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rtuCH!G~.ll ?AT!IDLOGICAL SOOI:E:rY

SEl-llN.t'.R On DISEASES Of ~~~ SKIN

25 Septecber 1952

ELSOll ll. H&L.\HG, M.D. t'fashifi6ton, D.C .

St atler i!otel Detroit, ~ichlgUn

Case No. 1 : Submitte d by LA:illEllCE ~m. GAl!l».!ll!, ~l. ~.

~e 2at ient ~tered the ~-Ospital for r epair of an ingui nal hernia and removal of' a small r e ctal p ol:;.p . l n addi t i on, the.re ~<as a flat, nodular , p l aque- li!ce dull .red lesion o! i rregular outline on the anterior aspect of the thigh measuri ng 2 . 5 x 2 em. The cent er reveal ed areas of healing a.."ld t!le· ·per ipheral por tions zones of c rust i ng ..- In addition , there 'f!Ore. a fe\-t singl e flat pat-che,s at the border of tile main l e s ione s eparate<! by nor mal awearirig skin.. The ent ire lesion was e.xcised ..

'*4* ·

Case Ho. 2 : Submit too by WALTER A. STRYn!R , M. D.

A 68 ye..:u: ol d male had had a r eddened area uyon the ·prepuc e for s;J.x months . The lesion apparently disappeared on occa.sion only to recur . 'Ther e 1<as no p;Un. A clear fluid occasionally exuded from the a~oa. P~~sical e~amL~tio~ revealed a slightly el evated shiny plaque on tr.e prepuce in ~he re~ion of the corona sulcus , extending onto the gl ans ]lCn:.s , Oir~umcision including and area of thickening o£ tho mUc osa. that extended onto t·n~ glans penis was -performed.

.. .. Case No . 3: Submitted by ROBERT J. 'FROST, M. D.

The material represented here i s f rom_ a warty les;i.on encircling t'l>.e anus of a .50 years of age, white mELle.

Thia les ion is kno"" i;o have been present for at leas t e i ght y e1'I'a• rAvi ne recurr ed follo~ing ~urgery~~ that time . Tho lesions, Which ~re oJ a tH3·arly, g l isteni ne character . are slow growi~ , and Et%cept.: for local itching, they are a sY"'!>tomic . Careful examination hab f ailed to reveal an assoc i ated carci noma in this area.

*** Case. N<> . 4: Submitted by LAJ;!1!B!ICE liK GAF1lN:!lR, M. D.

'Phe patient !>.ad a r a i sed cutaneous mass over the f irs t lumbar -ver-tebra. for an oir.ht r.~onth !)oriocl , \l.'hich bad re'cently booome ulcer~ted and jnfectea. Examination disclosed ~ -olovated, nodular papillary rr.ass rr.casurL-,g 4 . 5 x J em. rai sed 1..5 em. al>ove t he surroul1d.i."!g tissue. 'i'ha tumor mo.s firm in consistency ~ some:wl-~t see.lloped on. the axtcrn·al bor der . In the central portion , mi Jtuto a:reas of ulcoratio.n ware- seen. Serial /section r..ovee.lcd a -:r-ello.\rlsh- grey, :firm Sttbstanco unaseoCiated: with gross degenerati ve chnnges. ':'ha p r ocess cl.id not ox;tol'.d i ntQ t be uncior lyin!!: subcutaneous tissuo. .

Case ND. 5: SUbmit. ted by OSBORNE A. :s!UKES. ~!.D.

The p11tient , a 49 year ol d colored "female came t o the lwspital because of bleedir.g :'rom a mass in the lef t thi~. :The oass had a·een tn:~esent :r"or 9 years and had incr·ea.sed in_ s :! ze in the las t :rear: Phys i cal examination revealed e 4 co . irregular vascular mass fixed t o skin on mecUa1 aspect of lef~ thigh. A ~A"ide r 8sec·t ion was done which included skin. super:f'ici.al fascia end fascia lata.

The specimen i s a ro~~v r ound p ortion of skin 9 em. in di~ter wi tb subcutaneous and adipose tissue. Ar ising from the approxi­mate cen tor of the s_pec"imcn i s a. nodular. firm, t an mass measuri.ng ) ex 3 x 4 em. On section it extends thro~ all the subcutaneous tissue.. I t is enc-apsulated end measures 4 x 5 em. on cross sec­tion. Ther e are no nodes or ll>!lsses in the adip~se tiss ue. The tu.~r is whorled, slightly nodular a~d tan to r ed- tan. It s trips of tt.s -ca:nsulo with ea.so .

Case No. 6: SUbmi tted by Eli OO.'lil. M.D.

The patient i s a 35 vear old white ll>!lle who had a blue pigmented l.esion of the left upyer arrn of unkno"'n durat"ion r emoved i ncidental to he-rnia repair ..

Crossly, ~he le-sion .ras excised with an elUpHcal shaped segment of skin measuring 2 . .$ x l em. ,.-,e underlying subeutancou~'> t iss-ue was ramovc.d t o a dep th of 6 mm. Centrally on the akin surface there was a flat 5 mm. ,area. of purple p igmentation.. On b-isecting the specimen thi s was found to lie deep i n the dermis . T'oe actual color was dark" 'black.

case No. 7: ~~bmittod by H.J. LINN, M.D.

The p<>tient is a 6o year old white male. A brO\•n l'.airloss O'.acule over ll>!llar pr ominenc e Jles oeen. !)resant for 20 yQars . Increased in size duri!lg past :3 weeks. lfo bleeding or pain. 3iol's ied .

