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Fatal Irritation -

Cancer following Chronic Diseases

Dr Sampurna Roy MD   

                         


                  

Any kind of irritation can have a negative effect on our health and life.  It is important that we know the source, reason, severity and duration of irritation. 

If something irritates any part of the body for a short period of time we tend to ignore it and move on with our day to day activity.

When the irritation continues for months and years it can have a devastating effect on our overall well-being and health.

The main aim should be to permanantly eliminate the source of irritation before it becomes a deadly cancerous growth and spreads throughout our entire body.

Virchow believed that cancer was the result of prolonged stimulation of the tissues through 'chronic irritation'.

It is doubtful whether physical irritation acting alone can ever produce cancer, though it may certainly promote a tumour in a field already irritated by a carcinogenic agent.

Corns on the toes of those who wear ill-fitting shoes and callosities on the fingers of string instrumentalists do not become malignant. 

Cancer does not develop on a hyperplastic gum subjected to the friction of a jagged tooth or an ill-fitting denture. 

These are all examples of hyperplasia of protective epithelium in response to trauma, and once the stimulus is removed, regression may be expected.

There are a number of chronic diseases which may be complicated by malignancy. These are included in the list of precancerous lesions.

11 important Chronic Diseases that can later become Malignant Tumour:

1) Skin ulcers (Marjolinís ulcer) :

Chronic varicose ulcers, the sinuses of chronic osteomyelitis particularly of the tibia, and old burn scars may give rise to squamous-cell carcinoma.

These lesions are collectively called Marjolinís ulcer, though the name should properly be reserved for cancer developing in a chronic leg ulcer.  

Tropical ulcers (non-specific chronic skin ulcer) on dark-skinned patients may also become malignant. 

Marjolinís ulcer is a an aggressive, rapidly spreading malignant degeneration. 

The important features of Marjolinís ulcer are nodule formation, induration, and ulceration at the post-burned scars.

Histopathological examination confirms the diagnosis.

Other precancerous lesions of the skin are not discussed in this post.

Visit:  Dermpath-India ; Actinic keratosis; Bowenoid papulosis ; Bowen's disease ; Epidermodysplasia verruciformis ;

2) Tertiary Syphilitic Glossitis and Precancerous lesions of the Oral Cavity:

Tertiary syphilitic glossitis effecting the tongue is often complicated by dysplastic leukoplakia and carcinoma, but there may be other factors acting along with the infection.

Precancerous diseases of the oral cavity are the chronic lesions on which cancer of the oral cavity is known to develop.

Some of the common lesions are oral lichen planus, keratotic candidosis, tertiary syphilis, leukoplakia, erythroplasia and actinic cheilitis. Visit: Lichen planus-like lesions ; Syphilis ; Candidosis

3) Gastric ulcers :

Gastric ulcers may occasionally be the site of origin of cancer of the stomach.

Gastric ulcer caused by Helicobacter pylori (H. pylori) infections has slightly increased risk of gastric carcinoma.

Probably less than 4% of the ulcers are complicated by cancer.

It is generally held that there is no significant causal relationship between the two.

Duodenal ulcers are never complicated by cancer, which is in keeping with the mysterious resistance of the duodenum to carcinoma, except when involved in neoplasia of the ampulla of Vater.

4) Ulcerative colitis and Crohnís disease (Bowel):

Ulcerative colitis is an important precancerous condition.

About 4% of all cases develop carcinoma, but it is those with repeated relapses that are most at risk.

At least a third of all cases lasting 12  years develop cancer, usually multifocally.

The incidence is greatest when the disease starts before the age of 25 years and when the entire large bowel is affected.

Crohnís disease is also a precancerous condition, but probably less common than the closely related ulcerative colitis.

A number of cases have developed small-bowel carcinoma after a  duration of 15 years and at a much younger age than is usual for this uncommon tumour.

5) Gallstones:

Gallstones are found in about three-quarters of cases of cancer of the gallbladder.

Nevertheless, carcinoma is a rare complication of this very common condition.Gallbladder Pathology Online

6) Renal calculi and Schistosomiasis of bladder: (Genitourinary tract) :

  

Cancer of the renal pelvis is occasionally associated with calculi. Chronic renal calculi is a risk factor for the development of squamous metaplasia.

