―討論とコメントー - drmtl.orgdrmtl.org/data/087120818.pdf · Cellular blue nevus Blue nevus Spindle cellnevus Nevus pigmentosus, intradermal Ne゛JSpigmentosus with Histiocytoma

口皮会誌:87 (12), 818-823, 1977 (昭52）

Ｃ　Ｐ　Ｃ

―討論とコメントー

(要旨は87巻２号に掲載)

司会　Graham, J.Ｈ･ (Univ. of California,Irvine)一

一

ｍ〃＆木　　吉　治（愛媛大）

セクレタリー　中　村　　絹　代（慶応大）

　CPC-1.　診断例，色素細胞の共生を伴う神経系細胞

の増殖症　伊藤一弘（自治医大）,鈴木重興（済生会宇都

宮）

　診断名（他の出題者からのもの）

Cellular blue nevus

　Blue nevus

Spindle cell nevus

Nevus pigmentosus, intradermal

Ｎｅ゛JSpigmentosus with Histiocytoma

Pigmented neurofibroma

Pigmented schwannoma

神経系腫瘍

Histiocytoma

？

8211

１

Ｑ乙1111

　三原基之（鳥取大）：ＷＨＯの分類によるblue nevus

(markedly cellular)とcellular blue nevus　との鑑別

点はどこか.

　　Dr. Graham's Comments:　Pathological Diagnosis:

　CellularBlue Nevus

　　Comments:　The microscopic features are some-

what unusual but the diagnosisof cellularblue nevus

is favored. This interpretationis supported by the

n1司orityof those individuals who studied sectionsof

the lesion。Most observers consider the terminology

of pigmented neurofibronia and pigmented srhwaii-

noma as being essentiallysynonymous with cellular

blue nevus.

　哩Ｃ４↓Desmoplastlc malignant melanoma

　真家興隆（東北大）


Malignantmelanoma

　desmoplastic

　amelanotic

Fibrosarcoma

６ＱＪ１７

　　　　Leiomyoblastoma　　　　　　　　　　　ｌ

　　　　Pseudosarcomatous squamous cell

　　　　　carcinoma　　　　　　　　　　　　　　ｌ

　伊藤一弘（自治医大）：ＤＯＰＡ反応はどうだったで

しょうか．

　真家興隆；患者臨床経過について，右下腿中央で切

断したが，半年後の昭和52年１月，レ線上，肺野に多数

のクルミ大までの陰影を発現．肺転移として化学療法を

行っている．ドーパ反応は陰性であった.


　Desmoplastic Amelanotic Malignant Melanoma

　　Comments:　It is apparent that those individuals

who reviewed the sections are divided in their opinions

regarding histogenesis of the tumor cells from neural

crest origin, mesodermal tissues or from squamous

keratin ocytes.　The absence of melanosomes, tono-

filaments and desmosomes reported ｎ･om electron

microscopic studies by the contributor leaves definite

origin of the tumor cellsin doubt. l stillfavor that

山ｅ lesion represents ａ desmoplastic amelanotic ma-

lignant melanoma but cannot rule out spindle cell

squamous　carcinoma　with　ａ　pseudosarcomatous

stromal response, fibrosarcoma, malignant fibrous

histiocytoma or neurofibrosarcoma. Metastasis to

由e groin supports the diagnosis of a malignant

neoplasm but does not help settle origin of the tumor

cells. The negative DOPA stain seems to rule against

the diagnosis of malignant melanoma. If fresh tissue

becomes available n･om metastatic lesions. l recom-

mend tyrosine incubation studies be done and posi‘

tive results would support the diagnosis of malignant

melanoma. In my experience, most primary nail

bed lesions which show ａ desmoplastic stromal re-

sponse turn out to be malignant melanoma.