*** Case No . 8 : Submitted by L~ G't.~ , l·tD.

The p<>tient i s a 42 year old waite male who had a small cystic and byperkeratotic lesion on the skin overlyi ng the l ef t Achilles. ten­don . Cl inicall y , the histor,r states that this appeared follow~ a lOcal infection. ~he lesion ~as observed over a ·period of t hree months dlll':!.ng ·which t ine it bec ame elevated and cor nified. It was removed with an c l -i_pse of surroundirag skin. Tho lcsinn \iS.S raised, sharply circumscribed, l"'le, gra.v aLd firm,

Caac !To . 9: Submitted by l!!l!!l.!ll lL !'IlilruS . K. D.

The ~atient i s e 21 year old ! omalc . Sho was in California in 19!!.9: Shortl y after r ctm-nino: devel oped tlorEatltis on l egs , arms, lovsr back. x-ra..v of chest '"-0.& r.e&ativo , no other tos t s dono . .. as d:!.agnoaeU. in Da·,ton, 'lhi o by dero>a.~ologis t as eoce!C:.iodoa.ve os i s. lesion on back and arcs cleared ¥itr~ut treatme~t . ihose on l eg s ~ersisted. Now J yoars l ater, discre te i nfil t rated plaquco , red .,itb l<hi thh atr ophic cent er s . liot painful •

••• Case No . 10: Submi H ed by !!. J , Lilli! , f.!. D.

Four yea:r old male with """'11 hnrd nodules on doraum of banda f or 1-2 weeks. !lon- tondor . li"9tive blo:>d count, urino. and pllotoro&n~n of chest. X-ray of hands negative .

••• C<lse I:o . 11 : SUbmitt ed by J . A. K..4,Sl'l!:R , H.D.

S1xt :r-one ;<rear o l d ••hi t e f emal e complain& of -painful Skl...'l lollions , headache , fever ar~ malai se, Onset . 2 wooks be f ore admission t o ho•potal, 4/J0/52. wos gradual.

On admission natient was apathetic and eomewhat ntu~rou&. Tomuera­ture ~as l02.~°F. fluetuati~ between 98.0 and l 02. 0°F . ~or about 5 ~. 2.1te>l'1'bieh it roceinod nor=! for a •.roe!: . Following biopsy the !ec::x>ro.ture rose ngnin a~d ls <:<>ntinu~ at 96. 0 ~o 102. 0 a\ present (4 davs ) .

'!'ho skin loeions consist of mnn,v bluis h • .,.aro, e levat e<'. 'V!Culo­]lB'Du.l.ar arona 'orlilich appoc:r L'!d.urnted . :'hose ere on the extensor surl2ces of tho arms. f oro=os nnd legs .

CalciUJll , sodilllll and phosphorur. e.r~ "ithln normal limi ts . Alkaline phospp.ataso 4 .3 unit" and acid pbosphatnoo 2 . 2 unito . teukocvte s 9400 to 12,500 ~it~ 8~ Pl~ (11~ N.?. ) Eoaino~ila nover above~·

••• Case No. 12: Sub:nittcd bv t;EFHAN K. Pil\10JS . M.D.

?ift:l- fivo vc= old fc=lc . ?our y.:;ers duration , right malar area indis tinct!.'· limited, as:mptol!lll.tic . smooth. Plnquo, bro'mhh-red , 11 X 8 nm. in e i ametor . Slow GTO'•Ith. no ulcer ation. No systemic diB&2.80 ,

\

caso !To. 1): Su.bm tted by R. JJ;Sbt.STIJffi, lot D.

Baby boy D. This 1600 gm. new born na1c wns bor n by Cesar i an section for pl?-coata ?TCVia. ~t.e c hild wno co~lotely covered by greatly thickened r~d fissured skin. ~~ o! the fissurcG "er e 1 em. l\cross . ~hero was b1latore.1 ectrop1M c.nd. miU'ked de=orai~y of the cnr s.. Mouth and anus ve:-o gaping. !'ingw-s ••or o clp.wl iko and ll.!'\~:yloacd. ~he baby di ed on tho fourth ~.

Tho llOthcr M.s ht!.d 2 n orc:\1 children, one child. et:lll:u- to tbe prosont Qno nnd a spontAneo~u nbortion.

Case llo . 14: Submitted by A. J AMES FREllCli. H. D.

':"he O:"t i ent was a 74 y eP.r ~ld white eple, n.ptive of Mich:i.g:'.D., ""~ho bad vhited in South C•.rolina in 1950. F.e had hr.d ~. "alivor • o!" "000. in the skin of the dorSUJ:l of t!lo l e f t wri,; t at tl"~t t ime . The •sU ..,er• .. .,unci hcalod but r <>-opened spont<meousl.v in October , 1951, nnd e nl arged unti l the entire vorruon1 l esion wno exci sed in Decem­ber, 1951. A cultlll'e was not obt.Unod. i:ltt'.minntion of tho pntient in Jrutll:lTY, 1952 1nd.ic nted thP.t tho entir e 1ec~ion h2d been e~cis"d r.nd no recurrenc e HSS ! ourtd.

• •• C:o.se llo . 15: Submitted bv llP3HAlf !. "Th'lrU", l·l. D.

R.T., )3 yo~r old m?Jc . Known of vesic les nnd bull~e v1th crustin' on neck f or 15 vorors . !'istcr i s !~. J. , 39 yenr f oul c. For w.ny ycnr& or.J.pt1.on on scalp . o.xillo.c , !)erincuo. In n.x_Uln.o looks l ike chronic ~nfoctioue cczemnto i d d.o=~titis.

DIAGNOSES St!lll~IT'l'ED

Case .Jl2.:..

