The history of palliative medicine started from a humanitarian/religious background, and developed into classical, modern, and then present-day hospice care. The characteristics of the present palliative medicine are as follows. 1) Based on the attitude of medical workers toward cancer patients, cancerassociated physical and psychosocial pain and distress in patients are holistically managed with medical knowledge and skills. 2) Palliative medicine is applied to the entire clinical course from the diagnosis of cancer and the treatment process to the terminal stage. 3) Palliative medicine is performed by a team consisting of various specialists. 4) The subjects of palliative care are not only inpatients/families in palliative care wards but also inpatients with cancer in general wards, outpatients, patients receiving care at home, and the bereaved. Thus, palliative care has been recognized as a medical care field for cancer that is provided widely, continuously, and comprehensively, from the stage of cancer diagnosis/treatment to the terminal stage. [Skin Cancer (Japan) 2006; 21: 252-260]

View full abstract

An increase in the number of aged patients with cutaneous lymphomas has resulted in a difficulty in the treatment of these disorders. In particular, we have increasing numbers of aged patients with primary cutaneous anaplastic large cell lymphoma, cutaneous B cell lymphoma, adult T cell leukemia/ lymphoma, Sézary syndrome, and mycosis fungoides. The therapeutic options for these lymphomas include etoposide, interferon-γ, radiation, steroid pulse therapy, and THP-COP. According to the characteristics of each treatment and depending on the patients' general conditions, dermatologists should choose one or more of these therapeutic modalities to obtain a good result without severe side effects. [Skin Cancer (Japan) 2006; 21: 261-267]

View full abstract

Adult T-cell leukemia/lymphoma (ATLL) is a human malignancy associated with human T-cell leukemia virus type I (HTLV-I). ATLL frequently involves the skin.
To correlate the clinicopatholigical features and prognosis of ATLL patients with cutaneous lesions, we examined HTLV-I proviral state and the clinicopathological features of the cutaneous lesions of 80 cases with serum anti-ATL antibody, to clarify the correlation between macroscopic/histopathological findings and prognosis. Southern blot analysis was performed in all cases to detect monoclonal HTLV-I proviral DNA integration. The cutaneous lesions of 46 patients were positive for proviral DNA integration. The median survival time (MST) of the patients with monoclonal proviral DNA integration in cutaneous lesions was 14 months, which was markedly shorter than that of patients negative for proviral DNA integration (n=72 months). In the 46 cases with proviral DNA, 21 had solitary or multiple red nodules (including 3 with subcutaneous induration), 8 had multiple red papules, and 17 had erythema. Patients with papules and tumors had poorer prognoses than those with erythema. Histopathologically, the prognosis was poorer in patients with nodular or diffuse infiltration of medium to large sized lymphoma cells, compared to those with perivascular infiltration of small to medium sized lymphoma cells.
Our results showed a close correlation between clinicopathological features of HTLV-1 associated cutaneous lesions and prognosis. [Skin Cancer (Japan) 2006; 21: 268-272]

View full abstract

We treated 220 cases of melanoma between 1996 and 2005. Among them 32 cases showed recurrence and/or metastases: local recurrence 3, in-transit metastasis 4, regional lymph node metastasis 8, regional lymph node metastasis and visceral metastasis at the same time 5, and visceral metastasis 12 cases. Treatment modalities available at our Department are surgery, chemotherapy, immunotherapy, radiotherapy inclusing γ-knife for brain metastasis and radiofrequency ablation therapy for lung and liver metastasis.
It is important to consider a patient's age, performance status, and site and number of metastases before choosing the treatment modalities. Patient counseling is also important for treatment of recurrent and metastatic melanoma. Providing no treatment is an important consideration, especially in patients who are terminally ill, or those of advanced age. [Skin Cancer (Japan) 2006; 21: 273-278]

View full abstract

Angiosarcoma is an uncommon malignancy, accounting for only 2% of all sarcomas. Malignant hemangioendothelioma (MHE) accounts for more than 80% of all cutaneous angiosarcoma with a more dismal prognosis. Many treatment options do exist, but no standard treatment method had been discovered thus far. Most of the cases thus far have been treated with wide local excision followed by radiation or interleukin-2 based immunotherapy without considering the pathology of the primary tumor. However, it is very important to consider pathological features, for IL2-based immunotherapy is effective only in the lesions which are so-called plaque lesions, with higher differentiation and presence of tumor infiltrating lymphocytes (TIL) . On the other hand, poorly differentiated tumors without TIL should be treated with other options. Even if an appropriate treatment will lead to a complete remission of the primary tumor, distant metastasis frequently occurs within 1-2 years and becomes lethal. Effective adjuvant therapy for angiosarcoma should be established to inhibit frequent distant metastasis, [Skin Cancer (Japan) 2006; 21: 279-285]

