Overview

The NCCN Non-Melanoma Skin Cancer Panel has developed these guidelines outlining the treatment of dermatofibrosarcoma protuberans (DFSP) to supplement their other guidelines (NCCN Clinical Practice Guidelines in Oncology [NCCN Guidelines] for Basal Cell and Squamous Cell Skin Cancers and Merkel Cell Carcinoma; to view the most recent version of these guidelines, visit the NCCN Web site at www.NCCN.org). The NCCN Soft Tissue Sarcoma Panel provided expert input in the development of these guidelines. DFSP is an uncommon, low-grade sarcoma of fibroblast origin with an incidence rate of 4.2 to 4.5 cases per million persons per year in the United States.1,2 It rarely metastasizes. However, initial misdiagnosis, prolonged time to accurate diagnosis, and large

NCCN Clinical Practice Guidelines in Oncology for Dermatofibrosarcoma Protuberans

NCCN Categories of Evidence and Consensus

Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.

Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.

All recommendations are category 2A unless otherwise noted.

Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. tumor size at the time of diagnosis are common. Three-dimensional reconstruction of DFSP3 has shown tumors with highly irregular shapes and frequent finger-like extensions.4 As a result, incomplete removal and subsequent recurrence are common. The local recurrence rate for DFSP in studies ranges from 0% to 60%, whereas the rate of development of regional or distant metastatic disease is only 1% and 4% to 5%, respectively.5

Diagnosis

As with all solid tumors, clinical suspicion is confirmed with biopsy. In most cases, examination of hematoxylin and eosin-stained specimens using light microscopy results in an unequivocal diagnosis. However, differentiation of DFSP from dermatofibroma can sometimes be difficult. In these instances, immunostaining with CD34, factor XIIIa, metallothioneins, tenascin, and/or stromelysin-3 may be useful.59 Therefore, the panel recommends that appropriate and confirmatory immunostaining be performed in all cases of suspected DFSP. Finally, whether the histologic features of a high mitotic rate or evidence of fibrosarcomatous change (typically in > 5% of the surgical specimen) have prognostic significance in DFSP is unclear. Studies in the biomedical literature both support10,11 and refute12 this notion. Thus, the panel requested that these 2 features be noted in all pathology reports assessing this tumor.

When the clinician’s suspicion for DFSP is high but the initial biopsy does not support the diagnosis, rebiopsy is recommended and may show tumor presence. Multiple nonsupportive or equivocal biopsies over time, before definitive diagnosis, are common in the clinical history for this tumor; thus, DFSP is frequently misdiagnosed. Because metastatic disease is rare, an extensive workup is not routinely indicated unless suggestive aspects in the history and physical examination (H&P) or adverse prognostic histologic features are present. Stage I is local disease, stage II is regional disease, and stage III is distant disease.

F1NCCN Clinical Practice Guidelines in Oncology: Dermatofibrosarcoma Protuberans Version 1.2012

Version 1.2012, 9-27-11 ©2012 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 10, 3; 10.6004/jnccn.2012.0032

Treatment

Initial treatment of DFSP is surgical. Because of its proclivity for irregular and frequently deep subclinical extensions, every effort should be made to completely remove this tumor at initial therapy. If initial surgery yields positive margins, re-resection is recommended whenever possible, with the goal of achieving clear margins. The surgical approach to DFSP must be meticulously planned. Size and location of the tumor and cosmetic issues will dictate the most appropriate surgical procedure. As noted in the algorithm, some form of complete histologic assessment of all surgical margins before reconstruction is preferred. See the NCCN Guidelines for Soft Tissue Sarcoma for principles of sarcoma surgery (to view the most recent version of these guidelines, visit the NCCN Web site at www.NCCN.org [SARC-C]). Mohs or modified Mohs surgery3,4,1320 and traditional wide excision,21 typically with 2- to 4-cm margins to investing fascia that are subsequently verified to be clear through traditional pathologic examination, are all methods to achieve complete histologic assessment.14,22,23 In a recent series of 244 patients with DFSP, tumor depth was the only factor associated with disease-free survival in the primary setting, underscoring the importance to excise the deep fascia to remove any infiltrating tumor cells.24 In another retrospective review of 48 patients, positive margins were more frequent with wide excision than with Mohs, but the local recurrence rates were statistically similar (3.6% vs. 0%, respectively; P = 1.0).25 Confirmation of negative margins should precede any reconstruction that requires extensive undermining or tissue movement. If concern exists that the surgical margins are not completely clear, tissue rearrangement should be avoided and split-thickness skin grafting considered to monitor for recurrence.

