What is the best surgical treatment for dermatofibrosarcoma protuberans?

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing skin cancer that is primarily treated with surgery. Because this cancer can spread deep into the skin and surrounding tissue in an irregular way, it is notoriously difficult to ensure that it has been completely removed after conventional surgery and histological examination. Standard treatment in the UK is either wide local excision (WLE) or Mohs micrographic surgery (MMS). In WLE, the tumour and a predetermined margin of skin around it is removed. The margin is usually in the range of 1-5 cm. MMS involves removing the tumour and a much smaller margin around it, followed by immediate microscopic examination of the edges of the removed skin. Areas still containing tumour cells are then removed. This is repeated until all the edges are clear of tumour cells. This method allows the surgeon to track the tumour and only remove tissue where is it present. This study was carried out at several centres in the UK. Clinical records were examined of cases of DFSP between 1 January 2004 and 31 December 2013. This study includes the largest number of cases of DFSP reported in the UK: 483 new and 64 recurring cases of DFSP, in 11 plastic surgery and 15 dermatology departments. The methods used to perform these 547 surgeries were analysed. Almost 75% of cases of new DFSP were treated with WLE and 20% were treated with MMS. For recurring DFSP, 69% of patients had WLE and 23% had MMS. After a median follow-up period of just over 2 years for new DFSP and 1.6 years for recurring DFSP, the tumour returned in six patients after WLE and none after MMS. Although no DFSP were found to have returned after MMS, the study could not detect any significant difference in recurrences between the two surgical methods. Until data from more detailed studies are available, the choice of treatment for DFSP should be based on the patient's preference, treatment availability and cost. Linked Article: Durack et al. Br J Dermatol 2021; 184:731-739.