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Itch and malignancy prognosis in generalized pruritus: A 6-year follow-up of 125 patients
Volume 16 Number 6 June 1987
Epidermal class 11 HLA expression in atopic dermatitis
Ia antigen on epidermal keratinocytes in graft-versus-host disease. Nature 1981 ;293:149-50. 18. Tjernlund U, Scheynius A. Epidermal cell suspensions containing HLA-DR-expressing keratinocytes amplify the T-cell response in vitro to PPD. J Invest Dermatol 1986;87:172. 19. Breathnach SM, Shimada S, Korvac Z, Katz SI. Immunologic aspects of acute cutaneous graft-versus-host
disease. Decreased density and antigen presenting function of l a + Langerhans cells and absent antigen presenting capacity o f l a + keratinocytes. J Invest Dermatol 1986;86:226-34. 20. Gawkrodger DJ, Carr MM, Guy K, Hunter JAA. Epidermal expression of Class II HLA in allergic and irritant contact dermatitis reactions. Br J Dermatol 1985; 113:767.
Itch and malignancy prognosis in generalized pruritus: A 6-year follow-up of 125 patients Robert Paul, M.D., Riitta Paul, M.D., and Christer T. Jansen, M.D.
Turku, Finland When 125 patients with generalized pruritus were followed up for 6 years, 66% reported continuing pruritus. In four patients a malignancy had been identified at the time of the initial examination, and four other patients developed malignancies during the follow-up period. Seven of the patients died of the malignancy during the follow-up period. This incidence of malignancies does not differ significantly from the value expected in a general population, matched for age and sex. However, two of the cancers were lymphomas, and this incidence is significantly (p < 0.01) higher than that expected in a similarly matched population. As a whole our study indicates that no significant overall increase of malignant neoplasms is to be expected in patients with generalized pruritus and, therefore, any general efforts for cancer follow-up screening seem unwarranted in patients with pruritus. (J AM ACAD DERMATOL1987; 16:1179-82.)
Prolonged generalized pruritus is a problem not infrequently encountered by general practitioners, internists, and dermatologists. Diseases of the internal organs, such as liver failure, uremia, thyroid disease, and polycythemia, ~-4 may be the precipitating cause in 20% to 30% of these cases? Furthermore, pruritus is associated with malignant
From the Departments of Radiotherapy and Dermatology, University of Turku. Accepted for publication Dec. 9, 1986. Reprint requests to: Dr. Christer T. Jansen, Department of Dermatology, The UniversityCentral Hospital of Turku, SF-20520Turku, Finhmd.
diseases. No less than 30% of patients with Hodgkin's disease suffer from pruritus, 6 and patients suffering from lymphomas, leukemias, or solid malignant tumors may also itch. 7 However, there seems to be disagreement in the literature as to how often generalized pruritus is a heralding mark of an underlying malignancy, and figures from 3% to 47% have been reported. ,4.8-~0 We have followed up 125 patients with pruritus for 6 years in an attempt to record the frequency of cancer development and to compare it with frequencies o f malignancy in the general population. Cancer morbidity was screened by two postal inquiries at 3-year intervals, and the cancer mortality
1179
1180
Journal of the American Academy of Dermatology
Paul et al
Table I. Data on the malignancies found in 125 patients with pruritus during the 6-year follow-up period .
.
.
.
Case
Sex
Age (yr)
1 2 3 4 5 6 7 8
M M F F M M F M
62 60 78 59 77 74 72 82
Primary investigation
3-yr
6-yr
Malignancy
follow-up
follow-up
Time from pruritus to cancer diagnosis (mo)
Lymphoma Stomach cancer Breast cancer Lymphoma Lung cancer Lung cancer Renal cancer Lung cancer
+ + + + -
D D D D D -
D D D D D D D +
- 11" - 7* I 11 14 48 52 70
A minus s~gn indicates absence of malignancy, a plus sign denotes presence of cancer, and D means death of patient. *Cancer diagnosed before pruritus.
rate by information obtained from death certificates, which in the majority of cases was based on autopsy findings.
