Letters to the Editor
(a)
ACKNOWLEDGMENTS: We thank Drs Eishi Takahashi and Takashi Hashimoto (Department of Dermatology, National Defense Medical College) for their kind cooperation, especially in collecting the patient’s information.
(b)
CONFLICT OF INTEREST:
None declared.
Misaki ISE, Takeru FUNAKOSHI, Yuki FURUICHI, Haruki HONDA, Yumi FUJIO, Masayuki AMAGAI, Manabu OHYAMA (c)
(d)
(f)
Department of Dermatology, Keio University School of Medicine, Tokyo, Japan doi: 10.1111/1346-8138.12809
REFERENCES (e)
(g)
Figure 1. (a) Yellow to brown, large, stiff plaque with multiple dark red papules, nodules and petechiae was observed on the right upper to lateral abdominal wall. (b) A close-up image of multiple, dark red papules clearly indicating that tumor recurred after the surgical excision. (c) Panoramic view showing multiple nodules irregularly invading into the fibrous septa and the lobules of the subcutis and the cords of cells infiltrating into the dermis (hematoxylin–eosin [HE], original magnification 940). (d) Irregularly anastomosing vascular structures lined with enlarged endothelial cells pervading between collagen bundles (HE, 9400). (e) Pleomorphic epithelioid cells with enlarged nuclei and substantial amount of mitotic figures (HE, 9400). (f) Tumor cells were positive for anti-CD31 and (g) antifactor VIII-related antigen staining (3,30 -diaminobenzidine-tetrachloride, 9200).
1 Albores-Saavedra J, Schwartz AM, Henson DE et al. Cutaneous angiosarcoma. Analysis of 434 cases from the Surveillance, Epidemiology, and End Results Program, 1973-2007. Ann Diagn Pathol 2011; 15: 93–97. 2 Reynold HM, Walker CG, Dunbar PR et al. Functional anatomy of the lymphatics draining the skin: a detailed statistical analysis. J Anat 2010; 216: 344–355. 3 Mizukami A, Taguchi M, Suzuki T, Tsuchida T. Angiosarcoma: a report of 260 patients based on a study conducted by The Japanese Association of Dermatologic Surgery, and review of the literature. Skin Cancer 2009; 24: 350–362 (in Japanese). 4 Masuzawa M. Angiosarcoma of the scalp: strategy and evaluation at the Kitasato University Hospital. Skin Cancer 2009; 24: 377–384 (in Japanese). 5 Yamazaki N. Therapeutic strategy for angiosarcoma in the National Cancer Center Hospital. Skin Cancer 2009; 24: 385–391 (in Japanese).
SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article: Table S1. Summary of 19 cases of angiosarcoma on the abdominal wall reported in the Japanese and English-language published work.
Keloidal basal cell carcinoma possibly developed from classical nodulo-ulcerative type of basal cell carcinoma: Report of a case Dear Editor, An 81-year-old Japanese woman presented with an erosive skin lesion on her back of 1 month’s duration. Skin examination demonstrated a solitary, pinkish nodule with ulceration, which measured 20 mm 9 10 mm, on the upper back. The lesion consisted of two parts: a large keloid-like portion and a semicircular, nodulo-ulcerative portion (Fig. 1a). Dermoscopic
examination of the keloid-like lesion revealed variously sized arborizing vessels on the pinkish-white surface without pigment components (Fig. 1b). In contrast, the nodulo-ulcerative lesion demonstrated the typical dermoscopic features of pigmented basal cell carcinoma (BCC) including multiple blue-gray globules, large blue-gray ovoid nests and ulceration (Fig. 1b). Histological features of the keloid-like lesion showed numerous,
Correspondence: Toshio Demitsu, M.D., Department of Dermatology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan. Email: [email protected]
© 2015 Japanese Dermatological Association
427
Letters to the Editor
