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Caruso G, Barcellini A, Mazzeo R, Gallo R, Vitale MG, Passarelli A, Mangili G, Pignata S, Palaia I. Vulvar Paget’s Disease: A Systematic Review of the MITO Rare Cancer Group. Cancers (Basel) 2023; 15:cancers15061803. [PMID: 36980691 PMCID: PMC10046936 DOI: 10.3390/cancers15061803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/07/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Vulvar Paget’s disease (VPD) is a rare form of cutaneous adenocarcinoma of the vulva, which accounts for about 1–2% of all vulvar neoplasms and mainly affects post-menopausal women. The clinical presentation is usually non-specific and mimics chronic erythematous skin lesions; therefore, the diagnosis is often difficult and delayed. Although VPD is typically diagnosed at a locally advanced stage and has a high recurrence rate, the prognosis is overall favorable with a 5-year survival of nearly 90%. Due to the limited and poor-quality evidence, there is no global consensus on optimal management. Therefore, we performed a systematic review of the literature through the main electronic databases to deepen the current knowledge of this rare disease and discuss the available treatment strategies. Wide surgical excision is recommended as the standard-of-care treatment and should be tailored to the tumor position/extension and the patient’s performance status. The goal is to completely remove the tumor and achieve clear margins, thus reducing the rate of local recurrences. Non-surgical treatments, such as radiotherapy, chemotherapy, and topical approaches, can be considered, especially in the case of unresectable and recurrent disease. In the absence of clear recommendations, the decision-making process should be individualized, also considering the new emerging molecular targets, such as HER2 and PD-L1, which might pave the way for future targeted therapies. The current review aims to raise awareness of this rare disease and encourage international collaboration to collect larger-scale, high-quality evidence and standardize treatment.
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Affiliation(s)
- Giuseppe Caruso
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Amelia Barcellini
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy
| | - Roberta Mazzeo
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
- Correspondence:
| | - Roberta Gallo
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Maria Giuseppa Vitale
- Department of Oncology and Hematology, University Hospital of Modena, 41100 Modena, Italy
| | - Anna Passarelli
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCSS, “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Giorgia Mangili
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCSS, “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
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2
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Bui ATN, Dee EC, Virgen CA, Lian CG, Devlin PM, LeBoeuf NR. Recalcitrant extramammary Paget's disease treated successfully with high-dose-rate brachytherapy: A case series and review of the literature. Dermatol Ther 2021; 34:e14755. [PMID: 33406300 DOI: 10.1111/dth.14755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/21/2020] [Accepted: 12/31/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | - Edward Christopher Dee
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Cesar A Virgen
- Center for Cutaneous Oncology, Department of Dermatology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA.,Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christine G Lian
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Phillip M Devlin
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Nicole R LeBoeuf
- Harvard Medical School, Boston, Massachusetts, USA.,Center for Cutaneous Oncology, Department of Dermatology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA.,Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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3
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Weng S, Zhu N, Li D, Chen Y, Tan Y, Chen J, Yuan Y. Clinical Characteristics, Treatment, and Prognostic Factors of Patients With Primary Extramammary Paget's Disease (EMPD): A Retrospective Analysis of 44 Patients From a Single Center and an Analysis of Data From the Surveillance, Epidemiology, and End Results (SEER) Database. Front Oncol 2020; 10:1114. [PMID: 32983958 PMCID: PMC7477308 DOI: 10.3389/fonc.2020.01114] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/04/2020] [Indexed: 12/20/2022] Open
Abstract
Objective: Primary extramammary Paget's disease (EMPD) is a rare cutaneous malignancy. The aim of this article is to analyze clinical characteristics, evidence of the prognosis, and share treatment experience of primary EMPD. Methods: We extracted 771 patients' data from the Surveillance, Epidemiology, and End Results (SEER) program between 1973 and 2013 to investigate the characteristics and prognosis of patients with EMPD. In addition, 44 patients with primary EMPD in our hospital were retrospectively reviewed for 10 years. Results: Compared with patients younger than 65 years, patients diagnosed at 65–74 years [hazard ratio (HR), 2.453] and 75 years or older (HR, 5.750) had shorter survival. Patients with a primary site in the truncal skin (HR, 0.367) or scrotum (HR, 0.246) had better survival compared to those with a primary site in the perianal area. Compared with localized EMPD, EMPD with distant (HR, 18.821) and regional (HR, 2.180) metastases was associated with a worse prognosis. Patients who received radiotherapy had decreased survival, with an HR of 2.039. Patients with a higher N stage, M stage, and American Joint Committee on Cancer (AJCC) stage had a decreased prognosis (p < 0.001). Conclusions: Older age at diagnosis, primary site in the perianal area, distant metastasis, radiotherapy, and higher N stage, M stage, and AJCC stage may result in decreased survival.
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Affiliation(s)
- Shanshan Weng
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ning Zhu
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dan Li
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yurong Chen
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Medical Oncology, Zhuji People's Hospital of Zhejiang Province, Shaoxing, China
| | - Yinuo Tan
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiaqi Chen
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying Yuan
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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4
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Extramammary Paget's Disease: A Review of the Literature Part II: Treatment and Prognosis. Dermatol Surg 2020; 46:305-311. [PMID: 31688232 DOI: 10.1097/dss.0000000000002240] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Extramammary Paget's disease (EMPD) is a rare malignancy with unclear pathophysiology that occurs predominantly on apocrine-rich skin. Surgery is the treatment of choice; however, procedures tend to be extensive and associated with a high rate of recurrence. OBJECTIVE To review the current literature on EMPD regarding treatment and prognosis. MATERIALS AND METHODS Literature review using PubMed search for articles related to EMPD. RESULTS Extramammary Paget's disease classically presents as a slowly growing red plaque, which often mimics an inflammatory condition leading to significant delay in diagnosis. Diagnosis requires histopathologic examination and is often supported by immunohistochemical analysis. Once a diagnosis of EMPD is made, the patient must be risk-stratified and evaluated for an underlying malignancy. CONCLUSION Standard of treatment is surgery, with data suggesting that Mohs micrographic surgery may have superior clinical outcomes and lower recurrence rates. Alternatives such as photodynamic therapy and topicals have been explored and may be appropriate in certain situations. Patients with EMPD generally have a good prognosis with a 5-year overall survival rate of 75% to 95%.
