Bowenoid papulosis is clinically characterized by multiple, brown-black papules and plaques, occurring primarily on the genitalia of young adults, almost all under the age 40. The histologic appearance of Bowenoid papulosis is squamous cell carcinoma in situ similar to Bowen's disease. There is a broad consensus in the literature that Bowenoid papulosis is induced by human papilomavirus. It has been documented that the lesions have a tendency toward spontaneous regression, however, the lesions herein reported developed into invasive squamous cell carcinoma. The patient was a 27-year-old woman who had been Bowenoid papulosis on genitalia and bottock since she had been 13. The lesions had been treated by conservative therapy. The lesions developed invasive squamous cell carcinoma on buttock and therefore radical surgical therapy including rectal resection had to be done. We detected human papilomavirus-16 from both brown-black papules of Bowenoid papulosis and hyperkeratotic reddish tumor of squamous cell carcinoma in the method of polymerase chain reaction. We must notice Bowenoid papulosis can develope invasive squamous cell carcinoma.
The case was a 76 year-old female. She had a simple excision of a subcutaneous nodule done to her left buttock by a local doctor and came to our hospital when regional relapse occurred. At the time of the operation, which was one month after she had been admitted to our hospital, left inguinal lymphnode swellings were recognized. Histopathologically, the tumor consisted of fibroblast like cells with nucleus of various sizes and histiocyte like cells with cylinder shaped bright cytoplasm. A few giant cells were also found scatterly. Cells arranged in strif orm pattern were also found and we diagnosed it as a case of malignant fibrous histiocytoma. After radical excision with left groin lymphnode resection, 2 courses of chemotherapy of ADR 40mg and CDDP 50mg were commenced but relapsed occurred again. By radiation treatment, the tumor reduced in size transiently. Metastasis to the lungs and bones occured and the patient died one and a half years after the initial diagnosis.
Pyogenic granuloma (PG) is a rather frequently encountered tumor and seldom arouses much concern. One of its uncommon complications is the recurrence of multiple satellite lesions following excision or irritation of the primary growth, that was called Pyogenic granuloma with satellite lesions (PGWSL) . To date, 15 such cases have been reported in Japan. The original or the recurrent lesions usually showed a proliferation of angiomatous tissue usually found in PG. We report a case with many mitoses and high cellularity in histological feature and the pathogenesis of this uncommon entity is briefly reviewed. Case report: The patient was a 21-year-old Japanese male who developed, for almost 1 month, a solitary rapidly growing, easily bleeding lesion on the left scapula. The lesion was pediculate, dark red in color, measured 25mm in diameter. About 3 months after local excision of primary lesion, many small, 1-3mm in diameter sessile vascular papules developed around the site of the original tumor. They were completely asymptomatic. The physical examination revealed no other abnormality. On clinical diagnosis of PGWSL, the involved area was completely excised and skin graft was done under general anesthesia. For 2 years after the operation, there has been no recurrence. The histopathologic picture in satellite lesions showed a proliferation of capillary vessels immersed in an edematous and myxoid stroma in the dermis, which was usually found in normal solitary PG. The primary lesion showed a proliferation of capillary vessels with a little nuclear atypia, deep extension, many mitoses, and higher cellularity compared with the histology of normal PG. These histological features suggest that these tumor cells have intermediate characters between benign and malignant cells. Ultrastructural examination was carried out on the recurrent lesion and compared with normal PG. The nuclear envelopes of tumor cells were more irregular and they had much more rough endoplasmic reticulum than those of normal PG. In immunohistochemical study, including factor VIII related antigen (Factor VIII), intercellular adhesion molecule-1 (ICAM-I), HLA-DR, endothelial leukocyte adhesionmolecule-1 (ELAM) and basic fibroblast growth factor (bFGF), no apparent differences could be observed between recurrent lesion of our case and normal PG. In 16 cases of PGWSL reported in Japan, including this case, 9 patients were males and 7 females. Most were children or young adolescents and average age was 18. 14 cases had their lesions on the trunk and the other 2 had on their face. Five patients were treated with completely excision of the involved area as initial treatment of the recurrent lesion. In 8 cases, the lesions were simply excised or destroyed with cautery or appreciated with topical corticosteroid at first, while 2 of them were recurred and finally completely excised. Unfortunately the other 3 reported cases were not fully described about clinical treatment. Although the recurrence of PGWSL runs a benign course and there is no evidence that the satellites show metastasis, we consider that complete excision of the involved area is the best method when the lesions recur repeatedly or histopathological picture shows some atypia such as our case. Although the etiology of the development of PGWSL remains unknown, we consider that this entity has much more activity than normal PG.
