Letters to the Editor
(a)
Figure 1. (a) Gross appearance of the malignant melanoma. An irregularly pigmented nodule with ulceration is present on the medial malleolus of the right foot. (b) Dermoscopic findings revealed a nodal area exhibiting a nodule with black-to-bluish gray color with a whitish veil. A parallel ridge pattern was observed in the nodal margin, and irregular melanin discharge was confirmed. (c) Microscopic appearance of the malignant melanoma. Low-power view revealed tumor cell infiltration from the epidermis to the mid dermis. A discoid nest was observed in the reticular dermis beneath the junctional tumor cells. (d) High-power view of the junctional tumor cells. Atypical spindleshaped melanocytes grew within the epidermis and formed an irregularly sized nest along the junction. (e) High-power view of the black frame in (c). The tumor cells were slightly smaller than the junctional cells (d) and appeared to bridge the discoid nest and eccrine ducts (e, white arrow). (f) High-power view of the white frame in (c). Extensive tumor progression along the eccrine ducts in the dermis was observed.
(b)
(c)
(d)
(e)
Takayuki ISHII, Akiko TAKATA, Naohito HATTA Department of Dermatology, Toyama Prefectural Central Hospital, Toyama, Japan
(f)
doi: 10.1111/1346-8138.12791
REFERENCES
Committee on Cancer staging system does not mention treatment risks associated with sweat duct infiltration, indicating the need for future investigations.4
ACKNOWLEDGMENT: This work was partly supported by Japan’s National Cancer Center Research and Development Fund (26-A-4). CONFLICT OF INTEREST:
1 Zembowicz A, Kafanas A. Syringotropic melanoma: a variant of melanoma with prominent involvement of eccrine apparatus and risk of deep dermal invasion. Am J Dermatopathol 2012; 34: 151–156. 2 Kiryu H, Imayama S. Malignant melanoma cells in the eccrine apparatus. J Dermatol 2001; 28: 91–94. 3 Massi G, Vellone VG, Pagliarello C, Fabrizi G. Plantar melanoma that mimics melanocytic nevi: a report of 4 cases with lymph node metastases and with review of positive and negative controls. Am J Dermatopathol 2009; 31: 117–131. 4 Balch CM, Buzaid AC, Atkins MB et al. A new American Joint Committee on Cancer staging system for cutaneous melanoma. Cancer 2000; 88: 1484–1491.
None.
Multiple poromas following combination chemotherapy and autologous peripheral blood stem cell transplantation Dear Editor, A 63-year-old woman presented to our clinic in 2012 for evaluation of multiple red nodules on the abdomen and extremities. The lesions were asymptomatic, emerged from the right calf and had increased in number during the past 1 year. She had a history of acute myelocytic leukemia and was treated with
combination chemotherapy (idarubicin hydrochloride, cytarabine and prednisolone), followed by autologous peripheral blood stem cell transplantation in 1997. She was not under treatment at the time of the development of skin nodules. On physical examination, up to 12-mm, reddish, papillomatous, slightly pedunculated nodules were observed on her
Correspondence: Chiaki Takahashi, M.D., Department of Dermatology, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan. Email: [email protected]
430
© 2015 Japanese Dermatological Association
Letters to the Editor
(a)
(b)
(d)
(c)
(e)
Figure 1. (a) Multiple nodules on abdomen, bilateral legs and left forearm. (b) A 7-mm reddish nodule on the left calf. (c) The proliferative poroid cells filled dermal papillae connecting to the epidermis (94). (d) Ductal structures with cuticular cells (920) (e) and decapitation secretion are noted (940).
