Perianal Paget's disease. Report of three cases

Three cases of perianal Paget's disease are presented. Clinically, three patients had a chronic irritating perianal rash resistant to hydrocortisone cream. One patient had an underlying rectal adenocarcinoma. The controversies in the histogenesis of Paget's cells in perianal Paget's disease remain unresolved, but it appears that perianal Paget's disease probably is more than one disease and is biologically different from mammary Paget's disease.

Treatment of extensive extramammary Paget disease of male genitalia with Mohs micrographic surgery

It is often difficult to accurately judge the clinical tumor margins for extramammary Paget disease. Mohs micrographic surgery was used to extirpate a tumor which clinically measured 159.5 cm2. Following Mohs micrographic surgery, it was found that the actual dimensions of the tumor had been underestimated by 97 per cent. Since the Mohs micrographic surgeon microscopically examines the entire subcutaneous margin of the resected tumor, this technique provides an accurate method of determining the depth of tumor penetration. Mohs micrographic surgery allows for maximal conservation of normal tissue and yields higher cure rates than other conventional methods of treatment. When approaching tumors of the genitalia which may display poorly defined clinical margins, Mohs micrographic surgery should be considered the technique of choice.

Recurrent Paget's disease of the vulva after simple vulvectomy and skin grafting. A case report

A patient with recurrent Paget's disease of the vulva 11 years after simple vulvectomy and skin grafting is presented. This is the first report of an intra-epithelial vulvar Paget lesion with recurrence in a skin graft. The current hypotheses regarding the histogenesis of Paget's disease of the vulva are discussed.

Perianal Paget's disease

A case of extramammary, perianal Paget's disease with underlying rectal carcinoma is presented. The importance of awareness of the condition is stressed and the diagnosis and treatment are commented upon.

Role of preoperative topical 5-fluorouracil in preparation for Mohs micrographic surgery of extramammary Paget's disease

The true extent of the skin affected in extramammary Paget's disease is frequently well beyond its clinical borders. A case of extramammary Paget's disease of the scrotum was treated with Mohs micrographic surgery. Prior to surgery, 5-fluorouracil was applied topically for 10 days. This resulted in a sharply delineated, erythematous patch of biopsy-proved extramammary Paget's disease well beyond the original clinical borders. This increased the visible area of disease by 60%. Mohs micrographic surgery detected microscopic extramammary Paget's disease approximately 1 cm beyond the erythematous borders. The location of disease farthest from the margins was in the direction toward which this erythema was most advanced when the application of 5-fluorouracil was discontinued. At the time of writing, 3.5 years after treatment, the patient was free of disease. Topical 5-fluorouracil may have a role as an adjunct to surgery by highlighting subclinical areas of extramammary Paget's disease. It may also be useful postoperatively to detect early disease recurrence.

Mohs' surgery. New concepts and applications

During the past decade, Mohs' surgery has been used increasingly, mostly by dermatologists, for the treatment of cutaneous neoplasms, usually basal cell or squamous cell carcinomas. This use has given rise to new developments, both in the technique itself and in basic tumor biology. As more tumors are delineated microscopically in both their histologic and growth patterns, certain concepts are emerging that are important for successful management of skin cancer.

Perianal Paget's disease

Over the past 11 years (1974 to 1985) ten patients with perianal Paget's disease were treated. The average age was 64 years and half were male. Two patients were diagnosed as an incidental finding after hemorrhoidectomy and the remainder presented with a symptomatic perianal rash (itching and moisture) that averaged two years in duration. Physical examination in these patients demonstrated characteristic lesions (seven with erythematous or ulcerated, whitish gray lesions and one with a papillary lesion). Three patients presented with invasive carcinomas and, despite aggressive therapy, all developed metastatic disease. Two patients had local excisions with minimal margins and developed associated invasive cancers at four and ten years after diagnosis. The remaining five patients were treated by wide local excision and skin grafts. At present all are free of disease. The characteristic appearance of this lesion and its failure to respond quickly to conventional therapy should lead the clinician to obtain a biopsy which readily establishes the diagnosis. Experience confirms that wide local excision is adequate therapy, but adequate initial evaluation and close follow-up are necessary to identify other malignancies that may develop.

Spontaneous regression of perianal extramammary Paget's disease after partial surgical excision

A 62-year-old woman presented with a three-year history of a pruritic perianal lesion, which was histologically confirmed to be perianal extramammary Paget's disease. Partial surgical excision of the lesion was followed by complete spontaneous regression of the residual plaque.

