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Effect of Papain in the Shope Papilloma*
Vol. 45, No. 2
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
Copyright
1565
Printed in U.S.A.
by The Williams & Wilkins Co.
Preliminary and Short Report EFFECT OF PAPAIN IN THE SHOPE PAPILLOMA* ROYAL M. MONTGOMERY, M.D. AND RUDOLF GARRET, M.D.
The report of Miller and Stoughton (1) epithelium shows acanthosis and parakeratosis.
The acanthotic areas are in papillary configuration. Basophilic inclusion bodies are seen in the cytoplasm of the prickle cells. The dermis is not and shows no inflammatory exudate. because of its similarity to the human wart. This remarkable 2. Papilloma treated with papain in the base papilloma grows on cottontail rabbits in Kansas. shows in one area the dermis full of extravasated These papillomas can be transferred by inocula- red blood cells. The overlying papilloma is sepation into the skin of a white rabbit. from the dermis and disrupted with hemorOne of the difficulties encountered was the ac- rated (Fig. 1). At the base the cells arc disseciated quisition of sterile papain of a standard potency. rhage the main lesion and appear floating in the At first the sterilization method employed by from Miller and Stoughton was used. This was unsatis- hemorrhagic material (Fig. 2). The cells themare well preserved. factory since the potency standard varied. Later, selves 3. Lysis of the papilloma occurred and no prompted us to investigate the efficacy of papain
in the treatment of warts. We selected to test the effect of papain on the Shope papilloma
a prepared crystalline sterile papaint became specimen was taken. available.
4. The papilloma treated with Vitamin A (Fig.
The laboratory rabbits were inoculated with a shows a mild, acute inflammatory exudate in sample of Shope Papilloma which bad been 3.) dermis underlying the papilloma and mild ground up in a normal saline to make a 10 per the in the fibrous stalks of the papilloma. cent suspension (3 gms in 30 ml of normal saline). hemorrhage The abdomens of two white rabbits were Otherwise, the section is similar to that of the
untreated papilloma. 5. The papilloma treated with Vitamin A subabraded with No. 0 sandpaper and the suspension cutaneously shows a focal area of dcrmal edema immediately rubbed into the scarified skin. Three and hemorrhage without separation from the derand a half weeks later papillomata had developed mis. The papilloma itself shows a picture similar to a sufficient size to inoculate. These were about to that of the untreated Shope papilloma. one quarter inch high. Five areas were selected
clipped and shaved. The next day the skin was
When the papillomata were ten weeks old, further injections were made with a weaker
and were treated as follows:
1. A biopsy specimen of an untreated papilloma
papain solution (10 mgm in 2 ml normal saline) in 2. An injection of 0.5 ml of papain (10 mgm to three more areas. The papillomata were much this time. These other areas were 1 ml of normal saline) was made into the base of thickerasatfollows: the papilloma. A biopsy specimen was taken 1½ treated 6. 0.5 ml was injected superficially under a hours later. papilloma. A biopsy was taken 1½ hours 3. Following a similar injection in the subcu- thick taneous tissue just below the papilloma, a biopsy later. 7. 0.5 ml was injected deeper into the subcuspecimen also was to have been taken 1½ hours taneous of a flatter papilloma. The biopsy later but the papilloma had practically dissolved specimentissue was taken 1½ hours later. and it was impossible to obtain a specimen from 8. 0.5 ml was injected into an area similar to the area. 4. An injection of 0.5 ml of Vitamin A solution that of No. 7 and a biopsy specimen taken 1½ later. was given into the base of the wart and a biopsy hours The following are the histologic reports of the specimen removed in 1½ hours. 5. An injection of 0.5 ml of Vitamin A solu- biopsy specimens taken from the areas injected was removed.
