In July 2010, a man in his eighties visited our department because of a one-month history of a gradually growing subcutaneous tumor on his left upper arm. Clinical examination revealed an egg-sized elastic hard tumor on the left upper arm. Histological examination of the skin lesion revealed circumscribed nodular infiltrations into the dermis, the subcutaneous tissue and the fascia, and a fascicular infiltration composed of atypical spindle cells. An immunohistochemical study revealed that the tumor cells were vimentin, CD10, CD31 and VEGFR-1-positive, but von Willebrand factor, CD34, EMA, D2-40, desmin, SMA, S-100 protein, CD3, CD79a, CD68, and MNF116-negative. Therefore, the tumor was diagnosed as a spindle cell angiosarcoma.[Skin Cancer (Japan) 2012 ; 27 : 11-15]

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An 81-year-old man noted a nodule on the right temple in December, 2008. On May 11, 2009, physical examination revealed a red nodule, 12×10 mm in size, on the right temple. Histologically, a neoplasm consisting of spindle or polygonal cells with clear cytoplasm and nuclear pleomorphism was found in the dermis, and multinucleated cells and necrosis were present.
Immunohistochemistry showed that the tumor cells were positive for CD68, and negative for CD34, AE1/AE3, S-100 and α-SMA. The ki-67 index of tumor cells was 24.6%. The lesion was diagnosed as atypical fibroxanthoma. A wide excision was performed on June 23, 2009. A subcutaneous nodule in the right parotid area developed in February, 2010. MRI revealed a nodule, 20×16 mm in size, on the deep subcutis of the right parotid site. A right parotidectomy was performed, and showed histology similar to that of the tumor on the right temple.[Skin Cancer (Japan) 2012 ; 27 : 16-21]

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A 75-year-old man presented with a one-year history of a nodular mass in the axilla. Histological examination of an incisional biopsy performed at a local clinic revealed skin metastasis of renal cell carcinoma, and computed tomography revealed a right renal mass. The patient visited Takarazuka City Hospital and underwent right radical nephrectomy and excision of the axillary tumor. Subsequently, the patient developed a right postauricular swelling. Magnetic resonance imaging revealed a parotid gland tumor, suspected of being a Warthin tumor. The tumor was enucleated, and histological examination revealed parotid lymph node metastasis of renal cell carcinoma. Superficial parotidectomy with preservation of the facial nerve was then carried out. No local tumor recurrence on the skin or of the parotid lymph node has been detected. This case is the first report on skin and parotid lymph node metastasis from renal cell carcinoma.[Skin Cancer (Japan) 2012 ; 27 : 22-27]

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A 58-year-old female who had been diagnosed with Werner syndrome in her 20s, presented to our hospital in August 2006, complaining of a black lesion on the sole of her right foot, which she had noticed in 2005. At the initial examination, an ulcer (diameter : 8×5 mm), surrounded by black to light brown pigmentation, was observed on the calcaneal region of the right foot. Nuclear medicine imaging (NM) showed a possible invasive neoplasm in the left femur, suspected to be bone metastasis of the skin tumor. On magnetic resonance imaging (MRI), the ulcer measured 6 mm in depth. Based on these findings, though without histopathologic examination, the lesion was clinically diagnosed as malignant melanoma. Due to marked dermal and subcutaneous atrophy in the sole of the foot, related to Werner syndrome, an excision was not performed. Instead, the patient was treated with local injections of IFN-β(3 million units, once weekly). Currently, at 4.5 years after the initial examination, the serum level of 5SCD is elevated but stable between 10.4 and 16.6 nmol/l. Despite a slight increase in skin ulceration and an increase in the size of the black lesion, there is no other evidence of new distant metastatic lesion.[Skin Cancer (Japan) 2012 ; 27 : 28-32]

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Fifty-six patients with malignant melanoma that possessed no clinically detectable metastatic lesions during surgery from 2003 through 2010 at Sapporo Medical University were analyzed. Among them, seven patients developed recurrence during follow-up periods. At the site of the first recurrence, four patients developed regional metastasis (lymph node and in-transit metastases), and three patients developed distant organ metastases. The median of tumor thickness was 6.0 mm in four patients with regional metastases, while the median was 2.9 mm in three patients with distant metastases. The average tumor--free period of patients with distant organ metastasis was longer than that with regional metastasis (29 months vs 7.5 months). Thus, it is suggested that follow-up periods of more than three years are required.[Skin Cancer (Japan) 2012 ; 27 : 33-36]

