2 anatomic map to guide excision. A further tissue layer is removed and the same meticulous procedure is followed until microscopic examination shows no residual tumour. In our patient the tumour was completely removed after one stage of MMS. The defect was repaired with primary closure. Three years following treatment, there is no evidence of recurrence. 3. Discussion 3.1. Epidemiology. DFSP is a rare neoplasm accounting for 0.1% of all malignancies [4]. It typically occurs between the ages of 20 and 40 years, frequently arising on the trunk. The head and extremities are less commonly involved. DFSP of the clitoris and vulva are rare. DFSP of the vulva typically arises in the left labium majus [5]. The reason for this predilection is unclear. 3.2. Clinical Features. The tumour often presents as a solid, protuberant nodule. Due to its indolent nature, it often escapes detection in the early stages. Pain and ulceration may occur with tumours in an accelerated growth phase [3]. Aggressive local growth is characteristic. MRI can iden- tify the extent of the tumour and its relation to adjacent structures [4]. Lymphatic spread of DFSP is rare [2]. Metastatic DFSP is uncommon, occurring in less than 6% of cases. Metastases typically involve the lungs and bones [3]. 3.3. Pathology. The tumour most probably arises from a stem cell within the dermis. Local growth exhibits ﬁngerlike projections into surrounding tissue. Subsequently, it can invade the subcutaneous tissue, underlying fasciae, muscle and bone [3]. Correct histological diagnosis can be problematic as it is often diﬃcult to distinguish DFSP from other ﬁbrohistio- cytic neoplasms [3]. Comprehensive immunohistochemical studies aid the diagnosis. Histology typically shows elongated ﬁbroblasts with small nuclei arranged in a “storiform” pattern. Compared to ﬁbrous histiocytomas DFSP displays a more uniform appearance with little nuclear pleomorphism and low to moderate mitotic activity. Absence of necrosis and immuno- histochemical staining for CD34 diﬀerentiate DFSP from ﬁbrous histiocytomas [3]. 3.4. Treatment. Historically, the treatment for DFSP has been wide local excision (WLE) of both primary and recurrent lesions. The local recurrence rate of DFSP after WLE ranges from 0%–21% for trunk sites and 50%–75% for head and neck sites [1]. In the vulva the local recurrence rate after WLE ranges from 20%–49% [2]. Microscopic projections of the tumour beyond the central nodule often result in incomplete excision. Representative vertical sections used in WLE assess less than 1% of the total tumour margin. There is hence an increased risk of potentially missing these narrow projections, which may lead to tumour recurrence. Obstetrics and Gynecology International MMS uses systematic horizontal sectioning with 100% of the tumour margin being microscopically examined. This increases the likelihood of any tumour projections being detected. Since MMS allows for accurate margin control, maxi- mum preservation of healthy tissue with complete excision can be achieved. It, therefore, leaves the smallest post surgical defect and minimises recurrence. Nearly 75% of such wounds can be managed with primary closure. Tissue conservation was important in our case to pre- serve function, with the DFSP being close to the clitoris. Wide local excision with 3 cm margins as previously recom- mended [2] may have been unduly mutilating. MMS is now advocated to ensure precise margin control. The favorable success rate of MMS compared to WLE in patients with DFSP is well documented [1]. Site distribution for this technique has included head and neck, extremities, and the clitoris but not the vulva. The local recurrence rate after the ﬁrst MMS treatment for all patients with DFSP, has been reported as 7% over a 5- year period. 5 year cure rates have been reported as 92% for head and neck sites, 94% for trunk sites and 100% for DFSP in extremity sites. The 5-year cure rate for all sites was 93% after the ﬁrst MMS treatment and 98.5% after the second [1]. Local recurrence after MMS may be related to “skip” areas of tumour that become separated from the main tumour mass. However 25% of local-recurrences develop after 5 years [1]. Long term follow up is recommended. 4. Conclusion WLE for DFSP of the vulva has previously been described. MMS for DFSP of the vulva represents, however, a novel treatment. Treatment outcomes for DFSP at other sites are uniformly more favorable with MMS when compared with standard WLE [1]. This case also highlights the utility of Mohs Surgery in conserving normal tissue. We, therefore, propose that MMS is considered in all cases of primary or recurrent DFSP of the vulva. References [1] S. N. Snow, E. M. Gordon, P. O. Larson, et al., “Dermatoﬁ- brosarcoma protuberans: a report on 29 patients treated by mohs micrographic surgery with long term follow up and review of the literature,” Cancer, vol. 101, no. 1, pp. 28–38, 2004. [2] M. Moodley and J. Moodley, “Dermatoﬁbrosarcoma protuber- ans of the vulva: a case report and review of the literature,” Gynecologic Oncology, vol. 78, no. 1, pp. 74–75, 2000. [3] T. M. Soergel, D. L. Doering, D. O’Connor, et al., “Metastatic dermatoﬁbrosarcoma protuberans of the vulva: a case report,” Gynecologic Oncology, vol. 71, no. 2, pp. 320–324, 1998. [4] R. Ohlinger, S. Grunwald, G. Schwesinger, et al., “Dermatoﬁ- brosarcoma protuberans of the vulva,” Acta Obstetricia et Gynecologica Scandinavica, vol. 83, no. 7, pp. 685–686, 2004. [5] H. M. Gloster Jr., N. J. Lindner, and M. T. 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