We have presented a case of clear cell BCC that was first reported by Barr & Graham in 1979. The patient was a 75-year-old female, and the chief complaint was a tumor appearing on the right posterior head skin. Routine histological examination revealed typical BCC with a small amount of clear cells. On histochemistry, clear cells showed PAS (+), d-pas (-), and Alb (-) . These histological staining patterns were similar to those reported by Barnadas MA & Freeman RG in 1988. Immunohistochemistry with a panel of monoclonal antibodies against cytokeratins revearled that most tumor cells in our case showed similar staining patterns to those in typical BCC. However, the staining intensity was decreased in clear cells, which may have been caused by some degeneration of tumor cells.
A number of methods have been reported for reconstruction of defects after the excision of malignant tumors on the lower lip. Special interest has centered on Estlander's method, which makes triangular flaps of entire layers. The operative method is applied on a lateral part of the upper lip with a pedicle located on the median side, followed by downward transposition. The procedure can safely and easily reconstruct deficiencies in the lower lip with outstanding results. However, it requires a secondary commissuroplasty because the commissure on the affected side becomes smaller and round in shape. Several methods have been suggested for secondary commissuroplasty, but even with one of these methods, it is very difficult to create a satisfactory commissure in terms of aesthetic and functional considerations. As a new method for secondary operation, we performed the commissuroplasty with satisfactory results by forming two opposing triangular mucosal flaps in the vermilion area and a small triangular skin flap on the commissure. This method produces extremly good results, obtaining favorable commissure form and reconstruction of the mucosa of both upper lip and lower lips without an unnatural-looking color change in the mucosa or a step deformity in the vermilion. Our method could improve the results of Estlander's operations after tumor resection in the lower lip.
For surgical treatment of malignant tumors, it is important to clarify the depth and area of invasion of tumors and the relation to surrounding normal tissues such as adipose tissue, muscles and bones in addition to the histological diagnosis of the tumors before operation. For this purpose we clinically evaluated a magnetic resonance imaging (MRI) for diagnosing skin tumors. A MRI, SIGNA (GE), whic analyzes the tumors by a spin echo method (TR 1500, TE 20) was used in this study, and 29 slices of MRI in a tumor were accumulated crossing those tumors. The usefulness of three dimensional presentation of skin tumors performed by the MRI data was also discussed. For three dimensional presentation, VoxelflingerTM was applied and those images were compared with cross section of those tumors during operation and histological specimens. We applied the MRI examination on patients with malignant melanoma, malignant fibrous histiocytoma, fibrosarcoma and squamous cell carcinoma of skin. The MRI was a very useful tool to clarify the depth and area of invasion of malignant tumors and the relation to surrounding normal tissues. The effects of MRI was most remarkable when applied onpatients with malignant melanoma of soles. Three dimensional presentation obtained from the MRI data was also useful to know three dimensional condition of those tumors but it seems still to have limitation because of the analytical software of the computer. In conclusion, we suggest that MRI should be the imaging modality of choice in evaluating skin tumors especially of the extremities, and three-dimensional analysis will be beneficial as well as that of using slice images in the future.
Although solar keratosis (SK) is commonly classified histologically into five types i.e., hypertrophic, atrophic, acantholytic, bowenoid and pigmented types, we added another type, spongiotic clefting type, which has spongiotic suprabasal cleft. Squamous cell carcinoma (SCC) derived from SK has been reported to have such histologic types as de novo, acantholytic and bowenoid SCCKs and small celled carcinoma. Of 109 cases of SK studied, hypertrophic type was 56.9%, atrophic type 5.5%, acantholytic type 4.6%, bowenoid type 17.4% and spongiotic clefting type 15.6%, respectively. Of 17 cases of SCC from SK, de novo type was 23.5%, acantholytic type 47.0%, bowenoid type 5.9%, and small celled carcinoma 23.5%, respectively. Acantholytic type of SCC having the highest rate of occurrence, possibly, derives from acantholytic type of SK. Thus, it is supposed that tumor cells of acantholytic type of SK have higher tumor invading rate. Using PCNA and AgNORs as index of cell proliferating rate, we examined all types of SK. However we could not have any significant difference among them.
