CASE REPORTS
G ITi\LDERMATOL VENERE0L2010; 145:309-1 l
Micrographic surgery (Tiibingen torte technique) for the treatnlent of an invasive dermatofibrosarcoma protuberans with muscular involvement M. LEIGHEB
I,
E. ZAVATTARO
Dermatofibrosarcoma protuberans (DFSP) is an uncommon skin tumour characterized by a sIow, inflltrative growth and marked tendency towards local recurrences. Wide surgical excision of 3-5 cm from the margins incIuding the fascia is the recommended treatment. Mohs Micrographic Surgery has been shown to afford lower rates of recurrence. The Mohs Tiibillgen technique is a variant indicated for very large exci sions that allows a complete eradication of the tumour, pre serving heaIthy tissues. We report the case of a 45 year-old man affected by DFSP of the right shoulder deeply infiltrating the muscIes, referred to us for a recurrence after a large exci sion. We submitted the patient to Mohs-Tiibingen surgery in col laboration with an orthopaedic surgeon due to the presence of muscular involvement of DFSP. Two surgical operations were Ilecessary to obtain negative histology as the tumor was deeply inflltrating the prescapular muscIes. After three years of follow-up, the patient did not have any recurrence and the normaI mobility of the shouIder was preserved. Precocious diagnosis and adequate therapy are necessary for DFSP as not ollly the margills, but aIso the deep invasioll of the tumor have to be carefully cOlltrolled. KEY WORDS:
Dermatofibrosarcoma - Skin neoplasms - Mohs
surgery,
ermatofibrosarcoma protuberans (DFSP) is an uncommon skin tumour composed of spindle shaped cells that usually presents as a slow growing nodular lesions or plaques.
D
Receìved on AprilI, 2009.
Accepted for publication on March 16,20! O.
Corresponding author: Prof .Giorgio Leigheb. Dennatologìc Clinic, Departmem of Clinica! and Experimemal Medicine, Universi t)' of Piemonte Orientale. via Solaroli 17. 28100 Novara. IIal)'. E-mail:
[email protected]
VoI. 145 -:\0. 2
2,
F. BELLINZONA
2,
G. FURLAN
2,
G. LEIGHEB
2
IOrlhopaedics and Traumatology UniI lvfaggiore della Carità Hospital. Novara. Ital)' 1Dermatologic Clinic, Department ofClinical and Experimental Medicine Unlversitr o{'Piemonte Orientale A. Avogadro Novara, Italy
lt develops slowly in the dermis, but it can spread into soft tissues such as the subcutis, fascia and rarely the muscles, giving rise to frequent recurrences, even if without metastases. For these reasons, the recom mended treatments are represented by wide excision (3-5 cm from the margins) or Mohs' micrographic surgery (MMS), in order to allow for the complete eradication of the neoplasm. 1. 2 The "Tilbingen torte" technique is a variant of MMS performed on paraf tin-embedded sections, that permits the topographic microscopic evaluation of the entire periphery (outer margins and base) ofthe tumor. 3 ,"
Case report We report the ease of a 45 year-old man referred to our Dermatological Department with a recurrence 01' a CD34 positive DFSP 01' the shoulder. He had a history 01' tradi tional surgical excision performed by a plastic surgeon at 2 cm from the outer margins and including the fascia, 4 years before, Clinical evaluation showed multiple nodules forming a 4x6 em diameter plaque on the dorsal region of the right shoulder (Figure l A), whieh had appeared a few months before. It was asymptomatic, hard and deeply attaehed to the subcutis.
GIORNALE ITALlA"O DI DER:>'1ATOLOGIA E VE:\EREOLOGIA
309
LEIGHEB
DERMATOFIBROSARCO'vlA PROTL'BERANS WITH .\1USCULAR INVOLVEMENT
I.-Recurrellce rate ()f dennatofibrosarcoma protuberans after diffèrent surgical treatmems.
TABLE
Recurrcnce
Surgical tcchniquc*
WE
MMS MMS MMS MTS
('i{)
Follow-up (ranger'
7-47'7< lNlc
2-22 yrs) 5 mo-8 yrs (
2~7c
3mo-14.2vrs"
3 'le O
2 mo-9.7 y"rs 7 4 mo-8
yrs 5
On [he basi, 01' diffcr~nt snrgical trcatment, the rate 01' Ioca! r~currence 01' DFSP With \Vide cxcision. the percentagc of recurrence was reIuted lO the (7
