We performed a nationwide survey concerning the annual incidence of malignant skin tumors in 1987-2001 in Japan, an epidemiological survey about basal cell carcinoma, squamous cell carcinoma, malignant melanoma, actinic keratosis, and the like, and assessed the prognosis of these diseases. According to the nationwide survey, the number of patients with malignant skin tumors increased clearly, and the relative incidence was basal cell carcinoma > squamous cell carcinoma > malignant melanoma. The results of the epidemiological survey and prognosis assessment were evaluated in detail for malignant melanoma, and the cumulative survival rate was calculated by year, sex, disease type, clinical stage, and the like. [Skin Cancer (Japan) 2007; 22: 209-216]

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Several small hand-held gamma cameras have been developed commercially. Of these, a semiconductor gamma camera is suitable for surgical use because of the possibility of miniaturizing the detector system. We have developed a small semiconductor gamma camera (SSGC) for sentinel lymph node biopsy. Using animal studies and pilot clinical studies, this study is designed to characterize the performance of the SSGC for sentinel node biopsy. The camera head of the SSGC consists of a pixelized CdTe module with pixels in 32 rows attached to a collimator. The entire assembly was encased in a lead housing measuring 152×166×165mm. The effective visual field was 44.8×44.8mm. The SSGC showed significant potential for detection of sentinel lymph nodes in lymphoscintigraphy. The results of the studies suggest that the SSGC facilitates exploration of hot nodes in sentinel lymph node biopsy. [Skin Cancer (Japan) 2007; 22: 217-225]

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The new clinical practice guideline for the treatment of skin cancer in Japan was published in April, 2007. The guideline for squamous cell carcinoma of the skin (SCC) was composed of the clinical algorism and 11 clinical questions involving prevention, diagnosis, surgical margins, radiotherapy and chemotherapy for localized to metastatic lesions. Localized SCC is usually curable by simple excision, and surgical margins are recommended to range from 4 mm to 10 mm, depending on the risk factors of the primary tumor. Radiation therapy with or without surgical excision may be useful in specific clinical situations, particularly for patients with primary lesions requiring difficult or extensive surgery (e.g., eyelids, nose, ears or fingers) . The clinical evidence for treatment of SCC is limited. Further clinical study is needed especially in advanced cases. [Skin Cancer (Japan) 2007; 22: 226-232]

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These guidelines for the management of BCC have been prepared for dermatologists on behalf of the Japanese Association of Dermatologists. They presented evidence-based guidance for treatment. Basal cell carcinoma (BCC) is the most common skin malignancy in humans. BCCs are defined as slow-growing, locally invasive, malignant (but not life threatening), epidermal skin tumors, which also affect Japanese people. Many different and well-accepted treatments are used in the management of BCC. These guidelines aim to aid selection of the most appropriate treatment for individual patients.
We set up 19 clinical questions and indicated the algorithm for the management. Individual tumors can be divided into relatively low and high-risk categories, the recognized prognostic factors. This will allow the clinician to select the most appropriate forms of treatment. The first line of treatment of BCC is often surgical excision under frozen section control (not Mohs' micrographic surgery) . Numerous alternatives are available and include: curettage and electrodessication, cryosurgery, radiotherapy, topical therapy, PDT and imiquimode. Here we will discuss the contents and problems of each therapy. [Skin Cancer (Japan) 2007; 22: 233-238]

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Most levels of recommendation for clinical procedures and treatment for extra-mammary Paget's disease were graded low due to lack of quality evidence. Therefore, the existing situations and experts' opinions were also considered to determine the levels of recommendation. To improve the quality of this guideline, further studies concerning the management of patients with extra-mammary Paget's disease are required. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the doctor, following the consideration of clinical evidence as well as the recommendation of this guideline. [Skin Cancer (Japan) 2007; 22: 239-244]

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Japanese clinical practice guidelines for skin cancer were made in conformity with a process of evidence-based medicine. As they are available online and as a publication, they are intended to promote communication between clinicians and patients. It is important to recognize that the guidelines are “material” to decide a medical care policy, which never lose clinician's discretion. These guidelines must be continuously updated in the future; therefore, the opinions of both clinicians and patients who use them will be required. In order to mature as true, original Japanese guidelines, we will have to accumulate clinical evidence from Japanese sources. [Skin Cancer (Japan) 2007; 22: 245-251]

