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Kibbi N, Owen JL, Worley B, Wang JX, Harikumar V, Aasi SZ, Chandra S, Choi JN, Fujisawa Y, Iavazzo C, Kim JYS, Lawrence N, Leitao MM, MacLean AB, Ross JS, Rossi AM, Servaes S, Solomon MJ, Alam M. Anatomic Subtype Differences in Extramammary Paget Disease: A Meta-Analysis. JAMA Dermatol 2024; 160:417-424. [PMID: 38446447 PMCID: PMC10918581 DOI: 10.1001/jamadermatol.2024.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/28/2023] [Indexed: 03/07/2024]
Abstract
Importance Extramammary Paget disease (EMPD) is a rare, highly recurrent cutaneous malignant neoplasm of unclear origin. EMPD arises most commonly on the vulvar and penoscrotal skin. It is not presently known how anatomic subtype of EMPD affects disease presentation and management. Objective To compare demographic and tumor characteristics and treatment approaches for different EMPD subtypes. Recommendations for diagnosis and treatment are presented. Data Sources MEDLINE, Embase, Web of Science Core Collection, and Cochrane Reviews CENTRAL from December 1, 1990, to October 24, 2022. Study Selection Articles were excluded if they were not in English, reported fewer than 3 patients, did not specify information by anatomic subtype, or contained no case-level data. Metastatic cases on presentation were also excluded. Data Extraction and Synthesis Abstracts of 1295 eligible articles were independently reviewed by 5 coauthors, and 135 articles retained. Reporting was in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The analysis was cunducted in August 2019 and updated in November 2022. Findings Most vulvar EMPD cases were asymptomatic, and diagnosis was relatively delayed (mean, 25.1 months). Although most vulvar EMPD cases were intraepidermal (1247/1773 [70.3%]), radical surgeries were still performed in almost one-third of cases. Despite this aggressive surgical approach, 481 of 1423 (34%) recurred, commonly confined to the skin and mucosa (177/198 [89.4%]). By contrast, 152 of 1101 penoscrotal EMPD cases (14%) recurred, but more than one-third of these recurrences were regional or associated with distant metastases (54 of 152 [35.5%]). Perianal EMPD cases recurred in one-third of cases (74/218 [33.9%]), with one-third of these recurrences being regional or associated with distant metastasis (20 of 74 [27.0%]). Perianal EMPD also had the highest rate of invasive disease (50% of cases). Conclusions and Relevance The diagnosis and treatment of EMPD should differ based on anatomic subtypes. Considerations for updated practice may include less morbid treatments for vulvar EMPD, which is primarily epidermal, and close surveillance for local recurrence in vulvar EMPD and metastatic recurrence in perianal EMPD. Recurrences in penoscrotal subtype were less common, and selective surveillance in this subtype may be considered. Limitations of this study include the lack of replication cohorts and the exclusion of studies that did not stratify outcomes by anatomic subtype.
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Affiliation(s)
- Nour Kibbi
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Joshua L. Owen
- Dermatology Service, Audie L Murphy VA Medical Center, San Antonio, Texas
- Division of Dermatology, University of Texas Health San Antonio, San Antonio
| | | | - Jake X. Wang
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vishnu Harikumar
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Sumaira Z. Aasi
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Sunandana Chandra
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jennifer N. Choi
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Christos Iavazzo
- Department of Gynecologic Oncology, Metaxa Cancer Hospital, Piraeus, Greece
| | - John Y. S. Kim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Naomi Lawrence
- Division of Dermatology, Cooper Hospital, Rowan University, Camden, New Jersey
| | - Mario M. Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of OB/GYN, Weill Cornell Medical College, New York, New York
| | - Allan B. MacLean
- Department of Gynaecology, University College, London, United Kingdom
| | - Jeffrey S. Ross
- Departments of Pathology and Urology, Upstate Medical University, Syracuse, New York
- Medical Director, Foundation Medicine, Inc, Boston, Massachusetts
| | - Anthony M. Rossi
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sabah Servaes
- Department of Radiology, West Virginia University Children’s Hospital, Charleston, West Virginia
| | - Michael J. Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Murad Alam
- Department of Dermatology, Ehime University, To-on, Japan
- Department of Otolaryngology–Head and Neck Surgery and Surgery (Organ Transplantation), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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2
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Loughrey MB, Shepherd NA. Anal and Perianal Preneoplastic Lesions. Gastroenterol Clin North Am 2024; 53:201-220. [PMID: 38280748 DOI: 10.1016/j.gtc.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Anal cancer, mainly squamous cell carcinoma, is rare but increasing in prevalence, as is its precursor lesion, anal squamous dysplasia. They are both strongly associated with human papillomavirus infection. The 2-tiered Lower Anogenital Squamous Terminology classification, low-grade SIL and high-grade SIL, is preferred to the 3-tiered anal intraepithelial neoplasia classification because of better interobserver agreement and clearer management implications. Immunohistochemistry with p16 is helpful to corroborate the diagnosis of squamous dysplasia. Similarly, immunohistochemistry is helpful to differentiate primary Paget disease from secondary Paget disease, which is usually due to anal squamous mucosal/epidermal involvement by primary rectal adenocarcinoma.
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Affiliation(s)
- Maurice B Loughrey
- Department of Cellular Pathology, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BA, United Kingdom.
| | - Neil A Shepherd
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, United Kingdom
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3
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Yuan X, Xue R, Cao X. Network meta-analysis of treatments for perineal extramammary paget's disease: Focusing on performance of recurrence prevention. PLoS One 2023; 18:e0294152. [PMID: 37956192 PMCID: PMC10642846 DOI: 10.1371/journal.pone.0294152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION Perineal extramammary paget's disease (EMPD) is characterized with high recurrence rate. Although numerous therapeutic measures for this disease have been reported so far, it is unknown whether there is significant difference in their recurrence-preventing efficiency. This study aims to compare the recurrence outcomes of reported perineal EMPD treatments. METHODS We searched public databases of for published studies concerning perineal EMPD treatments. After screening by inclusion and exclusion criteria, we extracted the data relevant to recurrence rate, and conducted network meta-analysis (NMA) by using Bayesian random-effects approach. RESULTS Our analysis included 29 previous studies (involving both male and female patients) and 11 treatment designs which are wide local excision (WLE), local excision (LE), Mohs micrographic surgery (MMS), radiotherapy (RT), radical vulvectomy (RV), photodynamic therapy (PDT), lasers (LS), imiquimod, and WLE+RT, WLE+PDT, WLE+LS. Comparing with WLE, the MMS showed significant advantage in reducing recurrence [OR: 0.18 (0.03-0.87)], while none of the rest treatments has statistically significant results. After removing outlier studies, MMS still has the significant advantages [OR: 0.35 (0.11-0.82)], and LE turned to be the treatment with worst performance [OR: 13 (2.50-110)]. Covariance analysis of follow-up length, gender differences, and lesion locations indicated only short follow-up time could affect the recurrence statistics, which tend to conceal the real differences. Funnel plot demonstrated there is no significant small study effect. CONCLUSION MMS has the best performance on reducing perineal EMPD recurrence, while LE exhibits the worst capability in such regard. Recurrence-preventing abilities of other treatments have no significant difference between each other.