　ＣＰＣ･3.　Alveolar　rhabdomyosarcoma　玉置邦

彦，兼島景次，吉田実夫（東京大）


　　　　Alveolar rhabdomyosarcoma　　　　　１７

　　　　？　　　　　　　　　　　　　　　　　　　2


　Alveolar Rhabdomyosarcoma

　　Comments:　ｌ concur with the vast majority of

　those individuals who reviewed the sections that the

　lesion represents an alveolar rhabdomyｏｓａｒｃＱｍａ･

　CPC-4.　頭部腫瘤　北浦弘幸，稲田修一，前田元道

　（広島大），松村茂次郎，安東誠一，魚住　徹（同脳外

科），児玉哲郎（同中検病理），林　雄三（同第二病理）


Metastatic carcinoma

Metastatic adenocarcinoma

Metastatic tumor

Rhabdomyosarcoma, alveolar

Rhabdomyosarcoma, embryonal

Malignant hemagioendothelioma

Malignant hemangiopericytoma

Papillary ependymoma

Cutaneous meningioma

431222311

　　稲田修一：①　レ線学的検索，及び手術所見から本腫

瘍は，骨に主病変があり，骨原発あるいは，転移性の骨

腫瘍が考えられた．現在まで諸検査で主病巣以外に原発

巣をみとめていない．腫瘍は割面でｰ一部出血をみとめる

も大部分は灰黄色充実性であった．組織学的に著しく多

量のグリコーゲン穎粒を腫瘍細胞が有しており, rhabdo-

myosarcoma, Ewing's sarcoma が疑われた．腫瘍の発

生部位，肉眼所見, pseudo-rosetteformation等の組織像，

電顕所見よりEwing's sarcoma と見倣した. Hemangio-

endothelial sarcomaとは，肉眼像, glycogen granuleを

多量に有すること，電顕的にfilamentous structureを

みないことから否定している．


　Ewing゛sSarcoma, Metastatic

　　Comments:　The diversityof diagnoses made by

those individuals who reviewed the sectionsare in-

dicative of the difficultyof establishingorigin of the

tumor cells by light microscopy.　Five individuals

interpreted the lesion as being of vascular origin and

two of these made the diagnosis of malignant he-

mangioendothelioma　which　is　synonymous　with

undifferentiatedangiosarcoma. Two of the review-

ing members feltthat the lesion was of neural origin

and an unusual neuroblastoma of peripheral nerve

origin would have to be considered. The sections

show some suggestion of ａ rosette pattern but not

CPC 　　　　　　　　　　　　　　　　　　　　　　　　　　819

typical as should be seen in neuroblastoma. Electron

microscopic studies fail to support vascular origin of

the tumor cells and tends to rule against the diagnosis

of angiosarcoma. The lytic skull lesion and presence

of considerable glycogen in the tumor cells favor the

final diagnosis of Ewing's sarcoma. E wing's sarcoma

and imdifferentia ted angiosarcoma can show some

similar microscopic features.

　ＣＰＣ･5･　側額部に生じた腫瘍（上皮性か非上皮性か

判断しかねる症例）松本圭祐，山懸貞造，山田瑞穂（大

阪赤十字）,佐々木正道（同病理）


Sarcoma

　Liposarcoma

　Myxosarcoma

　Rhabdomyosarcoma

　Angiosarcoma

Hemangiopericytoma

Epithelioidleiomyoma

Clear cellhidradenoma

？

641112121


　Fibrous Histiocytoma

　　Comments:　It is apparent that the Association

　members who reviewed the sections favor the diagnosis

　of some form of sarcoma. Two individuals favored

　the interpretation of hemangiopericytoma.　The his-

　togenesis of hemangiopericytoma and fibrous his-

　tiocytoma are close and features of both diagnoses

　can sometimes be seen in the same lesion. I still

　prefer the diagnosis of ａ fibrohistiocytic lesion and

　feel that it is benign but cannot rule out malignant

　fibrous histiocytoma.　The contributors' ultrastruc-

　ture studies showed junction bodies and tonofilaments

　and they favor the diagnosis of hidradenoma. The

　softtissue location of the tumor and my histochemical

　studies on sections which demonstrate reticular fiber

　hyperplasia about many of the tumor cellsrule against

　the diagnosis of any form of sweat gland tumor.