This may lead to squamous cell carcinoma. Although it is a rare tumour in the upper urinary tract, patients with long-standing nephrolithiasis should be carefully monitored.

Besides renal calculi, squamous cell carcinoma of kidney may be associated with infection and chronic pyelonephritis.

Schistosomiasis may be a predisposing factor to bladder cancer in areas of heavy infestation.

In some of these cases the age of the patients are much lower than usual and the lesion is nearly always squamous cell carcinoma and not transitional-cell malignant tumour. 

7) Liver Cirrhosis :  

About 90% of primary liver cell cancer in humans is superimposed on a previous cirrhosis. 

Exogenous factors rather than racial constitution are important in causing the disease. 

Cirrhosis (that due to alcoholism) have a high incidence of liver cancer.

The fine, 'Morocco-leather' cirrhosis of hemochromatosis is complicated by carcinoma in a number of cases. 

Visit: Primary Hemochromatosis

Early diagnosis of hepatocellular carcinoma is critical in the management of patients with primary biliary cirrhosis.

8) Thyroid Goitre:

Thyroid carcinoma is often associated with the goitre of iodine deficiency. 

However, it has been established that cancer can arise independent of previous thyroid disease.

Though malignant tumour is found in goitrous glands, it occurs more frequently in glands that are otherwise normal.

Considering the frequency of goiter, cancer is a rare complication.

It is also possible that in some cases the tumour lay latent and masqueraded as a nodular goiter.

According to one study Papillary thyroid carcinoma is the more common histological type compared to follicular cancer.

9) Plummer-Vinson syndrome:

Post-cricoid carcinoma is usually noted it middle-aged women and may be associated with an iron deficiency anaemia.  

The patients usually have a history of glossitis and dysphagia.

This is the Plummer-Vinson syndrome.This syndrome was first described in 1906 by Paterson and soon afterwards by Kelly. Both were laryngologists.

It should be rightly called Paterson-Kelly Syndrome.The pathological basis of the condition is not clear.

Atrophic changes in the mucosa and underlying muscle of the mouth and pharynx have been described.

Later there is web formation and strictures.

This syndrome is known to be associated with an increased risk of squamous cell carcinoma of the upper airway tract, so the patients should be followed closely.

10) Pagetís disease:

 

In Pagetís disease of bone osteosarcoma is an occasional complication, occurring in about 1% of clinically apparent cases. Rarely a fibrosarcoma or chondrosarcoma may develop.

11) Lymphedema :

Lymphedema is a chronic disease associated with a congenital or acquired disorder of the lymphatic vessels or lymph nodes.

Chronic lymphatic oedema is occasionally complicated by an angiosarcoma of the skin.

It is known as lymphangiosarcoma. Post mastectomy angiosarcoma is a complication of severe, long-standing lymphedema of the arm that follows radical mastectomy particularly if combined with radiotheraphy to axilla (Stewart Treves Syndrome).

Visit: Pathology of Angiosarcoma.  

Lymphangiosarcoma or angiosarcoma has also been reported in patients with filarial disease and in those with chronic lymphedema of congenital type. 

Visit: Filariasis

Every case of prolonged irritation in any part of the body should be closely monitored.

In case of any chronic long lasting disease a detailed assessment involving clinical and laboratory investigations is required.

 

Further reading:

Genetic determinants and clinico-pathological outcomes of helicobacter pylori infection.

Inflammatory pathways in the early steps of colorectal cancer development.

Carcinogenesis in inflammatory bowel disease.

Small bowel adenocarcinomas complicating Crohn's disease are associated with dysplasia: a pathological and molecular study.

Marjolin's ulcers in the post-burned lesions and scars.

Secondary syphilis simulating oral hairy leukoplakia.

Histological evaluation in ulcerative colitis.

The risk factor of gallbladder cancer: hyperplasia of mucous epithelium caused by gallstones associates with p16/CyclinD1/CDK4 pathway.

Bladder cancer and schistosomiasis.

Squamous cell carcinoma of kidney co-existing with renal calculi: a rare tumour.

From cirrhosis to hepatocellular carcinoma: new molecular insights on inflammation and cellular senescence.

 

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Dr  Sampurna Roy  MD

Consultant Histopathologist (Kolkata - India)

 

 


 

 

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