Paget's disease of the skin. A unifying concept of histogenesis

Extramammary Paget disease of the vulva

Extramammary Paget disease (EMPD) is a rare neoplasm with uncertain histogenesis, usually presenting in the anogenital area, most commonly in the vulva. The disease is characterized by slow grow and high recurrence rates. This article reviews the epidemiological, clinical, morphological, genetic and treatment features of EMPD of the vulva reported in recent years.

Paget's Disease in Gynecomastia: Immunohistochemical Study of a Case

A case of Paget's disease and gynecomastia in a 70-year-old man is reported. Paget's disease was connected to an intraductal carcinoma, and the immunohistochemical study revealed similar positivity for cytokeratin A, carcinoembryonic antigen and epithelial membrane antigen in Paget cells and intraductal neoplastic cells whereas Paget cells resulted negative for cytokeratin B and C. The study using monoclonal anti-cytokeratin A (35 βH11), B (34 βE12) and C (34 βB4) could represent a good tool, supporting the theory of a ductal origin of Paget cells. A review of the literature has shown the rarity of Paget's disease in the male breast and revealed only two previous reports with an associated gynecomastia, in 2 patients with Klinefelter's syndrome and infiltrating breast carcinoma.

Extramammary Paget's disease of the perineum: Avoiding pitfalls in diagnosis and management

Extramammary Paget's disease (EMPD) is a rare entity, especially in the perinoscrotal region, and typically presents in elderly white patients as a pruritic white or red patch in the area of distribution of apocrine glands. Typically, it affects a single site. Since its manifestations are insidious and easily misdiagnosed, the appropriate management is delayed. Management of this problem is complex and effective treatment can not only lower recurrence rates but also provide an optimal reconstructive result. The present report describes three patients with scrotal EMPD. Based on literature search, the etiopathology, diagnosis and management of these lesions is discussed. Reconstructive options, with special emphasis on scrotal lesions, are also discussed.

Extramammary Paget's Disease of External Genitalia with Bowenoid Features

Extramammary Paget's disease (EMPD) is an uncommon intraepithelial adenocarcinoma, primarily affecting the apocrine-bearing skin. Bowen disease is an intraepithelial squamous cell carcinoma having the potential to become invasive carcinoma. The histopathological concomitant features between EMPD and Bowen disease have been described. One theory is that primary EMPD arises multicentrically, within the epidermis from the pluripotent stem cells. Herein, we describe a case of EMPD that had bowenoid features, and review the previous cases associated with the origin of EMPD.

Extramammary Paget's disease mimicking acantholytic squamous cell carcinoma in situ: a case report

BACKGROUND

Extramammary Paget's disease (EMPD) is an uncommon skin neoplasm characterized by Paget's cells with pale-staining cytoplasm in the epidermis, and cases with distinguished acantholysis but lacking characteristic Paget's cells were rarely reported in the literature.

METHODS

An 80-year-old male with lesion on scrotum was screened histologically and immunohistologically for the diagnosis of his tumor.

RESULTS

Histological examination showed acanthosis with cellular atypia and focal acantholysis, consistent with acantholytic squamous cell carcinoma in situ (SCCIS). No characteristic Paget's cells were observed in low magnification. Immunohistochemical staining showed carcinoembryonic antigen (CEA), cytokeratin 7 (CK7) and cytokeratin 8 (CK8) to be strongly expressed in the nests and singly arranged large tumor cells, and the surrounding epidermis was positive for CK5/6 and negative for CEA. Sporadic periodic acid-schiff (PAS)-positive cells could be seen in some areas.

CONCLUSIONS

These findings strongly indicated the diagnosis of EMPD mimicking acantholytic SCCIS.

Extramammary Paget disease in a retrorectal dermoid cyst: report of a unique case

Retrorectal (presacral) dermoid cysts are rare entities, also described as mature cystic or monodermal teratomas. We present a unique case arising in a 64-year-old man, in which the lining squamous epithelium showed marked expansion by Paget disease of extramammary type, and discuss the clinical, radiologic, and pathologic findings.