　Fibrohistiocytic cells can show junction bodies and

　perhaps the filamentous structures seen by the con-

　tributors might represent myofibriis which occur in

　pericytes.

　CPC-6. Glomus tumor 福田英三，今山修平，西

尾一方（九州大）


　　Glomus tumor　　　　　　　　　　　　16

　　　multipletype　　　　　　　　　　　　ｌ

　　　solitarytype　　　　　　　　　　　　　ｌ

　　Nevus spilus　　　　　　　　　　　　　　1

Dr. Graham's Comments: Pathological Diagnosis:

　８２０

　Glomangioma

　　Comments:　There is general agreement that the

lesion is of glomus cell origin and I favor the ter-

minology of glomangioma.

　CPC-7. Apoc万rine ducto-cardno:一犬ａ万三島　豊．

谷　昌寛，山本桂三，澄川康祐，市橋正光（神戸大）


Apocrine ducto-carcinoma

Apocrine carcinoma

Sweat gland carcinoma

Paget'sｄＩＳｅａｓｅ

Metastatic adenocarcinoma

C^I

CＯｌ1９4

1

　Dr. Graham°s Comments:　Patho】ogical Diagnosis:

Apocrine Ductocarcinoma

　Comments:　There is general agreement that the

lesion represents an apocrine carcinoma with pro-

minent ductal differentiation of the tumor cells.

The electron microscopic studies done by Dr. Yutaka

λdishima are convincing with regard to ductal origin

of the carcinoma cells. The presence of secretory

granules in the cytoplasm of the ductal carcinoma

cells account for the presence of considerable sial-

omucin　demonstrated　by　histochemical　methods.

This observation by Dr. Mishima of secretory granules

in ductal cells of the apocrine　acrosyringium re-

presents ａ significant finding which probably accounts

for the results of my histochemical studies on ex-

tramammary Paget's disease.　The presence of tumor

cellsin the patient's axillary lymph nodes support the

high biological potential for metastasis in malignant

　　　　　　　　　　　●　　●●neoplasms of apocrine origin.

　CFC-S. Cutaneous lｙ”・pholdhyperplasia?

原基之，山崎知行（鳥取大）


Cutaneous lymphoid hyperplasia

Malignant lymphoma

　lymphocytic

　polymorphous

　Mycosis fungoides

　Reticulosiscutis

　Lympho-histiocytic hyperplasia

　　　withmalignant potency

Parapsoriasisen plaques

Nodular vasculitis

？

″り９｀１１ｎ！Ｉ！

ＩＩＩＱＪ

一

一

一

　Dr. Graham゛ｓ Conin]ents: Pathological Diagnosis:

Cutaneous Reactive Lymphoid Hyperplasia Com-

patible with Disseminated Lymphocytoma Cuits

　Comments:　Classification　and　etiology　of the

patient°ｓdisease is difficult to determine and this is

apparent from those membｅｒs of the Japanese Der-

matological Association who reviewed the sections.

CPC

　Six individuals favored ａ benign reactive lymphoid

　hyperplasia whereas ａ total of eight called it some

　form of malignant lymphoma. Follow-up of the

　patient is important and this is often required to

　identify the true nature of this type of disease. When

　the clinical and microscopic features are correlated,

　the diagnosis of disseminated lymphocytoma cutis is

　favored.

　CPC-9.　Lymphomatoid papulosis の１例　加藤

三保子，杉山貞夫，神保孝一（札幌医大）


　　　　Lymphomatoid papulosis　　　　　　　l8

　　　　？　　　　　　　　　　　　　　　　　　　1

　加藤三保子：本症例に於いては四肢末端部の皮疹は，

丘疹以外に著明な発赤腫脹を伴っており，又，深く大き

な潰瘍を形成することが特徴である．この様な臨床症状

は，この間の本症の報告例に於いてごく稀に認められる

のみである.

