Sachiko Noro

Clinicopathological significance of sentinel node biopsy in Japanese patients with cutaneous malignant melanoma.

Sentinel node biopsy (SNB) for malignant melanoma began to be performed in our department in 1997. A total of 121 patients underwent SNB. Sentinel node (SN) were identified in 39 (83.0%) of the 47 cases in which the blue dye method alone was used, and in 71 (95.9%) of the 74 cases by combination of dye, radioisotope, and γ probe methods. The excised SN was cut through its longest meridian, and the cut surfaces were stained with hematoxylin and eosin (HE) and examined for the presence (SN+) or absence (SN−) of melanoma cells. If no melanoma cells were detected, serial sections were prepared and examined by sequential staining with HE, for S‐100 protein, with HE, for HMB‐45, with HE, and for Melan‐A. In this study minute metastasis (SNm+) was defined as tumor cells newly identified in the immunostained section. The thickness of tumors ranged 0–38.0 mm, and their mean thickness was 4.5 mm. There were 39 SN+ cases (39/110 [39 + 71]; 35.5%) and seven SNm+ cases (7/110 [39 + 71]; 6.4%). The 5‐year survival rate was significantly higher in the SN− group than in the SN+ group and SNm+ group combined (P = 0.0002). The survival rate of the SNm+ group was not significantly different from that of the SN+ group (P = 0.3848). The 5‐year survival rate of the SN+ group and SNm+ group combined was significantly higher than that of the group with clinically unequivocal metastatic nodes (P = 0.0001). Accurate SNB results will provide important prognostic information for Japanese patients with melanoma.

Case of Merkel cell carcinoma with squamous cell carcinoma possibly arising in chronic radiodermatitis of the hand.

We report a case of Merkel cell carcinoma (MCC) on the dorsal aspect of the right middle finger associated with multiple squamous cell carcinomas (SCC) possibly arising in chronic radiation dermatitis of the hand of an 80‐year‐old surgeon. In spite of resection of the primary lesion and right axillary lymph nodes, he died of the tumor 5 months after the first visit. Cutaneous and lymph node lesions of MCC were negative for Merkel cell polyoma virus (MCPyV) by immunostaining using monoclonal antibody (CM2B4) and anti‐large T antigen of MCPyV polyclonal antibody, and real‐time polymerase chain reaction. Several differences in clinicopathological findings have been found between MCPyV‐positive cases and negative ones. Several authors have reported that MCPyV‐negative cases have a worse prognosis than MCPyV‐positive ones. Furthermore, in cases of MCC associated with SCC, most tumors have been reported to be MCPyV‐negative. We should pay more attention to the relationship between the carcinogenesis of MCC and ionizing irradiation.

Three-Dimensional Image Fusion of SPECT and CT Scans for Locating Sentinel Lymph Nodes in Malignant Melanomas.

Image fusion software can derive a fusion image from single photon emission computed tomography and computed tomography scans. We applied a three-dimensional fusion image to detect sentinel lymph nodes (SLNs) in 3 patients with malignant melanomas of the lumbar, vulvar and head region, respectively. During each operation, we detected SLNs at the expected site, as indicated by the fusion images. The three-dimensional image fusion could thus be confirmed as a simple and helpful method for precisely localizing SLNs in these patients.

Bowen's disease with high telomerase activity

We describe an 81‐year‐old Japanese woman who had a palm‐sized, erythematous plaque with a nodular lesion on the lateral abdomen. The biopsy specimens taken from the erythematous plaque and reddish nodule show that bowenoid changes were present in the epidermis and epidermis to dermis, respectively. A sentinel lymph node biopsy (SNB) was performed with blue dye and radioisotope in her right groin region and two lymph nodes were found to be occupied by many atypical cells. The erythematous plaque with nodular lesion was completely removed with a 3‐cm margin under general anesthesia, and complete regional lymph node dissection was also performed. In addition, high telomerase activity was seen in the erythema plaque while using a telomeric repeat amplification protocol assay. In conclusion, some instances of Bowens disease might have high telomerase activity in the atypical cells and can progress to Bowens carcinoma. The SNB was regarded as a useful method to detect early lymph node metastases in this case.

