A 45-year-old woman presented with scaly erythema on her trunk and extremities and a swelling of her left lower leg, both of which were noticed 6 years ago. A biopsy specimen from the skin showed intraepidermal infiltration of atypical lymphocytes, the finding consistent with patch-stage of mycosis fungoides (MF) . Infiltration of the same small atypical lymphocytes was also observed in the fascia and the muscle of her left lower leg associated with prominent granulomatous reaction containing many multinuclear giant cells.
Immunohistochemistry showed that surface phenotypes of atypical lymphocytes infiltrating skin as well as muscle were CD3+, CD4+, CD5+, CD45RO+, CD8-, CD56-, TIAI-, and granzymeB-. Southern blot and PCR analysesshowed evidence of a clonal T-cell receptor rearrangement in skin specimens, but the results were ambiguous in muscle samples. No other visceral lesion was not detected. There was no evidence of either sarcoidosis or tuberculosis. Psoralen plus ultraviolet A therapy was effective for the skin lesion, but 30Gy of X-ray irradiation to the left lower leg made no response. The possible implications of the coexistence of the two separate lesions in the skin and the muscle were discussed. [Skin Cancer (Japan) 2003; 18: 255-258]

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A 66-year-old woman had noticed a nodule on her light groin 15 years ago. The nodule was excised two times because of recurrence. She came to our hospital because of a 3rd recurrence occurred. The nodule was widely excised with 5cm margins. Histopathologically, the tumor was mainly composed of spindle-shaped cells. In some areas of the lesion, the tumor cells were arranged in a storiform pattern, and in other areas myxoid changes were seen. Immunohistochemical study revealed that the tumor cells were positive for vimentin, factor XIII a, but negative for keratin, α-SMA, tdesmin, S-100, factor VIII, CD34 and EMA. Ultrastructurally, the tumor cells had a fibroblastic phenotype. Thus we diagnosed this tumor as malignant fibrous histiocytoma, myxoid type. Subsequently, a nodule had appeared on her forehead 2 years after the operation. Histopathologically, the nodule was diagnosed as myxoma, whereas the tumor which recurred about l year after the first operation was diagnosed as myxoid-MFH. One year later the tumor has recurred again; no systemic metastasis was detected. Recently it has been emphasized that, in most cases originally diagnosed as MFH, a specific line of differentiation is evident, and relatively few cases have to be classified as MFH or not otherwise specified. We assume that this case is myxofibrosarcoma rather than myxoid-MFH, because ultrastracturally, the tumor cells of this case were composed of only fibroblastic phenotype, and generally MFH reveals a more aggressive course than this case. [Skin Cancer (Japan) 2003; 18: 259-265]

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A 68-year-old Japanese man was referred to our hospital to have a tumor on his left shoulder treated, which had been operated on several times and had recurred. When he came to us, there was a red, lobulated, and scar-like fibrous tumor on the previously operated site. Histologically, the tumor consisted of two kinds of cells: one with wound nuclei, forming nests, the other, fibrous cells with spindle shaped nuclei. Both atypical cells were stained with S-100, vimentin, desmin, and NSE, while negative with SMA, CD68, EMA, CD34, myoglobin, and cytokeratin.
It is well known that malignant peripheral nerve sheath tumors (MPNST) are usually associated with patients with von Recklinghausen's disease, arising from the deep soft tissue, and growing even into the spinal and pelvic space. Our case seems to be a rare case, since the patient has no history of von Recklinghausen's disease, and the tumor is originated on the skin. The tumor cells had characteristics of nerve origin by immuno-histochemical staining patterns with an exception of positive staining by desmin. We should take great care of the local metastasis and the metastasis to the other organ as well since this tumor easily recurs and metastasizes, especially to the lung. [Skin Cancer (Japan) 2003; 18: 266-269]

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A 65-year-old woman attended our hospital with indurated subcutaneous nodule on the bilateral axillary regions, right arm, left chest, and left abdominal wall that grew to the size of about 1cm. Skin biopsy of the lesions showed infiltration of abnormal lymphocytes into the subcutaneous tissue. Immunohistochemically, tumor cells were positive for CD8, CD45RO, CD68, but negative for CD20, CD30, CD56. From the above findings, a diagnosis of subcutaneous panniculitis-like T-cell lymphoma was made. [Skin Cancer (Japan) 2003; 18: 270-273]