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Affiliation(s)
- Xiaobin Yuan
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- First College of Clinical Medicine, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ruizhi Xue
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- First College of Clinical Medicine, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiaoming Cao
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- First College of Clinical Medicine, Shanxi Medical University, Taiyuan, Shanxi, China
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4
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Rudnicki Y, Stapleton SM, Batra R, Gan T, Mathis KL, Kelley SR. Perianal Paget's-an aggressive disease. Colorectal Dis 2023. [PMID: 36945125 DOI: 10.1111/codi.16549] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/23/2023]
Abstract
AIM Perianal Paget's disease (PAPD) is a rare disorder with a predisposition to anal and colorectal malignancies and an unclear prognosis. Our previous 25-year series demonstrated a non-aggressive nature. This study aims to describe our updated institutional experience. METHODS This is a retrospective review of all patients diagnosed with primary PAPD from 1991 to 2021. A prospectively maintained institutional database was searched which included demographics, clinical and pathological manifestations, treatment methods, recurrence, oncological outcome and mortality. RESULTS Thirty patients were diagnosed with PAPD. Fifteen were women (50%); the average age at diagnosis was 71 ± 10.7 years, and the average lesion size was 3.7 ± 2.6 cm. At diagnosis, 12 (40%) were harbouring invasive anal adenocarcinoma. Eight (27%) developed adenocarcinomas concurrent with PAPD recurrence at a mean interval of 9 ± 4.4 years (range 1.9-14.8). The Kaplan-Meier curve estimated overall survival of 93%, 86%, 82%, 65% and 56% at 1, 3, 5, 10 and 15 years, respectively. Median survival was 16 years. Six (20%) had disease-related mortality. Initially, nine (30%) were treated with abdominoperineal resection (APR), 15 (50%) underwent local resection, three (10%) were treated with radiotherapy, two (7%) received only topical therapy and one (3%) chose observation. Fifteen (50%) experienced recurrence of PAPD, two after undergoing APR. Five (17%) had persistent disease until death. Only 10 (33%) did not experience PAPD recurrence, seven of whom underwent APR. The mean follow-up time was 9.2 ± 6.2 years. CONCLUSIONS Perianal Paget's disease is an aggressive entity with high rates of synchronous anal adenocarcinoma at diagnosis and development of metachronous adenocarcinoma later in life.
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Affiliation(s)
- Yaron Rudnicki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sahael M Stapleton
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rishi Batra
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Tong Gan
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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5
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Rastogi S, Thiede R, Sadowsky LM, Hua T, Rastogi A, Miller C, Schlosser BJ. Sex differences in initial treatment for genital extramammary Paget disease in the United States: A systematic review. J Am Acad Dermatol 2023; 88:577-586. [PMID: 31015011 DOI: 10.1016/j.jaad.2019.04.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 03/18/2019] [Accepted: 04/16/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Surgery is the standard treatment for genital extramammary Paget disease (gEMPD). OBJECTIVE To determine if gEMPD treatments and outcomes differ by sex and US region. METHODS A systematic review was performed of all English-language studies on initial gEMPD treatment in Medline via PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov. At least 2 reviewers performed title and abstract review and data extraction. Surgical categories included total skinning procedures, partial skinning procedures, Mohs micrographic surgery (MMS), or unspecified surgery. Chi-squared tests of association were used for comparisons. RESULTS A total of 60 studies comprising 302 (79.7%) female and 77 (20.3%) male patients met criteria. Women were most often initially recommended partial skinning procedures. In all, 74 (24.5%) women and 0 men underwent a total skinning procedure. Men were more likely to be offered MMS than women (40.3% vs 1.9%, P < .0001), despite men having a significantly greater extent of disease involving the perineum and perianal skin (21.1% vs 1.7%, P < .0001). Treatment recommendations varied by US region. LIMITATIONS Only 20 states were represented. CONCLUSION Women are more frequently offered total skinning procedures for gEMPD while men are more frequently offered MMS. MMS offers less recurrence and morbidity than total skinning procedures and should be recommended equally to both female and male patients with gEMPD.
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Affiliation(s)
- Supriya Rastogi
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinios
| | - Rebecca Thiede
- Division of Dermatology, The University of Arizona College of Medicine-Tucson, Tucson, Arizona
| | - Lauren M Sadowsky
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinios
| | - Tammy Hua
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinios
| | - Akash Rastogi
- Tufts University School of Medicine, Boston, Massachusetts
| | - Corinne Miller
- Galter Health Sciences Library, Feinberg School of Medicine, Northwestern University, Chicago, Illinios
| | - Bethanee J Schlosser
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinios.
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6
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Imaizumi J, Moritani K, Takamizawa Y, Inoue M, Tsukamoto S, Kanemitsu Y. A review of 14 cases of perianal Paget's disease: characteristics of anorectal cancer with pagetoid spread. World J Surg Oncol 2023; 21:17. [PMID: 36658590 PMCID: PMC9854029 DOI: 10.1186/s12957-022-02872-z] [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] [Received: 03/31/2022] [Accepted: 12/05/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Perianal Paget's disease (PPD) is an intraepithelial invasion of the perianal skin and is frequently associated with underlying anorectal carcinoma. The relatively rare nature of this disease has made it difficult to develop treatment recommendations. This study aims to analyze the clinical and pathological features of perianal Paget's disease (PPD) and to explore rational treatment options and follow-up for this disease. METHODS The National Cancer Center Hospital database was searched for all cases of perianal Paget's disease diagnosed between 2006 and 2021. In the 14 patients identified, we reviewed the diagnosis, management, and outcomes of adenocarcinoma with pagetoid spread, including suspected or recurrent cases. RESULTS All 14 cases met the inclusion criteria. The median follow-up period after diagnosis was 4.5 (range, 0.1-13.0) years. Pagetoid spread before initial treatment was suspected in 12 cases (85.7%). Underlying rectal cancer was identified in 6 cases, and no primary tumor was detected in the other 6 cases. Seven patients had recurrent disease, with the median time to recurrence of 34.6 (range, 19.2-81.7) months. The time to the first relapse was 3 months, and that to the second relapse was 6 months. The overall 5-year survival rate was 90.0%. CONCLUSIONS Endoscopic and radiologic evaluation, as well as immunohistologic examination, should be performed. is to differentiate PPD with and without underlying anorectal carcinoma. The time to first recurrence varies widely, and long-term and regular follow-up for more than 5 years is considered necessary for local recurrence and distant metastasis.