Malignant adnexal neoplasms

Malignant cutaneous adnexal neoplasms are one of the most challenging areas of dermatopathology. Tumors of the pilosebaceous apparatus can occur as single-lineage neoplasms or may manifest as complex proliferations with multilineal differentiation patterns including not only the germinative component of the hair bulb, the inner or outer root sheath epithelium and the sebaceous gland and duct, but also the sweat duct components that relate to the apocrine secretory apparatus which empties into the follicle near the follicular bulge. Eccrine and apocrine neoplasms present a bewildering array of morphologies, which often defy precise classification. The purpose of this review is to discuss in detail the malignant neoplasms of the cutaneous adnexae and their benign and prognostically indeterminate mimics.

Comparative genomic hybridization in extramammary Paget's disease

BACKGROUND

Extramammary Paget's disease (EMPD) is a distinct skin cancer of unknown histogenesis. Data from genome-wide surveys for chromosomal aberrations in EMPD are limited.

OBJECTIVES

To identify chromosomal aberrations that are present in EMPD.

METHODS

Fifteen cases of EMPD were analysed by comparative genomic hybridization (CGH). We used pooled DNA CGH, instead of studying a single sample. In addition, immunohistochemistry was performed for detection of androgen receptor (AR).

RESULTS

The most recurrent change was amplification at chromosomes Xcent-q21 and 19, and loss at 10q24-qter. In addition, expression of AR, located in chromosome X, was found in six cases.

CONCLUSIONS

Results suggest that AR may play a role in EMPD tumorigenesis.

Extramammary Paget disease of the scrotum with features of Bowen disease

The scrotum is an uncommon site for the presentation of extramammary Paget disease (EMPD). We describe a case of EMPD that was discovered in a patient who had been previously diagnosed and treated for squamous cell carcinoma in situ of the scrotum 3 years earlier. Pathologic examination of the current scrotectomy specimen revealed an erythematous patch with areas of pale induration. Microscopic examination revealed areas with the characteristic histology of Paget disease adjacent to areas characteristic of Bowen disease. Immunohistochemical findings demonstrated a strong expression of carcinoembryonic antigen, cytokeratin 7, and low-molecular-weight cytokeratins (CAM 5.2) in both of these areas, giving support to the overall diagnosis of EMPD. High-molecular-weight cytokeratins (34betaE12) were uncharacteristically expressed in the cytoplasm of the Paget cells with equal or greater strength than in the surrounding keratinocytes, suggesting some degree of squamous differentiation. Very few publications have reported the coexistence of EMPD with squamous cell carcinoma in situ, occurring mostly in the vulva. To our knowledge, our case is the first report of scrotal EMPD with features of Bowen disease. Our findings support the theory that primary EMPD arises multifocally from multipotential epidermal cells.

Extramammary Paget Disease of the Axilla Associated With Comedo-like Apocrine Carcinoma In Situ

Extramammary Paget disease of the axilla with underlying apocrine carcinoma has been reported only in six cases until now. This report deals with a seventh case characterized by the unique finding of comedo-like features evocative of large cell ductal breast carcinoma within an otherwise typical in situ apocrine carcinoma. This is characterized by spiral-shaped foci of epithelial proliferation with decapitation secretion and central masses of necrotic debris. A possible connection between the solid neoplasm and the overlying Paget disease is illustrated by a few apocrine-follicular units colonized by both the Paget cells and the structured adenocarcinoma. Here, although they display the same immunohistologic pattern of glandular differentiation, the two populations seem to be cytologically different and do not show signs of gradual transition to one another. Thus, they give the impression of parallel but distinct processes, which is consistent with the hypothesis of proliferative induction of a preexisting intraepidermal scattered population from the underlying adnexal carcinoma. The observed resemblance between apocrine carcinoma and comedo carcinoma of the breast, with its ontogenetic and phylogenetic implications, links not only the two neoplasms and the corresponding glands of origin but also mammary and extramammary Paget disease. This reinforces the unifying conception of Paget disease.

Extramammary Paget's disease of the penis and scrotum: excision, reconstruction and evaluation of occult malignancy

PURPOSE

We describe treatment and reconstruction in patients after surgery for extramammary Paget's disease of the penis and scrotum. We also investigated whether this disease causes an increased risk of undiagnosed visceral malignancy.

MATERIALS AND METHODS

We reviewed the databases at our institution from 1996 to 2000 and identified 6 men 67 to 87 years old (mean age 76). In addition, we reviewed the literature on the clinical and pathological features of this disease.

