Shigetoshi Nomoto

Two cases of vulval pigmented extramammary Paget's disease: histochemical and immunohistochemical studies.

We describe two Japanese female patients with pigmented extramammary Paget’s disease (EMPD); one patient had a dark brown plaque and the other had a reddish patch with a pigmented area, both affecting the vulval region. Histochemical and immunohistochemical examinations confirmed EMPD with melanocyte colonization; plump tumour cells with a large nucleus and pale cytoplasm that were positive for CAM 5.2 and CEA proliferated singly or in nests in the epidermis, and scattered among the tumour cells were many dendritic cells with a large amount of melanin that were positive for HMB‐45 and S‐100 protein. Fontana–Masson (FM) stain showed many positive cells with well‐developed dendritic processes within and around tumour nests. Histochemical and immunohistochemical studies of non‐pigmented EMPD cases on the same region showed that HMB‐45 positive cells were sparse or not detected at all, and that also FM staining‐positive cells were decreased or not detected, and their dendritic processes were poorly formed. The present study suggests that there might be heterogeneity in EMPD in terms of relationships between Paget’s cells and melanocytes.

Popliteal lymph node metastasis from malignant melanoma

Sentinel lymph node (SLN) biopsy has become widely accepted as a method of staging in the regional lymph nodes of patients with malignant melanoma. Popliteal lymph nodes have been rarely identified as SLNs in patients with melanoma at or distal to the knee. However, its significance has not been well established. We reported a case of a patient with melanoma on the heel, who had positive SLN metastases in both popliteal and groin lymph nodes. In addition, experience with the past cases metastasized to popliteal lymph nodes in our hospitals were reviewed. Among 76 patients with melanoma of the distal lower limb, five (6.6%) developed popliteal lymph node metastases in its clinical course. The primary tumor sites in four of five patients were located on the heel, especially on the lateral or proximal aspects. Although elective lymphadenectomy of popliteal node seems to be unnecessary considering the low incidence of metastasis, once the popliteal node is identified as SLN on lymphoscintigraphy, biopsy procedureshould be performed. [Skin Cancer (Japan) 2003; 18: 298-302]

A case of myxoid malignant fibrous histiocytoma

A 66-year-old woman had noticed a nodule on her light groin 15 years ago. The nodule was excised two times because of recurrence. She came to our hospital because of a 3rd recurrence occurred. The nodule was widely excised with 5cm margins. Histopathologically, the tumor was mainly composed of spindle-shaped cells. In some areas of the lesion, the tumor cells were arranged in a storiform pattern, and in other areas myxoid changes were seen. Immunohistochemical study revealed that the tumor cells were positive for vimentin, factor XIII a, but negative for keratin, α-SMA, tdesmin, S-100, factor VIII, CD34 and EMA. Ultrastructurally, the tumor cells had a fibroblastic phenotype. Thus we diagnosed this tumor as malignant fibrous histiocytoma, myxoid type. Subsequently, a nodule had appeared on her forehead 2 years after the operation. Histopathologically, the nodule was diagnosed as myxoma, whereas the tumor which recurred about l year after the first operation was diagnosed as myxoid-MFH. One year later the tumor has recurred again; no systemic metastasis was detected. Recently it has been emphasized that, in most cases originally diagnosed as MFH, a specific line of differentiation is evident, and relatively few cases have to be classified as MFH or not otherwise specified. We assume that this case is myxofibrosarcoma rather than myxoid-MFH, because ultrastracturally, the tumor cells of this case were composed of only fibroblastic phenotype, and generally MFH reveals a more aggressive course than this case. [Skin Cancer (Japan) 2003; 18: 259-265]

Metastatic sweat gland carcinoma successfully treated with thermoradiation therapy.

A 73-year-old female presented with a small ulcerated nodule on her left heel. It was excised with a margin of 10mm and reconstructed by skin grafting. The histological diagnosis was sweat gland carcinoma. Four months after the operation, a rapidly growing subcutaneous tumor was recognized on her left leg. The biopsy specimen showed metastatic sweat gland carcinoma. A combination therapy of intravenous cisplatin, 5-fluorouracil and subcutaneous peplomycin with 30Gy of irradiation was tried, but the patient could not endure its severe side effects. Subsequently, she was treated with 30.5Gy of additional irradiation combined with hyperthermia. A great response was observed. Wide local excision and left groin dissection followed. There was no evidence of metastasis during 5 years after the therapy. [Skin Cancer (Japan) 2002; 17: 123-126]

A case of synovial sarcoma.