　　Dr. Graham's Comments: Pathological Diagnosis:

　Lymphomatoid Papulosis

　　Comments:　The true nature of lymphomatoid

　papulosis remains ａmystery since the cytologic features

　are those of ａ malignant lymphoreticular process

　whereas the natural history favors a benign disorder.

　The uniform agreement regarding the diagnosis of

　lymphomatoid papulosis indicates support that the

　disease represents ａ clinicopathologic entity.

　ＣＰＣ･10･　興味ある経過を示したMalignant Ｌｙｍ･

phoma　青柳　俊，具志堅初男（北海道大）


Malignant lymphoma

　FoUicular lymphoma

　Reticulum ceil sarcoma

Malignant reticulohistiocytosis

Malignant histiocytoma

51111↓

―

　Dr. Graham's Comments: Pathological Diagnosis:

Malignant Lymphoma

　Comments:　It is obvious that the diagnosis of

malignant lymphoma is favored by the vast majority

of membｅｒs who reviewed the sections. Only ａ few

individuals made any attempt to classifythe patient's

disease　as　ａ　specific　malignant　lymphoreticular

disorder.

　CPC-11･　巨大な，下腿に生じたシリカ肉芽腫　小野

敏，吉井田美子，戸田　浄（東京逓信）


Foreign body granuloma

　Silicagranuloma

Necrobiosislipoidica

４３２

　　－

　Dr. Graham's Comments:　Pathological Diagnosis:

Necrobiosis Lipoidica

　　Comments:　l have reviewed the sections avail-

able for study on multiple occasions and stilldo not

find any evidence of birefringent particles as should

be seen in Silica granuloma when viewed under

polarized light. I am pleased that two members of

the Japanese Dermatological Association interpreted

the sections as necrobiosis lipoidica. The ｎｅｓａtive

studies and absence of ａ history of diabetes mellitus

favors the diagnosis of necrobiosis lipoidica. For com-

pleteness, the patienむshould be watched for the pro-

bable development of diabetes mellitus.

　CPC-12.　一種のHistiocytosis　仲村洋一，大槻典

男，福代良一（金沢大）


Histiocytosis

Multicentric reticulohistiocytosis

Palisading granuloma

　Necrobiosis lipoidica

Granulomatosis disciformis

　　　chronica et progressiva

χanthoma, plane

χanthoma, tuberous

Xanthomatous giant cell tumor

？

841141ワ｀１

９｀１１り４

　Dr. Graham's Comment's: Pathological Diagnosis:

Xanthoma　Secondary to Multiple Myeloma

　Comments:　The diversity of pathological diagnoses

supports the problem of classifying the patient's cut-

aneous disease as ａ specific disorder. Eight members

favored the interpretation of histiocytosis whereas the

majority of my colleagues in the United States who

reviewed the sections were uncertain about the exact

nature of the disease. This is ａ most unusual case

in my experience.　The follow-up information that

the patient has multiple myeloma favors the diagnosis

of secondary cutaneous xanthomatosis.

　CPC-13.　乳児に発症した疵賀状紅色苔癖の１例　早

川　実，村井　隆（京都大）


Lichen planus

　Lichen planus verrucosus

Lichenoid reaction

Pityriasislichenoides et

　varioliformisacuta

Histiocytosisｘ

？

３４１

４２５

　Dr. Graham's Oomments:　Pathological Diagnosis:

Lichenoid Dermatitis

　Comments:　The variety of diagnoses made by

CPC 　　　　　　　　　　　　　　　　　　　　　　　　　　　821

members of the Association support my difficulty in

arriving at a definite opinion about the patient's

disease. I stillhave doubts about the diagnosis of

any form of lichen planus but feel the features could

fit those of ａ lichenoid dermatitis such as lupus ｅｒy‘

thematosus or lichenoid drug eruption. Pityriasis

lichenoides et varioliformis acuta was the diagnosis

made by 柘ｕｒof the reviewers and ｌ should have

included this disease in the microscopic differential

diagnosis. Follow-up of the patient will be important

and continued observation of the natural history may

eventually identify the correct nature of the disease.

