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Pérez JC, Salgado AC, Pérez-Mies B, Rullán JAD, Ajuria-Illarramendi O, Alia EMG, Serrano Domingo JJ. Extramammary Paget Disease: a Therapeutic Challenge, for a Rare Entity. Curr Oncol Rep 2023; 25:1081-1094. [PMID: 37421583 PMCID: PMC10556167 DOI: 10.1007/s11912-023-01434-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW Extramammary Paget disease (EMPD) is a rare entity which is more frequently localized at the vulva, though it only accounts for 1-2% of vulvar neoplasms. It is a primary cutaneous adenocarcinoma whose cell of origin is still a matter of controversy: it can either arise from apocrine/eccrine glands or from stem cells. The diagnosis demands a biopsy and entails a histopathological analysis by which cells show similar characteristics as breast Paget disease. RECENT FINDINGS Treatment approach can entail surgery, radiotherapy, photodynamic therapy, systemic chemotherapy, and topical chemotherapy. For metastatic disease, many different chemotherapy regimens have been explored and even targeted therapy can play an important role in this disease. Since almost 30-40% of patients overexpress HER-2, trastuzumab and anti-HER-2 therapies can be employed in this setting. Due to its low incidence, there is almost no specific evidence on therapeutic interventions for this disease. Thus, there is a neat unmet need for molecular characterization of EMPD and diagnostic tools that allow clinicians to guide treatment both in the early and in the advanced disease settings. In this review, we aim to summarize available evidence about diagnosis and treatment of EMPD, both localized and metastatic, and to provide a comprehensive analysis that may help clinicians for therapeutic decisions.
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Affiliation(s)
- Jesús Chamorro Pérez
- Medical Oncology Department, Ramón y Cajal University Hospital, Carretera de Colmenar Viejo, Km 9.100, 28034 Madrid, CP Spain
| | - Alfonso Cortes Salgado
- Medical Oncology Department, Ramón y Cajal University Hospital, Carretera de Colmenar Viejo, Km 9.100, 28034 Madrid, CP Spain
| | - Belén Pérez-Mies
- Pathology Department, Ramón y Cajal University Hospital, Carretera de Colmenar Viejo, Km 9.100, 28034 Madrid, CP Spain
| | - Jose Antonio Domínguez Rullán
- Radiation Oncology Department, Ramón y Cajal University Hospital, Carretera de Colmenar Viejo, Km 9.100, 28034 Madrid, CP Spain
| | - Odile Ajuria-Illarramendi
- Nuclear Medicine Department, Ramón y Cajal University Hospital, Carretera de Colmenar Viejo, Km 9.100, 28034 Madrid, CP Spain
| | - Eva María Guerra Alia
- Medical Oncology Department, Ramón y Cajal University Hospital, Carretera de Colmenar Viejo, Km 9.100, 28034 Madrid, CP Spain
| | - Juan José Serrano Domingo
- Medical Oncology Department, Ramón y Cajal University Hospital, Carretera de Colmenar Viejo, Km 9.100, 28034 Madrid, CP Spain
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Caruso G, Barcellini A, Mazzeo R, Gallo R, Vitale MG, Passarelli A, Mangili G, Pignata S, Palaia I. Vulvar Paget’s Disease: A Systematic Review of the MITO Rare Cancer Group. Cancers (Basel) 2023; 15:cancers15061803. [PMID: 36980691 PMCID: PMC10046936 DOI: 10.3390/cancers15061803] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/07/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
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.
