Carcinoma in paleopathological material • 263 



examination is required that the disease is, in fact, carcinoma 

 and that the extent and severity is as imagined. An example of 

 a "75% certain diagnosis" for carcinoma of the breast would 

 be a terminally ill lady with a palpable breast mass and a bony 

 metastatic pattern on x-ray consistent with a primary in the 

 breast. An equivalent level of diagnostic certainty (or uncer- 

 tainty) in a patient with carcinoma of the colon would be the 

 finding of a constrictive lesion on barium enema and liver 

 metastases on CT scan. If a serum CEA level were markedly 

 elevated, the level of diagnostic confidence would be in- 

 creased. Findings in a patient of a stony hard prostate on 

 palpation, urinary retention, and x-ray findings of multiple, 

 osteoblastic lesions of the pelvis and spine would be highly 

 suggestive of carcinoma of the prostate. An increased serum 

 level of prostatic acid phosphatase would extend the level of 

 confidence even more. In none of these instances, however, 

 would a "100% certain diagnosis" be possible without a 

 biopsy. 



There are analogies to modem clinical medical diagnosis 

 in soft tissue paleopathology: 



HISTORY. The site and provenience may be of definite help, 

 such as when the remains are taken from a known burial site 

 for lepers, or where there is a mass burial suggesting that 

 many deaths occurred at the same time, as in a battle, famine, 

 or rapidly progressing disease. Provenience may suggest cer- 

 tain diseases common at the time and place. 



PHYSICAL EXAMINATION. This is essentially the gross autop- 

 sy of the mummy and the major source of our diagnostic 

 possibilities in paleopathology. Lesions in the soft tissue may 

 suggest carcinoma (versus tuberculosis, fungus, etc.) if the 

 primary site can be located, as carcinoma arises by definition 

 at an epithelial surface anatomically. The tumor, if primary, 

 is usually but not necessarily concentrated there (breast, col- 

 on, prostate). Many carcinomas have a rather characteristic, 

 natural course and way of spreading. Thus, carcinoma of the 

 prostate invades locally and metastasizes most often to bone 

 (80% of metastases), usually of the pelvis and vertebral col- 

 umn. Carcinoma of the colon proceeds to regional lymph 

 nodes and 75% of other metastases are in the liver, though not 

 commonly in bone (11.7% of metastases). Carcinoma of the 

 breast proceeds to the regional axillary nodes and when meta- 

 static elsewhere. 70% of metastases are in bone (ribs, long 

 bones, skull vertebrae), and lung (66% of metastases) (Del- 

 Regato et al. 1985:687,542,866). In each instance, a new 

 dimension over the x-ray appearance of the bony lesions 

 alone is added by soft tissue examination. Prior x-ray or CT 

 procedures may give an indication as to where attention 

 should be directed during the gross autopsy. Primary malig- 

 nant bone tumors are rare. When they occur, they often have 



a favored site. Metastases to bone, however, account for the 

 great majority of cancers in bone and also have favored dis- 

 tributions (Abrams et al. 1950:77). The size of a bony lesion 

 is not necessarily related to the primary site: a large defect 

 with several smaller ones does not mean that the large one is, 

 or is near to, the primary. A further caveat is that present-day 

 statistical data for sites of bony metastases are not compar- 

 able. 



RADIOLOGIC STUDIES. Since metastatic carcinoma to bone is 

 by far the most common malignant tumor of bone, and since 

 x-ray can detect lesions not visible from the surface, these 

 studies fomi a very important role in the study of carcinoma. 

 Bone is involved by metastases in up to 70% of malignancies 

 in some series (Jaflfe 1958:589-618), though it should not be 

 expected that any value near this figure is attainable in an- 

 cient material for a variety of reasons, including incomplete 

 skeletons. Further, ancient (untreated) cancer victims died 

 earlier in the course (from intercurrent disease, then as now) 

 and probably did not often manifest the fuller expression seen 

 now (Ortnerand Putschar 1981:365,366). In addition, series 

 from medical literature include metastases to bone marrow 

 and cancellous bone that have not yet involved the cortex. 

 Breast, lung, and kidney currently make up a large percent- 

 age of primary lesions involving bone, but their relative fre- 

 quency in ancient populations is absolutely unknown and 

 cannot even be estimated. 



The general advantage of radiologic procedures is their 

 nondestructiveness. Whatever anatomic relations still intact 

 after careful removal from the burial site, transportation, and 

 so forth, can be recorded before the autopsy starts if practica- 

 ble. This permits reevaluation of bone and soft tissue rela- 

 tions after completion of the autopsy. It also may suggest 

 whether an autopsy would even be fruitful. If x-ray shows all 

 of the organs to have undergone extensive degeneration and 

 amalgamation, the yield in soft tissue studies is low. Cost and 

 time need to be offset by potential gain. 



X-RAY. This simple procedure is often available even in re- 

 mote areas. When a lesion is osteoblastic (as most prostatic 

 carcinomas are) x-ray is very helpful. Unfortunately os- 

 teoblastic lesions are less common than osteolytic ones, 

 though they generally become visible earlier than osteolytic 

 lesions of comparable size. The pattern of metastasis may 

 suggest a primary site. Osteoblastic lesions involving the 

 pelvis and lower vertebrae in an older male are highly sug- 

 gestive of prostatic carcinoma. Breast tumor metastases to 

 bone may be either osteoblastic or osteolytic, while those of 

 colon carcinomas are usually osteolytic. An otherwise os- 

 teolytic lesion may appear osteoblastic if there is sufficient 

 bony destruction in addition to adequate time for repair. 



Zagreb Pateopathology Symp. 1988 