the weaker papain solution: tion was given in the subcutaneous tissue just with 6. There is one focal area of hemorrhage at the below the papilloma and a biopsy specimen re- base of the papilloma within the epithelium. In moved 1½ heurs later. area the epithelial cells are dissociated from The following were the pathological reports on this the main lesion and appear to float in the hemorthe 4 biopsy specimens: material. There is separation of the papil1. The untreated Shope papilloma shows a tu- rhagic from the subcutaneous tissue. The undermor that consisted of papillary projections cov- loma dermis is infiltrated by acute inflammatory ered by a hyperkeratotic layer of epithelium. The lying cells. 7. The flatter papilloma shows a focal area of
hemorrhage in the dermis with acute inflammatory
exudate and endothelial cell proliferation in the * From the Dermatology and Pathology De- blood vessels. There is a separation of the papilpartments of Roosevelt Hospital, New York, N.Y. loma from the subcutaneous tissue. There are a t Worthington Biochemical Laboratories, Free- few acute inflammatory cells present. The papilloma itself shows a picture similar to that of the hold, N.J. Received for publication July 11, 1964.
t Courtesy of Robert C. Mellors, M.D. Hospital
for Special Surgery, N.Y. § Aquasol A solution 50,000 u/ml. was used.
untreated papilloma.
8. Papain injected underneath another flatter papilloma shows an acute inflammatory exudate
126
•..•.
--a
FIG. 1. (H and E, x 100.) Papilloma treated with papain. Note hemorrhage in the dermis and separation of the papilloma from the underlying dermis.
Fjo. 2. (H and E, X 240.) Papilloma treated with papain. Note separation of epithelial
cells from the underlying dermis.
127
128
THE JOUENAL OF INVESTIGATIVE DERMATOLOGT
__
,,twak L fl
k
Fio. 3. (H and E, x 240.) Papilloma treated with Vitamin A. Note mild hemorrhage in
the dermis and good preservation of papilloma cells.
with hemorrhage in the dermis and within the themselves do not show any particular abnormality basal portion of the papilloma. In one area the in treated and untreated cases. Papillomas treated with Vitamin A show very epithelial cells are separated from the main lesion and again appear to be floating in the hemor- little reaction. rhagic material. Otherwise the picture is similar to that of the control papilloma. A third rabbit was prepared in the same manner as the first two. After four weeks, injections were
made into the papillomata at two sites. The
strength of the solution was 10 mgm of papain dissolved into 1.5 ml of normal saline solution. These other sites were treated as follows:
9. 0.4 ml was injected under the base of a large
COMMENT
The amount of reaction and separation of the papilloma from the dermis was increased when the more concentrated papain was used i.e. 10 mgm in 1 ml of saline as compared to 10 mgm in 2 ml of saline. The concentration of 10 mgm in 1.5 ml of saline did not appear to cause as much of a reaction as the 10 mgm of papain in 2 ml of
papilloma. A biopsy specimen was taken one saline. This was probably due to the smaller amounts which were injected i.e. 0.4 and 0.2 ml hour and twenty minutes later. 10. 0.2 ml was injected under the base of a instead of 0.5 ml.
smaller papilloma. A biopsy specimen was taken one hour and twenty minutes later. The pathological reports of these specimens were:
CONCLUSiON
Injections of Vitamin A solution had very little effect on the Shope papilloma.
9. Thefl papilloma shows hemorrhage in the Papain injected into the base of a Shope papildermis with some separation of the papilloma loma gave a proteolytic effect which separated the from the subcutaneous tissue. Otherwise there papilloma from the underlying dermis, without were no remarkable changes. any effect on the tumor cells themselves, as re10. The findiogs are similar to that in No. 9. by light microscopy. Summary of Pathology—The only abnormality vealed These findings suggest that treatment of human in the specimens treated with papain is that some warts with papain is worthy of a clinical trial. epithelial cells close to the site of injection apREFERENCE pear to be separated from the main lesion. These cells appear to float in the hemorrhagic and in- 1. Miller, R. F. and Stoughton, R. B.: Effects of papain in human skin. J. Invest. Derm., 35: flammatory material. Where the papilloma has 141, 1960. separated from the subcutaneous tissue, the cells
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
94
linolenic acid extract. Arch. This pdf is a scanned copy UV of irradiated a printed document.
