A Possible Case of Cancer in the Late Prehispanic Peruvian Andes

Katherine Wright and Danielle S. Kurin

Department of Archaeology, Durham University; Department of Anthropology, Vanderbilt University
Abstract
The cranium of a 35-40 year old adult male from the Chanka culture (AD 1000-1400) was excavated from the site of Cachi in Andahuaylas, Peru. The cranium presents lesions on the frontal and parietal bones. The osteolytic nature of three of the lesions suggested they may be the effect of a treponemal or neoplastic disease. Based on the shape and nature of the lesions, the age and sex of the individual, and the number of lesions, a differential diagnosis is presented that includes tuberculosis, Langerhans Cell Histiocytosis, multiple myeloma, and metastatic carcinoma. Ultimately, the lesions seen in MCH1.2 seem most likely to be caused by secondary metastatic carcinoma.
77th Annual Meeting of the Society for American Archaeology April 18-22, 2012 Memphis, TN Images below from Ortner, 2003

3. Differential Diagnosis
Tuberculosis
Tuberculosis is an infectious disease caused by the mycobacterium tuberculosis complex. Once the body detects the bacterias presence, it initiates an aggressive immune response that could affect nearby organ tissues. Pathognomic changes of tuberculosis are most commonly seen in the vertebral column, but associated lesions can also be seen in the skull. Cranial lesions are most commonly seen in subadults younger than 10, and are characterized by a round lytic focus of no more than 2 cm in diameter, perforation of both inner and outer tables, and commonly crossing suture lines. When seen in adults, cranial lesions usually have more extensive resorption of the inner table than the outer and the formation of a sequestrum (Ortner, 2003).

1. Introduction
This cranium, MCH1.2, was excavated from Pukamachay Cave, at the site of Cachi in Andahuaylas, Peru . The remains pertain to the Chanka culture and date to the early Late Intermediate Period (A.D. 1000-1250). Because the cave was badly looted, no post-cranial elements could be associated with the MCH1.2 cranium, and no other bones exhibited lytic lesions. The Chanka culture, which emerged following the collapse of the Wari Empire ca. AD 1000, was a society that witnessed high levels of endemic violence, as well as a higher frequency of pathological lesions indicative of disease than earlier imperial era populations. Medico-cultural interventions, such as amputation through dismemberment and trepanation were likely enacted by the Chanka society to cope with novel challenges in the aftermath of collapse and suggest a nuanced, emic understanding of health and disease (Kurin 2012).

Fig.2: Third lesion on the right parietal demonstrating new bone growth and a pinprick hole perforating the outer table.

Fig. 6: Lesion of tuberculosis showing penetration of both tables and formation of a sequestrum .

Wright, 2011

Multiple Myeloma
Multiple myeloma is a type of cancer in which plasma cells undergo malignant transformation and growth. The malignant plasma cells secrete a substance that triggers osteoclastic activity and inhibits osteoblastic activity (Rothschild et al., 1998; Marks and Hamilton, 2007). Therefore, reactive bone growth is not typically seen in cases of multiple myeloma. Lesions typically appear as sharply defined, multiple, spherical, small (3-10mm), consistently sized, punched out holes that penetrate all cranial tables and rarely show remodeled margins. The prevalence of multiple myeloma increases with age and is generally seen in older adults.
Fig. 7: Multiple punched out lesions of multiple myeloma.

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis (LCH) is a disease in which a proliferation of Langerhans cells (immune cells called histiocytes) leads to increased phagocytic activity, which can cause lytic lesions if the bone tissues are affected. LCH is most frequently seen in the skull, and generally affects subadults between the ages of 0 and 15. Lesions in the bone are usually lytic, without reactive bone formation, small and round, and may coalesce to create a geographic border (Ortner, 2003). The edges of LCH lesions are usually punched out, meaning sharply defined and circular, with scalloped edges (Marks and Hamilton, 2007; Rothschild et al., 1998).

Fig.3: Second lesion on the left frontal bone showing new bone growth and a pinprick hole perforating the outer table.

Fig. 1: Map of Peru showing the location of the Cachi site.

Wright, 2011

2. Materials and Methods

The sex and age of the individual were estimated using standards outlined by Buikstra and Ubelaker (1994). Dental eruption, dental wear, and cranial suture closure indicate the individual was between 35 and 40 at the time of death. Sex was determined as male based on the rugosity of the mastoid process, nuchal crest, supraorbital margin, and glabella. The largest lesion is located superior to and intersecting the right supraorbital margin. The lesion penetrates the inner table, diploe, and outer table of the skull. Destruction is the most extensive in the diploe, and more extensive in the outer table than the inner. table Two other lytic foci are evident: a smaller depressed area 25.4mm above the left suprarobital margin with a pinprick hole in the center, and a larger depressed area on the right parietal. Both these lesions present as depressions in the cranium, and the most extensive osteoclastic activity in the largest lesion is present in the diploe, suggesting the cause of the lesions originated within the diploe. There is new woven bone on the outer margins of the lesion.
Fig.4: Active lytic lesion on the right frontal bone of MCH1.2 showing extensive damage to the diploe and reactive bone formation along the margins.

