LETTERS AND COMMUNICATIONS
References 1. Brown GL, Curtsinger L 3rd, Brightwell JR, Ackerman DM, et al. Enhancement of epidermal regeneration by biosynthetic epidermal growth factor. J Exp Med 1986;163:1319–24.
5. Brown GL, Nanney LB, Griffen J, Cramer AB, et al. Enhancement of wound healing by topical treatment with epidermal growth factor. N Engl J Med 1989;321:76–9.
2. Tsang MW, Wong WK, Hung CS, Lai KM, et al. Human epidermal growth factor enhances healing of diabetic foot ulcers. Diabetes Care 2003;26:1856–61.
Dong Woo Suh, MD Bark Lynn Lew, MD, PhD Woo Young Sim, MD, PhD Department of Dermatology College of Medicine Kyung Hee University Seoul, Korea
3. Wu HG, Song SY, Kim YS, Oh YT, et al. Therapeutic effect of recombinant human epidermal growth factor (RhEGF) on mucositis in patients undergoing radiotherapy, with or without chemotherapy, for head and neck cancer: a double-blind placebo-controlled prospective phase 2 multi-institutional clinical trial. Cancer 2009;115:3699–708. 4. Chan SY, Wong RW. Expression of epidermal growth factor in transgenic mice causes growth retardation. J Biol Chem 2000;275:38693–8.
A Case of Metastatic Dermatofibrosarcoma Protuberans We recently published a review outlining the utility of Mohs surgery in the treatment of dermatofibrosarcoma protuberans (DFSP) and the management of more advanced disease.1 In August 2012, a patient with DFSP presented to our clinic, and we wanted to share her case as an illustration of several of the points we discussed in our review. The patient is a generally healthy 59-year-old African American female with a history of DFSP on her left lower back. She had first noticed a small skin colored “growth” on her left lower back in 2003. It was asymptomatic and slowly enlarging. She had the growth evaluated in 2005 by a physician who told her that it was “probably a keloid” and injected it with kenalog. The kenalog had no effect on the lesion, and it continued to slowly enlarge. She presented to her primary physician in 2008 and was referred to a plastic surgeon, who performed an excisional biopsy. Pathology demonstrated fibrosarcomatous variant of DFSP present at the surgical margin. She subsequently underwent a wide local excision with clear surgical margins. The patient had a computed tomographic (CT) scan of the chest, abdomen, and pelvis after her surgery in 2008, which showed postsurgical changes but no evidence of metastatic disease. She was subsequently referred to a radiation oncologist and was treated with a course of external beam radiation. She did well until 2011, when she noted a “bump” at the edge of her surgical scar. She re-presented to her plastic surgeon, who performed an
708
excisional biopsy, which demonstrated recurrence of her fibrosarcomatous variant of DFSP. She underwent a second, wide local excision that was again read as having clear surgical margins. No further imaging or treatment was pursued at that time. The patient first presented to our clinic in August 2012. She denied any new growth or specific complaints. She noted that she had read on the Internet that dermatologists often follow patients with DFSP, so she scheduled an office visit to establish care. On clinical examination, the patient had a 1.5 · 23-cm linear scar on her left lower back (Figure 1). Her lymph node examination was unremarkable, as was a complete review of systems. After reviewing her previous pathology reports, we thought it prudent to obtain
Figure 1. Surgical scar and radiation changes from prior surgeries on left lower back.