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Affiliation(s)
- Jun Imaizumi
- grid.272242.30000 0001 2168 5385Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045 Japan
| | - Konosuke Moritani
- grid.272242.30000 0001 2168 5385Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045 Japan
| | - Yasuyuki Takamizawa
- grid.272242.30000 0001 2168 5385Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045 Japan
| | - Manabu Inoue
- grid.272242.30000 0001 2168 5385Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045 Japan
| | - Shunsuke Tsukamoto
- grid.272242.30000 0001 2168 5385Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045 Japan
| | - Yukihide Kanemitsu
- grid.272242.30000 0001 2168 5385Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045 Japan
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7
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Shih AR, Zukerberg L. Advances and Annoyances in Anus Pathology. Surg Pathol Clin 2020; 13:557-566. [PMID: 32773199 DOI: 10.1016/j.path.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Anal lesions are commonly mistaken clinically for prolapse or hemorrhoids but span a wide spectrum of disorders. Anal lesions include squamous, glandular, melanocytic, infectious, and lymphoid tumors. This article provides a broad overview of anal disorders and highlights specific issues that may hinder diagnosis.
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Affiliation(s)
- Angela R Shih
- Department of Pathology and Laboratory Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02144, USA
| | - Lawrence Zukerberg
- Department of Pathology and Laboratory Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02144, USA.
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8
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Weng S, Zhu N, Li D, Chen Y, Tan Y, Chen J, Yuan Y. Clinical Characteristics, Treatment, and Prognostic Factors of Patients With Primary Extramammary Paget's Disease (EMPD): A Retrospective Analysis of 44 Patients From a Single Center and an Analysis of Data From the Surveillance, Epidemiology, and End Results (SEER) Database. Front Oncol 2020; 10:1114. [PMID: 32983958 PMCID: PMC7477308 DOI: 10.3389/fonc.2020.01114] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/04/2020] [Indexed: 12/20/2022] Open
Abstract
Objective: Primary extramammary Paget's disease (EMPD) is a rare cutaneous malignancy. The aim of this article is to analyze clinical characteristics, evidence of the prognosis, and share treatment experience of primary EMPD. Methods: We extracted 771 patients' data from the Surveillance, Epidemiology, and End Results (SEER) program between 1973 and 2013 to investigate the characteristics and prognosis of patients with EMPD. In addition, 44 patients with primary EMPD in our hospital were retrospectively reviewed for 10 years. Results: Compared with patients younger than 65 years, patients diagnosed at 65–74 years [hazard ratio (HR), 2.453] and 75 years or older (HR, 5.750) had shorter survival. Patients with a primary site in the truncal skin (HR, 0.367) or scrotum (HR, 0.246) had better survival compared to those with a primary site in the perianal area. Compared with localized EMPD, EMPD with distant (HR, 18.821) and regional (HR, 2.180) metastases was associated with a worse prognosis. Patients who received radiotherapy had decreased survival, with an HR of 2.039. Patients with a higher N stage, M stage, and American Joint Committee on Cancer (AJCC) stage had a decreased prognosis (p < 0.001). Conclusions: Older age at diagnosis, primary site in the perianal area, distant metastasis, radiotherapy, and higher N stage, M stage, and AJCC stage may result in decreased survival.
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Affiliation(s)
- Shanshan Weng
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ning Zhu
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dan Li
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yurong Chen
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Medical Oncology, Zhuji People's Hospital of Zhejiang Province, Shaoxing, China
| | - Yinuo Tan
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiaqi Chen
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying Yuan
- Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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9
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Extramammary Paget's Disease: A Review of the Literature Part II: Treatment and Prognosis. Dermatol Surg 2020; 46:305-311. [PMID: 31688232 DOI: 10.1097/dss.0000000000002240] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Extramammary Paget's disease (EMPD) is a rare malignancy with unclear pathophysiology that occurs predominantly on apocrine-rich skin. Surgery is the treatment of choice; however, procedures tend to be extensive and associated with a high rate of recurrence. OBJECTIVE To review the current literature on EMPD regarding treatment and prognosis. MATERIALS AND METHODS Literature review using PubMed search for articles related to EMPD. RESULTS Extramammary Paget's disease classically presents as a slowly growing red plaque, which often mimics an inflammatory condition leading to significant delay in diagnosis. Diagnosis requires histopathologic examination and is often supported by immunohistochemical analysis. Once a diagnosis of EMPD is made, the patient must be risk-stratified and evaluated for an underlying malignancy. CONCLUSION Standard of treatment is surgery, with data suggesting that Mohs micrographic surgery may have superior clinical outcomes and lower recurrence rates. Alternatives such as photodynamic therapy and topicals have been explored and may be appropriate in certain situations. Patients with EMPD generally have a good prognosis with a 5-year overall survival rate of 75% to 95%.