Folliculosebaceous cystic hamartoma associated with melanocytic nevus

Figure 1. Clinical findings. A dome-shaped nodule was observed on the right side of the nose. Dear Editor, Folliculosebaceous cystic hamartoma (FSCH), originally described by Kimura et al., is widely considered to consist of multiple tissue elements, including ectodermal and mesodermal components. In rare cases, FSCH is associated with other conditions, such as rosacea, nevus lipomatosus superficialis or portwine stain. In the present report, we describe a case of melanocytic nevus exhibiting features of FSCH. To the best of our knowledge, this is the first report describing a case in which the patient showed histopathological features of both FSCH and melanocytic nevus. A 64-year-old Japanese man visited an outpatient clinic run by the Department of Dermatology, Nippon Medical School. He complained of a nodule on the right side of his nose, which had been present since the past 3 years. Clinical examination revealed that this nodule was 1.0 cm in diameter, dome-shaped, elastic and hard (Fig. 1). Part of the lesion was grey (Fig. 1). Our clinical diagnosis was melanocytic nevus. The lesion was surgically removed under local anesthesia. Histological examination revealed a large, dilated, cystic structure lined by stratified squamous epithelium; the structure resembled the follicular infundibulum (Fig. 2). Multiple sebaceous lobules radiated from the periphery of the cystic structure. In some instances, sebaceous ducts were observed. The stroma surrounding the epithelial component of the cyst and the sebaceous lobules consisted of dense fibrous tissue with scattered adipocytes (Fig. 2). Clefts were present between this stroma and the surrounding altered stroma (Fig. 2). Additional clefts were observed between the altered stroma and the adjacent fibrous tissue (Fig. 2). Melanocytic nests, some of which contained abundant melanin granules in their cytoplasm, were observed throughout the

Malignant melanoma of the nasal vestibule

Dear Editor, Malignant melanomas arising from the nasal cavity and paranasal sinuses are rare and comprise less than 1% of all melanomas and less than 4% of sinonasal tumors. On clinical examination, a malignant melanoma usually appears as a sessile polypoid mass and in some cases as a friable or partially necrotic hemorrhagic lesion. The occurrence of malignant melanoma is extremely rare among those of the nasal cavity. Here, we report a case of thin melanoma observed on the nasal vestibule for which sentinel lymph node (SN) biopsy was performed. The patient was a 77-year-old woman who had visited an internist clinic at the University Hospital of Nippon Medical School for dizziness. She had a history of hypertension, diabetes mellitus and stroke. Her nasal cavity was examined at the otolaryngology clinic in order to determine the cause of dizziness, and a pigmented lesion was unexpectedly found in the left nasal vestibule during the course of this examination. On clinical examination, the pigmented lesion appeared as irregular brown-black macules and the diameter was approximately 17 mm (Fig. 1). There was no bleeding, mass or ulcer. Pigmented lesions were not detected anywhere else on the surface of the body, including the mucous membrane of the oral cavity to pharynx, and the cervical lymph nodes were not palpable. The clinical diagnosis was malignant melanoma. The pigmented lesion was resected by excisional biopsy in September 2008. Histological examination revealed that atypical melanocytes, which had pale cytoplasm and hyperchromatic irregular nuclei, proliferated within the mucosal epithelium and invaded into the lamina propria. The loss of mucosal epithelium was partially observed. The atypical melanocytes had formed nests and had infiltrated into the underlying lamina propria. Immunohistochemical analysis revealed that the neoplastic cells were strongly and diffusely positive for S-100 protein, HMB-45, and Melan-A. On the basis of these findings, we diagnosed the lesion as a malignant melanoma. The tumor thickness was 0.6 mm (Fig. 2). One month after excision of the lesion, an SN biopsy was performed using a radioisotope method, and blue dye. Twenty-four hours before the operation, 30 MBeq of technetium-99m (Tc)-phytate was injected into four sites of the lamina propria around the primary lesion. Lymphoscintigraphy was performed on the patients on two occasions, namely, immediately and at 4 h after injection of Tcphytate. Lymphoscintigrams revealed a hot node in the left submandibular region, and this region was diagnosed as an SN. Prior to the surgical resection, SN biopsy was done by using both vital dye (1 mL of 2% Patent Blue V) and radioactive isotope. These tracers were injected into the lamina propria around the tumor. One of the submandibular nodes was