An 81-year-old woman visited our hospital because of a 35×45mm tumor and red-white colored plaque spreading from the labium minus to the right side of the anus. At the first biopsy, the tumor was diagnosed as benign, and then cryotherapy was used. The tumor decreased in size temporarily, but became enlarged again. Therefore we performed a biopsy three times and finally obtained a diagnosis of verrucous carcinoma. She was treated with radiotherapy. Two months after the last irradiation, tumor metastasis to the lung and the inguinal lymph nodes were recognized. She died two months after the detection of the metastasis. Microscopic diagnosis of verrucous carcinoma may be difficult because of its well-differentiated character. Brush biopsy is not reliable enough ; deep and extensive histologic examination is required. The use of radiotherapy to treat verrucous carcinoma remains controversial, because it may potentially induce anaplastic transformation. Thus, the radiotherapy should be limited to inoperable cases such as that which we experienced.[Skin Cancer (Japan) 2010 ; 25 : 11-15]

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A guideline for cutaneous lymphomas in Japan was published by Iwatsuki and can be accessed on the JSD homepage. To date, the Internet-based clinical resource tool has a section on cutaneous lymphoma by Hoppe and Kim.
According to these sources, standard chemotherapy for advanced-phase MF includes CHOP, COMP and others. The CR rate of such therapy is reported to be 17% to 57% and the validity rate is 57% to 100%. A multi-center trial of the CHOP regimen in patients with progressive CTCL was performed in Japan. The CR rate was 28.6% and the validity rate was 57.1%. The low CR rate was attributed to drug-resistance systems. Indeed, over-expression of ABC transporter genes has been detected in cutaneous lymphomas. New anti-tumor agents such as vorinostat, anti-CCR4 monoclonal antibody and forodesine are undergoing clinical trials. Vorinostat has been approved for clinical use for patients with MF by the FDA in the USA.[Skin Cancer (Japan) 2010 ; 25 : 16-20]

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A 47-year-old man presented with a dark red tumor on his right shoulder, which enlarged rapidly in the last 3 months. Physical examination revealed a dark red tumor 33mm in diameter on the right shoulder. Histopathology of the excised tumor showed marked proliferation of spindle cells arranged in storiform pattern mainly within the dermis. We diagnosed this tumor as a cellular fibrous histiocytoma. Neither local recurrence nor distant metastasis occurred 8 months after surgery.[Skin Cancer (Japan) 2010 ; 25 : 21-24]

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A 70-year-old woman had a brownish macule on her left cheek for 8 years. The center of the lesion was treated with a laser, but the pigmentation enlarged and became darker. One and a half years later, a skin biopsy was taken from the lesion at another clinic and malignant melanoma was suspected. The lesion was totally resected and a diagnosis of malignant melanoma was made by the histopathology. In Japanese clinical guidelines for cutaneous melanoma, suggestions for postoperative treatment of stage IA are not described. Hence, dacarbazine was given for 5 days every 6 weeks. No local recurrence or metastasis was evident during this 7-month period.[Skin Cancer (Japan) 2009 ; 24 : 25-28]

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A 66-year-old man presented with a three-month history of swollen right leg and inguinal lymph nodes with erosion on his right thigh and scrotum. Histological examination resulted in a diagnosis of Paget's disease. The patient was treated with radiation therapy for bilateral inguinal and pelvic lymph nodes, thoracolumbar spine metastasis. Paget's disease recurred on his scrotum one year later from his first visit, and he suddenly developed wheezing and dyspnea without any trigger. He was diagnosed with exacerbation of interstitial pneumonia based on the findings of diffuse ground-glass opacities on chest computed tomography. Despite corticosteroid therapy, he died of respiratory failure. We encountered a case of developing Paget's disease with lethal exacerbation of interstitial pneumonia. Because malignant neoplasms including Paget's disease commonly occur in elderly patients, we have to pay medical attention especially for lung lesions.[Skin Cancer (Japan) 2010 ; 25 : 29-32]

