|Year : 2017 | Volume
| Issue : 2 | Page : 371-373
Bowen's disease: Two case reports of a giant and dwarf lesions
Sundar Nagakeerthana, Gurumoorthy Rajesh, Sankar Madhavi, Kaliaperumal Karthikeyan
Department of Dermatology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
|Date of Web Publication||23-Jun-2017|
Department of Dermatology, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry - 605 107
Source of Support: None, Conflict of Interest: None
Bowen's disease is a form of intraepidermal squamous cell carcinoma (SCC). It usually presents as a well-demarcated, slow growing erythematous patch, or plaque with a scaly or crusted surface. The size of the tumor varies from a few millimeters to several centimeters. The risk of progression into an invasive carcinoma is 3–5% in extragenital lesions and about 10% in genital lesions. We present two cases of Bowen's disease where the pattern, size, and perception of the disease between the patients varied. The two cases demonstrated two varying spectrum of the disease, one being a giant lesion and other a dwarf. One patient was more concerned about the lesion, whereas the other patient neglected the lesions, though widespread. High index of suspicion is required to diagnose such atypical presentations of Bowen's disease. As Bowen's disease has tendency to progress to SCC, it should be diagnosed and treated as early as possible.
Keywords: Bowen's disease, carcinoma, premalignant, squamous cell carcinoma
|How to cite this article:|
Nagakeerthana S, Rajesh G, Madhavi S, Karthikeyan K. Bowen's disease: Two case reports of a giant and dwarf lesions. J Can Res Ther 2017;13:371-3
| > Introduction|| |
Bowen's disease is a form of intraepidermal (in situ) squamous cell carcinoma (SCC), usually presents as a well-demarcated growing erythematous patch or plaque with a scaly or crusted surface. It is very common in the Caucasian population with an incidence of about 1.42/1000. As Bowen's disease may progress to SCC, it should be diagnosed and treated as early as possible. We present two cases of Bowen's disease where the pattern, size, and perception of the disease between the patients varied.
| > Case Reports|| |
A 73-year-old male, presented to our dermatology out-patient department with complaints of a gradually increasing localized itchy-raised lesion over buttocks for past 3 years and no history of any oozing from lesion. He was a known case of hypertension and diabetes mellitus for past 3 years and on regular treatment. Patient had applied an unknown topical medication for a long period and also history of chronic sun exposure. On examination, a well-defined hyperpigmented plaque of size 15 cm × 16 cm was seen over the right gluteal region [Figure 1]a. The center of the plaque showed depigmentation, areas of atrophy, and yellowish crust. Routine hematological examination revealed anemia, and other investigations were normal. Biopsy from the plaque revealed features suggestive of Bowen's disease with focal micro invasion [Figure 1]b. Wide local excision with split skin grafting was done, and patient is being followed up.
|Figure 1: (a) Large neglected Bowen's disease of size 15 cm × 16 cm seen over the right gluteal region. (b) Histopathology shows hyperkeratosis, acanthosis and adjacent epidermis showed cells with pleomorphism, hyperchromatism and dyskeratosis, with intact dermoepidermal junction (H and E, ×10)|
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A 57-year-old female came to our dermatology out-patient department with 1 year history of gradually increasing dark-raised lesion over left submammary region, associated with mild pain for past 1 week. Patient routinely wears saree, a traditional outfit of South India; therefore, the left side of abdomen may be exposed to sunlight and the lesion is prone to friction with the blouse. She had no history of similar lesion elsewhere in the body. Patient consulted us with concern of malignancy. On examination, scaly hyperpigmented plaque of size 1 cm × 1 cm coalescing with multiple hyperpigmented papules of size 0.3 cm arranged in a linear pattern seen over the left submammary region [Figure 2]a. Routine hematological examinations revealed anemia, other investigation were normal. Histological examination of initial punch biopsy specimen showed features suggestive of micro invasive SCC [Figure 2]b. A wide local excision was done and histopathology revealed hyperkeratosis, acanthosis, and adjacent epidermis showed cells with pleomorphism, hyperchromatism, and dyskeratosis. Focus of epidermis showed micro invasion surrounded by mild stromal reaction.
