Mohs micrographic surgery for extramammary Paget disease: A pooled analysis of individual patient data

Preliminary analysis of the efficacy of Mohs micrographic surgery combined with photodynamic therapy in a case of noninvasive extramammary Paget's disease

PURPOSE

To evaluate the efficacy of Mohs micrographic surgery (MMS) combined with photodynamic therapy (PDT) in treating non-invasive extramammary Paget's disease (EMPD).

MATERIALS AND METHODS

A 77-year-old male patient with non-invasive EMPD was treated with MMS followed by PDT. Preoperative fluorescence localization using 5-aminolevulinic acid (ALA) was performed to determine the surgical scope. MMS was conducted under lumbar anesthesia with intraoperative frozen-section pathology. Postoperative PDT was administered weekly for three sessions.

RESULTS

The patient achieved negative surgical margins after two rounds of intraoperative pathology. Postoperative follow-up over two years showed no recurrence, and the patient did not experience significant adverse reactions.

CONCLUSION

The combination of MMS and PDT was effective in treating non-invasive EMPD, demonstrating favorable clinical outcomes and no recurrence over the two-year follow-up period.

Cost-effectiveness analysis of margin-controlled surgery for vulvar Paget's disease

Objectives

To determine the cost of two surgical treatment approaches for vulvar Paget's disease and model the cost-effectiveness considering differences in recurrence and reoperation over time.

Methods

We assessed cost-effectiveness between excision guided by Mohs micrographic surgery (MMS-E) and traditional wide local excision (WLE). We examined billing data from patients with vulvar Paget's disease who underwent MMS-E (cases, n = 24, 2018-2022) or WLE (controls, n = 64, 1990-2020). We created typical treatment bundles incorporating physician-administered services and facility costs standardized to Medicare reimbursements in 2022 United States Dollars (USD). The primary measure of effectiveness was disease-free years of life. A secondary analysis estimated quality-adjusted life years (QALY). A Markov model simulated treatment pathways over a 10-year time horizon. Transition probabilities were based on institutional recurrence rates (3-year RR 6.7 % for MMS-E vs 34.1 % for WLE). We used a willingness-to-pay threshold of 100,000 USD per QALY.

Results

The cost of a single surgical episode was 34,664 USD for MMS-E and 14,969 USD for WLE. In the setting of lower recurrence rates with MMS-E, the incremental cost was 12,789 USD per disease-free year gained. A secondary analysis incorporating QALY showed an incremental cost of 72,820 USD per QALY.

Conclusions

MMS-E appears to be a cost-effective treatment for vulvar Paget's disease compared to historic standard of care. Our ability to estimate quality of life gained by avoiding disease recurrence was limited by scant data for this rare condition; thus, future studies incorporating health utility values are needed to facilitate a more comprehensive analysis.

Therapeutic outcomes and survival analysis of Extramammary Paget's disease: A multicentre retrospective study of 249 patients

BACKGROUND

Evidence regarding long-term therapeutic outcomes and disease-specific survival (DSS) in Extramammary Paget's disease (EMPD) is limited.

OBJECTIVES

To assess the DSS and outcomes of surgical and nonsurgical therapeutic modalities in a large cohort of EMPD patients.

METHODS

Retrospective chart review of EMPD patients from 20 Spanish tertiary care hospitals.

RESULTS

Data on 249 patients with a median follow-up of 60 months were analyzed. The estimated 5-, 10-, and 15-year DSS was 95.9%, 92.9%, and 88.5%, respectively. A significantly lower DSS was observed in patients showing deep dermal invasion (≥1 mm) or metastatic disease (P < .05). A ≥50% reduction in EMPD lesion size was achieved in 100% and 75.3% of patients treated with surgery and topical therapies, respectively. Tumor-free resection margins were obtained in 42.4% of the patients after wide local excision (WLE). The 5-year recurrence-free survival after Mohs micrographic surgery (MMS), WLE with tumor-free margins, WLE with positive margins, radiotherapy, and topical treatments was 63.0%, 51.4%, 20.4%, 30.1%, and 20.8%, respectively.

