Photodynamic therapy for residual neoplasms of the perianal skin

Photodynamic therapy in the treatment of extramammary paget’s disease

Extramammary Paget’s disease (EMPD) is a rare tumor that predominantly affects the skin containing apocrine glands. Due to insufficient data on the effectiveness of different methods, there is no single therapeutic approach to the treatment of patients with EMPD and their subsequent management. The use of surgical methods, laser therapy and local cytotoxic drugs has a number of limitations. The advantages of using photodynamic therapy (PDT) in EMPD are the absence of systemic toxicity, non-invasiveness, selectivity of action, the absence of carcinogenic potential, the possibility of conducting several courses of treatment, and good cosmetic results. In our review, we analyzed those published in 2000-2022 data on the results of PDT treatment of 114 patients with EMPD. As a result of treatment, complete regression of tumor foci was achieved in 40% of patients. Most authors note that PDT is more effective for small areas (up to 4 cm2).

Photodynamic therapy with topical photosensitizers in mucosal and semimucosal areas: Review from a dermatologic perspective

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.

Photosensitizers in clinical PDT

Photosensitizers in photodynamic therapy allow for the transfer and translation of light energy into a type II chemical reaction. In clinical practice, photosensitizers arise from three families-porphyrins, chlorophylls, and dyes. All clinically successful photosensitizers have the ability to a greater or lesser degree, to target specific tissues or their vasculature to achieve ablation. Each photosensitizer needs to reliably activate at a high enough light wavelength useful for therapy. Their ability to fluoresce and visualize the lesion is a bonus. Photosensitizers developed from each family have unique properties that have so far been minimally clinically exploited. This review looks at the potential benefits and consequences of each major photosensitizer that has been tried in a clinical setting.

Premalignant lesions of the anal canal and squamous cell carcinoma of the anal canal

Squamous cell carcinoma of the anus (SCCA) is a rare tumor. However, its incidence has been increasing in men and women over the past 25 years worldwide. Risk factors associated with this cancer are those behaviors that predispose individuals to human papillomavirus (HPV) infection and immunosuppression. Anal cancer is generally preceded by high-grade anal intraepithelial neoplasia (HGAIN), which is most prevalent in human immunodeficiency virus-positive men who have sex with men. High-risk patients may benefit from screening. The most common presentation is rectal bleeding, which is present in nearly 50% of patients. Twenty percent of patients have no symptoms at the time of presentation. Clinical staging of anal cancer requires a digital rectal exam and a positron emission tomography/computed tomography scan of the chest, abdomen, and pelvis. Endorectal/endoanal ultrasound appears to add more-specific staging information when compared with digital rectal examination alone. Treatment of anal cancer prior to the 1970s involved an abdominoperineal resection. However, the current standard of care for localized anal cancer is concurrent chemoradiation therapy, primarily because of its sphincter-saving and colostomy-sparing potential. Studies have addressed alternative chemoradiation regimens to improve the standard protocol of fluorouracil, misogynic, and radiation, but no alternative regimen has proven superior. Surgery is reserved for those patients with residual disease or recurrence.

Photodynamic therapy with systemic meta-tetrahydroxyphenylchlorin in the treatment of anal intraepithelial neoplasia, grade 3

BACKGROUND AND OBJECTIVE

Anal cancer and preneoplastic anal lesions (anal intraepithelial neoplasia, AIN) rising especially in men having sex with men (MSM). There are no widely accepted treatment standards for AIN. Photodynamic therapy (PDT) using the systemic sensitizer meta-tetrahydroxyphenylchlorin (mTHPC) has the potential to treat the anal area even when the exact borders of the preneoplastic anal lesion cannot easily be visualized.

STUDY DESIGN/MATERIALS AND METHODS

In this prospective intervention study, 15 HIV-positive MSM with AIN 3 were treated in 25 PDT-sessions using mTHPC intravenously administered at drug doses of 0.075-0.15 mg ml(-1) and illumination at 48  hours. The illumination was performed using a custom made applicator using either red light (652 nm) to a measured intended fluence of 10 and 20 J cm(-2) and green light (532 nm) to a measured intended fluence of 105, 210, and 340 J cm(-2) . Red and green illuminations were performed at a (green) equivalent fluence rate of 105 mW cm(-2) .

RESULTS

Initial complete response was seen in 7/25 (28%) of treatments and another 4/25 (16%) initial partial responses. After an average 8 months, recurrences were detected in 7/11 (64%) of sessions that initially showed response. A total 4/25 (16%) showed persistent complete response 6-15 months after green light illumination. Red light illuminations caused more significant side effects combined with no persistent complete response. Reported side effects were intense pain, bloody and purulent rectal discharge, and anal stricture formation, in one patient.

