Conservative Management of Extramammary Paget Disease With Imiquimod

Anatomic Subtype Differences in Extramammary Paget Disease: A Meta-Analysis

Importance

Extramammary Paget disease (EMPD) is a rare, highly recurrent cutaneous malignant neoplasm of unclear origin. EMPD arises most commonly on the vulvar and penoscrotal skin. It is not presently known how anatomic subtype of EMPD affects disease presentation and management.

Objective

To compare demographic and tumor characteristics and treatment approaches for different EMPD subtypes. Recommendations for diagnosis and treatment are presented.

Data Sources

MEDLINE, Embase, Web of Science Core Collection, and Cochrane Reviews CENTRAL from December 1, 1990, to October 24, 2022.

Study Selection

Articles were excluded if they were not in English, reported fewer than 3 patients, did not specify information by anatomic subtype, or contained no case-level data. Metastatic cases on presentation were also excluded.

Data Extraction and Synthesis

Abstracts of 1295 eligible articles were independently reviewed by 5 coauthors, and 135 articles retained. Reporting was in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The analysis was cunducted in August 2019 and updated in November 2022.

Findings

Most vulvar EMPD cases were asymptomatic, and diagnosis was relatively delayed (mean, 25.1 months). Although most vulvar EMPD cases were intraepidermal (1247/1773 [70.3%]), radical surgeries were still performed in almost one-third of cases. Despite this aggressive surgical approach, 481 of 1423 (34%) recurred, commonly confined to the skin and mucosa (177/198 [89.4%]). By contrast, 152 of 1101 penoscrotal EMPD cases (14%) recurred, but more than one-third of these recurrences were regional or associated with distant metastases (54 of 152 [35.5%]). Perianal EMPD cases recurred in one-third of cases (74/218 [33.9%]), with one-third of these recurrences being regional or associated with distant metastasis (20 of 74 [27.0%]). Perianal EMPD also had the highest rate of invasive disease (50% of cases).

Conclusions and Relevance

The diagnosis and treatment of EMPD should differ based on anatomic subtypes. Considerations for updated practice may include less morbid treatments for vulvar EMPD, which is primarily epidermal, and close surveillance for local recurrence in vulvar EMPD and metastatic recurrence in perianal EMPD. Recurrences in penoscrotal subtype were less common, and selective surveillance in this subtype may be considered. Limitations of this study include the lack of replication cohorts and the exclusion of studies that did not stratify outcomes by anatomic subtype.

Vulvar Paget’s Disease: A Systematic Review of the MITO Rare Cancer Group

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.

Advances in Topical Treatments of Cutaneous Malignancies

Surgical excision has been the preferred treatment for cutaneous malignancies, but can be affected by various considerations. Noninvasive, self-administered topical treatments represent an alternative option. The aim of this review was to evaluate and summarize evidence-based recommendations for topical treatments of basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (CSCC), in situ melanoma (MIS), and extramammary Paget's disease (EMPD). Studies were reviewed on PubMed. Included studies were summarized, assessed for biases, and assigned a level of evidence to develop treatment recommendations. For the treatment of superficial BCC, complete clearance rates ranged from 90 to 93% for 5% 5-fluorouracil (5-FU) and 71 to 76% for imiquimod (IMQ). For the treatment of nodular BCC, clearance rates for photodynamic therapy (PDT) were 91% at 3 months, with a sustained lesion clearance response rate of 76% after 5 years of follow-up. Clearance rates were 53 to 76% with IMQ. For squamous cell carcinoma in situ, clearance rates ranged from 52 to 98% for PDT, 67 to 92% for 5-FU, and 75 to 93% for IMQ. For MIS, clearance rates ranged from 53 to 92% for IMQ. For EMPD, 54% of 110 patients in cohort studies and case series had a clinical complete response with IMQ. While surgical intervention remains the standard of care for skin cancer, non-invasive, self-administered topical treatments are highly desirable alternative options. Ultimately, the patient and provider should find a treatment modality that aligns with the patient's expectations and maintenance of quality of life.

