We present a patient of a 63-year-old male who has been suffered from slightly redthumb-head sized tumor on his right wing nose. The tumor was growing rapidly and jutted out into the nasal membrane. Histological findings revealed that the slightly atypical fibroblast-like and histiocyte-like tumor cells grew from the upper dermis of the skin to the pro lamina propria mucosae of the nasal mucous membrane. We compared this tumor with other fibrohistiocytic tumor, clinically and histologically, therefore we thought that the diagnosis of this case might be MFH after all.
A 57-year-old female case of giant sweat gland carcinoma on the head is reported.She noticed a red papule on the parie-occipital area of the scalp in 1986. In 1994, the size of the lesion became 12×13×3cm and erythema appeared from the occipitalregion to the nape. The lymph nodes of right lateral cervical and left occipital regions were enlarged. She received chemotherapy using fluorouracil and peplomycin sulfate. The therapy was effective but discontinued because of the side effect. Therefore wechanged to a different combined chemotherapy (CAV: cisplatin, adriamycin, vindesine sulfate) . The reduction of the tumor size and erythema appeared. The tendency to bleed from the tumor was also observed as the effect of CAV therapy. As there have been few reports of chemotherapy for sweat gland carcinoma, it is hopeful that chemotherapy is established in unoperated cases of the carcinoma.
Mast cells are known as a major normal cellular constituents of dermal connective tissues. They contain an array of biologically active chemical mediators in their granule. Although physiological role of mast cells still remains unclear, they definitely play an important role in hypersensitivity reactions. Apart from typical mast cells in dermal connective tissues (connective tissue mast cells: CTMC), phenotypically distinct mast cell subpopulation, named mucosal mast cells (MMC), has been identified in intestinal and respiratory mucosa. Although phenotypic difference and compartmentalization of CTMC and MMC are clearly seen in mice and rats, our recent observations of Mongolian gerbil mast cells revealed that the phenotypes of mast cell subtypes in this animal was markedly different from those of mice and rats. Similar observation has been reported on human mast cell subsets. Since local mastocytosis or mast cell infiltration is frequently observed in various pathological conditions in the skin, such as ulticaria pigmentosa, neurofibromatosis, keroid, and malignant tumors, cautions should be paled for the characteristics of mast cells involved in the pathophysiology of dermal diseases.
The cutaneous adnexal carcinomas are relatively rare, so the concept and definition of these carcinomas remains controversial. The appendage carcinomas can be deviled into three groups: hair follicle carcinoma, sweat gland carcinoma and sebaceous carcinoma. This review presented the clinical and histopathological features, diagnosis, treatment and prognosis of each group of carcinoma.
Basal cell carcinoma is discussed form the viewpoint of clinicopathology. The importance of epidemiological research is stressed and an initiative should be taken by our Japanese Society for Skin Cancer. Generally speaking, basal cell carcinoma occurs often in people of advanced ages, but it may be seen in young individuals, to which attension should be given. Basal cell carcinoma may be mistaken for other conditions, and differential diagnoses are described. The relationships between basal cell carcinoma and pigment cells are discussed. Apoptosis is a concept born out of electron microscopical findings of basal cell carcinoma. The relationships between apoptosis and the hair cycle and the significance of apoptosis in basal cell carcinoma are discussed.
We reported two cases of malignant melanoma with multiple metastases who were satisfactorily treated with electron irradiation in reducing pain of bone metastases or improving disabling nervous symptoms respectively. Case 1: A 40-year-old woman who had underwent wide local excision of a pigment macule on the left sole following three courses of chemotherapy (DAV) under the diagnosis of multiple metastases of malignant melanoma was referred to us in September, 1993. On admission, she received combination chemotherapy with ranimustine, vincristine and peplomycin which failed to prevent the metastases. For the reduction of the pain and prevention of fracture of bone metastases, electron irradiation in combination with local microwave hyperthermia was performed. The schedule was 6 Gy a time, twice a week to the total of 36 Gy on each irradiation site. Although the patient died of brain metastases in February, 1995, the effect on the pain was remarkable. Oral morphine HCl could be reduced and withdrawn during irradiation. Case 2: A 67-year-old man was admitted for his primary melanoma nodule on the left sole and lymph node metastases on the left groin in December, 1993. After wide local excision and lymph node dissection, he was treated with systemic chemotherapy (5 courses of DAV) and local IFN-β injection on secondary skin metastases without satisfactory effect. Cisplatin was also ineffective for hemiplegia, hemianopia and agnosia which developed in July, 1994. Whole and local brain electron irradiation of total 37.8 Gy improved hemiplegia and hemianopia. Metastatic image on brain CT was reduced. Irradiation was obliged to stop for leukopenia and the patient died in February, 1995. Although radiotherapy is not the first choice for malignant melanoma, especially multiple metastases so far, even low LET beam, such as electron beam, is thought to be useful clinically from our experiences.
