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Background
This is a squamous cell carcinoma in situ arising in the skin. This carcinoma has not broken through the basement membrane of the dermal-epidermal junction and therefore does not have the potential to metastasize. In general, the same risk factors for squamous cell carcinoma apply here. In addition, arsenic ingestion and human papilloma virus infection may also play a role. About 8% of untreated cases may progress to invasive carcinoma. In the past, this disease was thought to be a marker for internal cancers, a claim that has since been refuted. Histologically, Bowen's disease shows full thickness replacement of the epidermis by dysplastic and atypical keratinocytes. There are several histological variants include pigmented, psoriasiform, atrophic, verrucous, irregular, and pagetoid. It is this last type which produces the most difficulty for the pathologist. As the name suggests, the dysplastic keratinocytes show a pagetoid spread throughout the epidermis mimicking both Paget's disease and melanoma. In these cases, immunoperoxidase studies may be helpful to differentiate between these entities.
OUTLINE
EPIDEMIOLOGY CHARACTERIZATION SYNONYMS Squamous cell carcinoma in situ
PATHOGENESIS CHARACTERIZATION Comparative histochemical study of Bowen's disease and actinic keratosis: preserved normal basal cells in Bowen's disease.
Ishida H, Kumakiri M, Ueda K, Lao LM, Yanagihara M, Asamoto K, Imamura Y, Noriki S, Fukuda M.
Department of Dermatology, Fukui Medical University, Yoshida-Gun, Japan.
Eur J Histochem 2001;45(2):177-90 Abstract quote
The degree of DNA-instability as revealed by immunohistochemical staining with anti-cytidine antibody after acid hydrolysis (DNA-instability test) has been recently used as a marker of malignancy.
This technique was applied to examine 17 skin tissue samples of Bowen's disease, 47 of actinic keratosis, 15 of squamous cell carcinoma, 5 of seborrheic keratosis, and 10 of normal skin. All benign neoplastic cells of seborrheic keratosis and normal epidermal cells were negative. On the other hand, all cancer cells were positive with the DNA-instability test, indicating their malignancy, but all basal cells in Bowen's disease were completely negative. Compatible with this result, the basal cells in Bowen's disease were characteristically normal as evident in other histochemical examinations. Thus, they were negative with p53 immunohistochemistry, with normal signals of chromosome 17 in situ hybridisation and argyrophilic nucleolar organiser region, and showed slightly enhanced proliferative activity as revealed by proliferating cell nuclear antigen immunohistochemistry.
Immunohistochemical staining with 34 beta E12 (monoclonal antibody against cytokeratins 1, 5, 10, and 14), which stains all normal epidermal keratinocytes including basal cells, showed that only the basal cells of Bowen's disease stained strongly and homogeneously, while all cancer cells in the upper layers of Bowen's disease and all layers of actinic keratosis were only sporadically or weakly stained. Staining with 34 beta B4 (monoclonal antibody against cytokeratin 1), which recognises the whole epidermis except for the basal layer in the normal epidermis, showed that the basal cells in the Bowen's disease were completely negative, and lower layer cells in the actinic keratosis and upper layer cells in Bowen's disease were only sporadically stained positive, although the superficial layer cells in actinic keratosis stained strongly and homogeneously.
Our findings clearly indicate that the basal cells in Bowen's disease are normal. In support of this conclusion, the same cells showed normal morphology on electron microscopy with preserved basement membrane, although the latter was often damaged in actinic keratosis.
HUMAN PAPILLOMA VIRUS
- Simultaneous human papillomavirus 6 (HPV 6) -positive condyloma acuminatum, HPV 31-positive Bowen's disease, and non HPV-associated extramammary Paget's disease coexisting within an area presenting clinically as condyloma acuminatum.
Egawa K, Honda Y.
Department of Dermatology, Kumamoto University School of Medicine, Kumamoto, Japan.
Am J Dermatopathol. 2005 Oct;27(5):439-42. Abstract quote
An 83-year-old Japanese man presented with multiple verrucous papules clustering on a plaque located on the frontal aspect of the scrotum.
