Dermatopathology: Practical & Conceptual

October – December 2010 | Volume 16, No. 4

“Precanceroses”: Cancers All! Contrary View of Behalf of Patients by A. Bernard Ackerman, M.D., and Joan M. Mones, D.O.

Hurt, Mark A.; Walsh, Sarah N.; Zelger, Bernhard

The Cover

Fig 1

Cover of “Precanceroses”: Cancers All! Contrary View of Behalf of Patients by A. Bernard Ackerman, M.D., and Joan M. Mones, D.O. A Monograph from Ardor Scribendi, Ltd. New York City, 2009. ISBN 978-1-893357-38-9.

Review by Sarah N. Walsh, M.D.

Contrary View on Behalf of Patients. “Precanceroses”: Cancers All! by A. Bernard Ackerman, M.D., and Joan M. Mones, D.O., is a 238 page soft cover monograph. The contents of the monograph consist of a foreword, glossary of relevant terms, a short historical perspective on the concept and term “precancerosis,” examples of “precancers,” and an afterward. The meat of this monograph, of course, is the examples of entities erroneously labeled, historically or otherwise, as precancers, each separated as its own section or chapter. The examples include solar keratosis and actinic chelitis, Bowen’s disease and Erythroplasia of Queyrat, bowenoid papulosis, fibroepithelioma of Pinkus, extramammary Paget’s disease, lentigo maligna and primary acquired melanosis of the conjunctiva, and large and small plaque parapsoriasis. The vast majority of the monograph is solid text; there are very few clinical or histological photographs. Each of the sections (chapters) of an example of a “precancerosis” is organized in a similar format which begins with a historical perspective, then by a list of the same 9 questions answered with both the conventional thought on the topic, followed by the authors’ concept of the topic, concluding with a list of references. A few of the topics/chapters, additionally, have a 10th question that addresses “other misconceptions” about the topic.

The style of writing in the monograph is typical of Dr. Ackerman, who prefers to use adjectives subsequent to the noun (e.g., “Perspective Historical”). While this style may be grammatically correct, it makes the text difficult and cumbersome to read, with some of the details in the text being lost in an effort to decipher them. The layout of the text is also done in Dr. Ackerman’s usual fashion, with numerous direct quotations from various articles in the literature on the topic. This style, while somewhat choppy and difficult to fluently read, is effective. Direct quotations from the actual references could not be any more convincing — it is what is written. Listing the references (partial) directly underneath it is good as well. This allows the reader to immediately see what authors, what journal, and in what year such ideas were written. This also allows the reader to follow a progression of ideas, if any, from year to year. With this format, the reader is able to see what concepts are consistently held by particular authors and to see in which journals these ideas are being put into print.

Overall, the authors of this monograph make compelling arguments for each topic presented and for why “precanceroses” do not exist. The authors also make one comment, in particular, that I feel should be taken to heart by all dermatopathologists, whether you agree with the rest of the monograph or not. The statement is found on page 37 and is as follows: “A histopathologist is not a diviner whose role it is to speculate about behavior of processes pathologic. The one and only responsibility of a histopathologist is to render diagnoses accurately and to couch those diagnoses in language that clinicians understand fully so that they are able to manage patients properly, i.e., rationally.”

There are a few points which I, as a reader, would like to ask the authors:

1. The authors give an example of how they “sign out” solar (actinic) keratosis or Bowen’s disease on the pathology report: “squamous cell carcinoma, solar keratotic type, very superficial (solar keratosis)” and “squamous cell carcinoma, Bowen’s type, very superficial (Bowen’s disease).” What ICD-9 code do they use for these diagnoses? 702.2 (actinic keratosis) or 232.x (squamous cell carcinoma in situ) vs. 173.x (squamous cell carcinoma)?