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We studied the difference between patients with malignant melanoma on the heel and those on the sole, excluding the heel. Data on thirty-eight patients (19 on the heel, 19 on the sole) was collected in Sasebo City General Hospital or Nagasaki Municipal Hospital. Since early melanomas on the heel usually appeared with a tinted color and uncertain border, most people see the spots as “a blotch” or “a stain”. Therefore they do not perceive them as a threat which results in delays in seeking medical attention. An average size of melanoma on the heel was statistically larger than that on the sole (414 mm² and 272 mm² respectively, p=0.024). Most of the patients who had some knowledge of melanoma visited a hospital before the size of the tumor exceeded 10 mm in diameter, and the tumor thickness was also less than 1 mm. For early detection and treatment, we should disseminate accurate information about melanoma particularly more widely.[Skin Cancer (Japan) 2012 ; 27 : 37-42]

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A 50-year-old woman noticed a painful nodule with alopecic lesion on the scalp three years ago, and it had been gradually increasing in size. A histological examination revealed adenocarcinoma with apocrine differentiation. Immunohistochemical findings showed that the tumor cells were positive for CK7, while they were negative for CK20. Furthermore, they were positive for ER, PR, AR and GCDFP-15, but negative for p63 and D2-40. A whole body examination including PET revealed no evidence of malignant tumor in mammary glands and other organs. Based on these findings, we diagnosed this case as primary cutaneous apocrine carcinoma (CAC). Additional wide local resection was performed, and at present one year after surgery, the patient remains well with no evidence of tumor recurrence or metastasis. In general, the differential between CAC and metastasis from breast carcinoma is so difficult to attain that only by immunohistochemical findings were we finally able to diagnose this case as CAC by its clinical course.[Skin Cancer (Japan) 2012 ; 27 : 43-47]

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Syringomatous carcinoma (SC) is a rare malignant appendageal tumour. Subsequently neoplasms in the same category with different degrees of differentiation were reported with various designations, such as eccrine epithelioma, basal cell tumor with eccrine differentiation, syringoid eccrine carcinoma, sclerosing sweat duct syringomatous carcinoma, sweat gland carcinoma with syringomatous features, and microcystic adnexal carcinoma. In 1990, Abenoza and Ackerman proposed the term ‘syringomatous carcinoma’ for the various neoplasms. Since then, 16 cases have been reported in Japan. We present the case of a 69-year-old woman with SC on the dorsum of her left middle finger proximal interphalangeal joint, in whom local excision of the tumor was performed. SC is characterized histopathologically by asymmetrical and deep invasion of tumour cells into the subcutaneous tissue and multiple small nests that resemble those of a syringoma, and duct formation.[Skin Cancer (Japan) 2012 ; 27 : 48-51]

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An-83-year-old Japanese male presented with a hyperpigmented skin lesion on the dorsum with gradual growth for several years. On physical examination, a 3.5×3 mm pigmented tumor with central ulceration and irregular borders was observed. On dermoscopy, the lesion showed a multicomponent pattern presenting atypical pigmentation, blue-whitish veil and irregular vessels. From these dermoscopic features, the lesion was suspected to be malignant melanoma ; subsequently, the tumor was surgically removed. Histological examination with hematoxylin-eosin staining revealed nests of basaloid cells, with palisading pattern in the dermis. Melanocytes were observed in the tumor nests, and fine melanin granules were also detected within the tumor cells. From these observations, a confirmed diagnosis of basal cell carcinoma was made. Before excision, serum the 5-S-cysteinyldopa (5-S-CD) level was high with 44.3 nmol/l, but it decreased to 16.7 nmol/l two months later. The elevation of 5-S-CD was considered due to melanin production in the tumor.[Skin Cancer (Japan) 2012 ; 27 : 52-55]

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We report two cases of basal cell carcinoma arising in the perianal region, which seemed vary rare. Case1 : An 82-year-old woman had noticed a perianal eruption with irritation 2 years ago. A 40×25 mm sized blackish flat nodule was located on the left side of her anus. Case2 : A 63-year-old woman requested examination of her perianal eruption with bleeding on defecation a few months following surgical therapy for basal cell carcinoma on her nape. There was a 10×8 mm sized blackish flat nodule with waxy gloss on the left side of here anus. Histopathological findings of both cases revealed features of solid basal cell carcinoma. The tumors were resected simply, and at present, there has been no evidence of local recurrence or metastasis.[Skin Cancer (Japan) 2012 ; 27 : 56-59]

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A 55-year-old man with schizophrenia had been treated in the psychiatry clinic since the age of 45. Approximately 20 years ago, he noticed a nodule on his upper lip, but did not have it assessed. Recently, he noticed the lesion was growing in size and visited a dermatologist. The diagnosis, based on a biopsy specimen, was mucoepidermoid carcinoma. He was therefore referred to our dermatology department. Physical examination revealed a hard and normal-colored 20×17 mm node with a central ulcer at the biopsy site on the upper lip. Imaging tests revealed no metastases. We removed the lesion surgically with a 5-mm border, and performed double advancement flap plastic surgery. During 9 months of follow-up, there was no evidence of recurrence.[Skin Cancer (Japan) 2012 ; 27 : 60-63]

