Why classify basal cell carcinomas?

Basal cell carcinoma of the skin is the commonest form of cancer in the white population. A simple pathological classification is presented and recommended for general use to aid clinicians in their management of cases. Basal cell carcinoma can be classified as nodular, infiltrative, superficial apparently multifocal and mixed in terms of the histological growth pattern. These patterns can be related to the likelihood of complete excision and, if excision is incomplete, to the frequency of recurrence.

Characteristics of incompletely excised basal cell carcinomas of the skin.

OBJECTIVES: To determine the proportion of basal cell carcinomas (BCCs) treated by excision biopsy that extended to the margins of surgical excision (incompletely excised tumours) and to identify their characteristics. DESIGN: Case series of BCCs submitted to a single pathologist in the first six months of 1995. SETTING: Rural and metropolitan (Perth) Western Australia. PATIENTS: 268 patients with 353 histologically confirmed BCCs. OUTCOME MEASURES: Age and sex of patients; discipline of referring doctor; anatomical site of BCC; macroscopic features; histological growth pattern; and completeness of excision. RESULTS: Sixteen per cent of BCCs (58/353) extended to the margin of surgical excision. Most of these were situated on the head or neck (43/58; 74%) and were flat (47/58; 81%); a high proportion of incompletely excised BCCs (21/58; 36%) had an infiltrative growth pattern. Recurrent BCCs (28/353; 8%), categorised from the history or because of histologically identified surgical scarring, were even more likely to be flat (26/28; 93%) and to show a microscopic infiltrative growth pattern (18/28; 64%). Seven of the 28 (25%) recurrent BCCs were incompletely excised; all seven were on the head and five had an infiltrative growth pattern. CONCLUSION: Incompletely excised BCCs are those most likely to recur. Because most recurrent tumours are situated on the head and neck and have an infiltrative growth pattern, we recommend that: Pathologists report on the microscopic growth pattern of BCCs as well as on completeness of excision. Clinicians attempt to excise head and neck BCCs with wide margins initially, where possible. Tumours extending to the margin of excision which are infiltrative in pattern and located on the head and neck may be particularly likely to recur, and immediate re-excision should be considered in these patients.

The pathology of Marburg virus disease.

A description of the postmortem pathological findings in a case of Marburg virus disease emphasizes the findings of focal necrosis in the liver, spleen and lymphoid tissue, disseminated intravascular coagulation and acute tubular necrosis. These features are compared and contrasted with those of other potentially fatal viral haemorrhagic fevers to help pathologists make an early diagnosis wherever possible.

Epidemiology of malignant melanoma of the skin in South Africa.

Malignant melanoma constitutes about 2% of all cancers occurring in South Africa. It is between 2,5 and 6 times more frequent in Whites than in Blacks, but the lowest incidence occurs in the Coloured population. The incidence of malignant melanoma in Whites (as reflected by mortality figures) varies with latitude, being higher nearer the Equator. The disease is more common among females and the older age groups in all sections of the population. Whites present with small lesions (generally less than 20 mm in diameter) which may be situated on any part of the body. In Blacks the tumours are large (sometimes more than 100 mm in diameter) when first seen and are predominantly situated on the sole of the foot and the palm of the hand. The 5-year survival rate is 20% in Blacks and 42% in Whites. The survival rates are more favourable in women.

Polyps and papillary lesions of the prostatic urethra.

There is confusion over the type and nature of polypoid and papillary lesions of the prostatic urethra. These are uncommon growths which may present clinically with hematuria, frequency, obstruction or hematospermia. Pathologically, they usually occur in the region of the verumontanum and show papillary epithelial overgrowth. There is much variation in the terminology applied to such lesions, and many different theories of histogenesis have been advanced. Both benign and malignant lesions may occur. Two cases, one benign and one malignant, are described. The literature is reviewed and a rational nomenclature and histogenesis are proposed.

Fungating Bowen's disease with presumed arsenic intoxication. A case report.

A patient with a bizarre fungating tumour of the anterior abdominal wall is described. The lesion had the histological features of Bowen's disease and also had the appearance of a basal cell carcinoma with sebaceous differentiation. In addition, the patient had 'raindrop' pigmentation typical of chronic arsenic intoxication. As far as we know, Bowen's disease has once previously been reported in a Black patient in South Africa. We have not encountered any other description in the literature of Bowen's disease presenting as a fungating tumour.

Unusual aspects of febrile neutrophilic dermatosis (Sweet's syndrome). Case reports.

Two patients with febrile neutrophilic dermatosis (FND) of Sweet's syndrome are described. One patient had acute myeloblastic leukaemia and FND antedated any changes in the peripheral blood. The second patient had bullous lesions which healed, with clinical cutis laxa (acquired anetoderma). In this patient FND had persisted for 8 years and histological examination of the skin lesions showed inflammation of the subcutaneous fat. To our knowledge this represents the first report of panniculitis due to FND.

Chordoid sarcoma of the hand. A case report.

Chordoid sarcoma is a rare, distinctive neoplasm that usually occurs in the soft tissue of the extremities. Despite its striking histological resemblance to chordoma at light microscopic level, both clinical and ultrastructural differences exist and chordoid sarcoma may in fact be related to tendosynovial sarcoma. Previous reports of extraskeletal myxoid chondrosarcoma, however, show that this tumour bears a striking light microscopic and ultrastructural similarity to chordoid sarcoma, which suggests that the latter may be a variant of extraskeletal myxoid chondrosarcoma. In this report a further case of chordoid sarcoma is presented; clinical, radiological, histological and ultramicroscopic features support a tendosynovial origin.