2. The questions are raised (page 79-81) about whether bowenoid papulosis is a hyperplasia or neoplasm, and if it is benign or malignant. I have never thought of these questions until now, and I am not convinced, by the authors’ concepts, that bowenoid papulosis is indeed a malignant neoplasm and not hyperplasia. The authors admit that some lesions of bowenoid papulosis involute in the absence of therapy and that no lesion of bowenoid papulosis, to date, has eventuated in metastatic squamous cell carcinoma. These two facts seem to argue that the lesion is a hyperplasia and not a neoplasm, or a malignant one at that! The authors give some justification of their concept by making an analogy to keratoacanthoma. However, many do not believe keratoacanthoma is a malignant neoplasm, and some think it’s not a neoplasm at all. Bowenoid papulosis is not locally destructive and there have been no documented cases of metastasis, so it does not, by the definition of “malignant” given by the authors of this monograph on page 10, fit.

3. On page 96, the question is “Is the neoplasm, premalignant fibroepithelial tumor of Pinkus, benign or malignant?” The authors cite a paper by Bowen and LeBoit under the “Wisdom Conventional” response of why those authors do not think these lesions are malignant: “However, to our knowledge, aggressive biological behavior with local destruction or with metastasis has not been published.” This is a valid reason, which adheres to the definition of “benign” given in this monograph by Ackerman and Mones on page 9. The only response for this by the authors, given under “Our Concept” on page 96, is the single word “Malignant.” This is not adequate or convincing.

4. The question of whether fibroepithelial tumor of Pinkus commonly involutes in the absence of therapy is raised on page 99. Under “Our Concept,” the authors’ response is that, “It does not involute in the absence of therapy, which is the rule for a malignant neoplasm.” While this statement is true, it is also a correct statement for a benign neoplasm, therefore this cannot be used as proof of the neoplasm being malignant.

5. The authors conclude, on page 156, that there is no benefit for molecular techniques in helping to diagnose melanoma, yet nothing was mentioned of FISH and CGH, which have been clearly shown to be of benefit in differentiating some cases of melanoma from nevi. The authors also state that there is “no value whatsoever” of p53, p63, etc. in determining the fundamental nature of “large plaque parapsoriasis.” Under “Wisdom Conventional,” a paragraph is cited from Magro et al about using RT-PCR for T cell receptor gene rearrangements to assess T cell clonality. The authors, under “Our Concept,” state there is “No value whatsoever” and that the diagnosis “of mycosis fungoides is based entirely on findings morphologic.” I think this statement is misleading. While TCR may not be necessary to make the definitive diagnosis of mycosis fungoides, it can be supportive, so I don’t think there is “No value whatsoever.”

While many questions and some disagreements with the authors arose for me in the course of reading this monograph, I think this is an excellent book, not only for the accurate message that precancers are all cancers, but that it stimulated deep thought and contemplation on ideas and concepts that are often taken for granted. Whether the reader agrees or disagrees with some or all of the material in this book, I think it is worth reading and reflecting on, which will ultimately make one a better, more informed, and more intellectually involved dermatopathologist.

Dr. Walsh is an Associate Dermatopathologist in Cutaneous Pathology, Maryland Heights, MO, USA. Contact her at the following email address: SarahNWalsh@aol.com .

Review by Bernhard Zelger, M.D.

“Life is a roller-coaster!” This is the feeling I had when performing the review about the monograph “Precanceroses”: Cancers all! Contrary view on behalf of patients (1) to which Mark Hurt had invited me in May 2010. On one hand it was a great chance to once more follow the open mind and clear thoughts of our beloved colleague, teacher and friend, A. Bernard Ackerman, on the other hand this monograph also clearly showed what happens when accuracy, exactness, consistency and tenacity, important ingredients of perfection, are missing. But let’s start and develop thoughts step by step.

First of all I was very glad about the invitation, and there was no question but to accept, thus having once more the pleasure to “share ideas” with Bernie and his colleague and co-author, Joan M. Mones, and to use this platform as a tribute to a giant in Dermatopathology and Dermatology — in my opinion the greatest ever and so far.

“Precanceroses”: Cancers all! Contrary view on behalf of patients (1) is a monograph in hard copy of 238 pages in DIN-A4 format, bound in turquoise and white with turquoise, white and black print on the cover. The authors are A. Bernard Ackerman and Joan M. Mones, and the book is published by Ardor Scribendi 2009, New York City. The book is structured into a foreword, a glossary of terms relevant, a perspective historical, 11 chapters on “precanceroses,” and it ends with an afterword.

