Pigmented Precancerous and Cancerous Changes in the Skin
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Pigmented Precancerous and Cancerous Changes in the Skin V. R. Khanolkar, M.D. (From lke Tata Memorial Hospital, Bombay, India) (Received for publication May 20, 1947) The changes to be described here concern pig- The present study is based on tumors from 15 mented Bowen's disease, squamous-cell carcinoma patients seen by us during the last 5 years at the and basal-cell carcinoma of skin. They do not in- Tata Memorial Hospital. Four of them showed clude the group of melanoma, melano-epithelioma multiple lesions, and will be considered separately or melano-carcinoma, nor the pigmentation in from the rest. The following table summarises in- conditions sometimes leading to cancer, such as, formation regarding age, sex, location etc. in the senile keratosis, keratosis resulting from arsenic, remaining 7 out of the first group of 11 cases. tar or radiation and xeroderma pigmentosum. These tumors were all deeply pigmented and The changes described in this paper have not at- histologically presented the structure of a basal- tracted enough attention of dermatologists, and cell or a basal-squamous type of carcinoma. They Eller and Anderson (8) have stated that pig- were similar in so many features, that only 4 out of mented basal cell carcinomas were "quite un- 11 have been described as illustrating their prob- common." At a recent symposium on "Malignant able mode of evolution. Case No. Nationality Age Sex Site Duration Diagnosis 1 Muslim 45 M Chin 1 year Basal sq. cell ca 2 Parsee 60 M Scalp 5 years Basal cell ca 3 Hindu 38 M Leg Mole since childhood, recent Basal cell ca (Deccani) growth 3 weeks 4 Hindu 54 M Forehead 8 years Basal cell ca (Gujarati) 5 Parsee 73 M Nasolabial fold 4 years Basal sq. cell ca 6 Parsee 59 F Arm 6 months pigmented mole start- Basal cell ca ed bleeding 7 European 50 F Forehead 2 years Basal sq. cell ca Melanomata" in Leeds, England (4) the opinion REPORT OF CASES was expressed that, "It was surprising but true, Case 8. 4# 13052.--A 64 year old lean Parsee saw that these (pigmented tumors of epidermal origin) a skin specialist for a fungus infection of his feet are not recognised by the majority of pathologists, and one finger. He also casually referred to an and there is very little in the literature about them. "eruption" on the chest which was diagnosed as a But it is very important that they should be recog- "precancerous condition." The patient was there- nised, for the prognosis and treatment in these fore referred to the Tata Memorial Hospital. On cases is exactly similar to that of the non-pig- examination a roughly oval skin lesion was seen mented tumors of the same series and quite dif- over the right lower ribs in the nipple line. It had ferent from that of the melanomata. The im- started as a small dark spot several years back and portant point is for the pathologists to recognise had gradually increased in a circular spreading that pigment formation is a function of a group of manner. There was neither pain nor itching but a tumors other than the true melanomata". It has slight oozing of clear fluid from the surface. The been suggested that many melanotic tumors re- lesion was about 5 cm. in diameter. Its edge was ported to have been cured by local excision or raised, about 1 ram. wide, wavy and dark purple radiation were probably tumors belonging to this in color. It was clearly demarcated from the ad- group. It is known that some of these tumors jacent normal skin. The central portion was originate from pigmented nevi and without a smooth, glazed and pale pink. A cluster of few histological examination are not easily distin- raised pigmented spots was seen in the center. A guished from true melanomas. biopsy from the edge showed the characters de- 692 Downloaded from cancerres.aacrjournals.org on September 26, 2021. © 1947 American Association for Cancer Research. Khanolkar--Pigmented Tumors oj the Skin 693 FIG. 1.--Case 8.: A camera lucida drawing of a section dendritic processes of proliferated melanoblasts in epi- of the entire tissue removed by biopsy. The oval bud in the thelial buds. Silver impregnation. Mag. X 100. center is over the spreading edge of the lesion; and the FIG. 3.--Case 9.: Photomicrograph showing cords of healed atrophic skin is seen towards its right. Masson's proliferating epithelial cells pushing into the dermis. The trichrome stain. Mag. X 65. central bud shows an area of degeneration and necrosis in FI6. 2.