24. Wynn, C. H. and Iqbal, M.: Isolation of rat
skin lysosomes and a comparison with liver Path., 80: 91, 1965. and spleen lysosomes. Biochem. J., 98: lOP, 37. Nicolaides, N.: Lipids, membranes, and the 1966.
human epidermis, p. 511, The Epidermis
Eds., Montagna, W. and Lobitz, W. C. Acascopic localization of acid phosphatase in demic Press, New York. human epidermis. J. Invest. Derm., 46: 431, 38. Wills, E. D. and Wilkinson, A. E.: Release of 1966. enzymes from lysosomes by irradiation and 26. Rowden, C.: Ultrastructural studies of kerathe relation of lipid peroxide formation to tinized epithelia of the mouse. I. Combined enzyme release. Biochem. J., 99: 657, 1966. electron microscope and cytochemical study 39. Lane, N. I. and Novikoff, A. B.: Effects of of lysosomes in mouse epidermis and esoarginine deprivation, ultraviolet radiation and X-radiation on cultured KB cells. J. phageal epithelium. J. Invest. Derm., 49: 181, 25. Olson, R. L. and Nordquist, R. E.: Ultramicro-
No warranty is given about the accuracy of the copy.
Users should refer to the original published dermal cells. Nature, 216: 1031, 1967. version of1965. the material. vest. Derm., 45: 448, 28. Hall, J. H., Smith, J. G., Jr. and Burnett, S. 41. Daniels, F., Jr. and Johnson, B. E.: In prepa1967.
Cell Biol., 27: 603, 1965.
27. Prose, P. H., Sedlis, E. and Bigelow, M.: The 40. Fukuyama, K., Epstein, W. L. and Epstein, demonstration of lysosomes in the diseased J. H.: Effect of ultraviolet light on RNA skin of infants with infantile eczema. J. Inand protein synthesis in differentiated epi-
C.: The lysosome in contact dermatitis: A ration. histochemical study. J. Invest. Derm., 49: 42. Ito, M.: Histochemical investigations of Unna's oxygen and reduction areas by means of 590, 1967. 29. Pearse, A. C. E.: p. 882, Histochemistry Theoultraviolet irradiation, Studies on Melanin, retical and Applied, 2nd ed., Churchill, London, 1960.
30. Pearse, A. C. E.: p. 910, Histacheini.stry Thearetscal and Applied, 2nd ed., Churchill, London, 1960.
31. Daniels, F., Jr., Brophy, D. and Lobitz, W. C.: Histochemical responses of human skin fol-
lowing ultraviolet irradiation. J. Invest. Derm.,37: 351, 1961.
32. Bitensky, L.: The demonstration of lysosomes by the controlled temperature freezing section method. Quart. J. Micr. Sci., 103: 205, 1952.
33. Diengdoh, J. V.: The demonstration of lysosomes in mouse skin. Quart. J. Micr. Sci., 105: 73, 1964.
34. Jarret, A., Spearman, R. I. C. and Hardy, J. A.:
Tohoku, J. Exp. Med., 65: Supplement V, 10, 1957.
43. Bitcnsky, L.: Lysosomes in normal and pathological cells, pp. 362—375, Lysasames Eds., de Reuck, A. V. S. and Cameron, M. Churchill, London, 1953.
44. Janoff, A. and Zweifach, B. W.: Production of inflammatory changes in the microcirculation by cationic proteins extracted from lysosomes. J. Exp. Med., 120: 747, 1964.
45. Herion, J. C., Spitznagel, J. K., Walker, R. I. and Zeya, H. I.: Pyrogenicity of granulocyte lysosomes. Amer. J. Physiol., 211: 693, 1966.
46. Baden, H. P. and Pearlman, C.: The effect of ultraviolet light on protein and nucleic acid synthesis in the epidermis. J. Invest. Derm.,
Histochemistry of keratinization. Brit. J. 43: 71, 1964. Derm., 71: 277, 1959. 35. De Duve, C. and Wattiaux, R.: Functions of 47. Bullough, W. S. and Laurence, E. B.: Mitotic control by internal secretion: the role of lysosomes. Ann. Rev. Physiol., 28: 435, 1966. the chalone-adrenalin complex. Exp. Cell. 36. Waravdekar, V. S., Saclaw, L. D., Jones, W. A. and Kuhns, J. C.: Skin changes induced by
Res., 33: 176, 1964.