Prediction of aggressive behavior in basal cell carcinoma.

In this study, a series of aggressively behaving basal cell carcinomas has been contrasted with a series of the nonaggressive type (metastasizing lesions were not considered in this study). Aggressive tumors were characteristically more likely to be ulcerative and infiltrative. They were composed of small groups of cells often displaying an irregular spiky appearance; infiltration of cells in cords, only one or two cells thick, could be seen. There was loss of peripheral palisading: the cells tended not to show differentiation. Hyalinization of the stroma was more common in the aggressive tumors. It is postulated that by utilizing these criteria, the pathologist can confidently diagnose the majority of cases and forewarn the clinician that a particular tumor is potentially aggressive. Adequate treatment and careful follow-up then become feasible.

Paraganglioma of the orbit - an exercise in diagnosis. A case report.

A case is described of a child presenting with an extremely large orbital tumour, which had an alveolar pattern on histological examination. The differential diagnosis, which included alveolar rhabdomyosarcoma, alveolar soft-part sarcoma and non-chromaffin paraganglioma, could only be made on electron microscopic examination. Exact diagnosis was important because of prognostic and therapeutic implications. The presence of neurosecretory granules in tumour cells was demonstrated on electron microscopy, confirming the diagnosis on non-chromaffin paraganglioma, a benign tumour which is extremely rare in this site.

Cutaneous necrosis caused by the bite of Chiracanthium spiders.

Spiders of the genus Chiracanthium are very common in and about homes in southern Africa. The bite of this spider results in cutaneous necrosis. The clinical and histopathological features and the natural history and identification of these spiders are discussed briefly.

The presentation of malignant melanoma.

Survival figures for patients with malignant melanoma in South Africa compare rather unfavourably with those from other countries, for example Queensland, Australia. The chief reason for this seems to be the late stage at which patients present with the tumour and hence the late diagnosis of melanoma in this country. A series of patients was studied and note was taken of their presenting symptoms and signs, which included growth of a pigmented lesion, bleeding, darkening, pain, tenderness and itching. Ulceration and satellitosis had developed in a small proportion of cases. Awareness of this tumour and education as to the circumstances in which it should be suspected should be encouraged, so as to ensure earlier diagnosis and treatment and thus higher survival rates.

Dilatation and curettage.

A retrospective study was undertaken in which the histopathology reports on 1,000 specimens of endometrial curettings were reviewed in order to assess the value of pathological examination of the endometrium. In this series the reports were of use in only one-half of the specimens submitted. A seemingly high proportion of specimens was unsuitable for histological assessment. The main factors contributing to the pathologist's inability to provide a useful report appear to be inadequacy of the specimen and a lack of information regarding the clinical and menstrual history. Alternative methods of endometrial sampling are also briefly reviewed.

Articular cartilage degradation and the pathology of haemophilic arthropathy.

Synovial membrane and specimens of articular cartilage, obtained from the affected knee joints of 5 haemophilic patients at the time of surgical synovectomy, were studied. All the synovial specimens showed villous proliferation and multiplication of synovial cells. Haemosiderin granules were present within synovial cells and in macrophages. There was congestion and capillary proliferation. An inflammatory infiltrate of plasma cells and lymphocytes was seen in some instances. Articular cartilage changes were classified into the following 4 grades according to severity: 1--an increase in the number of surface chondrocytes with fibrous metaplasia, and the appearance of superficial fissures; 2--a fibrous vascularized overgrowth, resembling rheumatoid pannus; 3--deep fissuring and necrosis of cartilage; 4--erosion and disappearance of articular cartilage with exposure of subchondral bone. In the first 3 grades, deep nests of chondrocytes containing haemosiderin were present. These cell aggregates became larger and more degenerate as cartilage degradation progressed. Damaged articular cartilage was deficient in glycosaminoglycan (acid mucopolysaccharide). No excess enzyme activity could be demonstrated within the cartilage matrix. Immunofluorescent studies were not helpful. Electron microscopical examination revealed siderosomes within degenerate chondrocytes and synovial cells. Granules resembling haemosiderin were also present in the cartilage matrix. It is considered that iron products affect both chondrocytes and matrix adversely and play a part in articular cartilage destruction in haemophilia.

Acral lentiginous melanoma or Hutchinson's melanotic freckle of the extremities. A case report.

An additional category of malignant melanoma of the skin, i.e. acral lentiginous melanoma, has been proposed by some authors. The lesion occurs on the extremities, particularly the soles of the feet, the palms of the hands and the digits, but otherwise has the clinical, histological and prognostic features of Hutchinson's melanotic freckle with melanoma. A case conforming to the description of Hutchinson's melanotic freckle of the sole of the foot occurring in a White patient is described. Reference is also made to previous studies of malignant melanoma of the extremities in Black patients. In 15% of these the histogenetic pattern of Hutchinson's melanotic freckle could be observed in the epidermis, adjacent to the invasive melanoma. This pattern was associated with a very much better prognosis than was the superficial spreading or nodular type. The advisability of introducing a new category of acral lentiginous melanoma is therefore questioned.