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OBSERVATION
An Inquiry Into the Nature of the Pigmented LesionAbove Franklin Delano Roosevelt’s Left Eyebrow
 A. Bernard Ackerman, MD; Steven Lomazow, MD
Background
:
Little note was taken when FranklinDelano Roosevelt was alive and since his death of thepigmented lesion above his left eyebrow that fulfilledclinical criteria for melanoma.
Observations
:
On morphologic grounds alone, it isimpossible to exclude the possibility that Roosevelt hada melanoma.
Conclusions
:
The failure of observers of Roosevelt,especiallyhisphysicians,tocommentonhisrivetingfa-cial lesion and to identify it as a probable melanomaspeaks volumes about how flawed were clinical criteriafor diagnosis of flat and slightly raised lesions of mela-noma in the 1930s and 1940s.
 Arch Dermatol. 2008;144(4):529-532
B
Y VIRTUE OF A VARIETY OF
technical considerations,such as the angle of thehead, the lighting of theface, and the brightnessand contrast of the print, the pigmentedlesionaboveFranklinDelanoRoosevelt’sleft eyebrow shows considerable varia-tion in intensity in many of the photo-graphs (
Figures 1
,
2
,
3
,
4
, and
5
) of the person most photographed in the20th century. In the photographs inwhich Roosevelt’s face is captured inprofile, the pigmented lesion appears toextend from the lower part of the fore-head to the base of the eyebrow.
OBSERVATIONS
The criteria currently touted for diagno-sis of a slightly raised lesion of mela-noma, a malignant neoplasm composedof abnormal melanocytes, are the“ABCDEs”: Asymmetry, Border irregu-larity, Color variability, Diameter greaterthan 6 mm, and Elevation (or, for someproponents of the mnemonic, Enlargingor Evolving). The fully developed pig-mented lesion above Roosevelt’s left eye-brow admirably fulfills those criteria. Butthe ABCDEs also are encountered fromtime 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 cellcarcinoma.
MELANOMA VS SOLARLENTIGO/SEBORRHEIC KERATOSIS
A solar lentigo is a benign neoplasm con-stituted of pigmented keratocytes. Whenitbecomeselevatedand,intheprocess,as-sumesanappearancemoreadvancedhis-topathologically,thesameconditionthenis referred to as a seborrheic keratosis of the reticulate type. On occasion, a solarlentigo/seborrheic keratosis may acquirecharacteristics that conform to theABCDEs.Rooseveltwasaninveteratesailorand had many solar lentigines, particu-larly on the dorsum of his hands, thesecontrasting strikingly with the pig-mentedlesionabovehislefteyebrow.De-spite that reality, not all solar lentiginesaretiny;somemayachieveasizelikethatof the lesion above Roosevelt’s left eye-brow—and even larger.On gross morphologic grounds alone,thepigmentedlesionaboveRoosevelt’slefteyebrow could be either a melanoma or asolar lentigo/seborrheic keratosis. Only astudyofsectionsoftissueobtainedbybi-opsy would enable the conundrum to beresolved conclusively. No evidence ex-ists that the lesion ever was biopsied ortreated in any way. Sad to say, most of Roosevelt’s medical records are missing;none at all pertinent to the pigmented le-sion above the left eyebrow have beenfound.Thefactthatthepigmentedlesionwasvariegateinshadesofbrownandverydarkbrowninthearciformportionofitismore
Author Affiliations:
AckermanAcademy of Dermatopathology(Dr Ackerman) andDepartments of Medicine andNeurology, Mount Sinai Schoolof Medicine (Dr Lomazow)New York, New York.Dr Lomazow is also in privatepractice in Belleville,New Jersey.
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consonant with melanoma than with solar lentigo/ seborrheickeratosis.Moreover,whereasalargesolarlen-tigo/seborrheic keratosis on a face usually is accompa-nied there by other large solar lentigines/seborrheickeratoses,melanomapresentsitselfconventionallyasanisolated lesion, as was the case for Roosevelt’s pig-mented lesion. That finding, too, favors a diagnosis of melanoma.However,melanoma,beingthemalignantneo-plasm irrepressible in growth that it is, would be ex-pected in the course of the 20 years from 1923 to 1943to have attained a diameter greater than that of the le-sion seen above Roosevelt’s left eyebrow (at the apogeeit was only about 2.5 cm
2.0 cm in diameter). Fur-thermore, for several years prior to 1943, the lesionshowed no sign of centrifugal extension or of progres-sive elevation above the surface of the skin. That behav-ior also militates somewhat against melanoma.Episodically,amelanomamayundergoinvolutioninthe form of ever-expanding hypopigmentation over thecourseofseveralyears,theprocessoftencausingthepig-mentedportionyetremainingtoassumeanarchlikecon-figuration. Only uncommonly does a melanoma regressentirely, leaving as residuum but a macule of hypopig-mentation.Althoughthearciformcharacterofthedark-est pigmentation of Roosevelt’s lesion surely is in keep-ing with the clinical appearance of partial regression of melanoma, it would be unusual for the lesion above theleft eyebrow to have undergone complete regression inthe rather short space of 4 years (ie, in the period fromearly 1940 to 1943). Biologically, such a phenomenonisunlikely.Forregressionintotoofamelanomathatsizetohaveoccurredshouldhavetakenconsiderablylonger.Solarlentigo/seborrheickeratosisalsoisknowntore-gresscompletely,butwhenthathappens,almostalwaysthe lesion is small, situated on the chest, and accompa-nied often by signs of inflammation so noticeably viola-
Figure 1.