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5
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Piras A, Sanfratello A, Boldrini L, La Vecchia M, Venuti V, Amari ML, Orlando M, Zichichi L, Angileri T, Daidone A. Paget's disease of scrotum and penis case report of a re-irradiation and review of the literature. Dermatol Ther 2020; 33:e13890. [PMID: 32584449 DOI: 10.1111/dth.13890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/21/2020] [Indexed: 12/19/2022]
Abstract
Extramammary Paget's disease (EMPD) is a rare cutaneous adenocarcinoma generally arising in the anogenital region. Surgery is still considered the treatment of choice for patients with EMPD, while Radiotherapy is a common alternative for inoperable cases and it's necessary in case of lack of surgical radicality. In this article, we described our experience and a review of the literature, with a particular focus on radiation-induced toxicity and on the feasibility of re-irradiation. A 70-year-old patient with EPMD underwent adjuvant radiotherapy in 2015. After 28 months for recurrence another radiant treatment was performed. No G3 (CTCAE v4) toxicity were recorded. In the last follow-up visit at 18 months, no signs of relapse were reported. A search strategy of the bibliographic database PubMed was performed. The inclusion criteria for the articles were case report, clinical prospective, or retrospective studies with histological confirmation of EMPD of scrotum and penis; studies with patients undergoing RT; studies in the past 30 years. In most of the 14 reported studies, RT was overall well tolerated. The major observed toxicity was G3 skin toxicity in one study. To our knowledge, there are no other cases of EPMD re-irradiation in literature. Our patient showed an excellent response and tolerated very well the high doses of both the radiation treatments. This suggests that the tolerance of skin to re-irradiation following a long period between the two treatments may be comparable to the normal constraints.
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Affiliation(s)
- Antonio Piras
- Villa Santa Teresa, Radioterapia Oncologica, Palermo, Italy
| | | | - Luca Boldrini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Roma, Italy
| | - Maria La Vecchia
- Radioterapia Oncologica, Università degli Studi di, Palermo, Italy
| | - Valeria Venuti
- Radioterapia Oncologica, Università degli Studi di, Palermo, Italy
| | | | - Marzia Orlando
- Villa Santa Teresa, Radioterapia Oncologica, Palermo, Italy
| | - Leonardo Zichichi
- U.O.C. Dermatologia e Venerologia, Ospedale San Antonio Abate, Trapani, Italy
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Snast I, Sharon E, Kaftory R, Noyman Y, Oren-Shabtai M, Lapidoth M, Hodak E, Mimouni D, Mazor S, Levi A. Nonsurgical Treatments for Extramammary Paget Disease: A Systematic Review and Meta-Analysis. Dermatology 2020; 236:493-499. [PMID: 32289785 DOI: 10.1159/000506832] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 02/27/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Surgery is commonly regarded as the mainstay of treatment of extramammary Paget disease (EMPD); however, nonsurgical approaches have gained popularity in recent years. OBJECTIVES To review the published evidence for the efficacy and safety of nonsurgical modes of therapy for EMPD. METHODS A systematic review and meta-analysis of nonsurgical EMPD treatments was performed. The primary outcome was complete response (CR); secondary outcomes were clinical regression by ≥50%, adverse events, and recurrence rate. RESULTS The systematic review included 43 observational studies (341 patients; 7 prospective cohort studies, 19 retrospective cohort studies, and 17 cases series) evaluating 5 treatment modalities. Imiquimod (13 studies, 110 patients) administered at variable doses ranging from daily to twice weekly for 2-56 weeks demonstrated CR of 54% (95% CI, 40-67%; I2 = 37%) and had a satisfactory safety profile. In 14 heterogeneous studies (122 patients) evaluating photodynamic therapy (PDT), only 36% (95% CI, 22-53%; I2 = 52%) of patients achieved CR. Radiotherapy (12 studies, 67 patients) showed CR of 97%, but was associated with local and systemic side effects. Ablative lasers and topical fluorouracil and calcipotriene lacked adequate evidence of efficacy. CONCLUSIONS Imiquimod and radiotherapy are the most appropriate nonsurgical modalities for EMPD treatment given their good efficacy and safety profile. PDT has limited efficacy but may be appropriate in selected clinical settings.
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Affiliation(s)
- Igor Snast
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel, .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Eran Sharon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Breast Surgery Clinic, Rabin Medical Center, Petah Tikva, Israel
| | - Ran Kaftory
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehonatan Noyman
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Meital Oren-Shabtai
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Lapidoth
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmilia Hodak
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Mimouni
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sigal Mazor
- Department of Community Dentistry, School of Dental Medicine, Hebrew University-Hadassah, Medical Center, Jerusalem, Israel
| | - Assi Levi
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Edey KA, Allan E, Murdoch JB, Cooper S, Bryant A. Interventions for the treatment of Paget's disease of the vulva. Cochrane Database Syst Rev 2019; 6:CD009245. [PMID: 31167037 PMCID: PMC6550364 DOI: 10.1002/14651858.cd009245.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in Issue 10, 2013.Extramammary Paget's disease is a rare form of superficial skin cancer. The most common site of involvement is the vulva. It is seen mainly in postmenopausal white women. Paget's disease of the vulva often spreads in an occult fashion, with margins extending beyond the apparent edges of the lesion. There is a range of interventions from surgical to non-invasive techniques or treatments. The challenges of interventions are to remove or treat disease that may not be visible, without overtreatment and with minimisation of morbidity from radical surgery. There is little consensus regarding treatment. Surgery, by default, is the most common treatment, but it is challenging to excise the disease adequately, and recurrence is common, leading to repeated operations, and destruction of anatomy. Alternative treatments of photodynamic therapy, laser therapy, radiotherapy, topical treatments or even chemotherapy have been mooted, and it is important to evaluate the available evidence. It is essential to assess whether newer cell-specific treatments, such as photodynamic therapy and imiquimod, can reduce the need for radical surgery. OBJECTIVES To evaluate the benefits and harms of different treatment modalities for the management of Paget's disease of the vulva. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid) and Embase (via Ovid) up to 8 May 2018. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) and well-designed non-randomised studies that compared different interventions in women with Paget's disease of the vulva, DATA COLLECTION AND ANALYSIS: Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no trials and, therefore, analysed no data. MAIN RESULTS The search for the original version of the review identified 635 unique references. We found 31 references (which reported on 30 studies) in full text after inspection of titles and abstracts, but we excluded them all as they did not meet the inclusion criteria. However, we have included a comprehensive narrative account of studies where we identified an analysis of more than 10 women, as this forms the only evidence base in this rare disease. Surgery continues to be the mainstay of treatment in the current literature, with other treatments limited to case reports or treatment of inoperable or recurrent disease.This update between September 2013 and May 2018 identified 35 new studies. None of these met the inclusion criteria. There was only one prospective study of 5% imiquimod in recurrent Paget's disease of the vulva, which although of good quality only included eight women. AUTHORS' CONCLUSIONS Since the last version of the review was published there are many more cases in the literature reporting a clinical response to 5% imiquimod cream. There is one prospective study of eight women treated with 5% imiquimod for recurrent Paget's disease of the vulva, and one prospective trial of 20 women was due to be reported. This increasing evidence for the safety and efficacy of 5% imiquimod will be helpful for women and clinicians alike. Ideally, a multicentre RCT of reasonable size is needed, but ongoing publications of high-quality non-randomised prospective studies will enhance the current available literature.