View full abstract

It is very important for dermatologists to determine whether malignant skin tumors are primary or metastatic. The determination affects the treatment and prognosis of these lesions. I present cases of malignant skin tumors that were difficult to distinguish as primary or metastatic.
Metastatic SCC is not continuous with the overlying epidermis and well demarcated pathologically. Poorly differentiated SCC demonstrates a pseudogland formation, and reveals a positivity for simple epithelial keratin proteins and vimentin. Immunohistochemical panels of GCDFP15 and cytokeratin20 are very useful in distinguishing between primary and secondary extramammary Paget's disease. It is important to recognize the existence of primary dermal melanomas. Metastatic melanoma sometimes demonstrates the morphological characteristics of clear cell sarcoma. Epidermotropic metastatic malignant melanoma can simulate primary melanoma in situ. [Skin Cancer (Japan) 2006; 21: 286-292]

View full abstract

A 43-year-old male had a malaise with his left eye in December 1994. A tumor of the palpebral conjunctiva of the left upper eyelid was excised in an ophthalmological clinic in March 1995. Histological diagnosis was mucoepidermoid carcinoma. Wide local excision was performed, and the tumor located at the palpebral conjunctiva of left upper eyelid was excised with a safety margin of 5-10mm. The defect was reconstructed using switch flap and cheek flap. There had been no recurrence for 5 years after surgery. However in December 2002a tumor of the palpebral conjunctiva of the left upper eyelid presented, and an immediate biopsy revealed that the tumor was a recurrence of the mucoepidermoid carcinoma. Additional excision of the palpebral conjunctiva of the left upper eyelid and radiation were performed. There has been no local recurrence or distant metastasis for 3 years after the second surgery. [Skin Cancer (Japan) 2006; 21: 293-297]

View full abstract

An 80-year-old woman suffered a burn on her left lower leg caused by a hot water bottle. The wound healed with conservative treatment, but a recurrence of the ulceration occurred one year and a half after primary wound healing. It resisted conservative treatment, and ulceration returned. For this reason a resection of the ulcer and skin grafting were performed seven months later. The histopathological diagnosis was basal cell carcinoma and additional wide resection was performed. There was no recurrence of the tumor two years after the second operation. Basal cell carcinoma arising from a burn scar in such a short term is rare. [Skin Cancer (Japan) 2006; 21: 298-301]

View full abstract

The case was a 22-year-old woman who noticed a subcutaneous tumor in her right chest seven years ago. After an excisional specimen revealed the features of Bednar tumor, the lesion was excised with a wide margin. A histological examination of the tumor showed spindle cells arranged in a storiform pattern and dendritic cells with melanin in the spindle cells. Fifty-six cases of Bednar tumor have been reported in Japan, including our case, between 1975 and 2006. We also studied them comparing them to 151 cases of dermatofibrosarcoma protuberans in Japan. [Skin Cancer (Japan) 2006; 21: 302-305]

View full abstract

An 87-year-old woman presented with a nodule on the right temple. She had noticed the erythematous nodule on the right temple four months ago, and the nodule had rapidly enlarged accompanied by ulceration. We first suspected squamous cell carcinoma, but histological findings from the nodule revealed a sheet hyperplasia of a rhabdoid cell to show nuclear fission image, good acid inclusion bodylike structure. Cytokeratin 7 and Vimentin were positive in these cells, but Desmin and S-100 protein were negative. We finally diagnosed this nodule as a malignant rhabdoid tumor. The patient was operated on meningioma at the age of 82 years. Metastasis of the meningioma was ruled out by different histological findings. For the following year until now, the tumor has not recurred and no signs of metastasis have developed. [Skin Cancer (Japan) 2006; 21: 306-309]

