Martin H. Brownstein

Metastatic tumors of the skin

The clinical and pathologic features of cutaneous metastasis were studied in 724 patients, with histopathologic confirmation of both the primary tumors and the secondary lesions in the skin. Cutaneous metastatic lesions from carcinoma of the lung and kidney were usually found in men, were often recognized before the primary tumor, and appeared in almost every area of the skin surface. Metastasis from carcinoma of the breast to the skin occurred almost exclusively in women, tended to be localized to the anterior chest wall, and was usually found after the primary tumor. Most cutaneous lesions metastasizing from squamous cell carcinoma of the oral cavity were found on the face or neck of men in whom there was previous histologic documentation of the primary tumor.

Gowden's disease. A cutaneous marker of breast cancer

Cowdens disease features facial trichilemmomas (a benign tumor of follicular epithelium), acral keratoses on the limbs, and oral mucosal papillomas and fibromas; it may also involve thyroid, gastrointestinal tract, ovaries, uterus, and breasts. Among 32 known cases of Cowdens disease, 21 are women, in 10 of whom breast cancer has already developed (bilateral in 4). The 11 women in whom breast cancer has not yet developed have fibroadenomas, fibrocystic disease, virginal hypertrophy of the breasts, and malformations of nipples and areolae. Their median age is only 36 years. Two have mothers with breast cancer and in one both mother and maternal grandmother had breast cancer. Dermatologic lesions, including pathognomonic multiple facial trichilemmomas, precede the development of malignancy and can identify women with a high risk of developing breast cancer.

The dermatopathology of Cowden's syndrome*

During the past 2 years we have studied eighty‐nine biopsy specimens from nineteen patients with Cowdens syndrome. Among fifty‐three facial lesions, twenty‐nine were trichilemmomas. Twenty‐ three of the others were consistent with trichilemmoma, showed a non‐specific benign verrucous acanthoma, or were not diagnostic; one was a bluenaevus. All fourteen oral mucosal biopsy specimens were benign fibromas. Nineteen of twenty‐two biopsy specimens from the hands and feet showed the pattern of benign keratosis. Multiple trichilemmomas were found in all patients with Cowdens syndrome, but at times several biopsy specimens were required before a diagnostic picture was un‐ covered. All patients with multiple facial trichilemmomas were found to have Cowdens syndrome. The combination of multiple facial trichilemmomas, oral fibromas, and benign acral keratoses enables one to diagnose Cowdens syndrome at a stage before serious internal complications develop.

Proliferating trichilemmal cyst: a simulant of squamous cell carcinoma.

Comparison of 50 proliferating trichilemmal cysts with 50 “ordinary” trichilemmal cysts indicated that both types almost invariably occurred on the scalps of women, were diagnosed clinically as cysts, followed a benign course, and featured trichilemmal keratinization. A spectrum was observed from trichilemmal cyst with minimal hyperplasia, to full‐blown proliferating trichilemmal cyst. Occasionally, patients had ordinary trichilemmal cysts on their scalps associated with a proliferating trichilemmal cyst. In addition to trichilemmal keratinization, which is characteristic of the follicular isthmus, proliferating trichilemmal cysts showed a wider range of differentiation, including features of the follicular infundibulum, the lower nonkeratinizing portion of the follicular outer root sheath, and sebaceous cells. Intense inflammatory infiltrate and cellular atypia, sometimes of significant proportions, were also seen in proliferating trichilemmal cysts. It is concluded that trauma and inflammation may induce a trichilemmal cyst to proliferate and show a broader spectrum of pilosebaceous differentiation and cellular atypia of pseudocarcinomatous proportions, while maintaining its benign biologic behavior.

Verrucous carcinoma of skin: epithelioma cuniculatum plantare.

Eight patients had plantar growths that were usually irregularly shaped, sharply outlined, verrucous, and several centimeters in greatest dimension. Clinical diagnoses included viral wart, deep mycosis, pyogenic granuloma, amelanotic melanoma, basal cell carcinoma, and eccrine poroma. The median age of the patients, and duration of the growth, were 52 and 16 years, respectively. Therapeutic modalities other than total excision were ineffective. The tumor, derived from surface epidermis, was composed of masses of pale‐staining benign‐appearing prickle cells, deeply invaginated by thick, compact, partially parakeratotic horn. Several lesions have recurred; amputation was required in one patient. This distinctive entity, apparently not described in the American literature, has been reported from Europe under such titles as epithelioma cuniculatum and papillomatosis cutis carcinoides. We believe that it is best interpreted as a form of verrucous carcinoma, the first cutaneous tumor–‐as opposed to lesions of mucous membranes and mucocutaneous junctions–‐to be so classified.

HERPES SIMPLEX AND VARICELLA-ZOSTER: COMPARATIVE HISTOPATHOLOGY OF 77 CASES

Biopsies of clinically diagnosed viral vesicles were obtained from 118 patients seen during a 15-month period. The durations of the lesions before biopsy were iecorded. Specimens weie removed under local anesthesia with a cutaneotis punch or scalpel. The tissue was processed routinely, sectioned at 6 micra, and stained with hematoxylin and eosin. Biopsies were considered acceptable for inclusion in tbe sttidy only if unequivocal multinucleated balloon cells were identified within the vesicle. On this basis, 41 of the samples were eliminated, leaving a definitive case series of 77. Clin-

Biphasic amyloidosis: link between macular and lichenoid forms*

A woman manifested lichen amyloidosus of the right lower limb and macular amyloidosis of her left leg with congenitally impaired cutaneous sensation. Another patient had bilateral lichenoid amyloidosis of her legs. Unilateral triamcinolone injections produced the picture of macular amyloidosis in the treated leg. Light and electron microscopic studies of biopsies from both patients showed similar amyloid deposits in the papillae; the significant difference was epidermal hyperplasia in the lichenoid lesions. We suggest the term biophasic for the existence of both macular and lichenoid amyloidosis in the same patient.

Trichilemmal horn: cutaneous horn showing trichilemmal keratinization

A unique and distinctive clinicopathological entity occurred in nineteen patients who ranged in age from 16 to 72 ‘median 50) years. Clinically, these were solitary cutaneous horns. Nine were on the limbs, four on the back, two on the face, three on the scalp, and in one the site was not known; the median duration was 2 years. Histologically, there was a benign picture with a protrusion of massive horn and trichilemmal keratinization at the base. This tumour, which I have named trichilemmal horn, must be differentiated from other lesions that show trichilemmal keratinization ‘trichilemmal cyst, proliferating trichilemmal cyst, keratoacanthoma) and from other cutaneous horns, including trichilemmomal horn ‘cutaneous horn overlying trichilemmoma).