Ediciones > Año 1947 > Artículo No. 1 2

Multiple Idiopathic Hemorrhagic Sarcoma of Kaposi
Wilbert Sachs; Rubem David Azulay; Jacinto Convit
REVISTA: Publicaciones - Dr. Jacinto Convit

NUMERO: Año 1947

TITULO: Multiple Idiopathic Hemorrhagic Sarcoma of Kaposi

AUTORES: Wilbert Sachs; Rubem David Azulay; Jacinto Convit

RESUMEN:

PALABRAS CLAVE:

MULTIPLE IDlOPATHlC HEMORRHAGIC SARCOMA OF J{APOSI* HIS1&#39;0PA&#39;r.tl0L()GIC STUD)&#39; WILBERT SACflS, M.O. Neto Yor.k, N . l&#39;". RU.BKM DA VlD AZULA Y, M.D. ~·iteroi, Hio dt: Janciro Af>O JACINTO CONV!T, M.D. Caraca.!, V ~luello. Mtmy t it.les aud coneopt6 of pathogeoceiá bt\VO IJoon adv:mcod &ince Kup~i (1) 6rst. described t. bis disea.ae in 1872 as 11ioio¡Jathic multiple pigmont. sarcoma of the alón." Pt\ulricr and Diss (2) t\ ~t.ributed the di.sease &#39;o l\ dysgene$id oC t.be v-.sels an.d their neuromuscular eie.ments, and a proliferation of Schwann cclls with íormation of the Wagner-~leiqncr &#39;)&#39;pe of tactilc corpu4ch:. Jludelo and C3illcau (3) beli<wcd tbe process wa.s due exclusively to tbe prolHemtion of &ympMhctic perivsseular norvo 6bers. Beeker and rl&#39;b&tclwr (4), despite the use of nerve s tairul, werc unabte to confirm tttese findi~, nor, aft.c!r studying the phagoc)<tie p ro~rtic8 o! t.he colls, did they t\&rte witb Dorficl (5) tbat t.he leaions were C&#39;s.uscd by llisei\Se of the r-et ieulo-endotbelial sy.stern. T hey suggest t.bat &#39;Kapo.!.; &#39;• e&t <:Onllhas a multiocntrie origin from·embryonal mesenchymtLl c<:Hs in t.he perithelial t issue and that degenerat.ion of thesc cells mny resul t. in a t.ruo ttm:oma witb metastMia. Dalla. Fo.vcrn (6), Lane tmd Greenwood (7)1 DuJlOnt (8) , and Dillard and Weidman (9) support.eo t.hc reticulo-c ndothc-lilll origin. &#39;fho lMt ~t.,.t cd tht\l Kaposi&#39;a sa.t·coml\ i~S primarily inHs.mme.tory in nature, but m!ly ix&#39;cOm(} &econdtLrily &Arcoma.tous. T hcy 1\lsn mtM!e tbe euggestion t hM the p rO<fU<&#39;t s of blood degenerat.ion might IM:l as the ~ndothclil&#39;\1 stlmulus . Polliher (10), DAI.zes, ) lerl(&#39; antl nuoorus Duv:\1 (11), áncl Lieberthsl (12} atrcmd the aarcOII\atou u~t u re ()f thc d i~:~.Su . E";og (l3) agr~l t hst t he lato s t a~es miv;ht acquire nooplastic pro~rtica 3nd givc ri.<tC&#39; to a spindle t(&#39;ll ttar<·oms, but pointed out.. t h&t \ho prominente of inftammatory signs indicated an inftttious origin oí granulorn&t()US typc ,,.;eh specia.l inYol" cmcnt of thc ~piiiArr endotheli um. )la<"Kt"C sud Cipollaro (14) ~n cu rred n·ith 1 his opinion. MacLcod (15) <&#39;Omsiclered t he proccM to be a p rolifenuion of organitiug conncet.ive t.issue " ; tll vas<"uhu dilat.ation. Cil<&#39;hris1 and Retron (16} thoughl thal thc diec.•nsc &tl\ttod 1\S s.n angioma ~nd ~hl.&#39; t.umor stagc resultcd from prolifcrat ion oí connectivo t.isauc ""d ondothelium. DcAmieia (17) Hnici thst it is intcrmcdie1o bctwet:&#39;n á grnnuloma nnd 1\ t~arcoma. Ramel (l .. ) cli\S3ified it 1\S an endolbeliom.a an<l l.