PATIENTS AND METHODS All patients were referred to the Department of Dermatology at the Turku University Hospital between Sept. 1, 1974, and Dec. 31, 1976, because of persistent, generalized, symmetric pruritus not related to any primary skin disorder or manifestation and severe enough to warrant inpatient investigation at a dermatologic clinic. In each case the pruritus had been unresponsive to symptomatic therapy with lubricating cream or topical corticosteroids and had interfered with the patient's sleep. Secondary to scratching, cutaneous excoriation with or without secondary infection was seen. Of the 125 patients who met the inclusion criteria, eighty-one were women and forty-four were men. The mean age of the w o m e n was 46.3 + 18.4 (mean __+ SD) years and of the male patients 62.7 _+ 17.0 years. An initial search for concomitant internal diseases disclosed diabetes in seven, liver disease in five, renal disease in four, thyroid disease in three, pernicious anemia in three, and polycythemia vera in three patients. Four patients had a malignant disease on entry into the study (Table I). A detailed account of the clinical and laboratory findings from the primary investigation has been published elsewhere. ~ Questionnaires were sent to the patients 3 years
and 6 years after the initial examination. The questionnaire contained inquiries about the current state of the skin complaint, medications, physician and hospital contacts, and the general state of health. In addition, it was specifically asked whether the patient had been suspected of having cancer or had a diagnosis of cancer. The first questionnaire was returned, at least partially answered, by 120 of the 125 patients and the second one by 113 patients. If a subject had died, relatives often provided the information. Information on the causes of death was obtained either from death certificates or by contacting the parish of the deceased, the hospital where the patients had died, or the Finnish Central Registry for Causes of Death. In those instances in which no response was obtained to the questionnaire and the current address of the patient was unknown, the Finnish Cancer Registry supplied the information as to whether cancer had been reported concerning the person in question. This nationwide registry has been in operation since 1953, and its coverage is virtually complete.*
RESULTS Persistence of pruritus Pruritus continued unabated 3 years after follow-up in 60 of the patients and 6 years in 44 of the patients (Table lI). The question was left un*Dr. Timo Hakulinen at the Finnish Cancer Registry provided assistance in establishing the incidence figures cited.
Volume 16 Number 6 June 1987
answered or the subject had died in 28 and 46 instances, respectively. Thus of the patients who were alive and had answered the question, 65% still suffered from pruritus at 3 years and 66% at 6 years of follow-up. The single patient with carcinoma who was still alive at the fol!ow-up had persistent itching.
Noncancer deaths During the study, 19 patients died of causes unrelated to malignant neoplasia. Of these, seven were women with a mean age of 70.4 _+ 9.9 ye .ars and 12 were men aged 75.2 _+ 8.6 years.
Cancer morbidity and deaths The cancer data of the patients are presented in Table II. At the time of the primary investigation, four patients were diagnosed as having cancer. Three years later these four plus one additional patient had died of cancer, but no other patient was known to suffer from malignancy. At 6 years of follow-up, two additional patients had died of cancer and one additional case had been diagnosed. The latter patient (case 8 in Table I) died of this condition a few months after the end of the follow-up. Of the seven patients who died of cancer during the follow-up, three were women with a mean age of 70.0 _+ 9.9 years and four were men aged 68.7 _+ 7.4 years. As shown in Table III, the incidence of cancer deaths did not differ significantly from the value expected from the statistics of the Finnish Cancer Registry. However, when the cases of lymphoma were considered separately, a significant overrepresentation was disclosed in the patient population with pruritus (p < 0.01). DISCUSSION Our study lends no support to the belief that patients with systemic pruritus would be more subject to the development of solid cancers than the general population. Indeed, the association mentioned in earlier literature between solid neoplasms and generalized pruritus has often been based on anecdotal reports. 10.i2-17 In contrast, it is well established that Hodgkin's disease and mycosis fungoides are associated with pruritus in a fair number of the cases. 6'13,16 Furthermore, when previously
Malignancy prognosis in generalized pruritus
1181
Table II. Persistence of pruritus Follow-up
Persistent pruritus No pruritus Question unanswered Dead
period
3-yr
6-yr
60 23 14 14
40 32 26 26
Table III. Comparison of expected and observed numbers of malignancies Expected Observed Significance All malignancies Lymphomas
7.99 0.078
7 2
NS p < 0.01
Expectance numbers were compiled from Finnish Cancer Registry statistics.
