A PATHOLOGIST'S SURVEY OF SUPERFICIAL TUMORS REMOVED IN A CASUALTY DEPARTMENT* T. F. HEWER

Professor of Pathology, University of Bristol. The Casualty Department of a large hospital provides a fascinating collection of clinical material, ranging as it does from street accidents and sudden severe medical or surgical illness to the patient who wishes to have a minor cutaneous blemish removed for cosmetic reasons. It is especially the people in the last category and those with less trivial but apparently minor superficial lesions who provide a wealth of varied t0 problems for the diagnostic histology department. Fortunately it is the custom send all such tissue for examination. From the pathologist's point of view these superficial lesions provide a most interest' of the can be obtained exercise. Some idea of the

variety

ing diagnostic list (Table i) which

by scrutiny

are represents the specimens received in twelve months. They listed not in order of frequency but in groups of more or less related conditions* the number of examples of each is indicated alongside. TABLE I No. of

Diagnosis Inflammatory Epithelial hyperplasia, Epidermal cyst

not

Specimens

primarily inflammatory

Keratosis senilis

2

Squamous papilloma Cornu cutaneum (sebaceous wart) Squamous carcinoma

Basal cell carcinoma Verruca vulgaris Verruca plantaris Molluscum sebaceum

38 2

14 22

8 2

( pseudocarcinomatosum] Benign calcified "epithelioma" Molluscum contagiosum Fibro-epithelial polyp Benign sweat gland tumour Malignant sweat gland tumour Secondary carcinoma Benign melanoma Malignant melanoma Blue

23 5 23

=

naevus

4 4 1

9 1 1

5 24 6 1

Benign juvenile melanoma Histiocytoma (sclerosing angioma) Haemangioma Lymphangioma Lipoma

22

Sarcoma

15 6

1

4 18 1

Neurofibroma

(five being neurofibrosarcoma) Leiomyoma

2

Keloid

5

Foreign body granuloma

2

Other Lesions Total

282

* Originally written for the Report of the South Western Regional Cancer Recor and reproduced with permission of the Director. This material came from the Casualty Department of the Bristol Royal Infirmary-

14

SURVEY OF SUPERFICIAL TUMORS REMOVED IN CASUALTY DEPT.

The epidermal cysts included eight sebaceous cysts but the remainder

rniXed

there

15 were a

very

implantation dermoids but several were simple cysts with n? sebaceous glands alongside, lined by degenerate squamous epithelium and containlng desquamated keratin and amorphous debris which did not appear sebaceous in the gross. Some of these were doubtless due to obstruction of sweat glands, irregular hair 0 ucles and other disorders of epithelial adnexa and all were unmistakably benign. A-n observation often made in the laboratory is that a large number of excised cutaneous lesions are described on the report form as sebaceous cysts. They are generally sent unopened?and we prefer to receive them like that?and in conse** *S not easy to determine at the time of excision whether they are cystic or This point is worth mentioning because there must be occasions in practice erea rounded subcutaneous tumour which appears cystic may in fact be a carcinoma astasis or one of the many forms of sub-epidermal basal cell carcinoma. SqUamous Papdlomata seldom gave much difficulty in diagnosis and the same Was t^ie henign calcified "epitheliomata" although the latter condition is t,rUe to be misleading and trap the unwary into making a false diagnosis ri(?Usly apt 0f bag;

were a

few

?

,

malignancy.

olluscum sebaceum 01

or,

as

it is often

called, kerato-acanthoma or?another

pseudocarcinomatosum is a condition that always causes the It ??lst anxiety. rapidly, in a few weeks, and forms a rounded projecting grows e tumour with central keratinization. Quite miraculously it regresses in a few ^ore Wee^s and leaves a scar. Histologically it is often impossible to be certain that it is6n0t

hist

i

rnolluscum

?

for

e

\yere

a true squamous carcinoma and consultation with the clinician is essential accurate diagnosis.

melanomata

are an

important

and

interesting

group.

Some of the

benign

ones

^?r cosmetic but suspicion of malignancy. The benign juveniiem?Ve^ .e n^lanoma, of which only example appeared in the year under review, is s0rn of its quite alarming histological appear^es mistakenly reported malignant the small lesions removed diagnosis fC0n? t^le The difficult specimensisforfaced with in the most on

reasons

one

as

on

more

account

were

ophthalmic surgeon peculiar difficulty removing Whole & the tend ^es.*on on *he lid margin and when the excision is for a diagnostic biopsy such c enC^ 1S-' very ProPerlY> to he conservative. Not infrequently the specimen in a S^?e ^keratinizing epidermis with no indication of the junction With r

theed?0n^StS

examination of every Out-Pa}^16 histological t^ie

piece of tissue removed in Casualty, in Senera^ practitioner's surgery is a most necessary precaution. at t^le ^egi?nal Cancer Records Bureau will always be informed when one to be malignant or equivocal because a follow-up in such proves cases is res/0ns. highest importance. This is perhaps particularly true in the case of the basal cell since they may not have been completely removed, and the IUalignarit Carcin?mata, me^anomata because these latter are not necessarily as malignant as their reputati0n at ^e fir t Su?gests and careful observation with prompt dissection of lymph nodes ?.Itl>inkthP,P'ara.nceof a recurrence may well be a life-saving measure. that there 6 most important point arising from a survey of material such as this is are numerous conditions on the borderline of malignancy: many of them ^ ^ear rep0rte^re an^ even when uncertainty is expressed by the pathologist I that the ^Us lost s^vT^6 *S not rePorted to the Cancer Bureau. I am sure a lot of patients are ls ^ anc^ ^ suggest that an improvement in the procedure of follow-up 0verdue One ho these T

?r *n

?

A Pathologist's Survey of Superficial Tumors Removed in a Casualty Department.

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