1:

~·

4 :

6 :

8:

~ ·

10:

ll•

lJ.:

l b:

12•

Pt;.-:A:;"' RF.roRN TO: :&.R • .n;NlilFI"S, K.D. Rocoiving Hospital Detroit 26, !Uchigan

~Ilil<R Oli DISB:.SES OF 'I'!!E SKIN

l!lCl!IGJUi P.U""'!!OLOGIC SOCIETY

oondunted at

DE'lROI'l', liiCH !GAN

s~~ER 25, 1952

DR. ELSON B. BELN!G

ARMED FORCES lllSTITUTE OF PATHOLOGY

WASHTIIGTON, D. C,

3740

CI.SE 1

BW.SN1 S DISEJ.SE

Usually on annular or ser piginous soli·te.ry scaley dull red plaque. The growth i s slow (5-35 years} and :>.ost co('imon on the glabrous a~ Oecaaione.lly there are multiple plaques and ao~times central invoLution.

The histopa~hologic picture •hews hyperkeratosis b!!lt pe.rticu­ta r ly surface scal~s of f~n or many paraker&tctic cells accom­panied by a diminished granular oell layer of the epider:>.is .

TI1e e ?ide~is exhibits acanthosis with enlar ged, distorted and i rregular rete pess ll.!ld disoriented cells with disturb9d :>crn.s.l prcgro3sive layor3 of epidor~l maturation.

rrithlr. the epidermis t here are scattered abnorcal individual kor~~ini•ed cells , numerous mitotic fi6ures at all depths , multinucleated cells with "cl~mping" of the nuclei a.nd scattered vacuolated epi thelial cells.

!nere are dilated capillaries ~d infl~_atoty cell infiltration, chiefly lymphocytes , in the upper corium. Some les i ons e~entually develop into a squamous cell oar~inoma but the percentage is controvorsial .

Individual histologic changes obser ved i:l Bowen's disease may occur i n senil e keratosis, nrsenical keratosis and radiation kera<osis , sometimes necessitating both the g6oss (clinical} and hiotnlogio picture £or exact diagnosis .

Clinically, Bowen'o disease may be confused ~th psoriasis and superficial epithelicmatosis (multicentric superfici al bacal cell carcinoma}.

P.eferenoes

Bowen, J . T.: Precancerous Dermatoses, J. Cut . Dis . SO: 241- 255, 1912

stol..lt., A.. P.: Ualigne.nt :!G..."'lifesta.tions of' Bo-.von's Disease , Ne:w York State J . :.:ed. 39 : 801- 309, 1939.

3740

Ci<SE 2

ERY'l'ERO?Ll.SIA OF QUID"Rhl'

The section sham~ olnngntion and rld&ni.o1> of the rote rldgoa ocoompo.niod by olonglltion and ntUT011'ing of tho oocnocti:ve ~issue pnpilloo. The normal ~ongs ~f •he epidermis are indis­tinct 1<1. th loss of the ;;rcnulo.r layer lllld tho pros once of plaques or pnr Bk&rntosis (it is probnbl o thnt nost of tho parakerntotic pl aques hnve bcon rubbed off . ) The calls thr oughout the epidermis ore similur; ovll.l in shape, poorly outlined and possess rel~tively l:lr go hyperohro!Mtio round or oval nuoloi. loli totio figure'!~ =e pr esent nt c.ll depths. Occasionlll cells show n vncuolc.ted c yto­plns.n. <hly n rare focus of kerc.tinizod cells "i thin the opi derms is oo•orvod. In tho corium =d prineipc.lly in the pc.pillnry zone there is on infiltrntion of pl~ cells , lymphocytes and mono­oy'"..es . Tho copillc.ries tu:d venules C.r<l dilnted ll:ld bypereoic .

The ch~gea in the present sce~ion oro those of ~ precanea~ous lesion and so were th~se in ~~yrnt's original oeso. Neverthe­less aoco nuthoritios believe the procosz is not pree~corous but perhaps nro t~lking ebcut so~ o~cr typo ot lesion. 3ls­tologicclly ~he losion is s'»'lar in many respeo~e to Sor.on' s diso:>so but leeks tho indiridud karctinized ooll• ::.nd nru.ltinu-

ole<>ted oolls.

Siadlar lesions m~y occur on tho v"lv~ and on tho bucenl muoosa.

References

Queyn:.t, L. : ot Syph. 22:

Erythrophsio du glend, Bull . Soc . Franc de Dor:>o

378- 382, 19ll

Sul:bcrgcr 1

;.!. B., <::.:1d Sn.tcnstein. D. L. : Erythroplnsi:l of Que:);--rat, /.rob . Dern. a: Syph. 28: 798-805 , 1933

Stilos , F •• Jr. : Dom. & Syph. 50:

Er:rthro?l:>sia of tho GlO.!'lS ?onis {queyr:>~), .nreb. 647- 650, 19M

3740

c.;ss 3

Ellll~Y FAGSf ' S DISEASE

~ost common in the axil l ary, genit al and porian~l regions. Grossly ch~racterized by an eczematous , red, oometi~s weepi ng, , exoori~ted, sonley or l i chenif iod surfnoe .

Hist ologically distinct ive large pnle staining pl eomorphic cel ls aomatimoo rti th c. vacuolated cytoplnam !l.lld relnti voly lo.rge palo nuol ei (Pngot ce l ls) are present, The P~get cel lo appear discrete from and pnler than the epidermal calls. They occur singly or in smnll groups without i ntercellular bridges and in some instances nppeo.r to cocpress the adjacent epidermal cells or to be free in n ap:u:e . The Pnget cells, when fl!'lf in number , llrO usudly more nu:r.erous in the lOW'er epide=is and may in-.olvo particularly the outer l~ra of hnir follicles and ~ent ducts ,

Otherwise the epidermis ·~~ibits veriouo grades of aoc.nthosis . hyperkeratosis o.nd a distinct ;;ronulo.r cell lnyer.