CONCLUSION

The results show that the use of systemic mTHPC is partially effective for the treatment of AIN 3.

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.

Effectiveness of photodynamic therapy for mammary and extra-mammary Paget's disease: a state of the science review

BACKGROUND

Paget's disease is a rare skin disorder occurring in the breast (mammary) or in the groin, genital, peri-anal and axillary regions (extra-mammary). Typical treatment involves surgical excision, which in the case of extra-mammary Paget's disease, can lead to significant morbidity. Photodynamic therapy (PDT) which uses a topical or intravenous photosensitizing agent that is activated by a light source to ablate abnormal tissue, offers a minimally invasive alternative. The purpose of this study was to assess the effectiveness of photodynamic therapy in the treatment of Paget's disease.

METHODS

Following Cochrane guidelines, a comprehensive systematic review of all clinical studies and reports examining the use of PDT for mammary and extra-mammary Paget's disease was conducted. Study quality was assessed using the Oxford Levels of Evidence Scale.

RESULTS

21 retrospective and 2 prospective non-comparative studies were identified and included in the review: 9 case reports with 1-2 patients and 14 case series with 1-16 patients. These reports totalled 99 patients with 133 extra-mammary Paget's lesions and 3 patients (with 3 lesions) with mammary Paget's disease. Follow-up periods were typically one year or less, with 77/133 extra-mammary lesions exhibiting complete response to PDT. One recurrent mammary skin lesion and two mammary lesions treated concomitantly with surgery also exhibited complete responses.

CONCLUSIONS

Evidence of the effectiveness of PDT for Paget's disease is promising, but limited. This may, in part, be explained by the rarity of the condition, making controlled comparative clinical trials challenging.

Neoplasms of anal canal and perianal skin

Tumors of the anus and perianal skin are rare. Their presentation can vary and often mimics common benign anal pathology, thereby delaying diagnosis and appropriate and timely treatment. The anatomy of this region is complex because it represents the progressive transition from the digestive system to the skin with many different co-existing types of cells and tissues. Squamous cell carcinoma of the anal canal is the most frequent tumor found in the anal and perianal region. Less-frequent lesions include Bowen's and Paget's disease, basal cell carcinoma, melanoma, and adenocarcinoma. This article aims to review the clinical presentation, diagnostic evaluation, and treatment options for neoplasms of the anal canal and perianal skin.

Premalignant neoplasms and squamous cell carcinoma of the anal margin

Premalignant and malignant lesions of the anal margin are rare. Understanding anal anatomy and performing a biopsy of any suspicious lesions are essential in avoiding a delay in diagnosis and appropriately treating these tumors. Wide local excision continues to remain the treatment of choice for many of these lesions. Combined multimodality treatment has come to play an important role in managing patient with more advanced or metastatic disease.

Retrospective analysis of perianal Paget’s disease with underlying anorectal carcinoma

AIM: To analyze clinical and pathological characteristics of an aggressive subtype of perianal Paget’s disease (PPD) and explore its rational treatment modalities.

METHODS: PPD patients were retrospectively collected in the institutional colorectal database of the Fudan University Shanghai Cancer Center. Detailed patient histories of past medical condition, diagnosis, treatment, and pathological findings were reviewed. Surgical specimen from diagnosis and surgery were reviewed by two independent pathologists for confirmation of diagnoses. Follow up was accomplished by clinical interview by cellphone.

RESULTS: In total, eight cases of PPD were analyzed. All patients had underlying anorectal adenocarcinoma, including seven with synchronous lesions and one with metachronous lesions. Moreover, all anorectal lesions had a mucin-producing component. The median age at diagnosis was 65 (range 29-81 years), and the male/female ratio was 7:1. The Median follow-up time of all patients was 61.5 mo (range 10-204 mo). One patient treated with abdominoperineal resection (APR) died from lung metastases 10 mo after the APR operation. The other patients are still free of disease at the time of this analysis.

CONCLUSION: PPD is a rare malignancy and is easily misdiagnosed. Underlying anorectal cancer was not unusual and was a significant prognostic factor. Rational treatment of both anorectal cancer and PPD lesion is essential for long-term survival.

