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

Anal and Perianal Preneoplastic Lesions

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.

Doença de Paget Extramamáría em Região Períneo-ínguino-escrotal

A doença de Paget extramamária constitui-se numa patologia rara. Existe uma estreita correlação com carcinoma anorretal quando a doença é perianal. Também está associada com malignidades internas e mau prognóstico. Os autores relatam um caso de Doença de Paget extramamária em região perineo-inguino-escrotal, num homem branco de 59 anos, que apresentava uma lesão de aproximadamente 6 cm de diâmetro, hiperpigmentada e pruriginosa, lesão esta que aumentou de tamanho e que vinha apresentando mínimo sangramento. Os exames de estadiamento foram normais, sem evidência de metástases. O exame anátomo-patológico da lesão revelou aspecto compatível com Doença de Paget extramamária. A conduta então foi a excisão ampliada da lesão e enxerto de pele fina. São discutidos os aspectos referentes à epidemiologia, patologia, estadiamento, prognóstico e tratamento desta neoplasia.

HDR-plesiotherapy for the treatment of anogenital extramammary Paget's disease

BACKGROUND

Extramammary Paget disease (EMPD) is a rare condition that most commonly affects the anogenital region in the elderly. It may be associated with an underlying invasive carcinoma. Surgical excision is nowadays considered a standard treatment for extramammary Paget's disease, although this approach might not be suitable for all patients. Good rates of local control and cosmetic outcome have been achieved by using high-dose-rate (HDR) plesiotherapy in the treatment of skin tumors arising in different locations.

MATERIAL AND METHODS

We present the results observed in a patient with EMPD treated by HDR plesiotherapy with a custom-made mold up to a final dose of 54 Gy in 12 fractions of 450 cGy over 4 weeks.

RESULTS

After a follow-up of 18 months, the patient is alive and without evidence of local or distant relapse. Acute toxicity was acceptable and cosmetic result was considered as excellent.

CONCLUSION

This technique represents an attractive alternative for those patients who are not candidates for surgical procedures because of unacceptable risk of disfigurements or functional impairment, medical contraindications or patient preference.

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.

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.

Uncommon anal neoplasms

The neoplasms of the anus discussed in this article are uncommon, and therefore lack a consistent diagnostic and treatment algorithm derived from prospective clinical trial datasets. There may be an opportunity to design prospective Phase II clinical trials, with established uniform surgical pathology, surgical technique guidelines, and endpoints. The American College of Surgeons Oncology Group may have an opportunity to design and carry out controlled clinical trials for select rare anal neoplasms. Such an effort may yield modern benchmarks with which to base subsequent patient care algorithms.

Paget's disease of the perianal region--an aggressive disease?

BACKGROUND

Perianal Paget's disease is a rare entity, often associated with internal malignancies and a poor prognosis.

METHODS

A chart review of patients with perianal Paget's disease who presented consecutively to Mayo during 25 years (starting in January 1970) was made. Patients included had Paget's disease located in or around the anus (3 cm). Patients were excluded for evidence of spread of vulvaperineal lesions or pagetoid extension of a rectal adenocarcinoma. Histology slides were reviewed, and immunohistochemistry was applied to confirm diagnoses. Follow-up was updated in all patients. Recurrence and survival curves were generated by the Kaplan-Meier method. Survival was compared with an age-matched population by the log-rank test.

RESULTS

Thirteen patients, eight females, were diagnosed (age +/- standard deviation of 68.3 +/- 10.6 years). All histologic diagnoses were confirmed with immunohistochemical staining results. Mean follow-up was 6.7 years, 8.8 for living patients. One patient had associated extramammary Paget's disease (scrotum). Lesions were located randomly at the dentate line, anal verge, and/or perianal area. Four patients had associated carcinomas; none of them were visceral. Eleven patients underwent local resection, without adjuvant therapy. Almost all recurrences were treated by wider local excision. The five-year recurrence rate was 61 percent. Overall five-year and ten-year survival was 67 percent, no different from the age-matched population (P = 0.546).

CONCLUSIONS

These results do not reflect an aggressive nature of perianal Paget's disease, despite a high rate of local recurrence. Both primary lesions and recurrences are susceptible to treatment by wider local resection. Long-term survival is no different from that of the normal age-matched population.

Perianal extramammary Paget's disease associated with primary linitis plastica of the rectum: report of a case

We report herein a case of perianal extramammary Paget's disease associated with primary linitis plastica of the rectum. An 82-year-old woman was admitted to our hospital for investigation and treatment of a perianal eczematous lesion. A skin biopsy of the lesion revealed perianal extramammary Paget's disease and a barium enema demonstrated diffuse narrowing with an irregular contour at the ampulla recti. Under a suspected diagnosis of linitis plastica of the rectum, an abdominoperineal resection was performed to resect both the rectal and perianal lesions with regional lymphadenectomy. Grossly, marked narrowing and wall thickness were observed at the lower rectum, and a histological diagnosis of signet ring cell carcinoma was confirmed. The perianal eczematous lesion revealed many atypical cells with clear cytoplasm, being Paget cells, throughout the entire epidermis. Sparse distributions of signet ring cells were also observed in the subcutaneous tissue beneath the perianal eczematous lesion. The pathogenesis of perianal extramammary Paget's disease in this patient was therefore considered to be an intraepidermal extension of primary linitis plastica of the rectum.