In controot to 8o'r1en 1s disease ll..'ld carcinomt\ in situ, dy1lker:l­totic cella and oultinuole~ted apidormnl giant cells ~re absent.

The corium shows n nonspecif ic 1nflnmmntory infi ltr~te ond h¥Per emio.,

Paget's diseo.se must be di f f erent iat ed from Bowen ' s dise~se , lllllelanotio lll4ligno.nt melc..'loma, m9tc.st o.tio co.roincoa, and intrn­epidermAl epitheliottA of Jo.dcssohn.

ReferenQes

'F.'oiner, !!. ;.., ?!>get's Dis"'!>•• of the Sldn <'ltd its Relation to Co.rcinoe£:. of' the Apoc rine Scent Glon.ds ,. J·\I:j . J. Co.ncer. 31: 373-403, 1937.

Pinkus , H., and Gould, S. Introepidormt\1 Carcino~.

E. : ;;:rlrc."!lllml!ID.ry Pngot' s Disense nnd Iu-ch. Derm. & Syph. 39 : 479-502, 1939.

Forolcor, i~. G. and lliller,. : . J . ! of the Perianal Skin, Cancer 2 :

Extr~~ry Pnget' a Disease 144-152, 1949.

C,\SS 4

T!:c section shows a basal ce~ c-:rcinoon of the adenoid cystic t.-pc. It is cocpriscd o:' b2sal- likc :Glls o.!'wn arrar>.g;od in an 1dcnoid or ribbony patT~rn. Those arc occasional delicate sup­porting cores of connective tissue ~nd c~ppill!!rles travers~ng tho tumor, but m:::ny f ields are entirely opithelL!l. In sane pl~cos cells 1rc separc t ed by tenuous bluo staining m~tcrial ( scme ~uthori tios interpret this cb•one;e 'ts secretion) ' "d other col:s ~ru associ nted wi th minute m~seos of pink staining hyaline a"ltori11.

;,::.t~ou;;.'l tho pr ese::>t tu.nor runs to a slr.gl.e adenoid cystic type, it is not unco -!Wn to s ee this t •po of tunor mixed with c:-.e "hich shows solid foci a s \tell as tho so-ealloo oihr structures. 1h<- ~donoid cystic v:>rlety is often olcv~t.cd ond- sessile and ir. gc:;~ru shows little tendency to infiltr•te the corium :md st.:b­cut.sncous tissue.

T!dn tll.t:lOr is not to be confused with the clinical 3nd pdbo1ogic entity of "Epitt:cliC1lla Adenoides Cysticu:n" described cy Brooke.

References

B::-ooko, H. G.: Epi t helioma Adcnoides C.vsticum. Brit. J . Derm., 4; 269-286, 1928

Foot, ~. C.: r.dnexal C:u-cinoma of the Skin. .:.m. J . Path. 23: l-:<7 , 191.7 .

Kron:pcckcr, E .: Der Beos'llzell€nkrobs. G. Fisher, Jena, 1903.

Le~.::ox,B. l'..nd ;veils,;.. L. ; Diffcr.>ntiation in the Rodent Ulcer Group of Tunours, British J . of C-mc"-r, 5: 195, 1951.

Lo\·cr, W.: Pathogoncsis of Benign Tw:tors of Cut:m.,.~s !.ppond~ges lnd of B sal Cell Epitheliom'l . /,rch. O<;rm. and Syph. 57: 679-721. , 191.8 .

ilontgcmery, H. : Histogenesis of 93Sll Coll EpitheliQna. Radiology, 25: 8-23' 1935.

Tolch, H. '- · and Wheelock, cinom!l , 1\rch. Path. , 48:

ll . 0.: Hi~togoncsis of Basal Cell Cnr-447-1.61, 191.9.

CAlli 5

l.toJiliipbwoaUe, slowly progressive, reddish-blue , flat grawtl1s :>f the cutis and subeut.is which develop, sometimes rapidly, into large projecting nodular 4nd pedunculated, occasionally ulcerated, gay or red !i:m masses. ).(ost co!tl![)o on trunk and thorax b)rt. may occur on head, neck and extremities.

Histological~ the picture r anges !rom short bands of unifonn spindle-shaped cells which i rregularly interlace to spindle-shaped cells which fan out .from a central point or capillary like a cart ­wheel. T'~ cells are usually accompanied by a fibrillar str oma. In addition to irregular, sometimes numerous, vascular channels there are scattered well formed vessels present. Tr~ margins of the lesion generally are indefinite and marked by an intermingling of rat tissue cells and tuoor. Peripherally the tumor usually shows a -.rell developed collagenous strocA. 'Ibis is in contrast to fascial fibrosarcooas which tend to push the fat aside and show less dl..ffer­entiation peripherally. O~casionally myXooatou,...like change oec=s within tumors of this type.

In contrast to fibrosarcoma these lesions rarelY metastasize &).though recurrence is not uneoooon.

The dennatofibrosarcoma protuberans( JOssibly a misnomer) <!Ild dermato­fibro<na are probably closely related.

References

Binkley, G.: DcrJ:~atofibrosareoma ?rotuberans, Arch: or DEill:t. and S7Ph., AOl. 578-5'JQ, 1939.

Jioppor, C. and Pirtlrus, H.: D<>nnatofibrosareoma Protuberans •. o\n. J. Clio. ? 3\h. 20: 171-176., 1950

Pack, G. T. and ~Mh, =: . J : Oen:latofibrosarcoma Protuberans. A. 11. A. Arch. or Surgery, 62: 391-41.1, 1951.

3740

CASE 6

BLIJE lEVUS

Blua- black, blue or gray, f l at or he;:dspherical , indurated cutaneous papules .