In the “Foreword,” Bernie Ackerman and Joan Mones explain the reasons for this monograph, and this is what they say: “This undertaking is meant to be read from start to finish, the hope being that that experience will be pleasurable at the same time that it is instructive. When the last word of the “Afterword” has been read, we are confident that all colleagues will agree with the title of the endeavour, to wit, ‘Precanceroses: Cancers All!’” I don’t know what others thought or will think, but I know what I thought and felt and that was as already mentioned—a roller-coaster—love and pain, admiration beside sorry and pity.

In “Glossary of terms relevant,” the authors give their definition of important terms, namely “atypical, benign, cancer, carcinoma, dysplasia, invasion, malignant, precancer, premalignant, and sarcoma.”

In “Perspective Historical,” the authors describe the development of the concept of “precancerosis” from its beginning in 1896 by Dubreuilh to the most recent past, where the concept of “precancerosis” is still very much alive in the realms of dermatology and pathology, including dematopathology, in this 21st century, highlighted by numerous quotations up to 2007, the time shortly before publication in 2009.

The 11 chapters on precanceroses to follow—namely: solar keratosis, Bowen’s disease, bowenoid papulosis, premalignant fibroepithelial tumor of Pinkus, extramammary Paget’s disease, lentigo maligna and large-plaque parapsoriasis—and analogues thereof, i.e., actinic cheilitis, erythroplasia of Queyrat, primary acquired melanosis of the conjunctiva, as well as small-plaque parapsoriasis — basically are all structured more or less identically starting with a historical perspective with numerous quotations; then, followed by a series of questions: 1. Is the “lesion in question” a neoplasm? 2. Is the “lesion in question” benign or malignant? 3. What are the evidences clinical of the “lesion in question” being malignant? 4. What are the evidences histopathologic of the “lesion in question” being malignant? 5. Does the “lesion in question” ever convert to or transform into the respective malignancy? 6. Are there apt synonyms and a meritorious replacement for the “lesion in question”? 7. Does the lesion in question, in the absence of therapy, involute commonly? 8. What is the value, if any, of p53, p63, etc for determining the nature fundamental of the “lesion in question”? 9. Should the “lesion in question” be treated? And, finally, 10. “What is the diagnosis most accurate a histopathologist can issue for the “lesion in question” on a “pathology report”? In each of these questions “Wisdom conventional” is given, followed by “Our concept.” Each chapter concludes with a list of relevant references.

At the end of the monograph, an “Afterword” expands the critique of precanceroses beyond the horizon of dermatology into other organs. It basically becomes a critique of vague concepts, a critique of terms and phrases dizzying and opaque given to that subject, and a proposal for rectifying what currently is a thoroughly untenable situation because the language, and the ideas expressed by it, are impenetrable to physicians, and, thereby are disadvantageous decidedly to patients.

The fascinating side of this monograph certainly is reflected by the brilliant personality of A. Bernard Ackerman manifesting with an open mind, careful observation, profound knowledge, critical thinking, and reasonable interpretation. This leads to a clear concept, in a language comprehensible to everyone, in a well structured manuscript starting with definitions, followed by historical perspective, details of every “precanceroses,” comprehensive literature and a final fundamental critique of the concept beyond the horizon of dermatology. Here, one can clearly see that and how hard Bernie had worked on these issues. Yet, one also recognizes that there is a break which leads us to a point where I am sure Bernie would not have given the permission to publish this book in its present form, Bernie being a perfectionist in the most outstanding way. What are the facts that I dare cite to form such critique on someone who has so tremendously contributed to dermatopathology and who can no longer defend himself?

First, there are many, many spelling errors as well as missing commas and dots, and this is far beyond the number of which one can usually find in similar monographs (a total list of 8 pages). I will not bother readers here with elaborating on every mistake, but will provide the authors in a separate file with all necessary changes. I do not understand how final proof reading by the second author nor by someone from Ardor Scribendi could miss all these errors.