~\ 1\K and Haslh&#39;ofer (19) intcrrlr(&#39;ted iL as a syslcmic {mgiot uat~is . Wc belien• that Kaposi&#39;s :)t}rC::oma is ne\&#39;er a simple inflammatory proccss. New blood n~".;:sels and spindle cells are present in nll our sections, (&#39;\·en thosc from a pinhead-sit.ed lesion or one week&#39;s durotion (figs. 1 sud 2). We fed tha.t from t hc beg\nning this disease is a pot.cn tinl sarcoma, that all IC$ions do not necessarily termiMte a.s neoplasms, and t.hnt it may be considel"cd n syst.omic angiosarcoma tosis. • From i.-bc N~w York. Skin and Cancer Unit, Ncw York l>osL-Gra.d u.o.tc Medicc.l &ht>ol and Hospital, Columbia U&#39;niversity. Received for r>ublicatíon Scptombet 24., 1946. 317 • 1 lDIOPATIUC H&MORRlfAGIC SARCOMA 0 )&#39; 1\APOSI 319 BISTOPATHOWGY ldiopathic multiple hcroonh.agic sarcoma of Kaposi is oft.en classifiod as early or b tel and ~ infiammatory 1 granulomat.ous or neoplastic. Such divi~ion is not cnlircly correct, for the pa ~hologic picture does not ahvays coincide with the dm ntion of thc process. Besidcs, more lhan one st.agc may exist at the samo time. Wtüle such a clat!sification is arbitrary, it is com·enient and oft.en helps to correlate the patho)ogic with the clinicsl picture. The pathologic picture of Kaposi&#39;s sarcoma shows new blood and lymph Yesscls, c·ellular elemcnts, connective tissuc hyperplasia t4nd hcmorrhage. The cellula.r elements include small round cells, wandering connective t issue cells, plasma cells, angjoblasts, spindle ceUs and fibroblasts. The proces:> is primary in the cutis; the epidermis shows no change unless secondarily in,·olved. The microscopic picture depends u pon the pha.se and t.ype of clinical Jesion examined. Any of the above features may predomi.nate and the seetion simulat.e such un- 1-elated dorrnatoses as angiomas, granulomas, apparently innocent innammatory l&#39;eact.ioos or highly ntalignant sarcomas. Before any of the features show pronounced prolirera.tion, t.he findings are those described by others in the early or inflammatory stage (fig. 3). 1&#39;he blood vessels of the upper and mid cutis are dilated, increased in number, frequently filled "·ith blood elcments, and arranged in groups or scattced diffuscly tbrough- • out thc cutis. Thc cndothelial cclls are S\VOllen and hs.ve Jarge v~ icular nuclei projecting into thc lumen (fig. 4). Thesc nuclei may be round and somewbat by~rc h1&#39;0ma tic, rathcr th.an oval and vesicular. Jnstead of being elongated, Lh~ cells may appear rectangular (cross-scdion of the cndothelial cell) and resemble somewhat the embryonic plasma ·oon of young granulat.ion t.issue. The lymph \&#39;essels and spaces ru&#39;() prominent. The cellular infiltration is sparse, perh·as<&#39;ular as well ns diffuse, s.nd composed of small round and wandering connect h·c tissue cclls, angioblnsts and sorne spindle oolls. Plasmá and mast ccUs are oocasionatly seen. Thcre is no hypcrpla~iia oí connect i\&#39;C tissue and no changes in the elastic tissue. Erythrocytes, or intt&#39;tlceltular or extracellular g¡"nnules of hemosiderin indi<~atc:; hemofl&#39;ha.ge. As thc process de\&#39;clops Oate tage-granulomatou:J or neoplastic), diffcrent picturcs are noted as vascular, <&#39;<>nnective t is..~ue or cellular hyperplasin becomcs prominent (tig. 5). With the proliferat.ion of . ,·essels, th<&#39; appearance is tha.t. of . an angioma (Ag. 6}. &#39;Vo.scular and cellular hyperplasia may mimic granuloma$1 FJo. l. SJ tO\n~o l.snvrRATION t ~ TRE Cu&#39;l&#39;"l$ or A KAPos J &#39;~t SARCOlo1A or O~ E W"&&K&#39;& D l.iRA&#39;MOl&#39; (50)() Fro . 