Derm Article

OBSERVATION

An Inquiry Into the Nature of the Pigmented Lesion Above Franklin Delano Roosevelt’s Left Eyebrow A. Bernard Ackerman, MD; Steven Lomazow, MD

Background: Little note was taken when Franklin

Conclusions: The failure of observers of Roosevelt,

Delano Roosevelt was alive and since his death of the pigmented lesion above his left eyebrow that fulfilled clinical criteria for melanoma. Observations: On morphologic grounds alone, it is

especially his physicians, to comment on his riveting facial lesion and to identify it as a probable melanoma speaks volumes about how flawed were clinical criteria for diagnosis of flat and slightly raised lesions of melanoma in the 1930s and 1940s.

impossible to exclude the possibility that Roosevelt had a melanoma.

Arch Dermatol. 2008;144(4):529-532

B

Y VIRTUE OF A VARIETY OF

technical considerations, such as the angle of the head, the lighting of the face, and the brightness and contrast of the print, the pigmented lesion above Franklin Delano Roosevelt’s left eyebrow shows considerable variation in intensity in many of the photographs (Figures 1, 2, 3, 4, and 5) of the person most photographed in the 20th century. In the photographs in which Roosevelt’s face is captured in profile, the pigmented lesion appears to extend from the lower part of the forehead to the base of the eyebrow. OBSERVATIONS

Author Affiliations: Ackerman Academy of Dermatopathology (Dr Ackerman) and Departments of Medicine and Neurology, Mount Sinai School of Medicine (Dr Lomazow) New York, New York. Dr Lomazow is also in private practice in Belleville, New Jersey.

The criteria currently touted for diagnosis of a slightly raised lesion of melanoma, a malignant neoplasm composed of abnormal melanocytes, are the “ABCDEs”: Asymmetry, Border irregularity, Color variability, Diameter greater than 6 mm, and Elevation (or, for some proponents of the mnemonic, Enlarging or Evolving). The fully developed pigmented lesion above Roosevelt’s left eyebrow admirably fulfills those criteria. But the ABCDEs also are encountered from time to time in a disparate variety of other pigmented lesions of the skin, among them being solar lentigo/ seborrheic keratosis, melanocytic nevi of different kinds, and pigmented basal cell carcinoma.

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MELANOMA VS SOLAR LENTIGO/SEBORRHEIC KERATOSIS A solar lentigo is a benign neoplasm constituted of pigmented keratocytes. When it becomes elevated and, in the process, assumes an appearance more advanced histopathologically, the same condition then is referred to as a seborrheic keratosis of the reticulate type. On occasion, a solar lentigo/seborrheic keratosis may acquire characteristics that conform to the ABCDEs. Roosevelt was an inveterate sailor and had many solar lentigines, particularly on the dorsum of his hands, these contrasting strikingly with the pigmented lesion above his left eyebrow. Despite that reality, not all solar lentigines are tiny; some may achieve a size like that of the lesion above Roosevelt’s left eyebrow—and even larger. On gross morphologic grounds alone, the pigmented lesion above Roosevelt’s left eyebrow could be either a melanoma or a solar lentigo/seborrheic keratosis. Only a study of sections of tissue obtained by biopsy would enable the conundrum to be resolved conclusively. No evidence exists that the lesion ever was biopsied or treated in any way. Sad to say, most of Roosevelt’s medical records are missing; none at all pertinent to the pigmented lesion above the left eyebrow have been found. The fact that the pigmented lesion was variegate in shades of brown and very dark brown in the arciform portion of it is more

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Figure 3. Franklin Delano Roosevelt in August 1938 (age 56 years) with an asymmetric, brown, seemingly barely raised plaque, darker in shape arciform at the top and on the right side of it, but lighter in a central zone macular. The plaque is larger in size than it was in 1933 (Figure 5).7

Figure 1. Franklin Delano Roosevelt in 1900 (age 18 years) with no pigmented lesion above his left eyebrow.7

Figure 2. Franklin Delano Roosevelt in 1923 (age 41 years) with a subtle, uniformly tan, poorly marginated macule above his left eyebrow.7