LIMITATIONS

Retrospective design.

CONCLUSIONS

EMPD is usually a chronic condition with favorable prognosis. MMS represents the therapeutic alternative with the greatest efficacy for the disease. Recurrence rates in patients with positive margins after WLE are similar to the ones observed in patients treated with topical agents.

Mohs surgery for female genital Paget's disease: a prospective observational trial

BACKGROUND

Extramammary Paget's disease recurs often after traditional surgical excision. Margin-controlled surgery improves the recurrence rate for male genital disease but is less studied for female anatomy.

OBJECTIVE

This study aimed to compare surgical and oncologic outcomes of margin-controlled surgery vs traditional surgical excision for female genital Paget's disease.

STUDY DESIGN

We conducted a prospective observational trial of patients with vulvar or perianal Paget's disease treated with surgical excision guided by Mohs micrographic surgery between 2018 and 2022. The multidisciplinary protocol consisted of office-based scouting biopsies and modified Mohs surgery followed by surgical excision with wound closure under general anesthesia. Modified Mohs surgery cleared peripheral disease margins using a moat technique with cytokeratin 7 staining. Medial disease margins (the clitoris, urethra, vagina, and anus) were assessed using a hybrid of Mohs surgery and intraoperative frozen sections. Surgical and oncologic outcomes were compared with the outcomes of a retrospective cohort of patients who underwent traditional surgical excision. The primary outcome was 3-year recurrence-free survival.

RESULTS

Three-year recurrence-free survival was 93.3% for Mohs-guided excision (n=24; 95% confidence interval, 81.5%-100.0%) compared to 65.9% for traditional excision (n=63; 95% confidence interval, 54.2%-80.0%) (P=.04). The maximum diameter of the excisional specimen was similar between groups (median, 11.3 vs 9.5 cm; P=.17), but complex reconstructive procedures were more common with the Mohs-guided approach (66.7% vs 30.2%; P<.01). Peripheral margin clearance was universally achieved with modified Mohs surgery, but positive medial margins were noted in 9 patients. Reasons included intentional organ sparing and poor performance of intraoperative hematoxylin and eosin frozen sections without cytokeratin 7. Grade 3 or higher postoperative complications were rare (0.0% for Mohs-guided excision vs 2.4% for traditional excision; P=.99).

CONCLUSION

Margin control with modified Mohs surgery significantly improved short-term recurrence-free survival after surgical excision for female genital Paget's disease. Use on medial anatomic structures (the clitoris, urethra, vagina, and anus) is challenging, and further optimization is needed for margin control in these areas. Mohs-guided surgical excision requires specialized, collaborative care and may be best accomplished at designated referral centers.

Fluorescein mapping for identification of residual satellite vulvar Paget's lesion

Background

Vulvar Paget disease (VPD) is a rare neoplastic condition exhibiting extensive multifocal involvement. It is clinically difficult to distinguish the margins of VPD from normal skin resulting in involved surgical margins leading to frequent lesion persistence and repeated excisions. Recently, fluorescein mapping has shown promise in providing accurate surgical margins in VPD. However, utilization of this technique after previous resection has not been explored.

Case

A 63-year-old female underwent wide local excision of a large microinvasive VPD with involved resection margins. Two months later, the patient underwent additional surgery to excise the involved margins and for sentinel inguinal lymph nodes evaluation. With gross visualization, the vulvar skin appeared normal. However, after intravenous fluorescein sodium injection and Wood's lamp illumination, residual satellite pathological area was observed and resected, revealing more microinvasive tumor.

Conclusion

Fluorescein mapping directly highlights sites of involvement in VPD and provides an improved estimation of disease extent which is otherwise not clinically visible.