We reported a case of malignant melanoma accompanied by multiple vitiligo withafairly Long course. The patient, a 74-year-old female, developed a small nodule with ulceration on the sole of the right foot. Physical examination revealed an ulcerated nodule on the right sole, multiple nodules on the right leg, and many hypopigmented macules on the Legs, trunk and neck. The tumors were resected and the patient underwent combination chemothelapy with DTIC, ACNU and VCR. Histological findings were consistant with amelanotic nodular melanoma. Two years after tumor resection, a nodule recurred on the right sole and was resected again. Although in-transit metastases repeatedly developed on the right lower lib after the second surgery, no evidence of distant metastasis was noted until she died of senility 13 years after the first tumor resection. The long survival observed in the present case might be related to the immune response Lo pigment cells, which was clinically manifested as melanoma associated vitiligo.
We reported a case of recurrent radiationinduced squamous cell carcinoma of theright ring finger of a 65-yearold orthopedist. He received his first amputation inanother hospital in 1989. One year later, recurrence on the stump occured and digitalray amputation was performed in July, 1992. But four months later recurrence on thefourth metacarpal region of the dorsal side was noticed. In May, 1993, we completelyremoved this tumor and dissected axillary lymph nodes after continuous cutaneousinfusion of PEP at a total dose of 50mg. Three months after surgery, epitrochlearlymph nodes metastases ocurred. Radiotherapy only was performed because thepatient refused amputation of the right upper arm. The treatment was not radical. It is difficult to decide to amputate the upper arm, taking into consideration of thequality of life of the patient. But amputation of the upper arm and dissection ofaxillary lymph nodes for a recurrent tumor of a hand would be a better treatment.
A case of eccrine porocarcinoma with lymphnode metastasis and local reccurence is described. The patient, a 76-year-old man, had a excision of a 3cm tumor on his foot before 7 months. Thirty three cases of sweat gland carcinoma treated at Chiba University Hospital between 1979 and 1994 were also analyzed. Lymphnode metastases were observed in 17 cases.
We report on the treatment of a brother and a sister diagnosed to have basal cell epithelioma (BCE) and the results of HLA. The brother was 79 years old and had a solid type BCE on the left ala of nose, while the sister aged 66 years old had a solid type BCE on the left retroauricular region. HLA indicated All, B54, CW1, DR4, DQ7 as common in these 2 cases. Of these, A11 and B54 are generally observed in Japanese. In this regard, CW1, DR4 or DQ7 was suspected to have a relationship, if any, to the incidence of BCE.
We have studied 161 lesions of solar keratoses in 67 patients. The peak for age distribution was between 70 and 79 years old. The majority of these cases had SK on the face. The solar keratoses with invasive lesion were in 9 (13%) of 67 patients. By an immunohistochemical study, 15 (50%) of 30 specimens without invasive lesion showed nuclear staining with anti-p53 antibody, while 8 (80%) of 10 specimens with invasive lesion were p53 positive. In the cases with high p53 expression (Labeling index exceeding 30%), there was no difference between SKs with invasive lesion and those without invasive lesion. The MMP-9 positive cells were observed in 5 (50%) of 10 specimens in SK with invasive lesion, suggesting that the expression of this proteinase may be involved in the process of SK invasion.
A 72-year-old man had a 1-year history of erythema on the left upper arm. A biopsy specimen was diagnosed as malignant lymphoma, diffuse large cell type. Atypical lymphocytic cells expressed B-cell lineage markers such as CD19, CD20 and CD22 antigens. Rearranged bands were observed for immunoglobulin heavy-chain gene by Southern blot analysis. Physical examination showed left tonsilla and left neck lymphnode swelling. CT scans showed multiple lesions considered to be stage IV.