Fig. 8: LCH lesions showing geographic shape and little reactive bone formation.

Secondary Metastatic Carcinoma

The most common cause of tumors affecting the skeleton is metastasis from other organs (Ortner, 2003). In secondary metastatic carcinoma, expanding blood-borne tumorous cells can grow and displace cancellous bone, eventually piercing the cortex and exposing the diploe (Assis, 2010; Smith, 2002). Secondary metastatic carcinoma is most commonly seen in adults and the elderly. Metastatic tumors to bone are most commonly osteolytic, but may also be osteoblastic or a mix of both. Lesions tend to be well-defined, and spherical in shape with an ellipsoid component or geographic (irregular) boundary. Lesions vary in size, and sometimes have raised margins (Ortner, 2003; Rothschild et al., 1998, p.244).

Marks and Hamilton, 2007

Fig. 9: Osteolytic lesion of secondary metastatic carcinoma with reactive bone and raising on the margins.

4. Conclusions
While the absence of postcranial elements makes an absolute diagnosis difficult, the nature of the lesions in MCH1.2 can rule out most of the previously detailed conditions. Tuberculosis can be ruled out as a cause of the cranial lesions in MCH1.2. First, cranial lesions usually present in younger individuals, and MCH1.2 is an adult. Furthermore, the lesions present more extensive resorbtion of the diploe and the outer tables rather than the inner table. The lesions are larger than 2mm, and do not cross suture lines. Langerhans Cell Histiocytosis can also be disregarded, mainly due to its early age of onset. Even so, the lesions seen in MCH1.2 are not punched out, and show some signs of reactive bone formation on the margins. Multiple myeloma seems a less likely diagnosis than metastatic carcinoma for MCH1.2. All of the lesions seem too large, too varied in size, and not numerous enough to be caused by multiple myeloma. The edges are not as sharp and punched out as they would be with a multiple myeloma diagnosis, and there are signs of osteoblastic boney reaction along the margins. Secondary metastatic carcinoma seems to be the most likely cause of the lesions, but is not a definite diagnosis. The largest lesion has an irregular, sharp, lacy margin with osteoblastic activity and exhibits the most destruction in the diploe. The other lesions seem to be varied in size and stage. Although further research and radiographic analysis are needed to make a certain diagnosis, the characteristics of the lesions and the age of the individual suggest a most probable diagnosis of secondary metastatic carcinoma in MCH1.2.

Wright, 2011

Fig.5: Pathological cranial lesions present in among Chanka populations in Andahuaylas. From left to right: porotic hyperostosis, periosteal reaction from a healing trepanation, degraded unhealed trepanation, healing trauma, and the lytic lesion from MCH1.2
References:

Fig.10: Right lateral view of MCH1.2 Acknowledgements: This project was supported by Fulbright-Hays and Vanderbilt University. Special thanks to the Proyecto
Bioarqueologico Andahuaylas crew including Enmanuel Gomez, Edison Mendoza Martinez, Anna Schneider, Kirsten Green, Kirsten Delay, and Jasmine Kelly. Thanks also to Dr. Rebecca Gowland of Durham University and Dr. Don Brothwell of the University of York.

Assis, S.C., 2010. Metastatic carcinoma in a 14th-19th century skeleton from Constancia. International Journal of Osteoarchaeology, 20(5), pp.603-620. Buikstra, J.E. and Ubelaker, D.H., 1994. Standards for data collection from human skeletal remains: Proceedings of a seminar at the Field Museum of Natural History. Arkansas Archeological Survey Research Series, 44. Kurin, D., 2012. The bioarchaeology of collapse: Ethnogenesis and ethnocide in post-imperial Andahuaylas Peru. Unpub. PhD. Vanderbilt University. Marks, M.K. and Hamilton, M.D., 2007. Metastatic carcinoma: Palaeopathology and differential diagnosis. International Journal of Osteoarchaeology,17, pp.217-234. Ortner, D.J., 2003. Identification of pathological conditions in human skeletal remains. San Diego: Academic Press. Rothschild, B.M., Hershkovitz, I. and Dutour, O., 1998. Clues potentially distinguishing lytic lesions of multiple myeloma from those of metastatic carcinoma. American Journal of Physical Anthropology, 105, pp.241-250. Smith, M.O., 2002. A probable case of metastatic carcinoma from the Late Prehistoric Eastern Tennessee River Valley. International Journal of Osteoarchaeology, 12, pp.235-247.