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ATLAS OF TUMOR PATHOLOGY

Third Series
Fascicle 1

NON-MELANOCYTIC TUMORS OF THE SKIN

by

GEORGE F. MURPHY, M.D.
Department of Dermatology
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania 19104

and

DAVID E. ELDER, M.B., Ch.B., F.R.C.P.A.
Department of Pathology and Laboratory Medicine
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania 19104

Published by the
ARMED FORCES INSTITUTE OF PATHOLOGY
Washington, D.C.

Under the Auspices of
UNIVERSITIES ASSOCIATED
FOR RESEARCH AND EDUCATION
IN PATHOLOGY, INC.
Bethesda, Maryland
1991

Accepted for Publication
1990

Available from the American Registry of Pathology
Armed Forces Institute of Pathology
Washington, D.C. 20306-6000
ISSN 0160-6344

ATLAS OF TUMOR PATHOLOGY

EDITOR
JUAN ROSAI, M.D.
Department of Pathology
Yale University School of Medicine
New Haven, Connecticut 06510-8070

ASSOCIATE EDITOR
LESLIE H. SOBIN, M.D.
Armed Forces Institute of Pathology
Washington, D.C. 20306-6000

EDITORIAL ADVISORY BOARD


John G. Batsakis, M.D.
U.T. M.D. Anderson Cancer Center
Houston, Texas 77030

Ronald A. DeLellis, M.D.
Tufts University School of Medicine
Boston, Massachusetts 02111

Glauco Frizzera, M.D.
Armed Forces Institute of Pathology
Washington, D.C. 20306-6000

Leonard B. Kahn, M.D.
Long Island Jewish Hospital
New Hyde Park, New York 11042

Richard L. Kempson, M.D.
Stanford University Medical School
Stanford, California 94305

Lance A. Liotta, M.D., Ph.D.
National Cancer Institute
Bethesda, Maryland 20892

Paul Peter Rosen, M.D.
Memorial Hospital
New York, New York 10021

Robert E. Scully, M.D.
Harvard Medical School and
Massachusetts General Hospital
Boston, Massachusetts 02114

Sharon Weiss, M.D.
University of Michigan School of Medicine
Ann Arbor, Michigan 48109-0602


EDITORS' NOTE

The Atlas of Tumor Pathology has a long and distinguished history. It was
first conceived at a Cancer Research Meeting held in St. Louis in September
1947 as an attempt to standardize the nomenclature of neoplastic diseases.
The first series was sponsored by the National Academy of Sciences-National
Research Council. The organization of this Sisyphean effort was entrusted to
the Subcommittee on Oncology of the Committee on Pathology, and Dr. Arthur
Purdy Stout was the first editor-in-chief. Many of the illustrations were
provided by the Medical Illustration Service of the Armed Forces Institute of
Pathology, the type was set by the Government Printing Office, and the final
printing was done at the Armed Forces Institute of Pathology (hence the
colloquial appellation "AFIP Fascicles"). The American Registry of Pathology
purchased the Fascicles from the Government Printing Office and sold them
virtually at cost. Over a period of 20 years, approximately 15,000 copies
each of nearly 40 Fascicles were produced. The worldwide impact that these
publications have had over the years has largely surpassed the original goal.
The Fascicles quickly became some of the most influential publications on
tumor pathology ever written, primarily because of their overall high quality
but also because their low cost made them easily accessible to pathologists
and other students of oncology the world over.

Upon completion of the first series, the National Academy of Sciences-
National Research Council handed further pursuit of the project over to the
newly created Universities Associated for Research and Education in Pathology
(UAREP). A second series was started, generously supported by grants from the
AFIP, the National Cancer Institute, and the American Cancer Society. Dr.
Harlan I. Firminger became the editor-in-chief and was succeeded by Dr.
William H. Hartmann. The second series Fascicles were produced as bound
volumes instead of loose leaflets. They featured a more comprehensive
coverage of the subjects, to the extent that the Fascicles could no longer be
regarded as "atlases" but rather as monographs describing and illustrating in
detail the tumors and tumor-like conditions of the various organs and
systems.

Once the second series was completed, with a success that matched that of the
first, UAREP and AFIP decided to embark on a third series. A new editor-in-
chief and an associate editor were selected, and a distinguished editorial
board was appointed. The mandate for the third series remains the same as for
the previous ones, i.e., to oversee the production of an eminently practical
publication with surgical pathologists as its primary audience, but also
aimed at other workers in oncology. The main purposes of this series are to
promote a consistent, unified, and biologically sound nomenclature; to guide
the surgical pathologist in the diagnosis of the various tumors and tumor-
like lesions; and to provide relevant histogenetic, pathogenetic, and
clinicopathologic information on these entities. Just as the second series
included data obtained from ultrastructural (and, in the more recent
Fascicles, immunohistochemical) examination, the third series will, in
addition, incorporate pertinent information obtained with the newer molecular
biology techniques. As in the past, a continuous attempt will be made to
correlate, whenever possible, the nomenclature used in the Fascicles with
that proposed by the World Health Organization's International Histological
Classification of Tumors. The format of the third series has been changed in
order to incorporate additional items and to ensure a consistency of style
throughout. Close cooperation between the various authors and their
respective liaisons from the editorial board will be emphasized to minimize
unnecessary repetition and discrepancies.