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An 79-year-old man noticed a small nodule on his left postauricular area about 3 years ago. It gradually became a fist-sized tumor. The surface was red and ulcerated. In addition, there had been brown tumors on both scapular areas since his childhood. Moreover, his parents had similar tumors. Histopathological findings revealed an eosinophilic nodule throughout the dermis. The nodule consisted of fibroblasts, and collagen fibers arranged parallel to the surface epidermis. Partially, a loose storiform pattern was seen. Capillary vessels proliferated perpendicular to the collagen fibers. There was nonspecific inflammation below the ulcer and hyalinization of collagen bundles in places. Immunohistochemical staining showed that the proliferating cells were fibroblasts. Almost all the cells were positive for vimentin, and negative for desmin, CD34, and S-100 protein. α-SMA was partially positive. Elastica-van-Gieson staining demonstrated the presence of collagen fibers. We diagnosed this case as keloid. The tumor size has not changed in spite of no particular treatment. [Skin Cancer (Japan) 2007; 22: 252-255]

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We reported two cases of basal cell carcinoma (BCC) that developed after radiation therapy. A 50-year-old woman, who had received an unknown amount of radiation therapy for the treatment of intracranial germinoma at the age of 22, presented with several tumors around the radiation ulcer. All tumors showed BCC. A 33-year-old woman, who had received an unknown amount of radiation therapy on the head for the treatment of leukemia at the age of 2, presented with a black nodule within the area of irradiation. The tumor showed BCC. We discuss the occurrence of BCC after radiation therapy. [Skin Cancer (Japan) 2007; 22: 256-262]

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A 77-year-old woman presented to us with a 10-year history of nodules on her face, which were diagnosed as multiple basal cell carcinomas. After a long period without follow-up visits the patient appeared to us with the complaint of a huge tumorous growth on her nose.
The tumor had reached 10 cm in size, was ulcerated, irregularly bordered and smelled. In addition, multiple black to brown nodules and papules were located over her face. A computed tomogram demonstrated a tumor invasion into the ethmoid bone, as well as a maxillary cyst. The giant tumor on her nose was successfully excised. On the basis of clinical and histopathological findings and a positive family history, this unique tumor was diagnosed as giant basal cell carcinoma, which had developed from basal cell nevus syndrome.
It is stressed that there may be possible further risks of aggressive and invasive basal cell carcinoma in this syndrome. [Skin Cancer (Japan) 2007; 22: 263-267]

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A 44-year-old Japanese male presented with pruritic eruption which he has had since the age of 42. Erythematous plaques, scalp hair loss and large patchy erythematous lesions on the trunk were found. Biopsy specimens from the erythematous scalp plaque showed extensive perifollicular and intrafollicular infiltrates of atypical lymphocytes with enlarged and convoluted nuclei. Immunohistochemical stains of the atypical lymphocytes showed positive reaction for CD3, CD4, CD 5, and negative reaction for CD8, CD20. Molecular genetic analysis of the T-cell receptor beta-chain showed a clonal rearrangement. There was no abnormal lymph node swelling or visceral involvement under image diagnosis. The patient was diagnosed with folliculotropic mycosis fungoides, stage lb. He was treated with total skin electron beam therapy (total 30Gy), and thick plaque were boosted by 6 MeV electron beams (total 14Gy). There has been no recurrence after radiotherapy for 5 months. [Skin Cancer (Japan) 2007; 22: 268-272]

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A 66-year-old man presented with primary penile malignant melanoma. He recognized a circular black pigmented spot on the penis in his childhood. When he was 65 years old, a part of the eruption developed into a black nodule (23mm×18mm×3mm) with ulceration. We diagnosed it as malignant melanoma (MM), resected it with a 3cm free margin and performed a sentinel lymph node biopsy and right inguinal lymphadenectomy. Primary penile malignant melanoma is rare, and only 37 cases have been reported in Japan. [Skin Cancer (Japan) 2007; 22: 273-276]