DFSP is characterized by a translocation between chromosomes 17 and 22 (t(17:22)) resulting in the overexpression of platelet-derived growth factor receptor (PDGFR) β.2628 These findings suggest that targeting PDGFRs may lead to the development of new therapeutic options for DFSP. In recently published results, imatinib mesylate, a protein tyrosine kinase inhibitor, has shown clinical activity against localized and metastatic DFSP tumors containing t(17:22).2933 Imatinib mesylate has recently been approved by the FDA for the treatment of unresectable, recurrent, and/or metastatic DFSP in adult patients.34 Because tumors lacking the t(17;22) translocation may not respond to imatinib molecular, analysis with cytogenetics may be useful before initiating imatinib therapy.

Radiation has occasionally been used as a primary therapeutic modality for DFSP,35 but it is more commonly used as adjuvant therapy after surgery.3638 Postoperative radiation therapy or imatinib mesylate should be considered for positive surgical margins if further resection is not feasible (unresectable disease). If a negative margin is achieved, no adjuvant treatment is necessary.

Recurrent tumors, whenever possible, should be resected. Radiation therapy, if not given previously, or imatinib mesylate should be considered if this is not possible, or if additional resection would lead to unacceptable functional or cosmetic outcomes. Clinical trials, imatinib mesylate, chemotherapy, radiation therapy, or re-resection as feasible under specific clinical circumstances should all be considered in the rare event of metastatic disease.

Several clinical trials are underway for the treatment of DFSP with imatinib (www.ClinicalTrials.gov).

Follow-Up

Finally, given the historically high local recurrence rates for DFSP, ongoing clinical follow-up of the primary site every 6 to 12 months is indicated, with rebiopsy of any suspicious regions. Although metastatic disease is rare, a guided H&P should also be performed, with additional imaging studies as indicated.

Individual Disclosures for the NCCN Guidelines Panel for Dermatofibrosarcoma Protuberans

T1

References

  • 1

    CriscioneVDWeinstockMA. Descriptive epidemiology of dermatofibrosarcoma protuberans in the United States, 1973 to 2002. J Am Acad Dermatol2007;56:968973.

    • Search Google Scholar
    • Export Citation
  • 2

    RouhaniPFletcherCDDevesaSSToroJR. Cutaneous soft tissue sarcoma incidence patterns in the U.S.: an analysis of 12,114 cases. Cancer2008;113:616627.

    • Search Google Scholar
    • Export Citation
  • 3

    HaycoxCLOdlandPBOlbrichtSMCaseyB. Dermatofibrosarcoma protuberans (DFSP): growth characteristics based on tumor modeling and a review of cases treated with Mohs micrographic surgery. Ann Plast Surg1997;38:246251.

    • Search Google Scholar
    • Export Citation
  • 4

    RatnerDThomasCOJohnsonTM. 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 Dermatol1997;37:600613.

    • Search Google Scholar
    • Export Citation
  • 5

    VidimosATHelmTNPapayFA. Dermatofibrosarcoma protuberans. In: Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden, MA: Blackwell Scientific; 1998:822831.

    • Search Google Scholar
    • Export Citation
  • 6

    CribierBNoaccoGPeltreBGrosshansE. Stromelysin 3 expression: a useful marker for the differential diagnosis dermatofibroma versus dermatofibrosarcoma protuberans. J Am Acad Dermatol2002;46:408413.

    • Search Google Scholar
    • Export Citation
  • 7

    KahnHJFeketeEFromL. Tenascin differentiates dermatofibroma from dermatofibrosarcoma protuberans: comparison with CD34 and factor XIIIa. Hum Pathol2001;32:5056.

    • Search Google Scholar
    • Export Citation
  • 8

    KimHJLeeJYKimSH. Stromelysin-3 expression in the differential diagnosis of dermatofibroma and dermatofibrosarcoma protuberans: comparison with factor XIIIa and CD34. Br J Dermatol2007;157:319324.

