A case of malignant melanoma with unknown primary site was reported. The patient was a 59-year-old man, who first noticed on September, 1993, an asymptomatic firm nodule about 3cm in diameter in his right axillar region. As the tumor increased in size, he became aware of erythematous change of the overlying skin, itching, pain and general fatigue. On April, 1994, the patient visited a division of surgery in a general hospital, and he was diagnosed as having malignant melanoma by incisional biopsy of the tumor. Then he was consulted to our department of Dermatology, University of Tsukuba Hospital. Physical examination revealed a large and firm subcutaneous nodule about 6cm in diameter at the right axilla accompanying dark erythematous and edematous change of the overlying skin. There were no findings suggestive for primary melanoma in the perianal, genital, oral or ocular mucocutaneous regions. The patient had no past history of previous operation for any eye diseases, moles or birthmarks, either. Even extensive examinations only detected a few small metastatic lymph nodes around the large tumor. We diagnosed the patient as a case of malignant melanoma with unknown primary site. The tumor was excised with a wide dissection of the overlying skin and a radical right axillar dissection on 35 days after the incisional biopsy. The patient took chemotherapy with CDDP, DTIC and VDS five times. He has been free from the disease for 25 months since the diagnosis was made.
A 65-year-old man, who was exposed to an atomic bomb in Nagasaki 1945, developed an ulcerated tumor on his right upper back in 1995. A squamous cell cercinoma (SCC) was ascertained histopathologically, not only in the back skin but also the right axillary lymph node. Neither of his face nor back skin showed characteristic color changes responsible for actinic damage. Furthermore it is wellknown that SCC occurs rarely in the trunk. These facts do not explain any susceptability of the occurrence of SCC to his back skin. Even though it has passed as many as fifty years after the tragedy by the atomic bomb, the exposure of the extremely huge amount of rays might cause a tumorigenesis.
We reported a case of squamous cell carcinoma (SCC) of the nail bed, with very rapid multiple metastases in various organs. A 65-year-old man had a hyperkeratotic tumor which had been around the nail bed of his right 5th toe for two months. A digital X-ray film of the toe showed the disappearance of the digital phalanx. A biopsy specimen of the tumor led us to diagnose as poorly differentiated SCC. Amputation of the toe at the level of metatarsal bone and therapeutic dissection of the right ilio-inguinal and popliteal lymphnodes were performed. Additionaly the patient was followed by radiation therapy. Histologically, the tumor invaded the bone underneath, and two metastatic lymphnodes were detected on his right groin. In spite of irradiation on his right foot toe and groin, many in-transit metastases appeared on his right leg and thigh three months later. Several times of resection and two courses of combination chemotherapy (cisplatin, 5-FU and peplomycin) could not inhibit the tumor progression. Bone and lung metastases occurred and he died seven months after the first visit. Although the prognosis of subungual SCCs is thought to be relatively favorable, some cases may take a miserable course.
A case of giant basal cell carcinoma is reported. A 61-year-old man had a 23×15cm in size ulcerous tumor, which was surrounded by a shiny black nodules, on his buttock. He didn't have visited to any hospitals for 10 years. When he came to consult us for the first time, he had severe anemia for bleeding from the tumor. The lesion was totally excised with more than 1cm margin, the defect of which was covered by a mesh skin graft. Histopathological findings showed that the tumor was nearly composed of solid type BCC, which intermingled with SCC like lesions. There was no evidence of metastasis for 22 months after operation.
A 74-year-old-male double cancer case of malignant hemangioendothelioma (MHE) and gastric mucinous adenocarcinoma was reported. Several months after he got a bruise on his head, he developed erythematous Iesions and hemorrhargic tumors on the parietal and the left occipital scalp around the bruised area. Histological examinations showed that the tumor cells priliferated in the dermis with marked extravasation and formed numerous tubular structures including red blood cells, indicating that the tumor was MHE. General examinations also revealed the multiple metastatic lesions in liver, stomach, and thoracic vertebrae. He was treated with intralesional and intra-veinal injections of recomdinant interleukin-2 (rIL-2). Though the activities of natural killer cells and lymphokine activated killer cells were increased during the rIL-2 treatments, the size of the scalp tumors rapidly increased and disseminated intravenous coagulations was odserved in the patient to be resulted in death. Autopsy examinations showed numerous metastatic lesions of MHE in lung, intestine, liver, spleen, mesentery, posterior peritoneum, and bone mallow. The histological examinations on the autopsy spiecemens revealed that both the primary and all metastatic iesions were composed of extensive necrotic tissues, but adenocarcinoma was not necrotic, suggesting that these necrotic degenerations of the MHE tumor masses were presumably induced by the applications of rIL-2.
