The TNM Classification of Malignant Tumours was revised by the International Union Against Cancer in 2002. The modifications include the addition of the presence/absence of ulceration, more detailed differentiation of tumor thickness, both microscopic and macroscopic regional lymph node metastasis, lung metastasis under distant metastasis, and abnormal LDH levels as prognostic factors, thereby considerably increasing the complexity of the classification system. In this paper, we comment on the new TNM Classification for malignant melanoma and present the results of a review of a statistical investigation of malignant melanoma (1992 to 1996) based on the new staging system. It was found that the survival rate generally corresponded to the extent of disease progression. [Skin Cancer (Japan) 2002; 17: 113-118]

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We report a rare case of cutaneous leiomyosarcoma (LMS) which arose in the auricle of a 77-year-old man. However its histopathological appearance resembled MFH, immunohistochemical results of positive stain for desmin, smooth-muscle actin and vimentin strongly supported the diagnosis of LMS. Although the tumor was considered to be a subcutaneous LMS from various aspects, which generally shows a worse prognosis, the patient survived 5 years after excision with minimal surgical margin. [Skin Cancer (Japan) 2002; 17: 119-122]

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A 73-year-old female presented with a small ulcerated nodule on her left heel. It was excised with a margin of 10mm and reconstructed by skin grafting. The histological diagnosis was sweat gland carcinoma. Four months after the operation, a rapidly growing subcutaneous tumor was recognized on her left leg. The biopsy specimen showed metastatic sweat gland carcinoma. A combination therapy of intravenous cisplatin, 5-fluorouracil and subcutaneous peplomycin with 30Gy of irradiation was tried, but the patient could not endure its severe side effects. Subsequently, she was treated with 30.5Gy of additional irradiation combined with hyperthermia. A great response was observed. Wide local excision and left groin dissection followed. There was no evidence of metastasis during 5 years after the therapy. [Skin Cancer (Japan) 2002; 17: 123-126]

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We performed an inguinal sentinel node biopsy using patent blue dye for 15 cases of malignant melanoma. The primary lesions were located on the plantar region (7 cases), back of the foot (1 case), the toes (5 cases), the inguinal area (1 case), and the knee (1 case) . The sentinel nodes were identified in 14 patients (93.3%), among which 3 positive nodes were detected. The sentinel nodes from the foot region mostly located within the area 3cm distal to the site where the greater saphenous vein fluxes to the femoral vein. Besides the preoperative careful physical examination, ultrasound scanning analysis was shown to be useful for the detection of the sentinel nodes. We also emphasize that adequate procedure should be performed to avoid damage to the afferent lymphatic channels at the time of the operation. [Skin Cancer (Japan) 2002; 17: 127-134]

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We reported two cases of trichoblastoma misdiagnosed as basal cell carcinoma. Case 1 was a 36-year-old woman with a normal skin-colored mass of 5×5mm on the left nasal ala. Case 2 was a 62-year-old man with an 18×13×5mm mass on the right upper eyelid. The results of histopathological examinations of both patients indicated basal cell carcinoma, and extensive resections were performed. The diagnosis was corrected to trichoblastoma based on the results of a subsequent detailed examination. [Skin Cancer (Japan) 2002; 17: 135-140]

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In 1989, a 75 year-old-woman visited our hospital with a macule on her left planta which had been present for one year. The macule was light and deep brown and its margin was not clear. A biopsy revealed no atypical melanocyte in the epidermis. The number of melanocytes had not increased. Malignant melanoma was ruled out. In 2000, she reappeared with an enlarged macule. It measured 4×3cm and contained black spots. Histologically, large melanocytes with a chromatin-rich nucleus were scattered in the basal layer and some of them formed nests. A diagnosis of acral lentiginous melanoma in situwas established. [Skin Cancer (Japan) 2002; 17: 141-143]

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In our department, sentinel lymph node (SLN) biopsy was introduced for skin cancer treatment in Oct 2000. Since then, we have used this procedure it in 33 cases (15 of SCC, 13 of MM, 2 of Paget's disease, and 2 of porocarcinoma and 1 of Merkel cell carcinoma) . We used the triple technique SLN procedure consisting of preoperative visualization of the lymph nodes (LN) from the initial site by dynamic lymphoscintigraphy, intraoperative visualization of those particular LNs with blue dye, and gamma probe detecting of the radiolabeled LNs. As a result, at least one SLN was identified in 29/33 (88%) of these patients. Three out of the 6 patients who had the initial site on the face showed negative lymphoscintigram. Three out of the 8 patients who had the initial site on the upper extremities had SLN on their upper arms in addition to the axillary region. One of the 9 patients who had the initial site on the lower extremities had SLN on the popliteal region in addition to the inguinal region. SLN biopsy improves the accuracy of staging, and identifies patients who are candidates for further surgery and/or adjuvant therapy. [Skin Cancer (Japan) 2002; 17: 144-147]