Histologically, there were three distinct epithelial changes compatible with condyloma acuminatum, Bowen's disease, and extramammary Paget's disease (EMPD). By in situ hybridization, the zone of condyloma acuminatum was positive for HPV 6 and well demarcated from HPV 31-positive Bowen's disease. EMPD was negative for targeted HPV 6/11/16/18/31/33 probes. Immunohistochemically, Paget's cells expressing cytokeratin 7 were distributed as scattered single cells or clusters mainly in the lower part of the HPV 6/31-positive epithelium.
To the best of our knowledge, this is the first reported case of the occurrence of condyloma acuminatum, Bowen's disease, and EMPD within the same lesion.
HISTOPATHO-
LOGICAL VARIANTSCHARACTERIZATION BOWENOID PAPULOSIS Considered a variant of Bowen's disease with a distinctive clinical appearance resembling seborrheic keratoses.
- Extragenital bowenoid papulosis associated with atypical human papillomavirus genotypes.
Papadopoulos AJ, Schwartz RA, Lefkowitz A, Tinkle LL, Janniger CK, Lambert WC.
Dermatology, Pediatrics and Pathology, New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07101-2714, USA.
J Cutan Med Surg. 2002 Mar-Apr;6(2):117-21. Epub 2002 Feb 13. Abstract quote
BACKGROUND: Bowenoid papulosis typically appears as grouped violaceous or red-brown papules in the genital or perianal regions and clinically resembles condylomata acuminata. Isolated extragenital bowenoid papulosis is rare and has been reported in only a few case reports.
OBJECTIVES: A 51-year-old immunocompetent, healthy woman had two solitary papules on the elbow; a 41-year-old HIV-positive man had a solitary cutaneous plaque on the abdomen. No genital, periungual, or other extragenital sites of involvement were noted in either patient. The diagnosis was confirmed histologically in both cases. Lesional skin from the female patient was tested with the Digenehybrid HPV DNA assay and was positive for a mixture of low-risk HPV subtypes (6, 11, 42, 43, 44). Lesional skin from the male patient was tested with polymerase chain reaction (PCR). Consensus primers targeted for the HPV L1 region, which is a highly conserved sequence common to more than 20 HPV subtypes encoding a viral capsid protein, were used. PCR using the consensus primers was positive, but type-specific probes for HPV types 6, 11, 16, 18, 45, 31, 33, 35, and 39 were negative.
CONCLUSIONS: To our knowledge, our male patient represents the first case of isolated bowenoid papulosis of the abdominal skin. Isolated upper-extremity bowenoid papulosis in our female patient is also a unique case in both location and involvement of low-risk HPV types (6, 11, 42, 43, 44), which have not been previously associated with extragenital bowenoid papulosis.
- Isolated extragenital bowenoid papulosis of the neck.
Johnson TM, Saluja A, Fader D, Blum D, Cotton J, Wang TS, Lowe L.
Department of Dermatology, University of Michigan Medical Center, and University of Michigan Comprehensive Cancer Center, Ann Arbor 48109-0314, USA.
J Am Acad Dermatol. 1999 Nov;41(5 Pt 2):867-70. Abstract quote
We report a case of extragenital bowenoid papulosis (BP) in a healthy immunocompetent 42-year-old man. The lesions occurred on the anterolateral aspects of the neck and were not associated with genital, oral, or periungual lesions.
Lesional skin tested positive with the Digene hybrid capture system cocktail assay that identifies infection with a mixture of high to intermediate oncogenic human papillomavirus (HPV) types, including types 16, 18, 31, 33, 35, 45, 51, 52, and 56. This cocktail assay identifies infection with HPV types typically associated with high-grade squamous intraepithelial lesions and invasive carcinoma.
This case represents the sixth case of isolated cutaneous BP occurring a significant distance from the genital region.DIFFUSE EPIDERMAL AND PERIADNEXAL SQUAMOUS CELL CARCINOMA IN SITU
- Diffuse epidermal and periadnexal squamous cell carcinoma in situ: a report of 13 patients.
Goldberg LH, Kimyai-Asadi A.
DermSurgery Associates, Houston, Texas, USA.
J Am Acad Dermatol. 2005 Oct;53(4):623-7. Abstract quote
BACKGROUND: Diffuse epidermal and periadnexal squamous cell carcinoma in situ (DEPS) is a condition in which large areas of skin are affected by atypical keratinocytes that grow beneath the epidermis and encase adnexal epithelia. Normal differentiation of the overlying epidermis and adnexal epithelium is seen.