2. HtcK Pow ~.¡n or F1o . .1 1 SKO\\&#39;JNG A xo t08L.\.STS Al"O Srt ~OL& ÚEt.LS (600X} Fao. 6. SKo,ruw Tl:ft: A.l&#39;\OI Ol.IATous As1)r..cr OF KAt•osr&#39;B S.\.RCOl.u (50X) Frc;. 7. SHOWI!\G V ASCU.LAR Hvr:&.RPLAi&#39;IA &#39;nTR A C&t..u·LAR lh$.,\ CTlON Com•os&o C tuEPt.Y OP ANotosr,,,sTs; A Fuw S t•JNDL!: Cl:t.l..S AK&#39;" Ptn;sE~T (50X) Fro. 8. SooWtl"O ,. L ocAJ .. U .ED An&,, 1 ~ KAvOS t &#39;~ füRC01tA, Sut C l.ATr ~G ÜLOlJCS Tn.aoR ( JOOX) Flo. 9. SnownoG Srt ~ot.-B Ca:a.t. SARCOMA wtTH Soa.~í> VA&et.:>ua l h rt;RI&#39;LA&JA A ~u P ro.MENT (t50X ) I·&#39;1<L 11 . S uowiNo Pt.AS)tA CELU:> "~o ~f \J LT I ~l&#39;c t.E.\TEo l &#39; t-AS)u C& a.r:.~ (1\LlnscnAt.Ko CELI.S) ~~ Mf l NFWrRATION o r KArosl&#39;s So~.ncoMA (600X) Frc. 12. SnowJNc;: A P OSJTH"& P~n u.&#39; Jl.EACT I O~ JI&#39;\ KAPOSt&#39;s So\RC<»>A ( lOOX) • 320 TBE JOUn!IU.L OF INVESTtGATlVE DERMATOLOGY ~ ~ Fto. 3. S How t ~o ,. DtYn:ss PROCE88 WITK Dn.ATED BLOoo ANo Ln.tPR VEssELS, SOME t .. Yll PH S PACJ;S, Al" O A M ODERA TE Cl-lt.LULAJl lNFl L-TBATI O~ (98X ) ., • / ;, - - &#39;""""&#39;......; =--.... Flo. 4. SuowaNo VA&eULAR R v PEa Pt.AStA, 11&#39;-&#39;TIWAt.. CHA:COt&#39;!S A ~ o,. C e t.Lt>t.Aa R EACTIOS COMPOSJ;O OP A l&#39;ó0109r..A&TA ASO S PJ ~Dt.& Cr. t.l..& (700X) IDIOI&#39;ATU)c Ut;MOilRHAGIC SARCOMA Of&#39; KAPOSI 321 glomus tumor nnd gr anuloma. pyogcnicum. Jf tbc vessels aro associa.ted with numerous n.ngiobla.sts, Kaposi &#39;s sm:coma. may sirnulate a.ngiosarcoma, perithelioma or cndotholioma (fig. 7). In some of our scctions, thoro wcrc arcas tbat in no wny diffcred from glomu tumor (fig. 8). Where spindle ccll proliferation is the chnractcristic f<--aturc, tbc result is a. spindle cell sarcoma (fig. 9). Masscs of oolls cxtcnd in all di~ti ons and at times show mitolic figures; othcr cellular elcmcnts, a.<; well as vns<:ular a.nd conncctivc tissue hyperplasia, are not prominent. lf th.e connective tissuc. rather than celh_Jla.r elernents, is increa.&#39;)Cd, thc picturc su ggc~ t s au angiofihroma. The grow~h of fibrous tissue is never F1c. 5. Su0\\&#39;1 !\&#39;0 VASCt:t..AB Al&#39;D Cor-:N t;(..&#39;TtVE TlsstJ& HvrtRrusrA A ~o ... PRo:-.orsct;o C ~t. J.\: L Ak Rl:,,c-rro~ ov A sOIOBLASTS ANO Srtsot.. E CEL~ Considerable pitcmon t is prcsent i.n the scc&ion (98X ) • cxtensh·e und fr<>qucntly separa tes thc process into lobules. Frequcntly, arcns cbaracwrist ic of lhc various dcrms toscs menlioncd ubove nrc seco in thc samc scction . &#39;fhc epidermis plays no primary role in the proeess, and changes such as thinning, acanthosis, or bre_aking down are secondary. The pathologic changes in Ka.posi&#39;s sarcoma are in thc cutis. Vascular hyperpla&ia, hemorrh.age, angioblasts and spindle cells are found throughout the evolution of t.he disease except pcrhaps io the de,•elopment of spindle ooll sarcoma where the prolileration of spindle celhs overshadows all other features. Since tlte cytology is so important in thc microscopic di.agnosis of tbis di.::!ca.se, further discussion of some of thc ccllular clemcnts