Secondly, some of the above errors are painful and can even in certain instances be misleading. For example, actinitic cheilitis derives from Greek “χειλη” for lip, and in the chapter on actinic cheilitis (not before and after) it is in the vast majority written “chelitis” (inconsistently, even within this chapter—exactly 19 times—it is written correctly). This would be annoying for A. Bernard Ackerman to read this chapter, he who loved the Latin & Greek high culture so much and who was a typhoon about correct usage. Less important is the wrong setting of commas on page 48, paragraph 4, line 5, which makes reading of this sentence elaborating on the number of histopathological diagnoses given for lip biopsy specimens and vermilionectomies a bit irritating. Similarly, some figures are missing or wrongly referred to, e.g. in the middle of page 97 referral to “Fig. 3″ which is not illustrated, or on page 185 “Figures 8 and 9,” which should read “Figures 2 and 3,” respectively, or on page 107, where in paragraph 3, line 3 should correctly read that “adenocarcinoma (extramammary Paget’s disease) extends from the epithelial compartment (finally) into the dermis,” not “epidermis” as written, or on page 124, paragraph 2, line 8 were a “male malignant” should correctly read “mole malignant,” or another overseen error is the title “Response from Dr. Ackerman to Dr. Schachat” on page 183, which is just vice versa, in an otherwise excellent conversation about the non-publication of a letter by Rodriguez-Sains and Ackerman to Dr. Schachat, the editor of the journal “Ophthalmology,” when publication of this contribution was rejected.

Thirdly, I miss what one would call “final logic and consistency.” It is OK to regard erythroplasia of Queyrat, primary acquired melanosis of the conjunctiva, and small plaque parapsoriasis as “analogues” of Bowen’s disease, lentigo maligna, and large plaque parapsoriasis, and it is also correct to contrast these analogues from their originals by pronouncing the special locations such as mucocutaneous junction or mucous membrane as well as conjunctiva, respectively. Yet, this should be provided in a consistent (and more logical) way, in particular on the page of “Contents” as well as in chapter titles and could thus read, e.g. Bowen’s disease and analogue, subchapter erythroplasia Queyrat (on mucocutaneous junction or mucous membrane), lentigo maligna and analogue, subchapter primary acquired melanosis of conjunctiva, and finally large-plaque parapsoriasis and analogue, subtitle small-plaque parapsoriasis, respectively. The titles chosen by the authors miss this glass clear logical structure and terms.

Fourth, there is some very minor academic incorrectness in the chapter “Glossary of terms relevant.” When the authors on page 9 define “benign,” they stress that this term should not be used to describe cytopathologic characteristics such as “benign appearing cells” or inflammatory diseases. This is all correct. By choosing, however, “benign familial chronic pemphigus (Hailey-Hailey disease),” there are better examples, as this disease basically is a genodermatosis, admittedly with inflammatory character.

Fifth, another academically suboptimally presented part is found on pages 213, 215, and 216, respectively. Here, when elaborating on large plaque parapsoriasis, the authors in their questions on what this disease really is, partially twice repeat the very same citations and sentences, respectively. I cannot imagine that this is the style the world-wide readership expects and knows from A. Bernard Ackerman.

Finally, when elaborating on primary acquired melanosis of the conjunctiva, in the interest of completeness of mucocutaneous melanoses, one would have expected at least a short section or paragraph about other variants such as those in the genitalia or on the lip and in the mouth.

I do not want to finish this review by leaving with the feeling as if I was “looking for the needle in the haystack.” By no means would this be justified, and those who know me a bit better and closer are aware how much I admire the personality of A. Bernard Ackerman, profited from his work, and loved his style. Yet, in the spirit of A. Bernard Ackerman himself (2, see point 13 of the “Introduction” on page 8 of this monograph on neoplasms with sebaceous differentiation), I also know that he would have loved everyone who critically reads, analyzes, and tries to amend his text and work, and how he would regard this work as a chance for collision of ideas with others to further develop the issue of our speciality. Unfortunately, Bernie will not be able to reply and rectify, but hopefully others will do so in his place.

The end of this review is reserved to once more accentuate my respect and great thanks to an outstanding personality by three flash lights provided in this monograph: “Precanceroses”: cancers all:

1. “Never, never, never, never, never, never, never, . . . give up!” And in my reflections I see Bernie Ackerman giving a lecture projecting a slide where a frog is in the mouth of a stork with his legs fighting not to be swallowed. When you want to get an impression of these feelings, please go to pages 180-183 and read the conversation about the rejection of a letter to the editor between him and the editor of the journal Ophthalmology, dealing about primary acquired melanosis of the conjunctiva and its nosologic status.