We report a case of Extramammary Paget's disease occurring in a siblings. Case 1 was the elderly brother, age of 83-years old at 1994, suffered from an eczematous lesion on his genital region. Skin biopsy revealed that the lesion was Paget's disease. He had a complication of inguinal hernia, which was surgicaly removed at the time of operation of Paget's disease. Case 2 was the young brother of case 1, age of 73-years old at 1987, also had Paget's disease coexistent with inguinal hernia. Case 2 underwent an operation of Paget's disease, seven years before case 1. In our case, the pedigree suggests that Extramammary Paget's disease would have an autosomal ressesive inheritance. The pedigree also shows that the inguinal hernia which were seen in three of four generations had an autosomal dominant inheritance.
We report a case of extramammary Paget's carcinoma successfully responded rIFN-α-2a. At the first visit, he had an infiltrated erythema on the right scrotum, and right inguinal lymphadenopathy. Computerized tomogram revealed pariaortic lymph node metastasis. We injected rIFN-α-2a (600 million IU) around the lesion at five or three times/week. This therapy inhibited lymph node enlargement and down regulated serum CEA level. The side effects were leukocytopenia, modest fever and appetite loss, which did not influenced to his social activity. Even for a patient with non curative operation and cardiac failure inducted rIFN-α-2a therapy without cytotoxic anti-tumor drugs.
The prognosis of malignant melanoma has been improving recently in Japan. One of the possible explanations for the favorable prognosis observed in the past 2 decadesis the increase in the number of stage I and II cases of acral lentiginous melanoma. Concurrently with such a trend, melanoma in situ has also increased in incidence. We have experienced 40 cases of melanoma in situ in the past 25 years. A clinicaldiagnosis of melanoma in situ was made in 27 of 40 cases; in the remaining 7 were diagnosed as pigmented nail streaks and 6 as acquired melanocytic nevus. Of the 40 lesions, 250 ccurred on the acral regions, 8 on the face, 6 on the oral mucousmembrane, and the remaining one on the trunk. No cases involved the extremitiesother than hands and feet. There was no sex difference, but female cases were predominant in the lesions developing on the mucous membrane and face. Almost all histological specimens showed the lentiginous type of proliferation of tumor cells. Corresponding to the fact that ALM is the most common type in the Japanese, thepredisposing sites for melanoma in situ in Japan were also the acral regions.
A case of pigmented Spitz nevus in a 12-year-old boy is reported. Approximately 3 years previously he noticed a small pigmentation on the right dorsum pedis, andgradually increased in size and elevated. Physical examination revealed a 13×10mm, dome-shaped, black nodule with irregular margin. An excisional biopsy specimen was histologically diagnosed as nodular malignant melanoma at that time. A wide excision with skin grafting and right inguinal lymph node dissection were performed. Recently, we checked clinically and histologically again and requested a fluorescence microscopy of formalin-fixed paraffin-embedded unstained specimen and a DNA distribution histogram. We put the various reports together and finally made the established diagnosis aspigmented Spitz nevus. Occasionally, a differentiation of a pigmented Spitz nevus from a malignant melanoma is very difficult. So, we need more information such as a fluorescent finding and a distribution histogram to avoid a misdiagnosis.
We report a case of sporadic dysplastic novus associated with malignant melanoma. A 29-year-old Japanese female had been noticed a black nodule on her right buttock three years' duration and was first recommended to consult it to our clinic by agynecologist after her first delivery. The nodule was flatly elevated and 18×8mm in diameter. Histological examination of the nodule revealed superficial spreading melanoma, Clark's level IV with a maximal tumor thickness of 1.8mm. There were metastases in the inguinal and parailiac lymph nodes. Aphysical examination revealed a total of ca. 120 brownish macules ranging from 2 to 9mm in diameter on her whole body surface. She had paler skin and sunburned easily. Four of these pigmented macules were histologically diagnosed as dysplastic nevi. Family history revealed neither dysplastic nevi nor malignant melanoma. This is a fifteenth report of a Japanese patient developing malignant melanoma in association with dysplastic nevi.
A 38-year-old man presented with a black pigmented fleck of his left upper eyelid. This had been present for 3 years. During 3 years it was gradually increased in size and spread from his upper eyelid to his lower eyelid and bulbar conjunctiva. The biopsies of the eyelid skin and bulbar conjunctiva were performed, and histology confirmed malignant melanoma in situ. Then the lesion was excised with 1.5cm margins and orbital exenteration was performed. Histology showed malignant melanoma 0.4mm thick with no dermal invasion. In this report we discussed surgical management of primary cutaneous malignant melanoma of the eyelid with conjunctival involvement.