Histologically t ho epidermis may show no change or a variabl e amount of a canthosis and either an i ncr ease or decrease in melanin pi!'l!!entation. '!he blue nevus is comprised of spl ....,, ,._ shaped melanoblast.s >lhich separate the llOlT.lBl collagen bundles of the corium. T' •« cells so:::eti.mes grow in illregular clw:>ps and often infiltrate about the sweat gland structures, but this latter appearance i s not an indication of c:alignant changes . 'Pe greatest nwnber o f melanoblasts is usually in the deep cutis although some­times tho rever se is true. Occasi onally a blue nevus i s combined with an intrademal nevus . I~ other variations the blue nevus i s ex traordinarily cellp:lar J..n !otming the so-called "ceUu.L::r blue nevus" 3nd relatively accelular in melanoblas t s when it nay be mistaken for a fibl'OI!U or nouro'fibr oma. Tho blue nevus must also be differentiated from tho derma tofibro= and malignant melanoma.

References

Ackerman, L. and Raga to, J . del.: Cancer Diagnosis , '1':-catnent and Prognosis , Ed. 1, St. Louis . 1947 . C. V. !!osby Co., p 170

Masson , P.: Ncuro-novi "blue". lt reh. tttie Vc.:chi" .ocr anat. pat . e 1!cd . Clin. 14: P• 1~28, 1950

J740

CASE 7

Over a considerable se@llent of the skin t.he epidermis and to sor.:.e degree the ad.,exal structures are atr ophic . In one area there is ?"l="ake:-atosis associated with an abse..'\t. granular cell layer. '!!:e nomaJ. rete ridges are absent, but irregular ridges of atypical acanthot.ic epidermis bulge in~ the Wlderly!..'lg coriuo. Sometimes tl:e basal cells are sepo.rated fr<lm the r emainir.g epidermis by a cystic space possi bly d ~-.. to edema . ~Jithin the enlarged irregular ridges tho eoi thelial cells tend to be disoriented and til ere are la.-&e pl.eoo:orphic o<:casionally multi.Jiuclea ted cells-not many but definitely present. Nowhere do the cells of tne epide rmal ridges actually i nvade the corium.

In some places, partie"ularl,y the basal. rc:n: of cells, there is ext~bited a r ather dense melanin pigmentation. This is not a :-ar e occur rence in association ~1ith senile ker atosis es­pecially at the margins of the lesion. Why the pigmentation OC<:'lrs is not known, but the change C!ly be :-elated to lentigo senilis. I t ie ·•ot to be confused \fith junctional nevus in l<hieh distinct nest s of nevus cells occur.

'It:e c.:>rium shD'>Is degeneration of the elastic tissue and mild chronic inflammn tion ,

'ffia senile keratosis is a precancer ous lesion lfhich oust "be d~~~erentiated from seborrheic ker atos1s(vcrruca senilis) , a non-precancerous one, and from senile l enti gines.

References

Ct!ro, !l . Jt. and Szyoanski, F. J. : Ker;ttoses, L!cd. Clinics of fl. A.-. .

C~wley, E. P. and Curtis , A. F. : Dero. & s;;pn. 62: 635-641, 1950

Seborrheic and Senile 35: 1-13, 1951

L-entigo Scnilis, Arch . of

Ct.sE 8

Toe section of skin shows a pointed papill!!ry grO¥Jtb of the cpidonnis vlith a depressed CUt>-Shaped base. ,.!though this is a co,.,-.on configurati on of the verruca vulgaris, the lesion is ktJOr.n uncar seve r al tern:s according to the location and shape (e. g., VGrruca digitata and verruca plantaris) .

Histolog.!.c.'! lly thora is mar ked a canthosis, hyperker atosis a nd pa.r akcratosi s which may appear as a single papi.ll?..ry projection or as a series of projections with coMeetive cores r3dinting in a fan s!l~pe from the b3se. Vacuolization 1ll!iJ' be prominent in tho prickle cell layor. B''sophille and acidophilic irregularly shnped cytoplasmic masses occur in the upper pri ckle cell zone and scrnetimes intrar.uclear inclusions. Above this a r ea the cells becon:e 2cido­pb!lic except for snail blue nuclei and form a pecG!iar type of pora­keratosis .

I nf'l.amnutory infiltr ate duo to secondary i nfection may bo present at the base .

Vcr ruc3 ?Lana juvenilis must be distinguished from lichen planus, epithelial nevus, a nd epidormodysp.lAsin verruciformis . ll:>lluscum contagiOS".lm is locAted within tho corium and the molluscum bodies are diagl".ostic .

T'-.e character istic a nd r~adily diagnosed ver ruca vulgaris is most c O!ll.'llon on the feet and ho3nds and in young people. I n older p€ople a nd elsc.:!lerc on the bod,y it may occ iU' as a papillilry or nat gro':'lth in which the cell inclusions arc indistinct or absent which renders diegnosis difficult.

Reference:

Strauss 1 !1. J . <1nd Bunting, H.: Virus-like Pnrticles Bodies in Skin P pillomas, J. of Invcstigativo Denn . 1950

Md Inclusion 15: 433-IJ.J ,

3'740

ChSE 9

:lECROi!I C6IS I.I?OIDIC.< D!Aa=;'i'ICORir.:

ClLlic -.ll,v oocrobiosis llpoidic~ di~bcticorum is characterized by =-t;lti pl e e:u-1;1 p'lpt.:l<>s ~nC. ol der yello" an:i violaceous f>l ·~.uas :o~oatl.y on the ext rcnities of diabetic(<)CI;g) 7-"ti~.-rt.s. Th~ les ion ::1ay occur bef or e the onset of t he sr-ptor.".s of diabet es mellitus .

:ii~tologic(llly the esse:lt.iu chan&e is in the corium. Tt.., c oll•gcn fibers shov: poorly demar cateci f oci of dogenera tion gnd hoaogcniza­t~on(m:-crobios!s) . E1 stlc fibers :.r e 3bsent within th~ necrobiotic i'~ci . Surrou.."ld.ing th:; areas o£ col.l.agen alteTatio!'l, Ulorc i s a Nnction of t!le connec tive tissue cells , but thls is seldcme so ~r.,rply defined os in grlnulo:n~ annular e . These a re a1oo i nfl..wr.matoey ce ll$ consisti tlg of l :;r..phoc;ttes , a fe11 pl.as:nil cells, monoc~tas , a nd !'~%'(; f'O!r-Orphonuiliar l~ukoc~-\.~s . n!"Wriol es 'l..'ld caplllaritS Sur­r ounded by ex-udate show s-.-:ollen onr.iotholi.'!l ccll3 .'!r.C tric,:cnir.(; . I~ so~n c ases complete obli~r~tlon occursa

':!:e Cegencrnted collag~n sh~s a fir.el y v-:~::olatod appcar:;._xc . Lipoids .r.ny be demonst r ated extraccllularl;r in gssociation >~ith t ho area" of degor.er lltcd collage:., a:1d t his demanst r etion aids in c :rrcrcnti ;ti.!'r~ the l esion !'ran granulox a:mu.L.vv . L'1 so::e cx::unpl es c f ;d rl:: m!l.r~\:!<i foreign body ginnt cell nu=ction occurs.

:to les ion I:lus t be ciistint;ui shed f rom gr3ilulcr.:a annul.arc, sarcoid, i:eyloi.Cosis , e:-yt!l\.tn3 i...:rtdur:ltt:n lnd ch~.ic.,l(bcrylli~) gr::ruloQB..

Hcl 11ig, E . B. : Surgoon, 109:

i!i!fercnccs

Chcmic31(Dcr:~llium) Gr~nul"""s o! Skin, The Hilitary 51.0-558, 1951

L'ymon, C. li . and Fisher 1 I . : ::.::crobiosis Lipoidic:!(Di,beti corun) :.rch. o f Dern. & Syph. 59: 150-164, 1949

CASE 10

Gr anuloca annulare is characterized by an elevated mdule or &rou;:> of nodules occurring cost frequent.l,y in the skin of the dorsu:n of the fingers, hands, feet, ankJ.os , wrists, buttoc!c and neck.

Hi~tologically the cor ium in a well developed l esion shows areas cf necrobiosis surrounded by c onnective tissuo cells often arranged in paliS3da fashion. Tr.o palisaded layer of cells is continuous with connec tive tissue irrogularly oriented. I .1 c.grly l esions th-ro m1y bo little or no necrobiosis and only fibrobl•stic and in!~~mltory cell reaction .

.1 !'c1< lyophocytes and rue poJ.3norphonuclc3r l eukocytes are pres ent, p.3rticulnrly in the perivascular areas of the arteriole s. S:>oo of t:>o arterioles show fairly marked thickening wherE>as otbcrs shw. little change. S::>::10 l esions witb mucicarmine stains she" the presence of muein in the connectiv<l tissue in the region of +.he areas o~ ::ccrosis. It is claia:ed tr<!lt tilLs obscrv~tion is of value in di!fcrcntL~ti.~g gr..aul0:1a annulare frcn necrobiosis llpoidica dia­boticoriWI>. The ch,nges are similnr to thoso observed in a r be\lllatoid nodule, but the latter is usually in tho subcutis or deeper.

Prun ty, F. C. and JJ.:mtgorery, H. s Gr~nulom:~ Annular e, Clinical and P · tnolo;:,.i.c .. l s Lucy, Arch. Detm. >~nd S:1 r.h . M; J94, 1942.

CAS& 11

Tho histologic ch~mgos nrc co:U'inod chiefly to tho doopor cutis :>nd tho subcutis . The oonnectivo tissue se pta of tho subcutis ~rc tr~ckecod by fibroblnstio proliforetion noco~~od by in­fil~r~~ior of infl~tory colla inoludL~g ~ lymphooytos, polYQorpho~ouclenr l oukocJtas, hiotioc>~• and multinuclo~~d foreign body gi~t col l a. Tho lnttor comnonly onco~ssos pink oollulcr nntoriol or vceuolcs. Tho mnrgins of tho sopt~ and tho included lobules of fat show mnny f at oolls repl ncod by pho.gocytio histiooytcs among tho r ot calls. Sm:lll ::u-torios and i.~ pnrticulc.r c.rterioles show t.':lickot'.ing =d ondothelic.l proliforc.ti=• 1n sn:::o plcces within tbe intor lobulor s o pte. t.~o ro o.ppocrs to bo necrosis of collo.gon..

Histologically orythcmn nodes~ is to bo difforentiot od fro~ orythoma indur~tum bv the ?r osenoo of n tuberculous rooction in tho lo.tter disoc.so. r.,c microaoopio ;>icturo in orytho!T-" nodosum. nodular non-suppurcti vu panniculitis (Wobor-Christi~ Dioocso), ond nodular vcsculitis is osscnti~ly s1milor.