Photodynamic therapy for anal cancer

Invasive anal cancers are generally successfully treated by combined chemotherapy with radiation therapy (XRT). For those patients who locally fail this intervention many are salvaged by surgery which generally results in permanent colostomy. We examined the treatment and outcome of Photofrin based photodynamic therapy (PDT) in a cohort of patients with anal cancer who failed locally despite chemo-radiation (N=6) and two patients with positive margins of resection after excision of small T(1) squamous cell anal cancers who refused further surgery or chemo-radiation. PDT consisted of outpatient infusion of Photofrin at 1.2mg/kg followed 48 h later by outpatient illumination. Red light (630 nm) illumination was delivered by a 5 cm diffusing fiber, treating transphincterally at 300 J/cm followed by microlens illumination at 200 J/cm(2) to the perianal tumor bed with 2 cm margin. All patients completed PDT without incident and all have maintained local control of disease in the anal region for the length of follow up (18-48 months). PDT may serve as a new means to salvage local failures and perhaps could be employed as a primary treatment modality in select patients with early stage of disease.

Anal neoplasms

A variety of lesions comprise tumors of the anal canal, with carcinoma in situ and epidermoid cancers being the most common. Less common anal neoplasms include adenocarcinoma, melanoma, gastrointestinal stromal cell tumors, neuroendocrine tumors, and Buschke-Lowenstein tumors. Treatment strategies are based on anatomic location and histopathology. In this article different tumors and management of each, including a brief review of local excision for rectal cancer, are discussed in turn.

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.

Cidofovir: clinical experience and future perspectives on an acyclic nucleoside phosphonate analog of cytosine in the treatment of refractory and premalignant HPV-associated anal lesions

BACKGROUND

Cidofovir, a nucleotide analog with antiviral activity against a broad range of DNA viruses including human papilloma viruses (HPV), is available off label to clinicians.

OBJECTIVE

To provide a better knowledge of pharmacology and effects when topically applied.

METHODS

After reviewing the chemistry, physiology, and animal studies, an overview of clinical studies is provided.

RESULTS/CONCLUSIONS

Cidofovir, as a result of its antiviral and antiproliferative activity and its ability to induce apoptosis, can offer a solution for the treatment of severe recurrent HPV-induced lesions. It can also be used to attempt to treat dysplastic lesions and as an adjuvant treatment. The long-lasting antiviral activity allows infrequent dosing. As a rule, cidofovir applied on the skin is well tolerated, even in long-term treatment. The dose-limiting nephrotoxicity of the drug is not a concern in patients with a glomerular filtration rate within the normal range. Cidofovir has clearly influenced the landscape of refractory and dysplastic anogenital condylomata acuminata and its use has increased over the last decade. However, further controlled clinical trials are needed to assess the role of cidofovir and its derivatives.

The management of Paget's disease of the vulva*

Paget's disease of the vulva is an uncommon lesion, and gynaecologists and dermatologists generally have limited experience in its management. The British Society for the Study of Vulval Disease has established a register of cases, and we present a review of 76 cases registered to date. The majority of patients were treated by surgical excision and reconstruction, but non-surgical therapies are an option. Recent literature is reviewed to allow comparison.

Photofrin photodynamic therapy: 2.0 mg/kg or not 2.0 mg/kg that is the question

Photodynamic therapy (PDT) is an innovative minimally invasive therapy that has great potential for both tumor ablation and normal tissue preservation. However, while in recent years the standards of surgery, radiation and chemotherapy have dramatically improved in terms of outcomes and morbidity, the same cannot be said of PDT in general and Photofrin((R))-based PDT in particular. As currently practiced PDT dosimetry has not really improved tumor ablation and diminished side effects over reports from two decades ago. We critically examine the clinical variables available for PDT dosimetry and conclude that the simple maneuver of diminishing drug dose, with an appropriate increase in light dose, can enhance disease control with a significantly lower risk of morbidity. This conclusion should also be applicable to most systemically introduced photosensitizer.

Anal intraepithelial neoplasia and anal cancer in dermatological practice

Anal intraepithelial neoplasia is considered to be a precursor lesion of invasive anal cancer. It is now increasingly recognized in high-risk groups, such as men who have sex with men and HIV-infected patients. Human papillomaviruses are considered to be an important aetiological agent in both anal intraepithelial neoplasia and anal cancer. Dermatologists are likely to encounter these conditions among the differential diagnoses to be considered in high-risk patients presenting with perianal and anal lesions. Anal cancer rates are also increasing among the HIV-infected and HIV-non-infected population. The successful treatment of anal intraepithelial neoplasia may reduce the risk of subsequent development of anal cancer. However, current therapies for anal intraepithelial neoplasia may be associated with treatment-related morbidity and are not well validated. It is currently not proven that they reduce the likelihood of the development of anal cancer. Nevertheless, screening for anal intraepithelial neoplasia is being advocated for high-risk groups and may become standard dermatological care for these patients. In view of recent developments in the understanding of this condition, this article reviews the current understanding of anal intraepithelial neoplasia and its treatment from a dermatological perspective.