RESULTS

In our 6 patients scrotal involvement was present in 83% and penile extramammary Paget's disease was present in 33%. Each man underwent wide local excision and large skin defects were immediately reconstructed with split-thickness skin grafts. In 1 case extramammary Paget's disease had spread to the superficial inguinal nodes. At a mean followup of 29 months there has been no local recurrence and internal malignancy has not been diagnosed. Our literature review revealed 13 patients with penoscrotal extramammary Paget's disease and visceral malignancy, including 12 (92%) with malignancy of the genitourinary system.

CONCLUSIONS

Extramammary Paget's disease of the penis and scrotum is a rare disease that can be managed by excision and immediate reconstruction with skin grafting or a local skin flap. Disease may spread to the regional lymph nodes. Although genitourinary cancer may accompany penoscrotal extramammary Paget's disease, an extensive search for cancer of the thorax or abdomen may be unnecessary because only 1 reported case of colon cancer has been associated with penile or scrotal extramammary Paget's disease.

Morphological evidence for field effect as a mechanism for tumour spread in mammary Paget's disease

AIMS

The histogenesis of mammary Paget's disease is controversial. The purpose of this study was to investigate the mechanism of tumour spread in the nipple epidermis by examining 28 cases of mammary Paget's disease associated with underlying intraductal carcinoma.

METHODS AND RESULTS

The atypical cells in the epidermis displayed a spectrum of cytological changes ranging from small-sized atypical cells located in the basal cell layer to large-sized atypical cells characteristic of Paget's cells in the upper layer of the epidermis. Serial sectioning revealed the presence of isolated, scattered and small atypical cells in the basal cell layer at the periphery of the epidermal lesion. The atypical cells, including those in the basal cell layer showed positive immunostaining for cytokeratin 7 and Her2/neu oncoprotein. Electron microscopy examination demonstrated the presence of intercellular junctions of desmosomal-like or desmosomal types between tumour cells and adjacent squamous cells. Furthermore, examination of the intraductal carcinoma of the breast tissue in cases of Paget's disease as well as control cases of intraductal carcinoma also revealed areas of skip lesions of intraductal carcinoma.

CONCLUSIONS

In view of these changes, it is unlikely that tumour expansion or tumour cell motility are sufficient explanations to account for the pattern of tumour spread in both the epidermis and the duct epithelium with skip lesions. A 'field effect' in the duct system harbouring intraductal carcinoma and the adjacent epidermis may play an important role in the tumour cell spread in the epidermis as well as in the ductal epithelium.

Mammary Paget's disease: evidence of diverse origin of the disease with a subgroup of Paget's disease developing from the superficial portion of lactiferous duct and a discontinuous pattern of tumor spread

The pattern of spread of intraductal carcinoma associated with mammary Paget's disease has not been well studied. The purpose of this study was to examine the site of origin and the pattern of tumor spread with a three-dimensional view by serial sectioning of the tissue blocks from 19 cases of Paget's disease. Intraductal carcinoma in the superficial portion of the lactiferous ducts was seen in continuity with the overlying epidermis with Paget's disease in all 19 cases. In seven cases that had adequate tissue sampling, five showed a continuous pattern of the intraductal carcinoma within the superficial as well as the deep breast tissue. In the remaining two cases, a portion of benign duct was identified between the intraductal carcinoma in the superficial lactiferous duct and the deep breast tissue. This discontinuous pattern of spread of the intraductal carcinoma was also identified in the foci of carcinoma in deep tissue. In the five cases in which the tumor involved the skin and only the superficial portions of the lactiferous duct, the leading edge of the intraductal carcinoma was seen orientated in the direction of the nipple towards the deep breast tissue. Our study of Paget's disease demonstrated that in addition to tumor spread along the lactiferous ducts from intraductal carcinoma in the deep tissue towards the nipple, there was a group of Paget's disease arising from the nipple. These lesions included: (i) lesions limited to the areolar tissue; and (ii) lesions with intraductal carcinoma involving the duct system in both superficial and deep breast tissue with and, possibly, without skip areas pattern of spread. Although certain cases of Paget's disease may appear superficial, an independent associated carcinoma in deep breast tissue has to be ruled out.