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We present a 59-year-old man with a 3-year history of pigmented macule on the left sole. Physical examination revealed a 24-mm in diameter, relatively welldemarcated, irregularly-shaped, black-brownish variegated hyperpigmented macule on the left sole. Neither elevation nor infiltration was noted. After a clinical diagnosis of acral lentiginous melanoma (ALM) in situ was made, the lesion was totally excised with a 10-mm margin above the fascia level, and the wound was covered with full-thickness skin graft. No elevation of 5-S cysteinyl dopa in his urine and blood before and after the operation was determined. Histopathological findings of the center of the lesion showed an increased number of melanocytes with minimal atypia and basal hyperpigmentation. The immunohistochemical staining against HMB-45 was negative. We further prepared sections from the darkest hyperpigmented area, lightly-pigmented area and moderately-pigmented area. The darkest area showed the significant increase of atypical melanocytes, forming small nests with basal hyperpigmentation and pigmentary incontinence. These findings collectively confirmed the diagnosis of ALM in situ. The present case suggests the importance of histological examination from multiple locations, corresponding to the macroscopic degrees of hyperpigmentation. [Skin Cancer (Japan) 2002; 17: 148-152]

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A 76-year-old woman had noticed a 15×21mm irregular-shaped black patch on her lower lip for 20 years. The serum level of 5-S-CD was 20.2nMol/l; (cf. She had been taking L-dopa for Parkinson's disease for a month.) . Histological examination of the black patch revealed that atypical melamocytes were present mainly in the basal cell layer and the spot was diagnosed as lentigo maligna. She had another black spot on the mucous membrane of the cheek, showing moderate proliferation of melamocytes with no atypia in the basal cell layer histologically. The black spot on the bucchal mucus was diagnosed as lentigo simplex. The high serum 5-S-CD level returned to normal after the L-dopa drug was discontinued. No recurrence was found during the follow up of over a year. [Skin Cancer (Japan) 2002; 17: 153-156]

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A 29-year-old Japanese woman was seen with a 12-year history of indurated erythematous lesions, which had been diagnosed as mycosis fungoides. While PUVA and recombinant interferon-γ were ineffective, electron beam irradiation (total dose, 40 Gy) improved her skin lesions.
Four months after radiotherapy, however, she developed marked lymph-adenopathy. She was treated with a combination of biweekly CHOP, etoposide, and methotrexate, which temporarily alleviated her condition. During the next 6 months, both her skin lesion and lymphadenopathy had progressed with the appearance of lymphoblasts in the bone marrow and peripheral blood. She died of multiple organ failure at the age of 30 years. [Skin Cancer (Japan) 2002; 17: 157-160]

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A 75-year-old man visited our hospital because of bilateral inguinal lymphadenopathy and purpuric erythema on the lower abdomen. He had erythematous plaque on the scrotum. Skin biopsy revealed Paget cells in the epidermis of the scrotum and lymph duct's ectasis containing aggregated Paget cells in the lower abdomen. Radiotherapy was performed with considerable effect. Ten weeks later, however, purpuric erythema recurred on his left buttock. Following oral low-dose Etoposide therapy, the purpuric erythema regressed gradually and disappeared. The serum CEA level decreased concomitantly and normalized. Despite fairly good response to oral low dose Etoposide therapy, the patient died of the disease 16 months after the initial admission. [SkinCancer (Japan) 2002; 17: 161-165]

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We report a case of a breast cancer metastasizing to the skin of the hip 24 years after breast cancer surgey. A 64-year-old woman noticed a 28×35mm-sized nodule on her right hip and then she noticed a right inguinal lymphadenopathy. Surgery for cancer of the right breast cancer with right axillary lymph node dissection had been performed 24 years before.
Histopathological features of a nodule on the right hip and an inguinal lymph node showed metastatic adenocarcinoma to the skin and lymph node and these cancer cells were immunohistochemically positive for anti-estrogen receptor antibody. There were no other metastases; therefore, the patient had been treated by administration of tamoxifen after metastasectomy of a cutaneous tumor and a metastatic lymph node.
We found nine cases of delayed cutaneous metastasis of a breast cancer in Japan from the literature, and we discuss charactaristic features of these cases. [Skin Cancer (Japan) 2002; 17: 166-169]

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Molecular genetic approaches to the study of melanoma and non-melanoma skin cancers have added new insights in the pathogenesis of these tumors. In this review, Twill discuss the following topics; 1) p53 clonal patches in sun-exposed normal skin, a Brash's model of photocarcinogenesis of cutaneous squamous cell carcinoma (SCC), and molecular epidemiology of SCC, 2) dysregulation of hedgehog signaling pathway in basal cell carcinoma and its role in the tumors arising from nevus sebaceous, 3) molecular genetic changes in malignant appendageal tumors and possible androgen dependence of extramammary Paget's disease, 4) roles of CDKN2A and other genes in the pathogenesis of melanoma and the use of comparative genomic hybridization in the differential diagnosis of melanoma from Spitz nevus. [Skin Cancer (Japan) 2002; 17: 170-176]