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Affiliation(s)
- Giuseppe Caruso
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Amelia Barcellini
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy
| | - Roberta Mazzeo
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
- Correspondence:
| | - Roberta Gallo
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Maria Giuseppa Vitale
- Department of Oncology and Hematology, University Hospital of Modena, 41100 Modena, Italy
| | - Anna Passarelli
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCSS, “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Giorgia Mangili
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCSS, “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
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Sun J, Zhao H, Fu L, Cui J, Yang Y. Global Trends and Research Progress of Photodynamic Therapy in Skin Cancer: A Bibliometric Analysis and Literature Review. Clin Cosmet Investig Dermatol 2023; 16:479-498. [PMID: 36851952 PMCID: PMC9961166 DOI: 10.2147/ccid.s401206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/16/2023] [Indexed: 02/25/2023]
Abstract
Background Based on photochemical reactions through the combined use of light and photosensitizers, photodynamic therapy (PDT) is gaining popularity for the treatment of skin cancer. Various photosensitizers and treatment regimens are continuously being developed for enhancing the efficacy of PDT on skin cancer. Reviewing the development history of PDT on skin cancer, and summarizing its development direction and research status, is conducive to the further research. Methods To evaluate the research trends and map knowledge structure, all publications covering PDT on skin cancer were retrieved and extracted from Web of Science database. We applied VOSviewer and CiteSpace softwares to evaluate and visualize the countries, institutes, authors, keywords and research trends. Literature review was performed for the analysis of the research status of PDT on skin cancer. Results A total of 2662 publications were identified. The elements, mechanism, pros and cons, representative molecular photosensitizers, current challenges and research progress of PDT on skin cancer were reviewed and summarized. Conclusion This study provides a comprehensive display of the field of PDT on skin cancer, which will help researchers further explore the mechanism and application of PDT more effectively and intuitively.
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Affiliation(s)
- Jiachen Sun
- Department of Dermatology, Fourth Medical Center of Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Hongqing Zhao
- Department of Dermatology, Fourth Medical Center of Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Lin Fu
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jing Cui
- Navy Clinical College, the Fifth School of Clinical Medicine, Anhui Medical University, Hefei, People's Republic of China
| | - Yuguang Yang
- Department of Dermatology, Fourth Medical Center of Chinese PLA General Hospital, Beijing, People's Republic of China
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Della Corte L, Cafasso V, Conte C, Cuomo L, Giampaolino P, Lavitola G, Bifulco G. Medical and Surgical Strategies in Vulvar Paget Disease: Let's Throw Some Light! J Pers Med 2023; 13:jpm13010100. [PMID: 36675761 PMCID: PMC9861591 DOI: 10.3390/jpm13010100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/19/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy
- Correspondence:
| | - Valeria Cafasso
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy
| | - Carmine Conte
- Department of General Surgery and Medical-Surgical Specialties—Institute of Obstetrics and Ginecology, A.O.U. Policlinico Rodolico—San Marco, University of Catania, 95124 Catania, Italy
| | - Lara Cuomo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy
| | | | - Giada Lavitola
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy
| | - Giuseppe Bifulco
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy
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Shim PJ, Zeitouni NC. Photodynamic therapy for extramammary Paget’s disease: A systematic review of the literature. Photodiagnosis Photodyn Ther 2020; 31:101911. [DOI: 10.1016/j.pdpdt.2020.101911] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/02/2020] [Indexed: 12/26/2022]
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Li Z, Wang Y, Wang J, Li S, Xiao Z, Feng Y, Gu J, Li J, Peng X, Li C, Zeng K. Evaluation of the efficacy of 5-aminolevulinic acid photodynamic therapy for the treatment of vulvar lichen sclerosus. Photodiagnosis Photodyn Ther 2019; 29:101596. [PMID: 31704505 DOI: 10.1016/j.pdpdt.2019.101596] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND This study aimed to evaluate the effects of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) on the improvement of symptoms and recurrence rate in patients with vulvar lichen sclerosus (VLS) and observe its side effects. METHODS The symptom scores before and after photodynamic therapy (PDT) in 13 enrolled patients with VLS were analyzed retrospectively. All patients were followed-up for at least 6 months to evaluate the recurrence rate after PDT. The patients were treated with PDT only during the study period. During the PDT treatment, a 20 % 5-aminolevulinic acid solution was applied to the lesions and marginal areas for 3 h, and the entire area was then irradiated with 635 nm red light of 80 J/cm2 at 80 mW/cm2 for 30 min. RESULTS In this study, the effective rate of PDT was 92.31 %. Lesions recurred in two patients at 6 months after PDT. Post-treatment, the total subjective, total objective, and the Dermatological Life Quality Index scores changed from 11.4, 4.3, and 13.4 at baseline to 4.9, 2, and 5.9, respectively. The difference was statistically significant (p <0.05). PDT was mildly toxic in most patients. CONCLUSIONS ALA-PDT is a safe and effective method for the treatment of VLS, and the therapeutic effects can be maintained for at least 3 months. The therapeutic effects may decrease during the 3-6-month period after PDT.