Invasive squamous cell carcinoma arising in refractory perianal Bowen's disease in a HIV-positive individual

A 54-year-old HIV-positive homosexual man presented with erythematous and pigmented plaques on background erythema in the perianal region, histologically consistent with Bowen's disease. Perianal Bowen's disease represents high-grade anal intraepithelial neoplasia, which is considered a precursor lesion of invasive anal squamous cell carcinoma. This patient's anal intraepithelial neoplasia was unresponsive to multiple treatment modalities including cryotherapy, serial curettage and cautery, topical 5-fluorouracil and 5-aminolaevulinic acid photodynamic therapy. He progressed to develop a poorly differentiated squamous cell carcinoma of the anus three and a half years after the Bowen's disease was diagnosed. The squamous cell carcinoma was treated with combined chemoradiation. A recurrence of high-grade anal intraepithelial neoplasia was noted 6 months after completion of chemoradiation.

Anal intraepithelial neoplasia

Background

Anal intraepithelial neoplasia (AIN) is believed to be a precursor of anal squamous cell cancer and its incidence is rising in high-risk groups, particularly those infected with the human immunodeficiency virus (HIV). The natural history of AIN is unclear and management strategies are lacking.

Methods

This review is based on a literature search (Medline and PubMed) with manual cross-referencing of all articles related to AIN.

Results and conclusions

The aetiology of AIN is intricately linked with human papilloma viruses. The pathological processes involved in the progression of AIN are becoming clearer but the natural history, particularly the rate of progression to invasive cancer, remains unknown. There is no standard management for AIN and this is mainly due to difficulties in both diagnosis and treatment. A variety of treatment options have been tried with varying success. Surgery is associated with significant recurrence, particularly in HIV-positive patients. Non surgical approaches with imiquimod, photodynamic therapy and vaccination are appealing, and further work is required. Long-term follow-up of these patients is essential until the natural history of AIN becomes clearer.

Photodynamic therapy for the treatment of extramammary Paget's disease

BACKGROUND

Surgical and ablative treatment modalities for extramammary Paget's disease (EMPD) have high recurrence rates and can be associated with significant morbidity.

OBJECTIVES

To evaluate photodynamic therapy (PDT) for the treatment of EMPD.

METHODS

We conducted a retrospective review of notes and histology of five men with anogenital, groin and axillary EMPD treated with PDT at Roswell Park Cancer Institute between 20 April 1995 and 1 February 2001.

RESULTS

Sixteen EMPD lesions were treated with topical aminolaevulinic acid (ALA)-PDT. Eleven of these lesions had failed previous Mohs micrographic surgery, excision or laser ablation. When evaluated 6 months after one treatment with ALA-PDT, eight of 16 (50%) sites achieved a complete clinical response (CR); six of eight CRs were in lesions that had failed prior conventional therapies. Three of the eight CRs (37.5%) recurred at 9, 10 and 10 months. One patient who was partially responsive to topical ALA-PDT subsequently received systemic Photofrin(R)-PDT, with a complete clinical and histological response at 1 year. Functional and cosmetic outcome was excellent in all patients.

CONCLUSIONS

PDT is an effective treatment for EMPD. Recurrence rates are high with topical ALA-PDT, but comparable with standard therapies. Topical ALA-PDT causes little scarring and is preferred for superficial disease and mucosal surfaces. Systemic Photofrin(R)-PDT may be better suited for bulky disease. While further studies are indicated, PDT is well tolerated and appears to be a useful therapy for EMPD.

Topical 5-aminolaevulinic acid photodynamic therapy for the treatment of skin conditions other than non-melanoma skin cancer

Topical 5-aminolaevulinic acid (ALA) photodynamic therapy (PDT) is used increasingly for superficial non-melanoma skin cancer (NMSC) and dysplasia. However, the relative accumulation of the photosensitizer protoporphyrin IX (PpIX) in diseased tissue is not specific for neoplastic disease, and has been shown after the application of ALA to benign proliferative skin conditions such as viral warts and psoriasis. This review appraises the quality of evidence available for the use of topical ALA-PDT in the treatment of skin conditions other than NMSC. The diseases that have been studied in most detail are recalcitrant viral warts, acne, psoriasis and cutaneous T-cell lymphoma. Publications relating to the treatment of other diseases by topical PDT are restricted to small case series or case reports. The relevant literature will be discussed and the potential for topical PDT in the treatment of several skin diseases is highlighted, although more detailed studies are required to clarify the role of PDT beyond the treatment of NMSC.