Metastatic in-situ perianal Paget's disease

Extra-mammary Paget's disease of the perianal region: a review of the literature emphasizing the operative management technique

The perianal skin is a common area for extra-mammary Paget's disease development. The unique clinical, histopathological, and immunohistochemical features which this medical phenomenon demonstrates, along with its rarity and frequent association with synchronous or metachronous carcinomas, present us with a treatment challenge. In order to organize the surgical treatment, it is important to determine whether the disease is localized exclusively to the perianal skin or associated with metastasis or anorectal carcinomas. Despite several controversies concerning its optimal therapeutic management, wide local excision of the skin and subcutaneous tissue in the perianal region is generally recommended for the treatment of the non-invasive form of the disease. Such an aggressive operative management usually results in a large perianal tissue defect, which can not be primarily suppressed without resultant tension and possible complications, requiring a special technique for its coverage. Various techniques have been described in the literature for the treatment of these defects, often associated with unfavourable long term results, i.e. split-thickness skin grafts and vacuum-assisted closure devices. More recently several authors have reported favourable results using various transposition or rotation local skin flaps, myocutaneous flaps of the gluteal and thigh muscles, and V-Y island flaps to cover these areas of tissue loss. In this article we present a short review of the literature concerning perianal Paget's disease with special attention to its management and a demonstration of the operative technique we prefer on patients with perianal non-invasive Paget's disease, i.e. wide local excision with a 2 cm margin in the anal mucosa and use of U and V-Y shaped perianal fatty-cutaneous island flaps for reconstruction by covering the bilateral anal skin defects.

Perianal Paget's disease: presentation of six cases and literature review

PURPOSE

Extramammary Paget's disease (EMPD) is frequently associated with adnexal or visceral synchronous or metachronous malignancies. Our purpose was to evaluate, retrospectively, the results obtained in six cases of EMPD and to review the literature.

METHODS

Six patients with the perianal Paget's disease had been treated in our division between March 1996 and December 2006. In three cases, the disease was confined in the epidermis; in one case, there was a microinvasion of the dermis, while in another one the dermis was infiltrated. The last case was associated to a low rectal adenocarcinoma. All patients underwent wide perianal excision and reconstruction with skin graft. We performed a transanal resection of the rectal adenocarcinoma. A review of the literature from 1990 to 2008 revealed 193 cases of perianal EMPD, 112 were intraepithelial/intradermal while 81 were associated with malignancies. Anorectal adenocarcinoma was already existing in two cases, synchronous in 48, and subsequent to diagnosis in 11.

RESULTS

In three cases, the disease recurred locally, but no patient developed metastatic spread. Five patients survived and are free of disease. The review of the literature allows a clear identification of the primitive EMPD and the form associated to anorectal adenocarcinoma and little information about cases associated with synchronous adnexal adenocarcinoma. The Paget's disease can relapse after radical surgery and has a capacity of metastatic spread.

CONCLUSIONS

Up to now, no clear guidelines have been established for the diagnosis of EMPD. The association with synchronous or metachronous carcinomas imposes a long-term follow-up with frequent clinical, radiological, and endoscopical controls.

Radiotherapy for perianal Paget's disease

The role of radiotherapy in the management of perianal Paget's disease (PPD) is not well defined in clinical practice or within the medical literature. We present 6 cases, document the radiotherapy details and review our results. A comprehensive literature search has been undertaken attempting to identify all published cases of PPD and survey the number receiving radiotherapy. To further define the role for radiotherapy in PPD these cases have been reviewed. Published results are sporadic and often poorly documented with respect to technical radiotherapy details. Two main roles for radiotherapy in PPD were found. One is as primary treatment for in situ or invasive disease and the other is following surgical relapse of in-situ or invasive disease. Other possible uses of radiotherapy in PPD such as neoadjuvant or adjuvant treatment or chemo-radiotherapy are discussed. Results of radiotherapy treatment for case of in situ and invasive disease are presented. We disagree with the view in some areas of the surgical literature that radiotherapy has no place in the management of the disease. Despite a thorough surveying of the literature however, precise recommendations on several areas of the technical radiotherapy treatment such as dose-fractionation schedules and field margins are difficult because of the small number of cases and poor general documentation. Our practice recommendations are presented. Radiotherapists should be encouraged to publish their experience in this disease to help define further a role for this treatment.