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A subcutaneous pedicle flap (SCPF) is very useful in reconstruction after resection of facial skin malignant tumors. The results are very excellent in texture match and color match with the surrounding area. It is often experienced in treatment of facial malignant skin tumors that the defect is wide, and no adequate donor is indicated near the defect. To utilize wider SCPFs and SCPFs in a more distant site, it is necessary to include richer vessels near the flap donor in the subcutaneous pedicle. Actually the pedicle is freely formed right under type, standing Z type, one-side lateral type, or two-side lateral type. The best target vessel should be chosen referring to anatomical knowledge, cadaver angiogram and animal angiograms, which indicates main vessels and vascular arcades. [Skin Cancer (Japan) 2003; 18: 274-277]

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Basal cell carcinoma (BCC) occurs and recurs most commonly on the nose. The authors conducted a study to establish reliable guidelines for resecting BCC on the nose. During a 20-year period from 1981 to 2000, the authors experienced 88 cases of BCC, in 37 (42%) of which tumor cells were found histologically to invade muscle layers. The authors propose the following methods of adequate excision and reconstructions in different areas of the nose.
Part I: Nasal ala (7 aggressive, 5 non-aggressive) . Full-depth or submucosal excision and one-step reconstruction by free composite graft is recommended.
Part II: Nasal groove (24 aggressive, 3 non-aggressive) . A two-step procedure. The tumor, including part of the muscle, should be excised. After complete removal of the tumor has been confirmed histologically, the defect should be reconstructed by naso-labial flap.
Part III: Lateral side of nasal dorsum (3 aggressive, 20 non-aggressive) . The tumor may be excised in a one-step procedure. It is desirable to cover the defect by naso-labial flap.
Part IV: Nasal dorsum (3 aggressive, 18 non-aggressive) . The tumor may be excised below SMAS and the defect should be covered by axial frontonasal flap.
Part V: Nasal tip and Columella (5 non-aggressive) . This area should be considered as a dangerous zone. A two-step procedure is recommended. [Skin Cancer (Japan) 2003; 18: 278-289]

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We report a case of basal cell epithelioma on the alar groove and the nasolabial groove.
The patient was a 74-year-old man who presented with an approximately 10-year history of an asymptomatic nodule at this location. Considering his heart function and age we planned to cover the skin defect using a local flap.
A novel technique using a local flap in facial reconstruction is presented in this report.
The name of this novel technique is “flap in flap technique”. This technique involves creating a secondary flap in the primary flap, and there has been no report of a similar technique. The theory and its application in a clinical case are presented in this report, which shows the V-Y flap in the V-Y flap. And by using this theory, other types of flap in flap will be produced. [Skin Cancer (Japan) 2003; 18: 290-293]

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We have examined the chemosensitivity of malignant melanoma (MM) using a collagen gel droplet embedded culture drug sensitivity test (CD-DST) for two years. In this study, tumor cells were exposed to drugs under the conditions that can reproduce the 24 hours plasma area under the time-drug concentration curve (AUC) in vitro. Eighteen tests were done for fourteen cases of MM. Five drugs (Cisplatin, Adriamycin, Dacarbazine, Nimustine hydrochloride and Vincristine sulfate) were tested. The success rate of the primary culture of MM cells was 77% (14/18) . Chemosensitivities of MM cells were: Cisplatin 23%, Adriamysin 41%, Vincristine 46%. No sensitivities of dacarbazine and nisumutine were detected. Dacarbazine is not suitable for CD-DST because Dacarbazine needs metabolism in the body to produce diazomethane, which is a strong alkylating agent and may have a major anti-cancer effect. Nimustine hydrochloride concentration may be determined by 3 hours plasma AUC because most Nimustine hydrochloride is excreted from plasma in 3 hours. [Skin Cancer (Japan) 2003; 18: 294-297]