A case is presented of a 49-year-old man with epidermotropic metastatic lung carcinoma who was diagnosed with lung cancer five months earlier. He had a painful dark reddish plaque that was gradually enlarged on the left breast for two months. A skin biopsy specimen showed a multifocal nest of adenocarcinoma which invaded into the epidermis. The case was diagnosed as having a metastatic lung carcinoma with epidermotropism.
A 65 years old woman with malignant melanoma in situ, measuring 4mm in diameter, was examined. She presented with slowly growing brown, flat lesion on the left tigh of 1 year duration. The edge of the lesion was irregular, and its color was variegated dark brown in center and lower end to brown in periphery. Histopathological findings showed the lesion to be asymmetrical with unsharp lateral margins and mild inflammatory infiltrates in the upper dermis. Rete ridges were slightly elongated and there were tumor cells with atypical nuclei nested and scattered in the lowere epidermis. The tumor cells reacted strongly to monoclonal anti-HMB-45 antibody.
A case of giant nevus with intramuscular tumor was reported. A 5-year-old girl had giant congenital nevus on her trunk and extremities. After five years of Laser treatment, she developed subcutaneous tumor on her left upper back. The tumor was solitary and located under the skin inside latissimus dorsi muscle. The tumor is graycolored, elastic hard in consistency, and nonadhesive to the surrounding tissue. Histopathologically, the tumor consisted of atipical spindle cells with bizarre nuclei. Mitotic figures were also seen. No lymph node structure was recognized and there was no malignant transformation on her giant nevus of the skin. The tumor cells weakly stained with S-100 protein and NSE, however HMB45 was negative. No recurrence has been found for 2 years after the operation. Our tentative diagnosis is malignant melanoma, whith is yet to be proved.
The venous flaps were performed in the reconstruction of the excised malignant skin tumors. Case 1, an 85-year-old man presented with a malignant melanoma on the left big toe. The tumor was amputated from the MP joint, and the exposed bone was reconstructed using a 40×50mm venous flap which was elevated on the left dorsal pedis. Case 2, a 77-year-old-woman presented with a squamous cell carcinoma on the left dosal hand. The tumor was excised, and the exposed tendon was reconstructed using a 35×25mm venous flap which was elevated on the left distal forearm. The both cases were successful, and the venous flap is effective for the reconstruction when the bone and tendon are exposed with a small region.
The annual trends in number of deaths from malignant skin and soft tissue tumors (ICD-10, C43, C44 and C49) in Japan, were investigated on the basis of the data from the Ministry of Health and Welfare population trend survey. The number of deaths from skin cancers had decreased remarkably from 1979 on, but had increased again since 1995. The general trends of deaths from both malignant melanoma and malignant soft tissue tumors were upward. The approximate annual increased ratio of deaths from a melanoma was 2.5%, and that from soft tissue tumors 2.6%. For lowering the number of deaths, it is essential to pay attention to treatment of an early and relatively early stages of an actinic keratosis-induced squamous cell carcinoma for age 80 and older, and also of the similar stages of a melanoma and soft tissue tumors for age 40 and older.
We report a patient with malignant melanoma(stage IV)who died 27 days after surgery. A 76 year-old Japanese man visited our clinic complaining of a 40×40×11mm nodule on the left lower leg. Malignant melanoma was diagnosed histologically, and multiple metastases to the liver were revealed by CT scanning. At this time, we had to decide whether or not surgery was indicated for the skin tumor. The merits of surgery included eradication of the tumor and removal of the offensive odor of the tumor and bleeding. The demerits were worsering of the patient's general condition and the risk of general anesthesia. We finally decided to carry out surgery in order to allow the patient to be discharged from the hospital. The patient was happy that the tumor had been resected and the defect repaired by a skingraft. Although laboratory data remained stable, the patient suddenly died of acute heart failure 27 days after the operation. This case illustrates the difficulty in deciding whether surgery is indicated for aged patients with skin tumors.
TdT-mediated dUTP-biotin nick end labeling (TUNEL) method was performed on 21 excisional skin samples from 15 patients with solid basal cell carcinoma (BCC), 2 patients with adenoid BCC, 2 patients with superficial BCC, one patient with solid BCC with a pilar differentiation and one patients with trichoepithlioma. Apoptosis was detected around a pseudocyst of solid BCC with cystic degeneration. Clusters of apoptosis were detected on a central portion of nodules of solid BCC and superficial BCC. However, clustera of apoptosis were not detected around cystic lesions of adenoid BCC, BCC with pilar degeneration and trichoepithelioma.