right thigh, lower abdomen, left forearm and bilateral calves (Fig. 1a,b). Excision of the two lesions was performed, and the histopathological findings of the right calf nodule showed wide exophytic well-demarcated tumor connecting to the epidermis (Fig. 1c). The rete ridges were irregularly elongated. The poroid tumor cells with ductal structures filled the papillary dermis (Fig. 1d), showing the typical features of poroma. On the other hand, the tumor on the left calf showed decapitation secretion (Fig. 1e), besides the poroid cells suggesting its apocrine origin. Poroma is a benign tumor composed of poroid cells of eccrine or apocrine gland differentiating into intraepidermal sweat duct. It usually occurs as a solitary nodule and multiple poromas are rare. Almost all reported cases of multiple poromas are of eccrine origin and only a single case of multiple apocrine poroma has been described.1 In our case, at least one tumor of the left calf showed typical decapitation secretion consistent with apocrine origin. However, without the positive findings such as decapitation secretion or connection to hair apparatus, the definite diagnosis of apocrine poroma is impossible, which would make the tentative diagnosis of “eccrine” poroma. Thus, the possibility remains that other lesions were actually apocrine poromas.
© 2015 Japanese Dermatological Association
Some cases of multiple poromas were based on congenital origin,2 others had the underlying diseases, mostly hematopoietic malignancies treated with various combination chemotherapy, radiation therapy as well as bone marrow or peripheral blood stem cell transplantation.3 These treatment modalities would induce damage to sweat ducts, and regenerations and remodeling of the damaged duct may be responsible for the development of multiple poromas.3 Local and/or systemic immunosuppression induced by treatments may also be responsible. This is consistent with the finding that radiationassociated multiple poromas develop on both irradiated and non-irradiated sites, and some poromas take a long time to emerge after these treatments.4,5 In conclusion, we described a case of multiple poromas including a tumor with apocrine differentiation. The patient had a history of acute myelocytic leukemia, for which combination chemotherapy and peripheral blood stem cell transplantation was performed. The hematopoietic malignancies and the treatment modalities may be responsible for the development of multiple poromas of eccrine as well as of apocrine origin.
CONFLICT OF INTEREST:
None declared.
431
Letters to the Editor
Chiaki TAKAHASHI, Kaoru NISHI, Masako MINAMI-HORI, Mari KISHIBE, Akemi ISHIDA-YAMAMOTO, Hajime IIZUKA Department of Dermatology, Asahikawa Medical University, Hokkaido, Japan doi: 10.1111/1346-8138.12794
REFERENCES 1 Hashizume S, Ansai S, Matsuoka Y, Omi T, Kawana S. Case of multiple apocrine poroma in a patient without receiving radiation or chemotherapy. J Dermatol 2014; 41: 174–175.
2 Wilkinson RD, Schopflocher P, Rozenfeld M. Hidrotic ectodermal dysplasia with diffuse eccrine poromatosis. Arch Dermatol 1977; 113: 472–476. 3 Fujii K, Aochi S, Takeshima C et al. Eccrine poromatosis associated with polychemotherapy. Acta Derm Venereol 2012; 92: 687–690. 4 Mahlberg MJ, McGinnis KS, Draft KS, Fakharzadeh SS. Multiple eccrine poromas in the setting of total body irradiation and immunosuppression. J Am Acad Dermatol 2006; 55: S46–S49. 5 Nguyen BT, Lortscher ND, Lee AR. Multiple poromas in a bone marrow transplant recipient: a case report. Dermatol Online J 2012; 18 (7): 9.