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 2. Black arrow points to a 3 · 2.6-cm mass in the superior segment of the right lower lobe.
a chest CT, given the higher incidence of metastasis in the fibroscarcomatous variant of DFSP and her large recurrent tumor history.2 The chest CT demonstrated a 3.3 · 2.6-cm mass in the superior segment of her right lower lobe, which was concerning for metastasis (Figure 2). A subsequent wedge resection confirmed the mass as metastatic DFSP. Negative surgical margins were obtained, and the patient recovered well from her surgery. She was subsequently referred to medical oncology, and her tumor was sent for testing for the COL1A/PDGFR translocation. A translocation was identified by fluorescent in situ hybridization testing, and she was started on imatinib 400 mg daily in October 2012. She has tolerated the medication well, and a recent CT did not show any evidence of metastatic disease. The oncology team plans to continue the current dose of imatinib indefinitely on the patient. This patient’s case demonstrates the difficulty that frequently comes with the diagnosis and treatment of
DFSP. Her diagnosis and definitive treatment came several years after her initial presentation, which is typical. Although wide local excision is an acceptable treatment modality, especially on the trunk, this case shows that even with a clear surgical margin, recurrence is possible due to the frequent asymmetric growth pattern of DFSP.3 Most significantly, this case highlights the importance of close follow-up and the consideration of serial imaging, especially in the case of fibrosarcomatous DFSP. It is likely prudent to obtain an initial staging chest CT in all cases of fibrosarcomatous DFSP, and as this case suggests, it may be worth repeating for surveillance after surgery, even if the margins are read as clear. Collaboration with multiple specialties is essential in the care of patients with advanced DFSP, and the dermatologic surgeon can play a key role on this team, as we frequently have more experience with this rare entity than other physicians. References 1. Bogucki B, Neuhaus I, Hurst EA. Dermatofibrosarcoma Protuberans: A Review of the Literature. Dermatol Surg 2012;38:537–51. 2. Abbott J, Oliveira A, Nascimento A. The prognostic significance of fibrosarcomatous transformation in dermatofibrosarcoma protuberans. Am J Surg Pathol 2006;30:436–43. 3. Ratner D, Thomas C, Johnson T, Sondak V, et al. Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans. Results of a multiinstitutional series with an analysis of the extent of microscopic spread. J Am Acad Dermatol 1997;37:600–13.
Benjamin Bogucki, MD Eva A. Hurst, MD Division of Dermatology Washington University School of Medicine St Louis, Missouri
40:6:JUNE 2014
709
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
References 1. Brown GL, Curtsinger L 3rd, Brightwell JR, Ackerman DM, et al. Enhancement of epidermal regeneration by biosynthetic epidermal growth factor. J Exp Med 1986;163:1319–24.
5. Brown GL, Nanney LB, Griffen J, Cramer AB, et al. Enhancement of wound healing by topical treatment with epidermal growth factor. N Engl J Med 1989;321:76–9.
2. Tsang MW, Wong WK, Hung CS, Lai KM, et al. Human epidermal growth factor enhances healing of diabetic foot ulcers. Diabetes Care 2003;26:1856–61.
Dong Woo Suh, MD Bark Lynn Lew, MD, PhD Woo Young Sim, MD, PhD Department of Dermatology College of Medicine Kyung Hee University Seoul, Korea
3. Wu HG, Song SY, Kim YS, Oh YT, et al. Therapeutic effect of recombinant human epidermal growth factor (RhEGF) on mucositis in patients undergoing radiotherapy, with or without chemotherapy, for head and neck cancer: a double-blind placebo-controlled prospective phase 2 multi-institutional clinical trial. Cancer 2009;115:3699–708. 4. Chan SY, Wong RW. Expression of epidermal growth factor in transgenic mice causes growth retardation. J Biol Chem 2000;275:38693–8.