    • Search Google Scholar
    • Export Citation
  • 9

    ZelgerBWOfnerDZelgerBG. Atrophic variants of dermatofibroma and dermatofibrosarcoma protuberans. Histopathology1995;26:519527.

  • 10

    MentzelTBehamAKatenkampD. Fibrosarcomatous (“high-grade”) dermatofibrosarcoma protuberans: clinicopathologic and immunohistochemical study of a series of 41 cases with emphasis on prognostic significance. Am J Surg Pathol1998;22:576587.

    • Search Google Scholar
    • Export Citation
  • 11

    BowneWBAntonescuCRLeungDH. Dermatofibrosarcoma protuberans: a clinicopathologic analysis of patients treated and followed at a single institution. Cancer2000;88:27112720.

    • Search Google Scholar
    • Export Citation
  • 12

    GoldblumJRReithJDWeissSW. Sarcomas arising in dermatofibrosarcoma protuberans: a reappraisal of biologic behavior in eighteen cases treated by wide local excision with extended clinical follow up. Am J Surg Pathol2000;24:11251130.

    • Search Google Scholar
    • Export Citation
  • 13

    DawesKWHankeCW. Dermatofibrosarcoma protuberans treated with Mohs micrographic surgery: cure rates and surgical margins. Dermatol Surg1996;22:530534.

    • Search Google Scholar
    • Export Citation
  • 14

    DuBayDCimminoVLoweL. Low recurrence rate after surgery for dermatofibrosarcoma protuberans: a multidisciplinary approach from a single institution. Cancer2004;100:10081016.

    • Search Google Scholar
    • Export Citation
  • 15

    GlosterHMJrHarrisKRRoenigkRK. A comparison between Mohs micrographic surgery and wide surgical excision for the treatment of dermatofibrosarcoma protuberans. J Am Acad Dermatol1996;35:8287.

    • Search Google Scholar
    • Export Citation
  • 16

    HaasAFSykesJM. Multispecialty approach to complex dermatofibrosarcoma protuberans of the forehead. Arch Otolaryngol Head Neck Surg1998;124:324327.

    • Search Google Scholar
    • Export Citation
  • 17

    HuetherMJZitelliJABrodlandDG. Mohs micrographic surgery for the treatment of spindle cell tumors of the skin. J Am Acad Dermatol2001;44:656659.

    • Search Google Scholar
    • Export Citation
  • 18

    PenningtonBELeffellDJ. Mohs micrographic surgery: established uses and emerging trends. Oncology (Williston Park)2005;19:11651171; discussion 1171–1162 1175.

    • Search Google Scholar
    • Export Citation
  • 19

    SondakVKCimminoVMLoweLM. Dermatofibrosarcoma protuberans: what is the best surgical approach?Surg Oncol1999;8:183189.

  • 20

    SnowSNGordonEMLarsonPO. Dermatofibrosarcoma protuberans: a report on 29 patients treated by Mohs micrographic surgery with long-term follow-up and review of the literature. Cancer2004;101:2838.

    • Search Google Scholar
    • Export Citation
  • 21

    KimmelZRatnerDKimJY. Peripheral excision margins for dermatofibrosarcoma protuberans: a meta-analysis of spatial data. Ann Surg Oncol2007;14:21132120.

    • Search Google Scholar
    • Export Citation
  • 22

    StojadinovicAKarpoffHMAntonescuCR. Dermatofibrosarcoma protuberans of the head and neck. Ann Surg Oncol2000;7:696704.

  • 23

    FarmaJMAmmoriJBZagerJS. Dermatofibrosarcoma protuberans: how wide should we resect?Ann Surg Oncol2010;17:21122118.

  • 24

    FieldsRCHameedMQinLX. Dermatofibrosarcoma protuberans (DFSP): predictors of recurrence and the use of systemic therapy. Ann Surg Oncol2011;18:328336.

    • Search Google Scholar
    • Export Citation
  • 25

    MeguerditchianANWangJLemaB. Wide excision or Mohs micrographic surgery for the treatment of primary dermatofibrosarcoma protuberans. Am J Clin Oncol2009;33:300303.

