Long-term outcome of patients with perianal Paget's disease

Malignancies of the anal margin and perianal skin

Malignancies of the anal margin and perianal skin are relatively uncommon lesions, comprising 3 to 4% of all anorectal malignancies. Commonly included in this group of cancers are Bowen's disease (intraepithelial squamous cell cancer), perianal Paget's disease (intraepithelial adenocarcinoma), invasive squamous cell cancer, basal cell cancer, and malignant melanoma. Buschke-Lowenstein tumor, or giant condyloma acuminatum, is not always included because this lesion is technically benign, although it displays aggressive local invasive behavior that makes it difficult to manage. Complaints are usually nonspecific, such as itching or burning, bleeding, pain, drainage, or a mass. Proper diagnosis requires a high index of suspicion on the part of the surgeon. Innocent local irritations will resolve in a short time with appropriate therapy; those that persist must be biopsied for tissue diagnosis. Wide local excision is the mainstay of treatment for early stage tumors as it preserves continence and obtains adequate local control. Adjunct therapies have been utilized in more advanced or recurrent lesions, including radiotherapy, photodynamic therapy, and imiquimod. All have met with a fair amount of success in controlling local disease; however, the number of patients treated in each instance is small, making it difficult to design an evidence-based treatment strategy. Invasion and metastasis are relatively rare in this group of neoplasms; perianal Paget's disease has the highest risk of associated underlying neoplasm. The most important consideration in developing a treatment strategy is which strategy would achieve the best clinical result with the least morbidity to the patient.

Perianal Paget's disease treated with wide excision and gluteal skin flap reconstruction: report of a case and review of the literature

BACKGROUND

Paget's disease of the anus is a rare perianal disorder. The condition is often associated with underlying invasive carcinoma and the prognosis is poor when underlying adenocarcinoma is present.

METHODS

We report the case of a 72-year-old woman suffering from a two-year history of perianal itching, bleeding, and irritation. Perianal Paget's disease was confirmed by histopathologic demonstration of Paget's cells from a biopsy. Synchronous malignancy and metastasis were excluded.

RESULTS

A first-stage operation consisted of a wide excisional biopsy with frozen section margin assessment. Permanent sections confirmed absence of invasive carcinoma and clear margins. Four days after wide excision, bilateral gluteal skin flap reconstruction was performed with a temporary diverting colostomy. No adjuvant therapy was necessary, and after one-year follow-up, the patient remains disease free.

CONCLUSION

Perianal Paget's disease continues to pose problems in diagnosis and treatment. Our case report of perianal Paget's disease shows one method of management for advanced non invasive disease.

Anal intraepithelial neoplasia and other neoplastic precursor lesions of the anal canal and perianal region

Anal cancer is rare and this helps to explain why anal pre-neoplastic conditions are poorly understood, especially with regard to their natural history and management. Anal intraepithelial neoplasia is closely linked to human papillomavirus infection and is particularly common in homosexuals and in immunosuppressed patients, especially those with HIV/AIDS. The high regression rates of low-grade anal intraepithelial neoplasia may simply reflect inconsistent pathologic reporting. Higher grades of anal intraepithelial neoplasia may remain static for long periods of time in immunocompetent patients, but those with HIV/AIDS show early and rapid malignant transformation. In general, most anal pre-neoplastic conditions are best diagnosed by biopsy and treated by surgical excision, although local recurrence is a problem. In anal Paget's disease, it is important to ascertain, at the time of diagnosis, whether it is due to a primary in-situ apocrine-type of neoplasia of the anus or if the disease is secondary to an invasive primary carcinoma of the rectum.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Extramammary Paget's Disease Presenting on the Face

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

At 5 months there was no evidence of recurrence.

CONCLUSION

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

Extramammary Paget's disease of the perianal region

OBJECTIVE

Perianal Paget's disease (PPD) is a rare entity. The standard treatment for either in situ or invasive extra mammary Paget's disease (EMPD) is surgical excision. Local recurrence and morbidity from surgery, especially in the elderly, can, however, be high. The aim of this article is to review our experience with PPD and question the currently preferred treatment approaches in light of its histopathology and therapeutic outcome.

PATIENTS AND METHODS

A chart review of our patients with PPD from 1996 to 2002 was carried out to determine their outcome after treatment. Data from review of the literature are presented.

RESULTS

Five patients with in situ disease (four females, median age 68 years) were diagnosed as having PPD. A complete surgical excision was attempted in 4 patients and the fifth was treated by photodynamic therapy. At present, all patients are alive, two are free of disease, one has persistent disease and two have local recurrence.

CONCLUSION

Considering the significant rate of recurrence even after wide local excision, the extent of surgery needed and the good prognosis with long-term survival, we question whether nonsurgical modalities should be considered in place of surgery as primary treatment for noninvasive PPD, with radical surgery being reserved for failures or invasive disease.