39歳女性の右足底から足背に生じた増殖性の皮下腫瘍を経験した。患者の治療拒否により放置され, 急速に増大した。腫瘍は骨に浸潤性に増殖し, 疹痛のため, 歩行も困難となった。生検時には, 腫瘍は単調な線維性の腫瘍細胞からなり, 免疫組織学的に明らかな分化傾向もみられず, 診断が困難であったが, 手術材料の病理所見ではわずかに扁平上皮細胞の胞巣を混じており, 組織学的に滑膜肉腫と診断し得た。また, 遺伝子学的検索でもSYT-SSX遺伝子複合体の発現が認められた。

Factors influencing deep invasion of basal cell carcinoma multiple linear regression analysis.

Basal cell carcinoma (BCC) usually grows slowly, increasing in size and depth of invasion over months to years. It is important prior to surgery to predict aggressive behavior of BCC, especially its deeper extension. In 216 primary BCCs treated with surgical excision, maximum vertical diameter, designated as “invasion index, ” from the surrounding skin surface to the bottom of the tumor was measured. As predictive factors, age, sex, duration, anatomical location, tumor horizontal diameter, histologic subtypes, and ulceration were listed. Multiple linear regression analysis, which was performed on the seven factors related to the invasion index, showed significant strength of influence of male sex, larger tumor horizontal diameter, and aggressive histologic subtypes (infiltrative, morpheic, and micronodular). When treating BCC having the three predictive factors, clinicians should keep in mind its potential for deeper invasion. [Skin Cancer (Japan) 2000; 15: 138-142]

Squamous cell carcinoma on the nail. A case of squamous cell carcinoma on nail division which caused multiorganic metastasis through rapid progress.

We reported a case of squamous cell carcinoma (SCC) of the nail bed, with very rapid multiple metastases in various organs. A 65-year-old man had a hyperkeratotic tumor which had been around the nail bed of his right 5th toe for two months. A digital X-ray film of the toe showed the disappearance of the digital phalanx. A biopsy specimen of the tumor led us to diagnose as poorly differentiated SCC. Amputation of the toe at the level of metatarsal bone and therapeutic dissection of the right ilio-inguinal and popliteal lymphnodes were performed. Additionaly the patient was followed by radiation therapy. Histologically, the tumor invaded the bone underneath, and two metastatic lymphnodes were detected on his right groin.In spite of irradiation on his right foot toe and groin, many in-transit metastases appeared on his right leg and thigh three months later. Several times of resection and two courses of combination chemotherapy (cisplatin, 5-FU and peplomycin) could not inhibit the tumor progression. Bone and lung metastases occurred and he died seven months after the first visit.Although the prognosis of subungual SCCs is thought to be relatively favorable, some cases may take a miserable course.

Metastatic cutaneous cancer. Report of a case produced in apex nasi and examination of 22 cases in Niigata Univ. .

A 64-year-old man had a rapidly growing tumor on his nasal apex. He had been treated for his lung cancer with left pneumonectomy and mediastinal lymph node clearing 6 months before. Since histological findings of the nose tumor and the lung tumor were very similar, the nose tumor was diagnosed as a metastatic skin cancer originating from lung cancer.We also studied 22 cases of metastatic skin cancers in our hospital experienced for 8 years. The mean age at their first visit was 63.4 years old. The most frequent primary tumors were lung cancer (31.6%) . Abdomen and chest were the most common metastatic lesions, unless face and back metastasis was less common. The avarage time of the appearance of the skin lesions after detection of the primary tumors was 28.7 months. The avarage time of death after the appearance of skin metastasis was 6.9 months. When metastatic skin cancers in nasal area are found, we had better to speculate the presense of kidney cancer first, and secondarily the presence of lung cancer as primary cancers.

A case of vascular sarcoma.

An 85-year-old man presented a dome-shaped violaceous tumor of 2 cm in diameter, in the center of a palm-sized erythematous macule on his frontal scalp. This lesion was considered to be a local recurrence of a nodular lesion which had been previously excised marginally 4 months before. The primary lesion was histologically reevaluated and diagnosed as a moderately differentiated type of angiosarcoma. The intravenous and intralesional injections of recombinant interleukin-2 (rIL-2) was started at total daily doses ranging from 70 to 105 JRU, 6 days a week. The recurrent lesion disappeared 5 weeks after the initiation of the therapy and no remnant of malignant tissue was recognized in the specimen of the excisional biopsy taken after the treatment. Seven weeks after the biopsy, sacral bone metastasis was noted by sacral pain and comfirmed by CT scan. Both scalp area and metastatic bone lesion were treated by low dose irradiation combined with systemic intravenous administration of rIL-2. However, the metastatic lesion did not show any response to the therapy. Three months later the patient died of respiratory failure caused by pneumothorax and pleuritis due to the multiple lung metastases. It is suggested that the systemic rIL-2 therapy alone is not so effective to the distant metastatic lesion in spite of the remarkable curative effect of intralesional injection of rIL-2 on the primary skin lesion of angiosarcoma.