published series on patients with pruritus are analyzed more closely, a remarkable number of patients with malignancies have in fact suffered from myeloproliferative and lymphoproliferative diseases. Thus in the series of Rajka, 4 who found malignancies in nine out of 34 patients (26%), the diagnosis included five cases of "lymphoma reticulosis" and one case of myeloma. Similarly, in the series of Caravati and Richardson, 3 who found malignancies in seven out of 15 patients with pruritus (47%), the diagnosis included five cases of "lymphoma reticulosis." Vickers, 9 who reported malignancies in 12 out of 76 patients (16%), did not specify diagnoses, but cancers were typed as "neoplasia or reticulosis." Our study does corroborate the studies cited as far as an increased incidence of lymphoma in patients with pruritus is concerned. However, the total incidence of malignancy was quite low: only eight out of 125 (6%). This figure is in conformity with the reports of Lyell, 2 who studied 60 patients with pruritus and found two malignancies (one lymphadenoma), Forman, 8who studied 64 patients and detected three malignancies (two lymphomas), and Beare, t who studied 43 patients and found three malignancies (one lymphoma). In the series of 44 patients with pruritus reported by Kantor and Lookingbill," in two patients cancer was diagnosed before evaluation, one was diagnosed at ini-
1182
Journal of the American Academy of Dermatology
Paul et al
tial evaluation, and one disclosed during the 6.5year follow-up. In addition, one patient developed chronic lymphatic leukemia. We believe that studies citing an incidence of malignancy higher than 10% in patients with pruritus during any reasonable follow-up period are based on selected patient groups not representing the patient population with pruritus as a whole. In fact, the overall malignancy rate in the patient population with pruritus is not much different from that of a similarly aged control population, and generalized pruritus is only a very vague or almost negligible indicator of any propensity for developing a malignant neoplastic disease. Therefore generally applied efforts for cancer tracing will not be cost-effective. REFERENCES 1. Beare J. Generalized pruritus. A study of 43 cases. CIin Exp Dermatol 1976; 1:343-52. 2. Lyell A. The itching patient. A review of the causes of pruritus. Scot Med J 1972;17:334-47. 3. Caravati CM, Richardson DR. Pruritus as a symptom of systemic disease. Va Meal Monthly 1969;96:656-8. 4. Rajka G. Investigation of patients suffering from generalized pruritus, with special references to systemic diseases. Acta Derm Venereol (Stockh) 1966;46"190-4. 5. Anonymous. No panacea for pruritus and still much ignorance. J A M A 1979;241:980.
6. Winkelmann R, Muller S. Pruritus. Ann Rev Med 1964; 15:53-64. 7. Moschella S. Cutaneous manifestations of internal malignancies. Med Clin North Am 1975;59:479-88. 8. Forman L. Pruritus and its management. Br Med J 1954;1:365-7. 9. Vickers C. Iron deficiency and the skin (abstr). Br J Dermatol 1973;89(suppl 9):10. 10. Verhave JH. Itching as precursor phenomenon of mammary cancer. Ned Tijdschr Geneeskd 1926;70:1082-3. 11. Paul R, Timonen T, Jansen CT. Pruritus curls. Finnish Med J 1980;35:3031-6. 11. Kantor GR, Lookingbill DP. Generalized pruritus and systemic disease. J AM ACAD DERMATOL 1983;9:375-82. 12, Becker SW, Kahn D, Rothman S. Cutaneous manifestations of internal malignant tumors. Arch Dermatol Syph 1942;45:1069-80. 13, Goldstein J, Hart J. Pruritus and purpura as unusual symptoms of carcinoma of the bronchus. Tubercle 1959;40:119-20. 14. Winkelmann RK. Dermatological clinics. 1. Comments on pruritus related to systemic disease. Mayo Clin Proc 1961 ;36:187-96. 15. Cormia FE. Pruritus, an uncommon but important symptom of systemic carcinoma. Arch Dermatol 1965;92: 37-9. 16. Schoenfeld Y, Weiberg A, Ben-Bassat M, Pinkhas J. Generalized pruritus in metastatic adenoeareinoma of the stomach. Dermatologica 1977;155:122-4. 17. Bluefarb SM. Cutaneous manifestations of the malignant lymphomas. Springfield, IL: Charles C Thomas, Publisher, 1959:245.