Malignant skin tumors are known to develop in areas of chronic radiodermatitis. We experienced a patient with multiple basal cell carcinomas that developed about 50 years after irradiation. The patient was a 77-year-old man who underwent radiotherapy in his twenties for caries in the left shoulder joint. The dose given was unknown. Black skin tumor appeared initially about 10 years before the first consultation. The skin around the tumor began to erode about six months before presentation. Biopsy of the tumor was done at another institution and revealed basal cell carcinoma(BCC), so the patient was referred to our department. In addition to the BCC measuring 35×20mm in the left shoulder, BCC measuring 17×20mm and 15×15mm were found on the chest and the left axilla, respectively. The lesions were excised with a margin of 5mm from the radiodermatitis, and the resultant skin defects were covered with latissimus dorsi flaps. All three tumors were basal cell carcinomas. The patient died of an unrelated disease six years after surgery and there was no recurrence of his tumors.
The goal of surgical treatment of basal cell carcinoma (BCC) is complete removal of the tumor. Preoperative clinical factors that predict deep invasion would help surgeons to decide the adequate depth of excision of BCCs. In the present study, we histologically assessed depth level of invasion of 174 cases of nodular or noduloulcerative BCC, and examined the statistical association of this parameter with predictive clinical factors, including age, gender, duration, maximum diameter and ulceration. In result, depth level of invasion significantly correlated with tumor maximum diameter and the presence of ulceration. These factors should be considered at excision of nodular or nodulo-ulcerative BCC.
The diagnosis of soft tissue tumors is difficult for several reasons. Many soft tissue tumors have overlapping histologic appearances, may change during the course of the disease. Liposarcoma is one of the most common soft tissue sarcoma. It is classified by the histological findings. Myxoid liposarcoma, the most common type of it, is difficult to distinguish from other myxoid tumors, especially myxoid malignant fibrous histiocytoma. Lipid stain and immunohistochemical examination are helpful for the diagnosis. We report a case of a 36-year old male with a tumor on his left leg. Histologically, we found round cells, signet-like cells, vacuolated cells and myxoid material. There were a few mitotic figures. Special stain (lipid stain, S-100 protein, vimentin, PAS, alucian blue, silver stain) and electron microscopic examination help us to diagnosis of the tumor.
We described a patient with Bowen's disease for whom re-operation was necessary ten years and eight months after the first operation because of recurrence. A 71-year-old Japanese man with a 28×26-mm areas of erythema surrounded by brownish plaques on the waist visited our clinic in December 1985. He had been worked at several mines in Japan about for 30 years. He had not suffered from syphilis and had taken no medicine containing arsenic. Bowen's disease was diagnosed on the basis of histology. Surgery was carried out in February 1986. However, in October 1996, he visited our clinic complaining of a 40×44mm area of brownish plaque at the operation scar on the waist. Re-operation was done, and the brownish plaque was resected leaving a margin of more than 5mm. It is not yet clear whether he had been exposed to arsenic without his knowledge while working in the mines. We think that the tumor recurred because the initial resection had not been complete due to the ill-defined borders of the lesion.
The subjects were 33 Japanese patients, reported in the past. The author obtained information through a questionnaire to the first author of each report except one. 33 patients consisted of 16 males and 17 females. Their ages ranged from 33 to 82 years (average: 61.0±13.2years) . 31 lesions were admitted on the face, one on the scalp and one on the right fifth toe. The duration from onset to visit ranged 2 weeks to 50 years (average: 10.4±12.4years) . The size varied from 6 to 100mm in greatest diameter (average: 26.4±18.8mm) . Among these patients, 11 recurrences were recognized (33.3%) . It may be difficult to excise completely tumors, located especially on the eyebrow to eyelid, and nasal ala and its neighboring area, because deep invasion may easily occur in these regions.
Microcystic adnexal carcinoma (MAC) is an aggressive, locally destructive cutaneous neoplasm with a high rate of recurrence. This tumor is often misdiagnosed clinically and histologically. The authors described again a 54-year-old woman with a large MAC, which had already been reported in 1988, focusing on 16-year follow-up and treatments of similar, uncontrollable cases in the literatures. The initial biopsy specimen must be large enough to demonstrate the identifying histologic features. Debulking of tumor for gross recurrences in the face may be a viable option in certain patients, depending on their overall health and the extent of deformity resultant from total tumor extirpation.