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We report a case of pedunculated malignant melanoma of the scrotum. A 48-year-old man noticed a pigmented macule on the scrotum 16 months previously. The lesion had enlarged and elevated gradually. When he visited our hospital on June 25, 2001, physical examination revealed an erosive, flesh-colored, 7.5cm in diameter, pedunculated tumor on the right side of his scrotum. In the broad neck of the tumor, black-colored macules were observed. Several right inguinal lymph nodes up to walnut-sized were palpable. Chest X-ray and computed tomography showed multiple pulmonary lesions. We diagnosed a malignant melanoma histologically, and performed a surgical resection with 3cm-margin and meshed split-thickness skin graft, right inguinal and external iliac lymph nodes dissection. UICC staging was IV (pT4bN2aM1b), and AJCC staging was IV (T4bN3M1b) . Multiple pulmonary metastases have enlarged and been increasing slowly, and yet the patient has been well during one year after initial diagnosis.
Primary malignant mela a of the scrotum is a rare entity. Between 1949 and 2002, only 12 cases have been reported in the world. We review them and discuss the reason why melanoma of the scrotum is so infrequent. [Skin Cancer (Japan) 2002; 17: 177-181]

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A case of intracranial metastatic amelanotic melanoma with cyst is presented. The case is a 51-year-old female with malignant melanoma arising on her right chest. Two years after wide excision, skin and brain metastasis occurred. Brain MR images demonstrated a tumor with cyst in the left occipital lobe. And this metastatic melanoma was recognized as amelanotic melanoma, because the tumor showed low intensity on T1 weighted images and high intensity on T2 weighted images. There are only a few earlier reports of melanoma with cyst. Moreover, intracranial amelanotic melanoma is also very rare. [Skin cancer (Japan) 2002; 17: 182-188]

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A 64-year-old male was referred to our hospital for evaluation of a large tumor extending from his left inguinal area to the scrotum. The removed tumor specimen showed that the epidermis was permeated with numerous Paget cells lying singly and in groups, and the dermis was infiltrated with tumor masses of relatively small Paget cells. These tumor cells showed a different immunostaining for CEA: the epidermal cells positive, but the dermal cells negative. He was diagnosed with Paget's carcinoma, suggestive of lung and adrenal metastases. The patient received four courses of combined chemotherapy with low dose FP with effect initially after operation, but he died of multiple metastases of Paget cells one year later. [Skin
Cancer (Japan) 2002; 17: 189-192]

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A 77-year-old female patient who developed an ulcerative squamous cell carcinoma in the dorsal aspect of her right great toe is described. Diagnosis of the condition was delayed because of a resemblance to a variety of benign ulcerations. We stress the importance of histological examination in the face of an ulcerative cutaneous condition unresponsive to standard treatment. [Skin Cancer (Japan) 2002; 17: 193-196]

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Basal cell carcinoma (BCC) possibly occurs anywhere on the skin, and the favourite localization is exposed areas such as the face and neck. We have experienced a rare case of large BCC on the left upper part of the scrotum.
A 76-year-old male had noticed a black-gray nodule on his scrotum about 8 months before visiting Tokoname municipal hospital. The tumor was firm, triangular-shaped with each side 45, 45 and 35 mm in length. Erosion and ulceration were seen in the lesion. The tumor was totally excised with a 5 mm margin under local anesthesia. The histopathological diagnosis was typical, solid BCC. Since the excision, neither recurrence nor metastasis of the tumor has been observed. [Skin Cancer (Japan) 2002 17: 197-200]

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We reported an 86-year-old female who visited out department on Sept. 14, 1998. She was diagnosed with malignant lymphoma which developed in the right inguinal region. She was in good health except for her lymphoma. First, a biopsy was performed after a diagnosis of SCC because of a nonsymptomatic dome-shaped tumor with granulomatous tumor. Histopathology showed that the tumor nest consisted of a clearly delineated proliferation of atypical and pleomophic T cells with multinuclei. After the diagnosis of T cell lymphoma, a wide local excision was carried out on Dec. 8, 1998. However, pulmonary metastasis occurred six weeks after the excision, and she died 10 weeks later of dyspnea. [Skin Cancer (Japan) 2002; 17: 201-204]

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A 21-year-old woman complained of a small nodule on her left lower leg that she had first noted at the site of an insect bite when she was 16 years old. The nodule became larger, and was 20×20 mm in size when she visited our hospital. It had a smooth surface and was clearly demarcated from the surrounding skin, but there was neither pain nor irritable sensation. The nodule was diagnosed as a hypertrophic scar arising after an insect bite and treatment using an adhesive tape containing steroid was started. Two months later, as the cystic region had become prominent, an excisional biopsy was performed and the specimen was diagnosed as dermatofibrosarcoma protuberans. A wide local excision was undertaken with a 5 cm margin that included a deep fascia. The defect was covered with artificial dermis and a split thickness skin graft. The patient had no recurrence or metastasis in the 6 months after the first operation.
As the tumor here resembled a keloid or hypertrophic scar in the early stages, it is recommended that physicians need to suspect a possible malignant tumor if a treatment resistant keloid or hypertrophic scar is presented.
Optimal resection of dermatofibrosarcoma protuberans and the application of Mohs micrographic surgery for such tumors are discussed. [Skin Cancer (Japan) 2002; 17: 205-208]

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