Karyotypic findings in tumors of the vulva and vagina

Neoplasms of the vulva and vagina together account for less than 5% of all female genital tract cancers, and very few cases have been analyzed using chromosome banding techniques. We report the karyotypic findings in a consecutive series of ten tumors of the vulva and vagina; in addition to five squamous cell carcinomas of the vulva, we present the first cytogenetic analysis of two malignant melanomas and a Paget disease of the vulva, as well as an adenocarcinoma and a squamous cell hyperplasia of the vagina. Whereas no clonal karyotypic changes were found in the squamous cell hyperplasia of the vagina, the remaining nine malignant tumors showed clonal chromosome abnormalities. An inverse correlation was found between the degree of histologic differentiation and karyotypic complexity in the squamous cell carcinomas of the vulva. The malignant melanomas had chromosomal aberrations that have previously been described in malignant melanomas occurring elsewhere, but were less karyotypically complex. Cytogenetically unrelated clones were detected in the Paget disease of the vulva but not in any of the other tumors; this finding is consonant with the interpretation that at least a proportion of Paget disease of the vulva arises multicentrically within the epidermis from pluripotent stem cells.

Nonneoplastic disorders of the eccrine glands

Eccrine glands are uniquely susceptible to a variety of pathologic processes. Alteration in the rate of sweat secretion manifests as hypohidrosis and hyperhidrosis. Obstruction of the eccrine duct leads to miliaria. The excretion of drugs into eccrine sweat may be a contributory factor in neutrophilic eccrine hidradenitis (NEH), syringosquamous metaplasia (SSM), coma bulla, and erythema multiforme (EM). Alterations in the electrolyte composition of eccrine sweat can be observed in several systemic diseases, most notably cystic fibrosis. This article summarizes current knowledge of eccrine gland pathophysiology.

Vulvar Paget's disease: a clinicopathologic and immunohistochemical study of 19 cases

Vulvar Paget's disease (VPD) is the most common type of extramammary Paget's disease; however, the frequency of dermal invasion and its clinical significance are unclear, as are the frequency and relationship of an associated regional internal cancer. Thus, we studied the clinicopathologic and immunohistochemical features of 19 patients with VPD. Patients ranged in age from 56 to 86 years (median 65). VPD was entirely intraepithelial (IE-VPD) in 13 patients. Three patients developed IE-VPD recurrence and one developed deeply invasive and metastatic VPD at 10.8 years. Five patients had invasive Paget's disease (INV-VPD) characterized by clinically occult microscopic foci of superficial dermal invasion, ranging in depth from 0.3 to 0.9 mm. All five patients were alive without disease after 12 months to 17 years (median 66 months). A regional internal cancer (CA ASSOC-VPD) occurred in one patient whose VPD was preceded by a deeply invasive grade 3 transitional cell carcinoma of the urinary bladder 9 months earlier. Immunophenotypes of 16 cases with IE-VPD or INV-VPD were CK7+/CK20-/GCDFP15+ in 14 cases and CK7+/CK20+/GCDFP15+ in two cases, with concordant immunophenotypes of the intraepithelial and invasive components in all cases studied. The patient with CA ASSOC-VPD had a CK7+/CK20+/GCDFP15- immunophenotype in the invasive TCC of the urinary bladder and the VPD. We conclude that the predominant form of VPD begins as a primary cutaneous intraepithelial neoplasm that is universally CK7+/GCDFP15+. Foci of unsuspected synchronous dermal invasion by Paget's cells can be expected in almost one third of cases. Subsequent progression into an invasive carcinoma occurs less often. Foci of "minimally invasive" carcinoma (<1 mm) probably do not adversely affect prognosis, whereas deeply invasive carcinoma behaves as a fully malignant adenocarcinoma. The rarer form of VPD appears to result from secondary intraepithelial spread from an associated regional internal carcinoma. The finding of Paget's cells that are CK20+/GCDFP15- suggests the presence of a regional internal carcinoma with a corresponding immunophenotype.