Franklin Delano Roosevelt in 1900 (age 18 years) with nopigmented 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
Figure 3.
Franklin Delano Roosevelt in August 1938 (age 56 years) with anasymmetric, brown, seemingly barely raised plaque, darker in shape arciformat 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
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ceous that at this stage of involution it is known univer-sallyas“lichenplanus–likekeratosis,”lichenplanusbeingan eruption typified by purple papules.If Roosevelt’s lesion did not undergo involution en-tirely,thenitmusthavebeenremovedsurgicallyorhavebeencamouflagedbymakeup.However,thereisnoevi-dence for either. No sign of a scar from a surgical exci-sionisapparent.Inshort,howhispigmentedlesioncameto disappear from 1940 to 1943 remains an enigma. In-dependent of that, on the basis of all that is known pres-ently about the morphologic aspects and biologic behav-iorofhislesion,itisimpossible,despitetheimponderables,to exclude melanoma.
ROOSEVELT’S PIGMENTED LESIONIN THE CONTEXT OF HIS HEALTH IN GENERAL
All details of Roosevelt’s health, especially during his 12years as the 32nd President of the United States, wereshrouded in secrecy while he was alive. The most fla-grant example of duplicity was that although Rooseveltneverwasabletosupporthisownweightwithouttheuseofmetalbracesonhislegsasaconsequenceofhishavingcontractedpoliomyelitisin1921,theAmericanpublicwasshieldedfromknowledgeofhisextraordinaryphysicaldis-ability. Most Americans were unaware that he was un-abletowalkwithoutassistance.Complicitinthis“splen-did deception” (the title of a biography of Roosevelt byhistorianHughG.Gallagher,
1
whoalsohadcontractedpo-liomyelitis)wereRoosevelt’sphysicians,aswasthepress.Of the tens of thousands of images of Roosevelt in pho-tographs and films, fewer than a handful show him com-promised physically, despite the fact he was wheelchairbound. Every aspect of his appearance and public per-sona was painstakingly orchestrated.Ross T. McIntire, MD, a career navy man who even-tuallyattainedtherankofViceAdmiralandSurgeonGen-eraloftheNavy,wasRoosevelt’spersonalphysicianfrom1933 until the President’s death in 1945. A specialist inhead,eye,ear,nose,andthroatdisease,McIntirewascho-sen to be Roosevelt’s personal physician not onlybecausethePresidentwaspronetosinusdisease,butbe-cause McIntire had a reputation for unwavering loyaltyand for “keeping a tight lip.” He was recommended forthat post by Roosevelt’s close friend, Cary T. Grayson,MD, who had been physician to Woodrow Wilson andwas a central figure in the cover-up of Wilson’s devas-tatingly disabling stroke in 1919.After Roosevelt’s death in April 1945, persistent ru-mors surfaced about his health. McIntire, in a book(largely ghostwritten) published in 1946,
2
denied thatRoosevelt had experienced any chronic malady of sig-nificance. Until McIntire’s death in 1959, any informa-tion germane to Roosevelt’s health was guarded closelyand effectively.In a volume that appeared in 1970, historian HughL’Etang
3
was the first to raise publicly the specter thatRoosevelt had a melanoma. His assertion was deflectedin an apparently coincidental but, more likely, a pur-posefullytimedarticlebyHowardG.Bruenn,MD,
4
acar-diologist who was the last surviving member of the in-nercircleofRoosevelt’sphysiciansandwhosawRoosevelton a daily basis from March 1944 to April 1945. Bruennset forth many previously undisclosed details that camefrom Roosevelt’s medical records, emphasizing those of a cardiologic and vascular character that the Presidenthad experienced during the last year of his life.
4
No ref-erence whatsoever was made by Bruenn to the pig-mentedskinlesionabovethelefteyebrow,despiteitbeingdecidedly unsightly. That omission, the wording of aneditorial that accompanied Bruenn’s article,
9
and corre-
A B
Figure 5.
Comparison of the appearance of the skin above Franklin DelanoRoosevelt’s left eyebrow in the 10 years from 1933 to 1943. A, Roosevelt in1933 (age 51 years) and B, in January 1943 (age 61 years), showing a veryfaint residual outline of what was a pigmented lesion. Note the markedcontrast in the appearance of the skin above the left eyebrow.
7
Figure 4.
Franklin Delano Roosevelt in August 1940 (age 58 years) with anasymmetric, apparently slightly raised lesion, brown in an arc at the superiorpole and hypopigmented in the lower two-thirds. No additional growth since1938 is apparent.
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