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10
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Giordano PG, Meneu Díaz JC, Aguilera Molina YY, Del Olmo López R, Tabodada Mostajo N. Perianal Paget's disease: A rare disorder masking an underlying anorectal carcinoma. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:322-323. [PMID: 32278503 DOI: 10.1016/j.gastrohep.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/20/2019] [Accepted: 12/09/2019] [Indexed: 06/11/2023]
Affiliation(s)
- Pietro Giovanni Giordano
- Servicio de Cirugía General y AP. Digestivo, Cirugía Robótica, Hospital Ruber Juan Bravo, Madrid, España.
| | - Juan Carlos Meneu Díaz
- Servicio de Cirugía General y AP. Digestivo, Cirugía Robótica, Hospital Ruber Juan Bravo, Madrid, España
| | | | - Rubén Del Olmo López
- Servicio de Cirugía General y AP. Digestivo, Cirugía Robótica, Hospital Ruber Juan Bravo, Madrid, España
| | - Nestor Tabodada Mostajo
- Servicio de Cirugía General y AP. Digestivo, Cirugía Robótica, Hospital Ruber Juan Bravo, Madrid, España
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11
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Lydrup E, Berg JO, Hjorth SV, Hølmich LR, Lock-Andersen J, Chakera AH. Extramammary Paget's Disease and Melanoma: 2 Cases of Double Cancers. Case Rep Dermatol 2020; 12:107-113. [PMID: 32518542 PMCID: PMC7265716 DOI: 10.1159/000507917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/15/2020] [Indexed: 11/19/2022] Open
Abstract
Extramammary Paget's disease (EMPD) is a rare intraepidermal neoplastic disease. There is a well-known relationship between EMPD and underlying malignancy. However, only a few cases of EMPD and cutaneous melanoma have been reported previously. In this case report we present 2 cases of such double cancers: one as a collision tumor, the other at separate sites. We discuss the pathogenesis, treatment, and importance of a thorough clinical and radiological examination and review the literature.
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Affiliation(s)
- Erika Lydrup
- Department of Plastic Surgery, Herlev-Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Jais Oliver Berg
- Department of Plastic Surgery, Herlev-Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Sofie Vetli Hjorth
- Department of Pathology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Lisbet Rosenkrantz Hølmich
- Department of Plastic Surgery, Herlev-Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Jørgen Lock-Andersen
- Department of Plastic Surgery, Herlev-Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Annette Hougaard Chakera
- Department of Plastic Surgery, Herlev-Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
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12
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Su T, Yang B, Gao T, Liu T, Li J. Polymer nanoparticle-assisted chemotherapy of pancreatic cancer. Ther Adv Med Oncol 2020; 12:1758835920915978. [PMID: 32426046 PMCID: PMC7222269 DOI: 10.1177/1758835920915978] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/20/2020] [Indexed: 12/16/2022] Open
Abstract
Pancreatic cancer is a lethal disease characterized by highly dense stroma fibrosis. Only 15-20% of patients with pancreatic cancer have resectable tumors, and only around 20% of them survive to 5 years. Traditional cancer treatments have little effect on their prognosis, and successful surgical resection combined with effective perioperative therapy is the main method for maximizing long-term survival. For this reason, chemotherapy is an adjunct treatment for resectable cancer and is the main therapy for incurable pancreatic cancer, including metastatic pancreatic adenocarcinoma. However, there are various side effects of chemotherapeutic medicine and low drug penetration because the complex tumor microenvironment limits the application of chemotherapy. As a novel strategy, polymer nanoparticles make it possible to target the tumor microenvironment, release cytotoxic agents through various responsive reactions, and thus overcome the treatment barrier. As drug carriers, polymer nanoparticles show marked advantages, such as increased drug delivery and efficiency, controlled drug release, decreased side effects, prolonged half-life, and evasion of immunogenic blockade. In this review, we discuss the factors that cause chemotherapy obstacles in pancreatic cancer, and introduce the application of polymer nanoparticles to treat pancreatic cancer.
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Affiliation(s)
- Tianqi Su
- Department of General Surgery, The Second Hospital of Jilin University, Changchun, People’s Republic of China
| | - Bo Yang
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, People’s Republic of China
| | - Tianren Gao
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, People’s Republic of China
| | - Tongjun Liu
- Department of General Surgery, Second Hospital of Jilin University, Changchun 130041, People’s Republic of China
| | - Jiannan Li
- Department of General Surgery, Second Hospital of Jilin University, Changchun 130041, People’s Republic of China
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Snast I, Sharon E, Kaftory R, Noyman Y, Oren-Shabtai M, Lapidoth M, Hodak E, Mimouni D, Mazor S, Levi A. Nonsurgical Treatments for Extramammary Paget Disease: A Systematic Review and Meta-Analysis. Dermatology 2020; 236:493-499. [PMID: 32289785 DOI: 10.1159/000506832] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 02/27/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Surgery is commonly regarded as the mainstay of treatment of extramammary Paget disease (EMPD); however, nonsurgical approaches have gained popularity in recent years. OBJECTIVES To review the published evidence for the efficacy and safety of nonsurgical modes of therapy for EMPD. METHODS A systematic review and meta-analysis of nonsurgical EMPD treatments was performed. The primary outcome was complete response (CR); secondary outcomes were clinical regression by ≥50%, adverse events, and recurrence rate. RESULTS The systematic review included 43 observational studies (341 patients; 7 prospective cohort studies, 19 retrospective cohort studies, and 17 cases series) evaluating 5 treatment modalities. Imiquimod (13 studies, 110 patients) administered at variable doses ranging from daily to twice weekly for 2-56 weeks demonstrated CR of 54% (95% CI, 40-67%; I2 = 37%) and had a satisfactory safety profile. In 14 heterogeneous studies (122 patients) evaluating photodynamic therapy (PDT), only 36% (95% CI, 22-53%; I2 = 52%) of patients achieved CR. Radiotherapy (12 studies, 67 patients) showed CR of 97%, but was associated with local and systemic side effects. Ablative lasers and topical fluorouracil and calcipotriene lacked adequate evidence of efficacy. CONCLUSIONS Imiquimod and radiotherapy are the most appropriate nonsurgical modalities for EMPD treatment given their good efficacy and safety profile. PDT has limited efficacy but may be appropriate in selected clinical settings.
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Affiliation(s)
- Igor Snast
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel, .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Eran Sharon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Breast Surgery Clinic, Rabin Medical Center, Petah Tikva, Israel
| | - Ran Kaftory
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehonatan Noyman
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Meital Oren-Shabtai
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Lapidoth
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmilia Hodak
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Mimouni
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sigal Mazor
- Department of Community Dentistry, School of Dental Medicine, Hebrew University-Hadassah, Medical Center, Jerusalem, Israel
| | - Assi Levi
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Extramammary Paget Disease: A Review of the Literature—Part I: History, Epidemiology, Pathogenesis, Presentation, Histopathology, and Diagnostic Work-up. Dermatol Surg 2020; 46:151-158. [DOI: 10.1097/dss.0000000000002064] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Extramammary Paget's disease (EMPD) is a rare and lethal intraepithelial malignancy that remains poorly understood. No standardized guidelines or consensus statements exist with regards to the diagnostic evaluation, therapeutic approaches and follow-up management. Complete surgical excision with negative margins has been accepted as the mainstay of treatment for EMPD to decrease the risk of local recurrence and to maximize durable cure. Non-invasive therapies, such as laser therapy, photodynamic therapy, radiotherapy and topical chemotherapy have been utilized, but are best reserved for non-surgical candidates. While the debate on the surgical approach between wide local excision (WLE) and Mohs micrographic surgery (MMS) continues, several studies have demonstrated the ability of WLE to be performed safely and effectively and to yield equally satisfactory outcomes with similar rates of recurrence to MMS. Patients undergoing surgical excision often require complex closures with skin grafting or local flaps to close genital defects. We aim to provide an up-to-date review of the current knowledge of EMPD. In addition to discussing the clinical presentation and prognostic outcomes, we focus and elaborate on the diagnostic approaches and treatment alternatives available. This information may serve as a primer for the urologist who may be called upon to treat this malignancy primarily or to provide wound coverage secondarily.