Erythema papulatum centrifugum developing around melanoma Dear Editor, Erythema papulatum centrifugum (EPC) was first-described decades ago by the Japanese dermatologist Watanabe. Here, we report an unusual case of EPC developing around a melanoma. The EPC even disappeared after the removal of the malignancy. A 35-year-old man had presented with a non-ulcerated pigmented plaque with a superimposed nodular area and heterogenous color on the back for the past 10 years. The nodule started to grow in size and evolve gradually in the preceding year. Also, an annular, erythematous rash had developed around the nodule (Fig. 1a). The gyrate erythema had disappeared and reappeared many times in the same region over 2 years, spread centrifugally each time, and was very recalcitrant to topical corticosteroids. The physical examination revealed a 3 cm 9 1.5 cm, asymmetrical, elevated nodule with variegated pigmentation over the back (Fig. 1b). A large, annular, erythematous rash, measuring more than 30 cm in diameter, composed of multiple interrupted small papules,
(a)
(b)
(c)
(d)
(e)
(f)
pseudo-vesicles and crusts at the margins was also disclosed (Fig. 1c). Histopathology of the nodule confirmed the diagnosis of melanoma, and the melanoma was staged IIA (pT3aN0M0). Histopathology of the annular erythema showed perivascular lymphocytic infiltrate and perieccrine inflammation with lymphocytes, plasma cells and mast cells (Fig. 1e,f). EPC was diagnosed based on relapsing clinical course, typical distribution, characteristic morphology and supportive pathology. Wide excision of the melanoma lesion was done with an adequate safety margin. Surprisingly, the EPC lesion completely disappeared a week after the excision (Fig. 1d). No recurrence of EPC was noticed during the follow-up period of at least 9 months. Erythema papulatum centrifugum is an unusual figurate erythema presenting as an annular rash with margins composed of grouped papules or papulovesicles, in which histopathology shows perieccrine inflammation.1,2 The exact pathogenesis of EPC is unknown and it may associate with male sex, summer time and hyperhidrosis.1,2 Our patient lived within the
Figure 1. (a) Preoperative view of the melanoma and erythema papulatum centrifugum (EPC). Close-up view of (b) the melanoma and (c) EPC. (d) Clearance of EPC after excision of melanoma. (e) Lowpower view of the histopathology of the EPC (hematoxylin–eosin [HE], original magnification 940). (f) High-power view of the marked area shown in (e) (HE, 9400).
Correspondence: Yi-Hsien Shih, M.D., Department of Dermatology, Shuang Ho Hospital, Taipei Medical University, 291 Zhongzheng Road, Zhonghe District, New Taipei City 23561, Taiwan. Email: [email protected]
432
© 2015 Japanese Dermatological Association
(a)
Figure 1. (a) Gross appearance of the malignant melanoma. An irregularly pigmented nodule with ulceration is present on the medial malleolus of the right foot. (b) Dermoscopic findings revealed a nodal area exhibiting a nodule with black-to-bluish gray color with a whitish veil. A parallel ridge pattern was observed in the nodal margin, and irregular melanin discharge was confirmed. (c) Microscopic appearance of the malignant melanoma. Low-power view revealed tumor cell infiltration from the epidermis to the mid dermis. A discoid nest was observed in the reticular dermis beneath the junctional tumor cells. (d) High-power view of the junctional tumor cells. Atypical spindleshaped melanocytes grew within the epidermis and formed an irregularly sized nest along the junction. (e) High-power view of the black frame in (c). The tumor cells were slightly smaller than the junctional cells (d) and appeared to bridge the discoid nest and eccrine ducts (e, white arrow). (f) High-power view of the white frame in (c). Extensive tumor progression along the eccrine ducts in the dermis was observed.
(b)
(c)
(d)
(e)
Takayuki ISHII, Akiko TAKATA, Naohito HATTA Department of Dermatology, Toyama Prefectural Central Hospital, Toyama, Japan
(f)
doi: 10.1111/1346-8138.12791
REFERENCES
Committee on Cancer staging system does not mention treatment risks associated with sweat duct infiltration, indicating the need for future investigations.4
ACKNOWLEDGMENT: This work was partly supported by Japan’s National Cancer Center Research and Development Fund (26-A-4). CONFLICT OF INTEREST:
1 Zembowicz A, Kafanas A. Syringotropic melanoma: a variant of melanoma with prominent involvement of eccrine apparatus and risk of deep dermal invasion. Am J Dermatopathol 2012; 34: 151–156. 2 Kiryu H, Imayama S. Malignant melanoma cells in the eccrine apparatus. J Dermatol 2001; 28: 91–94. 3 Massi G, Vellone VG, Pagliarello C, Fabrizi G. Plantar melanoma that mimics melanocytic nevi: a report of 4 cases with lymph node metastases and with review of positive and negative controls. Am J Dermatopathol 2009; 31: 117–131. 4 Balch CM, Buzaid AC, Atkins MB et al. A new American Joint Committee on Cancer staging system for cutaneous melanoma. Cancer 2000; 88: 1484–1491.