In August 1992, seventy-two-year-old man who had burned his scalp severely in his infancy presented with a progressive tumor of his vertex. The histology showed that the tumor was a squamous cell carcinoma. The outer growth size of the tumor was 47×37mm wide and 15mm high. The MRI revealed that the tumor had penetrated cranial bone and the lower end of the tumor had touched the dura. Additionally the vanguard of the tumor had already located besides the superior sagittal vein. We gave up the surgical removal because the superior sagittal vein at the rear of the coronal suture must be preserved. We started continuous subcutaneous peplomycin injection (Pepleo® 5mg/day) for the initial therapy. When the total dose of peplomycin reached to 20mg, he showed symptoms of lung fibrosis (fever, crepitant rale and blood PO2 decline) . We had to abandon the peplomycin therapy. Four weeks prednisolone administration got recovery from the lung fibrosis. Then we performed radiotherapy with combinations of local hyperthermia and oral etretinate administration. The electron irradiation schedule was 2 Gy a time with 5 times a week, and the total dose was 70 Gy. The local hyperthermia with microwave apparatus was done single time a week immediately after the electron irradiation. We combined the last two times' hyperthermia with 10mg cisplatin (Randa®) drip infusion respectively. The dose of oral etretinate was lmg per kg per day for a month. The combinations were through on November 13, 1992. The combinations controlled the tumor nicely. He has come our clinic every two week for fifteen months after the combinations. Additionally we have checked MRI and skin biopsies every two or three months. There has been no evidence both of the metastasis and the recurrence. Generally skin cancer arising from scars is contraindicated for radiotherapy because of the low blood flow and/or the hypoxia of the tissues decrease the sensitivity. In contrast to radiotherapy, hyperthermia is effective to the tumor under hypoxia. Our case has impressed that hyperthermia with combination of radiotherapy is effective to even skin cancer arising from scars.
In this report, we described a case of lentigo maligna, which had originally appeared on the sun-exposed area and then gradually extended into non-sun-exposed mucosal area. A 65-year-old woman had developed a pigmented skin lesion on the right ala of her nose. This lesion was gradually enlarged and extended into the mucosal part of her nasal cavity. The skin lesion, histologically diagnosed as a lentigo maligna, was excised and resulting skin defects were reconstructed by free skin grafts. This case was unique in the respect that the lentigo maligna extended into the non-sun exposed mucosal area.
A 4-month-old girl had diffuse bluish macules on her back at birth. On the macules black or reddish nodules developed gradually. Those lesions were clinically and histologically diagnosed as malignant melanoma. Excision and partial-thickness skin grafts were made. Six months after the operation, three subcutaneous nodules were seen on the sites of operation. After another operation no reccurence has been seen. We discussed this case in the context of defferential diagnosis of malignant melanoma associated with giant congenital nevus and multiple (agminated) Spitz nevus.
We report three cases of genital Paget's disease treated with combination chemotherapy. All cases showed dermal invasion of neoplastic cells and multiple metastasis. After the chemotherapy, blood CEA level and the size of metastatic lymphnodes were decreased.
