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Dermatofibrosarcoma Protuberans of the Scalp: A Challenging Tumor With a Proposed Modification to the Slow Mohs Technique.

Dermatofibrosarcoma protuberans (DFSP) is a malignant cutaneous spindle cell tumor.Histologically tumorfree margins must be achieved to ensure cure. The scalp is a common site of occurrence with higher rates of recurrence compared with other body sites. This in part is due to the locally invasivenatureofDFSP tentaclelike projections within septal and fascial planes making histological examination very difficult (Figure 1). The gold standardof care is slowMohsmicrographic surgery assisted by immunohistochemistry to highlight subtle margin involvement (Figure 2). As long as there is scope to extend the surgery both laterally and toward the deep margin on subsequent stages, differentiation of the deep and lateral margin on histology is not necessary. Once a plane is reached when further Mohs micrographic surgery (MMS) is limited in direction, for example, reaches the level of the skull bone, differentiation of lateral/deep margin involvement becomes paramount. Deep (periosteal) margin involvement would require multidisciplinary referral to neurosurgery and fall outside of the merit of MMS.