None.
Multiple poromas following combination chemotherapy and autologous peripheral blood stem cell transplantation Dear Editor, A 63-year-old woman presented to our clinic in 2012 for evaluation of multiple red nodules on the abdomen and extremities. The lesions were asymptomatic, emerged from the right calf and had increased in number during the past 1 year. She had a history of acute myelocytic leukemia and was treated with
combination chemotherapy (idarubicin hydrochloride, cytarabine and prednisolone), followed by autologous peripheral blood stem cell transplantation in 1997. She was not under treatment at the time of the development of skin nodules. On physical examination, up to 12-mm, reddish, papillomatous, slightly pedunculated nodules were observed on her
Correspondence: Chiaki Takahashi, M.D., Department of Dermatology, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan. Email: [email protected]
430
© 2015 Japanese Dermatological Association
Letters to the Editor
(a)
(b)
(d)
(c)
(e)
Figure 1. (a) Multiple nodules on abdomen, bilateral legs and left forearm. (b) A 7-mm reddish nodule on the left calf. (c) The proliferative poroid cells filled dermal papillae connecting to the epidermis (94). (d) Ductal structures with cuticular cells (920) (e) and decapitation secretion are noted (940).
right thigh, lower abdomen, left forearm and bilateral calves (Fig. 1a,b). Excision of the two lesions was performed, and the histopathological findings of the right calf nodule showed wide exophytic well-demarcated tumor connecting to the epidermis (Fig. 1c). The rete ridges were irregularly elongated. The poroid tumor cells with ductal structures filled the papillary dermis (Fig. 1d), showing the typical features of poroma. On the other hand, the tumor on the left calf showed decapitation secretion (Fig. 1e), besides the poroid cells suggesting its apocrine origin. Poroma is a benign tumor composed of poroid cells of eccrine or apocrine gland differentiating into intraepidermal sweat duct. It usually occurs as a solitary nodule and multiple poromas are rare. Almost all reported cases of multiple poromas are of eccrine origin and only a single case of multiple apocrine poroma has been described.1 In our case, at least one tumor of the left calf showed typical decapitation secretion consistent with apocrine origin. However, without the positive findings such as decapitation secretion or connection to hair apparatus, the definite diagnosis of apocrine poroma is impossible, which would make the tentative diagnosis of “eccrine” poroma. Thus, the possibility remains that other lesions were actually apocrine poromas.
© 2015 Japanese Dermatological Association
Some cases of multiple poromas were based on congenital origin,2 others had the underlying diseases, mostly hematopoietic malignancies treated with various combination chemotherapy, radiation therapy as well as bone marrow or peripheral blood stem cell transplantation.3 These treatment modalities would induce damage to sweat ducts, and regenerations and remodeling of the damaged duct may be responsible for the development of multiple poromas.3 Local and/or systemic immunosuppression induced by treatments may also be responsible. This is consistent with the finding that radiationassociated multiple poromas develop on both irradiated and non-irradiated sites, and some poromas take a long time to emerge after these treatments.4,5 In conclusion, we described a case of multiple poromas including a tumor with apocrine differentiation. The patient had a history of acute myelocytic leukemia, for which combination chemotherapy and peripheral blood stem cell transplantation was performed. The hematopoietic malignancies and the treatment modalities may be responsible for the development of multiple poromas of eccrine as well as of apocrine origin.
CONFLICT OF INTEREST:
None declared.