A 82-year-old female with squamous cell carcinoma (SCC) is reported. The tumor (#1) presented as a 1cm φ sized, riled, pigmented nodule with blackish scale on the right knee. After 2 months, another tumor (#2) presented as a 3cm φ sized, oval shaped, irregurar borderd subcutaneous nodule on the right thigh. We think #2 tumor is metastasis of #1 tumor. Because the biopsy of #1 tumor suggested SCC by hematoxylin-eosin staining, we excised the #1 & #2 tumors as one block with 3-5cm of margin. The immunohistochemistry revealed staining for keratin but not for vimentin at #1 tumor. But at #2 tumor staining for vimentin but not for keratin, suggesting that #2 tumor had originated from the mesenchyma, and also the histopathlogy by hematoxylin-eosin staining showed tumor like malignant fibrous histiocytoma. The definite diagnosis was difficult. However, it is difficult to think another malignant tumor appered on the right leg at the same time, and spindled SCC sometimes have displayed abnormal expression in the immunohistochemistry. Consequently, we think these tumors are SCC with mesenchymal metastasis.
We report a case of malignant melanoma arising on the neck of a 36-year-old female. Two nodular lesion in right lower lobe which were the metastatic lesions of malignant melanoma were detected three-year and eight-months after resection of the primary lesion. The pulmonary lesions were surgically resectable and right lower lobectomy was performed. Inspite of four courses of DAC-Tam therapy, metastases to right mammary gland, right axillar lymph node and brain were observed. She died of the tumor four-year and ten-months after resection of the primary lesion. Interestingly, no metastasis to the regional lymph node of the primary lesion had been noted until her death, however, it was observed in mammary gland which was the hematogeneous metastatic lesion.
The significance of the association between the appearance of hypopigmentation in patients with melanoma and the prognosis is still not clear. It was postulated that, in melanoma, an immune response is responsible for the destruction of the malignant as well as the normal pigmented cells, and that the eventual development of hypopigmented vitiligo-like patches in melanoma patients improves their prognosis. We report clinical and histological results in three patients with melanoma and widespread hypopigmented vitiligo-like patches. In the hypopigmented patches DOPA-reaction-positive basal melanocytes became far fewer than in the normal surrounding skin. Also, Mel-5-positive basal melanocytes became fewer than in the normal surrounding skin and the residual melanocytes showed long dendrites.
We report the clinico-pathological features of 7 cases of dermatofibrosarcoma protuberans. The tumor size were from 1.0 to 27cm in diameter. Local recurrence was seen in two cases under the follow up period of 4 months to 22 years. Histologicaly, the tumors of all cases were composed of spindle-shaped cells, and arranged in a storiform pattern. Immunoperoxydase staining with anti-CD34 (human progenitor cell antigen) and anti-factor XIIIa antibodies showed that CD34 was positive and XIIIa was negative in all cases. Clinically, early diagnosis and wide surgical excision are considered to be important to evade recurrence.
A survey of squamous cell carcinoma was carried out by reviewing the patient records at Tenri Hospital during a 10-year period since 1988 to 1997. (1) The number of patients with squamous cell carcinoma was 52. The male to female ratio was 1/1. (2) As to the anatomical sites of tumor, 30 cases, that was 57.7% of the total number of patients has lesions on the face. (3) In the distribution, adults of 60 years old accounted for 86.5% of the total number of patients. (4) The tumors had a pre-cancerous lesion in 19 cases. (5) All patients were operated. Skin grafts and Local flaps were mainly used in reconstruction. The local flaps were especially useful for reconstruction of the face. Only six patients were carried out the chemo-therapy and only one patient was carried out the irradiation.
A 78-year-old-man with a 10-year history of subcutaneous tumor on his upper back, visited our clinic in October 1996. The tumor had been excised three times, and the patient had received chemotherapy and radiation therapy before, but the tumor had recurred. The patient had a 5.5×6.0cm, poorly demarcated tumor and enlargement of anterior mediastinal lymph node was observed by computer tomography examination. A biopsy specimen revealed a dense proliferation of atypical spindle cells arranged in a storiform or herring-bone pattern extending into the subcutis. The operation specimens excised previously were also examined. The tumors were composed of spindle cells and/or histiocytelike cells, and the grade of the nuclear atypia became higher at each time of the recurrence. Immunohistochemical staining for CD34 was negative in the previous specimens but positive in the last one. A diagnosis of dermatofibrosarcoma protuberans was done and the tumor was extensively excised in November 1996. The patient had multiple metastases and died in April 1997.
The treatment of patients with advanced stage (stage III and IV) melanoma remains unsuccessful because of low response rates to chemotherapies and short remission duration. We have treated eight patients with combination chemotherapy consisting of cisplatin, dacarbazine, nimustine, and tamoxifen (DAC-Tam). Two patients with stage III melanoma who received this regimen as adjuvant therapy remain in CR for 23 and 30 months each. One patient with stage III who underwent in curative dissection of metastatic lymph node and five patients with stage IV melanoma showed progressive disease.