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Sentinel lymph node (SLN) biopsy has become widely accepted as a method of staging in the regional lymph nodes of patients with malignant melanoma. Popliteal lymph nodes have been rarely identified as SLNs in patients with melanoma at or distal to the knee. However, its significance has not been well established. We reported a case of a patient with melanoma on the heel, who had positive SLN metastases in both popliteal and groin lymph nodes. In addition, experience with the past cases metastasized to popliteal lymph nodes in our hospitals were reviewed. Among 76 patients with melanoma of the distal lower limb, five (6.6%) developed popliteal lymph node metastases in its clinical course. The primary tumor sites in four of five patients were located on the heel, especially on the lateral or proximal aspects. Although elective lymphadenectomy of popliteal node seems to be unnecessary considering the low incidence of metastasis, once the popliteal node is identified as SLN on lymphoscintigraphy, biopsy procedureshould be performed. [Skin Cancer (Japan) 2003; 18: 298-302]

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A case was found in a two-year-old girl. The Combined nevus was not visible on her body when she was born. Around six months after birth, a black spot started to appear on the outside of her right eyebrow. The size of the black spot was measured at 5×4mm when it was examined medically for the first time. It grew to 8×7mm in one year. The skin tumor showed the black nodal with a thickness of 9mm. The spot was made of a combination of two different pigmented cellular nevi. One was a Blue nevus, cellular type and the other was a Spitz nevus, dermal type. The boundary of the two diseased area was clearly defined. It has been more than one year since the operation and there has been no reappearance of the nevus. The Combined nevus, Blue nevus and Spitz nevus, has been reported only once in Japan so far, therefore the two-year-old girl's case is regarded as rare as hen's teeth. [Skin Cancer (Japan) 2003; 18: 303-307]

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We report a case of penile malignant melanoma that was treated with partial penectomy. A 93-year-old man noticed a black nodule within a pigmented macule on his glans penis. There was no palpable inguinal lymphadenopathy.
Histopathologically, it was malignant melanoma with a Breslow's tumor thickness of 6mm and Clark level 5 invasion. Staging with a computerized tomography showed no evidence of metastasis. Partial penectomy with a 3cm skin margin from the pigmented macule was performed. The patient was in good condition and without evidence of local recurrence or metastasis for eight months. Bilateral inguinal lymphnode metastases, which were found nine months after the operation, were treated by a local injection of interferon-beta. The quality of life of the patient has been well maintained as high as before the operation. [Skin Cancer (Japan) 2003; 18: 308-311]

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We experienced a 71-year-old man with an apocrine adenocarcinoma arising in the right axilla. The lesion was first noticed as a subcutaneous tumor two years ago, and it developed erosion on the surface. Histological examination revealed adenocarcinoma composed of atypical cells with abundant eosinophilic cytoplasm. The tumor cells showed GCDFP-15 (+), PAS (+), EMA (+), CEA (+), CK7 (+), MUC1 (+) . We diagnosed this tumor as apocrine adenocarcinoma of the skin. Metastases of many axillary lymph nodes and bone were found. Wide local resection, axillary lymph node dissection, radiation and chemotherapy were perfomed. So far local recurrence and increase of the metastases have not been found. [Skin Cancer (Japan) 2003; 18: 312-315]

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We report a 45-year-old white man with scaly erythematous plaques on the bilateral shoulders. The plaque on the left shoulder was 28×22mm in diameter with smooth surface and mild itching. The plaque on the right shoulder had a similar appearance and was 35×22mm in diameter. Eczema was suspected of the clinical feature by the former dermatologist and steroid ointment therapy was started. But he was not cured. The findings of each biopsied specimen showed superficial basal cell carcinoma. We performed wide local excision. The excised specimens had identical histologic features. [Skin Cancer (Japan) 2003; 18: 316-319]

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The patient was an 18-year-old male. On the left thigh, he had a purplish blue, smooth, and rubbery mass (8×8×4cm) . The lesion was composed of four lobules, and compression produced a bloody discharge. Hematoxylin and eosin staining of a biopsy specimen showed the uniform proliferation of small round tumor cells that had nuclei atypia with loosely arranged chromatin. Scattered mitotic figures were also seen, but there was no rosette formation. Periodic acid-Schiff staining revealed strongly positive granules in the cytoplasm, which were digested by diastase. On immunohistochemical staining, the tumor cells were positive for p30/p32MIC2 and vimentin, but negative for epithelial, neural, and myogenic markers. Cytogenetic studies revealed reciprocal translocation t (10; 11; 22) (p11. 2; q12; q24), and reverse transcriptase polymerase chain reaction demonstrated expression of the chimera gene EWS-FLI 1. General examination revealed no other tumor suggesting Ewing's sarcoma; these results indicated a diagnosis of primary extraosseus Ewing's sarcoma of the skin. [Skin Cancer (Japan) 2003; 18: 320-324]