View full abstract

A 62-year old Japanese man presented with an ulcerated mass on the posterior surface of his right thigh. He had been aware of the lesion for seven years but decided to see a doctor after it grew and became ulcerated. Biopsy results showed the tumor to be squamous cell carcinoma. By contrastenhanced magnetic resonance imaging, we found an inter-muscular mass of the biceps femons of the right thigh. After surgical resection, we further diagnosed it as a lymph node metastasis of squamous cell carcinoma. Interval nodes, which lie along the course of a lymphatic vessel between a lesion site and a recognized node field, are not uncommon in the trunk but rare in the leg. Based on the anatomical distribution between the lymph node and the primary lesion of the cancer, we determine that this lymph node was one of the interval nodes. [Skin Cancer (Japan) 2006; 21: 310-313]

View full abstract

A 68-year-old male patient was seen at our hospital in June 2003 with a subcutaneous tumor on the right buttock of one month's duration accompanied by the enlargement of the right inguinal lymph node. The tumor was histopathologically diagnosed as Merkel cell carcinoma (MCC). After resection with wide margin and lymph node dissection, we added X-ray irradiation in order to prevent local recurrence. He attained complete remission for twenty months. A follow-up CT in April 2005 revealed multiple liver metastases and the serological NSE level was 240ng/ml. First he was treated with EP regimen which was shown to be ineffective. We switched to CAV regimen resulting in complete remission. After a two-month duration of CR, a recurrence of MCC metastatic lesions was detected in the liver and pleura. Amrubicin wasn't effective. The selection of chemo-regimens of MCC is controversial. Further clinical study should reveal the optimal chemo-regimens in the treatment of MCC. [Skin Cancer (Japan) 2006; 21: 314-317]

View full abstract

We report a case of a 90-year-old man with angiosarcoma on his scalp, effectively treated with electron beam irradiation. He was referred to our hospital for dusky erythemas and purpuras widely developed on his whole scalp. The lesion was diagnosed histologically as angiosarcoma. However the patient was injected with IL-2 (a total dose of 4.7 million units), and we observed significant eosinophilia and acute renal failure one week later after starting IL-2. Subsequently, he was treated with electron beam therapy (a total of 90 grays) . The lesions were effectively treated and almost disappeared. In this case, the radiotherapy was beneficial for his quality of life. [Skin Cancer (Japan) 2006; 21: 318-322]

View full abstract

A 73-year-old man noticed he had an erythematous lesion on the scrotum at the age of 68 years. The skin lesion had not improved after being treated with an antimycotic ointment, and it gradually enlarged with exudates. On our first examination, the patient had a large erosive lesion, 43×37cm in diameter, on the scrotum, penis, inguinal areas and lower abdomen. A diagnosis of extramammary Paget's disease was historically made. The tumor was totally excised and the defect was reconstructed with splitthickness skin graft. Eight months after the operation, the patient died of general prostration caused by tumor metastasis. To our knowledge, our patient is the largest case of extramammary Paget's disease among the patients whose lesions were described in size. [Skin Cancer (Japan) 2006; 21: 323-326]

View full abstract

A four-month-old baby girl presented with eruptions which started on the trunk a month ago. A physical examination showed scaly erythematous maculopapular eruptions of rice-bean size on the trunk and the thighs. The lesions were distinct, with purpura and erosion evident in places.
The histology showed diffuse infiltration of large hystiocytic cells with bean-shaped nuclei in the dermis and epidermis. These cells were immunohistochemically positive for S-100 protein and CD 1 a. Electron microscope findings revealed the presence of Birbeck granules in the cytoplasm of the histiocytic cells. The patient was diagnosed with Langerhans cell histiocytosis, a single-system, multisite type, after systemic check up. The patient responded well to systemic chemotherapy, and the symptoms have since been in remission.
Isolated skin lesions in LCH occur primarily in early infancy, and show mostly benign prognosis. We reported a case of a single-system skin lesion in LCH, with an overview of some of the literature concerning its treatment and prognosis. [Skin Cancer (Japan) 2006; 21; 327-331]

View full abstract

The patient was a 58-year-old woman. We resected squamous cell carcinoma (SCC) about 4 cm in size from her forearm with a 2 cm margin of tumor free skin, and performed a sentinel lymph node (SLN) biopsy. Histopathological examination revealed no evidence of SLN metastasis. Since 8 months after the surgery, she had not visited our hospital. Two years after the surgery, she noticed that the tumor had gradually increased to her elbow. When she visited our hospital, there was an erosive tumor, 20cm in size. We diagnosed in-transit metastasis of SCC, transected her right superior limb from the shoulder joint and right axillary lymphadenectomy. Histopathological examination revealed no evidence of SCC and axillary lymph node metastasis. Peplomycin sulfate preoperatively, 7-courses of CDDP and 5-FU postoperatively were used for systemic chemotherapy. The patient has no sign of recurrence. [Skin Cancer (Japan) 2006; 21: 332-335]

