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Binda GA, Gagliardi G, Dal Conte I, Verra M, Cassoni P, Cavazzoni E, Stocco E, Delmonte S, De Nardi P, Sticchi L, Mistrangelo M. Practice parameters for the diagnosis and treatment of anal intraepithelial neoplasia (AIN) on behalf of the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol 2019; 23:513-528. [PMID: 31243606 DOI: 10.1007/s10151-019-02019-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/17/2019] [Indexed: 12/15/2022]
Abstract
Squamous cell carcinoma (SCC) of the anus is a human papilloma virus (HPV) related malignancy that is preceded by anal intraepithelial neoplasia (AIN) making this cancer, at least theoretically, a preventable disease. In the past 10 years the diagnosis, management and nomenclature of AIN has dramatically changed. Increased life expectancy in human immunodeficiency virus (HIV) positive patients due to highly active antiretroviral therapy (HAART) has caused an increase in the incidence of SCC of the anus. While many experts recommend screening and treatment of anal high-grade squamous intraepithelial lesion (HSIL), there is no consensus on the optimal management these lesions. Therefore, there is a need to review the current evidence on diagnosis and treatment of AIN and formulate recommendations to guide management. Surgeons who are members of the Italian Society of Colorectal Surgery (SICCR) with a recognized interest in AIN were invited to contribute on various topics after a comprehensive literature search. Levels of evidence were classified using the Oxford Centre for Evidence-based Medicine of 2009 and the strength of recommendation was graded according to the United States (US) preventive services task force. These recommendations are among the few entirely dedicated only to the precursors of SCC of the anus and provide an evidence-based summary of the current knowledge about the management of AIN that will serve as a reference for clinicians involved in the treatment of patients at risk for anal cancer.
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Affiliation(s)
- G A Binda
- Coloproctological Surgery, Biomedical Institute, Via Prà 1/b, 16157, Genoa, Italy.
| | - G Gagliardi
- Department of Surgery, University of Illinois at Chicago, Chicago, USA
| | - I Dal Conte
- Sexually Transmitted Infection Clinic, ASL Città di Torino, Turin, Italy
| | - M Verra
- Surgical Science Department, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - P Cassoni
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - E Cavazzoni
- Department of Surgery, University of Perugia School of Medicine, Perugia, Italy
| | - E Stocco
- Department of Surgery, ASS-5 Friuli Venezia Giulia, 33078, San Vito al Tagliamento, Italy
| | - S Delmonte
- Medical Science Department, Dermatologic Clinic, University of Turin, Turin, Italy
| | - P De Nardi
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - L Sticchi
- Hygiene Unit, Department of Health Sciences (DISSAL), IRCCS Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
| | - M Mistrangelo
- Surgical Science Department, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
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Chumbalkar V, Jennings TA, Ainechi S, Lee EC, Lee H. Extramammary Paget's Disease of Anal Canal Associated With Rectal Adenoma Without Invasive Carcinoma. Gastroenterology Res 2016; 9:99-102. [PMID: 28058078 PMCID: PMC5191897 DOI: 10.14740/gr727e] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2016] [Indexed: 01/27/2023] Open
Abstract
Extramammary Paget's disease (EMPD) is a rare disease which is found in apocrine-rich locations such as anogenital region, axilla and rarely in other sites. Perianal EMPD is often reported as the involvement of perianal skin, but involvement of anal mucosa is very rare. Based on pathogenesis and association with either synchronous or metachronous malignancy, EMPD can be divided into primary and secondary types. Treatment approach for these two types of Paget's disease and their prognosis is different, thus it is important to make the distinction. Secondary type of Paget's disease is almost always described in association with invasive malignancy. While secondary Paget's disease arising in association with ductal carcinoma in situ of the breast is common, secondary EMPD associated with precursor lesion of the rectum without invasion is exceedingly rare. We report a very rare case of secondary Paget's disease of the anal canal in association with rectal tubular adenoma (precursor lesion) without malignancy.
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Affiliation(s)
- Vaibhav Chumbalkar
- Pathology and Laboratory Medicine, Albany Medical College, Albany, NY, USA
| | - Timothy A Jennings
- Pathology and Laboratory Medicine, Albany Medical College, Albany, NY, USA
| | - Sanaz Ainechi
- Pathology and Laboratory Medicine, Albany Medical College, Albany, NY, USA
| | - Edward C Lee
- General Surgery, Albany Medical College, Albany, NY, USA
| | - Hwajeong Lee
- Pathology and Laboratory Medicine, Albany Medical College, Albany, NY, USA
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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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Liao X, Mao W, Lin A. Perianal Paget's Disease Co-Associated with Anorectal Adenocarcinoma: Primary or Secondary Disease? Case Rep Gastroenterol 2014; 8:186-92. [PMID: 24932167 PMCID: PMC4049023 DOI: 10.1159/000363177] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Perianal Paget's disease (PPD) represents a skin neoplasm which can be either primary or secondary to carcinoma from an adjacent internal organ. PPD with underlying colorectal adenocarcinoma is usually looked upon as a secondary disease. We report a rare case of co-associated PPD and anorectal adenocarcinoma. The PPD was found to be located near the anorectal adenocarcinoma with normal tissues between them. Immunohistochemical stains demonstrated that the Paget's cells were CK7+/GCDFP-15–/CK20–/MUC2–/CDX2–, whereas the anorectal adenocarcinoma was shown to be CK7+/GCDFP-15–/CK20+/MUC2+/CDX2+. This immunological phenotypic profile supported the notion that PPD and anorectal adenocarcinoma were of different origins, but could not define the exact origins of PPD. In our determination, this case was a primary PPD with anorectal adenocarcinoma. PPD remains a heterogeneous and complex pathology, and additional studies are required to differentiate between the various possible origins.