Sixty patients with malignant melanoma were studied. The sex ratio was male 29: female 31. The patient age ranged from 17 to 86 years (mean age, 59.6 years) . The primary tumors were 28 acral lentigenous melanomas, 17 superficial spreading melanomas, 4 nodular melanomas, 3 lentigo maligna melanomas and 2 mucosal melanomas. The level of tumor invasion was identified as II (2 patients), III (6 patients), IV (32 patients) and V (6 patients) . Tumor thickness was distinguished into four groups: less than 0.76mm (4 patients), between 0.76 and 1.50mm (5 patients), between 1.51 and 4.0mm (15 patients) and more than 4.0mm (18 patients) . Using the Kaplan-Meier life table method coupled with the log-rank test, univariate survival analyses were performed for 8 factors (age, sex, treatment history, histologic type of melanoma, level of invasion, tumor thickness, metastases to regional lymph nodes and pathologic stage). These variables other than stage, which was essentially a dependent factor, were further analyzed by the multivariate analytical method of the Cox proportional hazards model in order to determine the primary independent risk factor predicting survival in melanoma patients. The Kaplan-Meier life table method demonstrated the following three factors that worsen patient survival significantly evidence of metastasis to the regional nodes (p<0.0001), advancement of pathologic stage (p=0.021), and advancement of level (p=0.038) . Other factors like patient age, sex, treatment history, tumor thickness or histologic type did not significantly correlate with the patient survival. When the above factors except for stage were applied to the Cox proportional hazards multivariate analysis model, we were able to acquire amodel that significantly fitted the real data (p=0.012) . This model demonstrated that the regional lymph nodes metastasis and level were the variables that significantly reflects patient survival (p=0.017, 0.029 respectively) . Stepwise selection was then performed by removing the least important variable at respective steps until the remaining variables were all significantly important at the p<0.05 level. The regional lymph nodes metastasis and level were the variables that remained at the final step of the selection. The relative death rate (hazard ratio) of the regional lymph nodes metastasis and level were 9.07 and 12.6 respectively. Although tumor thickness has been reported to be the best prognostic indicator, it dose not necessarily predict patient survival when all stages are taken together. The characteristics of our materials may have reached the evidence that tumor thickness was not a significant prognostic factor.
A 34-year-old Japanese man had noticed a normal skin colored tumor on his right head about 4 years before, which gradually increased in size and elevated. At the initial consultation in our hospital, he had a soft peduncled tumor measuring 23×20×13mm, which was whitish and cauliflower-like. Clinical diagnosis was granuloma or malignant skin tumor, so biopsy was performed. Histological examination revealed the tumor to be an amelanotic malignant melanoma (AMM) in which melanin granules were not present, although S-100 protein and HMB-45 were found in the tumor cells. Surgical resection of the tumor was carried out along clinically 5cm normal skin margin. The skin defect remaining after tumor resection was covered with a skin graft and healed well. Two weeks after this surgery, Radical neck dissection was performed. There was no lymph node metastasis (0/58) . Accordingly, the diagnosis was an AMM with a pT4a, pN0, M0 (Stage III) . Sixteen months postoperatively, there has been no sign of recurrence.
We report a case of amelanotic polypoidal (pedunculated) melanoma of the scalp. This case is very difficult for diagnosis of malignant melanoma clinically. The patient was operated it by former doctor under the diagnosis of fibroma, but histological findings revealed malignant melanoma, so consulted to our clinic. We confirmed malignant melanoma histologically, extending to Clark's level IV, Breslow's tumor thickness: 6.8mm, pT3 N0 M0, Stage II. We performed it wide excision, skin graft and chemotherapy. Until now, we can not find local recurrence and metastatic lesion. Pedunculated Malignant Melanoma (PMM) is considered as a variant of the Nodular Melanoma (NM), and recently, it is not so rare growth pattern. Therefore when we face to pedunculated tumors, we should remember PMM.
Pancreatic carcinoma with skin metastases is rare. This paper describes two cases with metastatic skin cancer originally from pancreatic carcinoma. Case 1: A 45-year-old male had a reddish nodule on his scalp and subcutaneous nodules on his trunk. Biopsy specimen showed solid proliferation of adenocarcinoma cells. After admission, examination of the entire body led to discover pancreatic carcinoma in the pancreatic body. Case 2: A 55-year- old male had subcutaneous nodules on his scalp, neck, arms and trunk. Pathological study showed solid proliferation of adenocarcinoma cells in the subcutaneous fat tissue. Examination of the entire body showed pancreatic carcinoma in the pancreatic tail. Multiple metastases of both lungs and the liver were also detected. Reported eight cases of skin metastasis of pancreatic carcinoma in Japan during the period between 1985 and 1994, as well as presently reported two cases, showed that in all cases skin metastases were discovered prior to the detection of original tumor, implying clinical characteristics of such metastatic skin tumors.
