Hiroto Terashi

Analysis of 256 cases of basal cell carcinoma after either one‐step or two‐step surgery in a Japanese institution

Basal cell carcinoma (BCC) is a common skin cancer that arises from the cells of the basal layer of the epithelium or from the external root sheath of the hair follicle. In the present report, 256 cases treated surgically between 1999 and 2008 in our department were retrospectively analyzed. The most frequent BCC locations included the face (77.8%), especially the nose (26.9%) and eyelids (21.5%). Incomplete excisions occurred in 21 cases. Two patients experienced local recurrence; one of these patients exhibited a bone metastasis while the other had a metastasis of the parotid gland without the local recurrence. The rate of local BCC recurrence was 0.78%, which is lower than that described in previous reports. We categorized BCC into four histological types: superficial, solid, adenoid and infiltrative. The solid type was the most frequent histological type (62.1%). For preventive recurrence, we treated BCC patients with two‐step surgery when the tumor was large or histologically invasive. At the first step, we excised the tumor with a sufficient safety margin, and at the second step, we performed reconstruction after the histological confirmation that no remnant malignant cells were in the tumor margins. In the present report, no local recurrence occurred in patients following the two‐step surgery. Therefore, two‐step surgery is recommended for tumors at locations and with histological types related to frequent recurrence.

A case of dermatofibrosarcoma protuberans on the head of an elderly man

75歳男性。数年前より前頭部の腫瘤を指摘されていた。2007年6月中旬頃より急速に増大してきたため, 同年7月上旬, 済生会中津病院形成外科を受診した。初診時, 前頭部に4×3cmの可動性良好で表面凹凸不整な暗赤色腫瘤を認めた。腫瘤右前方に接して, 2×2cmの弾性硬で可動性良好な皮下結節を認めた。治療は, 腫瘍および皮下結節辺縁より1.5cm離して切開し, 骨膜上で切除した。病理組織学的には, storiform patternを示す紡錘型細胞の増生がみられ, 免疫組織染色では, CD34が陽性であったため, 隆起性皮膚線維肉腫と診断した。切除標本内の断端に腫瘍細胞は認められなかったが, 術後7ヵ月後に植皮部辺縁から再発した。腫瘍辺縁より3cm, 前回の植皮部辺縁より1.5cm離して切開し, 腫瘍直下は骨膜を切除し, その周囲は骨膜上で切除した。術後8ヵ月を経過して再発・転移は認めていない。

A case of a young woman with Bednar tumor

症例: 22歳女性。約7年前より自覚していた右前胸部皮下腫瘤を単純切除したところ, 病理所見にてBednar腫瘍と診断され, 拡大切除術を施行した。病理所見ではstoriform patternに増殖した異型性のある紡錐形細胞に加え, 腫瘍組織内にメラニン色素を有する樹状の細胞が散見された。Bednar腫瘍はDermatofibrosarcoma protuberans (DFSP) の亜型と考えられている稀な腫瘍で, 1975～2006年までの本邦報告例は自験例を含め56例であった。これらをDFSPの本邦報告例151例と比較検討し報告する。

Primary malignant melanoma of the vulva: a case report

A 73-year-old woman was referred to our hospital with a complaint of a black nodule on her vulva. Bilateral inguinal lymph nodes were palpable. The diagnosis of malignant melanoma of the vulva was made on clinical features. We performed a wide local excision immediately circumferentially to a distance of 2cm from the nodule and a bilateral ilio-inguinal lymph node dissection, including subcutaneous tissue between the nodule and the inguinal lymph nodes. We reconstructed the urethral orifice and vaginal orifice with the residual skin flaps. At present, 9 months after surgery, no recurrence has been noted, and no distant metastases have been observed. She has no difficulty in urination. We consider this method is effective for a moderate vulvar defect. [Skin Cancer (Japan) 2004 ;19: 233-237]

A case of squamous cell carcinoma of the scrotum associated with invasion of surrounding dermal lymphatic vessels and regional lymph node metastasis.

A-75-year-old man developed a rapidly growing tumor followed by swelling of regional lymph nodes, on the left side of his scrotum. Histopathological examination of the tumor revealed a deep invasion of atypical squamous cells associated with embolism of dermal lymphatic vessels by tumor cells, as far as 4cm apart from the tumor. Wide local excision of the tumor including total scrotal skin and bilateral ilioinguinal lymph node dissection was performed. Subsequently five courses of chemotherapy with cisplatin and fluorouracil and radiotherapy were added. In spite of these treatments, he had a recurrence located on the posterior border of the grafted skin of scrotum one year after the operation. [Skin Cancer (Japan) 2001; 16: 47-50]

A Case of Recurrent Dermatofibrosarcoma Protuberans Invading the Cerebral Parenchyma.

A 22-year-old Japanese man visited our hospital with a large tumor on his occipital region. He first noted a nodule on his scalp when he was 14-years-old in 1986. Although the tumor was excised in 1987, he noticed recurrence one year later. Since then, surgical excision of recurrent tumors had been performed six times. In 1994, he complained of frequent headaches, walking disturbance and visual disorder. Physical examination revealed several large nodules located on the anterior border of the previously grafted skin. Magnetic resonance imaging showed the scalp mass invading the cerebral parenchyma. The recurrent tumors were further resected five times. In spite of the radiotherapy and chemotherapy, the tumor progressively disseminated into spinal cord, and he died of respiratory failure in January, 2000. [Skin Cancer (Japan) 2001; 16: 77-82]

A case of squamous cell carcinoma with nerve invasion occurred in calcaneal burn scar.

Malignant skin tumors rarely show perineural spread or neural invasion. The incidence was reported to be 2.4-4.9% for squamous cell carcinoma of the skin. We report a case of squamous cell carcinoma arising on the burn scar of the right heel of a 31-year-old woman with perineural and endoneural invasion.Despite appropriate treatments including wide local excision, resection of medial calcaneal nerve and radioand chemotherapy, the tumor recurred near the site of the perineural invasion after 10 months. Her right leg was amputated above the knee.

2 cases of malignant lymphoma with cerebrospinal invasion.

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.