To its everlasting credit, the participation and commitment of the AFIP to
this venture is even more substantial and encompassing than in previous
series. It now extends to virtually all scientific, technical, and financial
aspects of the production.

The task confronting the various organizations and numerous individuals
involved in the third series is even more daunting than in the preceding
efforts because of the ever-increasing complexity of the matter at hand. It
is hoped that this combined effort — of which, needless to say, that
represented by the authors is first and foremost — will result in a series
worthy of its two illustrious predecessors and will be a suitable
introduction to the tumor pathology of the twenty-first century.

Juan Rosai, M.D.
Leslie H. Sobin, M.D.


DEDICATION

This book is dedicated to the memory of Piero Paci, M.D., surgical
pathologist at the Brigham and Women's Hospital and the Harvard Medical
School. His vast knowledge of pathology was not bounded by subspecialization,
and his approach to this discipline he loved blended assurance of experience
with selfless open-mindedness, always tempered by a critical turn of mind. He
taught students and colleagues how to mix diagnostic accuracy and judgment
with an extraordinary sense of humanity. "He liked to do things, rather than
write about them," commented one of his many friends and colleagues, Ramzi
Cotran. Countless numbers of patients benefited from his enormous diagnostic
expertise and his profound sense of caring. To this approach to the practice
of pathology, this first Fascicle of the Third Series is dedicated.


ACKNOWLEDGMENTS

The development and completion of this Fascicle depended upon the expertise,
devotion, and support of a diverse array of colleagues, friends, and family.
First, we are grateful to Dr. Herbert Z. Lund, whose fascicles on skin tumors
written some 30 years ago have provided a solid base for the formulation of
this present work. Drs. Martin C. Mihm and Wallace Clark provided us with
much of the training, knowledge, analytical sense, and appreciation of the
importance of a critically scientific and open-minded approach to
dermatopathology that prompted us to dare to undertake such a challenge. We
are indebted to Dr. Gerald Lazarus and to the patients and staff of the
University of Pennsylvania Dermatology Clinics for providing clinical
photographs and data, which is crucial to the comprehensive understanding of
cutaneous neoplasia. Drs. Steven Binnick, Jane Chatten, Wallace Clark,
Phillip Cooper, Terence Harrist, Ken Hashimoto, Antoinette Hood, Christine
Jaworsky, Bernett Johnson, Waine Johnson, Robert M. Lavker, Phil LeBoit,
Stuart Lessin, Virginia LiVolsi, Gwen Mazoujian, P. Michael Olmstead, Richard
Reed, Kurt Stenn, and Margaret Gray Wood, and the family of Dr. David Rulon
kindly provided slide material invaluable to the preparation of this work.
Drs. John Woosley and Rosalie Elenitsas, while serving as Fellows in our
Department, maintained an extraordinarily comprehensive teaching set that was
integral to the depiction of many of the tumors included in this work. Dr.
Elenitsas also provided invaluable editorial assistance. Coordination of
terminology used in this Fascicle with that of the new WHO Histological
Classification of Skin Tumors, currently in preparation, is being
accomplished with the collegial interaction and guidance of Dr. Peter Heenan.
Preparation of photomicrographs was facilitated by the expert assistance of
Ms. Diana Whitaker and Mr. William Witmer, and the histotechnologists of the
Departments of Pathology and Dermatology of the University of Pennsylvania
provided tissue specimens of unsurpassed quality. Ms. Jenny Michael provided
transcriptional and proofreading support that was invaluable to the
production of a finished text. Dr. Leslie Sobin of the Armed Forces Institute
of Pathology graciously provided written material not readily available to us
and assisted in the quality control of photomicrography. Drs. Sharon Weiss,
Juan Rosai, and outside reviewers unknown to us, generously and selflessly
gave time, effort, and expertise so that a roughly hewn draft could evolve
into a finished work.

Finally, we thank our wives, Sharon and Peggy, and our children, Erin, Emily,
Kate, and Kenneth for their love, patience, faith, and encouragement, without
which this volume would never have been accomplished.

George F. Murphy, M.D.
David E. Elder, M.B., Ch.B., F.R.C.P.A.

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