The Role of CD34 and D2-40 in the Differentiation of Dermatofibroma and Dermatofibrosarcoma Protuberans
Canan SADULLAHOĞLU1, Yelda DERE2, Türkan REZANKO ATASEVER3, Mine TUNAKAN ÖZTOP3, Önder KARAASLAN4
1Department of Pathology, Antalya Training and Research Hospital, Antalya, Turkey
2Mugla Sıtkı Koçman University Faculty of Medicine, Mugla, Turkey
3Izmir Ataturk Training and Research Hospital, Izmir, Turkey
4Department of Plastic and Reconstructive Surgery, Izmir Ataturk Training and Research Hospital, Izmir, Turkey
Keywords: Dermatofibroma, Dermatofibrosarcoma protuberans, CD34, D2-40, Podoplanin
Dermatofibroma (DF) is a benign fibrohistiocytic tumor whereas dermatofibrosarcoma protuberans (DFSP) has intermediate
malignant potential. CD34 is the most commonly used antibody in differentiating these tumors. Various studies have stated the rates of D2-40
expression as 0-50% in DFSPs and 86-100% in DFs. Our aim in this study was to determine the expression of CD34 and D2-40 in DFs and DFSPs
and the possible use of D2-40 in the differential diagnosis of these lesions.
Material and Method: This is a retrospective study including 30 DF and 15 DFSP cases which were reevaluated for epidermal changes, the
presence of a transmission zone (Grenz zone), infiltration of soft tissues, infiltration pattern and histologic subtypes in addition to cellular
pleomorphism, nuclear atypia, and necrosis. A manual immunohistochemistry procedure was performed with D2-40 and CD 34 antibodies
using a representative paraffin block.
Results: The average age was 37.36 and 42.86 years in the DF and DFSP cases. The average diameter was 0.9 and 5.03 cm, respectively, for the DFs
and DFSPs. There was a significant correlation between the two entities for sex, localization and diameter of the lesion. A significant difference
was found between the positivity of CD34 and D2-40 in DFs and DFSPs.
Conclusion: Additional immunohistochemical markers may be needed in DFs with CD34 positivity. Our results showed the additional helpful
role of this marker in problematic cases.
Dermatofibroma (DF) is a benign fibrohistiocytic tumor
usually seen in women and located in the limbs. Dermatofibrosarcoma
protuberans (DFSP) is a fibrohistiocytic tumor
with intermediate malignant potential. The recurrence
rate and the metastatic potential is higher in DFSP. Due to
the differences in treatment and prognosis, it is important
to diagnose these lesions correctly. In practice, CD34 and
Factor XIIIa markers are often used to distinguish DP from
. Some studies have reported focal positivity
with CD34 in DF, especially in the peripheral region of the
. D2-40, a monoclonal antibody usually known as
podoplanin, is the main marker of lymphatic endothelium.
Various studies have stated the rate of D2-40 expression
as 0-50% for DFSPs and 86-100% for DFs4-7
. In this
study, we aimed to determine the expression of CD34 and
D2-40 in DFs and DFSPs together with the possible use of
D2-40 as a second step marker after CD34 in differential
This study includes 30 DF and 15 DFSP cases diagnosed
at Izmir Katip Çelebi University Ataturk Training and
Research Hospitals Department of Pathology between 2005
and 2011. The study has ethical approval from the 9 Eylul
University Ethics Committee (approval no: 2011/35-17).
We collected demographic data of the cases from the
hospital records. The age and sex of the patients, the
localization and diameter of the lesion, and the state
of recurrence and metastasis were recorded. All the
hematoxylin-eosin stained slides were revised and
epidermal changes, the presence of a transmission zone
(Grenz zone) between the epidermis and the lesion, the
infiltration of perilesional soft tissues and the infiltration
pattern, and the histological subtypes were noted in addition
to the presence of cellular pleomorphism, nuclear atypia,
and necrosis. A demonstrative paraffin-embedded block
was selected for immunohistochemical study in all cases. A manual immunohistochemistry procedure was performed
with D2-40 (Monoclonal Mouse Anti-human, clone D2-
40, DAKO) and CD 34 (Monoclonal Mouse Anti-human,
clone QBEnd 10, DAKO) antibodies. Internal vascular
structures were accepted as positive control for CD34 and
mesothelioma was used as the external positive control for
D2-40. Cytoplasmic staining for CD34 and membranous
and cytoplasmic staining for D2-40 were accepted as
positive and the expressions were classified as follows: no
staining was negative; 1-25% of the cells staining, including
patchy and peripheral staining, was focal positive; and over
25% the cells staining was diffuse positive.
Statistical analysis was carried out with the SSPS 14.0
software (SPSS, Inc., Chicago, USA). The statistical
associations between CD34 and D2-40 expression in the
histological samples were assessed using the chi-squared
test. Clinicopathological variables were assessed with the
chi-squared and Fisher exact tests. A p value of less than
0.05 was considered to be statistically significant.