OBJECTIVE: Our aim was to describe the clinical features of DEPS.
METHODS: We undertook a retrospective case series of 13 patients with DEPS.
RESULTS: All 13 patients were fair-skinned men older than 50 years with a history of significant sun exposure. The lesions were present on the scalp, face, and neck. Histologic examination showed a growth of atypical keratinocytes in the lower epidermis with encasement of adnexal structures by atypical neoplastic keratinocytes. In the 52 cumulative patient-years of follow-up, we treated 80 invasive squamous cell and 48 basal cell carcinomas in these patients. Despite improvement of DEPS with aggressive topical and destructive therapy, multifocal recurrence would typically develop within a few months.
CONCLUSION: DEPS is characterized by diffuse involvement of chronically sun-exposed skin with atypical keratinocytes that grow along the inferior portion of the basal layer of the epidermis and around adnexal structures. The treatment of DEPS is challenging because of its widespread nature and deeper periadnexal involvement. DEPS is also associated with the development of invasive squamous cell and basal cell carcinomas.
PAPILLATED
Bowen disease usually presents as an irregular, asymptomatic, scaly or crusted erythematous plaque that can occur anywhere on the skin.
An unusual clinicopathologic variant is described which presents as a well-circumscribed, papillated, exophytic and endophytic, sometimes keratotic lesion. This papillated variant of Bowen disease exhibits keratinocytes with prominent perinuclear halos suggestive of koilocytic change associated with human papillomavirus (HPV) infections. Classic Bowen disease has been associated in previous studies with a variety of HPV types, especially types 16, 18, and 31.
Twenty-six patients with papillated Bowen disease were evaluated. The patients included 15 males and 11 females, ranging in age from 33 to 87 years old. Fifty-four percent (14) of the lesions involved the head and neck, 8% (2) involved the trunk, and the remaining 38% (10) involved extremities (including 3 lesions from the hands).
Lesions were examined using in situ hybridization with widely screening genomic probes for HPV types 6, 11, 16, 18, 30, 31, 33, 35, 45, 51, and 52. None of the specimens contained HPV DNA from the more common oncogenic HPV types.
Given the striking histologic appearance of these lesions, however, this does not exclude HPV infection detectable by more sensitive screening methods such as polymerase chain reaction.
Papillated Bowen disease is distinct from other variants, including the verrucous-hyperkeratotic type.
SPECIAL STAINS/
IMMUNOPEROXIDASECHARACTERIZATION p27
P27 and mib1 expression in actinic keratosis, Bowen disease, and squamous cell carcinoma.
Oh CW, Penneys N.
Department of Dermatology, College of Medicine, GyeongSang National University, Chinju, South Korea.
Am J Dermatopathol. 2004 Feb;26(1):22-6. Abstract quote
The histologic boundary between actinic keratosis, Bowen disease, and invasive squamous cell carcinoma is not clear in many cases. We determined nuclear expression of p27 (a protein associated with cellular quiescence) and Ki-67 (a marker of proliferation) immunohistochemically in actinic keratosis, Bowen disease, and squamous cell carcinoma to see if differential patterns of expression for p27 exist and how these might correlate with Ki-67 expression.
We determined a labeling index for p27-stained nuclei and assessed the pattern of Ki-67 expression. The student's t test was used to evaluate the p27 labeling index. The p27 labeling index was decreased in invasive aggregates of squamous cell carcinoma (76.9+/- 1.1%) when compared with those of normal epidermis (97.2+/- 2.4%), actinic keratosis (95.3 +/- 1.4%), and Bowen disease (98.0+/- 0.5%). Ki-67 was expressed in a scattered to confluent linear pattern in the basal/parabasal cell layer of normal epidermis and actinic keratosis. Keratinocytes in squamous cell carcinoma exhibited Ki-67 in the peripheral layers of the neoplasm and frequently within the tumor aggregates. Ki-67 was observed in nuclei throughout the full thickness of the epidermis in Bowen disease.