--Case 8.: Photomicrograph showing a net- the middle with a debris of pigment granules and des- work of fine argentophil fibers formed by the numerous quamated cells. Hematoxylin and eosin stain. Mag. X 100. scribed below. The lesion regressed rapidly and chromatin material. There was a minute area of completely with four exposures of 600 r units daily surface ulceration over the epithelial bud. The (85 kv; 1 A1; T. S. D. 15 cms. and a total radia- epidermis of the normal skin showed widely sep- tion of 2400 r). arated short rete cones. The basal layer of cells Histological examination.--The biopsy piece was darkly pigmented with fine brown particles. (Fig. 1) consisted of stratified squamous epithelium In the healed area, towards the center of the clothing a fibrovascular layer of dermis. The lesion, there was a complete obliteration of rete epidermis was thinner than the normal for that cones and the epithelium was flat and thin. The region and showed towards the middle of the basal cells were without pigment. In this area the section a small oval bud of proliferated basal cells pars papillaris of the dermis showed a loose, ir- pushing downwards in the dermis. The peripheral regular texture of collagen fibrils, interspersed cells were columnar, contained large oval nuclei with arcades of newly formed blood capillaries and and a small amount of pale basophilic cytoplasm. foci of mononuclear cellular exudate. The pilo- These cells were arranged in a palisade. The more sebaceous structures were distorted and atrophic. loosely arranged central cells were smaller with The downgrowing bud was lying in a bed of con- round or oval nuclei containing sparse granules of centrically arranged lax, edematous collagen Downloaded from cancerres.aacrjournals.org on September 26, 2021. © 1947 American Association for Cancer Research. 694 Cancer Research fibrils. Focal accumulations of lymphocytes and gradually involved in the degenerative process of histiocytes were lying outside this zone. In sec- the cells towards the center. The proliferating tions impregnated with silver the epithelial bud buds of epidermal tissue lay in a broad sheath of showed the proliferating basal cells interwoven loosely arranged collagen fibrils. Subjacent to the with a large number of melanoblasts connected superficially ulcerated epithelium, there was a with a meshwork of fine argentophile fibers (Fig. rich cellular exudate of lymphocytes, eosinophiles 2) formed by the numerous dendritic processes of and histiocytes, between richly sprouting blood these cells. The elastic tissue net was absent in capillaries. the superficial zone of the dermis except along the Case 10. #E788.--An olive-complexioned 63 few hair sheaths and ducts of sweat glands. There year old Anglo-Indian physician had a small hair- were few macrophage cells loaded with coarse less mole on his right forearm lateral to the flexor brown pigment in the dermis. The section gave tendons, about 6 cms. above the wrist for "many, an impression of healing at the center and a spread- many years." The color of the mole was uniformly ing neoplastic edge at the periphery, consisting of black and it was smooth on the surface. About proliferated basal cells and melanoblasts. In the two months back he noticed that the mole had healed area the epidermis and the surface zone of begun to increase in size and to itch. The physician the dermis were morphologically' altered, but no attributed this to long hours spent every day in trace had been left of the neoplastic epidermal filling a multitude of army forms. He remembered cells. that the itching sensation began one night and the Case 9. # 14275.- A fair complexioned Parsee, next morning there was a slight erythematous 47 years old, had two small pigmented moles on area round the mole. The surface became rough his body "ever since he could remember." One and raised with a couple of weeping points exuding was situated over the middle of the right clavicle a clear pinkish fluid. No scabs were formed. As and the other in front of the upper third of the the mole rapidly doubled its size, the physician right arm. The latter was slightly' raised above consulted a surgeon who excised the mole and gave the surface, about the size of a lentil (5 ram.) and him a rather gloomy prognosis about his condition. surrounded by an areola of brownish skin roughly He saw us with his excised tissue. 2.5 cm. broad. About eight years back the mole on A naked-eye examination of the tissue showed a the arm began to grow in size and the surface superficially ulcerated, small (6 ram.) brown "broke into scab covered black fragments" Re- nodule raised about 3 mm. above the surface. On cently the fragments began to itch and weep. He cut section an ovoid, dark brown, firm mass clearly consulted a surgeon who excised the two moles stood out from the dermis. It was darker near its and sent the one from the arm to us for histological outer edges. The microscopic examination re- investigation. vealed a sharply circumscribed nodule of neo- Microscopic examination showed a picture plastic cells (Fig.