Eighty-one cases of Bowen's disease and Bowen-carcinoma were observed for twenty-one years from 1974 to 1994. The male to female ratio was 1: 1. The number of patients had been increasing since 1981. The patients of Bowen's disease and Bowen-carcinoma occupied 0.09% of the total new out-patients in this period. The age distribution at the first consultation had a peak in the 8th decade of life. The common sites were lower leg, trunk, head and neck. Sixty-two percent of patients had tumors that were less than 3cm. There were 72 cases with solitary type (89%) and 9 cases with multiple type (11%) . Thirteen cases had visceral cancers. Almost all treatment in our clinic were excisions.
A case of pigmented squamous cell carcinoma (SCC) arising in the nose is described. The patient, a 84-year-old woman, had an ulcerated glossy black nodule on her nose. Histopathological examination revealed a SCC with many dendritic melanocytes and melanophages. Our case had an extremely atypical appearance for SCC. Clinically, it resembled a basal cell epithelioma.
Surgical excision of the eyelid often produces large defects that can result in significant visual impairment if reconstruction is not carefully planned and precisely executed. Every defect must be assessed individually to determine the simplest and best method of reconstruction. We used the step-ladder advancement flap and the V-Y advancement flap for reconstruction of the full-thickness upper lid defects. These flaps have the advantages of short operation time, with one stage, without require division of the pedicle; the remaining tissue can be used effectively; skin grafting is not required at the donor site; and provide exellent color and texture matching. For defects that cannot be closed primarily, the step-ladder advancement flap and the V-Y advancement flap are suitable methods.
Fifty-seven patients with angiosarcoma, who were consecutively registered for three years from 48 institutions, were treated with IL-2 containing maltidisciplinary therapy, and we studied the therapeutic results from a different point of view; sex, age, location of the lesion, duration from the onset, the kind of previous treatment, therapeutic regimen, the way of administration of IL-2, response rate and the survival rate. The survival rate at 30 months follow-up, was at 13.2% in 21 patients treated with combination of IL-2 and irradiation. At 36 months of evaluation of 12 patients after IL-2 and surgical treatment, survival rate was 40%. At 18 months of evaluation of 8 patients treated with IL-2, irradiation and surgical treatment, survival rate was 36.5%. Survival rate of three years of 17 patients who achieved a complete response (CR) was 81.5%. Survival rate of 29 months of 19 patients who received a partial response (PR) was 28%. And all patients who could not achieve CR and PR died until 13 months. The suvival time of the responding patients was significantly better than that of patients with MR, NC and PD, that is, CR group is better than PR group, CR group is better than MR, NC and PD group and PR group is better than MR, NC and PD group, respectively (G.W. p<0.01).
Case 1. A 26-year-old Japanese woman. She underwent mastectamy and axillarylymph node clearance of the left side at age 14. Subcutaneous nodules appeared on the left upper arm one year prior to her first examination which took place on August 1, 1986. The nodules continued enlarging. The left shoulder joint was amputated. One month later, multiple metastases appeared in the lungs and she died six months later. Case 2. A 60-year-old Japanese woman. She received hysterectomy and cobalt irradiation at age 47 because of uterine cancer. Since age 54, lymph edema of the right lower extremity has appeared. A blue fleck appeared on the right thigh 4 monthspreviously than the first examination (November 8, 1993) and later the fleck enlarged. She went into remission after radiation-thermal therapy and intraarterial injections of IL-2. Intraarterial combination immunochemotherapy with IL-2, adriamycin, cyclophosmamide, OK-432 were not so effective for further reccurrences. The tumorous ulcer on the right thigh enlarged to all planes of the right thigh. She died in renal failure amid repeated bacterial infections, loss of fluids and deterioration of the general condition one year and g months later. IL-2 appeared effective for the prevention of distant metastases since she had not shown any distant metastases of the tumor including the lung metastases.
A64-year-old man with Malignant hemangioendothelioma on the scalp and the face was successfully treated by combination therapy of rIL-2 injection, electron beam irradiation and surgical operation. One shot rIL-2 injection was conducted through the bilateral external carotid artery, followed by operation. On the operation, total scalp was excised and covered with free graft. As maintenance therapy, injection of rIL-2 has been performed 1-3 times a week.