consonant with melanoma than with solar lentigo/ seborrheic keratosis. Moreover, whereas a large solar lentigo/seborrheic keratosis on a face usually is accompanied there by other large solar lentigines/seborrheic keratoses, melanoma presents itself conventionally as an isolated lesion, as was the case for Roosevelt’s pigmented lesion. That finding, too, favors a diagnosis of melanoma. However, melanoma, being the malignant neoplasm irrepressible in growth that it is, would be expected in the course of the 20 years from 1923 to 1943 to have attained a diameter greater than that of the lesion seen above Roosevelt’s left eyebrow (at the apogee it was only about 2.5 cm ⫻ 2.0 cm in diameter). Furthermore, for several years prior to 1943, the lesion showed no sign of centrifugal extension or of progressive elevation above the surface of the skin. That behavior also militates somewhat against melanoma. Episodically, a melanoma may undergo involution in the form of ever-expanding hypopigmentation over the course of several years, the process often causing the pigmented portion yet remaining to assume an archlike configuration. Only uncommonly does a melanoma regress entirely, leaving as residuum but a macule of hypopigmentation. Although the arciform character of the darkest pigmentation of Roosevelt’s lesion surely is in keeping with the clinical appearance of partial regression of melanoma, it would be unusual for the lesion above the left eyebrow to have undergone complete regression in the rather short space of 4 years (ie, in the period from early 1940 to 1943). Biologically, such a phenomenon is unlikely. For regression in toto of a melanoma that size to have occurred should have taken considerably longer. Solar lentigo/seborrheic keratosis also is known to regress completely, but when that happens, almost always the lesion is small, situated on the chest, and accompanied often by signs of inflammation so noticeably viola-

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Figure 5. Comparison of the appearance of the skin above Franklin Delano Roosevelt’s left eyebrow in the 10 years from 1933 to 1943. A, Roosevelt in 1933 (age 51 years) and B, in January 1943 (age 61 years), showing a very faint residual outline of what was a pigmented lesion. Note the marked contrast in the appearance of the skin above the left eyebrow.7

Figure 4. Franklin Delano Roosevelt in August 1940 (age 58 years) with an asymmetric, apparently slightly raised lesion, brown in an arc at the superior pole and hypopigmented in the lower two-thirds. No additional growth since 1938 is apparent.7

ceous that at this stage of involution it is known universally as “lichen planus–like keratosis,” lichen planus being an eruption typified by purple papules. If Roosevelt’s lesion did not undergo involution entirely, then it must have been removed surgically or have been camouflaged by makeup. However, there is no evidence for either. No sign of a scar from a surgical excision is apparent. In short, how his pigmented lesion came to disappear from 1940 to 1943 remains an enigma. Independent of that, on the basis of all that is known presently about the morphologic aspects and biologic behavior of his lesion, it is impossible, despite the imponderables, to exclude melanoma. ROOSEVELT’S PIGMENTED LESION IN THE CONTEXT OF HIS HEALTH IN GENERAL All details of Roosevelt’s health, especially during his 12 years as the 32nd President of the United States, were shrouded in secrecy while he was alive. The most flagrant example of duplicity was that although Roosevelt never was able to support his own weight without the use of metal braces on his legs as a consequence of his having contracted poliomyelitis in 1921, the American public was shielded from knowledge of his extraordinary physical disability. Most Americans were unaware that he was unable to walk without assistance. Complicit in this “splendid deception” (the title of a biography of Roosevelt by historian Hugh G. Gallagher,1 who also had contracted poliomyelitis) were Roosevelt’s physicians, as was the press. Of the tens of thousands of images of Roosevelt in pho-

tographs and films, fewer than a handful show him compromised physically, despite the fact he was wheelchair bound. Every aspect of his appearance and public persona was painstakingly orchestrated. Ross T. McIntire, MD, a career navy man who eventually attained the rank of Vice Admiral and Surgeon General of the Navy, was Roosevelt’s personal physician from 1933 until the President’s death in 1945. A specialist in head, eye, ear, nose, and throat disease, McIntire was chosen to be Roosevelt’s personal physician not only because the President was prone to sinus disease, but because McIntire had a reputation for unwavering loyalty and for “keeping a tight lip.” He was recommended for that post by Roosevelt’s close friend, Cary T. Grayson, MD, who had been physician to Woodrow Wilson and was a central figure in the cover-up of Wilson’s devastatingly disabling stroke in 1919. After Roosevelt’s death in April 1945, persistent rumors surfaced about his health. McIntire, in a book (largely ghostwritten) published in 1946,2 denied that Roosevelt had experienced any chronic malady of significance. Until McIntire’s death in 1959, any information germane to Roosevelt’s health was guarded closely and effectively. In a volume that appeared in 1970, historian Hugh L’Etang3 was the first to raise publicly the specter that Roosevelt had a melanoma. His assertion was deflected in an apparently coincidental but, more likely, a purposefully timed article by Howard G. Bruenn, MD,4 a cardiologist who was the last surviving member of the inner circle of Roosevelt’s physicians and who saw Roosevelt on a daily basis from March 1944 to April 1945. Bruenn set forth many previously undisclosed details that came from Roosevelt’s medical records, emphasizing those of a cardiologic and vascular character that the President had experienced during the last year of his life.4 No reference whatsoever was made by Bruenn to the pigmented skin lesion above the left eyebrow, despite it being decidedly unsightly. That omission, the wording of an editorial that accompanied Bruenn’s article,9 and corre-

