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choosing follow-up visits only&#46; Two years later&#44; he presented again with erosion of the right hallux&#46; Physical examination showed widespread erosion of his right hallux&#44; which in part had a reddish nodule&#46; The nail had completely disappeared &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Histological examination revealed many atypical cells infiltrating irregularly from the epidermis to the dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; These atypical cells were immunoreactive for MART-1 and HMB-45&#46; For the same reason as before&#44; the patient and his family wanted only local symptomatic treatments at a nearby hospital&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Merkel cell carcinoma &#40;MCC&#41; is a rare cutaneous neuroendocrine cancer that is known to be a highly aggressive malignancy with frequent metastasis and a high mortality rate&#46; A previous review article revealed increased risk of a second primary cancer after the diagnosis of MCC&#44; and cutaneous malignant melanoma &#40;MM&#41; is one of the most common cancers after MCC&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Miller and Rabkin reported that occurrences of MM and MCC were similarly increased with sun exposure and immunosuppression&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Considering that ultra violet &#40;UV&#41; rays attenuate systemic immune responses <span class="elsevierStyleItalic">via</span> the induction of regulatory T-cells&#44; systemic immunosuppression may be an essential factor in the development of both conditions in a patient&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In the present case&#44; MCC occurred on the left cheek&#44; and MM occurred on the right hallux&#46; In Japan&#44; the majority of MM cases occur on the edges of limbs that are not directly affected by UV rays&#44; and external irritation has been considered one of the risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; systemic immunosuppression associated with aging and&#47;or UV irradiation may be a common cause of both conditions in the present case&#46; According to previous articles&#44; several cases in which MCC and MM developed in a patient have been reported from countries other than Japan&#59; however&#44; to the best of the authors&#8217; knowledge&#44; this is the first report of its type from Japan&#46; Interestingly&#44; there was a report of a case of MCC that developed in a patient during treatment with immune checkpoint inhibitors for MM&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> Given the increase of immune checkpoint inhibitors used to treat MM&#44; the number of cases in which both MCC and MM develop in a patient may increase in Japan&#44; as well as around the world&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#39; contributions</span><p id="par0015" class="elsevierStylePara elsevierViewall">Masato Ishikawa&#58; Drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Toshiyuki Yamamoto&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Letter
Malignant melanoma after treatment for Merkel cell carcinoma
Masato Ishikawa
Autor para correspondência
ishimasa@fmu.ac.jp

Corresponding author.
, Toshiyuki Yamamoto
Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 98-year-old male was referred complaining of a mass on his left cheek&#46; He had never received immunosuppressive therapy&#46; Physical examination showed a solid&#44; dome-shaped&#44; reddish tumor&#44; 35&#8239;mm in diameter&#44; on his left cheek&#46; Microscopic examination of a biopsy specimen revealed an infiltrative tumor in the dermis&#46; The tumor was composed of sheets and trabeculae of atypical cells with scant cytoplasm&#44; and round nuclei with stippled chromatin &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Immunohistochemistry results revealed that the tumor cells stained positive for cytokeratin 20 and neuron specific enolase&#46; The patient underwent total resection of the tumor&#46; However&#44; because of the patient&#8217;s advanced age&#44; neither the patient nor his family wished further treatment&#44; including radiotherapy&#44; choosing follow-up visits only&#46; Two years later&#44; he presented again with erosion of the right hallux&#46; Physical examination showed widespread erosion of his right hallux&#44; which in part had a reddish nodule&#46; The nail had completely disappeared &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Histological examination revealed many atypical cells infiltrating irregularly from the epidermis to the dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; These atypical cells were immunoreactive for MART-1 and HMB-45&#46; For the same reason as before&#44; the patient and his family wanted only local symptomatic treatments at a nearby hospital&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Merkel cell carcinoma &#40;MCC&#41; is a rare cutaneous neuroendocrine cancer that is known to be a highly aggressive malignancy with frequent metastasis and a high mortality rate&#46; A previous review article revealed increased risk of a second primary cancer after the diagnosis of MCC&#44; and cutaneous malignant melanoma &#40;MM&#41; is one of the most common cancers after MCC&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Miller and Rabkin reported that occurrences of MM and MCC were similarly increased with sun exposure and immunosuppression&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Considering that ultra violet &#40;UV&#41; rays attenuate systemic immune responses <span class="elsevierStyleItalic">via</span> the induction of regulatory T-cells&#44; systemic immunosuppression may be an essential factor in the development of both conditions in a patient&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In the present case&#44; MCC occurred on the left cheek&#44; and MM occurred on the right hallux&#46; In Japan&#44; the majority of MM cases occur on the edges of limbs that are not directly affected by UV rays&#44; and external irritation has been considered one of the risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; systemic immunosuppression associated with aging and&#47;or UV irradiation may be a common cause of both conditions in the present case&#46; According to previous articles&#44; several cases in which MCC and MM developed in a patient have been reported from countries other than Japan&#59; however&#44; to the best of the authors&#8217; knowledge&#44; this is the first report of its type from Japan&#46; Interestingly&#44; there was a report of a case of MCC that developed in a patient during treatment with immune checkpoint inhibitors for MM&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> Given the increase of immune checkpoint inhibitors used to treat MM&#44; the number of cases in which both MCC and MM develop in a patient may increase in Japan&#44; as well as around the world&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#39; contributions</span><p id="par0015" class="elsevierStylePara elsevierViewall">Masato Ishikawa&#58; Drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Toshiyuki Yamamoto&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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