basaloid tumor nests surrounded by homogenous, sclerotic collagen bundles (Fig. 1c). On the other, the semicircular lesion histologically revealed basaloid cell proliferation with palisading beneath the epidermis (Fig. 1c). The border area demonstrated that spike-like tumor nests of basaloid cells had invaded into the deep dermis. (Fig. 1c). The collagen bundles around the tumor cells in the keloid-like lesion were homogenous and thick, similar to early keloid (Fig. 1d). These characteristic findings were consistent with keloidal BCC (KBCC). The tumor was surgically excised with a 1-cm surgical margin under local anesthesia. The patient had no recurrence 7 months after tumor resection. Keloidal BCC has been described as a rare clinicopathological variant of BCC.1 Few cases of KBCC have been reported until now.1–4 The characteristics of KBCC demonstrate a keloid-like nodule, predominantly affecting the face, with the histological features of thick, homogenized, keloid-like collagen bundles intermingled with the basaloid tumor nests. Jones
(a)
(b)
et al.2 reported that eight of 1011 BCC showed thick sclerotic collagen. They concluded that KBCC was not a distinctive clinicopathological entity because keloid-like collagen in the stroma of the tumor could be observed in different histological types of BCC.1 Collagen bundles around the basaloid nests in the keloidal portion in the present case were not so prominent as KBCC previously reported.1,2,4 We suggest that maturation of collagen bundles in KBCC varies, possibly depending on the duration of the tumor or degree of perfection. Dermoscopy is a useful tool of diagnosis of BCC.5 The dermoscopic findings of KBCC have been unknown. In the present case, a keloid-like nodule revealed numerous arborizing vessels on the pinkish-white background without pigmented components. These vascular structures may be the diagnostic features of KBCC. The malignant potential of KBCC is not understood. KBCC histologically resembles morpheaform BCC. Misago et al.4 described that subclinical extension of KBCC is not as prominent as infiltrative/morpheaform BCC
(d)
(c)
Figure 1. (a) Clinical view. A nodular lesion with keloidal appearance (right part of the lesion) was accompanied by a semicircular, ring-formed, common type of basal cell carcinoma. (b) Dermoscopic examination revealed numerous arborizing vessels without pigmented components in the keloid-like lesion (upper right). The semicircular lesion demonstrated multiple blue-gray globules, large blue-gray ovoid nests and ulceration (lower left). (c) Histopathological findings of the keloid portion, border area and nodular portion. In the keloid-like lesion, the strands and cords of basaloid epithelial cells were embedded with eosinophilic, thick collagen bundles (K). In the border area, spiky tumor cell-nests also invaded into the deep dermis (B). The nodular portion demonstrated basaloid nests with palisading, which was consistent with the typical solid type of basal cell carcinoma (N) (hematoxylin–eosin [HE], original magnification 940). (d) Keloidal collagen bundles around the tumor in the keloid-like lesion. Eosinophilic, homogenous, sclerotic collagen bundles were observed around the tumor nests (HE, 9200).
428
© 2015 Japanese Dermatological Association
Letters to the Editor
because of the well-circumscribed, keloidal stroma containing neoplastic aggregations. The histological border of the keloidal portion was almost consistent with the clinical border of the lesion. No subclinical extension was seen in this case. The present case demonstrated a unique clinical manifestation in which a keloid-like nodule overlapped a nodulo-ulcerative BCC lesion. Accordingly, the keloid-like nodule of BCC might have arisen from the pre-existing nodulo-ulcerative BCC by mechanical stimulation of the back.
CONFLICT OF INTEREST:
None.