　CPC-14･　四肢の硬結性紅斑　猿田隆夫，大隈貞夫，

木村秀人，中溝慶生（九大温研）


Vasculitis,allergic

Vasculitis,necrotizing

　Periarteritisnodosa

　Vasculitis

　　　Nodularvasculitis

Superficialmigratory thrombophlebitis

Panniculitis

　χVeber-Christiandisease

　Erythema nodosum

？

4112111314


　Papulonecrotic Dermatitis

　　Comments:　Most of the individuals who reviewed

　the sections favored some form of vasculitis involving

　either the dermis or subcutaneous fat. My micro-

　scopic differential diagnosis supports the opinions that

　the patient has a primary vasculitis with secondary

　papulonecrotic　epidermal　changes.　This　type　of

　reaction can be caused by drugs, infectious diseases.

　biting　insects, and　systemic　disorders　including

　malignant lymphoma or leukemia.

　CPC-15.　有韓細胞癌を併発した持久性隆起性紅斑の

１例　出盛允啓，荒尾能喜（熊本大）


　　　　Erythema elevatum ditutinum　　　　　16

　　　　？　　　　　　　　　　　　　　　　　　　3


　Erythema Elevatum Diutinum

　　Comments:　There is general agreement about the

　diagnosis　of　erythema　elevatum　diutinum. The

　acute inflammatory cells and leukocytoclastic angiitis

　represents ａ paradox in this disorder since the lesions

　may be present for months to years･

　CPC-16. Granuloma faciale?|　田中雅祐．北村

征和，重見文雄（徳島大）


822

Granuloma faciale

PerifoUiculitis & folliculitis

Insect bite

711

1


Granuloma Faciale

　Comments:　There is general agreement on the

diagnosis of granuloma faciale which shows features

of leukocytoclastic angiitis somewhat similar to ery-

thema elevatum diutinum. An unusual feature of

this disease is the acute cellular reaction with neutro-

phils and eosinophils in lesions which have usually

been present for ａ long duration.

　CPC-17.　敗血症様症状を伴い，慢性に経過した血管

炎　荒田次郎（岡山大），高田真治（同第一内科）


Vasculitis, allergic

　　Periarteritisnodosa

　　Dermatitis nodularis necrotica

　　Malignant atrophic papulosis

　　Vasculitis

Pyoderma gangrenosum

　　necrosis

Bacterial purpura

i゛

512151112

　荒田次郎：皮膚の所見からだけは, allergic angiitis

とせざるを得ないかと思われるが，組織学的に好中球の

浸潤が少ない点が問題となる．経過その他の臨床検査所

見も通常のal】ergic angiitis と異なる．我々の'得てい

るevidenceだけからは結論的なことはいえないが，微量

細菌に対するreactiveなものとするのが最も考え易い

のではないかと考える.


Allergic Angiitis

　　Comments :　The vast majority of members favored

some form of vasculitis and five individuals agreed

with my interpretation　of allergic angiitis. The

etiology of allergic angiitis can be multiple and

varied and the nature of this patient's disease remains

uncertain although systemic disease most likely ac-

counted for the cutaneous eruption.

　ＣＰＣ･18･　一種の脂肪織炎？　浜田稔夫，長浜萬蔵

(大阪市大)

　診断名(他の出題者からのもの)

Panniculitis

　χVeber-Christian disease

　Erythema nodosum

　Cold panniculitis

Mucha-Habermann disease

Bacterial infection

？

9411112

CPC

　浜田稔夫：その後，前頭部の硬膜下に膿瘍が見出さ

れ，各種培養でＥ， c011が検出されたが，これも穿刺を

繰返しているのでcontaminationの可能性も考えられ

た．治療として抗生物質の投与にても効果はみられてい

ない. Corticoidの全身投与は行なっていない．３回目

の皮下硬結のbiopsyでもほぼ同様の組織像を示した

が，皮下の一部に血管（比較的大きな静脈）に血管炎の

所見がみられ, Erythema nodosum も考えている.