The staining pattern of Ki-67 in Bowen disease separated this entity from others under study. The combination pattern of p27 and Ki-67 staining can be used to support differentiation of actinic keratosis, Bowen disease, and squamous cell carcinoma.SYNDECAN-1
Immunolabeling pattern of syndecan-1 expression may distinguish pagetoid Bowen's disease, extramammary Paget's disease, and pagetoid malignant melanoma in situ.
Bayer-Garner IB, Reed JA.
Marshfield Clinic, Marshfield, WI, and Baylor College of Medicine, Houston, TX, USA.
J Cutan Pathol. 2004 Feb;31(2):169-73. Abstract quote
The differential diagnosis of pagetoid cells within the epidermis rests primarily between pagetoid Bowen's disease (PBD), extramammary Paget's disease (EPD), and pagetoid malignant melanoma (MIS) in situ. Although morphologic clues are often helpful in differentiating these lesions, the use of immunohistochemistry is often necessary to arrive at the correct diagnosis.
Syndecan-1 is a cell-surface proteoglycan that mediates adhesion between cells and the extracellular matrix, and between cells themselves. Twenty-two cases of PBD, four cases of intraepidermal EPD, and 13 cases of MIS were examined for syndecan-1 immunoreactivity. Cell-membrane syndecan-1 immunoreactivity was evident in PBD, cytoplasmic syndecan-1 immunoreactivity was evident in EPD, whereas immunoreactivity for syndecan-1 was not present in MIS.
The patterns of syndecan-1 immunoreactivity in these lesions may be a useful adjunct in the differentiation of PBD, EPD, and MIS.
DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES MERKEL CELL CARCINOMA A case of intraepidermal Merkel cell carcinoma within squamous cell carcinoma in-situ: Merkel cell carcinoma in-situ?
Al-Ahmadie HA, Mutasim DF, Mutema GK.
Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
Am J Dermatopathol. 2004 Jun;26(3):230-3. Abstract quote
We report a case of a 79-year-old Caucasian male who presented with a wrist lesion of combined intraepidermal Merkel cell carcinoma and squamous cell carcinoma in-situ.
The two tumors were tightly admixed and distinct, and both were without any dermal or invasive components. No features of transition between the two tumors were seen.
We suggest the term Merkel cell carcinoma in situ for tumors that demonstrate exclusive intraepidermal proliferation of neuroendocrine cells.
ONYCHOMATRICOMA
Bowen's disease clinically simulating an onychomatricoma.Baran R, Perrin C.
Nail Disease Center, Cannes, and the Histopathology Department, Hopital Pasteur, Nice.
J Am Acad Dermatol 2002 Dec;47(6):947-9 Abstract quote Onychomatricoma (OM) is an uncommon benign tumor clinically characterized by a thickened yellowish nail with transverse over curvature. A pigmented variant has recently been described.
Histologically, the diagnosis requires 3 prerequisites: (1) a fibroepithelial tumor consisting of 2 portions: the proximal zone (under the proximal nailfold, characterized by deep epithelial invaginations and a fibrillary and fibrocytic stroma), whereas the distal zone (corresponding to the lunula) presents with multiple digitations along its connective tissue axes; (2) a matricial tumor typified by a thick keratogenous zone; and (3) a thick nail plate, perforated by cavities.
We describe a case that appears clinically identical to a pigmented OM, but with histologic malignant patterns. Because histologic features were consistent with Bowen's disease, we ruled out a malignant OM.
We report a new variant of Bowen's disease presenting as OM, and this observation underlines the necessity for a histologic assessment of all forms of OM, especially those associated with a pigmented band (a sign sometimes observed in Bowen's disease).
SEBACEOUS CARCINOMA, INTRAEPITHELIAL
- Intraepithelial sebaceous carcinoma of the eyelid misdiagnosed as Bowen's disease.
Leibovitch I, Selva D, Huilgol S, Davis G, Dodd T, James CL.
Oculoplastic & Orbital Unit, Department of Ophthalmology and Visual Sciences, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia.
J Cutan Pathol. 2006 Apr;33(4):303-8. Abstract quote
Background: Sebaceous carcinoma (SC) is well known for its ability to masquerade clinically and histologically as a variety of periocular conditions resulting in a delayed diagnosis. We present a series of periocular SC cases and discuss the difficulties in histopathological diagnosis when this tumor presents with a Bowenoid pattern of intraepithelial spread.