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Affiliation(s)
| | - Ernest Allan
- Christie HospitalWilmslow RoadWithingtonManchesterUKM20 4BX
| | - John B Murdoch
- Spire Hospital BristolGynaecologyThe Glen, Redland HillDurdham DownBristolUKBS2 8EG
| | - Susan Cooper
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LJ
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
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8
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Simonds RM, Segal RJ, Sharma A. Extramammary Paget's disease: a review of the literature. Int J Dermatol 2018; 58:871-879. [PMID: 30569580 DOI: 10.1111/ijd.14328] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 11/08/2018] [Accepted: 11/14/2018] [Indexed: 01/01/2023]
Abstract
Extramammary Paget's disease (EMPD) is a rare cutaneous malignancy. The disease typically affects older individuals aged 60-80 years and is seen most frequently in postmenopausal Caucasian women and Asian men. EMPD exhibits a predilection for the genital and perianal regions and may be associated with an underlying carcinoma in adjacent organs. EMPD presents a challenge in both diagnosis and management. Often treated empirically as various dermatitides, the correct diagnosis is frequently delayed by many years. Following diagnosis, an extensive search for an associated malignancy should be initiated. If invasive disease is present on biopsy, a sentinel lymph node biopsy may guide further treatment. Mohs micrographic surgery appears to be superior to wide local excision when considering tissue sparing ability and disease recurrence. Nonsurgical interventions have also been investigated with varied results. Regardless of treatment method, long-term follow-up is recommended to monitor for local disease recurrence, development of internal malignancy, regional lymphadenopathy, or distant metastasis.
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Affiliation(s)
- Robert M Simonds
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert J Segal
- Division of Dermatology, University of Arizona, Tucson, AZ, USA
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9
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Hiratsuka J, Kamitani N, Tanaka R, Yoden E, Tokiya R, Suzuki M, Barth RF, Ono K. Boron neutron capture therapy for vulvar melanoma and genital extramammary Paget's disease with curative responses. Cancer Commun (Lond) 2018; 38:38. [PMID: 29914570 PMCID: PMC6006671 DOI: 10.1186/s40880-018-0297-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 05/04/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Although the most commonly recommended treatment for melanoma and extramammary Paget's disease (EMPD) of the genital region is wide surgical excision of the lesion, the procedure is highly invasive and can lead to functional and sexual problems. Alternative treatments have been used for local control when wide local excision was not feasible. Here, we describe four patients with genital malignancies who were treated with boron neutron capture therapy (BNCT). METHODS The four patients included one patient with vulvar melanoma (VM) and three with genital EMPD. They underwent BNCT at the Kyoto University Research Reactor between 2005 and 2014 using para-boronophenylalanine as the boron delivery agent. They were irradiated with an epithermal neutron beam between the curative tumor dose and the tolerable skin/mucosal doses. RESULTS All patients showed similar tumor and normal tissue responses following BNCT and achieved complete responses within 6 months. The most severe normal tissue response was moderate skin erosion during the first 2 months, which diminished gradually thereafter. Dysuria or contact pain persisted for 2 months and resolved completely by 4 months. CONCLUSIONS Treating VM and EMPD with BNCT resulted in complete local tumor control. Based on our clinical experience, we conclude that BNCT is a promising treatment for primary VM and EMPD of the genital region. Trial registration numbers UMIN000005124.
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Affiliation(s)
- Junichi Hiratsuka
- Department of Radiation Oncology, Kawasaki Medical School, 577, Matsushima, Kurashiki, Okayama 701-0192 Japan
| | - Nobuhiko Kamitani
- Department of Radiation Oncology, Kawasaki Medical School, 577, Matsushima, Kurashiki, Okayama 701-0192 Japan
| | - Ryo Tanaka
- Department of Dermatology, Kawasaki Medical School, Kurashiki, Okayama 701-0192 Japan
| | - Eisaku Yoden
- Department of Radiation Oncology, Kawasaki Medical School, 577, Matsushima, Kurashiki, Okayama 701-0192 Japan
| | - Ryuji Tokiya
- Department of Radiation Oncology, Kawasaki Medical School, 577, Matsushima, Kurashiki, Okayama 701-0192 Japan
| | - Minoru Suzuki
- Particle Radiation Oncology, Kyoto University Research Reactor Institute, Osaka, 590-0494 Japan
| | - Rolf F. Barth
- Department of Pathology, The Ohio State University, Columbus, OH 43210 USA
| | - Koji Ono
- Particle Radiation Oncology, Kyoto University Research Reactor Institute, Osaka, 590-0494 Japan
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10
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Tagliaferri L, Casà C, Macchia G, Pesce A, Garganese G, Gui B, Perotti G, Gentileschi S, Inzani F, Autorino R, Cammelli S, Morganti AG, Valentini V, Gambacorta MA. The Role of Radiotherapy in Extramammary Paget Disease: A Systematic Review. Int J Gynecol Cancer 2018. [PMID: 29538255 DOI: 10.1097/igc.0000000000001237] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE/PURPOSE Extramammary Paget disease (EMPD) is a rare neoplasm of the skin generally affecting the anogenital area. Because of the low-frequency of the disease, no specific guidelines about the treatment strategy are available. Surgery is the recommended therapy for resectable and localized disease, but several other local treatments have been reported such as radiotherapy (RT). Most articles report small retrospective studies, referring to patients treated decades ago with large heterogeneity in terms of RT dose and technique. The aim of this study was to systematically review the main experiences in RT for the treatment of EMPD in the past 30 years. MATERIALS AND METHODS A systematic search of the bibliographic databases PubMed and Scopus from January 1986 to January 2017 was performed including studies published in English, Italian, Spanish, French, and German language. RESULTS According to the search strategy, 19 full-text articles, published from 1991 to 2015, fulfilled inclusion criteria and were included in the final review. All articles were retrospective analyses with no randomized controlled trials. These studies evaluated 195 EMPD patients treated with RT, delivered in several settings. A large variability in terms of RT doses, fractionation, clinical setting, and techniques was found.Radiotherapy was administered as definitive treatment for primary or recurrent disease after surgery in 18 studies with doses ranging from 30 to 80.2 Gy delivered in 3 to 43 fractions. Radiotherapy was administered as postoperative adjuvant treatment in 9 articles with doses ranging between 32 and 64.8 Gy in 20 to 30 fractions. Two studies reported the RT use in preoperative neoadjuvant setting with doses ranging between 40 and 43.30 Gy, and 2 experiences reported the RT treatment for in situ EMPD, using 39.6 to 40 Gy. Adverse events were reported in almost all but 2 articles and were grade 2 or lower.The 18 studies evaluating RT as definitive treatment for primary or recurrent disease after surgery reported a complete response rate ranging from 50% to 100%, with a variable rate of local relapse or persistent disease ranging from 0% to 80% of cases. The 9 studies evaluating RT as postoperative adjuvant treatment reported a local relapse or persistent disease rate of 0% to 62.5%. A dose-response relationship was reported suggesting doses greater than or equal to 60 Gy for gross tumor volume treatment. Local control, disease-free survival, and overall survival at 12, 20, and 60 months have been retrieved for available data, respectively.In patients with EMPD and concurrent underlying internal malignancy, the prognosis was often worsened by the latter. In this setting, literature analysis showed a potential RT palliative role for symptoms control or local control maintenance.Derma tumor invasion greater than 1 mm and lymph node metastases were reported to be important prognostic factors for distant metastases or death. CONCLUSIONS To date, literature highlights the role of RT in the management of EMPD, but with low level of evidences.