A comparative immunohistochemical study of mammary and extramammary Paget's disease and superficial spreading melanoma, with particular emphasis on melanocytic markers

A comparative immunohistochemical study was performed on Paget's disease of the nipple (PDN), extramammary Paget's disease (EMPD) and cutaneous superficial spreading melanoma (SSM) using antibodies to S100, NK1-C3 and HMB45, cytokeratin (CAM 5.2) and c-erb B2 oncoprotein (21N). Conventional histochemical stains for intracytoplasmic mucin and melanin were also done. Of the 20 cases of PDN, positivity was seen in 12 with S100, 16 with NK1-C3, none with HMB45, 20 with CAM 5.2 and 19 with 21N. All 5 cases of EMPD were CAM 5.2 positive and HMB45, S100 and 21N negative. Three EMPD were NK1-C3 positive. All 10 cases of SSM were S100, NK1-C3 and HMB45 positive and all were CAM5.2 and 21N negative. Mucin was demonstrable in 11 cases of PDN and all of EMPD but none of SSM. Melanin was seen in 2 PDN, 3 EMPD and all SSM cases. Identification of mucin and melanin, therefore, proved an unreliable means of distinguishing these diseases. Immunohistochemistry for cytokeratin and HMB45 appear to be the most specific markers in differentiating Paget's disease and SSM. Antibodies to c-erb B2 may also be valuable in this situation.

Extramammary Paget's disease with distant skin metastasis

We report a 68-year-old Japanese man with invasive extramammary Paget's disease (EPD) which started in the left inguinal area and enlarged to include the scrotal skin, penis, and pubic area, resulting in lymph edema of the entire left leg. Histopathological examination of one nodule revealed an intraepidermal and intradermal arrangement of solid tumor cells with characteristic pale cytoplasm. The tumor was found to have disseminated to regional and systemic lymph nodes, lungs, bones, and the left adrenal gland. In addition, the patient had a metastatic cutaneous nodule on the scalp. Histology of the skin metastasis showed that the proliferation of Paget cells was confined to the dermis. This type of metastatic spread of EPD is very rare; only two other apparent cases in Japan have been reported.

An electron microscopic study of clinical Paget's disease of the nipple

An ultrastructural study of the epidermis from eight patients with clinical Paget's disease of the nipple supports the epidermotropic theory. There was no evidence that the Paget's cells originated from keratinocytes. We propose the hypothesis that Paget's cells represent transformed ductal cells, from the subjacent lactiferous ducts of the nipple, which have migrated into the epidermis, either as neoplastic cells or as normal ductal cells with secondary in situ transformation in the epidermis.

Mammary and extramammary Paget's disease: expression of Ca 15-3, Ka-93, Ca 19-9 and CD44 in Paget cells and adjacent normal skin

The histogenesis of mammary Paget's disease (MPD) and extramammary Paget's disease (EMPD) cells remains controversial. The purpose of this study was to investigate MPD and EMPD immunohistochemically with antibodies to some tumour markers (Ca 15-3, KA-93 and Ca 19-9), and a cell surface receptor for hyaluronate (CD44), as these have been shown to be expressed in normal eccrine or apocrine glands and/or the epidermis, as well as some tumours. Surgically excised, formalin-fixed, paraffin-embedded tissues, or frozen tissues, from seven mammary, five vulvar, two scrotal and two axillary lesions were studied. Paget cells stained strongly with antibodies to Ca 15-3 and KA-93, but did not stain with those to Ca 19-9 and CD44. Staining with the antibody to Ca 15-3 was also observed in the ductal and secretory portions of the eccrine and apocrine glands, and in the sebaceous gland cells. Staining with the antibody to KA-93 was also seen in the apocrine secretory coils, lactiferous duct, epidermal dendritic cells, and cells in the dermal inflammatory infiltrate. Staining with the antibody to Ca 19-9 was observed only in the eccrine duct, and that to CD44 was seen in eccrine secretory cells and epidermal keratinocytes. These findings suggest that the origin of Paget cells may be the secretory cells of apocrine sweat glands (in EMPD) or the luminal lactiferous ducts (in MPD). We found that the antibodies to Ca 15-3 and CD44 were useful in differentiating Paget cells from surrounding keratinocytes, by showing positive and negative immunoreactivity, respectively.

Intraepidermal squamous carcinoma (Bowen's disease) of the nipple

A case of Bowen's disease of the nipple clinically resembling Paget's disease is reported. This lesion was differentiated from other pagetoid lesions by negative histochemical stains for mucin and melanin, positive immunohistochemical preparation for high-molecular weight cytokeratin 66 kd (904) using adequate controls, and electron microscopic findings of squamous cell features. The therapeutic implications of such a pagetoid nipple lesion in the absence of an underlying breast carcinoma are discussed.