is warranted. This, we realize, • 322 THE JOURNAL Of&#39; JNVESTlGATlVE DERMATOLOOY is beset ";th many difficulties because o&#39;r inability to actually proYe contentions, and the vast differenc~ of opioion whioh exist umong authorities as to genesis, morphology and nomenclature. · Spituile oelts are found only in spindle cell sarcoma, or in a process which may eventua.te in sucb a sarcoma. We are led to bclieve th.at the sarcomatous process is not due to a simple accumulation of spindJe oolls from the parent cells, but ma.y depend on proliferation of these cells from otber spindle ceHs. The numerous rnitotic figures found in these cells would suhstantiate this view (fig. 10). The cytoplasrn of the spindle cell is scant and t he cell t.apers toa point at either end ; the nucleus is narrow, oval and vesicular with loosely arranged and lightly stained chromatin. The length of the cell is approximently twice Fw. lO. SeowiNO Sa&#39; JNDWO: CEa.us WITK MITOTIC F1o~; at ~S JS KAPOSJ &#39;8 SAl\COWA (700X) that of the nucleus. Wo doubt th.a.t this cell plays a.ny role in t.he production of collagen. Many different. types of cella, even epithelial cells, may ha. ve spiodle shspes; such oells sbould be refered to, notas spindle cells, but as spindle-shaped oolls. Thc relation of the jibrobla!lt to the spindle cell is un){nown. Contrary to the opinion of rnany, we believe that the two oells are different in. morphology, in function a.nd probably in derivation. The fibrobla.st is much larger in all dimensions and often has fiber-like projcctions extcnding from the tapering points. It ha8 an oval vesicular nucleus which is largcr and of greater diameter than the nucleua of t hc spindle cell. The fibt·oblast is approxirnently t,wo t.o throo times the size of the spindle cell. Unlike the spindle cell, the fibroblast doos forro collagen. 10l01&#39;A&#39;l&#39;lil(; Ht:MOIUUUGIC oRCO!\IA OF KAl&#39;OS The angiablast i.s thought to arisc from endotJ1elial cells and is referrcd to by sorne observe~ as an endothelioid cello Maximow and Blum (20) belicvc that the tenn o.ngiobla.st should not be used at allo Whilc the term endot.helioid cell ma.y be a.cceptable, \\&#39;e prefer to ret.aio the naroe angiobla.st because these cells are said to give rise to new vessels and because the mature cell usually does not resemble a.n endotheli.al cell. The angioblast has a round nucleus approximately H-2 times the size of the nucleus of a lymphocyteo It stains deeply, but the chromatin does not appear as a solid mass. As a rule, Jittle or no cytoplasm is observedo Bowever, a few of our sections show thc angioblasts with considerable cytoplasmo o Tbis is not unlike the polyhedral, pa.vcmcnt-like appearauce of endothelia.l oells when the flat surface is examinedo The origin of plasma ceU.s is stiU unset tled. lt is possible that they may be derh·ed fTom the endot helial cell or from an intermedia.ry cell which itself has arisen from a.n endothelial cell. The plasma. cell is acorn· or pear-shaped with sn eccentric nucleuso The chromatin of the oucleu.s is arran.ged a.t the periphery in several minute collections like the spokes of a wbeel. Tbe cytopl.asm is homogeneouso 1&#39;he cell is