The average of age in the DF and DFSP cases was 37.36
and 42.86 years, respectively. In the DF group, 22 (73.3%)
cases were female and 8 (26.7%) were male. The male
patients formed 60% of the DFSP cases with 9 cases. The
localizations of the DF was the limbs in 70%, the trunk in
23% and the head and neck region in 7%s. DFSPs were
located on the trunk in 66.7%, head and neck region in
20%, and the limbs in 13.3%. The average diameter of DFs
and DFSPs were measured as 0.9 and 5.03 cm, respectively.
No significant relationship was found between the DFs and
DFSPs according to age distribution (p=0.245). However,
there was a significant correlation for sex, localization and
diameter of the lesion between the two entities (p=0.03,
p=0.002, p=0.001). Eleven of 15 DFSPs had follow-up in
our study and only one of these had a lung metastasis in the
two years after the diagnosis.
Epidermal hyperplasia and Grenz zone were more frequent
in DFs whereas the infiltration of lipomatous tissue and mitosis were usually observed in DFSPs (Figure 1A,B).
Among the DF cases, 6 could be subclassifed as the
atrophic type in 3, the cellular type in 2 and the lipidized
type in 1 whereas 24 were unclassified. One of the 15 DFSP
cases showed fibrosarcoma-like and 2 showed malignant
fibrous histiocytoma-like areas. In addition 2 DFSPs were
associated with myxoid changes.
Click Here to Zoom
|Figure 1: A) Grenz zone in Dermatofibroma, (H&E;
x40). B) Honeycomb infiltration of lipomatous tissue in
Dermatofibrosarcoma Protuberans (H&E; x200). C) Diffuse
positivity of CD34 in Dermatofibrosarcoma Protuberans (CD34;
Seven DF cases expressed CD34 only focally while diffuse
CD34 expression was observed in 14 (93.3%) of the DFSPs
(Figure 1C). None of the DF cases showed diffuse expression
of CD34. Focal positivity was mostly in the peripheral
region or in central areas but patchy (Figure 2A). The
atrophic type (3 cases), cellular type (2 cases) and lipidized
type (1 case) had no CD34 expression. CD34 positivity was
lower in the myxoid and sarcomatoid differentiated areas
of DFSPs (Figure 2B).
Click Here to Zoom
|Figure 2: A) CD34 showed focal positivity in the peripheral
region of Dermatofibroma (CD34; x400), and B) in myxoid
areas of Dermatofibroma Protuberans (CD34; x200). C) Diffuse
positivity of D2-40 in Dermatofibroma (D2-40; x100).
Six of the 30 (20%) DFs showed focal and 23 cases (76.7%)
showed diffuse D2-40 expression (Figure 2C). Of the 15
DFSPs, only 3 (20%) showed focal and 2 (13.3%) showed
diffuse positivity with D2-40. A significant difference was
found between the CD34 and D2-40 positivity of the DFs
and DFSPs (p=0.000, p=0.000) (Table I).
Click Here to Zoom
|Table I: The positivity rate of CD34 and D2-40 in Dermatofibroma and Dermatofibrosarcoma Protuberans
Dermatofibroma (DF) and Dermatofibrosarcoma protuberans
(DFSP) are fibrohistiocytic tumors with unknown
. DFs are generally seen in females with a
limb localization and a mean diameter of 1 cm while DFSPs
are more common in males with a trunk localization and
a mean diameter of 5 cm1,8,9
. In our study, the mean
age of DFs and DFSPs were not statistically significantly
different and were concordant with the literature. DFs and
DFSPs had a sex distribution, size and localization similar
to that reported in the literature1,2
. DFSP has a local
recurrence rate of 7% after extensive resection with negative
margins. Its metastasis rate is 5%, most commonly to the
regional lymph nodes and lung1,2
. We followed-up 11
DFSP cases in this study and only one had lung metastasis
in the two years after the diagnosis.
We also found that histopathologic features such as a
Grenz zone and epidermal hyperplasia were more common
in DFs, as reported by Korkolis et al.10.
CD34 is a 115 KD cell surface glycoprotein expressed by
myeloid and lymphoid progenitors and endothelial cells8,11,12. In our study, CD34 positivity was observed in
23.4% of DFs and was only focally positive in the peripheral
region of the lesion. However, 14 of the 15 DFSPs (93.3%)
showed diffuse CD34 positivity, as in the findings reported
by Reimann and Fletcher13 and Raica et al.14. The
focal positivity in one case could be related to the extensive
myxoid change seen in that case.
D2-40 (podoplanin) is a monoclonal antibody of sialoglycoprotein
and is used as a lymphatic endothelial marker in
determining lymphatic invasion of solid tumors. Tumors
with D2-40 expression include lymphangiomas and Kaposi
sarcoma, ependymoma, meningioma, chondroid tumors
The results of studies on D2-40 expression in soft tissue
tumors have shown that follicular dendritic cells and tumors
originating from these cells express D2-40. However, there
is limited data on the expression of D2-40 in DF and DFSPs4-6. The more frequent expression of D2-40 in DFs in
our study is concordant with reports suggesting a dermal
dendrocytic origin of the lesion. In addition, D2-40 was
expressed less in DFSPs, suggesting that the DFSP does not
originate from dermal dendrocytes and does not contain
cells epithelial-mesenchymal transition6.