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Neurotropic melanoma is a rare tumor which invades and extends along nerves, either in the penneural space or in the endoneurium. Neurotropic melanoma also overlaps with dermal tumors that we regard as superficial malignant epithelioid schwannomas. So it often appears fibrous in origin and may be considered to be benign. Despite this benign appearance histologically, the tumor behaves aggressively with multiple local recurrences. A wrong diagnosis seriously affects the consequence of the treatment. In one case, the tumor invaded the transverse cervical nerve. In another case, the tumor invaded the posterior cutaneous nerve of radial nerve despite middle finger amputation. We report two cases of neurotropic melanoma whose medical treatment caused problems due to the difficulty of initial diagnosis. [Skin Cancer (Japan) 2007; 22: 277-281]

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A 65-year-old male with subcutaneous nodules on his left axillary area and left side of his back was admitted to our clinic on suspicion of malignant melanoma. A histopathological examination revealed a proliferation of melanoma cells in the deep dermis to subcutaneous fat tissue with increased dermal melanocytes and axillary lymph node metastases. A pathological diagnosis of malignant blue nevus was made.
After five courses of DAV-Feron chemotherapy, new black nodules grew on his left axillary area and were pathologically diagnosed as a recurrence of melanoma. On PET-CT, metastatic lesions to his lungs and liver were detected and the chemotherapy was changed to DAC-Tam. Dac-Tam therapy has shown a partial effect on the metastatic lesions. [Skin Cancer (Japan) 2007; 22: 282-285]

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A 13-year-old boy suffering from neurofibromatosis type 1 noticed a subcutaneous tumor (3×3cm) on the left trunk in January, 2005. The tumor was diagnosed as neurofibroma by skin biopsy, and was carefully observed without treatment. Since the tumor became enlarged gradually, a second biopsy was taken in July, 2006. After the biopsy, the tumor enlarged rapidly to 20×20cm in size, and induced respiratory failure. An immediate excision of the tumor was performed. The tumor was histologically diagnosed as a malignant peripheral nerve sheath tumor. After the surgical treatment, adjuvant chemotherapy and radiotherapy were performed, and the boy has been free from recurrence or metastasis for eleven months. [Skin Cancer (Japan) 2007; 22: 286-289]

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We report a case of a malignant peripheral nerve sheath tumor (MPNST) with NF1.
A 63-year-old man had multiple subcutaneous neurofibromas for years. In 2006, when he was 63 years old, one of the neurofibromas on his back became enlarged and ulcerated. On histolosical examination, the new tumor occupied the dermis in a neurofibroma. The tumor cells were atypical with premorphic nuclei and were positive for S-100 protein. We diagnosed MPNST which comprised part of a neurofibroma.
Cutaneous MPNST is rarer than its deep form. Cutaneous MPNST has a better prognosis than its deep form. But approximately 60% of the cases have local recurrence. [Skin Cancer (Japan) 2007; 22: 290-292]

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A 32-year-old male with dermatofibrosarcoma protuberans (DFSP), which presented as a subcutaneous mass on his left upper arm, is reported. The lesion with a 4-year history had increased in size. An excisional biopsy of the lesion revealed a spindle cell tumor with low malignant potential. Wide resection was performed after 4 weeks. Histologically, the tumor cell was composed of spindle-shaped cells, arranged in storiform pattern. Immunohistological analysis showed that the tumor cells were positive for CD34. We reported a rare variant of DFSP confined to the subcutaneous tissue. [Skin Cancer (Japan) 2007; 22: 293-296]

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The patient was a 73-year-old male who had noticed a rice sized nodule on his forehead one month before the first visit to our physical clinic. Following a clinical diagnosis of malignancy, he was referred to our clinic. Physical examination at the first visit showed a dome-like, elastic hard nodule, (2.5×2.3cm in size) on the scalp. He was diagnosed with acute-type ATLL based on the histopathological and molecular biological analysis. In addition, because he had recognized digestive organ symptoms such as diarrhea, and the adult T-cell leukemia/lymphoma for a month, we performed digestive tract endoscopy. The examination disclosed that there were a lot of ulcers in the colon, and irregular thickening of the gastric mucosa. On histological examination of the mucosae, these lesions showed ATLL cell infiltration. [Skin Cancer (Japan) 2007; 22: 297-302]