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11
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Velenik V, Šegedin B, Anderluh F, Oblak I, Strojan P. Radiotherapy for Perianal Paget's Disease: A Case Report. TUMORI JOURNAL 2018; 94:750-3. [DOI: 10.1177/030089160809400520] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Perianal Paget's disease was first described in 1893. Since then, fewer than 300 cases have been reported in the literature. It might be associated with an underlying malignancy. Most of the patients are treated with surgical excision, which is often mutilating and of variable efficacy. In the present report, we describe the case of an 80-year-old woman with perianal Paget's disease. She was treated at our institution with radiotherapy with curative intent. The pertinent literature is reviewed, and the controversies in diagnosis and management are discussed. Conclusions Our single-case experience supports the opinion that radiotherapy is a viable treatment option with curative potential for patients with perianal Paget's disease. For the treatment of in situ disease, hypofractionated regimens to a total dose of 40–44 Gy and orthovoltage X-ray beams are recommended.
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Affiliation(s)
- Vaneja Velenik
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Barbara Šegedin
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Franc Anderluh
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Irena Oblak
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Primož Strojan
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
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Tolia M, Tsoukalas N, Sofoudis C, Giaginis C, Spyropoulou D, Kardamakis D, Kouloulias V, Kyrgias G. Primary extramammary invasive Paget's vulvar disease: what is the standard, what are the challenges and what is the future for radiotherapy? BMC Cancer 2016; 16:563. [PMID: 27473174 PMCID: PMC4966592 DOI: 10.1186/s12885-016-2622-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 07/26/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Primary invasive Extramammary Paget's vulvar disease is a rare tumor that is challenging to control. Wide surgical excision represents the standard treatment approach for Primary invasive Extramammary Paget's vulvar disease. The goal of the current study was to analyze the appropriate indications of radiotherapy in Primary invasive Extramammary Paget's vulvar disease because they are still controversial. DISCUSSION We searched the Cochrane Gynecological Cancer Group Trials Register, Cochrane Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE database up to September 2015. Radiotherapy was delivered as a treatment in various settings: i) Radical in 28 cases (range: 60-63 Gy), ii) Adjuvant in 25 cases (range: 39-60 Gy), iii) Salvage in recurrence of 3 patients (63 Gy) and iv) Neoadjuvant in one patient (43.3 Gy). A radiotherapy field that covered the gross tumor site with a 2-5 cm margin for the microscopic disease has been used. Radiotherapy of the inguinal, pelvic or para-aortic lymph node should be considered only for the cases with lymph node metastases within these areas. Radiotherapy alone is an alternative therapeutic approach for patients with extensive inoperable disease or medical contraindications. Definitive radiotherapy can be used in elderly patients and/or with medical contraindications. Adjuvant radiotherapy may be considered in presence of risk factors associated with local recurrence as dermal invasion, lymph node metastasis, close or positive surgical margins, perineal, large tumor diameter, multifocal lesions, extensive disease, coexisting histology of adenocarcinoma or vulvar carcinoma, high Ki-67 expression, adnexal involvement and probably in overexpression of HER-2/neu. Salvage radiotherapy can be given in inoperable loco-regional recurrence and to those who refused additional surgery.
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Affiliation(s)
- Maria Tolia
- Department of Radiotherapy, University of Thessaly, School of Health Sciences, Faculty of Medicine, Biopolis, Larissa, 411 10, Greece.
| | - Nikolaos Tsoukalas
- Oncology Clinic, 401 General Military Hospital, Mesogeion 138 & Katehaki, 115 25, Athens, Greece
| | - Chrisostomos Sofoudis
- LITO Obstetrics, Gynaecology & Surgery Centre, 7-13 Mouson Str, Psychiko-Athens, 154 52, Greece
| | - Constantinos Giaginis
- Department of Food Science and Nutrition, University of the Aegean, Myrina, Lemnos, 814 40, Greece
| | - Despoina Spyropoulou
- Department of Radiation Oncology, University of Patra Medical School, Patra, 265 04, Greece
| | - Dimitrios Kardamakis
- Department of Radiation Oncology, University of Patra Medical School, Patra, 265 04, Greece
| | - Vasileios Kouloulias
- Second Department of Radiology, Radiation Therapy Oncology Unit, University Hospital of Athens "ATTIKON", Rimini 1, Haidari, 124 64, Athens, Greece
| | - George Kyrgias
- Department of Radiotherapy, University of Thessaly, School of Health Sciences, Faculty of Medicine, Biopolis, Larissa, 411 10, Greece
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Bontinck H, Bontinck J, Rondou T, Pattyn P, Lockefeer F. Perianal Paget's disease: case report and review of the literature. Acta Chir Belg 2016; 116:187-192. [PMID: 27426653 DOI: 10.1080/00015458.2016.1139832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A peri-anal skin lesion, often eczema-like and with symptoms of pruritus, that does not resolve after classical local therapy should be biopsied. We present a case of peri-anal extramammary Paget's disease (EMDP) and associated anal adenocarcinoma. Reviewing the literature, more than 30% of patients with EMDP present a second primary tumour in their past, present or future history. In Europe, the risk of developing a new primary tumour in patients with this condition is increased compared with the standard population. In cases of peri-anal Paget's disease (PPD), specific histochemical markers allow us to differentiate between a primary and a secondary form, the secondary one is strongly associated with colorectal and anal tumours. We provide information about the most commonly suggested therapy for PPD with or without associated malignancy and about the recommended follow-up.
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Clinicopathologic Features and Treatment Outcomes of Primary Extramammary Paget Disease of the Vulva. J Low Genit Tract Dis 2015; 19:145-8. [DOI: 10.1097/lgt.0000000000000063] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Choi Y, Park W, Lee J, Cho EY, Moon GH. Aggressive clinical course of extramammary Paget disease after radiotherapy. Radiat Oncol J 2014; 32:95-8. [PMID: 25061578 PMCID: PMC4104225 DOI: 10.3857/roj.2014.32.2.95] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 04/23/2014] [Accepted: 05/07/2014] [Indexed: 11/03/2022] Open
Abstract
Extramammary Paget disease (EMPD) is a rare disease, especially in Asian populations. Surgical resection is considered the primary treatment option. Recently, radiotherapy has been suggested as an EMPD treatment, either as an alternative to surgical resection or in combination with surgical resection. This report reviewed a patient with EMPD who was treated with wide excision of the EMPD site followed by radiotherapy for remaining gross lymph node metastases. The aim of this report was to determine the optimal treatment for advanced EMPD.
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Affiliation(s)
- Yunseon Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeeyun Lee
- Department of Hematology and Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Yoon Cho
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Goo-Hyun Moon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Möller MG, Lugo-Baruqui JA, Milikowski C, Salgado CJ. Staged marginal contoured and central excision technique in the surgical management of perianal Paget's disease. Am J Surg 2014; 207:485-92. [DOI: 10.1016/j.amjsurg.2013.04.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 04/09/2013] [Accepted: 04/29/2013] [Indexed: 11/30/2022]
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Lu YS, Jeng CH, Lin HC, Hsieh CH, Lin YH, Lo KC. Reconstruction of the massive defect after excision of penoscrotal and perianal extramammary Paget's disease. FORMOSAN JOURNAL OF SURGERY 2014. [DOI: 10.1016/j.fjs.2013.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Itonaga T, Nakayama H, Okubo M, Mikami R, Nogi S, Tajima Y, Sugahara S, Tokuuye K. Radiotherapy in Patients with Extramammary Paget's Disease - Our Own Experience and Review of the Literature. Oncol Res Treat 2014; 37:18-22. [DOI: 10.1159/000358161] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 11/11/2013] [Indexed: 11/19/2022]
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Hata M, Koike I, Wada H, Miyagi E, Kasuya T, Kaizu H, Matsui T, Mukai Y, Ito E, Inoue T. Radiation therapy for extramammary Paget's disease: treatment outcomes and prognostic factors. Ann Oncol 2014; 25:291-297. [DOI: 10.1093/annonc/mdt478] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Edey KA, Allan E, Murdoch JB, Cooper S, Bryant A. Interventions for the treatment of Paget's disease of the vulva. Cochrane Database Syst Rev 2013:CD009245. [PMID: 24163070 DOI: 10.1002/14651858.cd009245.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Extra-mammary Paget's disease is a rare form of superficial skin cancer. The most common site of involvement is the vulva. It is seen mainly in postmenopausal white women. Paget's disease of the vulva often spreads in an occult fashion, with margins extending beyond the apparent edges of the lesion. There is a range of interventions from surgical to non-invasive techniques or treatments. The challenges of interventions are to remove or treat disease that may not be visible, without overtreatment and with minimisation of morbidity from radical surgery. There is little consensus regarding treatment. Surgery, by default, is the most common treatment, but it is challenging to excise the disease adequately, and recurrence is common, leading to repeated operations, and destruction of anatomy. Alternative treatments of photodynamic therapy, laser therapy, radiotherapy, topical treatments or even chemotherapy have been mooted, and it is important to evaluate the available evidence. It is essential to assess whether newer cell-specific treatments, such as photodynamic therapy and imiquimod, can reduce the need for radical surgery. OBJECTIVES To evaluate the benefits and harms of different treatment modalities for the management of Paget's disease of the vulva. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Trials Register, the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to September 2013. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles and contacted experts in the field. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) and well-designed non-randomised studies that compared different interventions in women with Paget's disease of the vulva, DATA COLLECTION AND ANALYSIS Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no trials and, therefore, no data were analysed. MAIN RESULTS The search strategy identified 635 unique references. We found 31 references (which reported on 30 studies) in full text after inspection of titles and abstracts, but we excluded them all as they did not meet the inclusion criteria. However, we have included a comprehensive narrative account of studies where we identified an analysis of more than 10 women, as this forms the only evidence base in this rare disease. Surgery continues to be the mainstay of treatment in the current literature, with other treatments limited to case reports or treatment of inoperable or recurrent disease. AUTHORS' CONCLUSIONS We found no reliable evidence to inform decisions about different interventions for women with Paget's disease of the vulva. Ideally, a multicentre RCT of reasonable size is needed. In particular, evidence regarding the increasing use of imiquimod would be helpful to women and clinicians alike. Well-designed non-randomised studies, that use multivariate analysis to adjust for baseline imbalances, as well as other key methodological strengths, are also lacking.
