani et el., imatinib inhibited the growth of metastatic lung lesions in a patient with DFSP .
In conclusion, although DFSP in the breast is rare, clinical suspicion is of paramount importance for an accurate diagnosis and vigilant follow-up for the pigmented lesion is necessary.
Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We would like to acknowledge radiologist Yun Joo Park for helpful assistance in editing the manuscript.
- Swan MC, Banwell PE, Hollowood K, Goodacre TE: Late recurrence of dermatofibrosarcoma protuberans in the female breast: a case report. Br J Plast Surg. 2005, 58: 84-87. 10.1016/j.bjps.2004.06.017.View ArticlePubMedGoogle Scholar
- Sakuragi T, Fujiwara K, Akashi-Tanaka S, Tsuda H, Fukutomi T: A Case of Dermatofibrosarcoma Protuberans in the Skin over the Breast. Breast Cancer. 1997, 4: 53-56. 10.1007/BF02967057.View ArticlePubMedGoogle Scholar
- Lee SJ, Mahoney MC, Shaughnessy E: Dermatofibrosarcoma protuberans of the breast: imaging features and review of the literature. AJR Am J Roentgenol. 2009, 193: W64-69. 10.2214/AJR.08.2141.View ArticlePubMedGoogle Scholar
- Bendix-Hansen K, Myhre-Jensen O, Kaae S: Dermatofibrosarcoma protuberans. A clinico-pathological study of nineteen cases and review of world literature. Scand J Plast Reconstr Surg. 1983, 17: 247-252. 10.3109/02844318309013125.View ArticlePubMedGoogle Scholar
- Hashimoto K, Brownstein MH, Jakobiec FA: Dermatofibrosarcoma protuberans. A tumor with perineural and endoneural cell features. Arch Dermatol. 1974, 110: 874-885. 10.1001/archderm.110.6.874.View ArticlePubMedGoogle Scholar
- Paik-Kwon Lee, Hyun-Tai Kim, Young-Jin Kim: A case of Dermatofibrosarcoma Protuberans in a breast. J Korean Soc Plast Reconstr Surg. 2002, 29: 221-224.Google Scholar
- Tsang AK, Wong FC, Ng PW, Loke SL, Tse GM: Fine needle aspiration cytology of dermatofibrosarcoma protuberans in the breast: a case report. Pathology. 2005, 37: 84-86. 10.1080/00313020400024733.View ArticlePubMedGoogle Scholar
- Dragoumis DM, Katsohi LA, Amplianitis IK, Tsiftsoglou AP: Late local recurrence of dermatofibrosarcoma protuberans in the skin of female breast. World J Surg Oncol. 8: 48-10.1186/1477-7819-8-48.Google Scholar
- Rutgers EJ, Kroon BB, Albus-Lutter CE, Gortzak E: Dermatofibrosarcoma protuberans: treatment and prognosis. Eur J Surg Oncol. 1992, 18: 241-248.PubMedGoogle Scholar
- McPeak CJ, Cruz T, Nicastri AD: Dermatofibrosarcoma protuberans: an analysis of 86 cases--five with metastasis. Ann Surg. 1967, 166: 803-816. 10.1097/00000658-196711000-00011.PubMed CentralView ArticlePubMedGoogle Scholar
- Brenner W, Schaefler K, Chhabra H, Postel A: Dermatofibrosarcoma protuberans metastatic to a regional lymph node. Report of a case and review. Cancer. 1975, 36: 1897-1902. 10.1002/1097-0142(197511)36:5<1897::AID-CNCR2820360547>3.0.CO;2-X.View ArticlePubMedGoogle Scholar
- Nouri K, Lodha R, Jimenez G, Robins P: Mohs micrographic surgery for dermatofibrosarcoma protuberans: University of Miami and NYU experience. Dermatol Surg. 2002, 28: 1060-1064. 10.1046/j.1524-4725.2002.02084.x. discussion 1064PubMedGoogle Scholar
- Mizutani K, Tamada Y, Hara K, Tsuzuki T, Saeki H, Tamaki K, Matsumoto Y: Imatinib mesylate inhibits the growth of metastatic lung lesions in a patient with dermatofibrosarcoma protuberans. Br J Dermatol. 2004, 151: 235-237. 10.1111/j.1365-2133.2004.06024.x.View ArticlePubMedGoogle Scholar
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