BACKGROUND: The National Comprehensive Cancer Network (NCCN) guidelines recommend preoperative biopsy for diagnosing dermatofibrosarcoma protuberans (DFSP) but limited data support this approach. We characterized DFSP diagnostic practices and compared clinical outcomes based on technique. METHODS: Data were collected for adult patients who underwent resection for initial DFSP presentation between 2003 and 2021 at 10 international institutions. Patients were categorized by excisional versus preoperative biopsy (incisional, punch, core needle biopsies, or fine needle aspiration), and univariate and multivariable analyses were performed. RESULTS: The cohort included 321 patients, with excisional biopsy performed in 51.4% and preoperative biopsy performed in 48.6% of patients. Biopsy type was stable throughout the study period (p = 0.08). There were no differences in sex, disease presentation, or preoperative imaging. In unadjusted analysis, biopsy varied by practitioner specialty, with general surgeons performing nearly 50% of excisional biopsies. Despite similar planned circumferential margins and anatomic location, preoperative biopsy was associated with higher index R0 rate (60.1% vs. 78.6%), fewer total excisions, and fewer complications (38.2% vs. 25.6%, all p < 0.05). However, adjuvant radiotherapy (11.7% vs. 6.0%) and final R0 rates (91.5% vs. 88.4%) were comparable regardless of technique (p > 0.05). In adjusted analysis, excisional biopsy was associated with extremity tumors (odds ratio [OR] 1.79, confidence interval [CI] 1.21-2.66, p = 0.004), treatment in non-academic settings (OR 2.28, CI 1.10-4.73, p = 0.03), and inversely with preoperative imaging (OR 0.47, CI 0.24-0.93, p = 0.03). CONCLUSION: Preoperative biopsy is associated with margin-negative resection, fewer re-excisions, and reduced complications. Clinical suspicion of DFSP is paramount, and preoperative imaging may critically inform biopsy selection prior to index resection.

Department of General Surgery Temple University Hospital Philadelphia PA USA

Department of Medical Oncology Bern University Hospital University of Bern Bern Switzerland

Department of Musculoskeletal Oncology National Cancer Center Hospital Tokyo Japan

Department of Plastic and Hand Surgery Inselspital Bern University Hospital University of Bern Bern Switzerland

Department of Surgery and Clinic of Comprehensive Cancer Care Masaryk Memorial Cancer Institute Brno Czech Republic

Department of Surgery Duke University Hospital Durham NC USA

Department of Surgical Oncology University Hospitals Leuven Leuven Belgium

Division of Biostatistics and Bioinformatics Fox Chase Cancer Center Philadelphia PA USA

Division of Hematology and Medical Oncology Fox Chase Cancer Center Philadelphia PA USA

Division of Surgery Institute of Oncology Ljubljana Ljubljana Slovenia

Division of Surgical Oncology Emory University Hospital Atlanta GA USA

Division of Surgical Oncology Fox Chase Cancer Center Philadelphia PA USA

Division of Surgical Oncology Ottawa Hospital Ottawa ON Canada

Sarcoma Unit Queen Elizabeth Hospital Birmingham UK

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