An 88‐year‐old Japanese female visited our department with an asymptomatic nodule on the right cheek. Other than treatment for hypertension for 15 years, the patient had been healthy. She had noticed the nodule one year earlier, and it had slowly enlarged to 25 × 25 × 5 mm, with redness, an irregular‐surface with ulcer formation, and was bony‐hard with no tenderness (Fig. 1). There were no regional lymphadenopathies. These clinical features suggested a soft tissue tumor or basal cell carcinoma. Histopathological examinations revealed that the tumor was visible from the upper dermis beneath the flattered and partly eroded epidermis, and showed atypical and pleomorphic tumor cells with large, irregularly shaped nuclei, and variable amounts of cytoplasm (Fig. 2). Some had bizarre nuclei, and occasional mitotic figures. These histopathological findings were suggestive of malignant fibrous histiocytoma. Magnetic resonance imaging showed that the tumor extended from the upper dermis to the subcutaneous tissue, was attached to the right maxillary bone, and involved the right orbit inferior margin. Apparent invasion to the bone was not seen. The tumor was resected and included skin, subcutaneous tissue, lower orbital adipose tissue, and fascia. A skin graft was taken from the thigh to cover the tumor resection. The resected tumor specimen measured 28 × 28 × 15 mm. Although the histopathological examination results were similar to the biopsy results, the tumor cells were arranged in irregular, intertwining bands, known as a storiform pattern in some areas, and focal necrosis was also seen. The tumor cells were markedly atypical with bizarre nuclei. Subcutaneous fat tissue was widely involved, and the tumor extended into the muscle tissue. In addition, the margin was positive for tumor cells in the deeper area of the tumor. Two weeks after the first operation, the patient had developed a small, firm nodule in the center of the skin graft that rapidly enlarged to form a 10‐mm tumor, which was likely the regrowth of the remaining tumor cells. A wide excision was considered, but because of her age and the extensiveness of the excision, containing maxillary bone, alternative treatment was pursued. Radiation therapy was performed five times per week, with a total dose of 60 gray. During the radiation therapy, the tumor enlargement stopped, and a skin ulcer on the grafted skin was made. The tumor started to decrease in size 1 month after the radiation therapy, and it continued to reduce in size until no tumor mass was seen by magnetic resonance imaging. No recurrence and no metastasis have occurred during the 3 years since cessation of the radiation therapy (Fig. 3).
1
Red, irregular‐surface with ulcer formation, and bony‐hard tumor on the right cheek
2
Histological sections of the skin biopsy specimen. (a) The tumor as seen from the upper dermis beneath the flattered and partially eroded epidermis. H&E ×40. (b) The tumor cells are atypical and pleomorphic, and have large, bizzare nuclei. H&E ×100
3
Clinical appearance 3...