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Affiliation(s)
- Joon Yau Leong
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia PA, USA
| | - Paul H Chung
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia PA, USA
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Abstract
The histologic differential diagnosis of perianal Paget disease includes malignant melanoma, pagetoid spread of squamous cell carcinoma, and secondary involvement by colorectal carcinoma. While consideration of these entities is useful when establishing a diagnosis, it does not apply when patients with Paget disease undergo surveillance for recurrent disease. Treatment of perianal Paget disease consists of a combination of surgical excision with skin grafts and topical chemotherapeutic agents that induce cytologic alterations in benign cells and simulate recurrent malignancy. To evaluate the therapy-related changes and possible diagnostic pitfalls in patients with Paget disease, we reviewed 412 posttreatment tissue samples from 3 women with primary perianal Paget disease who underwent wide excision, skin grafting, and topical 5-fluorouracil therapy. Biopsy samples from engrafted skin often displayed single and clustered cells with hyperchromatic nuclei dispersed in the deep epidermis. Similar cells were scattered throughout all levels of the epidermis in biopsy samples following topical chemotherapy. The abnormal cells were negative for cytokeratin 7 (CK7) and mucicarmine in both situations. Disease ultimately recurred in all patients; some Paget cells showed classic features with eosinophilic or mucinous cytoplasm and eccentric nuclei, whereas others were smaller with less conspicuous atypia. All Paget cells showed strong, membranous CK7 staining. In short, treatment of perianal Paget disease can elicit cytologic abnormalities in benign epithelial cells that simulate the cytologic features of recurrent disease, and can diminish the atypia of Paget cells. Immunohistochemical stains for CK7 can be helpful when evaluating surveillance samples from these patients.
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Chung PH, Leong JY, Voelzke BB. Surgical Experience With Genital and Perineal Extramammary Paget's Disease. Urology 2019; 128:90-95. [PMID: 30902697 DOI: 10.1016/j.urology.2019.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/04/2019] [Accepted: 03/08/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe our surgical experience for the treatment and management of extramammary Paget's disease (EMPD). METHODS Our surgical approach involves excising a 2-cm margin of normal appearing skin around the EMPD-suspicious lesion. Prior to excision, the tissue is oriented and demarcated into predefined segments in coordination with a pathologist. Frozen sections are performed when necessary to guide additional excision. Xenograft or wet-to-dry dressings are applied depending on size and location of the wound while the specimen is expeditiously reviewed over the following 24-48 hours. If positive margins remain, further excision of the corresponding skin segment is performed. Delayed complex wound closure +/- split thickness skin grafting is performed once negative margins are confirmed. RESULTS Ten EMPD patients were referred to two academic centers between 2014 and 2018. Two patients had positive lymph nodes at diagnosis and underwent palliative surgery and died within 12 and 29 months. The remaining 8 patients underwent a median of 1 surgery (range 0-3) with referring providers before undergoing a median of 3 surgeries (range 2-5) at our institutions to achieve negative surgical margins and wound reconstruction (7 split thickness skin grafts, 1 secondary closure). At mean follow-up of 15 months, 1 patient recurred, required further excision, and remains disease free. CONCLUSION EMPD is a rare malignancy with poorly described treatment methodologies. Due to its multifocal distribution and asymmetric spread, obtaining negative margins can be challenging. Our systematic approach to obtaining wide margins and documenting excised skin has enabled us to achieve negative margins for this challenging malignancy.
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Affiliation(s)
- Paul H Chung
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
| | - Joon Yau Leong
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Bryan B Voelzke
- Department of Urology, University of Washington Medical Center, Seattle, WA
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Affiliation(s)
- Jeff Choi
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Allison Zemek
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Gordon K Lee
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Cindy Kin
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA.
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Murata T, Honda T, Egawa G, Kitoh A, Dainichi T, Otsuka A, Nakajima S, Kore-eda S, Kaku Y, Nakamizo S, Endo Y, Fujisawa A, Miyachi Y, Kabashima K. Three-dimensional evaluation of subclinical extension of extramammary Paget disease: visualization of the histological border and its comparison to the clinical border. Br J Dermatol 2017; 177:229-237. [DOI: 10.1111/bjd.15282] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2016] [Indexed: 02/01/2023]
Affiliation(s)
- T. Murata
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
- Research Fellow of the Japan Society for the Promotion of Science
| | - T. Honda
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | - G. Egawa
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | - A. Kitoh
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | - T. Dainichi
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | - A. Otsuka
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | - S. Nakajima
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | | | - Y. Kaku
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | - S. Nakamizo
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | - Y. Endo
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | - A. Fujisawa
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | - Y. Miyachi
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
| | - K. Kabashima
- Department of Dermatology; Kyoto University Graduate School of Medicine; 54 Shogoin-Kawahara Sakyo-ku, Kyoto 606-8507 Japan
- Singapore Immunology Network (SIgN) and Institute of Medical Biology; Agency for Science, Technology and Research (A*STAR); 8A Biomedical Grove, IMMUNOS Building #3-4 Biopolis 138648 Singapore
- PRESTO; Japan Science and Technology Agency; 4-1-8 Honcho Kawaguchi, Saitama 332-0012 Japan
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21
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Surgical Treatment and Outcomes of Patients With Extramammary Paget Disease: A Cohort Study. Dermatol Surg 2017; 43:708-714. [DOI: 10.1097/dss.0000000000001051] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Surgical Treatment of Cutaneous Extramammary Paget’s Disease. CURRENT DERMATOLOGY REPORTS 2016. [DOI: 10.1007/s13671-016-0142-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Wong DSY, Ko LWL, Cheung TH. Extramammary Paget's disease: Surgical control from the plastic surgery perspective. SURGICAL PRACTICE 2016. [DOI: 10.1111/1744-1633.12188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- David Sau-Yan Wong
- Division of Plastic, Reconstructive & Aesthetic Surgery, Department of Surgery; The Chinese University of Hong Kong, Prince of Wales Hospital; Hong Kong China
| | - Loretta Wing-Lam Ko
- Division of Plastic, Reconstructive & Aesthetic Surgery, Department of Surgery; The Chinese University of Hong Kong, Prince of Wales Hospital; Hong Kong China
| | - Tak-Hong Cheung
- Department of Obstetrics & Gynaecology; The Chinese University of Hong Kong, Prince of Wales Hospital; Hong Kong China
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Abstract
Background: Perianal Pa get's disease is an uncommon intraepithelial neoplasm that involves areas affluent with apocrine glands, most frequently in the female external genitalia, but may also affect the perianal region. Objective: We present the pathologic and clinical management of a case of Paget's disease involving the perianal region, in which diagnosis was delayed for 8 years. Conclusions: The importance of a high index of suspicion for early diagnosis is emphasized, which should be followed by aggressive surgical treatment with wide excision and local reconstruction.