Rapid staining with carcinoembryonic antigen aids limited excision of extramammary Paget's disease treated by Mohs surgery

Extensive extramammary Paget's (EMPD) disease of the perineum in a 68-year-old man was treated by Mohs surgery. To facilitate identification of involved tissue a rapid staining carcinoembryonic antigen was used. This technique proved a useful adjunct to conventional hemotoxylin-eosin (H&E) stains. It was especially useful in highlighting involvement in areas of marked dysplasia/artifact where discrimination is often difficult. It is recommended that such a technique offers considerable benefits over H&E staining when confronted by such tissue morphology.

A comparative study of cytokeratin expression in Paget cells located at various sites

BACKGROUND

Extramammary Paget disease appears in anogenital, axillary, or other areas. In this study, the authors addressed the question of whether the histogenesis of 35 cases of Paget disease arising at different sites was the same.

METHODS

Specimens of 35 cases of extramammary Paget disease (16 genital; 9 invasive carcinomas of genital; 6 axillary; 1 periumbilical; and 3 perianal), 4 cases of mammary Paget disease, 4 cases of breast carcinomas, and 6 cases of anal carcinomas of perianal spread from primary rectal adenocarcinomas were retrieved and stained by the avidin-biotin-complex method, using various kinds of monoclonal antikeratin antibodies.

RESULTS

There was no significant difference in cytokeratin expression among these cases of extramammary Paget disease. Simple epithelial keratins were expressed in Paget cells in extramammary Paget disease, but no expression of differentiation-specific or noncornifying stratified squamous epithelial keratins was observed, regardless of the degree of invasion. Paget cells in extramammary Paget disease revealed a similar cytokeratin expression to that in secretory cells of normal apocrine or eccrine glands. In addition, there was no significant difference in cytokeratin expression in tumor cells among extramammary and mammary Paget disease, breast carcinomas, and anal carcinomas.

CONCLUSIONS

Cases of Paget disease arising at different locations could not be distinguished from each other based on cytokeratin expression. In addition, antikeratin antibodies against simple epithelial keratins were demonstrated to be more useful for the identification of Paget cells in the paraffin sections than were conventional antibodies, such as an antibody against carcinoembryonic antigen (CEA).

A case of perianal Paget's disease associated with a sigmoid colon carcinoma

A case of perianal invasive Paget's disease associated with a sigmoid colon carcinoma is presented. The chief complaint was perianal irritation for a year. Histologic examination yielded a correct diagnosis and abdominosacral resection with wide excision of the cutaneous component was performed. Histology of the resected specimen revealed the Paget's disease to be invasive of the dermis, the sigmoid colon carcinoma to be in Dukes' A stage and the two lesions to be different. The patient has been disease-free for more than 5 years after the operation.

Cytoreductive combination chemotherapy for regionally advanced unresectable extramammary Paget carcinoma

Extramammary Paget carcinoma (EPC) is considered to originate from the eccrine and apocrine glands of the adnexal skin of the axilla, vulva or penis, scrotum, or perineum. If immunohistochemical techniques with the use of cytoskeletal markers are applied in addition to histologic examination, EPC lesions are found to be multifocal adenocarcinoma of the adnexal sweat glands. So far, therapeutic approaches have included primary surgery, followed optionally by radiation therapy. It is possible to achieve a cure only when manifestations are detected early and confined regionally. The role of palliative chemotherapy has not yet been assessed in this disease, particularly because of the lack of compliance and follow-up in patients with EPC.

Marjolin's ulcer: immunohistochemical study of 17 cases and comparison with common squamous cell carcinoma and basal cell carcinoma

Formalin-fixed, paraffin-embedded biopsy specimens of 17 cases of squamous cell carcinoma of Marjolin's ulcer (SCC-MU), 6 cases of common SCC (SCC), and 5 cases of basal cell carcinoma (BCC) were stained with three monoclonal antikeratin antibodies (CAM 5.2, MAK-6, and MA-903), a monoclonal antivimentin antibody (V9), and a polyclonal anticarcinoembryonic antigen antiserum (A115). Neoplastic cells of SCC-MU, SCC, and BCC showed consistently negative staining for CAM 5.2. A wide range of reactivity, from negative to diffuse strong positivity, among neoplastic cells of SCC-MU and SCC was noted with MAK-6. Alternatively, neoplastic cells of SCC-MU, SCC, and BCC consistently showed diffuse moderate to strong reactivity with MA-903. These findings imply that SCC-MU has largely high-molecular-weight keratins. They also showed a wide range of reactivity with V9. However, neoplastic cells of five of the six SCC and five cases of BCC were negative for V9. These findings suggest that neoplastic cells of SCC-MU contain vimentin in higher frequency than in the more usual SCC.