A Case of Metastatic Dermatofibrosarcoma Protuberans We recently published a review outlining the utility of Mohs surgery in the treatment of dermatofibrosarcoma protuberans (DFSP) and the management of more advanced disease.1 In August 2012, a patient with DFSP presented to our clinic, and we wanted to share her case as an illustration of several of the points we discussed in our review. The patient is a generally healthy 59-year-old African American female with a history of DFSP on her left lower back. She had first noticed a small skin colored “growth” on her left lower back in 2003. It was asymptomatic and slowly enlarging. She had the growth evaluated in 2005 by a physician who told her that it was “probably a keloid” and injected it with kenalog. The kenalog had no effect on the lesion, and it continued to slowly enlarge. She presented to her primary physician in 2008 and was referred to a plastic surgeon, who performed an excisional biopsy. Pathology demonstrated fibrosarcomatous variant of DFSP present at the surgical margin. She subsequently underwent a wide local excision with clear surgical margins. The patient had a computed tomographic (CT) scan of the chest, abdomen, and pelvis after her surgery in 2008, which showed postsurgical changes but no evidence of metastatic disease. She was subsequently referred to a radiation oncologist and was treated with a course of external beam radiation. She did well until 2011, when she noted a “bump” at the edge of her surgical scar. She re-presented to her plastic surgeon, who performed an
708
excisional biopsy, which demonstrated recurrence of her fibrosarcomatous variant of DFSP. She underwent a second, wide local excision that was again read as having clear surgical margins. No further imaging or treatment was pursued at that time. The patient first presented to our clinic in August 2012. She denied any new growth or specific complaints. She noted that she had read on the Internet that dermatologists often follow patients with DFSP, so she scheduled an office visit to establish care. On clinical examination, the patient had a 1.5 · 23-cm linear scar on her left lower back (Figure 1). Her lymph node examination was unremarkable, as was a complete review of systems. After reviewing her previous pathology reports, we thought it prudent to obtain
Figure 1. Surgical scar and radiation changes from prior surgeries on left lower back.
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 2. Black arrow points to a 3 · 2.6-cm mass in the superior segment of the right lower lobe.
a chest CT, given the higher incidence of metastasis in the fibroscarcomatous variant of DFSP and her large recurrent tumor history.2 The chest CT demonstrated a 3.3 · 2.6-cm mass in the superior segment of her right lower lobe, which was concerning for metastasis (Figure 2). A subsequent wedge resection confirmed the mass as metastatic DFSP. Negative surgical margins were obtained, and the patient recovered well from her surgery. She was subsequently referred to medical oncology, and her tumor was sent for testing for the COL1A/PDGFR translocation. A translocation was identified by fluorescent in situ hybridization testing, and she was started on imatinib 400 mg daily in October 2012. She has tolerated the medication well, and a recent CT did not show any evidence of metastatic disease. The oncology team plans to continue the current dose of imatinib indefinitely on the patient. This patient’s case demonstrates the difficulty that frequently comes with the diagnosis and treatment of
DFSP. Her diagnosis and definitive treatment came several years after her initial presentation, which is typical. Although wide local excision is an acceptable treatment modality, especially on the trunk, this case shows that even with a clear surgical margin, recurrence is possible due to the frequent asymmetric growth pattern of DFSP.3 Most significantly, this case highlights the importance of close follow-up and the consideration of serial imaging, especially in the case of fibrosarcomatous DFSP. It is likely prudent to obtain an initial staging chest CT in all cases of fibrosarcomatous DFSP, and as this case suggests, it may be worth repeating for surveillance after surgery, even if the margins are read as clear. Collaboration with multiple specialties is essential in the care of patients with advanced DFSP, and the dermatologic surgeon can play a key role on this team, as we frequently have more experience with this rare entity than other physicians. References 1. Bogucki B, Neuhaus I, Hurst EA. Dermatofibrosarcoma Protuberans: A Review of the Literature. Dermatol Surg 2012;38:537–51. 2. Abbott J, Oliveira A, Nascimento A. The prognostic significance of fibrosarcomatous transformation in dermatofibrosarcoma protuberans. Am J Surg Pathol 2006;30:436–43. 3. Ratner D, Thomas C, Johnson T, Sondak V, et al. Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans. Results of a multiinstitutional series with an analysis of the extent of microscopic spread. J Am Acad Dermatol 1997;37:600–13.
Benjamin Bogucki, MD Eva A. Hurst, MD Division of Dermatology Washington University School of Medicine St Louis, Missouri
40:6:JUNE 2014
709
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