Surgical considerations in anal cancer

SCC of the anus is rare; however, the surgeon is bound to encounter some of these patients during his or her career. It is important that the anatomic location and the histology be defined because the initial treatment may initially differ. Multimodality therapy is the treatment of choice in SCC of the anal canal, with surgery reserved for persistent or recurrent tumors. Multimodality therapy can be used selectively in SCC of the perianal skin, especially in large bulky tumors, followed by definitive surgery. Nevertheless, the initial treatment of perianal neoplasms is surgical therapy. In general, inguinal node metastases are treated with chemoradiation. In highly selected patients, groin dissections are performed, but this procedure is not routine.

Wide local excision and split-thickness skin graft for circumferential Paget's disease of the anus

BACKGROUND

Our aim was to evaluate the results of wide local excision followed by split-thickness skin graft for circumferential perianal Paget's disease.

METHODS

Between 1995 and 1999, 5 patients with perianal Paget's disease underwent wide local excision of the disease. The circumferential involvement was documented by preoperative mapping. Standard orthograde bowel cleansing and oral antibiotics were given the day prior to surgery. The wound was allowed to granulate and confirmation of negative margins was obtained on permanent sections taken from the excised specimens. On postoperative day 4, split-thickness skin grafts harvested from the lateral thigh were applied (surface using area ranging from 100 cm(2) to 240 cm(2)). The grafts were secured in place with a 3-0 Vicryl suture and covered with a pressure dressing. After 4 days of bedrest, the dressing was taken down under anesthesia (day 8).

RESULTS

Graft survival was 100% in 3 patients, 80% in 1 patient, and 70% in another. Postoperatively, clinical follow-up was conducted at 3-month intervals. In 2 patients, anal stenosis developed after the operation and resolved by gentle self-dilation. At a mean follow-up of 42 months (range 21 to 78), adequate cosmetic and functional results were obtained. Recurrence of Paget's disease has occurred in 1 patient (at 21 months) and an invasive anal gland carcinoma was found in 1 patient (at 48 months).

CONCLUSIONS

Wide local excision and circumferential split-thickness skin grafting achieves adequate cosmetic and functional results without the need for diverting colostomy. However, there is a considerable recurrence rate after surgery, which warrants very close follow-up to rule out recurrent disease or underlying adenocarcinoma.

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.

Paget's disease of the vulva: pathology, pattern of involvement, and prognosis

OBJECTIVE

The aim of this study was to determine prognostic factors and risk factors for recurrence in patients with Paget's disease of the vulva.

METHODS

The medical records of 76 patients with a diagnosis of Paget's disease of the vulva were retrospectively reviewed. The diagnosis in each case was confirmed by reviewing the pathology. Patients were then divided into four groups by diagnosis: intraepithelial Paget's disease (IEP) (n = 46), invasive Paget's disease (IP) (n = 9), intraepithelial Paget's disease with underlying adenocarcinoma (IEPUA) (n = 13), and intraepithelial Paget's disease with a coexisting cancer (CCA) (n = 8). Comorbid conditions, location of disease, pathologic diagnosis, method of treatment, margin status, and current status of the patient were evaluated. Descriptive statistical data and univariate analysis were generated using the Statview statistical package.

RESULTS

A diagnosis of IEPUA, IP, or CCA predicted a poor survival (P = 0. 0017). Patients who had received chemotherapy or radiation as treatment had a poor survival (P < 0.0001 and 0.0002). Patients with clitoral Paget's disease had a higher incidence of death from disease (P = 0.026). When death from all causes was considered, patients treated with wide local excision (WLE) had a significantly longer survival than patients treated with other more radical treatments (P = 0.02). Risk factors for recurrence included treatment with WLE (P = 0.004).

CONCLUSIONS

Patients with IP, IEPUA, or CCA have a poorer prognosis than patients with IEP. Location of Paget's disease is important for prognosis; and patients with clitoral Paget's disease may require more aggressive treatment. WLE is associated with a higher risk of recurrence, but overall patients with WLE tend to survive longer than patients treated more radically.

The Roswell Park Cancer Institute experience with extramammary Paget's disease

Extramammary Paget's disease (EMPD) is a rare intraepithelial neoplasm. Common sites of occurrence include the vulva, perianal region, perineum and scrotum. Despite frequent recurrences, surgery is the standard treatment. This study examines the recurrence rate for EMPD treated by conventional surgical management. Alternative and multimodal therapeutic approaches are reviewed. This retrospective analysis included all 30 patients treated for EMPD at Roswell Park Cancer Institute (RPCI) between 1970 and 1998. Following conventional surgical treatment, 44% of our patients developed recurrence. Vulvectomy provided the lowest recurrence rate, but involved extensive tissue loss and functional debility. Multimodal treatment using Mohs' micrographic surgery and photodynamic therapy has been used at RPCI to manage EMPD with minimal tissue loss and no functional impairment. Surgical treatment offers a moderate chance of EMPD cure. Long-term multimodal approaches require close follow-up, but may conserve both tissue and function.