ABSTRACTS
Treatment of ehromomycosis with liquid nitrogen De Souza Sittart JA, Valente NYS. Med Cutan Ibero Lat Am 1986;14:227-32 (Spanish) Five patients with ehromomycosis were treated with liquid nitrogen application. The evolution of disease had been of 1 to 25 years, with four patients with verrucous patches and one patient with a sarcoidlike lesion. All cultures showed Fonsecaea pedrosoi. The authors believe that this method of treatment is more economic and avoids hospitalization and surgery. The efficacy of this method has been proved by follow-up of the patients during a period between 2 and 4 years, without any recurrence. Yehudi M. Fehnan, M.D.
Immunoehemical localization of S-100 protein in granular cell myoblastoma Giron GP, Tapia FJ. Mcd Cutan lbero Lat Am 1986;14:101-8 (Spanish) Three cases of granular cell myoblastoma were studied to determine the presence and distribution of the S-100 specific protein in
the neoplastic cells with the use of immunocytochemical staining technics, through the modified avidin-biotin method. Positive immunostaining was observed in the three cases histogenetically originating from neuroectoderm, specifically from Schwann cells; also, the presence of strongly positive staining in Schwann cells of peripheral nerve fibers situated inside and outside the tumor supports the concept of the neurogenic origin of this interesting tumor. Yehudi M. Fehnan, M.D.
Nasal rhinosporidiosis: a case report Mattedi SGM, Cunha A, Boni ES, Palhano L, Anais Bras Dermatol 1986;61:14 ! -4 (Portuguese) A case of nasal rhinosporidiosis of rural origin was observed in the northern region of the Espirito-Santo state (Brazil). The authors detected a nasal polyp in a t2-year-old black boy that presented nasal obstruction and bleeding. The laboratory diagnosis was realized by direct myeologic and histopathologic examination, with the confirmation of the rhinospofidial forms. Yehudi M. Felman, M.D.
Epidermal class 11 HLA expression in atopic dermatitis
Ia antigen on epidermal keratinocytes in graft-versus-host disease. Nature 1981 ;293:149-50. 18. Tjernlund U, Scheynius A. Epidermal cell suspensions containing HLA-DR-expressing keratinocytes amplify the T-cell response in vitro to PPD. J Invest Dermatol 1986;87:172. 19. Breathnach SM, Shimada S, Korvac Z, Katz SI. Immunologic aspects of acute cutaneous graft-versus-host
disease. Decreased density and antigen presenting function of l a + Langerhans cells and absent antigen presenting capacity o f l a + keratinocytes. J Invest Dermatol 1986;86:226-34. 20. Gawkrodger DJ, Carr MM, Guy K, Hunter JAA. Epidermal expression of Class II HLA in allergic and irritant contact dermatitis reactions. Br J Dermatol 1985; 113:767.
Itch and malignancy prognosis in generalized pruritus: A 6-year follow-up of 125 patients Robert Paul, M.D., Riitta Paul, M.D., and Christer T. Jansen, M.D.
Turku, Finland When 125 patients with generalized pruritus were followed up for 6 years, 66% reported continuing pruritus. In four patients a malignancy had been identified at the time of the initial examination, and four other patients developed malignancies during the follow-up period. Seven of the patients died of the malignancy during the follow-up period. This incidence of malignancies does not differ significantly from the value expected in a general population, matched for age and sex. However, two of the cancers were lymphomas, and this incidence is significantly (p < 0.01) higher than that expected in a similarly matched population. As a whole our study indicates that no significant overall increase of malignant neoplasms is to be expected in patients with generalized pruritus and, therefore, any general efforts for cancer follow-up screening seem unwarranted in patients with pruritus. (J AM ACAD DERMATOL1987; 16:1179-82.)