Methods: A retrospective case study of all patients with SC of the eyelid treated in our Hospital, from 1997 to 2004, was conducted.
Results: Eight patients were identified (four females and four males). Seven cases involved the upper eyelid. Initial clinical diagnoses included blepharitis (three cases), blepharoconjunctivitis (one case), cicatrizing conjunctivitis (one case), and lid lesions (two cases). Histopathologically, 87.5% of cases were misdiagnosed as Bowen's disease (BD) on the initial biopsy. Six of these cases showed no invasive disease on the initial biopsy and were eventually found to be invasive SC on subsequent excisions. In one case, the tumor was wholly in situ. Delay in diagnosis ranged from 0 to 56 months.
Conclusions: SC should always be considered in the histological differential diagnosis of any eyelid lesion which resembles BD, particularly if the upper eyelid is involved or if multivacuolated cytoplasmic clear cell changes are seen.
PROGNOSIS AND TREATMENT CHARACTERIZATION PROGNOSIS TREATMENT Conventional therapies include cryotherapy, radiotherapy, electrodesiccation and curettage, laser destruction, photodynamic therapy, and 5-FU treatment.
Topical 5-FU has been used with success in treating Bowen's disease with a reported 92% cure rate after a 2- to 3-month regimen of twice-daily application.
Bowen's disease on the lower limbs may be slow to respond to topical 5-FU, but this may be improved with iontophoresis.
Interferons alfa and gamma have both been used systemically or as intralesional treatment for Bowen's disease induced by papillomavirus in the genital and perianal areas.
IMIQUIMOD J Am Acad Dermatol 2001;44:462-70.
Phase II, open-label study in 16 patients, treating a single biopsy-proven plaque of Bowen's disease that was 1 cm or larger in diameter, with once-daily self-application of imiquimod 5% cream for 16 weeks. A biopsy was performed on the treated area 6 weeks after the end of treatment, with patient follow-up at 3 and 6 months. Lymphocyte CD4/CD8 ratios were analyzed in pretreatment and posttreatment biopsy specimens by immunophenotyping the lymphocytic infiltrate.
Results: Sixteen patients with Bowen's disease lesions ranging from 1 to 5.4 cm in diameter (0.7-21.6 cm2 in area) were treated. Fifteen of these lesions were on the legs, and one was on the shoulder. Fourteen of the 15 patients (93% per protocol analysis) had no residual tumor present in their 6-week posttreatment biopsy specimens. One patient died of unrelated intercurrent illness before a biopsy specimen could be obtained. The median CD4/CD8 lymphocyte ratio in pretreatment biopsy specimens was 2:1, and this was reversed to a median of 1:2.2 in the posttreatment specimens. Ten patients completed 16 weeks of treatment, but 6 patients ceased treatment early (between 4 and 8 weeks) because of local skin reactions.
Conclusion: Imiquimod 5% cream appears to be an effective treatment for Bowen's disease on the lower limbs. The 93% positive treatment response in biopsy-proven cases (excludes patient who died from an intercurrent illness who did not undergo a posttreatment biopsy) compares favorably with other current treatment modalities. The dosing schedule and length of treatment for Bowen's disease require further evaluation.
Squamous cell carcinoma in situ of the penis successfully treated with imiquimod 5% cream.Schroeder TL, Sengelmann RD.
Washington University.
J Am Acad Dermatol 2002 Apr;46(4):545-8 Abstract quote BACKGROUND: Multiple treatments for squamous cell carcinoma in situ (SCCIS) of the penis have been used with variable success and morbidity. Surgery and destructive treatment modalities have significant risk of scarring, deformity, and impaired function.
OBJECTIVE: The purpose of this study was to determine whether topical imiquimod 5% cream is a potentially effective treatment for SCCIS of the penis and to qualify treatment associated morbidity.
METHODS: The case of a patient with extensive penile SCCIS is reported. The patient was treated with topical imiquimod 5%, administered daily until blistering occurred (2 cycles). Biopsy specimens were obtained to confirm tumor clearance.
RESULTS: One month after therapy was completed, no clinical or histologic evidence of residual tumor was found. Adverse effects of imiquimod included localized tenderness and erythema. No evidence of scarring, deformity, loss of function, or tumor recurrence was noted 18 months after treatment.