Kazutaka NAGASHIMA,1 Toshio DEMITSU,1 Toshinobu NAKAMURA,1 Satoshi NAKAMURA,1 Tomoko YAMADA,1 Maki KAKURAI,1 Naoka UMEMOTO,1 Takashi DOHMOTO,1 Ichiro IMAGAWA,2 Kozo YONEDA3
1
Department of Dermatology, Saitama Medical Center, Jichi Medical University, 2Imagawa Clinic of Dermatology, Saitama City, and 3 Department of Dermatology, Faculty of Medicine, Kagawa University, Takmatsu, Japan doi: 10.1111/1346-8138.12796
REFERENCES ~a MC, Pique E, Escalonilla P. Keloidal 1 Requena L, Martın L, Farin basal cell carcinoma. A new clinicopathological variant of basal cell carcinoma. Br J Dermatol 1996; 134: 953–957. 2 Lewis JE. Keloidal basal cell carcinoma. Am J Dermatopathol 2007; 29: 485. € er A. Keloidal basal cell carcinoma: 3 Jones M, Bresch M, Alvarez D, Bo not a distinctive clinicopathological entity. Br J Dermatol 2009; 160: 127–131. 4 Misago N, Ogusu Y, Narisawa Y. Keloidal basal cell carcinoma after radiation therapy. Eur J Dermatol 2004; 14: 182–185. 5 Menzies SW, Westerhoff K, Rabinovitz H et al. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol 2000; 136: 1012– 1016.
Case of syringotropic malignant melanoma with formation of a tumor nest directly below the primary tumor Dear Editor, Tumor cells of malignant melanoma can spread along the eccrine sweat ducts and invade the dermis.1–3 However, such syringotropic melanomas are rare and have been mentioned in few reports. Here we report a case of malignant melanoma with dermal invasion from within the eccrine apparatus. A 67-year-old man presented with a black nodule on his right foot; the nodule had been present for more than 10 years, but 2 months before presentation, it started growing in size and had ulcerated. A physical examination revealed a black nodule on the right medial malleolus, which was 30 9 20 mm in size (Fig. 1a). Dermoscopic findings showed black-to-bluish gray lesions with a whitish veil. Parallel ridge pattern was observed at the nodal margin (Fig. 1b). No distant metastasis was noted on computed tomography. The tumor was resected with a 15-mm margin. Because atypical melanocytes spread in the periderm of the sentinel lymph node, we performed right inguinal lymph node dissection, and no additional metastasis was noted. Microscopic findings showed atypical spindle-shaped melanocytes growing within the epidermis, which formed an irregularly sized nest along the junction; the dermal invasion from the junction into the papillary dermis was present. In addition, a discoid nest was observed in the reticular dermis beneath the dermal invasion from the junctional nests (Fig. 1c). Tumor cells in the dermal nest were slightly smaller than junctional tumor cells and showed atypia (Fig. 1d,e). Moreover, extensive tumor progression along the eccrine ducts in the der-
mis was observed (Fig. 1e,f). Tumor cells that invaded the dermis appeared to bridge the discoid nest and eccrine ducts (Fig. 1e, white arrow). All tumor cells (epidermal, dermal, and sentinel lymph node) were positive for melan-A and human melanoma black-45. Lymphovascular invasion was not detected by Elastica van Gieson and D2-40 at the primary site. The final diagnosis was acral lentiginous melanoma (pT3b, N1b, M0, Breslow’s thickness 2.7 mm). The patient subsequently developed lung and liver metastases; he died 9 months after the initial surgery. In situ tumor invasion along the sweat duct is rarely observed in acral lentiginous melanoma. The definition of syringotropic melanoma is melanoma spreading within the eccrine apparatus into the reticular dermis and/or subcutaneous tissue deeper than any associated (if present) invasive melanoma.1 Only three reports (22 cases) exist regarding malignant melanoma developing from within the eccrine apparatus.1–3 Furthermore, reports of tumor cells from the eccrine apparatus breaking through the basement membrane and forming invasive nests, as in the present case, are extremely rare.1 In syringotropic melanoma, tumor cells may be present along the sweat ducts up to the deep dermis even though the lesion is in situ. Therefore, removal of sufficient depth, including adequate adipose tissue, is preferred. Furthermore, melanoma invading from within the eccrine apparatus does not meet the criteria of Clark’s progression models and Breslow’s method of providing depth of the invasion. The American Joint
Correspondence: Takayuki Ishii, M.D., Department of Dermatology, Toyama Prefectural Central Hospital, 2-2-78 Nishinagae, Toyama 930-8550, Japan. Email: [email protected].
