We report a 73-year-old Japanese male with cutaneous leiomyosarcoma on the upper back. At his first visit to our hospital, we found a painful, 20×30 mm, dark red-brown plaque on his back. Although we suspected a malignant tumor such as dermatofibrosarcoma protuberans, the tumor was diagnosed as being a keloid following an initial skin punch biopsy. Therefore, an intra-lesional excision was performed for the following treatment. Histologically, the tumor was composed of spindle cells with blunted nuclei in a fascicular pattern. The tumor cells were located mainly in the superficial dermis, and partially in the middle dermis. Immunohistochemical analysis showed that the tumor cells were positive for desmin and α-smooth muscle actin, and negative for CD34. Cutaneous leiomyosarcoma was diagnosed after the second resection of the tumor. He underwent a wide excision with a 4-cm margin. During the follow up over the 2 subsequent years, there was no evidence of disease recurrence or metastasis.[Skin Cancer (Japan) 2012 ; 27 : 318-321]

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A 99-year-old man presented to our hospital in December 2010 complaining of skin tumors on his scalp, which he had noticed in May 2010. At the initial examination, two skin tumors (3.5×3 cm, 5.5×5 cm in diameter) with crater-shaped ulcers, surrounded by erythema, were observed on the frontal and the occipital regions of the scalp, respectively. The serum level of squamous cell carcinoma antigen (SCC) was high (5.2ng/ml). A histological examination revealed that these tumors were squamous cell carcinomas. A whole body examination, including PET-CT, showed no evidence of distant or lymph node metastasis. The TMN classification was pT2or3N0M0. The patient and his family decided against surgical treatment because of his age ; therefore, radiation therapy was used instead. After the irradiation (3 Gy/fraction, total 54 Gy), the tumors gradually decreased in size and finally disappeared with residual crusts. During the course of the therapy, the tumors has not metastasized or recurred.[Skin Cancer (Japan) 2012 ; 27 : 322-325]

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Among 148 patients with stage Ⅰ-Ⅲ melanoma between 1989 and 2008 in Niigata Cancer Center Hospital, in-transit metastases (ITM) have occurred in 18 patients as initial recurrence. The median relapse-free survival time from primary surgery to ITM was 9 months, and the significant risk factors were T4b and regional lymph node metastasis. Distant metastases have occurred in 13 patients after ITM with a median period of 8 months, and 11 have died. The patients with ITM had a median survival of 36 months and a 5-year survival rate of 34 percent, which were preferable compared with metastases to regional lymph nodes and distant organs. Therapeutic regimens including the extent of excision for ITM, had no significant influence on the prognosis. As the optimal treatment of ITM remains poorly defined, each patient's situation requires a unique approach.[Skin Cancer (Japan) 2012 ; 27 : 326-332]

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A 39-year-old woman was examined due to a small subcutaneous mass on the left inner thigh observed after four months of psychiatric hospitalization for schizophrenia. After four months of follow-up observation, the mass rapidly enlarged and she was transferred to our department. An approximately 20cm subcutaneous mass with a collapsed center and marked fetid odor extended from the left crotch the inner thigh. The patient was non-ambulatory and repeatedly experienced extensive bleeding from the mass. Imaging findings revealed deep invasion extending to the gracilis muscle. Total resection, including the muscle body, and free skin grafting were therefore performed. Systemic conditions improved, and she regained ambulation, thus improving quality of life. By 8 months after the operation, no local recurrence has been detected, but lung metastases had developed. Histopathological examination of the resected specimen demonstrated heterogeneous proliferation of small round tumor cells that were positive for MIC2 and PAS. Although genetic analysis via fluorescence in situ hybridization failed to identify the ESW-FL11gene, extraskeletal Ewing's sarcoma was considered the most likely diagnosis.[Skin Cancer (Japan) 2012 ; 27 : 333-338]

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A 42-year-old male noticed a subcutaneous small nodule in the abdomen 7 years ago. On the initial consultation in our department, a red, elastic-hard, cauliflower-like giant tumor measuring 17×16×9 cm was detected in the abdomen. The tumor surface was destroyed and hemorrhagic. Resection and mesh skin grafting were performed at an area horizontally 5 cm from the tumor peduncle margin. Since the border between the deep tumor area and rectus abdominis was partially unclear on magnetic resonance imaging, the anterior sheath of the rectus abdominis was also resected. In the totally extirpated specimen, CD34-negative, spindle tumor cells comprised approximately 70% of the tumor, showing a herringbone pattern, while CD34-positive, spindle tumor cells comprised the remaining 30%, showing a storiform pattern. COL1A1-PDGFB fusion gene was detected in the tumor tissue, and a diagnosis of dermatofibrosarcoma protuberans with fibrosarcomatous change was made. There has been no relapse or metastasis during the 1-year-and-2-month postoperative follow-up.[Skin Cancer (Japan) 2012 ; 27 : 339-344]

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A 75-year-old woman had recognized small subcutanous nodules on her right breast after mastitis. She presented to our hospital with breast tumors after she had three lesions removed five months ago. The elastic hard, smooth-surface tumors on her right breast had reached 23×14 mm and 8×8 mm. A skin biopsy revealed abundant deposition of large lymphoid cells with cell atypia in the dermis. Immunohistochemical findings showed these cells were CD20(+), CD79a(+), bcl-2(+), bcl-6(+), MUM-1(+). At this time we diagnosed her as having diffuse large B-cell lymphoma (DLBCL). We found diffuse fluorodeoxyglucose (FDG) uptake in her right breast tumor and right axillary lymph node by (18) FDG-positron emission tomography/computed tomography (PET/CT). The patient was treated with R-CHOP therapy (Rituximab, Cytoxan, doxorubicin, vincristine, and predonisone) for a total of 6 cycles, resulting in complete disappearance of the tumor within five months. Eight months after the therapy, there has been no recurrence of the skin lesion suggesting DLBCL.[Skin Cancer (Japan) 2012 ; 27 : 345-349]