easily seen and recognized with the bematoxylin stain and only rarely are special sta.in.s necessary to determine th.e nature of the cello The shape of the plasma cell may differ from the uaual and occasionally appear round, rectanguhu or even spindle-shapedo Beside the common plasma cell, multinucleated or Moarsch.alko plasma cells ma.y be seen (figo 11). The derivation of the smallrou:nd cell is undeeidedo Some believe them to be related to lymphocytes, othen; do noto &#39;Ve a,re inclined to agree with tbe latter. The p~ence of small rouo.d cells in this process is a response t.o tissue injury a.nd is no different from their presence in ao.y ot.heto pathologic processo The morphology of the smaU round cell is different from that of th.e lymphocyte as seen in lymphat.ic leuk~mia.. The nucleus is more solid, irregular in sbape and size, and has no cytoplasm about ito Such cells are not seen in the circulating blood n.or in the lumen of vesselso o \Ve beUeve hem()rrhage is secondary rather than primary, and is th.e result of er~·throcytes waodering int.o the surrounding tissue from imperfectly formed new \&#39;essels or through ruptured or damaged \&#39;es...c;elso The proliferation of thinwalled vessels is thu to be considered the primary process and b.emorrhage is secondaryo DlFFERENTlAL DJAONOSIS Tl\e diseases to be considered in the differential diagnosis depend on the characteristic feature or features noted. The list of such diseases is long, and only the moro important will be discu..~d hereo In the early phases of Kaposi&#39;s sarcoma, before extensive hyperplasi.a has occurred, t he telangiectatic, the purpuric, the hemorrhagic and the simple inflammatory processes must be differentiatedo Tela.ngiectasia is not rclatod to hyperplasia of blood and l)rmph vesselso In hyperplasia, there are new vessels, especially capillaries; in tela.ngiect~sia, t.he picture is t.ha.t oí a dila.~ , t.ortuous vessel cut at many poiotso Ea.rly in the process, hemorrha.ge is not a difTerential point unless combined with other features of Kaposi&#39;s sarcoma: Most 324 TJfE IOQRNAL OP INVEST1GATIVE DERMATOLOOY important is a con ·ideralion of cylology, including plasma cells, angiobla.sts and spindle cells. These cells, vascular hyperplasia and hemorrhage are not. a part of a simple inftammatory process. A thorough st.udy and proper estimation of tbcse fcatures should lead to a correct. diagnosis. With definite hyperplasia of the vascular, connective tissuc or other ccllular clements, sorne of the graoulomas and neoplasms must be cxcludcd. Thc absence of epithelioid cell , giant cells and tubercles eliminates tuberculosis. Tbe presence of angioblasts and spindle cells plus the lack of vascular chnnges and plasma cell collarets rule out syphilis. Granulation tissue diffcrs in dcvelopment and e&#39; ·olution, ~rminates in complete fil>rosis, shows cells not seen in Kaposi&#39;s sarcoma, fibroblasts and plasma cells al&#39;e usually more abundant, angioblasts scarse and spindle cells are absent. 