A 75-year-old Japanese woman associated with adenocarcinoma is reported. An erythematous patch started on the right side of the abdomen 5 years ago, which had enlarged to a dark pigmented crusting, partly eroding lesion, the size of 12×5cm at first examination. There was a 2×3cm satellite lesion. Histopathology revealed an apparent picture of Bowen's disease in the epidermal tumorous lesion, while there was adenocarcinoma in the dermis and the subcutaneous tissue. Immunohistochemical staining was undertaken with 13 monoclonal antibodies. The Bowen's disease and the adenocarcinoma showed respective different antigenecities. Extramammary Paget's disease and Bowen's disease have been suspected clinically. However, histopathologically this case was compatible with Bowen's disease, with negative PAS stain and alcian blue stain. It was not compatible with extramammary Paget's disease. Immunohistochemically, it was all positive except for anti-Lewis X antibody; these data were compatible with extramammary Paget's disease. The antigenecity of adenoma resembled that of the eccrine glands, and therefore, the adenocarcinoma was assumed to be of eccrine gland origin. Hirai stated that invasive extramammary Paget's disease acquires antigenecities similar to those of eccrine glands such as blood-type associated antigen antigenecity, according as they take the form of adenomatous structure. Our case was in agreement with the latter, namely it has acquired the antigenecity of eccrine glands. Human milk fat globule membranes (HMFGM) have at least six antigenecities. Hilkens and his co-workers produced many monoclonal antibodies, and they classified them according the molecules such as MAM-1 and MAM-6. In our case, the epidermal tumor did not react with these antigens, but the adenomatous lesions reacted with both MAM-3 antigen and MAM-6 antigen. The cell membrane and the cytoplasma of the inner cells of adenoma were positive for MAM-3 antigen and MAM-6 antigen, similar to the eccrine duct portion in the same specimen, Based on these findings, it is hardly a case of extramammary Paget's disease changing into invasive adenocarcinoma. Our case apparently showed two portions, an epidermal portion showing Bowen's disease and adenocarcinoma having features of adnexal, especially, eccrine gland origin. These two lesions showed respective antigenecities. A diagnosis was made of Bowen's carcinoma with adenomatous structure.
Two cases of hidroacanthoma simplex with porocarcinoma in situ are reported. The first case was an 80-year-old woman with a tumor on the right back and the other was an 85-year-old woman with a tumor on the right side of her abdomen. On histological examination, both tumors showed intraepidermal epithlioma. These tumor cells had atypical nuclei and a fairly abundant, pale-stained cytoplasm. Some of them had periodic acid-Schiff positive, diastase-digestive granules and alcian blue at pH 2.5 positive substances. Immunohistochemical studies revealed positive reaction for carcinoembryonic antigen and epithelial membrane antigen in both tumor cells.
A case of an 86-year-old man with Merkel cell carcinoma is reported. A small papule on the right cheek gradually enlarged, resulting in a dome-shaped nodule in two months. Electron microscopically, the tumor cells contained 100 to 150nm dense-core granules and aggregation of intermediate filaments in the cytoplasm. Immunocytochemically, the cells were positive for neuron-specific enolase, cytokeratins (CAM5.2 and MA902) and epithelial membrane antigen. Because the tumor rapidly enlarged in the next one month, interferon-β (3×106U, once a day) was intradermally injected around the tumor for 5 days. The tumor was then excised 2 cm apart from the margin. Neither tumor recurrence nor metastasis has been observed in a follow-up period of 18 months after surgery. Intralesional injections of interferon independently or in combination with excision may be preferable treatment modalities of Merkel cell carcinoma.
Although basal cell carcinoma (BCC) with a diameter of 20mm or less is in general recommended to treat with 4 or 5mm surgical margin, there is no appropriate guideline what millimeters around the tumor one must excise in case the diameter of BCC is more than 20mm. Nine cases of BCC greater than 20mm, which histopathological sections were sliced at the center of the tumor, were measured their smaller tumor free width of the lateral ends of the specimen through their 50 serial sections retrospectively. They were actually undertaken operation with a surgical margin ranged between 4 and 10mm. No tumor cell was present in the both lateral ends of the nine histopathological samples with a width of 2 to llmm tumor free area, though their surgical margin was variable. Then it was calculated that at least 4mm excisional margin was required to eradicate the tumor thoroughly histopathologically. Since the subclinical extension of BCC is asymmetric, it is supposed that, there is a possibility of local recurrence, unless the tumor is excised with 2 or 3mm safety margin. Therefore the adequate surgical margin for BCC more than 20mm was concluded as 7mm when one can get at least 3mm tumor free area. Moreover the correlation between histopathological types of BCC and the severity of subclinical extension was not significant, though morphealike BCC was expected to be widely extended. Since the clinical margin of morphealike BCC is ill-defined, one must mark the margin much wider than usual, and then 7mm surgical margin is indicated for any histopathological types of BCC.