    • Search Google Scholar
    • Export Citation
  • 26

    McArthurG. Molecularly targeted treatment for dermatofibrosarcoma protuberans. Semin Oncol2004;31:3036.

  • 27

    SjoblomTShimizuAO’BrienKP. Growth inhibition of dermatofibrosarcoma protuberans tumors by the platelet-derived growth factor receptor antagonist STI571 through induction of apoptosis. Cancer Res2001;61:57785783.

    • Search Google Scholar
    • Export Citation
  • 28

    MendenhallWMZloteckiRAScarboroughMT. Dermatofibrosarcoma protuberans. Cancer2004;101:25032508.

  • 29

    LabropoulosSVFletcherJAOliveiraAM. Sustained complete remission of metastatic dermatofibrosarcoma protuberans with imatinib mesylate. Anticancer Drugs2005;16:461466.

    • Search Google Scholar
    • Export Citation
  • 30

    McArthurGADemetriGDvan OosteromA. Molecular and clinical analysis of locally advanced dermatofibrosarcoma protuberans treated with imatinib: imatinib target exploration consortium study B2225. J Clin Oncol2005;23:866873.

    • Search Google Scholar
    • Export Citation
  • 31

    RubinBPSchuetzeSMEaryJF. Molecular targeting of platelet-derived growth factor B by imatinib mesylate in a patient with metastatic dermatofibrosarcoma protuberans. J Clin Oncol2002;20:35863591.

    • Search Google Scholar
    • Export Citation
  • 32

    UgurelSUtikalJMohrP. Imatinib in locally advanced dermatofibrosarcoma protuberans (DFSP): a phase II trial of the Dermatologic Cooperative Oncology Group (DeCOG) [abstract]. J Clin Oncol2006;24(Suppl 18):Abstract 9561.

    • Search Google Scholar
    • Export Citation
  • 33

    RutkowskiPVan GlabbekeMRankinCJ. Imatinib mesylate in advanced dermatofibrosarcoma protuberans: pooled analysis of two phase II clinical trials. J Clin Oncol2010;28:17721779.

    • Search Google Scholar
    • Export Citation
  • 34

    McArthurGA. Molecular targeting of dermatofibrosarcoma protuberans: a new approach to a surgical disease. J Natl Compr Canc Netw2007;5:557562.

    • Search Google Scholar
    • Export Citation
  • 35

    SuitHSpiroIMankinHJ. Radiation in management of patients with dermatofibrosarcoma protuberans. J Clin Oncol1996;14:23652369.

  • 36

    BalloMTZagarsGKPistersPPollackA. The role of radiation therapy in the management of dermatofibrosarcoma protuberans. Int J Radiat Oncol Biol Phys1998;40:823827.

    • Search Google Scholar
    • Export Citation
  • 37

    DaganRMorrisCGZloteckiRA. Radiotherapy in the treatment of dermatofibrosarcoma protuberans. Am J Clin Oncol2005;28:537539.

  • 38

    SunLMWangCJHuangCC. Dermatofibrosarcoma protuberans: treatment results of 35 cases. Radiother Oncol2000;57:175181.

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    NCCN Clinical Practice Guidelines in Oncology: Dermatofibrosarcoma Protuberans Version 1.2012

    Version 1.2012, 9-27-11 ©2012 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

References

  • 1

    CriscioneVDWeinstockMA. Descriptive epidemiology of dermatofibrosarcoma protuberans in the United States, 1973 to 2002. J Am Acad Dermatol2007;56:968973.

    • Search Google Scholar
    • Export Citation
  • 2

    RouhaniPFletcherCDDevesaSSToroJR. Cutaneous soft tissue sarcoma incidence patterns in the U.S.: an analysis of 12,114 cases. Cancer2008;113:616627.

    • Search Google Scholar
    • Export Citation
  • 3

    HaycoxCLOdlandPBOlbrichtSMCaseyB. Dermatofibrosarcoma protuberans (DFSP): growth characteristics based on tumor modeling and a review of cases treated with Mohs micrographic surgery. Ann Plast Surg1997;38:246251.

    • Search Google Scholar
    • Export Citation
  • 4

    RatnerDThomasCOJohnsonTM. 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 Dermatol1997;37:600613.