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
Copyright
1565
Printed in U.S.A.
by The Williams & Wilkins Co.
Preliminary and Short Report EFFECT OF PAPAIN IN THE SHOPE PAPILLOMA* ROYAL M. MONTGOMERY, M.D. AND RUDOLF GARRET, M.D.
The report of Miller and Stoughton (1) epithelium shows acanthosis and parakeratosis.
The acanthotic areas are in papillary configuration. Basophilic inclusion bodies are seen in the cytoplasm of the prickle cells. The dermis is not and shows no inflammatory exudate. because of its similarity to the human wart. This remarkable 2. Papilloma treated with papain in the base papilloma grows on cottontail rabbits in Kansas. shows in one area the dermis full of extravasated These papillomas can be transferred by inocula- red blood cells. The overlying papilloma is sepation into the skin of a white rabbit. from the dermis and disrupted with hemorOne of the difficulties encountered was the ac- rated (Fig. 1). At the base the cells arc disseciated quisition of sterile papain of a standard potency. rhage the main lesion and appear floating in the At first the sterilization method employed by from Miller and Stoughton was used. This was unsatis- hemorrhagic material (Fig. 2). The cells themare well preserved. factory since the potency standard varied. Later, selves 3. Lysis of the papilloma occurred and no prompted us to investigate the efficacy of papain
in the treatment of warts. We selected to test the effect of papain on the Shope papilloma
a prepared crystalline sterile papaint became specimen was taken. available.
4. The papilloma treated with Vitamin A (Fig.
The laboratory rabbits were inoculated with a shows a mild, acute inflammatory exudate in sample of Shope Papilloma which bad been 3.) dermis underlying the papilloma and mild ground up in a normal saline to make a 10 per the in the fibrous stalks of the papilloma. cent suspension (3 gms in 30 ml of normal saline). hemorrhage The abdomens of two white rabbits were Otherwise, the section is similar to that of the
untreated papilloma. 5. The papilloma treated with Vitamin A subabraded with No. 0 sandpaper and the suspension cutaneously shows a focal area of dcrmal edema immediately rubbed into the scarified skin. Three and hemorrhage without separation from the derand a half weeks later papillomata had developed mis. The papilloma itself shows a picture similar to a sufficient size to inoculate. These were about to that of the untreated Shope papilloma. one quarter inch high. Five areas were selected
clipped and shaved. The next day the skin was
When the papillomata were ten weeks old, further injections were made with a weaker
and were treated as follows:
1. A biopsy specimen of an untreated papilloma
papain solution (10 mgm in 2 ml normal saline) in 2. An injection of 0.5 ml of papain (10 mgm to three more areas. The papillomata were much this time. These other areas were 1 ml of normal saline) was made into the base of thickerasatfollows: the papilloma. A biopsy specimen was taken 1½ treated 6. 0.5 ml was injected superficially under a hours later. papilloma. A biopsy was taken 1½ hours 3. Following a similar injection in the subcu- thick taneous tissue just below the papilloma, a biopsy later. 7. 0.5 ml was injected deeper into the subcuspecimen also was to have been taken 1½ hours taneous of a flatter papilloma. The biopsy later but the papilloma had practically dissolved specimentissue was taken 1½ hours later. and it was impossible to obtain a specimen from 8. 0.5 ml was injected into an area similar to the area. 4. An injection of 0.5 ml of Vitamin A solution that of No. 7 and a biopsy specimen taken 1½ later. was given into the base of the wart and a biopsy hours The following are the histologic reports of the specimen removed in 1½ hours. 5. An injection of 0.5 ml of Vitamin A solu- biopsy specimens taken from the areas injected was removed.