Prolonged generalized pruritus is a problem not infrequently encountered by general practitioners, internists, and dermatologists. Diseases of the internal organs, such as liver failure, uremia, thyroid disease, and polycythemia, ~-4 may be the precipitating cause in 20% to 30% of these cases? Furthermore, pruritus is associated with malignant
From the Departments of Radiotherapy and Dermatology, University of Turku. Accepted for publication Dec. 9, 1986. Reprint requests to: Dr. Christer T. Jansen, Department of Dermatology, The UniversityCentral Hospital of Turku, SF-20520Turku, Finhmd.
diseases. No less than 30% of patients with Hodgkin's disease suffer from pruritus, 6 and patients suffering from lymphomas, leukemias, or solid malignant tumors may also itch. 7 However, there seems to be disagreement in the literature as to how often generalized pruritus is a heralding mark of an underlying malignancy, and figures from 3% to 47% have been reported. ,4.8-~0 We have followed up 125 patients with pruritus for 6 years in an attempt to record the frequency of cancer development and to compare it with frequencies o f malignancy in the general population. Cancer morbidity was screened by two postal inquiries at 3-year intervals, and the cancer mortality
1179
1180
Journal of the American Academy of Dermatology
Paul et al
Table I. Data on the malignancies found in 125 patients with pruritus during the 6-year follow-up period .
.
.
.
Case
Sex
Age (yr)
1 2 3 4 5 6 7 8
M M F F M M F M
62 60 78 59 77 74 72 82
Primary investigation
3-yr
6-yr
Malignancy
follow-up
follow-up
Time from pruritus to cancer diagnosis (mo)
Lymphoma Stomach cancer Breast cancer Lymphoma Lung cancer Lung cancer Renal cancer Lung cancer
+ + + + -
D D D D D -
D D D D D D D +
- 11" - 7* I 11 14 48 52 70
A minus s~gn indicates absence of malignancy, a plus sign denotes presence of cancer, and D means death of patient. *Cancer diagnosed before pruritus.
rate by information obtained from death certificates, which in the majority of cases was based on autopsy findings.
PATIENTS AND METHODS All patients were referred to the Department of Dermatology at the Turku University Hospital between Sept. 1, 1974, and Dec. 31, 1976, because of persistent, generalized, symmetric pruritus not related to any primary skin disorder or manifestation and severe enough to warrant inpatient investigation at a dermatologic clinic. In each case the pruritus had been unresponsive to symptomatic therapy with lubricating cream or topical corticosteroids and had interfered with the patient's sleep. Secondary to scratching, cutaneous excoriation with or without secondary infection was seen. Of the 125 patients who met the inclusion criteria, eighty-one were women and forty-four were men. The mean age of the w o m e n was 46.3 + 18.4 (mean __+ SD) years and of the male patients 62.7 _+ 17.0 years. An initial search for concomitant internal diseases disclosed diabetes in seven, liver disease in five, renal disease in four, thyroid disease in three, pernicious anemia in three, and polycythemia vera in three patients. Four patients had a malignant disease on entry into the study (Table I). A detailed account of the clinical and laboratory findings from the primary investigation has been published elsewhere. ~ Questionnaires were sent to the patients 3 years
and 6 years after the initial examination. The questionnaire contained inquiries about the current state of the skin complaint, medications, physician and hospital contacts, and the general state of health. In addition, it was specifically asked whether the patient had been suspected of having cancer or had a diagnosis of cancer. The first questionnaire was returned, at least partially answered, by 120 of the 125 patients and the second one by 113 patients. If a subject had died, relatives often provided the information. Information on the causes of death was obtained either from death certificates or by contacting the parish of the deceased, the hospital where the patients had died, or the Finnish Central Registry for Causes of Death. In those instances in which no response was obtained to the questionnaire and the current address of the patient was unknown, the Finnish Cancer Registry supplied the information as to whether cancer had been reported concerning the person in question. This nationwide registry has been in operation since 1953, and its coverage is virtually complete.*
RESULTS Persistence of pruritus Pruritus continued unabated 3 years after follow-up in 60 of the patients and 6 years in 44 of the patients (Table lI). The question was left un*Dr. Timo Hakulinen at the Finnish Cancer Registry provided assistance in establishing the incidence figures cited.