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Affiliation(s)
- Zhijia Li
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Yajie Wang
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
| | - Jingying Wang
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Songshan Li
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Zixuan Xiao
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Yingjun Feng
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Jingjing Gu
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
| | - Junpeng Li
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Xiaoming Peng
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Changxing Li
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Kang Zeng
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
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Vicentini C, Vignion‐Dewalle A, Thecua E, Lecomte F, Maire C, Deleporte P, Béhal H, Kerob D, Duhamel A, Mordon S, Mortier L. Photodynamic therapy for actinic keratosis of the forehead and scalp: a randomized, controlled, phaseIIclinical study evaluating the noninferiority of a new protocol involving irradiation with a light‐emitting, fabric‐based device (the Flexitheralight protocol) compared with the conventional protocol involving irradiation with the AktiliteCL128 lamp. Br J Dermatol 2019; 180:765-773. [DOI: 10.1111/bjd.17350] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2018] [Indexed: 11/30/2022]
Affiliation(s)
- C. Vicentini
- Univ. Lille INSERM, CHU Lille, U1189 – ONCO‐THAI – Image Assisted Laser Therapy for Oncology F‐59000 LilleFrance
- Department of Dermatology CHU Lille F‐59000 LilleFrance
| | - A.S. Vignion‐Dewalle
- Univ. Lille INSERM, CHU Lille, U1189 – ONCO‐THAI – Image Assisted Laser Therapy for Oncology F‐59000 LilleFrance
| | - E. Thecua
- Univ. Lille INSERM, CHU Lille, U1189 – ONCO‐THAI – Image Assisted Laser Therapy for Oncology F‐59000 LilleFrance
| | - F. Lecomte
- Univ. Lille INSERM, CHU Lille, U1189 – ONCO‐THAI – Image Assisted Laser Therapy for Oncology F‐59000 LilleFrance
| | - C. Maire
- Univ. Lille INSERM, CHU Lille, U1189 – ONCO‐THAI – Image Assisted Laser Therapy for Oncology F‐59000 LilleFrance
- Department of Dermatology CHU Lille F‐59000 LilleFrance
| | - P. Deleporte
- Univ. Lille INSERM, CHU Lille, U1189 – ONCO‐THAI – Image Assisted Laser Therapy for Oncology F‐59000 LilleFrance
| | - H. Béhal
- Univ. Lille CHU Lille EA 2694 – Santé Publique: épidémiologie et qualité des soins, Unité de Biostatistiques F‐59000 LilleFrance
| | - D. Kerob
- Galderma International SAS F‐92927 La Défense France
| | - A. Duhamel
- Univ. Lille CHU Lille EA 2694 – Santé Publique: épidémiologie et qualité des soins, Unité de Biostatistiques F‐59000 LilleFrance
| | - S. Mordon
- Univ. Lille INSERM, CHU Lille, U1189 – ONCO‐THAI – Image Assisted Laser Therapy for Oncology F‐59000 LilleFrance
| | - L. Mortier
- Univ. Lille INSERM, CHU Lille, U1189 – ONCO‐THAI – Image Assisted Laser Therapy for Oncology F‐59000 LilleFrance
- Department of Dermatology CHU Lille F‐59000 LilleFrance
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Simonds RM, Segal RJ, Sharma A. Extramammary Paget's disease: a review of the literature. Int J Dermatol 2018; 58:871-879. [PMID: 30569580 DOI: 10.1111/ijd.14328] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 11/08/2018] [Accepted: 11/14/2018] [Indexed: 01/01/2023]
Abstract
Extramammary Paget's disease (EMPD) is a rare cutaneous malignancy. The disease typically affects older individuals aged 60-80 years and is seen most frequently in postmenopausal Caucasian women and Asian men. EMPD exhibits a predilection for the genital and perianal regions and may be associated with an underlying carcinoma in adjacent organs. EMPD presents a challenge in both diagnosis and management. Often treated empirically as various dermatitides, the correct diagnosis is frequently delayed by many years. Following diagnosis, an extensive search for an associated malignancy should be initiated. If invasive disease is present on biopsy, a sentinel lymph node biopsy may guide further treatment. Mohs micrographic surgery appears to be superior to wide local excision when considering tissue sparing ability and disease recurrence. Nonsurgical interventions have also been investigated with varied results. Regardless of treatment method, long-term follow-up is recommended to monitor for local disease recurrence, development of internal malignancy, regional lymphadenopathy, or distant metastasis.