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An 82-year-old male visited a dermatologist for skin eruption in the left axilla 1 year and 3 months before visiting us. The lesion was treated externally as mycosis, but showed no improvement. As a result, the patient was referred to our department. A 5-cm erythematous lesion with partial erosion was present in the left axilla, and was diagnosed as extramammary Paget's disease by skin biopsy. The lesion was excised from the deep adipose tissue layer at 1-cm from the margin, followed by mesh skin grafting. There was no enlargement of the axillary lymph nodes. Left axillary lymph node swelling was noted 1 year and 2 months after surgery, and axillary lymph node metastasis was diagnosed by lymph node biopsy. Left axillary lymphadenectomy was subsequently performed. On whole body examination, no metastasis to any other organ was noted. As postoperative adjuvant therapy, irradiation at a total dose of 50Gy and 4 cycles of weekly administration of 40mg taxotere were given. No recurrence or metastasis of the tumor had occurred as of 10 months after lymphadenectomy, nor were there severe adverse effects of postoperative adjuvant therapy.[Skin Cancer (Japan) 2010 ; 25 : 33-37]

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An 84-year-old man was referred to us for evaluation of a rapidly enlarging tumor on the left arm. Physical examination revealed a large suspensory tumor, 10×8cm in diameter, with elastic-hard consistency and reddish surface. His axillary lymph nodes were not palpable. Histologically, the tumor cells had scanty cytoplasm and round nuclei and expressed CK20 and chromogranin A. Electron microscopic examination demonstrated perinuclear microfilaments and dense core granules in the cytoplasm of the tumor cells. The tumor was diagnosed as Merkel cell carcinoma. The primary lesion and left axillary lymph nodes were irradiated after excision. Five months after resection, however, epidural, lymph node and skin metastases occurred. As reported in the literature, the size of tumors may be one of the significant prognostic factors in Merkel cell carcinoma.[Skin Cancer (Japan) 2010 ; 25 : 38-41]

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We report a case of primary cutaneous diffuse large B cell lymphoma, leg type in a 93-year-old man. He exhibited multiple asymptomatic red nodules on his left lower leg, a subcutaneous nodule on his left thigh and a blueberry-like nodule at the extranasal site with a duration of 5 years. Histopathological examination of the left lower leg revealed a dense infiltrate of atypical lymphocytes. The overlying epidermis was spared, with a distinct grenz zone. Individual tumor cells expressed CD20 and CD79α, but were negative for CD3, CD5, CD45RO and CD30. A monoclonal immunoglobulin heavy chain gene rearrangement by PCR was revealed in the involved tissue of the left thigh. By FISH assay, reciprocal translocation of chromosomes No. 8 and 14 was revealed. On physical examination, no superficial lymphadenopathy was observed. PET and CT scans showed no evidence of visceral involvement. Although low-dose etoposide therapy was administered (50-75mg/day), tumors continued to grow, and he died 2 months later due to DIC.[Skin Cancer (Japan) 2010 ; 25 : 42-46]

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A 65-year-old woman recognized a tumor on her scalp sometime in 1997. She visited our hospital on Sep. 9, 2004, complaining of a gradual increase in the size of the tumor. Although we had planned to perform surgical excision, she canceled the arrangement and did not visit us. On Aug. 3, 2006, she was suddenly admitted to our hospital due to loss of consciousness. Her scalp tumor was removed surgically, and was diagnosed as SCC. After the operation, we found a metastatic tumor in her left lung. We treated her with five courses of CA therapy (chemotherapy) and added oral administration of etretinate in the last two courses. Nevertheless, she died on Oct. 28, 2008. Among the types of chemotherapy suitable for SCC, cisplatin is mainly used in foreign countries. On the other hand, several protocols, CA therapy for example, are used in Japan. Besides, etretinate is expected due to its efficacy for malignant tumors, but the functional mechanism is still unknown.[Skin Cancer (Japan) 2010 ; 25 : 47-51]