Volume 16 Number 6 June 1987
answered or the subject had died in 28 and 46 instances, respectively. Thus of the patients who were alive and had answered the question, 65% still suffered from pruritus at 3 years and 66% at 6 years of follow-up. The single patient with carcinoma who was still alive at the fol!ow-up had persistent itching.
Noncancer deaths During the study, 19 patients died of causes unrelated to malignant neoplasia. Of these, seven were women with a mean age of 70.4 _+ 9.9 ye .ars and 12 were men aged 75.2 _+ 8.6 years.
Cancer morbidity and deaths The cancer data of the patients are presented in Table II. At the time of the primary investigation, four patients were diagnosed as having cancer. Three years later these four plus one additional patient had died of cancer, but no other patient was known to suffer from malignancy. At 6 years of follow-up, two additional patients had died of cancer and one additional case had been diagnosed. The latter patient (case 8 in Table I) died of this condition a few months after the end of the follow-up. Of the seven patients who died of cancer during the follow-up, three were women with a mean age of 70.0 _+ 9.9 years and four were men aged 68.7 _+ 7.4 years. As shown in Table III, the incidence of cancer deaths did not differ significantly from the value expected from the statistics of the Finnish Cancer Registry. However, when the cases of lymphoma were considered separately, a significant overrepresentation was disclosed in the patient population with pruritus (p < 0.01). DISCUSSION Our study lends no support to the belief that patients with systemic pruritus would be more subject to the development of solid cancers than the general population. Indeed, the association mentioned in earlier literature between solid neoplasms and generalized pruritus has often been based on anecdotal reports. 10.i2-17 In contrast, it is well established that Hodgkin's disease and mycosis fungoides are associated with pruritus in a fair number of the cases. 6'13,16 Furthermore, when previously
Malignancy prognosis in generalized pruritus
1181
Table II. Persistence of pruritus Follow-up
Persistent pruritus No pruritus Question unanswered Dead
period
3-yr
6-yr
60 23 14 14
40 32 26 26
Table III. Comparison of expected and observed numbers of malignancies Expected Observed Significance All malignancies Lymphomas
7.99 0.078
7 2
NS p < 0.01
Expectance numbers were compiled from Finnish Cancer Registry statistics.
published series on patients with pruritus are analyzed more closely, a remarkable number of patients with malignancies have in fact suffered from myeloproliferative and lymphoproliferative diseases. Thus in the series of Rajka, 4 who found malignancies in nine out of 34 patients (26%), the diagnosis included five cases of "lymphoma reticulosis" and one case of myeloma. Similarly, in the series of Caravati and Richardson, 3 who found malignancies in seven out of 15 patients with pruritus (47%), the diagnosis included five cases of "lymphoma reticulosis." Vickers, 9 who reported malignancies in 12 out of 76 patients (16%), did not specify diagnoses, but cancers were typed as "neoplasia or reticulosis." Our study does corroborate the studies cited as far as an increased incidence of lymphoma in patients with pruritus is concerned. However, the total incidence of malignancy was quite low: only eight out of 125 (6%). This figure is in conformity with the reports of Lyell, 2 who studied 60 patients with pruritus and found two malignancies (one lymphadenoma), Forman, 8who studied 64 patients and detected three malignancies (two lymphomas), and Beare, t who studied 43 patients and found three malignancies (one lymphoma). In the series of 44 patients with pruritus reported by Kantor and Lookingbill," in two patients cancer was diagnosed before evaluation, one was diagnosed at ini-
1182
Journal of the American Academy of Dermatology
Paul et al
tial evaluation, and one disclosed during the 6.5year follow-up. In addition, one patient developed chronic lymphatic leukemia. We believe that studies citing an incidence of malignancy higher than 10% in patients with pruritus during any reasonable follow-up period are based on selected patient groups not representing the patient population with pruritus as a whole. In fact, the overall malignancy rate in the patient population with pruritus is not much different from that of a similarly aged control population, and generalized pruritus is only a very vague or almost negligible indicator of any propensity for developing a malignant neoplastic disease. Therefore generally applied efforts for cancer tracing will not be cost-effective. REFERENCES 1. Beare J. Generalized pruritus. A study of 43 cases. CIin Exp Dermatol 1976; 1:343-52. 2. Lyell A. The itching patient. A review of the causes of pruritus. Scot Med J 1972;17:334-47. 3. Caravati CM, Richardson DR. Pruritus as a symptom of systemic disease. Va Meal Monthly 1969;96:656-8. 4. Rajka G. Investigation of patients suffering from generalized pruritus, with special references to systemic diseases. Acta Derm Venereol (Stockh) 1966;46"190-4. 5. Anonymous. No panacea for pruritus and still much ignorance. J A M A 1979;241:980.