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Figure 6. In his textbook of dermatology published in 1917, William A. Pusey, MD,8 diagnosed this extensive lesion as a “pigmented senile patch” but had a biopsy sample been taken and read by a competent dermatopathologist, the findings surely would have been those of melanoma, presumably in situ.

spondence between Bruenn and Roosevelt’s children suggest a deliberate attempt to minimize the impact of L’Etang’s assertion of melanoma. In 1979, Harry S. Goldsmith, MD,5 a well-respected surgeon, raised, for the first time in a peer-reviewed medical journal, the possibility that Roosevelt’s pigmented lesion was a melanoma. Goldsmith5 cited reports and observations of creditable and competent physicians and, in addition, presented what he deemed to be photographic evidence of the existence and then the disappearance of the lesion in question. Goldsmith’s article gained considerable attention at the time it was published, but the emphatic public denial by Bruenn served to quash the hypothesis of melanoma and preserve the prevailing idea that the cause of Roosevelt’s medical conditions and ultimately his death was primarily of a cardiovascular nature. When contacted by Time magazine, Bruenn baldly stated: “Roosevelt did not have a cancer. This can be stated with certainty.6(p58)” Goldsmith’s proposition was reduced to mere footnote. COMMENT

Given the fact that melanoma, solely on the basis of clinical inspection, should have been the most likely suspect for Roosevelt’s lesion, why was that possibility never raised? How could it have gone undiagnosed by derma-

tologists throughout the United States and the world who regularly observed it in photographs and in films? Astoundingly, to our knowledge, the only reference during Roosevelt’s lifetime to that lesion was by McIntire7 in a letter written in January 1940 in response to a colleague, Reuben Peterson, MD, in which the physician/ admiral assured that the lesion was “under observation at all times.” In the 1920s, 1930s, and 1940s, a lesion such as Roosevelt’s was not diagnosed as melanoma, even by dermatologists, but was considered to be benign—that is, a senile pigmented patch (Figure 6)—or, at worst, a premalignant neoplasm designated as a Hutchinson melanotic freckle or precancerous circumscribed melanosis. Even in the late 1950s, such a lesion was deemed to be a precursor of melanoma, not a melanoma per se. The editorial that appeared in 1970 in the Annals of Internal Medicine complementary to the article by Bruenn affirmed that “there was no clinical evidence for such a lesion [melanoma] and no autopsy was performed.”9(p530) But that statement certainly is not in synchrony with the attributes of Roosevelt’s lesion. On clinical grounds alone—that is, gross inspection—it is impossible to exclude melanoma. Because it seems that the lesion described herein never was biopsied, the answer to the question of the authentic character of it must for now be couched as supposition. Accepted for Publication: August 30, 2007. Correspondence: A. Bernard Ackerman, MD, Ackerman Academy of Dermatopathology, 145 E 32nd St, 10th Floor, New York, NY 10016 (jdelarose@ameripath .com). Author Contributions: Study concept and design: Ackerman and Lomazow. Acquisition of data: Ackerman and Lomazow. Analysis and interpretation of data: Ackerman. Drafting of the manuscript: Ackerman. Critical revision of the manuscript for important intellectual content: Ackerman and Lomazow. Study supervision: Lomazow. Financial Disclosure: None reported. Additional Contributions: We thank the staff of the Franklin Roosevelt Library at Hyde Park, New York, for its assistance. REFERENCES 1. Gallagher HG. FDR’s Splendid Deception. New York, NY: Dodd Mead & Co; 1985. 2. McIntire RT, Creel G. White House Physician. New York, NY: G.P Putnam’s Sons; 1946. 3. L’Etang H. The Pathology of Leadership. New York, NY: Hawthorne Books; 1946: 86-102. 4. Bruenn HG. Clinical notes on the illness and death of President Franklin D. Roosevelt. Ann Intern Med. 1970;72(4):579-591. 5. Goldsmith HS. Unanswered mysteries in the death of Franklin D. Roosevelt. Surg Gynecol Obstet. 1979;149(6):899-908. 6. Did Roosevelt have cancer? Time. December 17, 1979;114(25):58. 7. Franklin Delano Roosevelt Library. Ross McIntire Collection, Box 4. Hyde Park, NY: Franklin Delano Roosevelt Library. 8. Pusey WA. The Principles and Practice of Dermatology: Designed for Students and Practitioners. New York, NY: Appleton; 1917. 9. Medicine and history. Ann Intern Med. 1970;72(4):530.

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