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A 72-year-old male was suffering from a chronic ulcer on his left lower leg treated by a cardiovascular surgeon for 40 years. One year ago, the plastic surgeon performed a biopsy at the site of the tumor on the ulcer, and histological examination suspected it to be malignant. He consulted our hospital for treatment of the tumor. A 25×15 cm-sized mass was located on his left lower leg. Above-knee amputation was performed. A pathological diagnosis of squamous cell carcinoma, and stage III (T3N0M0) was established. No relapse or metastasis has been observed during a 10-month follow-up period. Plastic surgeons and dermatologists can diagnose and treat not only chronic ulcers but also skin cancer. We can advise cardiovascular surgeons, podiatrists, and other medical staff that SCC often occurs on chronic venous ulcers, and that biopsy for early diagnosis is important.[Skin Cancer (Japan) 2012 ; 27 : 64-66]

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A 61-year-old man suffered from spinal cord injury following an altitude fall and became bedridden when he was thirty years old. Decubitus and a subcutaneous abscess were noticed at his left greater trochanter at the age of 38 years. Afterwards, the subcutaneous abscess was continuously observed in the same region. A hypodermic abscess developed in this part at the age of 60 years, and this region was diagnosed as squamous cell carcinoma by skin biopsy. He did not show multiple organ metastasis and we performed a disarticulation operation on his left hip. Squamous cell carcinoma was proved to have invaded his left acetabulum. We performed radiotherapy to control his cancer pain on the L4 metastasis 5 months after the operation. He had hematuresis and disturbance of consciousness during a period of 10 months after the operation, and he died because of acute renal failure caused by the invasion of the tumor into the ureter.[Skin Cancer (Japan) 2012 ; 27 : 67-71]

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In cases of skin cancers detected by post-operative histopathological examination, even with a preoperative diagnosis as a benign skin lesion, or in cases of incompletely excised of skin cancers, re-excision is needed. In the first treatment, if the simple suture after tumor resection was performed, re-excision has been performed to keep the safety margin horizontally from the scar in general. However, we think that the vertical margin of safety is ensured in this method. Therefore, the post-operative scar was made to open, the wound returns to the same state as when the initial tumor resection took place. Then, the horizontally safety margin was detached and we excised from the position where the tumor existed. A vertical incision was perpendicularly performed from the skin incision to safety layer. Therefore, we performed en bloc resection as the skin and subcutaneous tissue and fascia. This method is considered to be identical to the initial surgery for malignant tumors.[Skin Cancer (Japan) 2012 ; 27 : 72-77]

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Groin dissection is performed for various malignant skin tumors of the trunk that develop below the umbilical line or on the lower extremities ; this procedure is used for prophylactic treatment or in cases where lymphogenous metastasis is detected. Previous studies have revealed that anatomical features of inguinal and iliac lymph nodes, and methods for resecting lymph nodes have been established. However, optimum procedures for skin flap incision and optimum flap thickness have not yet been established. In this study, groin dissection was performed on 3 patients by using real-time fluorescence navigation with indocyanine green. Using this method, we achieved reliable groin dissection, but skin necrosis occurred in all cases. Thus, our results indicate that improvement in skin incision procedures is necessary for safe and reliable groin dissection.[Skin Cancer (Japan) 2012 ; 27 : 78-82]

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A 43-year-old woman was referred to our university hospital with a reddish tumor which measured 2×3 cm on her left elbow. The tumor has grown rapidly during the last month. Incisional biopsy revealed Merkel cell carcinoma. FDG-PET showed no other lesions outside of the primary site, and MRI disclosed invasion into subcutaneous tissue. Wide excision was performed on the left elbow, including the deep fascia, with a 2-cm margin from the tumor. Sentinel lymph node biopsy in the left axillary region showed negative for metastasis. Postoperative staging was T2N0M0 Stage IIA. As postoperative adjuvant therapy, a total of 48.4 Gy radiotherapy was administered from the left elbow to the axillar region, and synchronous carboplatin and etoposide were given in weeks 1, 4, 7, and 10. There has been neither local recurrence nor distant metastasis for 2 years and 8 months after surgery.[Skin Cancer (Japan) 2012 ; 27 : 83-87]