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Affiliation(s)
- Katharine A Edey
- Gynaecology, St Michael's Hospital, Southwell Street, Bristol, UK, BS2 8EG
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Kim IY, Yun SJ, Lee JS, Jung S, Jung TY, Moon KS, Jang WY. Brain metastasis from extramammary Paget's disease of the scrotum. J Clin Neurosci 2013; 21:694-6. [PMID: 24210806 DOI: 10.1016/j.jocn.2013.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 05/23/2013] [Accepted: 05/26/2013] [Indexed: 11/29/2022]
Abstract
We present to our knowledge the first patient with histopathologically proven brain metastasis from extramammary Paget's disease (EMPD) and discuss the effect of brain radiation therapy for this condition. A 68-year-old man presented to our hospital with headache and gait disturbance. Brain MRI showed multiple enhancing mass lesions, and two large cystic lesions in the left cerebellum. The patient had been diagnosed with scrotal Paget's disease 3 months previously but no further management had been performed due to his refusal. The patient underwent stereotactic aspiration and biopsy of the two large cystic lesions. A histopathological examination revealed that the tumor was a metastatic adenocarcinoma. Immunohistochemical staining revealed that the tumor cells were strongly positive for cytokeratin 7 and moderately positive for carcinoembryonic antigen and gross cystic disease fluid protein 15. These findings were similar to those of his scrotal skin lesions and were consistent with metastatic EMPD. The patient underwent brain radiation therapy with a total radiation dose of 30 Gy in 10 fractions. The patient improved neurologically so as to be self-ambulatory, and a mild improvement in the metastatic tumors was found on follow-up MRI. We had planned systemic chemotherapy, but the patient died of acute respiratory failure 2 months after radiation therapy.
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Affiliation(s)
- In-Young Kim
- Brain Tumor Clinic and Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, 160, Ilsimri, Hwasun-eup, Hwasun-gun, Chonnam 519-809, Republic of Korea; Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea.
| | - Suk-Jung Yun
- Department of Dermatology, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Ji-Shin Lee
- Department of Pathology, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Shin Jung
- Brain Tumor Clinic and Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, 160, Ilsimri, Hwasun-eup, Hwasun-gun, Chonnam 519-809, Republic of Korea; Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Tae-Young Jung
- Brain Tumor Clinic and Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, 160, Ilsimri, Hwasun-eup, Hwasun-gun, Chonnam 519-809, Republic of Korea; Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Kyung-Sub Moon
- Brain Tumor Clinic and Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, 160, Ilsimri, Hwasun-eup, Hwasun-gun, Chonnam 519-809, Republic of Korea; Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Woo-Youl Jang
- Brain Tumor Clinic and Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, 160, Ilsimri, Hwasun-eup, Hwasun-gun, Chonnam 519-809, Republic of Korea
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Moretto P, Nair V, Hallani SE, Malone S, Belanger E, Morash C, Canil C. Management of penoscrotal extramammary Paget disease: case series and review of the literature. Curr Oncol 2013; 20:e311-20. [PMID: 23904770 PMCID: PMC3728060 DOI: 10.3747/co.20.1353] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Extramammary Paget disease (empd) is a rare, slow-growing neoplasm, considered to be an adenocarcinoma of the apocrine glands. In men, the penoscrotal region is the most commonly affected area. The disease can present as carcinoma in situ or as invasive disease that can subsequently metastasize to lymph nodes and distant sites. Because of the rarity of empd, the medical literature available to guide management of the disease is limited, particularly in patients with metastases. In addition, metastatic disease may pose a diagnostic challenge, because invasive cancer of the genitourinary or gastrointestinal tract can occur in association with empd. In the present case series, we describe our experience in treating penoscrotal empd with multimodality therapy, and we review the existing literature concerning its diagnosis and management.
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Affiliation(s)
- P. Moretto
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - V.J. Nair
- Division of Radiation Oncology, Department of Radiology, The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - S. El Hallani
- Division of Anatomical Pathology, Department of Pathology and Laboratory Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - S. Malone
- Division of Radiation Oncology, Department of Radiology, The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - E. Belanger
- Division of Anatomical Pathology, Department of Pathology and Laboratory Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - C. Morash
- Division of Urology, The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - C.M. Canil
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
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Penoscrotal extramammary Paget's disease: surgical techniques and follow-up experiences with thirty patients. Asian J Androl 2013; 15:508-12. [PMID: 23685910 DOI: 10.1038/aja.2013.27] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 02/08/2013] [Accepted: 03/06/2013] [Indexed: 11/08/2022] Open
Abstract
To report the surgical management, complications and prognosis of patients with penoscrotal extramammary Paget's disease (EMPD) at different clinical stages. Between 2003 and 2008, a total of 30 male patients with penoscrotal EMPD were enrolled and evaluated. All enrolled subjects received frozen biopsy-guided local wide resection and immediate reconstruction. Patients were followed every 3 months postoperatively. Among the 30 patients who accepted and underwent frozen biopsy-guided local wide resection treatment and reconstruction, two (6.7%) cases exhibited positive margins, verified by pathological examination, and underwent re-excision after surgery. The technique of primary closure or an adjacent flap was used in 10 (33.3%) cases, split-thickness skin grafts were used in 15 (50%), and an anterolateral thigh perforator flap was used in five cases (16.7%). The postoperative complications were acceptable. The mean follow-up time was 64.9 ± 29.6 months. Of all 30 cases, 22 patients (73.3%) survived with no evidence of recurrence, four patients (13.3%) exhibited local recurrence, two patients (6.7%) exhibited both local recurrence and distant metastasis and the remaining two patients (6.7%) exhibited distant metastasis. Five patients died from metastasis or cachexia. Current surgical techniques, including primary closure, adjacent flaps, split-thickness skin flaps and anterolateral thigh perforator flaps are able to reconstruct all types of defects with acceptable complications. Some patients with negative margins went on to exhibit local recurrence, potentially due to adnexal carcinoma or internal malignancy.
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Boulard C, Duval Modeste AB, Boullie MC, Marpeau L, Courville P, Joly P. Traitement de la maladie de Paget vulvaire par cryochirurgie et photothérapie dynamique topique. Ann Dermatol Venereol 2013; 140:282-6. [DOI: 10.1016/j.annder.2013.01.425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 12/10/2012] [Accepted: 01/11/2013] [Indexed: 12/11/2022]
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27
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Extramammary Paget's disease with invasive adenocarcinoma of the penoscrotum: Case report and systematic review. UROLOGICAL SCIENCE 2013. [DOI: 10.1016/j.urols.2013.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Mengjun B, Zheng-Qiang W, Tasleem MM. Extramammary Paget's Disease of the Perianal Region: A Review of the Literature Emphasizing Management. Dermatol Surg 2013; 39:69-75. [DOI: 10.1111/dsu.12019] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ito Y, Igawa S, Ohishi Y, Uehara J, Yamamoto AI, Iizuka H. Prognostic Indicators in 35 Patients with Extramammary Paget's Disease. Dermatol Surg 2012; 38:1938-44. [DOI: 10.1111/j.1524-4725.2012.02584.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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30
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Delport ES. Extramammary Paget's disease of the vulva: An annotated review of the current literature. Australas J Dermatol 2012; 54:9-21. [PMID: 22671146 DOI: 10.1111/j.1440-0960.2012.00898.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Extramammary Paget's disease is a rare and unusual neoplastic entity that presents mainly on apocrine gland-bearing skin. The vulva is the most common site of involvement but any area of the anogenital skin can be affected. Due to its rarity, variable clinical course and deceptive histological appearance it has a high misdiagnosis rate and both gynaecologists and dermatologists have limited experience in its management. The significance of the disease lies in its association with underlying malignancy as well as its inherent ability to invade the dermis and metastasise. The management is notoriously complicated and recurrence rates are high despite aggressive surgeries. Several alternative modalities are being explored, with results that are often variable and unpredictable. This review summarises the histopathological, clinical and therapeutic features of extramammary Paget's disease of the vulva reported in recent years.
