[Extramammary Paget's disease]

The treatment strategy for extramammary Paget's disease depends on the presence of metastasis. For the group of patients with primary tumor limited to the epidermis, the aim of treatment is local control by precise detection of the tumor margin. For patients without indications for surgery, radiotherapy or photodynamic therapy would be the treatment of choice. On the other hand, the prognosis of patients with distant metastases is desperate. Although a limited response to combination chemotherapy was observed, no survival benefit has been proven yet. New modalities of treatment such as molecular targeting drugs and hormonal therapy are expected.

Extramammary Paget’s Disease: Isolated Localization on the Groin—Wide Local Excision With Immediate Reconstruction

BACKGROUND

Extramammary Paget's disease is a rare cutaneous malignancy, which occurring frequently in the elderly and affecting primarily the genital, perianal, and axillary regions. Unfortunately, surgical and ablative treatment modalities for extramammary Paget's disease have a high recurrence rate and are often associated with significant morbidity.

METHODS

We present a case of a 51-year-old Caucasian man with Paget's disease of the right groin. The isolated localization of Paget's disease in the groin is extremely rare. Wide local excision of the tumor is currently the standard of care treatment. All publications found in the literature reporting this rare entity were reviewed for the purpose of further delineating a treatment regimen for this rare pathology.

RESULTS

Six years after surgery, the patient remains disease free with a very acceptable aesthetic result. Currently, only 11 cases of Paget's disease have been reported with an isolated localization to the groin.

CONCLUSIONS

Paget's disease of the groin has an extremely low incidence. Various treatments are described in the literature, early wide local excision may be the treatment of choice.

Maladie de Paget de la vulve : intérêt de l'étude du ganglion sentinelle

Paget's disease of the vulva is difficult to diagnose, as far as the extent of this lesion is concerned, since it is often coupled with invasive adenocarcinoma of the vulva. Thus, we present two cases of Paget's disease of the vulva, with use of sentinel lymph node analysis- a non-validated technique in this very context. Evaluation of sentinel lymph node may be useful in case of micro-invasive Paget's disease.

Paget's disease of the vulva: clinicopathologic study of type 1 cases treated at a single institution

The aim of this study was to evaluate clinicopathologic characteristics of primary cutaneous Paget's disease of the vulva. Between 1986 and 2005, 22 patients with primary cutaneous Paget's disease of the vulva (type 1) were treated at Tohoku University Hospital. Medical records were reviewed for pathologic diagnosis, patient age, associated neoplasms, type(s) of eczema, symptom duration, treatment, surgical procedures, recurrence, and length of follow-up. Patient age ranged from 51 to 85 years (median 71.5 years). Median duration of symptoms was 24 months (range 2-60 months). Type 1a (intraepithelial) Paget's disease accounted for 18 patients, with 3 type 1b (invasive) cases and 1 type 1c (intraepithelial disease with underlying adenocarcinoma) case. Mean length of follow-up was 53.7 months, and median follow-up was 49 months (range 6-199 months). Only two patients had an associated internal malignancy: T-cell leukemia and breast cancer. Mapping biopsy was performed in 14 of the 18 type 1a cases. All patients were free of disease at the surgical margins and are alive without recurrence. The four patients with type 1b or 1c disease had lymph node metastases. Two has died of disease, and two are alive with no recurrence. The rate of secondary malignancy seems to be low in primary cutaneous Paget's disease of the vulva. Mapping biopsy with careful examination of characteristic skin surface may be useful for surgery of type 1a cases. Inguinal lymphadenectomy is recommended in cases with question of invasion or known underlying adenocarcinoma.

Extramammary Paget's disease resistant to surgery and imiquimod monotherapy but responsive to imiquimod combination topical chemotherapy with 5-fluorouracil and retinoic acid: a case report

Extramammary Paget's disease (EMPD) is an uncommon skin neoplasm that usually affects the elderly population and occurs in the genital, anorectal, or axillary areas. The recommended treatment of EMPD involves surgical excision, including Mohs micrographic surgery; however, surgery is associated with a high rate of recurrence. There have been reports of successful treatment of recurrence with monochemotherapy involving topical imiquimod 5% cream. We report a case of EMPD recurrence after surgery that was resistant to imiquimod monotherapy but that completely resolved after imiquimod was combined with topical 5-fluorouracil (5-FU) and retinoic acid. To our knowledge, this is the first reported case of imiquimod combination therapy with 5-FU and retinoic acid for the treatment of recurrent EMPD.

Role of Multiple Scouting Biopsies before Mohs Micrographic Surgery for Extramammary Paget's Disease

BACKGROUND

Extramammary Paget's disease (EMPD) frequently extends subclinically, resulting in high recurrence rates after surgical excision. Mohs micrographic surgery (MMS) improves cure rates but may require time-consuming reexcision of subclinical extension. A mechanism to estimate the location and extent of subclinical extension would be helpful.

OBJECTIVE

To describe and evaluate a technique for multiple scouting biopsies before MMS for EMPD.

METHOD

A retrospective review of patients at Mayo Clinic who had multiple scouting biopsies before MMS for EMPD without dermal invasion.

TECHNIQUE

The clinical extent of EMPD is identified. The scouting biopsy sites are determined and documented with photographs. The scouting biopsy specimens are sent for permanent sections. The results of the scouting biopsies help guide the extent of the initial Mohs layer. The tumor is cleared with MMS. An additional 1 mm peripheral margin of tissue is usually submitted for permanent sections.

RESULTS

Multiple scouting biopsies were done in five patients. Four of the five patients had at least one true-positive result. At least one true-negative result was obtained in all five patients. Two patients had at least one false-negative result.

CONCLUSION

Multiple scouting biopsies before MMS for EMPD without dermal invasion can be a beneficial adjuvant technique.

Paget's disease of the vulva--a review of our experience

OBJECTIVE

The aim of our study was to review our experience with Paget's disease of the vulvar relative to initial examination, treatment and oncological outcome.

METHODS

Ten women with extramammary Paget's diseases of the vulva were treated during the 10-year period. The charts of these patients were reviewed and data were collected regarding patient demographics, symptoms, previous Paget's disease, surgical treatments and time to recurrence.

RESULTS

Eight women (80%) were treated with wide local excision or partial vulvectomy, and two patients (20%) required radical resection for invasive adenocarcinoma. The group of women who had invasive diseases also underwent inquinofemoral lymphadenectomy and no lymphatic metastases were noted. Three women (30%) experienced recurrence. The mean time to relapse was 30 months (range 3-88 months).

CONCLUSION

Recurrence is very common and long-term monitoring is recommended with careful examination of any abnormal vulvar lesion.

Liposuctioned rectus abdominis myocutaneous flap to cover a vulval skin defect

A woman with genital Paget disease had a reconstruction with a rectus abdominis myocutaneous flap after primary liposuction during operation. The patient recovered satisfactorily.

Extramammary Paget's disease of penis and scrotum

OBJECTIVES

To make clear the uncertainty of the clinical outcome of extramammary Paget's disease (EMPD). Penile and scrotal involvement of EMPD is exceedingly rare, and only small series or case reports have been reported.

METHODS

From 1995 to 2003, 36 patients with penile and scrotal EMPD were treated and followed up. Local wide excision was done in all patients with or without intraoperative frozen biopsy analysis.

RESULTS

Of the 36 patients, 13 (36.1%) underwent intraoperative frozen biopsy analysis and only 1 patient (7.7%) had a positive surgical margin. However, 23 (63.9%) underwent local wide excision with excessive surgical margins of up to 1 to 2 cm only by gross examination, but 17 (73.9%) of them had positive surgical margins (P <0.01). Of the 17 patients with positive surgical margins, 8 developed local recurrence at a median of 8 months of follow-up (P <0.05). One patient who had invasion to the subcutaneous tissue died of metastatic EMPD and internal malignancy (renal cell carcinoma) at 17 months after the initial operation. No patient had underlying adnexal carcinoma.

CONCLUSIONS

The results of our study indicate that local wide excision with intraoperative frozen biopsy analysis is essential to the complete treatment of EMPD.

[Sentinel node navigation surgery in melanoma and non-melanoma malignant skin tumor]

Sentinel node biopsy (SNB) has been performed for melanomas by many researchers since Morton's report in 1992. The technique has been well discussed, however, there have been only few reports about the application of SNB for treatment strategy of melanoma patients. Besides, we have not yet enough information of the clinical significance of SNB for non-melanoma malignant skin tumors. In this paper, we report two new findings of SNB for melanoma patients from the results of a multi-institutional study of SNB in 203 cases of melanoma. Firstly, the incidence of metastasis in non-sentinel node (non-SN) is less than 1% if no metastasis in SN; the identification rate of SN was 97.5%, the false negative rate was 0.98%, and correct diagnosis rate was 99.0%. Secondly, the incidence of metastasis in non-SN is less than 36.4% when patients had pSN 1 or pSN 2 metastasis. That means total removal of lymphnode metastasis can be achieved in 63.6% patients with lymphnode metastasis through SNB. Finally, we studied the usefulness of SNB on 71 cases of non-melanoma malignant skin tumors, and found the SN concept was also applicable for squamous cell carcinoma or invasive case of genital Paget's disease (Paget's carcinoma). Especially, we believe SNB for patients with Paget's carcinoma is as useful as for melanoma patients according our results of 25 cases; the identification rate of SN was 97.6%, the false negative rate was 0%, and correct diagnosis rate was 100%. SNB should be applied for patients with Paget's carcinoma as a diagnostic method of lymphnode metastasis and to determine the indication of lymphnode dissection, and its usefulness must be analyzed in the near future.

Mohs micrographic surgery: established uses and emerging trends

Mohs micrographic surgery is a surgical technique that seeks to ensure the clearance of cutaneous tumors while maximizing normal tissue conservation. This is accomplished through the sequential removal of thin layers of tissue in which the entire peripheral and deep margins are examined for residual tumor. This approach appears to be superior to conventional surgical excision in the treatment of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), the two most common cancers of the skin. Its efficacy in treating BCC and SCC has led clinicians to explore the role of Mohs micrographic surgery in the management of less common cutaneous neoplasms, such as melanoma, Merkel cell carcinoma, dermatofibrosarcoma protuberans, extramammary Paget's disease, and microcystic adnexal carcinoma.

Extramammary Paget's disease of the genitalia with clinically clear margins can be adequately resected with 1 cm margin

For the treatment of extramammary Paget's disease (EMPD), wide excision has been recommended because of unpredictable spread of tumor cells. EMPD lesions are often well circumscribed. Should all the lesions of EMPD be resected with a 3 cm margin? Forty-six patients with EMPD were surgically treated with a 1 cm margin. Width of tumor cell free area from the last lesional cells at the borders to the resected edge was measured with micro-oculometer. The microscopic gap between the histopathological tumor border and the clinical border scored by scalpel tract was also measured. The tumor cell free area measured 10.2 +/- 2.48 mm. The microscopic gap between the histopathological and clinical borders measured 0.334 +/- 1.183 mm. Thus, the clinically determined border of well-defined lesions of EMPD corresponded well to the histopathologic border. No local recurrence was observed in 24 to 115 months of follow-up. Well-demarcated lesions of EMPD can be adequately managed with 1 cm margin resection.

[Viral-induced tumours and pre-malignant cutaneous diseases of the perianal region]

HPV-induced tumours and pre-malignant cutaneous diseases of the anal region are rare, without the exception of condylomata acuminata. Often imposing like an eczema (especially M. Bowen, M. Paget) the danger of mis-interpretation and thereby mis-therapy is great, so that they are not seldom diagnosed in the stage of malignant degeneration. A comparatively high rate of recurrence is caused by primarily insufficient (surgical) therapy, but also by secondary transformation of still unchanged dermal areas and by re-infection. Therefore after-care is indicated.

Cytology of secondary vulvar Paget's disease of urothelial origin: a case report

BACKGROUND

Primary cutaneous Paget's disease of the vulva is an intraepithelial adenocarcinoma most likely arising from a cutaneous stem cell with sweat gland epithelial differentiation or can be of sweat gland origin. Primary vulvar Paget's disease, however, can be mimicked by an internal noncutaneous neoplasm htat has extended to secondarily involve the vulva. Most commonly, this is due to an anal or rectal adenocarcinoma or a urothelial carcinoma. These malignancies may be detected in a vaginal or vulvar cytologic smear.

CASE

An 81-year-old woman with a past history of urothelial carcinoma in situ of the bladder presented severalyears subsequent to treatment for bladder cancer with extensive vulvar and vaginal disease, clinically interpreted as primary vulvar Paget's disease involving the vagina. Vaginal cytology showed a high grade malignancy. The patient subsequently underwent radical (total deep) vulvectomy and vaginal excision. Subsequent investigation of her bladder showed recurrent urothelial carcinoma in situ with extensive spread to the vagina and vulva, simulating primary cutaneous vulvar Paget's disease.

CONCLUSION

It is important to recognize secondary vulvar Paget's disease, although uncommon, because of the difference in therapy for primary and secondary vulvar Paget's disease. Certain cytologic characteristics in a vaginal or vulvar smear in a patient with suspected vulvar Paget's disease may aid in distinguishing them.

Scrotal skin replacement for extramammary Paget's disease--a technique

We describe a new method of "silk hat skin replacement" for extramammary Paget's disease in the scrotum. This method takes only a short time, and a scrotal raphe can be reconstructed.

Vulvar Paget's disease with underlying adenocarcinoma simulating breast carcinoma: case report and review of the literature

We report a case of extramammary Paget's disease with underlying adenocarcinoma simulating breast carcinoma of the vulva. An 82-year-old woman was found to have a 5 x 3-cm bulky tumor located in the left labium major, infiltrating to the clitoris, left labium minor, and left lateral tissue of the vulva. Small biopsy of the vulva showed intraepidermal proliferation of Paget cells. The patient underwent wide local excision of the vulvar tumor and dissection of left inguinal lymph nodes. Histopathological examination of the resected specimens revealed that Paget cells were distributed singly or tended to form small nests in the epidermis, and that association of these cells with the underlying carcinoma invading to the subcutis could be seen. The underlying carcinoma was composed of squamoid solid nests with central necrotic debris, mimicking 'comedocarcinoma' of the breast. In other areas, the tumor cells were present in tubular formations and solid cords reminiscent of invasive ductal carcinoma of the breast. Immunohistochemically, the Paget cells and the underlying carcinoma cells were positive for carcinoembryonic antigen, epithelial membrane antigen, estrogen receptors, and glandular keratins except for CK 20. We speculate that our case is vulvar Paget's disease presenting as a manifestation of underlying breast carcinoma of the vulva, which might have arisen from either the ectopic breast tissue or anogenital mammary-like glands.

