Letters to the editor

discontinued because of frequent polymicrobial infections. Treatment of HIV-infected psoriasis patients should be tailored based on disease severity and the input from an infectious disease specialist.2 Biologics may be given with a favourable benefit/ risk ratio provided the patient’s underlying HIV infection is controlled (CD4 count of >200/lL).9 H. Saeki,1,* T. Ito,1 M. Hayashi,1 O. Fukuchi,1 Y. Umezawa,1 Y. Nobeyama,1 K. Teruya,2 H. Nakagawa1 1

Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan, 2AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan *Correspondence: H. Saeki. E-mail: [email protected]

References 1 Lee ES, Heller MM, Kamangar F et al. Long-term etanercept use for severe generalized psoriasis in an HIV-infected individual: a case study. J Drugs Dermatol 2012; 11: 413–414. 2 Menon K, Van Voorhees AS, Bebo BF Jr et al. Psoriasis in patients with HIV infection: from the medical board of the National Psoriasis Foundation. J Am Acad Dermatol 2010; 62: 291–299. 3 Aboulafia DM, Bundow D, Wilske K, Ochs UI. Etanercept for the treatment of human immunodeficiency virus-associated psoriatic arthritis. Mayo Clin Proc 2000; 75: 1093–1098. 4 Linardaki G, Katsarou O, Ioannidou P et al. Effective etanercept treatment for psoriatic arthritis complicating concomitant human immunodeficiency virus and hepatitis C virus infection. J Rheumatol 2007; 34: 1353–1355. 5 Mikhail M, Weinberg JM, Smith BL. Successful treatment with etanercept of von Zumbusch pustular psoriasis in a patient with human immunodeficiency virus. Arch Dermatol 2008; 144: 453–456. 6 Bartke U, Venten I, Kreuter A et al. Human immunodeficiency virusassociated psoriasis and psoriatic arthritis treated with infliximab. Br J Dermatol 2004; 150: 784–786. 7 Sellam J, Bouvard B, Masson C et al. Use of infliximab to treat psoriatic arthritis in HIV-positive patients. Joint Bone Spine 2007; 74: 197–200. 8 Cepeda EJ, Williams FM, Ishimori ML et al. The use of anti-tumor necrosis factor therapy in HIV-positive individual with rheumatic disease. Ann Rheum Dis 2008; 67: 710–712. 9 Paparizos V, Rallis E, Kirsten L, Kyriakis K. Ustekinumab for the treatment of HIV psoriasis. J Dermatolog Treat 2012; 23: 398–399. 10 Umezawa Y, Nobeyama Y, Hayashi M et al. Drug survival rates in patients with psoriasis after treatment with biologics. J Dermatol 2013; 40: 1008–1013. DOI: 10.1111/jdv.12531

Primary mucinous carcinoma of the skin with in-transit metastasis Editor Primary mucinous carcinoma of the skin (PMCS) is a rare cutaneous tumour derived from the sweat glands.1 About 150 cases