Bandarchi et al. have stated that all DFs showed D2-40
with 100% negativity in DFSPs and recommended D2-
40 as a helpful marker in differentiating these two lesions4. In addition, Kaddu and Leinweber suggested that
D2-40 expression could be used in differentiating cellular
neurothekeomas and DFs from similar entities in their
study on 30 DFs and 15 cellular thekeomas5. Our results
also showed a statistically significant relationship between
the D2-40 expressions of DFs and DFSPs. However, a
controversial result from the Xu et al. study revealed that
many malignant or benign subtypes of soft tissue tumors
may show D2-40 expression with no statistically significant
In conclusion, DFs and DFSPs may show similar
morphological and immunohistochemical features causing
problems in the differential diagnosis, especially in cases
without adequate sampling of the lesions. Additional
immunohistochemical markers may be needed in DFs with
CD34 positivity or DFSPs with myxoid degeneration and
sarcomatous differentiation where the CD34 positivity decreases. Our results showed that the higher positivity of
D2-40 in DFs compared to DFSPs indicates an additional
helpful role for this marker in the differential diagnosis
of problematic cases. Further studies are needed to prove
the importance of D2-40 in fibrohistiocytic tumors and
especially DFs because of the controversial results reported
in the literature. In addition, more studies are needed to
enlighten the histogenesis of these tumors which may be
categorized by their origin in the future.
Thanks to Prof. Dr. Fulya Çakalağaoğlu and Dr. Neşe Ekinci
for her contribution to the study and Hüseyin Candan for
CONFLICT of INTEREST
The authors declare no conflict of interest.
1) Weiss WS, Goldblum JR. Benign fibrohistiocytic tumors and
fibrohistiocytic tumors of intermediate malignancy, In: Enzinger
& Weisss soft tissue tumors. Philadelphia: Elsevier; 2008. 331-
2) Strutton G, Rubin AI, Weedon D. Tumors and tumor-like
proliferations of fibrous and related tissues. In: Strutton G, Rubin
AI, Weedon D, editors. Weedons skin pathology. Philadelphia:
Elsevier; 2011. 810-844.
3) L uzar B, Calonje E. Cutaneous fibrohistiocytic tumours- an
update. Histopathology. 2010;56:148-65.
4) Bandarchi B, Ma L, Marginean C, Hafezi S, Zubovits J, Rasty G.
D2-40, a novel immunohistochemical marker in differentiating
dermatofibroma from dermatofibrosarcoma protuberans. Mod
5) K addu S, Leinweber B. Podoplanin expression in fibrous histiocytomas
and cellular neurothekeomas. Am J Dermatopathol.
6) Xu Y, Agose A, Kawashima H, et al. High-level expression
of podoplanin in benign and malignant soft tissue tumors;
Immunohistochemical and quantitative real-time RT-PCR
analysis. Oncol Rep. 2011;25:599-607.
7) Plaza JA, Ortega PF, Stockman DL, Suster S. Value of P63 and
podoplanin (D2-40) immunoreactivity in the distinction between
primary cutaneous tumors and adenocarcinomas metastatic to
the skin: A clinicopathologic and immunohistochemical study of
79 cases. J Cutan Pathol. 2010;37:403-10.
8) Han TY, Chang HS, Lee JHK et al. A clinical and histopathological
study of 122 cases dermatofibroma (Benign Fibrous
Histiocytoma). Ann Dermatol. 2011;23(2):185-91.
9) Sanmartin O, Llombart B, López-Guerrero JA, Serra C, Requena
C, Guillén C. Dermatofibrosarcoma protuberans. Actas
10) K orkolis DP1, Liapakis IE, Vassilopoulos PP. Dermatofibrosarcoma
protuberans: Clinicopathological aspects of an unusual
cutaneous tumor. Anticancer Res. 2007;27:1631-4.
11) Tardio JC. CD34-reactive tumors of the skin. An updated review
of an ever-growing list of lesions. J Cutan Pathol. 2008;36:89-102.
12) L i N, McNiff J, Hui P. Differential expression of HMGA1 and
HMGA2 in dermatofibroma and dermatofibrosarcoma protuberans:
Potential diagnostic applications, and comparison with
histologic findings, CD34, and Factor XIIIa immunoreactivity.
Am J Dermatopathol. 2004;26:267-72.
13) Reimann JD, Fletcher CDM. Myxoid dermatofibrosarcoma
protuberans: A rare variant analyzed in a series of 23 cases. Am J
Surg Pathol. 2007;31:1371-77.
14) Raica M, Cimpean AM, Ribatti D. The role of podoplanin in
tumor progression and metastasis. Anticancer Res. 2008;28: