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Disseminated superficial actinic porokeratosis and squamous cell carcinoma: a report of two cases
Letters
to the Editor
[lo] Dupre A, Christol B, Bonafe JL et al. Pachyonychie congenitale. Description de 3 cas familiaux traitement par le retinoide aromatique. (RO 10.9359). Ann Dermatol Venereal (Paris) 1981;108:145-149.
7
Disseminated superficial actinic porokeratosis and squamous cell carcinoma: a report of two cases
with elevated hyperkeratotic borders and atrophic center on the legs and forearms. There was an infiltrated cutaneous horn on the distal third of the right forearm (Fig. 1). Histopathological studies of a papule on the left leg revealed characteristics of PK. Excision of the cutaneous horn showed a welldifferentiated microinfiltrative SCC arising from the epidermis beneath the comoid lamella (Fig. 2). The cancer prone nature of PK has been clearly established. In a Japanese series of 198 cases [7], the
To the Editor: Porokeratosis (PK) is a specific disorder of keratinization characterized histologically by the presence of a cornoid lamella. In disseminated superficial actinic porokeratosis (DSAP) the process is confined to sun-exposed areas, involving mainly the extremities. Although epidermal malignancies, especially squamous cell carcinoma (SCC) may occur in all types of PK, they are rare in DSAP. To our knowledge, five cases of SCC [l-4] and two of Bowen’s disease [5,6] in DSAP have been reported. We report herein two new patients with SCC arising in DSAP. Case 1: A 74-year-old-man, a retired agricultural worker, consulted due to pruriginous skin lesions on his legs, arms and forearms, which had evolved over 1 year. He noticed the progressive development of hyperkeratosis in one skin lesion. Physical examination revealed multiple 1-7 mm oval papules, with well-defined, slightly elevated and hyperkeratotic borders and an atrophic center located on the legs, arms and forearms. On the distal third of the left leg, an hyperkeratotic, slightly infiltrated lesion of 1.2 cm in diameter was observed. A biopsy specimen of two typical papules showed an atrophic epidermis with a typical comoid lamella. Histologic sections from the hyperkeratotic lesion revealed a proliferation of atypical squamous cells arising from the epidermis. This extended into the papillary dermis, revealing a welldifferentiated squamous cell carcinoma. Adjacent sections in a border of the tumor showed a small comoid lamella. Case 2: A 76-year-old-man, a retired agricultural worker, referred pruriginous skin lesions on the legs and forearms, which had evolved over 10 years. He had observed the growth and induration of a cutaneous lesion on the right forearm over the previous 3 months. Physical examination revealed numerous oval papules, 3-4 mm in diameter, hyperpigmented,
Corresponding author.
PII: SO926-9959(97)00095-O
Fig. 1. Case 2. Prominent hyperkeratotic lesion (squamous cell carcinoma) surrounded by other lesions with hyperkeratotic borders and atrophic center (DSAP lesions).
researchhas supported this hypothesis. DNA ploidy abnormalities in the epidermal cells of PK skin lesions, and chromosomal abnormalities in cultured keratinocytes and fibroblasts of PK patient skin have been detected [7]. Actinic damageseemsnot to play an important role in malignant induction in PK, given the low incidence of malignancy in DSAP and given the fact that dermal fibroblasts of PK patients are not hypersensitive to ultraviolet light, whereas they are hypersensitive to ionizing radiation [7]. L.F. Del Cadlo”*, C. Soria’, N. DiesCaballero’, J.F. Garcia Garciab, D. Garcia Almagro* “Department of Dermatology, ‘Virgen De La Salud’ Hospital, Avda. Barber, 30, 45004, Toledo, Spain bDepartment of Pathology, ‘V&en De La Salud’ Hospital, Avda. Barber, 30, 45004, Toledo, Spain
111Shrum JR, Cooper
Fig. 2. Microinfiltrative squamous cell carcinoma arising from the epidermis beneath the cornoid lamella (H and E).
frequency of malignant transformation in PK was 11.6%; the localized type had the greatestmalignant potential (23.8%). In the same series there were no casesof malignant transformation over DSAP. Sasson and Krain [8] reviewed all casesof PK in the English language literature in the last 30 years. They found 281 cases of PK, 21 of which had an associatedmalignancy that developed within a lesion of PK. The most frequent reported type of PK was DSAP (116 cases) with a malignant transformation rate of 3.4% (4 cases), the lowest rate excluding punctate PK (10 cases,0 malignancies). In 1970, histological studies established that the cancerprone nature of PK was related to an abnormal clone of epidermal keratinocytes [9]. Subsequent
PH. Greer KE et al. Squamous cell carcinoma in disseminated superlicial actinic porokeratosis. J Am Acad Dermatol 1982;6:58-62. 121Chemosky ME, Rapini RP. Squamous cell carcinoma in lesions of disseminated superficial actinic porokeratosis: a report of two cases. Arch Dermatol 1986;122:853-854. 131Leache A, Soto de Del&s J, V&zquez Doval J et al. Squamous cell carcinoma arising from a lesion of disseminated superficial actinic porokeratosis. Clin Exp Dermatol 1991;16:460462. [41 Remond B, Dompmartin A, Mandard JC et al. Squamous cell carcinoma and disseminated superficial actinic porokeratosis. Ann Dermatol Venereol 1994;121(1):50-52. [51 Jaqueti G, Hemanz JM, Garcia Almagro D. Poroqueratosis actinica diseminada supexftcial con degeneration bowenoide. Med Cut ILA 1978:2:173-177. 161Besenhard HM, Korting HC, Stolz W et al. Disseminierte superlizielle aktinische porokeratose (DSAP) mit morbus Bowen. Hautarzt 1988;39:286-290. [71 Otsuka F, Iwata M, Watanabe R et al. Porokeratosis: clinical and cellular characterization of its cancer-prone nature. J Dermatol 1992;19:702-706. [81 Sasson M, Krain AD. Porokeratosis and cutaneous malignancy. A review. Dermatol Surg 1996;22:339-342. [9] Reed RJ, Leone P. Porokeratosis - mutant clonal keratosis of the epidermis. Arch Dermatol 1970,101:340-347.
* Corresponding author. C/Alameda No. 21, 45400, Mom, Toledo, Spain. Tel.: +34 9 25269205/25300220. PII: SO926-9959(97)00094-9
to the Editor
[lo] Dupre A, Christol B, Bonafe JL et al. Pachyonychie congenitale. Description de 3 cas familiaux traitement par le retinoide aromatique. (RO 10.9359). Ann Dermatol Venereal (Paris) 1981;108:145-149.
7
Disseminated superficial actinic porokeratosis and squamous cell carcinoma: a report of two cases
with elevated hyperkeratotic borders and atrophic center on the legs and forearms. There was an infiltrated cutaneous horn on the distal third of the right forearm (Fig. 1). Histopathological studies of a papule on the left leg revealed characteristics of PK. Excision of the cutaneous horn showed a welldifferentiated microinfiltrative SCC arising from the epidermis beneath the comoid lamella (Fig. 2). The cancer prone nature of PK has been clearly established. In a Japanese series of 198 cases [7], the
To the Editor: Porokeratosis (PK) is a specific disorder of keratinization characterized histologically by the presence of a cornoid lamella. In disseminated superficial actinic porokeratosis (DSAP) the process is confined to sun-exposed areas, involving mainly the extremities. Although epidermal malignancies, especially squamous cell carcinoma (SCC) may occur in all types of PK, they are rare in DSAP. To our knowledge, five cases of SCC [l-4] and two of Bowen’s disease [5,6] in DSAP have been reported. We report herein two new patients with SCC arising in DSAP. Case 1: A 74-year-old-man, a retired agricultural worker, consulted due to pruriginous skin lesions on his legs, arms and forearms, which had evolved over 1 year. He noticed the progressive development of hyperkeratosis in one skin lesion. Physical examination revealed multiple 1-7 mm oval papules, with well-defined, slightly elevated and hyperkeratotic borders and an atrophic center located on the legs, arms and forearms. On the distal third of the left leg, an hyperkeratotic, slightly infiltrated lesion of 1.2 cm in diameter was observed. A biopsy specimen of two typical papules showed an atrophic epidermis with a typical comoid lamella. Histologic sections from the hyperkeratotic lesion revealed a proliferation of atypical squamous cells arising from the epidermis. This extended into the papillary dermis, revealing a welldifferentiated squamous cell carcinoma. Adjacent sections in a border of the tumor showed a small comoid lamella. Case 2: A 76-year-old-man, a retired agricultural worker, referred pruriginous skin lesions on the legs and forearms, which had evolved over 10 years. He had observed the growth and induration of a cutaneous lesion on the right forearm over the previous 3 months. Physical examination revealed numerous oval papules, 3-4 mm in diameter, hyperpigmented,
Corresponding author.
PII: SO926-9959(97)00095-O
Fig. 1. Case 2. Prominent hyperkeratotic lesion (squamous cell carcinoma) surrounded by other lesions with hyperkeratotic borders and atrophic center (DSAP lesions).
researchhas supported this hypothesis. DNA ploidy abnormalities in the epidermal cells of PK skin lesions, and chromosomal abnormalities in cultured keratinocytes and fibroblasts of PK patient skin have been detected [7]. Actinic damageseemsnot to play an important role in malignant induction in PK, given the low incidence of malignancy in DSAP and given the fact that dermal fibroblasts of PK patients are not hypersensitive to ultraviolet light, whereas they are hypersensitive to ionizing radiation [7]. L.F. Del Cadlo”*, C. Soria’, N. DiesCaballero’, J.F. Garcia Garciab, D. Garcia Almagro* “Department of Dermatology, ‘Virgen De La Salud’ Hospital, Avda. Barber, 30, 45004, Toledo, Spain bDepartment of Pathology, ‘V&en De La Salud’ Hospital, Avda. Barber, 30, 45004, Toledo, Spain
111Shrum JR, Cooper
Fig. 2. Microinfiltrative squamous cell carcinoma arising from the epidermis beneath the cornoid lamella (H and E).
frequency of malignant transformation in PK was 11.6%; the localized type had the greatestmalignant potential (23.8%). In the same series there were no casesof malignant transformation over DSAP. Sasson and Krain [8] reviewed all casesof PK in the English language literature in the last 30 years. They found 281 cases of PK, 21 of which had an associatedmalignancy that developed within a lesion of PK. The most frequent reported type of PK was DSAP (116 cases) with a malignant transformation rate of 3.4% (4 cases), the lowest rate excluding punctate PK (10 cases,0 malignancies). In 1970, histological studies established that the cancerprone nature of PK was related to an abnormal clone of epidermal keratinocytes [9]. Subsequent
PH. Greer KE et al. Squamous cell carcinoma in disseminated superlicial actinic porokeratosis. J Am Acad Dermatol 1982;6:58-62. 121Chemosky ME, Rapini RP. Squamous cell carcinoma in lesions of disseminated superficial actinic porokeratosis: a report of two cases. Arch Dermatol 1986;122:853-854. 131Leache A, Soto de Del&s J, V&zquez Doval J et al. Squamous cell carcinoma arising from a lesion of disseminated superficial actinic porokeratosis. Clin Exp Dermatol 1991;16:460462. [41 Remond B, Dompmartin A, Mandard JC et al. Squamous cell carcinoma and disseminated superficial actinic porokeratosis. Ann Dermatol Venereol 1994;121(1):50-52. [51 Jaqueti G, Hemanz JM, Garcia Almagro D. Poroqueratosis actinica diseminada supexftcial con degeneration bowenoide. Med Cut ILA 1978:2:173-177. 161Besenhard HM, Korting HC, Stolz W et al. Disseminierte superlizielle aktinische porokeratose (DSAP) mit morbus Bowen. Hautarzt 1988;39:286-290. [71 Otsuka F, Iwata M, Watanabe R et al. Porokeratosis: clinical and cellular characterization of its cancer-prone nature. J Dermatol 1992;19:702-706. [81 Sasson M, Krain AD. Porokeratosis and cutaneous malignancy. A review. Dermatol Surg 1996;22:339-342. [9] Reed RJ, Leone P. Porokeratosis - mutant clonal keratosis of the epidermis. Arch Dermatol 1970,101:340-347.
* Corresponding author. C/Alameda No. 21, 45400, Mom, Toledo, Spain. Tel.: +34 9 25269205/25300220. PII: SO926-9959(97)00094-9