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of PMCS have been reported, and the prognosis is known to be relatively good.2 The local recurrence rate has been reported to be 30–40%3; however, distant and regional lymph node metastasis occurs only rarely. Moreover, no well-authenticated case of in-transit metastasis in PMCS has ever been reported. Herein, we describe the first case of PMCS with in-transit cutaneous metastasis. A 60-year-old Japanese woman presented with a 1-year history of a slow-growing nodule on her left eyebrow arch. Physical examination showed a slightly reddish nodule measuring 5 mm in diameter (Fig. 1a). No regional lymph node was palpable. A biopsy specimen showed small cellular nests of adenocarcinomas lying in pools of extracellular mucin that were separated by fibrocollagenous septae (Fig. 2a,b). The tumour cells were diffusely positive for cytokeratin (CK) 7 (Fig. 2c), epithelioid membrane antigen (EMA), oestrogen receptor (ER) and progesterone receptor (PR), but negative for CK20 (Fig. 2d). Furthermore, they were slightly positive for p63 (Fig. 2e) and focally positive for Gross cystic disease fluid protein-15 (GCDFP15) (Fig. 2f). Neither mucinous carcinoma of other visceral organs nor any metastatic spread was detected by complete examination, including positron emission tomography–computed tomography, gastrointestinal endoscopy, mammography screening and ultrasonographic examination of the mammary glands and major salivary glands. From these findings, we made the final diagnosis of PMCS. The tumour was completely excised by using the modified Mohs micrographic surgical technique that we described previously.4 At 2 years after the primary operation, another indurated nodule measuring 3 mm in diameter appeared on the left cheek (Fig. 1b). This nodule was also removed completely, and the surgical specimen led to the diagnosis of mucinous carcinoma of the skin. We performed wholebody examination as before. However, we were unable to detect any regional lymph node metastasis or other organ metastasis. Finally, the nodule on the left cheek was diagnosed as in-transit metastasis of PMCS. The patient has been doing well and has had no recurrence for 3 years. Only one case of PMCS with suspected in-transit metastases has been described in the English literature5; however, the authors, Bang et al.,6 pointed out that the uncharacteristic histology of positive staining for CK20 and negative staining for CK7 was inconsistent with PMCS. In our case, the fact that the tumour cells stained positive for CK7, ER, PgR, EMA, p63 and GCDFP-15, but negative for CK20 mostly suggested that the lesion was mucinous carcinoma of primary cutaneous origin. Several reports on lymphatic drainage in the human face have been published. Nijhawan et al.7 found that the lymphatic flow in the eyebrow area was destined for the submandibular lymph nodes. In our case, a secondary lesion occurred in a lymphatic stream that was identical to that of the primary lesion (Fig. 1c). We concluded that the cause was in-transit metastasis of PMCS.

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Figure 1 (a) Clinical manifestations of the skin lesion at first referral. A 5-mm-diameter tumor is seen on the left eyebrow. (b) Clinical manifestations of the skin lesion at 2 years after the removal. A 3-mm-diameter tumor is seen on the left cheek. (c) Schematic of lymph flow on the face. †: primary cite of PMCS; *: in-transit metastasis of PMCS. Both are in the same lymphatic flow that is destined for the submandibular lymph nodes.

Figure 2 Histological findings of the primary skin lesion. A surgical specimen shows small cellular nests of adenocarcinomas lying in pools of extracellular mucin that are separated by fibrocollagenous septae. (a) Hematoxylin and eosin; scanning image. (b) Hematoxylin and eosin; original magnification 9100. Immunohistochemical findings. The tumor cells are strongly positive for CK7 (c), and negative for CK20 (d) (original magnification 940). They are slightly positive for p63 (e) and focally positive for GCDFP15 (f).

In conclusion, we herein reported the first conclusive case of PMCS with in-transit metastasis. We should bear in mind that it is necessary to follow-up for not only local recurrence but also in-transit metastasis in PMCS.

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E. Homma, H. Hata,* S. Aoyagi, H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan *Correspondence: H. Hata. E-mail: [email protected]

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Letters to the editor

References 1 Mendoza S, Helwig EB. Mucinous (adenocystic) carcinoma of the skin. Arch Dermatol 1971; 103: 68–78. 2 Breiting L, Christensen L, Dahlstrøm K et al. Primary mucinous carcinoma of the skin: a population-based study. Int J Dermatol 2008; 47: 242–245. 3 Weedon D. Tumors of cutaneous appendages. In: Houston M., Davie B., eds. Weedon’s Skin Pathology. Elsevier, Amsterdam, UK, 2009: 757–807. 4 Aoyagi S, Hata H, Homma E et al. Controlling the histological margin for non-melanoma skin cancer conveniently using a double-bladed scalpel. J Surg Oncol 2010; 101: 175–179. 5 Jih MH, Friedman PM, Kimyai-Asadi A, Goldberg LH. A rare case of fatal primary cutaneous mucinous carcinoma of the scalp with multiple

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in-transit and pulmonary metastases. J Am Acad Dermatol 2005; 52: S76– S80. 6 Bang RH, Bang R, Padilla RS. Case of fatal cutaneous mucinous carcinoma of the scalp with multiple in-transit and pulmonary metastases unlikely to have been of primary cutaneous origin. J Am Acad Dermatol 2006; 55: 726–727. 7 Nijhawan N, Marriott C, Harvey JT. Lymphatic drainage patterns of the human eyelid: assessed by lymphoscintigraphy. Ophthal Plast Reconstr Surg 2010; 26: 281–285. DOI: 10.1111/jdv.12533

© 2014 European Academy of Dermatology and Venereology

Primary mucinous carcinoma of the skin with in-transit metastasis.

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