    • Search Google Scholar
    • Export Citation
  • 5

    VidimosATHelmTNPapayFA. Dermatofibrosarcoma protuberans. In: Cutaneous Oncology: Pathophysiology Diagnosis and Management. Malden, MA: Blackwell Scientific; 1998:822831.

    • Search Google Scholar
    • Export Citation
  • 6

    CribierBNoaccoGPeltreBGrosshansE. Stromelysin 3 expression: a useful marker for the differential diagnosis dermatofibroma versus dermatofibrosarcoma protuberans. J Am Acad Dermatol2002;46:408413.

    • Search Google Scholar
    • Export Citation
  • 7

    KahnHJFeketeEFromL. Tenascin differentiates dermatofibroma from dermatofibrosarcoma protuberans: comparison with CD34 and factor XIIIa. Hum Pathol2001;32:5056.

    • Search Google Scholar
    • Export Citation
  • 8

    KimHJLeeJYKimSH. Stromelysin-3 expression in the differential diagnosis of dermatofibroma and dermatofibrosarcoma protuberans: comparison with factor XIIIa and CD34. Br J Dermatol2007;157:319324.

    • Search Google Scholar
    • Export Citation
  • 9

    ZelgerBWOfnerDZelgerBG. Atrophic variants of dermatofibroma and dermatofibrosarcoma protuberans. Histopathology1995;26:519527.

  • 10

    MentzelTBehamAKatenkampD. Fibrosarcomatous (“high-grade”) dermatofibrosarcoma protuberans: clinicopathologic and immunohistochemical study of a series of 41 cases with emphasis on prognostic significance. Am J Surg Pathol1998;22:576587.

    • Search Google Scholar
    • Export Citation
  • 11

    BowneWBAntonescuCRLeungDH. Dermatofibrosarcoma protuberans: a clinicopathologic analysis of patients treated and followed at a single institution. Cancer2000;88:27112720.

    • Search Google Scholar
    • Export Citation
  • 12

    GoldblumJRReithJDWeissSW. Sarcomas arising in dermatofibrosarcoma protuberans: a reappraisal of biologic behavior in eighteen cases treated by wide local excision with extended clinical follow up. Am J Surg Pathol2000;24:11251130.

    • Search Google Scholar
    • Export Citation
  • 13

    DawesKWHankeCW. Dermatofibrosarcoma protuberans treated with Mohs micrographic surgery: cure rates and surgical margins. Dermatol Surg1996;22:530534.

    • Search Google Scholar
    • Export Citation
  • 14

    DuBayDCimminoVLoweL. Low recurrence rate after surgery for dermatofibrosarcoma protuberans: a multidisciplinary approach from a single institution. Cancer2004;100:10081016.

    • Search Google Scholar
    • Export Citation
  • 15

    GlosterHMJrHarrisKRRoenigkRK. A comparison between Mohs micrographic surgery and wide surgical excision for the treatment of dermatofibrosarcoma protuberans. J Am Acad Dermatol1996;35:8287.

    • Search Google Scholar
    • Export Citation
  • 16

    HaasAFSykesJM. Multispecialty approach to complex dermatofibrosarcoma protuberans of the forehead. Arch Otolaryngol Head Neck Surg1998;124:324327.

    • Search Google Scholar
    • Export Citation
  • 17

    HuetherMJZitelliJABrodlandDG. Mohs micrographic surgery for the treatment of spindle cell tumors of the skin. J Am Acad Dermatol2001;44:656659.

    • Search Google Scholar
    • Export Citation
  • 18

    PenningtonBELeffellDJ. Mohs micrographic surgery: established uses and emerging trends. Oncology (Williston Park)2005;19:11651171; discussion 1171–1162 1175.

    • Search Google Scholar
    • Export Citation
  • 19

    SondakVKCimminoVMLoweLM. Dermatofibrosarcoma protuberans: what is the best surgical approach?Surg Oncol1999;8:183189.

  • 20

    SnowSNGordonEMLarsonPO. Dermatofibrosarcoma protuberans: a report on 29 patients treated by Mohs micrographic surgery with long-term follow-up and review of the literature. Cancer2004;101:2838.