View full abstract

We report 2 cases of basal cell carcinoma with difficulty in clinical diagnosis. Case 1: A 71-year-old female noticed a brownish erythema on her right leg 3 months ago. The lesion was 16×14mm in diameter with crusts and scales. Case 2: A 63-year-old male noticed a brownish erythema on his right leg 3 years ago. The lesion was 15×15mm in diameter with crusts and scales. Dermoscopy showed no pigment network in both cases. Leaf-like areas, multiple blue-gray dots/globules, small ulcers, arborizing vessels in case 1 and multiple blue-gray dots/globules, small ulcers, arborizing vessels in case2 suggested these tumors are basal cell carcinoma. Histologically, the tumors in both cases showed typical features of superficial basal cell carcinoma. We were very impressed that dermoscopy was such a useful tool for the diagnosis of basal cell carcinoma. [Skin Cancer (Japan) 2006; 21: 336-339]

View full abstract

We report a case of rapidly aggressive eccrine porocarcinoma. A 51-year-old man presented with a partially ulcerated giant tumor on the scalp. Although he had noticed a small tumor from his adolescence, it rapidly grew larger in these three months. Despite surgical resection, including underlying cranial bone, cervical lymph nodes became involved within one month. Lymph nodal dissection and local radiotherapy were performed, but the tumor recurred at the neighboring skin and lymph nodes. In spite of systemic chemotherapy and local irradiation, the skin lesion spread to the anterior chest and upper abdomen, and the patient died of pulmonary failure. [Skin Cancer (Japan) 2006; 21: 340-344]

View full abstract

The first case was a 52-year-old woman who noticed multiple cutaneous nodules with erythema on her right cheek. The second case was a 19-year-old female who noticed cutaneous nodules on her upper arms. Histologically, there was a grenz zone in the upper dermis and nested-like or sheet-like proliferation of the centrocyte-like cells were around reactive lymphoid follicule. In case 2, there was proliferation of plasma cells at the periphery of the lymphocytic infiltration with chain restriction. Tumor cells were positive for CD20, and negative for CD5, CD10. The polymerase chain reaction method using DNA extracted from a paraffin section showed a rearrangement band of the IgH chain gene. In both cases, primary cutaneous marginal zone B-cell lymphoma was diagnosed. [Skin Cancer (Japan) 2006; 21: 345-349]

View full abstract

We report a case of a 52-year-old Japanese man who presented with subcutaneous nodules and follicular papules on his face and back. The histological examination of a biopsy specimen suggested follicular and nodular pattern of atypical mononucleocytes at dermis and subcutis. The cells of the neoplasm that share these patterns expressed CD10, CD20 and CD79a. The patient displayed the t (14; 18) (q32; q21) translocation. The computed tomography showed generalized lymphadenopathy. CHOP therapy was effective for these lesions. [Skin Cancer (Japan) 2006; 21: 350-353]

View full abstract

We presented the case of a 65-year-old Japanese man, diagnosed with senile EBV-associated B-cell lymphoproliferative disorder, whose chief complaint was multiple skin nodules and tumors. Histological findings showed massive infiltration with extensive necrosis in the lower dermis and subcutaneous fat, which was composed of large and small lymphoid cells. The large atypical cells were immunohistochemically positive for CD20, CD79a and CD30 and were also positive for nuclear signals of EBERs using in situ hybridization studies. Rearrangement of immunoglobulin H chain was noted by Southern blot hybridization studies. Further examination revealed swollen lymph nodes in the abdomen and axillar region, a high level of sIL-2R and depressed cellular immunity. Rituximab-CHOP chemotherapy was effective for the skin lesions and lymph nodes; however, repeated opportunistic infections retarded the therapy, so that the skin lesions often relapsed. The patient reached complete remission and was discharged after the admission period of 1 year and 5 months. [Skin Cancer (Japan) 2006; 21: 354-358]