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Affiliation(s)
- Xiujun Liao
- Departments of Colorectal Surgery, The 3rd People's Hospital of Hangzhou, Hangzhou, China
| | - Weiming Mao
- Departments of Colorectal Surgery, The 3rd People's Hospital of Hangzhou, Hangzhou, China
| | - A'Li Lin
- Departments of Pathology, The 3rd People's Hospital of Hangzhou, Hangzhou, China
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Kriz M, Hegyi J, Ruzicka T, Berking C. Fluorescence diagnostics as a guide for demarcation and biopsy of suspected anal cancer. Int J Dermatol 2012; 51:31-4. [PMID: 22182375 DOI: 10.1111/j.1365-4632.2011.04951.x] [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] [Indexed: 11/29/2022]
Abstract
BACKGROUND Malignant epithelial tumors of the perianal skin are relatively rare however show high recurrence rates. A preoperative precise diagnosis and demarcation of the involved cancerous skin remains challenging but is worthwhile to minimize tissue defects and possible limitations of quality of life. OBJECTIVES To show the use of fluorescence diagnostics (FD) in the management of chronic perianal disease. METHODS FD was performed using methylaminolevulinate (MAL) for three hours topically followed by visualization with blue light (405 nm). RESULTS We report on two patients in whom FD helped to demarcate the involved tissue or to direct biopsy to ascertain the final diagnosis. In one patient with a history of Bowen's disease and recurrent anal carcinoma, biopsy showed extramammary Paget's disease and thus was treated by surgical anoplasty. The other patient had a history of chronic anal eczema, and FD-directed biopsy could exclude suspected malignancy so that the anal eczema was treated by local therapy. CONCLUSIONS FD is a non-invasive technique which can be used in the perianal region in order to delineate pathologic processes which may reduce the number of surgical interventions.
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Affiliation(s)
- Martin Kriz
- Department of Dermatology and Allergology, Ludwig-Maximilian University, Munich, Germany
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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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Cancer anal et papillomavirus humains : une pathologie en miroir de celle du cancer du col utérin. ACTA ACUST UNITED AC 2010; 38:250-4. [DOI: 10.1016/j.gyobfe.2010.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Indexed: 11/18/2022]
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Lee PK, Wilkins KB. Condyloma and Other Infections Including Human Immunodeficiency Virus. Surg Clin North Am 2010; 90:99-112, Table of Contents. [DOI: 10.1016/j.suc.2009.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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9
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Young M, Miller R. Immunosuppression. Diagn Cytopathol 2010. [DOI: 10.1016/b978-0-7020-3154-0.00016-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Selvaggi F, Guadagni I, Pellino G, de Rosa M, Imbrogno G, Sciaudone G. Perianal Paget's disease happening with mucinous adenocarcinoma of the anal canal: managing rarities. J Cutan Pathol 2009; 37:1182-3. [DOI: 10.1111/j.1600-0560.2009.01395.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Walts AE, Lechago J, Hu B, Shwayder M, Sandweiss L, Bose S. P16 and Ki67 Immunostains Decrease Intra- and Interobserver Variability in the Diagnosis and Grading of Anal Intraepithelial Neoplasia (AIN). CLINICAL MEDICINE. PATHOLOGY 2008; 1:7-13. [PMID: 21876646 PMCID: PMC3159996 DOI: 10.4137/cpath.s501] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Significant variation is reported in the diagnosis of HPV-associated AIN. We previously observed that band-like positivity for p16 in >90% of contiguous cells coupled with Ki67 positivity in >50% of lesional cells is strongly associated with high grade AIN. This study was undertaken to determine if addition of p16 and Ki67 immunostaining would reduce inter- and intraobserver variability in diagnosis and grading of AIN. DESIGN H&E stained slides of 60 anal biopsies were reviewed by three pathologists and consensus diagnoses were achieved: 25 negative, 12 low (condyloma and/or AIN I) and 23 high (9 AIN II and 14 AIN III) grade lesions. The H&E stained slides were diagnosed independently by three additional ("participant") pathologists. Several weeks later they re-examined these slides in conjunction with corresponding p16 and Ki67 immunostains. RESULTS Addition of p16 and Ki67 immunostains reduced intra- and interobserver variability, improved concurrence with consensus diagnoses and reduced two-step differences in diagnosis. Negative and high grade AIN diagnoses showed the most improvement in concurrence levels. CONCLUSION Addition of p16 and Ki67 immunostains is helpful in the diagnosis and grading of AIN.
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Affiliation(s)
- Ann E. Walts
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Juan Lechago
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Bing Hu
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - MaryBeth Shwayder
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Lynn Sandweiss
- Department of Pathology and Laboratory Medicine, UCLA Medical Center, Los Angeles, CA
| | - Shikha Bose
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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