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Affiliation(s)
- Robert M Simonds
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert J Segal
- Division of Dermatology, University of Arizona, Tucson, AZ, USA
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Grandi V, Sessa M, Pisano L, Rossi R, Galvan A, Gattai R, Mori M, Tiradritti L, Bacci S, Zuccati G, Cappugi P, Pimpinelli N. Photodynamic therapy with topical photosensitizers in mucosal and semimucosal areas: Review from a dermatologic perspective. Photodiagnosis Photodyn Ther 2018; 23:119-131. [PMID: 29669264 DOI: 10.1016/j.pdpdt.2018.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 04/03/2018] [Accepted: 04/10/2018] [Indexed: 02/07/2023]
Abstract
Photodynamic Therapy is a procedure based on the interaction between a Photosensitizer, a light source with a specific wavelength and oxygen. The aim of this review is to provide a brief and updated analysis of scientific reports on the use of PDT with topical PS in the management of oncological, infectious, and inflammatory disorders involving mucosal and semimucosal areas, with a specific focus on diseases of dermatologic interest.
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Affiliation(s)
- Vieri Grandi
- University of Florence School of Health Sciences, Department of Surgical and Translational Medicine, Section of Dermatology, P. Palagi Hospital, Viale Michelangelo 41, 50125, Florence, Italy.
| | - Maurizio Sessa
- University of Campania "Luigi Vanvitelli", Department of Experimental Medicine, Section of Pharmacology "L. Donatelli", Via L. De Crecchio 7, Naples, Italy
| | - Luigi Pisano
- University of Florence School of Health Sciences, Department of Surgical and Translational Medicine, Section of Dermatology, P. Palagi Hospital, Viale Michelangelo 41, 50125, Florence, Italy
| | - Riccardo Rossi
- University of Florence School of Health Sciences, Department of Surgical and Translational Medicine, Section of Dermatology, P. Palagi Hospital, Viale Michelangelo 41, 50125, Florence, Italy
| | - Arturo Galvan
- Private Practice Dermatologist, C.M.R, Via S. Giovanni Bosco, 24, 36015, Schio, Italy
| | - Riccardo Gattai
- University of Florence School of Health Sciences, Department of Surgical and Translational Medicine, Largo Brambilla 3, 50141, Florence, Italy
| | - Moira Mori
- University of Florence School of Health Sciences, Department of Surgical and Translational Medicine, Section of Dermatology, P. Palagi Hospital, Viale Michelangelo 41, 50125, Florence, Italy
| | - Luana Tiradritti
- University of Florence School of Health Sciences, Department of Surgical and Translational Medicine, Section of Dermatology, P. Palagi Hospital, Viale Michelangelo 41, 50125, Florence, Italy
| | - Stefano Bacci
- Department of Clinical and Experimental Medicine, Research Unit of Histology and Embriology, University of Florence, 50141, Florence, Italy
| | - Giuliano Zuccati
- University of Florence School of Health Sciences, Department of Surgical and Translational Medicine, Section of Dermatology, P. Palagi Hospital, Viale Michelangelo 41, 50125, Florence, Italy
| | - Pietro Cappugi
- University of Florence School of Health Sciences, Department of Surgical and Translational Medicine, Section of Dermatology, P. Palagi Hospital, Viale Michelangelo 41, 50125, Florence, Italy
| | - Nicola Pimpinelli
- University of Florence School of Health Sciences, Department of Surgical and Translational Medicine, Section of Dermatology, P. Palagi Hospital, Viale Michelangelo 41, 50125, Florence, Italy
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