Norri S. Al-Waili  ( House 34, Street 42, Section 729, Al-Mashtel, New Baghdad, Baghdad, Iraq. )

It has been suggested that prostaglandins (PGs) might be responsible for haematological disorders and impaired immunity in burns, surgical trauma, chronic infections and malignancies^1-4. Malignant cells produce excessive amounts of PGs^5-7 - which are suppressive of T and B lympho­cyte functions^8,9. PGs inhibit macrophage cyto­toxicity¹⁰ which are considered primary anti­neoplastic surveillance cells¹¹. PGs cause marked suppression of antibody production against T-de­pendent and T-independent antigens, modulation of serum albumin and globulin and lowering of granulocytic precursor cells^1,3,12. Hence, for im­munotherapy of cancer, it has been proposed that PGs synthesis inhibitors (PGSI) might have a pla­ce in the management of tumours by enhancing immune response to hamper the growth or even destroy the cancer cells^1,2,13. Accordingly indome­thacin, a potent PGSI, was used successfully in the treatment of chorionic carcinoma¹³. The effect of indomethacin on basal cell carcinoma is pre­sented.

A 55 year old lady presented with a skin lesion above the upper lip. The lesion had started ten years ago as a small nodule with itching, which increased gradually between nose and upper lip to become 3 x 4 cm in diameter. It became indurated with erosion, crusting and with a small ulcer. Oc­ casional bleeding occurred with itching. The le­sion was removed surgically five years ago and recurred in following years. Biopsy confirmed the diagnosis of basal cell carcinoma. Laboratory in­vestigations revealed a baemoglobin of 11 g/dl, white blood cells 10000/cm with 72% neutrophils, 26% lymphocytes and 2% eosinophils, ESR 30 mm/hr, serum iron 65 mg% and serum iron bind­ing capacity 410%. Biochemical tests were normal. The patient was given an appointment for plastic surgical removal. Meanwhile, she was treated with indomethacin after informed consent. An indom­ethacin suppository was used (100 mg/day) since the patient bad a history of gastritis. She was ad­vised to attend the clinic weekly for follow-up and to report any side effects. Within one month of the treatment, the lesion had decreased in size and no more bleeding or crusting was encountered. At three months, the lesion bad regresse4 and completely disappeared and the treatment was withdrawn. Laboratory in­vestigations showed a haemoglobin 12 g/dl, white cell count 8,900/cm with 54% neutrophils and 41% lymphocytes, ESR 15 mm/br, serum iron 110 mg% and serum iron binding capacity 420 mg%. No side effects were reported apart from mild headache and epigastric pain which did not cause withdr­awal from the study. No recurrence was noted and one year follow-up was uneventful.

PGs affect tumour growth and metastasis in a manner not fully understood. However, PGs in-crease cell division and DNA, RNA, protein and collagen synthesis^14,15. Therefore, in humans, PGSI alone or in combination with steroids was found to have some effects in the management of xeroderma pigmentosum tumours and psoriasis in which there is increased cell division and DNA synthesis^16,17. Moreovçr, PGSI could reduce tum­our growth, prolong survival and enhance tumour response to radiotherapy and chemotherapy^18-21. However, controversy still exists concerning the actual role of indomethacin on cell division and tumours. It has been found that indomethacin sti­mulated cell division and replication^22,23 and in­hibited tumour growth in vivo, whereas it stimulated tumour replication in vitro²⁴. On the other hand, oral indomethacin caused inhibition of murine mammary tumours²⁵. Higher levels of indometbacin inhibit proliferation of Rajilympho­id cells²⁶ and Walker carcinoma²⁷. Therefore, the mode of action of indometbacin on basal cell car­cinoma could be ascribed to:
1. Indomethacin might reverse tumour-indu­ced immunosuppression by neutralization of the excessive amount of PGs produced by cancer cells as has been suggested in the case of chorionic carcinoma treated by indome­thacin.
2. Indomethacin might reduce cell division and DNA, RNA and protein synthesis.
Basal cell carcinoma is the commonest mali­gnant tumour of the skin in the white race. It is more frequent and aggressive in patients who are immunosuppressed. The treatment consists of radiotherapy, surgery and chemotherapy. More interestingly, basal cell carcinoma can be destro­yed by induction of a specific immunological res­ponse in the site of the lesions. This is performed by contact sensitization to a hapten such as DNCB with a challenge dose²⁸. The approach used in the case described was to enhance host immunity to hamper or even kill cancer cells. This was probably obtained with the use of PGSI, indomethacin. The patient showed good response to indomethacin therapy by:
1. Reggression of tumour was achieved within three months.
2. No recurrence of the lesion was noticed dur­ing one year post- treatment.
3. There was obvious elevations of haemoglo­bin, serum iron and blood lymphocytes.
Therefore, indomethacin alone or in com­bination with other treatment including radiot­herapy or chemotherapy might have a place in the management of basal cell carcinoma. Other con­trolled and extensive studies should be conducted in special centres to identify the real clinical value of this preliminary observation.

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2. Al-Waili, N., Al-Azzawi, H., and Al-Niami, M. Bone marrow cellular elements and peripheral blood indices following acute haemorrhage and prostaglandin E2 treatment. Saudi Med. 3., 1983; 4:236.
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