Extramammary Paget's disease: comparative histopathologic studies of intraductal carcinoma of the breast and apocrine adenocarcinoma

We examined 32 cases (38 lesions) of extramammary Paget's disease (EMPD) in relation to comparative studies on intraductal carcinoma of the breast (ductal carcinoma in situ, DCIS) and apocrine adenocarcinoma (AAC). Lesions included scrotum (18 lesions), vulva (8), axilla (6), groin (3), penis (2) and chest wall (1), and the distribution was compatible with that of apocrine or supernumerary mammary glands. Histologically, extra-mammary Paget's and DCIS cells exhibited a large amount of a pale-stained cytoplasm. The cytoplasm of AAC cells frequently contained granules, was eosinophilic and differed from that of Paget's or DCIS cells. Immunohistochemical studies revealed positive reactions for polyclonal and monoclonal antibodies to carcinoembryonic antigen in all EMPD and most DCIS, but not in AAC. Recent studies have shown that extramammary Paget's cells exhibit characteristics of glandular epithelial cells and that most cases of EMPD are not accompanied by an underlying carcinoma. The results obtained in this study, coupled with data on the frequency of the supernumerary breasts, lead to the speculation that extramammary Paget's cells originate from ectopic mammary glands or from pluripotential germinative cells in the epidermis, capable of differentiating toward the mammary glands.

Pigmented Paget's disease of the male breast

Paget's disease of the breast presents as an eczematous lesion of the nipple. Histologically, it is characterized by malignant intraepidermal cells associated with an underlying ductal carcinoma. Paget's disease of the male breast is rare. Although melanin has been found within the malignant cells of Paget's disease, no clinically pigmented lesion has yet been reported. We present a case of pigmented Paget's disease of the male breast and review the pathogenesis of this disease.

Aggressive digital papillary adenocarcinoma

Aggressive digital papillary adenocarcinoma is a rare neoplasm of eccrine sweat gland origin. An acral location and a high recurrence rate are characteristic features. Its histopathologic features are distinctive, and the tumor expresses carcinoembryonic and S-100 protein antigens. We demonstrated immunoreactivity of the tumor to ferritin antibody, a new immunohistologic marker for sweat gland malignancies.

Immunohistology is valuable in distinguishing between Paget's disease, Bowen's disease and superficial spreading malignant melanoma

Thirty-nine lesions, originally diagnosed as Paget's disease (19), superficial spreading melanoma (13) or Bowen's disease (7), were reviewed. Supplementary immunohistochemistry on routine processed tissue, using antibodies to cytokeratins (PKK1 and M717) and to S-100 protein, was carried out. Two of the lesions, originally classified as Bowen's disease and superficial spreading type malignant melanoma respectively, were reclassified as Paget's disease based on the immunohistochemical findings. Both lesions contained pagetoid cells positive with PKK1. The results indicate that immunohistochemistry may sometimes be valuable in establishing the correct diagnosis in such lesions.

Perianal Paget's disease. Classification and review of management: report of two cases

Fewer than 100 cases of Paget's disease located in the perianal skin have been reported since the extramammary location was first described in 1893. Two patients seen and treated in the authors' institutions with disease limited to the epidermis and its adnexae are described to illustrate the usual presentation and pathobiology of the disease. A staging classification based on the disease pathology has been developed from the cases reported in the literature and correlated with appropriate surgical treatment. Stage I disease treated with wide local excision promises unlimited survival, whereas the prognosis worsens for Stage II, with synchronous localized malignancies, and for Stages III and IV, with regional and distant metastatic disease, respectively.