Medical and Surgical Strategies in Vulvar Paget Disease: Let's Throw Some Light!

BACKGROUND

Vulvar Paget's disease (VPD) is defined as a neoplasm of epithelial origin, mostly in postmenopausal women. Due to the extreme rarity of VPD, limited data about recommended treatment options are available. Surgical excision has been the treatment of choice although in the recent decade medical treatments have been proposed.

METHODS

A systematic computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane Library), from 2003 to September 2022, in order to analyze all medical and surgical strategies used for the treatment of VPD.

RESULTS

Thirty-four articles were included in this review with findings as follows: 390 patients were treated with medical or other conservative treatment while 2802 patients were treated surgically; 235/434 (54%) patients had a complete response, 67/434 (15%) a partial response, 10/434 (2.3%) a stable disease, 3/434 (0.7%) disease progress, 3/434 (0.7%) died of the disease, 55/434 (13%) died of other causes during follow up while 7/434 (1.6%) had to stop topical treatments with 5% imiquimod cream because of side effects; 239/434 patients (55%) had a recurrence and 11/434 (2.5%) were lost to follow-up. The length of follow-up was variable, according to the different studies analyzed.

CONCLUSION

VPD is a chronic disease with a high recurrence rate and low mortality. There are no significant differences in recurrence rates in patients who undergo surgery and those who do not and the margin status at the time of primary surgery and recurrence. Several surgical and medical approaches providing both local control of the disease and minimal tissue damage have been developed. Clock mapping, a recent preoperative vulvo-vaginal workup tool, can predict the invasiveness and the extension of VPD. However, to date, due to the different treatment options available and in the absence of a global consensus, it is critical to tailor treatments to individual patient characteristics and biopsy histopathologic findings, to ensure the best type of therapy.

Efficacy and safety of HpD-PDT for Extramammary Paget's Disease refractory to conventional therapy: A prospective, open-label and single arm pilot study

BACKGROUND

Extramammary Paget's Disease (EMPD) is an intraepithelial cancer that is prone to recurrence and sometimes refractory to therapy. A few EMPD cases have been treated with Photodynamic therapy (PDT), which reported high complete remission (CR) rates and low recurrence with hematoporphyrin derivatives (HpD) The aim of this study was to further explore the efficacy and safety of HpD-PDT for EMPD patients.

METHODS

Open-label, single arm, pilot study was designed to investigate the role of HpD-PDT in EMPD. The HpD sensitizer was given intravenously at a dose of 3 or 5 mg/kg 48 h before light irradiation with a laser 630 nm red light at a dose level of 150-200 J/cm². Clinical parameters involving gender, age, disease course, previous treatment, tumor thickness, long diameter of lesion, TNM staging, EMPD staging, HpD dosage, Visual Analogue Scale (VAS) score, 1st month visit result, subsequent treatment, follow up period and endpoint outcomes were collected to evaluate efficacy and safety of the intervention.

RESULTS

Eleven patients with pathologic confirmed EMPD were treated with HpD-PDT. The thickness of skin lesions which were located in vulva, penis, scrotum, and perianal area is 0.8∼6.7 mm (mean thickness 2.9 mm). All patients were followed up for an average of 17.4 months (12∼27 months). Complete remission (CR) rate and partial remission (PR) rate at the 1st month were 90.1% (10/11) and 9.1% (1/11) respectively. At the end of follow-up, 72.7% of the subjects (8/11) showed CR. Pain, infection, photosensitivity and uroschesis are recorded as adverse events (AEs) in this population, and no event of hepatic impairment was reported. After treatment, all the eleven patients showed different degrees of scar in the treatment site, but none of them had any structural or functional abnormalities.

CONCLUSIONS

According to our study, HpD-PDT in EMPD is able to offer acceptable disease outcomes including relatively high CR rate, with good cosmetic and functional outcomes, and could be considered a potential recommended therapy for patients with EMPD.