© 2015 Japanese Dermatological Association
429
(a)
ACKNOWLEDGMENTS: We thank Drs Eishi Takahashi and Takashi Hashimoto (Department of Dermatology, National Defense Medical College) for their kind cooperation, especially in collecting the patient’s information.
(b)
CONFLICT OF INTEREST:
None declared.
Misaki ISE, Takeru FUNAKOSHI, Yuki FURUICHI, Haruki HONDA, Yumi FUJIO, Masayuki AMAGAI, Manabu OHYAMA (c)
(d)
(f)
Department of Dermatology, Keio University School of Medicine, Tokyo, Japan doi: 10.1111/1346-8138.12809
REFERENCES (e)
(g)
Figure 1. (a) Yellow to brown, large, stiff plaque with multiple dark red papules, nodules and petechiae was observed on the right upper to lateral abdominal wall. (b) A close-up image of multiple, dark red papules clearly indicating that tumor recurred after the surgical excision. (c) Panoramic view showing multiple nodules irregularly invading into the fibrous septa and the lobules of the subcutis and the cords of cells infiltrating into the dermis (hematoxylin–eosin [HE], original magnification 940). (d) Irregularly anastomosing vascular structures lined with enlarged endothelial cells pervading between collagen bundles (HE, 9400). (e) Pleomorphic epithelioid cells with enlarged nuclei and substantial amount of mitotic figures (HE, 9400). (f) Tumor cells were positive for anti-CD31 and (g) antifactor VIII-related antigen staining (3,30 -diaminobenzidine-tetrachloride, 9200).
1 Albores-Saavedra J, Schwartz AM, Henson DE et al. Cutaneous angiosarcoma. Analysis of 434 cases from the Surveillance, Epidemiology, and End Results Program, 1973-2007. Ann Diagn Pathol 2011; 15: 93–97. 2 Reynold HM, Walker CG, Dunbar PR et al. Functional anatomy of the lymphatics draining the skin: a detailed statistical analysis. J Anat 2010; 216: 344–355. 3 Mizukami A, Taguchi M, Suzuki T, Tsuchida T. Angiosarcoma: a report of 260 patients based on a study conducted by The Japanese Association of Dermatologic Surgery, and review of the literature. Skin Cancer 2009; 24: 350–362 (in Japanese). 4 Masuzawa M. Angiosarcoma of the scalp: strategy and evaluation at the Kitasato University Hospital. Skin Cancer 2009; 24: 377–384 (in Japanese). 5 Yamazaki N. Therapeutic strategy for angiosarcoma in the National Cancer Center Hospital. Skin Cancer 2009; 24: 385–391 (in Japanese).
SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article: Table S1. Summary of 19 cases of angiosarcoma on the abdominal wall reported in the Japanese and English-language published work.
Keloidal basal cell carcinoma possibly developed from classical nodulo-ulcerative type of basal cell carcinoma: Report of a case Dear Editor, An 81-year-old Japanese woman presented with an erosive skin lesion on her back of 1 month’s duration. Skin examination demonstrated a solitary, pinkish nodule with ulceration, which measured 20 mm 9 10 mm, on the upper back. The lesion consisted of two parts: a large keloid-like portion and a semicircular, nodulo-ulcerative portion (Fig. 1a). Dermoscopic
examination of the keloid-like lesion revealed variously sized arborizing vessels on the pinkish-white surface without pigment components (Fig. 1b). In contrast, the nodulo-ulcerative lesion demonstrated the typical dermoscopic features of pigmented basal cell carcinoma (BCC) including multiple blue-gray globules, large blue-gray ovoid nests and ulceration (Fig. 1b). Histological features of the keloid-like lesion showed numerous,
Correspondence: Toshio Demitsu, M.D., Department of Dermatology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan. Email: [email protected]
© 2015 Japanese Dermatological Association
427
Letters to the Editor