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Marcos S, Montero A, Capuz B, Martinez-Ollero J, Hernanz R, Fernández E, Polo A, Ramos A. HDR-plesiotherapy for the treatment of anogenital extramammary Paget's disease. Rep Pract Oncol Radiother 2012; 17:163-7. [PMID: 24377019 DOI: 10.1016/j.rpor.2012.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Revised: 01/07/2012] [Accepted: 03/10/2012] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Extramammary Paget disease (EMPD) is a rare condition that most commonly affects the anogenital region in the elderly. It may be associated with an underlying invasive carcinoma. Surgical excision is nowadays considered a standard treatment for extramammary Paget's disease, although this approach might not be suitable for all patients. Good rates of local control and cosmetic outcome have been achieved by using high-dose-rate (HDR) plesiotherapy in the treatment of skin tumors arising in different locations. MATERIAL AND METHODS We present the results observed in a patient with EMPD treated by HDR plesiotherapy with a custom-made mold up to a final dose of 54 Gy in 12 fractions of 450 cGy over 4 weeks. RESULTS After a follow-up of 18 months, the patient is alive and without evidence of local or distant relapse. Acute toxicity was acceptable and cosmetic result was considered as excellent. CONCLUSION This technique represents an attractive alternative for those patients who are not candidates for surgical procedures because of unacceptable risk of disfigurements or functional impairment, medical contraindications or patient preference.
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Affiliation(s)
- Soraya Marcos
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Angel Montero
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Belén Capuz
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | | | - Raúl Hernanz
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Eva Fernández
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Alfredo Polo
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Alfredo Ramos
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
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Karam A, Dorigo O. Treatment outcomes in a large cohort of patients with invasive Extramammary Paget's disease. Gynecol Oncol 2012; 125:346-51. [DOI: 10.1016/j.ygyno.2012.01.032] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 12/28/2011] [Accepted: 01/19/2012] [Indexed: 11/16/2022]
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Radiotherapy for extramammary Paget disease of the anogenital region. J Am Acad Dermatol 2011; 65:192-4. [DOI: 10.1016/j.jaad.2009.11.689] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Revised: 11/18/2009] [Accepted: 11/27/2009] [Indexed: 11/21/2022]
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Management of Unusual Cutaneous Malignancies: Atypical Fibroxanthoma, Malignant Fibrous Histiocytoma, Sebaceous Carcinoma, Extramammary Paget Disease. Dermatol Clin 2011; 29:201-16, viii. [DOI: 10.1016/j.det.2011.02.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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35
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Wagner G, Sachse MM. Extramammary Paget disease - clinical appearance, pathogenesis, management. J Dtsch Dermatol Ges 2011; 9:448-54. [PMID: 21205169 DOI: 10.1111/j.1610-0387.2010.07581.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Extramammary Paget disease is a rare malignant neoplasm. With regard to the pathogenesis, two prognostically different forms can be distinguished. The primary form of extramammary Paget disease is an in situ carcinoma of the apocrine gland ducts. In contrast, the secondary form is characterized by an intraepithelial spread due to an underlying carcinoma of the skin or other organ systems. Extramammary Paget disease occurs in older patients. The predilection sites include the entire anogenital skin and less often the axillary region. We present five different patients with this disease, thereby demonstrating its variation in clinical morphology. The lesion usually presents as an erythematous sharply defined spot. The polygonal borders, caused by the centrifugal growth of the tumor, may provide a diagnostic clue. The treatment of choice for extramammary Paget disease remains Mohs' microscopic surgery. However, radiotherapy or topical applications may be alternative treatment options in selected cases. In patients with the secondary form of extramam-mary Paget disease, treatment of the primary tumor is the main approach.
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Affiliation(s)
- Gunnar Wagner
- Department of Dermatology, Bremerhaven Hospital (Reinkenheide), Bremerhaven, Germany.
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Hata M, Omura M, Koike I, Wada H, Miyagi E, Tayama Y, Odagiri K, Minagawa Y, Ogino I, Inoue T. Role of radiotherapy as curative treatment of extramammary Paget's disease. Int J Radiat Oncol Biol Phys 2010; 80:47-54. [PMID: 20951507 DOI: 10.1016/j.ijrobp.2010.01.073] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Revised: 01/13/2010] [Accepted: 01/13/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE Extramammary Paget's disease (EMPD) is a relatively rare malignancy that usually arises in the genital areas. Wide surgical excision remains the standard and most reliable curative treatment of EMPD. However, surgery is sometimes not possible, because many patients are elderly, and complete excision can be difficult owing to the tumor location. We, therefore, performed a review to determine the role of radiotherapy (RT) for EMPD. METHODS AND MATERIALS A total of 22 patients with EMPD in their external genitalia (4 men and 18 women, age 52-94 years at RT) underwent RT with curative intent. Nine patients had regional lymph node metastases. A total dose of 45-70.2 Gy (median, 60) was delivered to the pelvis, including the tumors, in 25-39 fractions (median, 33). RESULTS In all but 3 patients, the irradiated tumors were controlled during a follow-up period of 8-133 months (median, 42). Of the 22 patients, 13 developed recurrences, including local progression within the radiation field in 3 and lymph node and/or distant metastases outside the radiation field in 10, at 3-43 months after treatment. The 2- and 5-year local progression-free rates were 91% and 84%, respectively. Of the 22 patients, 7 patients had died at 33-73 months after RT. The cause of death was tumor progression in 4, infectious pneumonia in 2, and renal failure in 1 patient. The overall and cause-specific survival rates were 100% for both at 2 years and 53% and 73% at 5 years, respectively. No therapy-related Grade 3 or greater toxicity was observed. CONCLUSIONS RT is safe and effective for patients with EMPD. It appears to contribute to prolonged survival as a result of good tumor control.
