What specialty should a patient with dermatofibrosarcoma be referred to?

Dermatofibrosarcoma Protuberans Specialty Referral

Patients with dermatofibrosarcoma protuberans (DFSP) should be managed jointly between specialist skin cancer multidisciplinary teams (MDTs) and sarcoma MDTs, with surgery performed by surgeons experienced in this disease. 1

Primary Referral Pathway

Standard DFSP (Classic Type)

• Joint management between specialist skin cancer MDTs and sarcoma MDTs is required 1
• Surgical treatment should be undertaken by surgeons with specific expertise in DFSP management 1
• Pathology evaluation by physicians with expertise in sarcoma/soft tissue pathology or dermatopathology is preferred 1

High-Risk DFSP Requiring Sarcoma Center Referral

Immediate referral to a specialized sarcoma center is mandatory for: 1, 2

• Fibrosarcomatous transformation (FS-DFSP) - carries 10-23.5% metastatic risk and 14.7% mortality risk 2
• Metastatic disease - requires multidisciplinary consultation at sarcoma centers 1, 2
• Locally advanced or unresectable disease - for consideration of neoadjuvant imatinib and complex surgical planning 1
• Recurrent disease - particularly multiple recurrences requiring specialized management 1

Surgical Specialty Considerations

Mohs Micrographic Surgery

• Dermatologic surgeons trained in Mohs surgery are preferred for peripheral margin assessment 1
• This approach achieves the lowest recurrence rates (0-6.6% vs 1.7-30.8% with standard wide excision) 1

Plastic and Reconstructive Surgery

• Required when wide excision necessitates resurfacing procedures to achieve adequate margins 1
• Essential for head and neck locations where functional and cosmetic outcomes are critical 1, 3
• Multidisciplinary approach combining Mohs surgery with plastic surgery reconstruction has shown zero recurrence in published series 4

Critical Pitfalls to Avoid

Do not manage DFSP in isolation without MDT involvement - the infiltrative growth pattern and high local recurrence risk (historically up to 60%) necessitate specialized multidisciplinary care 1

Do not delay referral when fibrosarcomatous transformation is identified - FS-DFSP has nearly 20-fold higher mortality than classic DFSP and requires immediate sarcoma center evaluation with CT imaging of draining nodal basin and chest 2

Pre-operative communication between MDTs is paramount - particularly for complex anatomic locations or when reconstruction will be needed 1