Microinvasive Paget's disease

BACKGROUND

Microinvasive squamous cell carcinoma of the vulva is defined as stromal invasion < or =1 mm and is treated by wide local resection. Whether criteria for microinvasive squamous cell carcinoma can be applied to Paget's disease of the vulva is unknown because of the rarity of that disease.

CASES

We initially evaluated three cases of microinvasive Paget's disease by using sentinel lymph node (SLN) analysis. The SLNs in two patients were negative; and these patients had no recurrence of invasive or metastatic Paget's disease. The other patient had a positive SLN (the only positive lymph node) and subsequently received complete lymph node dissection of the groin bilaterally.

CONCLUSION

Evaluation of SLNs may be valid for evaluating microinvasive Paget's disease.

Extramammary Paget's disease: Surgical treatment with Mohs micrographic surgery

BACKGROUND

Extramammary Paget's disease (EMPD) is an uncommon tumor that has a high rate of recurrence after conventional surgical treatments.

OBJECTIVE

Our purpose was to establish the efficacy of Mohs micrographic surgery (MMS) in the treatment of EMPD, and to make treatment recommendations with regard to surgical margins. We also attempted to summarize the published recurrence rates of EMPD after standard surgical management.

METHODS

In a retrospective chart review, pertinent demographic data, tumor data, treatment characteristics, and follow-up data were tabulated. A search of the literature for recurrence rates after MMS and non-MMS surgical treatment modalities was performed.

RESULTS

The recurrence rate after treatment with MMS was 16% for primary EMPD and 50% for recurrent EMPD. The 5-year tumor-free rates (Kaplan-Meier analysis) were 80% for primary tumors and 56% for recurrent tumors. Using MMS, the salvage rate (and, hence, overall cure rate) was 100%. Margins of 5 cm were required to clear 97% of the tumors. The recurrence rate after non-MMS (from the literature) is 33% to 60%.

CONCLUSION

MMS is effective, and superior to standard surgical management in the treatment of EMPD. We recommend a 5-cm margin of normal skin if MMS cannot be offered.

Extramammary Paget's Disease Presenting on the Face

BACKGROUND

Extramammary Paget's disease is a rare neoplasm primarily affecting apocrine gland bearing skin. Although primarily affecting the anogenital area, the tumor also rarely appears in nonapocrine bearing skin and is referred as ectopic extramammary Paget's disease.

OBJECTIVE

To our knowledge, we present only the second case of ectopic extramammary Paget's disease appearing on the face.

METHODS

Using Mohs micrographic surgery, a rare case of ectopic extramammary Paget's disease on the face was treated in three stages.

RESULTS

At 5 months there was no evidence of recurrence.

CONCLUSION

Ectopic extramammary Paget's disease is a rare disease that can be effectively treated with Mohs micrographic surgery.

Operative morbidity associated with groin dissections

PURPOSE

Groin dissection remains the treatment of choice for malignant neoplasms of the skin in the lower extremities and perineum. We sought to quantify the hospital complications after groin dissection, and to identify the patient- and procedure-related factors affecting these complications.

METHODS

We reviewed 20 consecutive patients who underwent a collective 25 groin dissections for malignant neoplasms of the skin between 1996 and 2002 to determine the incidence and degree of morbidity, and to analyze the clinical factors associated with morbidity. An S-shaped incision was used for the first 8 procedures, whereas a straight incision was used for the next 17.

RESULTS

The overall incidences of complications were 24% for wound infection, 52% for skin flap problems, 32% for seromas, 40% for edema, and 4% for hemorrhage, whereas the incidences of moderate to severe complications were 16% for wound infection, 16% for skin flap problems, 12% for seromas, 4% for edema, and 4% for hemorrhage. The incidence of wound infection tended to be higher after S-shaped incisions than after straight incisions ( P = 0.059), and the incidence of leg edema was significantly higher after S-shaped incisions than after straight incisions ( P = 0.028).

CONCLUSION

S-shaped incisions more often resulted in lymphatic collection and stagnation, with a higher incidence of wound infections and leg edema than straight incisions. Therefore, we now perform straight incisions to minimize the risk of wound infections and leg edema.