TRIAL REGISTRATION

Chinese Clinical Trial Register (ChiCTR-1900024965).

Trial watch: FDA-approved Toll-like receptor agonists for cancer therapy

Toll-like receptors (TLRs) have first been characterized for their capacity to detect conserved microbial components like lipopolysaccharide (LPS) and double-stranded RNA, resulting in the elicitation of potent (innate) immune responses against invading pathogens. More recently, TLRs have also been shown to promote the activation of the cognate immune system against cancer cells. Today, only three TLR agonists are approved by FDA for use in humans: the bacillus Calmette-Guérin (BCG), monophosphoryl lipid A (MPL) and imiquimod. BCG (an attenuated strain of Mycobacterium bovis) is mainly used as a vaccine against tuberculosis, but also for the immunotherapy of in situ bladder carcinoma. MPL (derived from the LPS of Salmonella minnesota) is included in the formulation of Cervarix®, a vaccine against human papillomavirus-16 and -18. Imiquimod (a synthetic imidazoquinoline) is routinely employed for actinic keratosis, superficial basal cell carcinoma, and external genital warts (condylomata acuminata). In this Trial Watch, we will summarize the results of recently completed clinical trials and discuss the progress of ongoing studies that have evaluated/are evaluating FDA-approved TLR agonists as off-label medications for cancer therapy.

Nonsurgical Treatments for Extramammary Paget Disease: A Systematic Review and Meta-Analysis

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.

Imiquimod in dermatology: an overview

Imiquimod is an immune response modifier commercially available as a 3.75 and 5% cream. Topical imiquimod stimulates the innate and adaptive immune responses and induces cytokine production. This allows its use for the treatment of a wide variety of benign and malignant skin conditions due to its potential antiviral, antitumor, and immunoregulatory effects. Currently, topical imiquimod is US Food and Drug Administration (FDA)-approved for the treatment of anogenital warts, actinic keratosis, and superficial basal cell carcinomas. However, it has also shown a beneficial effect in the treatment of many other skin disorders. In this review, we describe existing evidence on the mechanism of action of topical imiquimod, its FDA-approved indications, off-label uses, and side effects.

Effects of imiquimod on vulvar Paget's disease: a systematic review of literature

OBJECTIVE

To examine the effectiveness of topical imiquimod therapy for vulvar Paget's disease.

METHODS

A systematic literature search was conducted using three public search engines with entry keywords "Paget's disease" and "imiquimod". Case reports describing imiquimod treatment for vulvar Paget's disease were examined for demographics, treatment patterns, and outcome (63 cases).

RESULTS

Median age was 68, and nearly a half of cases were recurrent disease (50.8%) with surgical resection being the most common prior treatment modality (62.5%). All cases used 5% imiquimod and the median treatment duration was 4months. The most common initial treatment frequency was 3-4times/week (68.3%) followed by 5-7 (17.4%) and 1-2times/week (14.3%). Frequency-reduction due to adverse effects was seen in 9.5% with the initial 5-7times/week regimen being associated with the highest reduction rate (1-2, 3-4, and 5-7times/week: 0%, 2.3%, and 81.8%, p<0.01). In 46 (73.0%) cases, a complete remission (CR) to imiquimod therapy was reported, with 2, 4, and 6-month cumulative CR rates being 9.8%, 31.1%, and 71.6%, respectively. With median follow-up duration of 12months after the completion of imiquimod treatment, 2 (5.7%) of the 35 women who had a CR developed disease recurrence. Age, disease status (primary versus recurrent), and treatment frequency after dose reduction were not associated with CR rates (all, p>0.05).

CONCLUSION

Our results suggested that imiquimod therapy may be an effective possible treatment option for vulvar Paget's disease, especially for women who have experienced recurrence after multiple surgical resections or who are with poor surgical candidates.