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Affiliation(s)
- Zion Zibly
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Aviv, Israel
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Carbotta G, Sallustio P, Prestera A, Laforgia R, Lobascio P, Palasciano N. Perineal Paget's disease: A rare disorder and review of literature. Ann Med Surg (Lond) 2016; 9:50-2. [PMID: 27408714 PMCID: PMC4930340 DOI: 10.1016/j.amsu.2016.06.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/18/2016] [Accepted: 06/19/2016] [Indexed: 11/26/2022] Open
Abstract
Introduction Extramammary Paget's disease (EMPD) occurs commonly in perineum, vulva and perineal region and is considered as a complex disorder due to different clinical and histological features. Presentation of case A 61 years old woman had a dermatologic evaluation for anal itch and underwent a skin biopsy with diagnostic of Paget disease in perianal region. Pelvic magnetic resonance showed a huge tumor which involved skin, derma and gluteus and she firstly refused any surgical treatment. One year later, because of increasing of the tumor and bleeding, she underwent the surgical procedure with a complete excision, resection of the skin of the anus, inguinal lymphadenectomy and left colostomy. Because of lymph nodes metastasis, a VLS Miles was sequentially performed. She started oncological follow up that showed liver, lung and pelvic metastasis. She survived for 24 months after surgery. Discussion In literature, less than 200 cases of perineal Paget's disease have been reported. EMPD in some cases has an associated adenocarcinoma, which has been associated with a worse prognosis and high mortality. Wrong diagnosis and a superficial consideration of a benign evolution should be considered as the first mistake in clinical practice. Conclusion Our surgical approach is considered in literature as the best one for those cases, followed by the oncological treatment. Those patients need to be better studied and more attention should be paid to the clinical presentation. A case of Extramammary Paget's disease (EMPD) is proposed. Clinical presentation needs to be well studied and considered for the diagnostic. A wide surgical excision and oncological treatment are mandatory to face this kind of tumor.
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Affiliation(s)
- Giuseppe Carbotta
- General Surgery Unit, Department of Emergency and Organ Transplantation-University of Bari, Italy
| | - Pierluca Sallustio
- General Surgery Unit, Department of Emergency and Organ Transplantation-University of Bari, Italy
| | - Antonio Prestera
- General Surgery Unit, Department of Emergency and Organ Transplantation-University of Bari, Italy
| | - Rita Laforgia
- General Surgery Unit, Department of Emergency and Organ Transplantation-University of Bari, Italy
| | - Pierluigi Lobascio
- General Surgery Unit, Department of Emergency and Organ Transplantation-University of Bari, Italy
| | - Nicola Palasciano
- General Surgery Unit, Department of Emergency and Organ Transplantation-University of Bari, Italy
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Abstract
Pruritus ani is a common condition with many different potential causes. Because of this, it can be difficult to treat. It is important to identify and eliminate any inciting factors, which are often unintentional consequences of the patient's attempts to alleviate symptoms. If no reversible cause is found, simple measures with diet modification and perianal hygiene are tried before using topical medications or procedures.
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Affiliation(s)
- Parswa Ansari
- Hofstra North Shore-LIJ School of Medicine, Lenox Hill Hospital, New York
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27
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Abstract
PURPOSE Perianal Paget's disease is a rare intraepithelial adenocarcinoma of the perianal skin and the second most common localization of extramammary Paget's disease. This study was designed to evaluate long-term outcomes in patients with perianal Paget's disease. METHODS We identified patients who were treated for perianal Paget's disease between 1981 and 2013. Patient demographics, family history, associated malignancies, treatments, histopathological features, need for re-operations, and long-term outcomes were documented. RESULTS Our study cohort consisted of 15 male and 10 female patients with a median age of 67 (40-83) years. Four patients had concurrent anorectal adenocarcinoma (two anal canal, two rectal) when perianal Paget's disease was diagnosed. Index operations performed were wide local excision (14 patients), local excision (five patients), abdominoperineal resection (four patients), and radiotherapy (two patients). Five patients developed invasive carcinoma (three anal canal, one vulvar, one perianal squamous cell carcinoma) during a median follow-up time of 60 (3-299) months. Thirteen patients were re-operated. Fifteen patients had a reconstructive procedure following excision. Overall survival was similar between the patients who were treated with wide local excision and local excision regardless of surgical margin status at index excision (P = 0.75). CONCLUSIONS Since there is a risk for developing invasive carcinoma in the anal canal and perineum in patients with perianal Paget's disease, close follow-up is needed after R0 or R1 excision. Physicians should be aware of the risk of cancers associated with perianal Paget's disease and should rule out them during management.