2. When you want to get an impression how much he suffered from terms and phrases dizzying and opaque based on wrong concepts and ideas disadvantageous partim disastrous decidedly to patients, please, read the afterward. Herein, as already mentioned before, he expands the issue of “precanceroses” far beyond the horizon of Dermatology and Dermatopathology, always in the best interest of the patient as outlined in the subtitle of the book “Contrary view on behalf of patients.” He really, really, really, really, really, really, really, . . . was a great thinker and doctor.

3. This is my most personal tribute to you, Bernie. I mentioned that in the “Foreword” A. Bernard Ackerman and Joan Mones explained the reasons for this monograph and this is once more what they said: “This undertaking is meant to be read from start to finish, the hope being that that experience will be pleasurable at the same time that it is instructive. When the last word of the “Afterword” has been read, we are confident that all colleagues will agree with the title of the endeavour, to wit, “Precanceroses: Cancers all!” The reader will remember what I wrote before which was very critical, but there was still another feeling at this moment: Bernie is right! And I am very proud to say that he knew for sure that I was already convinced by his ideas and thoughts. Please, read page 15 of the monograph on “Precanceroses”: Cancers All or the original article by Jancin B in Cutaneous Oncology 2007, in which he refers to on the bottom of this page 15. Herein, my colleague Dr. Alexis Sidoroff, from the Medical University of Innsbruck (Austria), is cited: “Since our histopathologist started calling AKs (actinic keratoses) carcinoma in situ I’ve had four patients in my outpatient clinic crying because they were given the diagnosis of cancer. They had to wait 3 weeks for a follow-up appointment to have somebody explain the situation to them, and it was 3 weeks of hell. They were afraid of dying. So, I think from the patient’s point of view this classification is a big mistake.” Suffice to say the dermatopathologist is me. Also suffice to say, that I have stopped calling actinic keratosis carcinoma in situ exactly for the reasons elaborated by Bernie in this monograph on precanceroses, and that nowadays I diagnose squamous cell carcinoma, type actinic keratosis, often with a comment with suggestions for optimal treatment of patients when I have the feeling the clinician, such as some heroic surgeons or other colleagues, will profit from this comment. Further suffice to say that I absolutely agree that something runs markedly wrong when patients get the information of diagnosis cancer without the instant possibility of adequate additional information and psychological management. Three weeks waiting for an appointment is absolutely ridiculous in such instance. Suffice to say that another argument, frequently cited in such situations, namely that insurance companies will not provide patients further access to their services when maculated by the diagnosis of cancer, is, in my understanding, in the very same way ridiculous and annoying as before the handling of patients. One must be able to speak to insurance companies and their representatives and make them also clear what cancer means or more important what cancer does not mean. It cannot be that the understanding of biologic systems becomes manipulated by the incompetence of lawyers and economists. “Logic must triumph” is what Bernie always taught us. And I think you, the reader of this journal and review, will see what Bernie has reached: “We continue in open mind with critical thinking.” Thank you, thank you, thank you, thank you, thank you, thank you, thank you, . . . so much, Bernie! We miss you!

Reply by Joan M. Mones, D.O.

I thank Drs. Walsh and Zelger for their exceptional reviews of Precanceroses: Cancers All!, the monograph that I co-authored with the late Dr. Bernard Ackerman. At the outset, I must respond to the statement made by Dr. Zelger “I am sure Bernie would not have given the permission to publish this book in its present form.” This is simply not true. According to Ms. Betsy Stevens, Editorial Director of Ardor Scribendi, Dr. Ackerman approved this book to be published, as written, before his death and he maintained full editorial control over its contents. In response to Dr. Walsh’s query as to the ICD-9 coding of the diagnosis “squamous-cell carcinoma, solar keratotic type, very superficial (solar keratosis)” it should be coded as would be for a solar keratosis i.e. using the ICD-9 code 702. “Squamous-cell carcinoma, Bowen’s type, very superficial (Bowen’s disease)” is coded as would be for squamous-cell carcinoma in-situ using the ICD-9 code 232 and squamous-cell carcinoma is coded using the ICD-9 code 173.