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We describe a 72-year-old male with extramammary Paget's disease on the lower abdomen. About 1 year before, the patient had noticed a plaque on his lower abdomen. The lesion gradually increased in size. Physical examination revealed an erythematous brown plaque, 34 × 65 mm in diameter, with sharp margins. The clinical features were similar to those of Bowen's disease. Histpathologic findings revealed numerous pagetoid cells with clear and abundant cytoplasm. They were distributed individually or in small clusters within the epidermis. The nuclei of these cells appeared abnormal or irregularly shaped. Initially, we supposed pagetoid Bowen's disease and extramammary Paget's disease and malignant melanoma. Immunohistological investigation showed that the malignant cells were negative for HMB-45 or S-100, and positive for CEA and GCDFP-15. Finally, the patient was diagnosed as having extramammary Paget's disease.[Skin Cancer (Japan) 2012 ; 27 : 88-92]

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The efficacy of neoadjuvant therapy, in addition to adjuvant chemotherapy, for extramammary Paget's disease (EMPD) has not been widely investigated. Here, we report a case of advanced EMPD that was successfully treated with surgical resection and docetaxel chemotherapy after normalization of serum CEA levels using neoadjuvant therapy. A 70-year-old man presented with decolorized or faint erythematous multiple plaques on his scrotum and penis. His serum CEA levels were markedly elevated. Clinical and imaging examinations showed no evidence of visceral or lymphatic metastases, but biopsied lymph nodes from both inguinal lesions showed clear metastases. Three courses of neoadjuvant chemotherapy with docetaxel resulted in normalization of serum CEA. Wide tumor resection and bilateral groin dissection were then performed. Histopathological findings for the skin lesion revealed intraepidermal Pagetoid proliferation of tumor cells together with partial dermal invasion. Metastases were detected in most of the inguinal lymph nodes up to the right Cloquet's node. Several courses of adjuvant chemotherapy with docetaxel were administered and one year later no metastasis or visceral involvement was detected. Therefore, our results suggest that neoadjuvant and adjuvant chemotherapy with docetaxel is helpful for treatment of advanced EMPD.[Skin Cancer (Japan) 2012 ; 27 : 93-97]

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A 55-year-old Japanese man with pigmented mammary Paget's disease (p-MPD) is reported. Physical examination revealed a 50×45 mm, blackish tumor with ulceration. Dermoscopic diagnosis of p-MPD is difficult because it usually shows a nonspecific pattern. Histopathology of the lesion disclosed intraepidermal and dermal atypical cells forming small clusters and underlying intraductal carcinoma. The tumor cells were positive for cytokeratin7, estrogen receptor, progesterone receptor, but negative for S-100 protein, melan-A and HMB-45. Paget's disease of the breast is usually non pigmented and occurs almost exclusively in women. P-MPD of the male is extremely rare.[Skin Cancer (Japan) 2012 ; 27 : 98-101]

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The outcomes of patients with metastatic melanoma are poor. But 2009 AJCC Melanoma Staging shows lung metastasis has a somewhat better prognosis than other visceral metastases. In our institute, three patients with lung metastases from cutaneous melanoma who were surgically treated had prolonged survival.
Between 2003 and 2010, 3 patients underwent surgery for lung metastases from cutaneous malignant melanoma. Their clinical features were examined and compared with those in patients with only lung metastases who did not undergo surgery.
The median disease free interval (DFI), overall survival (OS) and 2-years overall survival rates with surgical treatment patients were 31months, 24months and 100% respectively. On the other hand, DFI, OS, 2-years overall survival rates with patients without surgical treatment were 13months, 11months and 0% respectively.
Patients should be selected for surgery after consideration of performance status, DFI, number of metastases, extra pulmonary metastasis and complete resectablility.[Skin Cancer (Japan) 2012 ; 27 : 102-106]

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We report two cases of malignant melanoma effectively treated with radiation. A 74-year-old man visited our hospital suffering from epistaxis. A tumor was found in his nasopharynx and diagnosed as malignant melanoma. Treatment consisted of radiation therapy rather than surgery. Metastasizing cervical lymph nodes were found and dissected. Over six years of post-therapy, the tumor has not metastasized.
A 72-year-old woman underwent surgery for malignant melanoma in the lower rectum. Seven years later, dysarthria appeared. Metastatic malignant melanoma was found in her hypopharynx and treated with radiation therapy. The tumor gradually decreased in size and finally disappeared. Malignant melanoma is known to be resistant to radiation therapy. However, recent technological innovation in equipment for radiation therapy has made it possible to deliver a high dose of radiation to the tumor while sparing normal tissue. In the future, radiation therapy may be an option for the treatment of malignant melanoma.[Skin Cancer (Japan) 2012 ; 27 : 107-113]

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A 72-year-old female who presented with a case of lichen sclerosus et atrophicus (LSA) developing vulvar squamous cell carcinoma (SCC) was reported. Erosive and elevated lesions had been noticed in the vulvar whitish area. Biopsy merely revealed intraepithelial atypia. A subsequent, fully excised skin specimen demonstrated a range of LSA, leukoplakia and SCC in situ.[Skin Cancer (Japan) 2012 ; 27 : 114-118]

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