the weaker papain solution: tion was given in the subcutaneous tissue just with 6. There is one focal area of hemorrhage at the below the papilloma and a biopsy specimen re- base of the papilloma within the epithelium. In moved 1½ heurs later. area the epithelial cells are dissociated from The following were the pathological reports on this the main lesion and appear to float in the hemorthe 4 biopsy specimens: material. There is separation of the papil1. The untreated Shope papilloma shows a tu- rhagic from the subcutaneous tissue. The undermor that consisted of papillary projections cov- loma dermis is infiltrated by acute inflammatory ered by a hyperkeratotic layer of epithelium. The lying cells. 7. The flatter papilloma shows a focal area of
hemorrhage in the dermis with acute inflammatory
exudate and endothelial cell proliferation in the * From the Dermatology and Pathology De- blood vessels. There is a separation of the papilpartments of Roosevelt Hospital, New York, N.Y. loma from the subcutaneous tissue. There are a t Worthington Biochemical Laboratories, Free- few acute inflammatory cells present. The papilloma itself shows a picture similar to that of the hold, N.J. Received for publication July 11, 1964.
t Courtesy of Robert C. Mellors, M.D. Hospital
for Special Surgery, N.Y. § Aquasol A solution 50,000 u/ml. was used.
untreated papilloma.
8. Papain injected underneath another flatter papilloma shows an acute inflammatory exudate
126
•..•.
--a
FIG. 1. (H and E, x 100.) Papilloma treated with papain. Note hemorrhage in the dermis and separation of the papilloma from the underlying dermis.
Fjo. 2. (H and E, X 240.) Papilloma treated with papain. Note separation of epithelial
cells from the underlying dermis.
127
128
THE JOUENAL OF INVESTIGATIVE DERMATOLOGT
__
,,twak L fl
k
Fio. 3. (H and E, x 240.) Papilloma treated with Vitamin A. Note mild hemorrhage in
the dermis and good preservation of papilloma cells.
with hemorrhage in the dermis and within the themselves do not show any particular abnormality basal portion of the papilloma. In one area the in treated and untreated cases. Papillomas treated with Vitamin A show very epithelial cells are separated from the main lesion and again appear to be floating in the hemor- little reaction. rhagic material. Otherwise the picture is similar to that of the control papilloma. A third rabbit was prepared in the same manner as the first two. After four weeks, injections were
made into the papillomata at two sites. The
strength of the solution was 10 mgm of papain dissolved into 1.5 ml of normal saline solution. These other sites were treated as follows:
9. 0.4 ml was injected under the base of a large
COMMENT
The amount of reaction and separation of the papilloma from the dermis was increased when the more concentrated papain was used i.e. 10 mgm in 1 ml of saline as compared to 10 mgm in 2 ml of saline. The concentration of 10 mgm in 1.5 ml of saline did not appear to cause as much of a reaction as the 10 mgm of papain in 2 ml of
papilloma. A biopsy specimen was taken one saline. This was probably due to the smaller amounts which were injected i.e. 0.4 and 0.2 ml hour and twenty minutes later. 10. 0.2 ml was injected under the base of a instead of 0.5 ml.
smaller papilloma. A biopsy specimen was taken one hour and twenty minutes later. The pathological reports of these specimens were:
CONCLUSiON
Injections of Vitamin A solution had very little effect on the Shope papilloma.
9. Thefl papilloma shows hemorrhage in the Papain injected into the base of a Shope papildermis with some separation of the papilloma loma gave a proteolytic effect which separated the from the subcutaneous tissue. Otherwise there papilloma from the underlying dermis, without were no remarkable changes. any effect on the tumor cells themselves, as re10. The findiogs are similar to that in No. 9. by light microscopy. Summary of Pathology—The only abnormality vealed These findings suggest that treatment of human in the specimens treated with papain is that some warts with papain is worthy of a clinical trial. epithelial cells close to the site of injection apREFERENCE pear to be separated from the main lesion. These cells appear to float in the hemorrhagic and in- 1. Miller, R. F. and Stoughton, R. B.: Effects of papain in human skin. J. Invest. Derm., 35: flammatory material. Where the papilloma has 141, 1960. separated from the subcutaneous tissue, the cells
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
94
linolenic acid extract. Arch. This pdf is a scanned copy UV of irradiated a printed document.