CONCLUSION: Imiquimod 5% cream may represent an alternative treatment option for SCCIS of the penis.
PHOTODYNAMIC THERAPY Arch Dermatol. 2001;137:319-324
Background:
Photodynamic therapy (PDT) using topical -aminolevulinic acid (-ALA) is an effective treatment for Bowen disease and certain basal cell carcinomas (BCCs), but its place in clinical practice remains to be established. Patients with large and/or multiple lesions of Bowen disease or BCC can represent a considerable therapeutic challenge. We suggest that -ALA PDT may be of particular benefit in such patients.Observation:
In an open study, 35 (88%) of 40 large patches of Bowen disease, all with a maximum diameter greater than 20 mm, cleared following 1 to 3 treatments of -ALA PDT, although 4 patches recurred within 12 months. -Aminolevulinic acid PDT was also used to treat 40 large BCCs, with an identical 88% initial clearance (after 1-3 treatments), with 4 recurrences within 34 months (range, 12-60 months). In 10 further patients with multiple (3) patches of Bowen disease, 44 (98%) of 45 patches cleared following -ALA PDT, although 4 lesions recurred over 12 months. In 3 patients with multiple BCCs, PDT cleared 52 (90%) of 58 lesions, with 2 recurrences during 41 months (range, 12-52 months). Treatments were well tolerated, with only 5 patients with solitary large lesions requiring local anesthesia.Conclusions:
-Aminolevulinic acid PDT is an effective tissue-sparing modality achieving good cosmesis. We propose that -ALA PDT be considered as a first-line therapy for large and/or multiple areas of Bowen disease and superficial BCCs.RADIATION Radiation therapy for Bowen's disease: Lessons for lesions of the lower extremity
Margaret T. Dupree, MD Rex A. Kiteley, MD Karen Weismantle, MD Reed Panos, MD Peter A. S. Johnstone, MD, MA
San Diego, California
J Am Acad Dermatol 2001;45:401-4. Abstract quote
Objective: A retrospective outcomes review of radiotherapy for Bowen's disease was performed to analyze all patients treated with radiation therapy between 1993 and 1997 at the Naval Medical Center, San Diego.
Methods: Eleven patients with 16 lesions were treated with a median time-dose-fractionation value of 105 (range, 93-108).
Results: All 11 patients were without evidence of disease within 1 to 2 months of completing treatment. Four of the 16 lesions (25%) were unhealed at time of last follow-up; the remainder healed with good cosmetic result. All unhealed lesions were on the lower extremity. Median follow-up was 27.5 months (range, 9-57 months).
Conclusion: Radiation remains a good therapeutic option in selected patients with Bowen's disease, but caution should be exercised before selection of patients with lesions in potentially poor healing areas, such as the lower extremity.
SURGERY
- Cutaneous squamous carcinoma in situ (Bowen's disease): treatment with Mohs micrographic surgery.
Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R.
Oculoplastic and Orbital Division, Department of Ophthalmology and Visual Sciences, Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia.
J Am Acad Dermatol. 2005 Jun;52(6):997-1002. Abstract quote
BACKGROUND: Bowen's disease (BD), also known as squamous intraepidermal carcinoma, is a malignant skin tumor with a potential to progress to invasive carcinoma.
OBJECTIVE: We sought to report a large series of patients with BD treated with Mohs micrographic surgery (MMS).
METHODS: This prospective, multicenter, case series included all patients in Australia treated with MMS for BD, who were monitored by the Skin and Cancer Foundation between 1993 and 2002.
RESULTS: There were 270 cases; the majority (93.4%) were located in the head and neck area. In 50.7% of cases it was a recurrent tumor. In 20% the tumor was initially misdiagnosed as basal cell carcinoma or squamous cell carcinoma. No cases with perineural invasion were diagnosed. There were 6 cases of recurrence (6.3%) of 95 patients who completed a 5-year follow-up period after MMS.
CONCLUSION: The low 5-year recurrence rate of BD with MMS emphasizes the importance of margin-controlled excision, especially in the head and neck area where tissue preservation is essential.Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
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Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.
Erythroplasia of Queyrat-Variant of Bowen's disease occurring on the penis.
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