6. Winkelmann R, Muller S. Pruritus. Ann Rev Med 1964; 15:53-64. 7. Moschella S. Cutaneous manifestations of internal malignancies. Med Clin North Am 1975;59:479-88. 8. Forman L. Pruritus and its management. Br Med J 1954;1:365-7. 9. Vickers C. Iron deficiency and the skin (abstr). Br J Dermatol 1973;89(suppl 9):10. 10. Verhave JH. Itching as precursor phenomenon of mammary cancer. Ned Tijdschr Geneeskd 1926;70:1082-3. 11. Paul R, Timonen T, Jansen CT. Pruritus curls. Finnish Med J 1980;35:3031-6. 11. Kantor GR, Lookingbill DP. Generalized pruritus and systemic disease. J AM ACAD DERMATOL 1983;9:375-82. 12, Becker SW, Kahn D, Rothman S. Cutaneous manifestations of internal malignant tumors. Arch Dermatol Syph 1942;45:1069-80. 13, Goldstein J, Hart J. Pruritus and purpura as unusual symptoms of carcinoma of the bronchus. Tubercle 1959;40:119-20. 14. Winkelmann RK. Dermatological clinics. 1. Comments on pruritus related to systemic disease. Mayo Clin Proc 1961 ;36:187-96. 15. Cormia FE. Pruritus, an uncommon but important symptom of systemic carcinoma. Arch Dermatol 1965;92: 37-9. 16. Schoenfeld Y, Weiberg A, Ben-Bassat M, Pinkhas J. Generalized pruritus in metastatic adenoeareinoma of the stomach. Dermatologica 1977;155:122-4. 17. Bluefarb SM. Cutaneous manifestations of the malignant lymphomas. Springfield, IL: Charles C Thomas, Publisher, 1959:245.
ABSTRACTS
Treatment of ehromomycosis with liquid nitrogen De Souza Sittart JA, Valente NYS. Med Cutan Ibero Lat Am 1986;14:227-32 (Spanish) Five patients with ehromomycosis were treated with liquid nitrogen application. The evolution of disease had been of 1 to 25 years, with four patients with verrucous patches and one patient with a sarcoidlike lesion. All cultures showed Fonsecaea pedrosoi. The authors believe that this method of treatment is more economic and avoids hospitalization and surgery. The efficacy of this method has been proved by follow-up of the patients during a period between 2 and 4 years, without any recurrence. Yehudi M. Fehnan, M.D.
Immunoehemical localization of S-100 protein in granular cell myoblastoma Giron GP, Tapia FJ. Mcd Cutan lbero Lat Am 1986;14:101-8 (Spanish) Three cases of granular cell myoblastoma were studied to determine the presence and distribution of the S-100 specific protein in
the neoplastic cells with the use of immunocytochemical staining technics, through the modified avidin-biotin method. Positive immunostaining was observed in the three cases histogenetically originating from neuroectoderm, specifically from Schwann cells; also, the presence of strongly positive staining in Schwann cells of peripheral nerve fibers situated inside and outside the tumor supports the concept of the neurogenic origin of this interesting tumor. Yehudi M. Fehnan, M.D.
Nasal rhinosporidiosis: a case report Mattedi SGM, Cunha A, Boni ES, Palhano L, Anais Bras Dermatol 1986;61:14 ! -4 (Portuguese) A case of nasal rhinosporidiosis of rural origin was observed in the northern region of the Espirito-Santo state (Brazil). The authors detected a nasal polyp in a t2-year-old black boy that presented nasal obstruction and bleeding. The laboratory diagnosis was realized by direct myeologic and histopathologic examination, with the confirmation of the rhinospofidial forms. Yehudi M. Felman, M.D.