24. Wynn, C. H. and Iqbal, M.: Isolation of rat
skin lysosomes and a comparison with liver Path., 80: 91, 1965. and spleen lysosomes. Biochem. J., 98: lOP, 37. Nicolaides, N.: Lipids, membranes, and the 1966.
human epidermis, p. 511, The Epidermis
Eds., Montagna, W. and Lobitz, W. C. Acascopic localization of acid phosphatase in demic Press, New York. human epidermis. J. Invest. Derm., 46: 431, 38. Wills, E. D. and Wilkinson, A. E.: Release of 1966. enzymes from lysosomes by irradiation and 26. Rowden, C.: Ultrastructural studies of kerathe relation of lipid peroxide formation to tinized epithelia of the mouse. I. Combined enzyme release. Biochem. J., 99: 657, 1966. electron microscope and cytochemical study 39. Lane, N. I. and Novikoff, A. B.: Effects of of lysosomes in mouse epidermis and esoarginine deprivation, ultraviolet radiation and X-radiation on cultured KB cells. J. phageal epithelium. J. Invest. Derm., 49: 181, 25. Olson, R. L. and Nordquist, R. E.: Ultramicro-
No warranty is given about the accuracy of the copy.
Users should refer to the original published dermal cells. Nature, 216: 1031, 1967. version of1965. the material. vest. Derm., 45: 448, 28. Hall, J. H., Smith, J. G., Jr. and Burnett, S. 41. Daniels, F., Jr. and Johnson, B. E.: In prepa1967.
Cell Biol., 27: 603, 1965.
27. Prose, P. H., Sedlis, E. and Bigelow, M.: The 40. Fukuyama, K., Epstein, W. L. and Epstein, demonstration of lysosomes in the diseased J. H.: Effect of ultraviolet light on RNA skin of infants with infantile eczema. J. Inand protein synthesis in differentiated epi-
C.: The lysosome in contact dermatitis: A ration. histochemical study. J. Invest. Derm., 49: 42. Ito, M.: Histochemical investigations of Unna's oxygen and reduction areas by means of 590, 1967. 29. Pearse, A. C. E.: p. 882, Histochemistry Theoultraviolet irradiation, Studies on Melanin, retical and Applied, 2nd ed., Churchill, London, 1960.
30. Pearse, A. C. E.: p. 910, Histacheini.stry Thearetscal and Applied, 2nd ed., Churchill, London, 1960.
31. Daniels, F., Jr., Brophy, D. and Lobitz, W. C.: Histochemical responses of human skin fol-
lowing ultraviolet irradiation. J. Invest. Derm.,37: 351, 1961.
32. Bitensky, L.: The demonstration of lysosomes by the controlled temperature freezing section method. Quart. J. Micr. Sci., 103: 205, 1952.
33. Diengdoh, J. V.: The demonstration of lysosomes in mouse skin. Quart. J. Micr. Sci., 105: 73, 1964.
34. Jarret, A., Spearman, R. I. C. and Hardy, J. A.:
Tohoku, J. Exp. Med., 65: Supplement V, 10, 1957.
43. Bitcnsky, L.: Lysosomes in normal and pathological cells, pp. 362—375, Lysasames Eds., de Reuck, A. V. S. and Cameron, M. Churchill, London, 1953.
44. Janoff, A. and Zweifach, B. W.: Production of inflammatory changes in the microcirculation by cationic proteins extracted from lysosomes. J. Exp. Med., 120: 747, 1964.
45. Herion, J. C., Spitznagel, J. K., Walker, R. I. and Zeya, H. I.: Pyrogenicity of granulocyte lysosomes. Amer. J. Physiol., 211: 693, 1966.
46. Baden, H. P. and Pearlman, C.: The effect of ultraviolet light on protein and nucleic acid synthesis in the epidermis. J. Invest. Derm.,
Histochemistry of keratinization. Brit. J. 43: 71, 1964. Derm., 71: 277, 1959. 35. De Duve, C. and Wattiaux, R.: Functions of 47. Bullough, W. S. and Laurence, E. B.: Mitotic control by internal secretion: the role of lysosomes. Ann. Rev. Physiol., 28: 435, 1966. the chalone-adrenalin complex. Exp. Cell. 36. Waravdekar, V. S., Saclaw, L. D., Jones, W. A. and Kuhns, J. C.: Skin changes induced by
Res., 33: 176, 1964.