1\.mong the neopla.sms to be considered, Lhe most common and important are angioma, angiosarcoma, spindle ccll sarcoma, glomus tumor and granulom.a pyogenicum. Tho typical and usual angioma givcs little t rouble, but if cellular elements are also prcscnt the likcness may be striking. Thc ccllular elements are angioblasts and we believe that this iype of angioma is often referred to as endothcJioma or perithclioml\. There are msny, with whom we sgree, who seriously question the ex~nce of peritheliomas. We fecl that.they an;> angiomas associated ,,·ith aogioblasts. The diffcrential diagnosis of such angiomas, which are common in our c>.-perience, is cstablished by thc abscnce of hcmorrhage and spindle cells. Positive Perls&#39; reaetion (fig. 12) r plasma cells and incrcased lymphat.ic Yessels and spaces) is not present in angiosnrcoma. Without these feat.ures, the only way to diffcrentiate Ka.posi&#39;s sa.rcoma from angiosarcoma. may be the proper diagnosis of thc paront lesion. Spindle cell sarcoma. dc\&#39;eloping from a multiple idiopatbic hcmotThugic sarcoma <lillers littlo from the picturo of one not rclated to l{nposi&#39;s sarcoma. Al times, the pre3ence of angioblasts and plasma cells wili belp to C$tabli h the diagnosis. Differentiation is not difficult if corrobora.ting eddencc of Kaposi&#39;s sarcoma is present (fig. 13). Tho clinica.l picturc and history may he of considerable importante. Glomus tumor and gmnuloma pyogenicum are the most common ncoplasms to be differentiated from Kaposi&#39;s sarcoma. The microscopio diagnosi · of glomus tumor is comparat,ivcly simple on sections staiued with hematoxylin and eosin; we ñnd no need of special staios. Capillari~, even in the form of angioma.ta, are obscrved and about them is an intense uniform focal infiltration of a.ngioblasts; no othor cell.s are notcd. Although muscle and nerve t i.ssuc take part in the prooess, wo do not stress their presence. In clloically and microscopically provcn cases of Kaposi&#39;s sarcoma., we frequently find areas typical of glomus tumor and establish tho proper diagnosis onJy after careful study of the entire section. The vascular changes in granuloma pyogenicum are similar to those of Ka.posi&#39;s sarcoma, but the cytology is different. Angioblasts are nurocrous and diffusely arranged, but plasma cells are not conspicuous unless the lesion is secondarily io!ected, and spindle cells are not seen. Granuloma pyogenicum has little tendency to 6brosis. DIOPATIIIC lfE)10RRllACIC S.\RCOliA OF KAPOSI 325 A positivo Perls&#39; ren.ct ions is obt.aincd in th.e vast mnjorit.y of lcsionli of l&#39;ap~i&#39;s sarcoma; it is seldom mi&~ing. Onc would expect thn.t. hem o~idorin would n.lso be prescnt in glomus tumor nnd gt-anuloma pyogenicum, hut nJter careful study or thcse lcsions, we wcre nblc to demonstratc its prcsencc in only a small pcroentagc of cases. Thc similatity of Ow microscopic fi n din~ . thc proliferat ion of V<&#39;SSCls, t.hc com· pletc lack or only pa.rt ial do,·clopment of fibrooi , and the role> of the augio- • blast. lcad us to belicvc that glomus tumor, granuloma pyogenicum and Kaposi&#39;s sarcoma mny ha ve a common origin and be cla.ssificd togetber undcr the hcading 13. SHowtso,. Sru~ot.E CELLSARCOMA D t:VBLOPIXO PROM" KA Po 1&#39;s SARCOM." (lOO X) of nngiobln toma. ~lu ltiple idiopathic homorrhDgic sarcom. a is from its inc()p tion u malig,:ant proc~" de,·eloping from thc \&#39;:lSculnr systcm of the skin anc i n t cm~• l organs. Th\1 , it may be considered n l&#39;ys tcmic angi0$8•·comato:;u of tlte aogioblastoma gr<Jup. svM)t:\RY l . Thc pnthology of multiplc idiopatluc h<&#39;morrhogic sarcoma re,·eat ~ \&#39;tt •• cular hyperplasia, hcmon hngc, angioblasts and spindl cclls as eon.st.ant featurcs. 