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Ito T, Kaku Y, Nagae K, Nakano-Nakamura M, Nakahara T, Oda Y, Hagihara A, Furue M, Uchi H. Tumor thickness as a prognostic factor in extramammary Paget's disease. J Dermatol 2014; 42:269-75. [DOI: 10.1111/1346-8138.12764] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/30/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Takamichi Ito
- Department of Dermatology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
- Department of Anatomic Pathology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Yumiko Kaku
- Department of Dermatology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Konosuke Nagae
- Department of Dermatology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Misa Nakano-Nakamura
- Department of Dermatology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Takeshi Nakahara
- Department of Dermatology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Akihito Hagihara
- Department of Health Services Management and Policy; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Masutaka Furue
- Department of Dermatology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Hiroshi Uchi
- Department of Dermatology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
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30
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Rajendran S, Koh CE, Solomon MJ. Extramammary Paget's disease of the perianal region: a 20-year experience. ANZ J Surg 2014; 87:132-137. [PMID: 25113623 DOI: 10.1111/ans.12814] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND To evaluate the results obtained from cases of perianal Paget's disease (PPD) and to provide a current perspective in the diagnostic evaluation and surgical management of this condition. METHODS A retrospective review of a single quaternary referral centre's experience with PPD from January 1994 to December 2013 was performed. Medical records were reviewed to collect data on demographics, preoperative investigations, complications, pathology and recurrence. A review of existing literature was also performed. RESULTS Five patients (four females, one male) with histologically confirmed PPD were identified. The median age of presentation was 72 (range 61 to 78). Three patients were recurrences following previous excisions and first presentations in two patients. Only one patient had an underlying diagnosis of cancer. The median time to diagnosis was 24 months. Four patients underwent wide local excision with skin graft and/or local flap reconstruction and one patient required an abdominoperineal excision for recurrence. Four patients had involved lateral margins despite wide local excision but follow-up to date has only revealed one local recurrence. A review of available literature suggests that synchronous cancers can occur in up to 33% of patients and that a further 10% may be associated with metachronous cancers. Surveillance recommendations seem anecdotal and do not appear to be supported by available literature. CONCLUSION PPD is a management challenge. Association with synchronous and metachronous carcinomas may not be as strong as initially thought. Surgery is the mainstay treatment with the need to balance between minimizing disease recurrence and functional sequelae from excessive tissue loss.
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Affiliation(s)
- Saissan Rajendran
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Cherry E Koh
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Chandawarkar RY, Ricchuiti D, Amjad I, Marsico RE, Wells MD. Extramammary Paget's disease of the perineum: Avoiding pitfalls in diagnosis and management. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2014; 11:205-8. [PMID: 24009439 DOI: 10.1177/229255030301100406] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Rajiv Y Chandawarkar
- Division of Plastic Surgery, Summa Health System, Akron General Medical Center & NorthEastern Ohio Universities College of Medicine, Akron, Ohio, USA
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Management of Adenocarcinoma in the Setting of Recently Operated Perianal Paget's Disease. Case Rep Surg 2013; 2013:510813. [PMID: 23762735 PMCID: PMC3671514 DOI: 10.1155/2013/510813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 05/02/2013] [Indexed: 11/23/2022] Open
Abstract
Perianal Paget's disease only rarely presents with a synchronous invasive anal or rectal cancer. The purpose of this study is to present a case of an otherwise healthy patient who developed perianal Paget's disease. He was then found to have an invasive rectal adenocarcinoma, after having undergone an extensive resection and reconstruction with a bilateral V-to-Y reconstruction. This report describes an overview of perianal Paget's disease, the management of this disease in association with anal or rectal cancer, and our patient's outcome.
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Penoscrotal extramammary Paget's disease: surgical techniques and follow-up experiences with thirty patients. Asian J Androl 2013; 15:508-12. [PMID: 23685910 DOI: 10.1038/aja.2013.27] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 02/08/2013] [Accepted: 03/06/2013] [Indexed: 11/08/2022] Open
Abstract
To report the surgical management, complications and prognosis of patients with penoscrotal extramammary Paget's disease (EMPD) at different clinical stages. Between 2003 and 2008, a total of 30 male patients with penoscrotal EMPD were enrolled and evaluated. All enrolled subjects received frozen biopsy-guided local wide resection and immediate reconstruction. Patients were followed every 3 months postoperatively. Among the 30 patients who accepted and underwent frozen biopsy-guided local wide resection treatment and reconstruction, two (6.7%) cases exhibited positive margins, verified by pathological examination, and underwent re-excision after surgery. The technique of primary closure or an adjacent flap was used in 10 (33.3%) cases, split-thickness skin grafts were used in 15 (50%), and an anterolateral thigh perforator flap was used in five cases (16.7%). The postoperative complications were acceptable. The mean follow-up time was 64.9 ± 29.6 months. Of all 30 cases, 22 patients (73.3%) survived with no evidence of recurrence, four patients (13.3%) exhibited local recurrence, two patients (6.7%) exhibited both local recurrence and distant metastasis and the remaining two patients (6.7%) exhibited distant metastasis. Five patients died from metastasis or cachexia. Current surgical techniques, including primary closure, adjacent flaps, split-thickness skin flaps and anterolateral thigh perforator flaps are able to reconstruct all types of defects with acceptable complications. Some patients with negative margins went on to exhibit local recurrence, potentially due to adnexal carcinoma or internal malignancy.
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35
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Bae JM, Choi YY, Kim H, Oh BH, Roh MR, Nam K, Chung KY. Mohs micrographic surgery for extramammary Paget disease: A pooled analysis of individual patient data. J Am Acad Dermatol 2013; 68:632-637. [DOI: 10.1016/j.jaad.2012.12.960] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 11/20/2012] [Accepted: 12/09/2012] [Indexed: 11/25/2022]
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Shah KR, Boland CR, Patel M, Thrash B, Menter A. Cutaneous manifestations of gastrointestinal disease. J Am Acad Dermatol 2013; 68:189.e1-21; quiz 210. [DOI: 10.1016/j.jaad.2012.10.037] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 10/11/2012] [Accepted: 10/13/2012] [Indexed: 01/13/2023]
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Extramammary Paget disease in peristomal skin: report of a unique case. J Gastrointest Surg 2012; 16:1967-71. [PMID: 22547349 DOI: 10.1007/s11605-012-1900-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 04/17/2012] [Indexed: 01/31/2023]
Abstract
PURPOSE Extramammary Paget disease is a rare neoplasm most often found in the perianal area which can be primary in origin or secondary from underlying colorectal adenocarcinoma with epidermotropic spreading. However, the occurrence of extramammary Paget disease has not been described in peristomal skin. METHODS We describe a single case of Paget disease in the peristomal skin of a 61-year-old woman with ulcerative colitis who underwent a proctocolectomy 33 years prior to now with chronic intestinal obstruction and an area of "ectopic mucosa" adjacent to her ileostomy. The patient was taken to surgery for exploratory laparotomy and revision of her stoma. RESULTS Macroscopic and microscopic examinations of the peristomal lesion demonstrated Paget disease with intraepidermal spreading of dysplastic intestinal/glandular cells but no invasive adenocarcinoma in the peristomal skin after extensive sampling. CONCLUSIONS To our knowledge, this is the first reported case of extramammary Paget disease occurring in peristomal skin. The current case emphasizes the importance of recognizing such disease and the potential for associated neoplasia in patients with intestinal stomas.