|Figure 2: (a) Linear streaky Bowen's disease seen over left submammary region, (b) histopathology shows numerous atypical keratinocytes (H and E, ×40)|
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| > Discussion|| |
Bowen's disease is an in situ SCC which was first described by John Bowen in 1912. It presents as a slow-growing, sharply demarcated erythematous scaly patch. It may also have features such as hyperkeratosis, crusting, fissuring, or pigmentary changes. Although Bowen's disease is usually seen in sites of chronic sun exposure, it can occur on any mucocutaneous surface. The size of the tumor varies from a few millimeters to several centimeters.
Bowen's disease may occur at any age in adults but is rare before the age of 30 years; most patients are aged over sixty and the male-to female ratio is found to be approximately equal., Lesions are usually solitary but are multiple in 10–20% of patients. Any site may be affected, common sites involved are flexural, perianal, subungual, and genital region, involvement of palms or soles is uncommon. A study by Kossard and Rosen were 1001 patients with Bowen's disease were analyzed showed female preponderance, and the lower limbs in women and on the scalp and ears in men were the commonly affected site. Psoriasiform, atrophic, verrucous, hypertrophic, pigmented, and irregular variants have been reported. The risk of progression into an invasive carcinoma is 3–5% in extragenital lesions and about 10% in genital lesions.
Several etiological factors of Bowen's disease have been reported, such as chronic solar damage, arsenic exposure, immunosuppression, human papilloma viruses, and some others such as ionizing radiation, chronic injury, or dermatoses. There are several cases of Bowen's disease arising in seborrhoeic keratosis, and it has also been reported in porokeratoses and in a Becker's nevus.,
In our patients, two patterns were observed, the linear pattern along the submammary region and the large lesion almost involving the entire right gluteal region. One patient was more concerned about the lesion whereas the other patient neglected and was not worried about the lesions though the lesions were widespread, and surface changes such as erosion, crusting, depigmentation, and atrophy were present, which were signs of development of invasive carcinoma. These two cases demonstrate two varying spectrum of the disease, one being a giant lesion (15 cm × 16 cm) over sun protected area of the body, whereas the other was a dwarf over sun exposed region of abdomen.
Most of the times Bowen's disease could not be easily distinguished from other skin lesions without a histopathological examination. Histologically, Bowen's disease is characterized by hyperkeratosis, parakeratosis, and acanthosis with thickened and elongated rete ridges. Scattered atypical cells and frequent mitoses are present. The keratinocytes show loss of maturity and polarity, giving the epidermis a disordered or “windblown” appearance. The dermal epidermal junction is intact, which distinguishes Bowen's disease from invasive SCC. Moderate inflammatory infiltrate of lymphocytes and histiocytes may be present.
The choice of treatment should be guided by efficacy, location, and size of Bowen's disease, number of lesions, availability of the therapy, the clinician's expertise, patient factors such as age, immune status, concomitant medication, comorbidities and compliance; cosmetic outcome and the patient's preference. Treatment options for Bowen's disease includes cryotherapy, curettage with cautery, excision, 5-fluorouracil, radiotherapy, carbon dioxide laser, photodynamic therapy, and 5% imiquimod therapy. In our patient, wide local excision was done in both the case considering a possible malignant transformation.
There is no risk of metastasis with Bowen's disease because it is confined to the epidermis; however, if the disease is not treated completely it may progress to invasive SCC, which then carries a risk of metastasis. High index of suspicion is required to diagnose such atypical presentations of Bowen's disease. The uniqueness seen in our patients was linear streaky Bowen's disease and a large neglected Bowen's disease. To the best of our knowledge, this is the largest Bowen's disease reported in the literature.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]