    • Search Google Scholar
    • Export Citation
  • 21

    KimmelZRatnerDKimJY. Peripheral excision margins for dermatofibrosarcoma protuberans: a meta-analysis of spatial data. Ann Surg Oncol2007;14:21132120.

    • Search Google Scholar
    • Export Citation
  • 22

    StojadinovicAKarpoffHMAntonescuCR. Dermatofibrosarcoma protuberans of the head and neck. Ann Surg Oncol2000;7:696704.

  • 23

    FarmaJMAmmoriJBZagerJS. Dermatofibrosarcoma protuberans: how wide should we resect?Ann Surg Oncol2010;17:21122118.

  • 24

    FieldsRCHameedMQinLX. Dermatofibrosarcoma protuberans (DFSP): predictors of recurrence and the use of systemic therapy. Ann Surg Oncol2011;18:328336.

    • Search Google Scholar
    • Export Citation
  • 25

    MeguerditchianANWangJLemaB. Wide excision or Mohs micrographic surgery for the treatment of primary dermatofibrosarcoma protuberans. Am J Clin Oncol2009;33:300303.

    • Search Google Scholar
    • Export Citation
  • 26

    McArthurG. Molecularly targeted treatment for dermatofibrosarcoma protuberans. Semin Oncol2004;31:3036.

  • 27

    SjoblomTShimizuAO’BrienKP. Growth inhibition of dermatofibrosarcoma protuberans tumors by the platelet-derived growth factor receptor antagonist STI571 through induction of apoptosis. Cancer Res2001;61:57785783.

    • Search Google Scholar
    • Export Citation
  • 28

    MendenhallWMZloteckiRAScarboroughMT. Dermatofibrosarcoma protuberans. Cancer2004;101:25032508.

  • 29

    LabropoulosSVFletcherJAOliveiraAM. Sustained complete remission of metastatic dermatofibrosarcoma protuberans with imatinib mesylate. Anticancer Drugs2005;16:461466.

    • Search Google Scholar
    • Export Citation
  • 30

    McArthurGADemetriGDvan OosteromA. Molecular and clinical analysis of locally advanced dermatofibrosarcoma protuberans treated with imatinib: imatinib target exploration consortium study B2225. J Clin Oncol2005;23:866873.

    • Search Google Scholar
    • Export Citation
  • 31

    RubinBPSchuetzeSMEaryJF. Molecular targeting of platelet-derived growth factor B by imatinib mesylate in a patient with metastatic dermatofibrosarcoma protuberans. J Clin Oncol2002;20:35863591.

    • Search Google Scholar
    • Export Citation
  • 32

    UgurelSUtikalJMohrP. Imatinib in locally advanced dermatofibrosarcoma protuberans (DFSP): a phase II trial of the Dermatologic Cooperative Oncology Group (DeCOG) [abstract]. J Clin Oncol2006;24(Suppl 18):Abstract 9561.

    • Search Google Scholar
    • Export Citation
  • 33

    RutkowskiPVan GlabbekeMRankinCJ. Imatinib mesylate in advanced dermatofibrosarcoma protuberans: pooled analysis of two phase II clinical trials. J Clin Oncol2010;28:17721779.

    • Search Google Scholar
    • Export Citation
  • 34

    McArthurGA. Molecular targeting of dermatofibrosarcoma protuberans: a new approach to a surgical disease. J Natl Compr Canc Netw2007;5:557562.

    • Search Google Scholar
    • Export Citation
  • 35

    SuitHSpiroIMankinHJ. Radiation in management of patients with dermatofibrosarcoma protuberans. J Clin Oncol1996;14:23652369.

  • 36

    BalloMTZagarsGKPistersPPollackA. The role of radiation therapy in the management of dermatofibrosarcoma protuberans. Int J Radiat Oncol Biol Phys1998;40:823827.

    • Search Google Scholar
    • Export Citation
  • 37

    DaganRMorrisCGZloteckiRA. Radiotherapy in the treatment of dermatofibrosarcoma protuberans. Am J Clin Oncol2005;28:537539.

  • 38

    SunLMWangCJHuangCC. Dermatofibrosarcoma protuberans: treatment results of 35 cases. Radiother Oncol2000;57:175181.

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