A case of Mycosis Fungoides (MF) with involvement of the esophagus and oral mucosa is reported. These lesions responded well to intensive chemotherapy and disappeared macroscopically in his clinical course. After a strain of chemotherapy, he could get back to his daily life for about one year with oral administration of etoposide plus maintenance chemotherapy once in every six month. He died about two years after the extracutaneous involvement was recognized because of the cerebral hernia caused by tuberculous meningoencephalitis. This is the first report of MF case who showed the symptom of esophageal stenosis caused by the massive involvement. There have been ten cases of MF with oral involvement preveously and most of them showed poor prognosis.
Two cases of malignant lymphoma with skin and secondary central nervous system (CNS) involvement were reported. Case 1: A 69-year-old male presented with the skin, paranasal cavity, laryngeal and intrathoracic involvement by B cell lympboma (diffuse medium cell type). He also complained of paraesthesia on the left leg. Although these lesions almost disappeared after VEPA therapy, the patient complained of clounding of conciousness and poor memory two months later. Examination revealed leptomeningeal involvement and epidural spinal cord compression. Lumbar puncture disclosed numerous atypical cells which were positive for CD20. The patient died of pneumonia after few months, although these atypical cells in the spinal fluid disappeared after intrathecal chemo-therapy. Case 2: A 61-year-old male developed cutaneous T cell lymphoma (diffuse medium cell type) without any other symptoms. The skin lesions disappeared after VEPA therapy. He suddenly developed clouding of conciousness and poor memory after one year of remission. CT scans showed an intracerebral mass. In spite of whole brain irradiation and both systemic and intrathecal chemotherapy, the tumor did not decrease in size and the patient died of pneumonia after 1.5 years. In the literature, CNS involvement developed 5-10% of adult malignant lymphoma. The risk factors for secondary CNS involvement were considered to be stage IV diseases, B symptoms, diffuse large cell or mixed cell type, involvement of the testis, peripheral blood, nasal/paranasal sinuses and bone marrow. Thus, the case 1 might have been given a prophylactic treatment, since he had several signs described above.
Growth patterns of malignant cutaneous tumors in 21 patients obtained by magneti resonance imaging (MRI) were assessed in contrast with those in histological examinations. Degree of intradermal invasion in MRI pictures of the lesions was well corresponded with that in histological examinations. In general, intensit of tumor images was higher in T2 weighted images than that of T1 weighted images. It is very likely that cellularity, inflammation, edema and degeneration of the lesions may cause the phenomena. MRI seems to be better to analyze tumor invasion arising in head and neck region than other imaging method such as CT scan, xerography and FCR, because MRI enables us to select slice freely, when the lesion occurs in unevenly surfaced region.
A case of prostatic carcinoma with skin metastases is reported. The patient showed four cutaneous nodules on the head. We biopsied one of them, and found out that it is skin metastases of an adenocarcinoma. After admission to Tsukuba Univ. Department of Dermatology, prostatic carcinoma was detected. Prostatic carcinoma rarely metastasizes to the skin, and it occupies less than 1% of the metastatic carcinoma of the skin.