basaloid tumor nests surrounded by homogenous, sclerotic collagen bundles (Fig. 1c). On the other, the semicircular lesion histologically revealed basaloid cell proliferation with palisading beneath the epidermis (Fig. 1c). The border area demonstrated that spike-like tumor nests of basaloid cells had invaded into the deep dermis. (Fig. 1c). The collagen bundles around the tumor cells in the keloid-like lesion were homogenous and thick, similar to early keloid (Fig. 1d). These characteristic findings were consistent with keloidal BCC (KBCC). The tumor was surgically excised with a 1-cm surgical margin under local anesthesia. The patient had no recurrence 7 months after tumor resection. Keloidal BCC has been described as a rare clinicopathological variant of BCC.1 Few cases of KBCC have been reported until now.1–4 The characteristics of KBCC demonstrate a keloid-like nodule, predominantly affecting the face, with the histological features of thick, homogenized, keloid-like collagen bundles intermingled with the basaloid tumor nests. Jones
(a)
(b)
et al.2 reported that eight of 1011 BCC showed thick sclerotic collagen. They concluded that KBCC was not a distinctive clinicopathological entity because keloid-like collagen in the stroma of the tumor could be observed in different histological types of BCC.1 Collagen bundles around the basaloid nests in the keloidal portion in the present case were not so prominent as KBCC previously reported.1,2,4 We suggest that maturation of collagen bundles in KBCC varies, possibly depending on the duration of the tumor or degree of perfection. Dermoscopy is a useful tool of diagnosis of BCC.5 The dermoscopic findings of KBCC have been unknown. In the present case, a keloid-like nodule revealed numerous arborizing vessels on the pinkish-white background without pigmented components. These vascular structures may be the diagnostic features of KBCC. The malignant potential of KBCC is not understood. KBCC histologically resembles morpheaform BCC. Misago et al.4 described that subclinical extension of KBCC is not as prominent as infiltrative/morpheaform BCC
(d)
(c)
Figure 1. (a) Clinical view. A nodular lesion with keloidal appearance (right part of the lesion) was accompanied by a semicircular, ring-formed, common type of basal cell carcinoma. (b) Dermoscopic examination revealed numerous arborizing vessels without pigmented components in the keloid-like lesion (upper right). The semicircular lesion demonstrated multiple blue-gray globules, large blue-gray ovoid nests and ulceration (lower left). (c) Histopathological findings of the keloid portion, border area and nodular portion. In the keloid-like lesion, the strands and cords of basaloid epithelial cells were embedded with eosinophilic, thick collagen bundles (K). In the border area, spiky tumor cell-nests also invaded into the deep dermis (B). The nodular portion demonstrated basaloid nests with palisading, which was consistent with the typical solid type of basal cell carcinoma (N) (hematoxylin–eosin [HE], original magnification 940). (d) Keloidal collagen bundles around the tumor in the keloid-like lesion. Eosinophilic, homogenous, sclerotic collagen bundles were observed around the tumor nests (HE, 9200).
428
© 2015 Japanese Dermatological Association
Letters to the Editor
because of the well-circumscribed, keloidal stroma containing neoplastic aggregations. The histological border of the keloidal portion was almost consistent with the clinical border of the lesion. No subclinical extension was seen in this case. The present case demonstrated a unique clinical manifestation in which a keloid-like nodule overlapped a nodulo-ulcerative BCC lesion. Accordingly, the keloid-like nodule of BCC might have arisen from the pre-existing nodulo-ulcerative BCC by mechanical stimulation of the back.
CONFLICT OF INTEREST:
None.
