Cheek region most likely location of dermatofibrosarcoma protuberans, study finds

Dermatofibrosarcoma protuberans (DFSP) of the face. Photo by Tontonflingueur via Wikimedia Commons

Dermatofibrosarcoma protuberans (DFSP) rarely affects the head and face—but when it does, new research suggests the cheek is the prime location. In what is described as the largest clinical cohort of facial DFSP to date, investigators at a single Chinese institution have mapped the complex distribution of the tumour across facial subunits, uncovering distinct anatomic and biological patterns that may shape diagnosis and treatment.

The retrospective analysis, published in the Chinese Journal of Plastic and Reconstructive Surgery, reviewed records of 161 patients with a histologically confirmed case of the rare and locally aggressive cutaneous sarcoma. The researchers identified 26 cases (16.1%) of DFSP involving the head and face.

“Tumour locations were mapped according to well-defined facial fat compartments, including the cheek, scalp, forehead, and temporal region, nasolabial and jowl, and otic areas,” said lead author Dr. Zhu Zhu in a press release. “The cheek emerged as the dominant site, accounting for 65.38 per cent of all head-and-face DFSPs, whereas no tumours were found in the nasal or orbital compartments.”

This disproportionate clustering raises the possibility that regional anatomic or biological factors influence tumour development. Compared with patients whose tumours arose elsewhere on the head or face, those with cheek DFSP were significantly older (mean age 48.82 vs. 37.22 years, p=0.04). Sex, tumour size, depth, recurrence rate, and trauma history did not differ significantly between locations.

Histological analysis further underscored spatial heterogeneity. “Most tumours were conventional DFSP (88.5 per cent), but three cases were fibrosarcomatous DFSP (FS-DFSP), a more aggressive subtype associated with higher recurrence and metastatic risk. Notably, all FS-DFSP cases occurred in non-cheek regions, whereas none were observed in the cheek (p=0.032),” Dr. Zhu reported.

The authors propose that local adipose composition may underlie these patterns. “The cheek is one of the most adipose-rich regions of the face, and DFSP characteristically infiltrates subcutaneous fat in a honeycomb pattern,” Dr. Zhu said. “Experimental and clinical evidence suggests that adipose-derived cells, inflammatory mediators, growth factors, and metabolic substrates within fat tissue may create a permissive microenvironment that supports DFSP growth while restraining aggressive fibrosarcomatous transformation.”

By contrast, non-cheek regions—such as the scalp and forehead—contain less subcutaneous fat, potentially exposing tumour cells to metabolic stress that favours dedifferentiation toward more aggressive phenotypes.

Beyond offering a clearer understanding of DFSP pathogenesis, the study provides practical clinical implications. Recognizing the cheek’s predilection for DFSP could sharpen early diagnosis in a region prone to misdiagnosis due to overlapping benign lesions and complicated anatomy. Moreover, the findings may inform surgical planning and reconstructive strategies, aligning oncologic safety with functional and aesthetic preservation.

As Dr. Zhu and colleagues note, “Recognition of this distribution pattern may assist dermatologists in the clinical assessment and management of patients, particularly for lesions involving the cheeks.”