2. :\t times, Kapoti &#39;s 8-llrcoma simulutcs thc sim ple i u flammat~1·y pT·ocessrK, n.ngiomns, granulom~tli 1utd ncoplasms; u microscopic differential diagnosis cnn he made. 3. Thc im¡)Ort.ant cellulnr clements of Kaposi&#39;s sarcoma a re discussed. -4 . Jt i · ~uggested that glomu tumor, granuloma pyogcnicum, and Kaposi&#39;s sarcoma are angioblsstomas. 32G THE JOURN:\L OF I N\&#39;f;s&#39;rlGA&#39;J1VE DEIU.tATOLOG1: • 5. It is furtll ct· . ugge~tcd that 1ütp0$i&#39; · sarcoma may be tlassified undcr aogiobhu~toma ns 1\ sy ·temic a n gio~rconmtosis. REFERENCES 1. li" rosr, MoRti.: Idiopat biiche• multiplca Pi ¡roe o ~o sarkom dcr Ha u t. Areb. r. Dennat. u. Syph. 4: 265, !812. 2 . P .H J&#39;I&#39;l.UtiR, L. )f. ANO Dts:S, A.: .K&pc;>~>Í &#39;~ ldiopathie s~r.-oma is not t\ genuine sarcoma but ~ ncurovn.s.cul!H dyRgencsis. Brit. J . Derml\t. 4l: 93-105, l !)29. 3. Huo1u,o, L . .\Nl> CAILLEAt:, Jo".: L!i Sareoml\te&e Ldiop&lhie pigmcntL\Írc mult.i¡>lo de Kaposi et Se3 int~pretatio l\8 histogeaiti<¡ues eL patbogeniques. Ann. de derma". et. syph. 2: ~li-&45, 1931. 4. DECK8Jt, S. W. A="D TU.-\TC}nm, 11. W. : ;\lultiple ldioptt.tbic Hemorrhagie Sarcom& of Kaposi. J. ln\&#39;Ost. Dermut . 1: 37~3~8. 1938. 5. DOfU&#39; PEL, J .: l Hst..ogcnesis o! Multiple Idi<>pat.hic Hcmorrbagic Sarcoma of 1\aposi. Arch. Dernu.t. & Sypb. 26: ~. 1932. 6. D.\t.t..A FA \ &#39;eRA, e. B.: Ueb.!r das sogenaon(en Ss.rcom& "idiopathicum roultiple lut.e· morrhagicum. (Kaposi). Areb . r. Dermat. u. Syph . 109: 387, HHl. 7. LA:-a:, C. G. AND Otu~X!&#39;\\&#39;OOD, A. M.: Lymphoblastomn. (Mycosis Fungoides) Md llemorrh& gic SarcomA of 1\apoai in t.he Samc Pcrson. Arcb, Derm&t.. & Sypb. 27: 643o-057, 1933. 8. DLI&#39;OXT, A. : Noto sur la mt\11\<lie de &#39;nsp08i. Bull. Asttoe. rrant; p. l&#39;étude du cancer. 28: 489, 1934. . 9. DUA.AltO, G. J . ,\SO WEII>)JAS, l~. D.; Mult.iplc Hemorrhl\slC Sarcoma or Kaposi . Arch. Dermat.. & Syph. U : 203, 1925 lO. PoLt.rnEB, S.: Quo\ed by Psutrier, L. ;\f. and Disa, A. (se.e 2) 11. BALtll~, :\lerle A.!I:O R t &#39; .BEX5 Ot&#39;YAL: Sareom3t~ primotive multiplo de peau . BuJI. Soc. Frsnc. d~ derrnal. e{ syph. 18: 1:2. 1007. 12. L t Y.lJl&#39;lRTtlAL, D.: Iui(lpa.thic Muhiplc Hcmorrhugic Sarconu. (Rapusi). J. A. ~1. A. t61 :J205-1207, 1008. . 13. E\\&#39; ISO, J .: )\eopla$~ic DistM~&. Plliladclplüa, W. D. Saundcra Compsny. l9t0. 14. MM.:l\t:e, Gt:oRm: l\lu.LI:!H ,,~o Crrou .. \no, AsntOI&#39;\&#39; C.: ldiopathic Multi¡>le Hrmor· rbt\gic Sarcotnl:&#39; (Kaposi). A m. J . Canc·er. 26: 1-28. 193G. 15. ll&#39;fACLl-lOU, J .: Xotes on th6 luslology o! mulliple idiopMhic bemorrhagic t>arcoma. Hrit. J . Dermat. 17: 173, 1005. 16. Glt.clnUt.T, T C. 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  Ediciones > Año 1947 > Artículo No. 1 2
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