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A 33-year-old Japanese female visited us with a brownish, pigmented macule on the left sole. She had noted the pigmented lesion for the last ten years. Physical examination showed a solitary black-brownish pigmented macule with an irregular border which measured 7×5 mm in diameter. Dermoscopic examination demonstrated the parallel furrow pattern as well as the irregular fibrillar pattern, suggesting benign melanocytic nevi. Histology revealed solitary melanocytes and melanocytic proliferation forming nests in the epidermis. Pagetoid spread and infiltration to the appendage were also observed. We diagnosed the case as pseudomelanoma, termed by Saida, rather than acral melanoma in situ. Similar diagnostic terms have been reported as acral-lentiginous nevus and melanocytic acral nevus with intraepidermal ascent of cells (MANIAC). Further accumulation of similar cases to clarify the mechanism of the discrepancy between benign dermoscopic findings and malignant histologic features in the pigmented lesions of the foot is recommended.[Skin Cancer (Japan) 2012 ; 27 : 350-354]

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An 87-year-old man noticed a nodule on his abdomen a month ago, which had been increasing in size. Computed tomography (CT) demonstrated a tumor within the subcutaneous adipose tissue which showed iso-density to the muscle, and which was 22 mm in size. When magnetic resonance imaging (MRI) was performed two months later, the tumor showed rapid growth to 34 mm in size, and infiltration to the muscle. Histopathological examination of an incisional biopsy suggested spindle cell sarcoma. Immunohistochemical examination showed the tumor cells were negative for CD34, smooth muscle actin and pan-cytokeratin. Based on these findings, synovial sarcoma was suspected, and we proceeded with molecular diagnostic analysis by FISH (fluorescence in situ hybridization) using a dual-color, break-apart SS18 probe. As a result, translocation involving the SS18 gene was detected by the split signal, and a diagnosis of synovial sarcoma was confirmed.[Skin Cancer (Japan) 2012 ; 27 : 355-360]

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A 76-year-old man presented with a 12×15 cm tumour with erythematous plaques on his right groin. Histological findings of the hypopigmented macules and plaques showed atypical Paget's cells in the epidermis and dermis. A computed tomography scan revealed multiple lymph node metastases both in the right inguinal area and in the pelvis. We adopted a chemotherapy regimen with docetaxel and S-1 as neoadjuvant agents. After 3 courses of chemotherapy, a remarkable decrease in the size of lymph node metastases was obtained and he was treated with a wide resection of the primary lesion and lymph node metastases. No tumour cells and only necrosis were observed in the pelvic lymph nodes.
Standard therapy has not been established for advanced extramammary Paget's disease. This is a preliminary trial ; however, neoadjuvant chemotherapy is worth further investigation in this disease.[Skin Cancer (Japan) 2012 ; 27 : 361-366]

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A 32-year-old man presented with multiple small cutaneous nodules on the face and a 30 × 28 mm red-colored tumor on the nose. Their pathologic features were diagnosed as sebaceous adenoma and squamous cell carcinoma, respectively. The patient's family history revealed that his mother and brother suffered from colon cancer. Microsatellite instability analysis revealed high instability, although immunohistochemical stainings showed expression of hMSH2 and hMLH1 proteins in the sebaceous adenoma and squamous carcinoma. In addition, duodenal and colon cancers were identified by gastrointestinal endoscopy. Based on pathologic diagnosis, family history, positive high microsatellite instability, and internal malignancy, a diagnosis of Muir-Torre syndrome was made. All tumors except for sebaceous adenomas were excised surgically and the patient is free from disease 9 months after surgery. Cutaneous squamous cell carcinoma may develop in patients with Muir-Torre syndrome and gastrointestinal carcinoma may also occur even in the younger^* patients, as with our case.[Skin Cancer (Japan) 2012 ; 27 : 367-372]

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We report 3 cases of Merkel cell carcinoma (MCC) successfully treated with radiation monotherapy. Case 1 : A 90-year-old woman was referred to our hospital with a 10 × 9 cm reddish tumor on her left cheek. Case 2 : An 80-year-old male presented with a reddish nodule on the left eyebrow. Case 3 : An 86-year-old male presented with a 1-cm nodule on his left forearm 4 months after the previous excision of the tumor on the same region. All 3 tumors were diagnosed as MCC by skin biopsy. Radiation therapy was performed in all cases. Each tumor disappeared after radiation, and there was no evidence of local recurrence or distant metastasis during a follow-up period (12-29 months). Although a combination of wide excision and adjuvant radiation therapy is the optimal therapeutic approach for the treatment of MCC, radiation monotherapy has as high a local control effect as surgery and adjuvant radiation. Radiation monotherapy should be used, especially in inoperable cases.[Skin Cancer (Japan) 2012 ; 27 : 373-378]

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A 55-year-old man presented with a black-colored pigmented line on the right first fingernail over a period of 5 years. He was referred to our department with the lesion that had enlarged and regressed gradually over the course of 3 years. The width of the line was 7 mm, and Hutchinson's sign was not observed. The color and shade of the line varied from light to dark with focal regressions. Staging with positron emission tomography and computed tomography showed no evidence of metastasis. We made the diagnosis of subungual malignant melanoma (MM) in situ, and treated the lesion with wide local excision (5-mm margin from the nail), and split-thickness skin graft. Additionally, a sentinel lymph node biopsy was performed. Clinical and histopathological examination revealed subungual MM in situ with focal regression. After 1 year, there has been no evidence of post-operative recurrence.[Skin Cancer (Japan) 2012 ; 27 : 379-382]

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