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A 74-year-old male presented with a 6-month history of an erythematous plaque on the apex of his nose. A biopsy specimen from the tumor showed squamous cell carcinoma (SCC) . Ultrasonography showed bilateral submandibular lymphadenopathy and a biopsy from the right mandibular lymph node showed metastasis. The tumor on the nose was excised with a 10mm margin and the defect was covered with a skin graft. A biopsy from the left mandibular lymph nodes showed metastasis in one of two lymph nodes and a bilateral superior neck dissection was performed. Postoperatively, a combination of one course of chemotherapy with cisplatin and doxorubicin and radiotherapy for the neck and clavicle were administered. There has been no recurrence or metastasis of the tumor for five years after surgery. Our case indicates that bilateral neck lymph node metastases may occur in patients with mid-line SCC. [Skin Cancer (Japan)2007; 22: 303-306]

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A 90-year-old woman presented with a tumor on her external genitalia. A biopsy of the lesions confirmed the diagnosis of squamous cell carcinoma with a right inguinal lymph node metastasis. We performed subtotal integumentectomy. Four months after the operation a left inguinal and para-aortic lymph node metastases were found, and she then underwent a left superficial inguinal lymph node resection. Seven months later lung metastasis rapidly appeared, and she died 9 months after the operation. In cases of the oldest old, we often struggle with the choice of the appropriate medical management for their complications and invasive surgical procedure. Furthermore we have to consider how to improve the patient's quality of life as well as local treatment of the tumor itself. It is important that we comprehensively judge the progression, activity of daily living after the operation, living environment after the discharge from the hospital, and how to support the patient's family and select the best therapy. [Skin Cancer (Japan)2007; 22: 307-311]

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An 87-year-old woman developed a nodule on her left cheek that gradually increased in size (12mm). A skin biopsy specimen taken by a local medical doctor revealed squamous cell carcinoma. She was referred to our hospital because the malignant tumor remained at the end of the specimen. The tumor was surgically resected completely with an 8mm margin, and there was no evidence of metastasis (Stage I, T1N0M0) . About 10 months later, December of 2005, her right cervical lymph nodes were swelling. The resected lymph nodes were filled with malignant cells. Although it is generally accepted that squamous cell carcinoma rarely spreads to other organs in the early stages, lymph node metastasis was found in this case. Although the adaptation of the sentinel lymph node biopsy for squamous cell carcinoma has not been defined, an accumulation of early cases should be required for further studies. [Skin Cancer (Japan)2007; 22: 312-315]

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We report a case of multiple Bowen's disease induced by cutting oil. The patient was a 71-year-old man who had developed multiple small lesions with erythema between his left fingers, on both of his hands and forearms over a period of five years. Skin biopsy of some of the lesions revealed Bowen's disease. After the patient had been exposed to cutting oil while wearing cotton gloves for three years, he was exposed to a night-soil treatment chemical, a strongly acidic solution, virtually with his bare hands. The night-soil treatment chemical induced erosions on his hands, with subsequent development of Bowen's disease as described above. The cutting oil was reported to contain a carcinogenic substance, 3, 4-benzopyrene. The cutting oil appeared to have induced multiple lesions of Bowen's disease, along with the strongly acidic night-soil treatment chemical. [Skin Cancer (Japan)2007; 22: 316-319]

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A 71-year-old female was referred to our hospital with a 10-year history of a 40×35mm black macule in the left sole. The excised lesion was histologically diagnosed as malignant melanoma with a 0.5mm tumor thickness. Sentinel lymph node biopsy and radiographic examination revealed no evidence of nodal or distant metastasis. The patient's tumor stage was assessed as stage I A (pT1aN0M0) . A month later, her younger sister, who was 68 years old, visited to our hospital with a clinical presentation of a year's history of a black macule in the right big toe. Surgical specimen showed an in situ lesion of melanoma cells. There has been no evidence of recurrence in either case. Familial malignant melanoma in a sibling is rare. To our knowledge, only four family cases were previously reported in Japan. We reported a case of familial malignant melanoma with a few considerations of literature. [Skin Cancer (Japan)2007; 22: 320-324]

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