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A 49-year-old man noted a nodule on the top of his head in 2005. In July 2008, he visited our hospital because of its continued growth and tenderness. Physical examination revealed a skin-colored, firm, raised nodule measuring 20×17mm in diameter. The tumor was excised. Histologically, it was diagnosed as an adnexal tumor showing dual (sebaceous and sweat gland) differentiation. Marked Nuclear atypia and abnormal mitosis were found. Because it was found that the tumor had been incompletely excised, additional excision with a 2cm margin was performed. We report a rare case of adnexal tumor.[Skin Cancer (Japan) 2010 ; 25 : 52-55]

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A 40-year-old woman, who had NF1, visited us in May, 2008, with a giant skin tumor, 15cm in diameter, with a granulomatous, necrotic and ulcerative appearance on the left neck. The patient had noticed the development of the tumor 6 months before. Based on histopathological findings with positive S-100 and vimentin stainings, a diagnosis of malignant peripheral nerve sheath tumor was established. The patient was unable to undergo a complete excision, because the tumor had a rapid progression with multiple metastases on the lungs, pleura and liver. The patient succumbed to the disease about 5 months later. The poor prognosis seemed to be due to the giant size and the cervical location of the tumor. This case indicated that an early and precise diagnosis is required for malignant peripheral nerve sheath tumor to improve the prognosis.[Skin Cancer (Japan) 2010 ; 25 : 56-60]

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In the treatment of advanced skin cancer, the surgeon is often faced with the problem of a lesion that is inaccessible to curative surgery. Its offensive smell and bleeding reduce the patient's QOL. In two patients with advanced skin cancer and metastatic skin tumor, we have employed a chemosurgical technique using Mohs paste, resulting in control of the continuous bleeding and offensive smell. Mohs paste increases the prospect of improving the QOL for patients with advanced skin cancer.[Skin Cancer (Japan) 2010 ; 25 : 61-64]

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A case of cutaneous metastasis from hepatocellular carcinoma (HCC) is reporterd. An 80-year-old male developed a nodule on his right cheek 2 months before his first visit to our department. The nodule was multilobular, soybean sized, dark red in color, soft and bled easily. The same shaped small nodule was also seen at his right nasal cavity. We performed an excisional biopsy for both nodules. H&E stain examinations revealed that the tumor cells had characteristics similar to those of his previous specimen from HCC. We diagnosed them as cutaneous metastasis from hepatocellular carcinoma. Cutaneous metastasis from HCC is extremely rare. According to reports, metastatic tumors from HCC frequently occur in the head region. The survival period after diagnosis of skin metastasis is generally short. It is conceivable that the number of patients who show cutaneous metastasis of HCC will increase in the future, under the condition of recent improvement for HCC intensive therapy.[Skin Cancer (Japan) 2010 ; 25 : 65-68]

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Sentinel lymph node (SLN) biopsy has become widely accepted as a method of staging in the regional lymph nodes of patient with malignant melanoma, and an SLN biopsy is a significant prognosis factor. An interval SN is defined as a lymph node or group of lymph nodes located between the primary melanoma and an anatomically well-defined lymph node group directly draining the skin. As shown in previous reports, these interval SNs seem to be at the same metastatic risk as are SNs in the usual, classic areas.
We found that 1 of 5 interval SNs were metastatic. This study showed that preoperative lymphoscintigraphy must review all known lymphatic areas in order to exclude an interval SN.[Skin Cancer (Japan) 2010 ; 25 : 69-74]

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We report a case of a 51-year-old female neurofibromatosis type 1 (NF-1) patient with endocranial invasion of malignant peripheral nerve sheath tumor (MPNST) which occurred in her scalp. A neurosurgeon had carried out marginal excision twice, but resulted in recurrences. After we excised the tumor, an 8cm diameter area of arachnoid had been exposed. The defect of arachnoid has been repaired by free pericranial graft, and the bone defect has been reconstructed with a cranial bone bridge (cranioplasty). A free latissimus dorsi musculocutaneous flap was placed over the bone bridge. After the operation, the patient was treated with adjuvant radiotherapy. There are no signs of sinking skin flap syndrome, and no evidence of recurrence or metastasis.[Skin Cancer (Japan) 2010 ; 25 : 75-80]