　Panniculitis Compatible with Erythema Nodosum

　　Comments:　Pannicu】itis　or　ａ　specific　disease

affecting the subcutaneous tissue was favored by １５

members. Follow-up of the patient may eventually

reveal the cause of the panniculitis. When the clinical

and microscopic features are correlated, I favor the

diagnosis of erythema nodosum which may be ａ

recurrent problem and does not produce ulcerative

lesions.

　CPC5-19.　Lichen planus?　橋本　淳（兵庫医大）


Lichen planus

Lichenoid reaction with

　neuromatous hyperplasia

Poikiloderma

Chronic Dermatitis

Secondary pigmentation

Lentigo senilis

Roseola pigmentosa

Erythema dyschromicum perstans

？

９

ＩＩＩりＪＩ1１11


Lichenoid Fixed Drug Eruption

　Comments:　The majority of those individuals

who reviewed the sections favored the interpretation

of lichen planus and ｌ cannot rule out this diagnosis

but favor the interpretation of lichenoid drug erup-

tion. Several diagnoses considered by the members

reflect the gross and microscopic characteristics of the

pigmentation。I favor that the neuromatous struc。

tures and smooth muscle bundles are normal for the

anatomical location of the biopsy which probably

came from the perianal area or scrotal skin.

　CPC-20.　大腿部に生じた癈痕ケロイド様皮疹　藤田

優，田辺義次，岡本昭二（千葉大）


Mucinosis

　Lichen myxedematosus

　Myxedema tuberosum

　　　circumscriptum

　Scleromyxedema

７り４

ＩＩ

Lupus erythematosus discoides

Lupus erythematosus profundus

Lichen sclerosuset atrophicus

Scar

？

41111


Lupus Erythematosus Profundus

　Comments :　Most of the diagnoses reflect the opini-

on of some form of cutaneous mucinosis and this sup-

ports my interpretation of lupus erythematosus pro-

fundus which　generally shows　an abundance of

hyaluronic acid in the ground substance of the dermis

and affected subcutaneous fat. Dermatomyositis can

show identical ground substance changes but deposi-

tion of immunoglobulins at basement membrane sites

and in the walls of blood vessels 亀vors the diagnosis

of lupus erythematosus profundus. A total of five

members made the diagnosis of lupus erythematosus

and in my experience the profundus type follows the

natural history of the chronic discoid or chronic

disseminate varieties of the disease.　Direct im-

munofluorescent studies of ａ tissue specimen from

CPC 　　　　　　　　　　　　　　　　　　　　　　　　　　　823

the lesion should be positive for immunoglobulins and

this would definitely support the diagnosis of lupus

erythematosus profundiis.

　General Summarizing Comments:　l wish to ex-

press my sincere appreciation to Professor Hitoshi

Hatano and Professor Toshiaki Yasuda for inviting

me to participate in the 76th Annual Meeting of the

Japanese Dermatological Association and for the

opportunity to serve as Guest Moderator ｎ)ｒthe first

Clinicopathologic Conference.　l also wish to thank

Professor Yoshiharu Miki and Dr. Kinuyo Nakamura

fi]ｒtheir fine assistance in preparing for the Clinico-

pathologic Conference. I congratulate those members

of the Japanese　Dermatological Association who

contributed such an outstanding group of cases which

truly challenged my knowledge of derma topathology.

The kind hospitality of Japanese dermatologists and

the opportunity to visit your beautiful country was

most gratifying to my wife and ｍｅ。

　　　　　　　　　　　　　JAMES Ｈ．GRAHAM, Ｍ,Ｄ。

　　　　　　　　　　　　　May ｌ６，1977

Documents

―討論とコメントー - drmtl.orgdrmtl.org/data/087120818.pdf · Cellular blue nevus Blue nevus Spindle cellnevus Nevus pigmentosus, intradermal Ne゛JSpigmentosus with Histiocytoma