Breast conserving treatment of Paget's disease

Between 1971 and 1984, 13 patients with histologically proven Paget's disease were treated conservatively with radiotherapy only. The disease was clinically confined to the nipple or surrounding skin, without signs of an underlying tumor. With a mean follow-up of 58.6 months (ranging between 15 and 118 months), and a median follow up of 52 months, no recurrences locally or at distance were seen. Therefore in these selected cases a mastectomy could be avoided. The results with this breast conserving management suggest a place for radiotherapy in the treatment of Paget's disease limited to the nipple.

Immunoenzyme techniques in dermatopathology

The advantages and disadvantages of the immunofluorescence and immunoperoxidase techniques and an introductory description of the major variations of the basic immunoperoxidase method are discussed. The ability to identify intermediate filaments, T and B lymphocyte cell markers, S-100 proteins, myelin basic protein, and carcinoembryonic antigen in tissue sections can assist the dermatopathologist in classifying undifferentiated or histologically similar-appearing tumors. A systematic approach to the diagnosis of a majority of these tumors with the use of immunoenzyme staining is provided.

The histogenesis of mammary and extramammary Paget's disease

The histogenesis of mammary and extramammary Paget's disease has been studied by immunohistochemical staining of paraffin-embedded tissue using a panel of epithelial cell markers, which react with secretory or ductal epithelium, but not stratified epithelium. These markers included a monoclonal antibody E29 to epithelial membrane antigen EMA, the cytokeratin marker CAM 5.2 and three new monoclonal antibodies raised to human milk fat globule membrane (LICR-LON-TW19 and H.10.A) and a human bladder cell cancer line (3.77). The findings demonstrate that both mammary and extramammary Paget's disease are of epithelial cell origin and share antigens expressed by simple epithelia. Some antigens, such as EMA and low molecular weight cytokeratins are consistently present in both diseases, whereas other antigens, identified by H.10.A and TW19 are found more frequently in cases of extramammary Paget's disease. This panel of monoclonal antibodies also proved useful in distinguishing Paget's disease from pagetoid melanoma and clear cell Bowen's disease.

Immunohistochemical staining properties of keratin type intermediate filaments in mammary and extramammary Paget's disease

Utilizing three different anti-keratin antibodies and the avidin-biotin peroxidase complex system on sections of formalin-fixed paraffin-embedded tissues and on cryostat sections, immunohistochemical localization of keratin type intermediate filaments in mammary Paget's disease and extramammary Paget's disease was investigated. Anti-keratin antibodies EAB-903 and EAB-904, which recognize 66K and 57K dalton keratin peptides, did not decorate any Paget's cells in either mammary or extramammary Paget's disease. On the other hand, anti-keratin antibody MAK-6, which recognizes 52.5K, 50K, 48K, 45K and 40K daltons keratin peptides, did decorate Paget's cells in both Paget's diseases. These staining properties of Paget's cells were the same as those of secretory cells in normal human sweat glands and mammary glands. Anti-keratin antibody MAK-6 is thought to be useful in the diagnosis of mammary and extramammary Paget's diseases.

Paget's disease of the anus: a clinicopathological study

Paget's disease of the anus is a rare disorder of controversial origin and is frequently associated with malignancy. We studied eight patients and carried out immunohistochemical studies to determine whether particular functional profiles might be indicators of a malignant association. One patient presented with synchronous carcinoma and two developed carcinomas 3 and 10 years after excision of Paget's disease. Five patients underwent wide local excision and have not developed cancer (median follow-up 6 years, range 5-13 years). However, four patients developed recurrent Paget's disease. Immunohistochemical studies showed that in general Paget cells stained positively with CAM 5.2 (a cytokeratin marker), gross cystic disease fluid protein (a marker for apocrine cells), human milk fat globule glycoprotein (HMFG 1 and 2) and carcinoembryonic antigen but negatively for PR3A5 (a marker for colonic goblet cells). Three cases had a staining profile which was quite different from that usually observed and these were associated with malignancy. One showed an antigenic profile more typical of a large bowel carcinoma. Paget's disease of the anus appears to run one of two clinical courses: to develop malignancy; or to recur locally, often on repeated occasions. Wide local excision is the treatment of choice but long-term follow-up is necessary because of the cancer risk. An immunohistochemical staining pattern which is different from usual may indicate a higher malignant risk and/or identify some cases of Paget's disease as representing a downward 'pagetoid' extension from a anorectal adenocarcinoma rather than a true epidermotropic apocrine neoplasm of the perianal skin.