Kazutaka NAGASHIMA,1 Toshio DEMITSU,1 Toshinobu NAKAMURA,1 Satoshi NAKAMURA,1 Tomoko YAMADA,1 Maki KAKURAI,1 Naoka UMEMOTO,1 Takashi DOHMOTO,1 Ichiro IMAGAWA,2 Kozo YONEDA3
1
Department of Dermatology, Saitama Medical Center, Jichi Medical University, 2Imagawa Clinic of Dermatology, Saitama City, and 3 Department of Dermatology, Faculty of Medicine, Kagawa University, Takmatsu, Japan doi: 10.1111/1346-8138.12796
REFERENCES ~a MC, Pique E, Escalonilla P. Keloidal 1 Requena L, Martın L, Farin basal cell carcinoma. A new clinicopathological variant of basal cell carcinoma. Br J Dermatol 1996; 134: 953–957. 2 Lewis JE. Keloidal basal cell carcinoma. Am J Dermatopathol 2007; 29: 485. € er A. Keloidal basal cell carcinoma: 3 Jones M, Bresch M, Alvarez D, Bo not a distinctive clinicopathological entity. Br J Dermatol 2009; 160: 127–131. 4 Misago N, Ogusu Y, Narisawa Y. Keloidal basal cell carcinoma after radiation therapy. Eur J Dermatol 2004; 14: 182–185. 5 Menzies SW, Westerhoff K, Rabinovitz H et al. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol 2000; 136: 1012– 1016.
Case of syringotropic malignant melanoma with formation of a tumor nest directly below the primary tumor Dear Editor, Tumor cells of malignant melanoma can spread along the eccrine sweat ducts and invade the dermis.1–3 However, such syringotropic melanomas are rare and have been mentioned in few reports. Here we report a case of malignant melanoma with dermal invasion from within the eccrine apparatus. A 67-year-old man presented with a black nodule on his right foot; the nodule had been present for more than 10 years, but 2 months before presentation, it started growing in size and had ulcerated. A physical examination revealed a black nodule on the right medial malleolus, which was 30 9 20 mm in size (Fig. 1a). Dermoscopic findings showed black-to-bluish gray lesions with a whitish veil. Parallel ridge pattern was observed at the nodal margin (Fig. 1b). No distant metastasis was noted on computed tomography. The tumor was resected with a 15-mm margin. Because atypical melanocytes spread in the periderm of the sentinel lymph node, we performed right inguinal lymph node dissection, and no additional metastasis was noted. Microscopic findings showed atypical spindle-shaped melanocytes growing within the epidermis, which formed an irregularly sized nest along the junction; the dermal invasion from the junction into the papillary dermis was present. In addition, a discoid nest was observed in the reticular dermis beneath the dermal invasion from the junctional nests (Fig. 1c). Tumor cells in the dermal nest were slightly smaller than junctional tumor cells and showed atypia (Fig. 1d,e). Moreover, extensive tumor progression along the eccrine ducts in the der-
mis was observed (Fig. 1e,f). Tumor cells that invaded the dermis appeared to bridge the discoid nest and eccrine ducts (Fig. 1e, white arrow). All tumor cells (epidermal, dermal, and sentinel lymph node) were positive for melan-A and human melanoma black-45. Lymphovascular invasion was not detected by Elastica van Gieson and D2-40 at the primary site. The final diagnosis was acral lentiginous melanoma (pT3b, N1b, M0, Breslow’s thickness 2.7 mm). The patient subsequently developed lung and liver metastases; he died 9 months after the initial surgery. In situ tumor invasion along the sweat duct is rarely observed in acral lentiginous melanoma. The definition of syringotropic melanoma is melanoma spreading within the eccrine apparatus into the reticular dermis and/or subcutaneous tissue deeper than any associated (if present) invasive melanoma.1 Only three reports (22 cases) exist regarding malignant melanoma developing from within the eccrine apparatus.1–3 Furthermore, reports of tumor cells from the eccrine apparatus breaking through the basement membrane and forming invasive nests, as in the present case, are extremely rare.1 In syringotropic melanoma, tumor cells may be present along the sweat ducts up to the deep dermis even though the lesion is in situ. Therefore, removal of sufficient depth, including adequate adipose tissue, is preferred. Furthermore, melanoma invading from within the eccrine apparatus does not meet the criteria of Clark’s progression models and Breslow’s method of providing depth of the invasion. The American Joint
Correspondence: Takayuki Ishii, M.D., Department of Dermatology, Toyama Prefectural Central Hospital, 2-2-78 Nishinagae, Toyama 930-8550, Japan. Email: [email protected].
© 2015 Japanese Dermatological Association
429