Treatment of primary vulvar paget disease with 5% imiquimod cream

INTRODUCTION

Our objective was to evaluate the efficacy of conservative treatment with imiquimod in Paget vulvar disease.

MATERIALS AND METHODS

We describe a case series that includes 10 patients with histopathologic diagnosis of extramammary Paget disease of the vulva, who were treated with 5% imiquimod cream. Of these patients, 3 were treated for recurrent disease and 7 were treated for initial primary disease. The patients applied the cream every other day until the lesions were no longer clinically detected.They were previously instructed on how and where to apply the cream by making them use a mirror while following the physician's directions.

RESULTS

Complete clinical and histologic remission of the disease was achieved in 9 patients. The remaining patient had partial histologic response and is still under treatment. The treatment was well tolerated despite moderate irritation. No recurrences were observed during a mean follow-up of 18 months.

CONCLUSIONS

On the basis of the results, the authors consider that 5% imiquimod cream could be considered a safe and effective therapeutic option for the treatment of primary vulvar Paget disease. Further studies are needed to determine the real efficacy and safety of 5% imiquimod cream for the treatment of this infrequent disease.

Imiquimod therapy for extramammary Paget's disease of the vulva: a viable non-surgical alternative

Extramammary Paget's disease (EMPD) is a rare intraepidermal adenocarcinoma that can affect the vulval skin. Surgical excision is the gold-standard treatment, however, recurrence rates are high and extensive excisions can produce long-lasting cosmetic and functional defects. We describe one of the largest case series to-date (n = 6) on the use of topical 5% imiquimod cream as a novel treatment option and discuss our experiences. With the addition of our six cases to the literature, there are now 29 documented cases of vulval EMPD treated with 5% imiquimod cream. Of these, 50% of primary disease cases and 73% of recurrent primary disease cases have achieved clinical resolution with 5% imiquimod therapy alone. These findings suggest that imiquimod provides a viable alternative to surgical excision for vulval EMPD. However, we acknowledge that this is a simple retrospective analysis and that treatment scheduling and follow-up needs investigation in a trial setting.

Topical pharmacotherapy for skin cancer: part II. Clinical applications

The purpose of the paper is to provide an in-depth, evidence-based analysis of the clinical use of topical treatments for skin cancer. A comprehensive review of topical drugs has been performed, including 5-fluorouracil, imiquimod, diclofenac, ingenol mebutate, retinoids, resiquimod, piroxicam, dobesilate, and betulinic acid. The evaluated studies were rated according to their level of evidence level (I-V), as indicated by recent guidelines for evidence-based medicine, The Oxford 2011 Levels of Evidence. Therapeutic response is generally related to tumor type, extent, and localization, and also to patient compliance. Careful patient selection is required in order to achieve the desired goal of complete tumor clearance.

Clinicopathologic study of vulvar Paget's disease in China

OBJECTIVE

To assess the clinicopathologic characteristics of patients with vulvar Paget's disease who were admitted in our hospital or of cases reported in a Chinese journal.

METHODS

The age, disease course, clinical manifestation, pathologic diagnosis, treatment, and follow-up data of patients with vulvar Paget's disease were reviewed.

RESULTS

There were 85 cases of vulvar Paget's disease reviewed. The mean age of patients with vulvar Paget's disease was 64.4 years, and their mean disease course was 52.36 months. The patients' primary clinical manifestations were pruritus. Treatment included simple vulvectomy, wide local excision, partial vulvectomy, radical vulvectomy with/without groin dissection, and radiotherapy. Intraepithelial Paget's disease was the most common pathology type (61.5%) followed by invasive Paget's disease (20.0%). There were 7 patients who had a history of secondary malignancy. The mean follow-up period was 43.6 months. The recurrence rate was as high as 43.5%. No significant relationships between margin status, lymph node involvement, pathology type, and recurrence were found (p > .05).

CONCLUSIONS

Vulvar Paget's disease has a high local recurrence risk and a long-term follow-up is required.