431
Letters to the Editor
Chiaki TAKAHASHI, Kaoru NISHI, Masako MINAMI-HORI, Mari KISHIBE, Akemi ISHIDA-YAMAMOTO, Hajime IIZUKA Department of Dermatology, Asahikawa Medical University, Hokkaido, Japan doi: 10.1111/1346-8138.12794
REFERENCES 1 Hashizume S, Ansai S, Matsuoka Y, Omi T, Kawana S. Case of multiple apocrine poroma in a patient without receiving radiation or chemotherapy. J Dermatol 2014; 41: 174–175.
2 Wilkinson RD, Schopflocher P, Rozenfeld M. Hidrotic ectodermal dysplasia with diffuse eccrine poromatosis. Arch Dermatol 1977; 113: 472–476. 3 Fujii K, Aochi S, Takeshima C et al. Eccrine poromatosis associated with polychemotherapy. Acta Derm Venereol 2012; 92: 687–690. 4 Mahlberg MJ, McGinnis KS, Draft KS, Fakharzadeh SS. Multiple eccrine poromas in the setting of total body irradiation and immunosuppression. J Am Acad Dermatol 2006; 55: S46–S49. 5 Nguyen BT, Lortscher ND, Lee AR. Multiple poromas in a bone marrow transplant recipient: a case report. Dermatol Online J 2012; 18 (7): 9.
Erythema papulatum centrifugum developing around melanoma Dear Editor, Erythema papulatum centrifugum (EPC) was first-described decades ago by the Japanese dermatologist Watanabe. Here, we report an unusual case of EPC developing around a melanoma. The EPC even disappeared after the removal of the malignancy. A 35-year-old man had presented with a non-ulcerated pigmented plaque with a superimposed nodular area and heterogenous color on the back for the past 10 years. The nodule started to grow in size and evolve gradually in the preceding year. Also, an annular, erythematous rash had developed around the nodule (Fig. 1a). The gyrate erythema had disappeared and reappeared many times in the same region over 2 years, spread centrifugally each time, and was very recalcitrant to topical corticosteroids. The physical examination revealed a 3 cm 9 1.5 cm, asymmetrical, elevated nodule with variegated pigmentation over the back (Fig. 1b). A large, annular, erythematous rash, measuring more than 30 cm in diameter, composed of multiple interrupted small papules,
(a)
(b)
(c)
(d)
(e)
(f)
pseudo-vesicles and crusts at the margins was also disclosed (Fig. 1c). Histopathology of the nodule confirmed the diagnosis of melanoma, and the melanoma was staged IIA (pT3aN0M0). Histopathology of the annular erythema showed perivascular lymphocytic infiltrate and perieccrine inflammation with lymphocytes, plasma cells and mast cells (Fig. 1e,f). EPC was diagnosed based on relapsing clinical course, typical distribution, characteristic morphology and supportive pathology. Wide excision of the melanoma lesion was done with an adequate safety margin. Surprisingly, the EPC lesion completely disappeared a week after the excision (Fig. 1d). No recurrence of EPC was noticed during the follow-up period of at least 9 months. Erythema papulatum centrifugum is an unusual figurate erythema presenting as an annular rash with margins composed of grouped papules or papulovesicles, in which histopathology shows perieccrine inflammation.1,2 The exact pathogenesis of EPC is unknown and it may associate with male sex, summer time and hyperhidrosis.1,2 Our patient lived within the
Figure 1. (a) Preoperative view of the melanoma and erythema papulatum centrifugum (EPC). Close-up view of (b) the melanoma and (c) EPC. (d) Clearance of EPC after excision of melanoma. (e) Lowpower view of the histopathology of the EPC (hematoxylin–eosin [HE], original magnification 940). (f) High-power view of the marked area shown in (e) (HE, 9400).
Correspondence: Yi-Hsien Shih, M.D., Department of Dermatology, Shuang Ho Hospital, Taipei Medical University, 291 Zhongzheng Road, Zhonghe District, New Taipei City 23561, Taiwan. Email: [email protected]
432
© 2015 Japanese Dermatological Association