Extramammary Paget's disease of the vulva and anus: use of intraoperative frozen-section margins

Thirteen consecutive cases of vulvar Paget's disease treated by us between 1975 and 1984 underwent pathologic retrospective review. In the first group of eight patients having Paget's disease not involving the anal mucosa, the extent of disease was completely defined by frozen-section margins. Additional intraoperative resections were necessary in five of the eight. None had residual involvement on permanent sections and none had recurrences in 3 to 8 years of follow-up, although two died of unrelated causes. A second group of two patients early in the series had frozen sections to define some but not all of the margins. Both had positive perineal margins on permanent sections. One has required two subsequent revisions after 3 years of follow-up and the other has been free of disease during 9 years of follow-up. A third group of three patients all had anal mucosal involvement and all had associated mucinous adenocarcinoma of the rectum. Frozen sections actually discovered the presence of one of the three carcinomas. After appropriate radical operations, all three are alive and free of disease between 2 and 9 years of follow-up. It is concluded: patients with vulvar Paget's disease can reduce the need for subsequent operations with the use of frozen sections to define surgical margins; anal mucosal involvement of Paget's disease represents an ominous sign of underlying carcinoma.

Osteogenic sarcoma

Guarded optimism could be clearly stated for the treatment of osteogenic sarcoma. Improved methods of diagnosis and staging have been made possible by the computed tomography (CT) scan and other new modalities. The advent of pre- and postoperative chemotherapy has significantly enhanced survival rates that are now approaching 85%. Improved concepts of en bloc resection and better reconstructive techniques suggest that limb salvage procedures are not only possible but can provide excellent functional results in the context of muscle loss. Continued work must be directed toward improving the reconstructive techniques to provide implants with permanence, particularly for young patients and to clearly define the indications for such procedures. Patients presenting with thoracic lesions, although difficult to treat, can expect a 30%--45% long-term survival following repetitive thoracotomies.

[Reconstructive surgery of the anoperineal region]

The embryology and anatomy of the ano-perineal region explain the complex pathology which is difficult to treat. Six types of lesions are discussed. Congenital skin lesions: naevus or angiomas, requiring the same procedures of local autoplasty and graft as those of other regions, whenever they are extensive. Infectious lesions are dominated by Verneuil's disease, chronic hidradenitis or acne conglobata. Treatment involves wide excision which is sufficiently deep, followed by skin graft. Cancerous or pre-cancerous lesions. A distinction must be made between Bowen's disease and Paget's disease: the first is a precancerous lesion and the second is a sign of underlying carcinoma. The treatment is very different for the two conditions. Radiation dermatitis is not exceptional. Surgical treatment is required, but it is difficult. Radio-necroses can be repaired with epiplooplasty and a musculo-cutaneous flap from gluteus maximus. Post-traumatic and surgical sequelae sometimes need to be repaired by a plastic operation. Anal continence can be treated by surgical repair.

Surgical treatment of genital Paget's disease in men

Twenty-one men with genital Paget's disease were treated in our clinic from 1968 to 1983. We report our policy regarding treatment of the clinical disorder, particularly our surgical approach. We also stress that, when considering treatment, the circumstances of the aged patients should take precedence over aggressive treatment of the clinical state of the dermal disease.

Extramammary Paget's disease. Arising in knee region in association with sweat gland carcinoma

We report a case of extramammary Paget's disease (EMPD) arising in the knee region in association with an underlying sweat gland carcinoma. Inguinal lymph node metastases were present initially. Paget's cells, intradermal tumor cells, and metastatic tumor cells showed similar reactions to a variety of histochemical stains and positive results with immunohistochemical staining using carcinoembryonic antigen (CEA). Control sections in cases of Bowen's disease and superficial, spreading malignant melanoma showed a negative staining reaction with CEA, providing further evidence that this technique is useful in distinguishing Paget's disease (PD) from histologically similar conditions. We provide a summary of previous cases of EMPD arising in unusual locations and a brief consideration of possible mechanisms of the origin of PD.

Adenocarcinoma of the scrotum (extramammary Paget's disease): case report and review of the literature

A case is reported of extramammary Paget's disease of the scrotum, with metastases to the superficial femoral lymph nodes. Extramammary Paget's disease and its urological spectrum are reviewed, and the management is discussed. Treatment consisted of surgery and irradiation therapy. The patient appears to be free of disease, despite metastatic nodal involvement, 2 1/2 years after diagnosis.

Bilateral superomedial thigh flaps for primary reconstruction of scrotum and vulva

The use of bilateral superomedial thigh flaps for primary reconstruction of scrotum and vulva is presented. These flaps have proved to be reliable, ensuring good healing and providing almost normal sensation. Further indirect evidence that these are arterial flaps is given.