Rctoroncos

Montgomery, H. , 0 1 l.oory1 P. J... , nnd Bnrkcr , !1. W. : Nodulo.r Vasculo.r Disoo.sos of tho Logs , Erythema lnduro.twn o.nd Al liod Conditions. 128! 335, 1945

l!umphroy, J. B. nnd Po.gcl , if. : Tho Tis suo Response t o !loot-Killed stl"Cptooocci in tho Skin of llor=l Subjects, ond in ?orsona with Rhe~tic Fcvor, Rhe~toid " rtbritis , SUbo.eutc Bo.ctorio.l Ecdo­o·.rditis ru1d Erythomn !lodosU!l, Brit. J . o£ Exporimontc.l Po.th., U!Z- 288, 1949

Fronoh, .~ J . : Hyporsonsitivity in tho Pathogenesis of the 3istopo.thologio Changes Assoointed \nth Sul!'on=ido Chomothoro.py, iol!SJr. J . of Po.th . ZZ : 579- ?01, 1945

5740

C!..sE 12

GRIJ-.11LO:.lf, FACIAIE

Histologic oxccino.tion o.f tho skin sh"''" o.n cssontitl.lly nor=.l epider.nis be:>c:1th ?thieh is n nnrra.• plc.to or nonar.l corium. Bonenth this non:>nl •nno c.nd oontcrcd in the c:idoori=. extend­ing to 1:hc subcutis, is o.n infln=tory in.filtr:>tc w?dch =uses :1 cild thickening or tho COriU.":lo The in.flruor..:>tory cells CO!lSist o~ polynorp~onuolo~r l oukooytoa (soma eosinophilic ) , lY3Phocy-.cs , ~nocytos, pl~scn colla o.nd histiooytos . Tho distribution is irra&.Uo.r ::.nd :>at uniform o.ncl ao1:10ti!:Jes there <>re ::inutc clusters of ooo cell typo . n. taw Russel oolls c:-c noted and are c or:sidered to bo nonapoeifie . t;outrophil1o leukocytes nrc sot:'!Ct~s but not nl~ys disposed in porivuscu!Ar collnrs nnd this is bes~ obsc~ o.round tho clHr.tocl c-.pill•.rios nwcy from the =in cxuclntc. ::.=.f of tho ~pill~rios and nrtoriolos exhibit only clil~tction nncl s~ollcn onclo~~olium without npproci nb!c ic~iekcning. In c. fer i.nstta~cos tho w:>ll of tho vc asol shO"i'ts pink stnining hyz.l;no =tcri<>l which extends into tho pcrivnscul~ c.rca.

Thas lesion nlao hna boon c~llod oosinophilic gr~ulo~, ~non­s;>coific t om which is confusing with tho other so- ctl.ll ed eosin­ophil ic grnnulomuo of s£1n ~cl other org~s.

G.ranul Om:> rncialo iB to bo d.ifforonti!lt od f r om 1nsoot bi to o.nd r oticulohistiooytomn.

rho present section nlso contains o small intr<>do~l nevus .

Roforcnoos

Zoe , F. G. : Roticulohistiooyto~ ("Gcnglincuro~") of tho Skin British J. ~r ~rm. & Syph. 62 : 351-355, 1950

Buloy, H. Y..: Eooicophil Gr'l.nulomo. of tho Skin, J. Invest. Dorm. 7: 291 , 1946

Cobonc, J. R. , Stra ith, C. L, ~d Finkus, R.: with Bosinophilio, I.r<:h. of Dorm. a: Syph . 61:

•

F4Cinl Grenulo~s 442-454, 1950

374{)

CbS£ 13

CONGEHr<bL ICRiHYOSIS

Iho aoction of fetal skin shows mass1vo byporkcrntosis associated with hypertrophy ru':d po.p1ll::.r.f foJ:"CO.tion of tho epidermis . Rotc ridgoa tend to be o longt:.tod or.d tho oponingo of tho pilnscbo.ooo• s npporet usea ~ro widened end filled with horny antoriel. Tno epide rmis is clo~rly diff~rentiatod into tho usual loyor s including o w~ll dofinod str~tum gr~ulosum (somo outhoritios ·~ n well dcfi."'od str!lt\0:1 gr anulos um is pnsont only on tho s col p) . Sobo.oe ous glnnds , sweat glP~:td.s. and hair folliolos nro pres oct and sh~v no ~bnormnlitios other than can bo oooountod for by the hyporkor~totic onc~so~nt.

Tho ho.irs c.ro cncor.!p<issod in horny nntorinl which sug~s;;s th:>t both o ro propelled cutwcrd togethe r and oro sooowh~t tangled no o.r t ho surfeoo. The connective tissuo po.pillt10 of the ccriu=. oro elongated nnd con1:~i.!l dilntod eepill:nrlos . Focally tho stror..o. in tho oori= is quite oollulc.r but thor o ia :.o opprocic.blo in­fl~~tory ooll infiltration.

Iho ci~tor of the section i ncludes o fiosuro whore tho opido~s is rolotl.voly thi."'. '!'be underlying cnpillt.rios do not exhibi t :l-3 much hyporomic. a.s is usua.lly obsor·10d :)t the sito of !l fissure .

This typo of oongonitnl i chthyosis is tho most severo. Other l os a sovoro typos lmvc been dcsi gnntod c.s tho mild tuld tile lnto typon of oongcni tnl ichthyosis ond ichthyos i s simpl ex .

Somo oxrumplos of ichthyosis must be diffcrontioted fro~ epithol iol no•ri {Gpi thGlial M.mar tom.s) end f r om Jcorntosis pilc.ris .

