Background and Objectives: In extramammary Pagets disease (EPD), the prognosis is serious in cases in which the tumor cells invade into the dermis from the epidermis or metastasis to lymph nodes occur. Recently, some authors have suggested the usefulness of a sentinel node biopsy, but there is a paucity of data for EPD. We review the usefulness and the indications for sentinel node biopsy in EPD. Methods: The study included a retrospective analysis of 35 patients with EPD. (SNB was performed in 17 cases, and we compared the pre-and-post operative clinical appearance and histological findings in the two groups. Results: We found discrepancies in the histological findings (invasion level) between the biopsy specimens and the postoperative specimens. However in 18 of 25 cases which included erosions, indurated plaques, or nodules at the first clinical presentation, dermal invasions of tumor cells were histologically detected. Dermal invasions were not found in the 4 patients without clinical findings suggesting dermal invasion (erosions, indurated plaques, or nodules). In our study, the identification rate of SNB was 95.7%, and the correct diagnosis rate was 100%. Conclusion: Our study indicated that, in some cases, it was impossible to predict the presence of the dermal invasion of Pagetʼs cells based only on the preoperative biopsy specimen. SNB is strongly recommended when indurated plaques, erosions, and nodules are found in EPD lesions.
Recently, it is becoming increasingly important to protect the skin from ultraviolet rays. However, many Japanese schools do not permit the use of sunscreens in swimming pools, the main reason being “pollution of pool water”. In Osaka Prefecture after the swimming season in the summer of 2007, we examined the quality of swimming pool water (pH, turbidity, free residual chlorine, potassium permanganate consumption, Escherichia coli, and trihalomethane) at 14 junior high schools: sunscreens allowed in 4; conditional use in 3; banned in 7. The results showed that, among the 6 standards for school environmental health defined by the Ministry of Education, Culture, Sports, Science and Technology, there were no deviations from the reference values for turbidity, potassium permanganate consumption, Escherichia coli, or trihalomethane. Free residual chlorine and pH tended to deviate from the reference values at schools where sunscreen agents were permitted to be used freely or under certain conditions. A statistical investigation is difficult to perform due to the small number of samples and differences in conditions at each school, but if the residual chlorine concentration in pool water is periodically measured and controlled and makeup water is added, then it appears that there should be no problem in using sunscreen agents in order to prevent damage caused by ultraviolet rays.
We report a case of pyoderma gangrenosum (PG), which was refractory to steroid therapy but successfully treated with combination of predonisolone (PSL) and cyclosporine (CyA). A 33-year-old man with inactive Crohnʼs disease was referred to our department with 5-month history of painful ulcer on the leg. Oral PSL (30 mg/day) was already given under the suspicion of PG in other clinic. Because of poor response to the therapy, treatment with steroid pulse therapy (methyl-PSL at 1g/day for 3 days) was additionally started and followed by oral PSL (60 mg/day), but without obvious effects. On the first visit, physical examination revealed a localized, granulomatously elevated ulcer covered with white-yellowish necrosis on the lateral region of right lower leg. A lesional biopsy showed a diffuse neutrophic infiltrate from the entire dermis to the muscle. In addition, computed tomography revealed deep venous thrombosis (DVT) in veins of the right leg .A diagnosis of PG complicated by DVT in the affected limb was made. Anticoagulant therapy and CyA (3 mg/kg/day) were introduced, resulting in a rapid stabilization of disease activity. After tapering of PSL to 10 mg/day, the remaining ulcer was treated with skin grafting, without relapse of the skin lesions. Although PG is often challenging to manage and requires aggressive local and systemic treatments, no guidelines for treatment have been established. We also survey 10 cases of PG experienced in our clinic over the last 5 years and discuss their treatment.
We treated two cases of parotid lymph node metastases of cutaneous head and neck melanoma. Case 1, a 35-year-old man, had a melanoma on the right cheek (tumor thickness: 1.7 mm). Parotid lymph node micrometastasis was detected by sentinel lymph node (SLN) biopsy. Superficial parotidectomy and selective neck dissection (SND) (level I and II) were performed. The pathologic staging was pT2aN1aM0 stage IIIA. Six courses of DAV-Feron therapy were added as adjuvant therapy, and the patient is free of disease 62 months after the operation. Case 2, a 40-year-old woman, had a melanoma on the left temple (tumor thickness: 22 mm). A parotid node metastasis, 1.5 cm in diameter, was detected by SLN biopsy. Superficial parotidectomy and SND (level I, II and III) were performed. The pathologic staging was pT4bN1bM0 stage IIIC. Despite adjuvant therapy using a course of DAV-feron, parotid lymph node metastasis reoccurred 4 months after the operation. After the local excision of this metastatic lymph node, additional radiotherapy for parotid region and neck was employed. Eight months after the operation, lung metastases arose, and several courses of DTIC therapy have been performed. We discussed the surgical management of parotid region and cervical lymph nodes and the additional postoperative local treatment options such as radiotherapy when parotid lymph node metastases are detected. We conclude that SND of levels I to III and superficial parotidectomy including preauricular node dissection should be applied in cases of parotid lymph node metastases.