View full abstract

Dermoscopic parallel-ridge pattern is important in making a diagnosis of malignant melanoma on sole skin. Here, we report a case of lentigo simplex with parallel-ridge pattern, that was probably induced by anti-cancer drugs. A woman in her 30's was under treatment with anti-cancer drugs for a malignant soft tissue tumor. She was referred to our department because of a growing oval pigmented macule on her right sole.
One month later, the size of the macule had increased in size from 5.5×5.5mm to 7.5×5.5mm. Both the color and border of the macule were irregular. Dermoscopic examination showed the macule had a parallel-ridge pattern. Because these dermoscopic and clinical findings suggested that this macule was malignant melanoma, we performed excisional biopsy. Pathological examination showed that the macule was lentigo simplex. We speculated that this macule may have been induced by anti-cancer drugs. [Skin Cancer (Japan) 2006; 21: 359-362]

View full abstract

A 51-year-old female presented with a black macule on the left sole. The tumor appeared in September, 2005 and the size gradually increased. She visited our hospital on August 26, 2005. A 30×20mm-sized irregular and non indurated black macule was identified during the first examination. The dermatoscopy showed a parellel ridge pattern. The histological analysis of the resected tumor showed atypical melanocytes in the basal layer epidermis. These atypical melanocytes were all HMB 45 positive. Based on these observations, we diagnosed the patient as having malignant melanoma in situ.
In addition, there were large black macules on the mucous membrane of the cheek, multiple small black macules on the palmoplantar, and black longitudinal streaks on the nail. Evidence of Peutz-Jeghers syndrome, gastrointestinal polyposis, gene and endocrine abnormality were not found. We diagnosed the patient as having Laugier-Hunziker-Baran syndrome. [Skin Cancer (Japan) 2006; 21: 363-367]

View full abstract

Case 1: A 73-year-old woman presented with vaginal malignant melanoma. She underwent surgical procedures and three courses of chemotherapy (DAV-Feron) from September 30. Case 2: A 49-year-old woman presented with vulvar malignant melanoma. She was hospitalized at our department, and one course of DAV-Feron treatment was given on December 15. Her condition, however, showed no improvement and she died on March 15, 2006. Of all malignant melanomas, those arising primarily in the female genital organ are relatively rare and their detection is often delayed because of their anatomical features, the patients' sense of embarrassment, etc. Their standard treatment is based on the same therapy as that used for malignant skin melanomas. However, progressive melanomas are intractable with a poor prognosis. Therefore, through accumulating more data on similar cases, a further advance in their treatment is called for. [Skin Cancer (Japan) 2006; 21: 368-371]

View full abstract

Conjunctival melanoma is rare with an annual incidence in Japan of less than 5 cases.
In 2002, TNM classification was proposed by UICC, but stage was not proposed.
The standard management of conjunctival melanoma is local resection, but local recurrence, regional metastasis, and, distant metastasis are not rare conditions. The sentinel lymph nodes are thought to be the first metastasis for the majority of the patients; so, we should examine the lymph nodes by sentinel lymph node biopsy to improve the prognosis of the conjunctival melanoma.
We describe a patient with conjunctival melanoma who underwent SLN biopsy by the RI method at the time of the resection of the conjunctival melanoma. [Skin Cancer (Japan) 2006; 21: 372-375]

View full abstract

We reported two cases of melanoma with gastrointestinal tract metastasis. The first case was a 72-year-old woman who underwent resection of acral lentiginous melanoma (tumor theckness: 2.5 mm) on her right medial malleolus in 1998. She received elective right inguinal lymphadenectomy followed by 6 courses of DAVFeron therapy. Two years later, umbilical metastasis was resected. The multiple organ metastases were found and treated by 2 courses of DAC-Tam therapy in 2001. In December 2001, she presented with severe anemia, and endoscopy revealed continuous hemorrhage caused by duodenal metastasis. She underwent hemostasis by transarterial embolization. She died from multiple organ failure in January 2003. The second case was a 51-year-old woman who underwent resection of superficial spreading melanoma (tumor thickness: 0.9 mm) on her left chest 7 years previously and who presented with left axillary lymph node metastasis. Endoscopy revealed multiple amelanotic polyps in her stomach, which were resected in July 2002 and treated by a course of DAC-Tam+Feron therapy. Lung metastasis was found 3 months after the resection and the patient died in January 2003. [Skin Cancer (Japan) 2006; 21: 376-379]

View full abstract