Report of Two Cases -A metastatic Angiosarcoma Case and A Case of Recurrent Squamous Cell Carcinoma Case 1: A 64-year-old woman was referred to us with multiple faint red masses on her scalp in June 1988. Wide excision including whole scalp and the periosteum beneath the affected area was done. The defect was covered with split thickness skin grafts. Postoperatively, the patient received radiotherapy and chemotherapy with rIL-2. One year and two months later she developed a subcutaneous tumor of left preauricular region. The patient accordingly received total parotidectomy combined with excision of the overlying skin and of temporal and zygomatic branches of facial nerve, and neck lymph node dissection. Pathologically, parotid lymph node metastasis was confirmed, but no neck lymph node metastasis was observed (0/32). The defect was reconstructed by pectoralis major musculocutaneous flap, followed by radiation therapy to the parotid area and neck. The patient is alive and well 4 years 7 months after the primary operation. Case 2: A 58-year-old man was first seen by us in March 1989 at Obihiro Kosei Hospital with multiple abscesses and suppurating sinuses involving the buttocks. In May 1989 excision of the skin and subcutaneous tissues including sinuses was performed. The defect was covered with split thickness skin grafts. The graft healed well. One month later, however, abscesses and sinuses of right buttock recurred, resulting elevated fungating tumor masses. Biopsy of the tumor showed squamous cell carcinoma. In January 1990, whole tumor was removed with rectum after a colostomy was made. The tissue defect was covered with gluteus maximus musculocutaneous flap and split thickness skin grafts, followed by radiation therapy and chemotherapy with Peplomycin and Carboquone. One year later, pus discharge was observed, and recurrence of S.C.C. was confirmed pathologically. CT and MRI findings demonstrated the tumor recurrence involved prostate, upper urethra, posterior wall of bladder, and sacrum. In May 1991, total pelvic exenteration combined with sacral resection was performed at Hokkaido University Hospital. The resultant tissue defect was reconstructed with free latissimus dorsi musculocutaneous flap, followed by chemotherapy with Bleomycin. The patient was alive and well 2 years 8 months after the total pelvic exenteration.
We report efficacy of combination therapy consisting of systemic recombinant interferon-γ (INF-γ) and local electron beam radiation to early tumor-stage of mycosis fungoides. A 80 year-old male patient was seen with erythema, pigmentation and papular eruption on his entire body surface. Some nodles with partial erosion and ulceration was observed mainly on his upper extremities. After confirming the diagnosis on biopsied specimens, we first start to treat him with systemic radiation therapy with electron beam. This resulted in partial remission while erythema and papules recurred after 6 months. Intravenous injection of INF-γ (2, 000, 000IU/day×days), was tried and found effective for erythematous patches but not effective for nodular lesions. We started local radiation on the nodular lesions with electron beam (2Gy/day), combined with systemic INF-γ. The combination therapy led the patientin well-controlled condition. It has been usually suggested that INF-γ is usefull forerythematous and early infiltrating stage of mycosis fungoides. We here emphasize a possible benefit of electron beam local radiation on the nodules in early tumor stage of mycosis fungoides during BRM (biological response modifier) therapy with systemic INF-γ.
We investigated the concentration of 5-fluorourasil (5-FU) in the normal and tumoral tissue among eight patients (male; 6, female; 2, mean age; 64.8) with Paget's disease. Thirty minutes after completing the drip infusion of 5-FU (250mg/100ml of normal saline/hr), both normal and tumoral specimens were removed respectively. These specimens were kept under -70°C until study. The concentration of 5-FU was measured by high performance liquid chromatpgraphy. The concentration of 5-FU in the tumor was significantly higher than that in the normal (p<0.03) . The present data gave a further support that the combination chemotherapy based on 5-FU might be effective for sweat gland carcinoma including Paget's disease.
A 86 years-old male patient with B-cell lymphoma is reported. This case wascharacterized by multiple nodal lesions mainly on the breast and upper back. Thehistological picture was classified of the diffuse large sized cell type. This patient wastreated by combination chemotherapy, but after about 7 monthes died with leukemicchange and lung failure. High age patient of cutaneous B cell lymphoma should betreated carefully, since they are compromized hosts and they usually have a lot ofsystemic diseases.
A case of squamous cell carcinoma on the scar of Buerger's disease was described. The patient was 63 years old male and had taken several conservative therapy for Buerger's disease during about 40 years. In July 1991, a new ulcerative lesion developed in the residual scar on the superior aspect of his right foot. Two months later, the ulcer was expanded and he noticed a painful nodule on the edge of the ulcer. The nodule was rapidly enlarged to the hen's egg size. At his first visit to us, a mass, 65×55×30mm in size was obserbed. The surface was smooth and partialy covered with necrotic tissue. The color was almost normal skin color. Three enlarged lymphnodes were palpated in his right groin. A biopsy specimen of the tumor was obtained. The diagnosis of squamous cell carcinoma (SCC) of almost well differenciated type and partialy poorly differenciated type was made. In July 1992, thigh amptation and inguinal lymphnodes dissection were performed.