Malignancy Arising Within Cutaneous Tattoos: Case of Dermatofibrosarcoma Protuberans and Review of Literature

August 2011 | Volume 10 | Issue 8 | Original Article | 837 | Copyright © 2011

Kavitha K. Reddy MD,a C. William Hanke MD, MPH,b Emily P. Tierney MDa,b

aDepartment of Dermatology, Boston University School of Medicine, Boston, Massachusetts
bLaser and Skin Surgery Center of Indiana, Carmel, Indiana

Abstract

Background. Dermatofibrosarcoma protuberans (DFSP) is an uncommon tumor of the skin with high rates of local recurrence. Several reports describe a frequent history of local trauma. In one prior case, a DFSP arising in a tattoo site has been reported. Mohs micrographic surgery (MMS) has been used successfully for treatment.
Objective. To present a case of dermatofibrosarcoma protuberans arising in the site of a prior and current tattoo, and treated with Mohs micrographic surgery.
Methods. We present findings of a case of a DFSP arising in a tattoo and a review of Medline literature on the association between tattoos and cutaneous malignancy, and treatment of DFSP with MMS.
Results. Review of the literature confirms multiple reports of DFSP arising in sites of local trauma, as well as malignancies arising in sites of tattoos. The recurrence rate for MMS treatment of DFSP (0-6.6%) was found to be significantly lower than that for patients treated with wide local excision (13% to 95%).
Conclusions. DFSP should be considered in the differential diagnosis of neoplasms arising within areas of tattoos. Sites of local trauma and tattoos may show predilection for benign and malignant changes and should be evaluated during regular skin exams. Review of the literature confirms MMS is an ideal treatment modality for DFSP as the tumor often extends far beyond clinical margins.

J Drugs Dermatol. 2011;10(8):910-915.

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BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is an uncommon dermal and subcutaneous neoplasm with a predilection for the trunk of young to middle-aged adults. The tumor presents clinically as solitary or multiple skin-colored, red, or violaceous indurated plaques or nodules. The history often describes a slowly growing painless lump. Aggressive local recurrence occurs if inadequately excised. Metastasis is rare but has been reported in multiply recurrent tumors, primarily to the lungs.1-8

The pathogenesis remains unclear. The cell of origin is believed to be fibroblastic or neural-related.1,2 Reciprocal translocation allowing the collagen type I alpha-1 gene to continuously activate the platelet derived growth factor (PDGF) B-chain gene, t(17;22)(q22;q13), characterizes tumor cells and presumably supports malignant growth. A number of authors have reported cases of DFSP arising at sites of local trauma and suggested a causal relationship2-9,21-23 Cases to date include the development of DFSP at sites of surgical scars, burn scars, and at sites of prior immunization and therapeutic irradiation.3-14

DFSP was reported to arise in the site of a cutaneous tattoo in one prior report.24 The tattoo was on the forearm and had been present for eight years. Benign and malignant tumors, along with inflammatory disorders, have been described in association with decorative tattooing. Reported neoplasms include seborrheic keratosis, basal cell carcinoma, squamous cell carcinoma, malignant melanoma and DFSP.25-30 Further reported is the development of DFSP at sites of trauma, ranging from vaccination sites to bayonet wounds,3 surgical scars,32-34 burn scars,35-36 sites of prior immunization5-8 and therapeutic irradiation. 12,30 Increased frequency of trauma to the hands and feet is thought to account for a higher incidence of acral DFSP in children and adolescents compared to adults.31 Trauma preceded tumor development by periods ranging from two months to 20 years, although shorter periods tended to pre- dominate.3 A clinical history of previous local trauma was obtained in up to 10–20 percent of all cases of DFSP by some authors.3,8,10,21

Scars are often a predisposing factor in the development of cutaneous malignancy and there have been several previous

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