P.cforcncos

ai:Jonda , !!. w. ond Dolcn, w. D. : Iohthyosio Congonitn ?atalis , Severo Typo (!Inrloquin Fetus) The Bulle tin of tho IntenntioJOel i.ssocintior. of lled. Uuseums , 32: 1- 21, 1951

3740

CASE 14

CHR~OBLASTOMYOOSIS

The cpidornti.s of tho skin shows notioo:.blo nonnt hosis '01 th irrogu­hr prolif•nntion of the r ;>to rid~es into tho corium md on tho aurfnco hyporkoratoais c~ pcrnkoretos!s. Bcnoeth the ncentnotic opi thalium tho coriwn is thickened by atrcmnl prolifc=tior, m. thin which ther e is nn infl"-""'tltor y infiltrnto, Thor o io a diffuse infiltrntion of gm..'lul:>r loukoeytcs , lyt>phocytcs :uld pl :ur:. colla as woll ns fce~l nbscos sos of leukocytes and ocCQSionclly ~~ti­nuclo".tod giant oolls . Within soma bt' tho obscessos thoro oro chrocatic cells of o fungus like those chrocoblostocycosis ,

hs n gonor~l rule in tho mycotic gr~~uloE~S1 ovon if tho organisms c.re so sc~-ec c.s to cscopo i:.:::~Cdi:1to dotoction. tho prosonco ot suppurntiyc or grnnulo~~tous i~£l~tion and cxtonsivo noenthosis or psouclo- opitheliomntous hypcrplc.sin nlm1ys cpponru ca squr..moua hyper?lnsin except oeoesionnlly nbout hair follicles ~horo ~~ o.ppco.ro.nco is JLC}ro bt.-sel in typo .

Psoudo-opitholio~tous h;~orplnsia ~y be produced by nnny diffo r­ont ngont,, Ex-mp1oG oro nycotio granulo~s, granulo~ inguin~c , bromide grcnulomo.s, tor oign bodies rutd opidormul inclusions.

Chromoblnsto~oosis is CClUsod by three different fungi end mny bo nodul~r, ~orrucou~ psorias iform nnd oi cntr icinl , Histol ogi ­oolly tho picture is gr-~ulo~tous. ~liory abscesses ClTO common but miliary gro.nulooo.s and varying dogree 3 of fibrous =Y occur, Tho brown or black orcsoont s hopod ~~d roundocl oodios , singly or in clusters ~ro oh~rnoteristic .

Rc..foronccs

Binford, o. H., F~ss , G, ond Emmons, C, W, : Chromoblnstomycosis, Ar ch. Dor:n. « Syph. 49 , 398-402, 1944

Woidmo.n, F. D, nnd Rosonth:1l , L. H. : Chr mr.obla stomyeosis: A Uo·r. end Ir>portcnt Blc.ctomycoois in ll<>rth J~norio<>; Report of o. C!lSc in Philodelphic., .!.rch. Don:;. 4: Syph. ~: 62 , 1941

Pardo- Ca.stollo, V. : Rio Loon, E., and Trespnlc.cios , F. : C!lromo­blnstoJ:,YCoSis in Cubn, t.rc!:. Dorm. it. Syph. 45: 19, 1942

3740

cas:.: 15

Fl.UILilJ. EElliGN CHRONIC l'H!!'l'RIGUS

A .frequently !~llitll bullous 1nd vesicular dt!J:matiti.s ..irrrolvill8 nostly the neck, axilLle M~d flexors.

'i!!n s~cti~n of the s!dn is e~acterized by ~he presence o! fissuring lacun~o or bullae within tho epidermis ~ccC>:lfl.:lnied by !l lllild .:.nflam.­Jll)torj· reaction. The bullae commonly involves an approcbbk !X>tA:h of tr.~ eoidcr:nis . Both the b~se and roo! bf tho bullae 3re iomod by ~!:~ o!>idcr.:lis with the r oof scxoet.imes being ruptured and covered ~ith ~ crust of serum and loukocytes . The b~se is cov.er~d b7 one or mcro l'ty<>r s of epithelial colls <>rranged 1!\ cxag@"'rated or enlarged r ete ~idgcs v:hich extend into th" coriwu p roducill8 " villous pattern. CorJJ'ctive tissue P"Pillie support :md SCJ>"..T:ltc the abnor1Ml rete r.:..c t;~s . Thc~o pap~c together 11i th the iJ:-Clcdi!Jte coriu::l frequc.ntj_y era .adcmatous, mildly congcstd lnd in!iltr .gted wi th in!l>~r.~.~tory cells ine:~::U.ng lymphocytes , pl:!.sma cells ~nd pol.y:norphonuclc~r leukocytes (soc.~ eosinophilic) . The hair follicles in the inv<>lved ~rc~s m.~"' show ~t;r~p::y.

Somo of the cpithel i>l cells of the m~rgins o~ the bullae sho11 ncantho-2.~sis, ell.ilcr sl.n~ or in sruUJ. groups, ancL occnsionall,y cells become shr-.!!l<(en. Ther e is little or no tendency to the forcatlon oo 1 -u-ge "ko::-:t7.inized11 cclls(corps ronds) as s een in Daricr' s Disease. A few ir1ilru-...m:t tory cells mny be pr<:sont i n the bull:te and the contiguous cpi­tt.ol!.un.

F,-.il!.al benign c!-.ronic p=mphigus and kor;~tosis CollicuLuis 'Ire con­sidered by some to be vari.~nts of ~ single di sease and by others ns separ,t c processes . Likewise some consider f~lial benign chronic pe=!phigus to be ~ v•ric ty of pemphigus .

Senile kcr .ltosis arrl squamous cell c:1rcinanas ma,y :tlso sho11 lncunae ~or:r.~tion histologicnlly and must be differentinted !ron f .'lllliJ.i.:tl ben!;;" chronic peaphigus.

Roferoxes

l'r:ld{, S . 3 • .:~nd Rein, C. R. : Dyskcr :ttoid Dcrm.:ltosis., i. rch . Berm. and Syph., L5: 129, 1942.

iiailiy , H. nnd H:tilcy, H.: Fnmililll Benign Chronic Pemphigus , 39: 679-685' 1939.

Levar , Vt . F. ; P=phigus, f • • U. " · -'rch . Dern:. nnd Syph.. 64: 72:1-753, 1951.

Pels, I . R. ~nd Good!:an, H. H.: Cr i t e r ia for tho Histologic Diagnosis of Kerntosis Folllcul.ari.s(Darier) 1 39: 438-455 , 1939.