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Image IQ: When is a biopsy required?
In this quiz, Kaivon Sobhani, B.S., and, Eve Lowenstein, M.D., Ph.D., FAAD, address dermatofibrosarcoma protuberans (DFSP), keloids, hypertrophic scars and dermatofibromas.
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A 74-year-old African American male presents with several dark brown skin colored, firm, raised lesions extending across his chest to his axilla and extending below his breast. They first appeared 30 years ago after he was severely burned in an accident. The lesions are occasionally itchy, but not painful. Recently, he experienced chest tightness with difficulty breathing deeply. He has no history of cancer or heart disease.
What is the diagnosis?
A. Dermatofibrosarcoma protuberans (DFSP)
B. Dermatofibroma
C. Keloid
D. Hypertrophic scar
ANSWER: C) Keloid
* Click on the image for the next question.
Which of the following images requires a biopsy?
Dermatofibrosarcoma protuberans (DFSP), dermatofibromas, keloids and hypertrophic scars are four separate conditions requiring assessment, but only one requires a biopsy.
DFSP (photo 1) is an uncommon, cutaneous tumor characterized by aggressive local growth and a tendency to recur after surgical excision. Clinically, DFSP lesions may be mistaken for keloids (photo 2), however keloids are benign growths with no metastatic potential and are the consequence to aberrant scar formation. Keloids extend beyond the site of injury, unlike hypertrophic scars (photo 3), which are confined to the site of injury. Dermatofibromas (photo 4) are benign dermal proliferation of fibroblasts.
ANSWER: Photo 1
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Which of these is best managed with injection of Triamcinolone acetonide (Kenalog)?
1. Dermatofibrosarcoma protuberans (DFSP)
2. Keloid
3. Hypertrophic scar
4. Dermatofibroma
ANSWER: Keloid and hypertrophic scar
* Click on the image for the next question.
Which is best managed by Mohs micrographic surgery (MMS)?
1. Dermatofibrosarcoma protuberans (DFSP)
2. Keloid
3. Hypertrophic scar
4. Dermatofibroma
ANSWER: Dermatofibrosarcoma protuberans (DFSP).
Of the following choices, only DFSP has malignant potential and should be managed with MMS. Although DFSP has low malignant potential, it has a tendency to recur due to tentaclelike growth pattern of tumor cells. Thus, MMS provides the best chance of excising the tumor with clear margins.
* Click on the image for the next question.
Which of these has thickened hyalinized collagen bundles arranged haphazardly with an increased number of fibroblasts?
1. Dermatofibrosarcoma protuberans (DFSP)
2. Keloid
3. Hypertrophic scar
4. Dermatofibroma
ANSWER: Keloid
* Click on the image for the next question.
Which of these exhibits pleomorphic cells arranged in a herringbone pattern?
1. Dermatofibrosarcoma protuberans (DFSP)
2. Keloid
3. Hypertrophic scar
4. Dermatofibroma
ANSWER: None of the above. The correct answer is fibrosarcoma.
* Click on the image for the next question.
Which of these exhibits cells in a storiform pattern?
1. Dermatofibrosarcoma protuberans (DFSP)
2. Keloid
3. Hypertrophic scar
4. Dermatofibroma
ANSWER: Dermatofibrosarcoma protuberans (DFSP).
The storiform pattern observed in DFSP can be contrasted to the herringbone pattern observed in fibrosarcoma and the haphazardly arranged bundles of collagen seen in keloids.
* Click on the image for the next question.
Which of these has a pigmented variant known as a Bednar tumor?
1. Dermatofibrosarcoma protuberans (DFSP)
2. Keloid
3. Hypertrophic scar
4. Dermatofibroma
ANSWER: Dermatofibrosarcoma protuberans (DFSP).
A Bednar tumor (also called pigmented DFSP) is a rare variant of DFSP that has cells with melanin pigment. The majority are located on the trunk and proximal extremities.
* Click on the image for the next question.
Which of these can metastasize?
1. Dermatofibrosarcoma protuberans (DFSP)
2. Keloid
3. Hypertrophic scar
4. Dermatofibroma
ANSWER: Dermatofibrosarcoma protuberans (DFSP)
* Click on the image for the next question.
Which of these is more common in black and Hispanic populations?
1. Dermatofibrosarcoma protuberans (DFSP)
2. Keloid
3. Hypertrophic scar
4. Dermatofibroma
ANSWER: Keloid
* Click on the image for the next question.
Which of these is CD34 positive and factor VIIIa negative?
1. Dermatofibrosarcoma protuberans (DFSP)
2. Keloid
3. Hypertrophic scar
4. Dermatofibroma
ANSWER: Dermatofibrosarcoma protuberans (DFSP)
* Click on the image for the next question.
True or false: Genetics play heavily into the propensity to make keloids?
ANSWER: True.
Keloids are seen much more commonly in darker skin individuals. Furthermore, certain syndromes have a propensity to make keloid including Rubinstein-Taybi syndrome 1, Geominne syndrome, Ehler-Danlos and possibly Turner’s Syndrome.14-16 Furthermore, in Caucasians of northern European ancestry, the HLA-DRB1*15 allele has recently been shown to be associated with keloid formation.