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Inose T, Asao T, Nakamura J, Ide M, Fukuchi M, Kuwano H. Double anal canal cancers associated with a long history of perianal Paget’s disease: report of a case. Surg Today 2012; 42:697-702. [DOI: 10.1007/s00595-012-0178-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 07/05/2011] [Indexed: 11/30/2022]
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Boehringer A, Leiter U, Metzler G, Moehrle M, Garbe C, Breuninger H. Extramammary Paget's Disease: Extended Subclinical Growth Detected Using Three-Dimensional Histology in Routine Paraffin Procedure and Course of the Disease. Dermatol Surg 2011; 37:1417-26. [DOI: 10.1111/j.1524-4725.2011.02091.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kyriazanos ID, Stamos NP, Miliadis L, Noussis G, Stoidis CN. Extra-mammary Paget's disease of the perianal region: a review of the literature emphasizing the operative management technique. Surg Oncol 2011; 20:e61-71. [PMID: 20884199 DOI: 10.1016/j.suronc.2010.09.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2010] [Revised: 09/07/2010] [Accepted: 09/08/2010] [Indexed: 12/13/2022]
Abstract
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.
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Abstract
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.
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Affiliation(s)
- Daniel Leonard
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Abstract
CONTEXT The anal canal possesses complex anatomy and histology and gives rise to a variety of tumor types. Challenging issues remain with regard to both the pathologic diagnosis and the clinical management of these tumors. OBJECTIVES To provide an updated overview of the histogenesis, clinical and pathologic characteristics, diagnostic terminology, and relevant clinical management of the various types of anal canal tumors. DATA SOURCES Recent literature on clinical and pathologic characteristics of anal canal tumors. CONCLUSIONS Although most anal canal tumors are of squamous lineage, a complex variety of other tumors also occurs. Recognition of such diverse tumor entities will allow accurate pathologic diagnosis and most optimal clinical management.
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Affiliation(s)
- Jinru Shia
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.
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Sahai A, Kodner IJ. Premalignant neoplasms and squamous cell carcinoma of the anal margin. Clin Colon Rectal Surg 2010; 19:88-93. [PMID: 20011315 DOI: 10.1055/s-2006-942349] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Aalok Sahai
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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Lian P, Gu WL, Zhang Z, Cai GX, Wang MH, Xu Y, Sheng WQ, Cai SJ. Retrospective analysis of perianal Paget’s disease with underlying anorectal carcinoma. World J Gastroenterol 2010; 16:2943-8. [PMID: 20556842 PMCID: PMC2887592 DOI: 10.3748/wjg.v16.i23.2943] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Abstract
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.
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Abstract
Perianal Paget's disease is a rare malignancy. It is rarely isolated and often associated with an underlying adenocarcinoma. It usually presents with anal itchiness and discomfort and can be misdiagnosed as hemorrhoids. Once the diagnosis of perianal Paget's disease is granted, extensive work-up to find an underlying primary malignancy is crucial. Surgery is the standard modality of treatment of extramammary Paget's disease (EMPD) with recurrence rates of 44–60%. Other different treatment modalities including radiotherapy, laser therapy, topical and systemic chemotherapy and the new emerging, promising photodynamic therapy are in the field of study. A 76-year-old man was referred to our hospital with a one-year history of anal itchiness and intermittent rectal bleeding. Skin shave and punch biopsies from the perianal area were reported back as perianal Paget's disease with no underlying adenocarcinoma. The immunohistochemical stains were positive for cytokeratin 7 but also positive for cytokeratin 20 and CEA which indicated the essentiality of extensive investigations to find a primary malignancy. Skin exam showed no primary source. The investigations were unable to find the primary malignancy. Given the results of immunohistochemical stains we recommended local perianal Paget's disease resection. The intraoperative frozen section showed adenocarcinoma around the anal sphincter. Ten days later the patient underwent an abdominoperineal resection and the final pathology report showed extensive adenocarcinoma in three quadrants of the perianal area with focal involvement of the rectal mucosa. We recommended an adjuvant chemotherapy with FOLFOX following surgery given the bulkiness of the disease. We conclude that once perianal Paget's disease is diagnosed, an extensive work-up should be done to find the underlying primary malignancy. Immunohistochemical stains are helpful in raising the suspicion of underlying primary malignancy. Finding an underlying primary malignancy in patients with EMPD is prompt to choose the treatment modality and estimate the prognosis.
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Affiliation(s)
- M N Al Hallak
- University of North Dakota School of Medicine, MeritCare Health System, Roger Maris Cancer Center, Department of Radiation, Fargo, N. Dak., USA
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Abstract
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.
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Affiliation(s)
- A B MacLean
- Department of Obstetrics and Gynaecology, Royal Free and University College Medical School, London, UK.
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Long-term functional and quality of life outcomes of patients after repair of large perianal skin defects for Paget's and Bowen's disease. J Gastrointest Surg 2009; 13:951-5. [PMID: 19224296 DOI: 10.1007/s11605-009-0822-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Accepted: 01/28/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The assessment of long- term functional and quality of life outcomes of these patients following repair of large defects after surgical excision has not been reported. METHODS Between 1992 and 2004, at two institutions, 18 patients underwent repair of a perianal defect for Paget's disease (n = 8) or Bowen's disease (n = 10) and were alive with intestinal continuity at last follow-up. Patients were mailed the fecal incontinence quality of life scale (FIQL) and the SF-36. RESULTS Fourteen patients (78%) responded. Median follow-up for responders was 5 years. Mean age was 65 years with 12 females. Subcutaneous skin flaps (11) and split-thickness skin grafts (three) were used to repair the perianal defects, which were circumferential in 11 patients (79%). Nine patients reported incontinence and completed the FIQL. The FIQL scores of patients reporting incontinence were lower for lifestyle, coping/behavior, and embarrassment but not significantly different for depression compared to patients without incontinence. SF-36 scores of the patients were not significantly different from the normative population. CONCLUSION Functional results after repair of large perianal defects are acceptable and overall quality of life (QOL) is similar to the normative population although a large proportion of patients have some form of incontinence that impacts certain aspects of their QOL.
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