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The morphology of pigmented skin lesions (PSLs) comes from differences in distribution and in concentration of melanin and hemoglobin pigment molecules. Those differences may be analyzed qualitatively and quantitatively using diffuse reflectance spectra in the visible to near infrared wavelength region. We have expressed differences in concentration distribution of both pigment molecules numerically with the use of diffuse reflectance spectra varying from site to site. Performance of the parameter has been studied on fifteen cases of PSLs : six cases of melanoma, five cases of seborrheic keratosis, and four cases of nevus. It has been demonstrated that the parameter can discriminate melanoma from others with a sensitivity of 85% and a specificity of 91%. It has also been suggested that the parameter reflects both boundary irregularity and variation in colors of PSLs.[Skin Cancer (Japan) 2010 ; 25 : 81-84]

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Though actinic keratoses resected with a positive lateral margin are often left without further treatment, they rarely relapse. We studied the local recurrence ratio among 127 patients with actinic keratosis who underwent resection with a 1mm surgical margin. Since as many as 22% of those who had a positive lateral margin experienced recurrence, they needed either re-operation or watchful follow-up. Only 2% of those who had a negative lateral margin and 7% of those who had a doubtful positive margin experienced recurrence. It was allowed that the patients of these two groupes required no more treatment. Although an adequate surgical margin for actinic keratosis resection has not been recommended, we concluded that a 1mm margin is suitable, because 96% of the patients with actinic keratosis after a 1mm margin resection experienced no local recurrence.[Skin Cancer (Japan) 2010 ; 25 : 85-89]

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A 73-year-old female patient noticed a tumor on her left vulva about half a year before her first visit. She presented with a 50mm diameter, reddish, surface-papillary, pedunculated tumor on her left vulva. Also her whole genital area showed erythematous plaques with atrophy of the clitoris and narrowing of the vaginal opening. The tumor was widely excised including the plaques. Histological examination revealed squamous cell carcinoma with lichen sclerosus et atrophicus. Follow-up is necessary for patients with vulvar lichen sclerosus et atrophicus due to possible occurrence of malignancy.[Skin Cancer (Japan) 2010 ; 25 : 90-93]

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We reported a case of clear cell sarcoma of the foot. The patient was a 63-year-old woman who first noticed a small brown nodule on the left medial malleolar region about one year before her first visit to our hospital. She underwent an excisional biopsy by a dermatologist, and the histological diagnosis was clear cell sarcoma. Sentinel lymph node biopsy revealed micrometastases in the inguinal lymph node. Therefore wide local excision and radical inguinal lymph node dissection following DAV-Feron therapy were performed. MRI showed multiple brain metastases five months after surgery and these were successfully treated with γ-knife radiosurgery. She shows no other distant metastasis or local recurrence at 22 months after surgery. Clear cell sarcoma called malignant melanoma of the soft parts is a highly malignant soft tissue tumor. This tumor constitutes less than 1% of all soft tissue malignant sarcomas and has a poor prognosis because of the high incidence of local recurrence and metastases even as a small lesion. Adjuvant chemotherapy and radiotherapy are not confirmed to be effective. Early radical surgery and elective regional lymph node dissection is recommended.[Skin Cancer (Japan) 2010 ; 25 : 94-100]

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We examined the location of sentinel lymph nodes in extramammary Paget's disease (3 cases). We injected Iopamidol (Iopamiron 300) intracutaneously around the lesion and identified sentinel lymph nodes using 3D-CT. To realize the anatomical location of the sentinel lymph nodes before operating, we were able to easily and quickly detect the sentinel lymph nodes by using this method.[Skin Cancer (Japan) 2010 ; 25 : 101-104]

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