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MESH Headings
- Aged
- Aged, 80 and over
- Disease-Free Survival
- Dose Fractionation, Radiation
- Female
- Genital Neoplasms, Female/pathology
- Genital Neoplasms, Female/radiotherapy
- Genital Neoplasms, Male/pathology
- Genital Neoplasms, Male/radiotherapy
- Humans
- Male
- Middle Aged
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/radiotherapy
- Paget Disease, Extramammary/mortality
- Paget Disease, Extramammary/radiotherapy
- Retrospective Studies
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Affiliation(s)
- Masaharu Hata
- Department of Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan.
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Cotter SE, Devlin PM, Sahni D, Hansen JL, O'Farrell DA, Ng AK, Wang LC. Treatment of Cutaneous Metastases of Merkel Cell Carcinoma With Surface-Mold Computer-Optimized High-Dose-Rate Brachytherapy. J Clin Oncol 2010; 28:e464-6. [DOI: 10.1200/jco.2010.29.0635] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Shane E. Cotter
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA
| | - Phillip M. Devlin
- Dana-Farber/Brigham & Women's Cancer Center, Harvard Medical School, Boston, MA
| | - Debjani Sahni
- Dana-Farber/Brigham & Women's Cancer Center, Harvard Medical School, Boston, MA
| | - Jorgen L. Hansen
- Dana-Farber/Brigham & Women's Cancer Center, Harvard Medical School, Boston, MA
| | | | - Andrea K. Ng
- Dana-Farber/Brigham & Women's Cancer Center, Harvard Medical School, Boston, MA
| | - Linda C. Wang
- Dana-Farber/Brigham & Women's Cancer Center, Harvard Medical School, Boston, MA
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Abstract
Mohs micrographic surgery (MMS) has been shown to reduce recurrence rates when used to excise many different mucocutaneous neoplasms, especially of the head and neck. The low recurrence rates are due to careful microscopic evaluation of the horizontal and vertical surgical margins. This article discusses the utility and limitations of MMS in controlling neoplasia of the male genitalia. Specific penoscrotal neoplasias discussed in this article include invasive and in situ squamous cell carcinoma, basal cell carcinoma, extramammary Paget disease, and granular cell tumor.
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Affiliation(s)
- Michael J Wells
- Department of Dermatology, Texas Tech University Health Sciences Center, Lubbock, TX 79407, USA.
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Zhang N, Gong K, Zhang X, Yang Y, Na Y. Extramammary Paget's disease of scrotum—report of 25 cases and literature review. Urol Oncol 2010; 28:28-33. [DOI: 10.1016/j.urolonc.2008.07.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2008] [Revised: 06/30/2008] [Accepted: 07/02/2008] [Indexed: 11/28/2022]
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Ben D, Liu L, Ma B, Li Y, Xia Z. Extramammary Paget's disease arising from a burn scar of right forearm: An uncommon case report. Burns 2009; 36:e145-7. [PMID: 19303717 DOI: 10.1016/j.burns.2008.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 11/18/2008] [Indexed: 10/21/2022]
Affiliation(s)
- Daofeng Ben
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University Shanghai, 168# Changhai Road, Shanghai 200433, PR China
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Tanaka VDA, Sanches JA, Torezan L, Niwa AB, Neto CF. Mammary and extramammary Paget's disease: a study of 14 cases and the associated therapeutic difficulties. Clinics (Sao Paulo) 2009; 64:599-606. [PMID: 19578667 PMCID: PMC2705154 DOI: 10.1590/s1807-59322009000600018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
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43
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Wang Z, Lu M, Dong GQ, Jiang YQ, Lin MS, Cai ZK, Ying J, Ren X, Liu B. Penile and Scrotal Paget’s disease: 130 Chinese patients with long-term follow-up. BJU Int 2008; 102:485-8. [DOI: 10.1111/j.1464-410x.2008.07575.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yanagi T, Kato N, Yamane N, Osawa R. Radiotherapy for extramammary Paget's disease: histopathological findings after radiotherapy. Clin Exp Dermatol 2007; 32:506-8. [PMID: 17489988 DOI: 10.1111/j.1365-2230.2007.02425.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Several reports have suggested the efficacy of radiotherapy for treating extramammary Paget's disease (EMPD); however, these reports comprised only clinical observations, without in-depth histopathological observations. We report our experience of genital EMPD treated by radiotherapy in two elderly women, and the marked efficacy of radiotherapy, confirmed both by clinical observation and by detailed histopathological investigations. Our cases agree with the notion that radiotherapy is useful as an alternative therapy for EMPD, and should be considered particularly in elderly patients who may not tolerate surgery well.
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Affiliation(s)
- T Yanagi
- Department of Dermatology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan.
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Son SH, Lee JS, Kim YS, Ryu MR, Chung SM, Namkoong SE, Han GT, Lee HJ, Yoon SC. The role of radiation therapy for the extramammary paget's disease of the vulva ; experience of 3 cases. Cancer Res Treat 2005; 37:365-9. [PMID: 19956374 DOI: 10.4143/crt.2005.37.6.365] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Accepted: 12/08/2005] [Indexed: 11/21/2022] Open
Abstract
We have experienced three cases of extramammary Paget's disease (EMPD) of the vulva that received radiation therapy (RT). Here, we analyze the efficacy of RT and include a literature survey.Three patients with EMPD of the vulva were treated with curative RT between 1993 and 1998. One of the patients had associated underlying adenocarcinoma of the vulva. The total doses of radiation administered were 54~78 Gy/6~8 weeks. Radiation fields encompassed 2 to 3 cm outer margins free from all visible disease including or not including the inguinal area using a 9 MeV electron or a 6 MV photon beam. Follow-up durations after radiotherapy were 0.6~11 years. Complete response was obtained in all three patients. Marginal failure occurred in one patient, and another patient with underlying adenocarcinoma treated by vulvectomy with bilateral inguinal lymph node dissection followed by external RT showed no relapse. Radiation induced side effects were transient acute confluent wet desquamation in the treated area resulting in mild late atrophic skin changes.Although surgery is currently considered the preferred primary treatment for EMPD, it has a high relapse rate due to the multifocal nature of the disease. We conclude that RT is of benefit in some selected cases of EMPD.
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Affiliation(s)
- Seok-Hyun Son
- Department of Radiation Oncology, The Catholic University of Korea College of Medicine, Seoul, Korea
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