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We described a case of epithelioid sarcoma of a 70-year-old woman. She had a slowly enlarging lesion for 5 years on her right finger. On examination, she had an ill-defined erythematous nodule with hard consistency on the dorsal aspect of her middle finger. The overlying skin showed ulceration. A biopsy specimen showed the proliferation of two types of cells, polygonal cells and spindle cells, with central necrosis. Immunohistochemically, the tumor cells were positive for keratin, CAM5.2, EMA and vimentin. Surgical specimen showed nodular arrangement of tumor cells with necrosis in the center of the nodule. There was no evidence of recurrence or metastasis eleven months after the amputation of the forefinger and the middle finger. [Skin Cancer (Japan) 2003; 18: 325-328]

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We reported a case of subcutaneous extramedullary hematopoiesis (EMH) in myelofibrosis (MF) . A 58-year-old woman diagnosed with MF had noticed multiple subcutaneous nodules on her neck, chest and back one month before. She visited our office on September 6th, 2002, because her nodules gradually increased in size. The white blood cell count was 102, 450/μl with metamyelocytes 3%, myelocytes 8%, blasts 1% and nucleated RBC were shown in peripheral blood. An abdominal CT scan showed swelling of the liver, spleen and kidney. Histopathology of subcutaneous tumor revealed proliferation of hematopoietic cells, erythroid series, myeloid series and megakaryocytic series. The diagnosis of subcutaneous EMH with MF was established. This case was treated with hydroxycarbamide. We analyzed 11 such cases in Japan. [Skin Cancer (Japan) 2003; 18: 329-333]

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In reconstruction of resultant defects after excision of malignant soft tissue neoplasms, flap transfer is required for coverage of exposed major vessels, nerves, tendons, or bone. A perforator flap is effectively used for reconstruction of lower extremity defects because the flap is thin and provides low morbidity. In this report, a 72-year-old female presented with undifferentiated sarcoma of the knee. She was successfully treated with a pedicled anterior tibial perforator flap. In addition, a 68-year-old male presented with malignant fibrohistiocytoma of the leg. His limb was uneventfully reconstructed with a free deep inferior epigastric perforator flap. These two cases are described in this report. [Skin Cancer (Japan) 2003; 18: 334-337]

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We experienced intravascular large B-cell lymphoma which could early be diagnosed by skin biopsy. A 79-year-old woman presented induration as much as the size of the hand with heat, tenderness and telangiectases on the inside of both of her thighs. Histopathologically, the atypical cells were shown in the veins of the dermis. Immunohistochemically, the atypical cells showed positive for L26, CD79a and LCA, but negative for UCHL-l, CD3, keratin and vimentin.
We diagnosed this tumor as intravascular large B-cell lymphoma. [Skin Cancer (Japan) 2003; 18: 338-341]

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A 76-year-old female presented with an eruption between her eyes from which she had suffered for more than 10 years. A biopsy had been performed at another hospital 10 years before, with no evidence of malignancy. In April 2002, she presented at our hospital with a 2.2cm×1.4cm irregular butterfly-shaped, black and brown pigmented macule between her eyes.
We confirmed the presence of lentigo maligna by biopsy 10 years after the eruption had first appeared.
Although the face is a predilection site for lentigo maligna, the area between the eyes is rarely affected. [Skin Cancer (Japan) 2003; 18: 342-345]

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We report on seven patients with extramammary Paget's disease who visited the Department of Dermatology, Fukui Medical University Hospital between April 1998 and December 1999. Four of the patients were males and three were females. Red plaque was found in the genital area of all patients and was found to consist of carcinoma in situ. Six patients were treated by surgical excision of the tumor, and a skin graft. Inguinal lymph node dissections were not performed, because all cases were carcinoma in situ and the Inguinal lymph nodes were not swollen. Radiotherapy or chemotherapy was not performed after surgical treatment in any of these cases. One patient refused surgical treatment, so radiotherapy was performed. All patients are alive and healthy. [Skin Cancer (Japan) 2003; 18: 346-350]

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