Pathologically Confirmed Subcutaneous Fat and Lymphovascular Invasion of a Hypopigmented Area in Extramammary Paget Disease

Extramammary Paget disease (EMPD) is a rare adenocarcinoma that usually occurs in areas of the body that are rich in apocrine sweat glands. Great depth of tumor invasion is a well-known risk factor for worse prognosis. Paget cells usually are limited to the epidermis, whereas invasive EMPD, which infiltrates the dermis, is relatively rare. It is even rarer for the tumor to spread beyond the dermis. Only 3.1% of patients with EMPD of the penis and scrotum have exhibited infiltration of the subcutaneous fat layer. We report a case of a 62-year-old male with EMPD that invaded the subcutaneous fat layer. He presented with a several-year history of a slowly expanding erythematous plaque with the hypopigmented area on the left penoscrotum. One month before presentation, the patient had undergone punch biopsy at another hospital and diagnosed with EMPD. He had no personal history of urogenital cancers. The patient was treated with Mohs micrographic surgery, and negative margins were achieved after four stages. The histopathologic findings revealed Paget cells scattered throughout the epidermis. At the hypopigmented area, Paget cells extended to the subcutaneous fat layer with lymphovascular invasion. There was no evidence of recurrence at seven months postoperatively. Herein, we describe a case of hypopigmented EMPD that infiltrated the subcutaneous layer, which rarely has been reported in Korea.

The role of sentinel lymph node biopsy in extramammary paget disease: a systematic review

Sentinel lymph node biopsy is increasingly used to detect subclinical nodal metastases in extramammary Paget disease. We performed a comprehensive systematic review of the literature to further explore the role of sentinel lymph node biopsy in extramammary Paget disease. Five databases were searched for relevant terms. Articles were included if they were in English and presented primary data on at least one patient with extramammary Paget disease who underwent sentinel lymph node biopsy in the absence of lymphadenopathy or known metastatic disease. Twenty-eight articles were included, with 366 subjects. Seventy-seven sentinel node biopsies (21.2%) were positive, including 12 in which the primary tumor had microinvasion (15.6%) and 56 with deep invasion (72.7%). Of the positive cases, 11 (14.3%) had no further treatment, 54 (70.1%) underwent nodal dissection, 4 (5.2%) were treated with systemic agents, and 1 (1.3%) had radiation. After a mean follow up of 24 months, 9 subjects with a positive lymph node biopsy experienced nodal recurrence (11.7%), 15 had distant metastases (19.5%), and 13 died of the disease (16.9%). In conclusion, invasive extramammary Paget disease is strongly associated with poor outcomes including nodal metastasis, distant metastasis, and disease specific death. Sentinel lymph node biopsy is a useful tool to screen for subclinical nodal metastases in invasive disease, and can be used to help guide clinical management.

Impact of combining photodynamic diagnosis with reflectance confocal microscopy, on tumor margin detection and surgical outcomes in patients with extramammary Paget disease

Background The recurrence rate of extramammary Paget disease after surgical resection is high due to the lesions' poorly delineated and unclear margins. Aims To evaluate the impact of non-invasive tumour margin detection via photodynamic diagnosis plus reflectance confocal microscopy on the surgical outcomes of patients with extramammary Paget disease. Methods Thirty-six patients with histopathologically confirmed primary extramammary Paget disease between January 2017 and June 2018 were included in this study. The skin lesion margins were preoperatively observed using the naked eye, photodynamic diagnosis, and reflectance confocal microscopy. An incision was made 0.5-2 cm from the outermost non-invasive detection marker line. The incision depth was more significant than the follicle level or the deepest level affected by the tumour in the biopsy specimens. After the skin lesions were removed, a pathological examination of the specimens was conducted to ensure clear margins to prevent tumour recurrence and metastases. Results A total of 166 good-quality tissue sections were selected from 36 patients. The tumour surfaces and deep margins were within the scope of resection. Six patients (6/36, 15.4%) experienced local recurrence 2-12 months postoperatively. One patient (1/36, 2.8%) had lymph node metastasis without local recurrence 36 months postoperatively and died 50 months postoperatively (1/36, 2.8%). Limitations This study is limited by the small patient population, especially the number of patients with mucous membrane involvement. Conclusion Using photodynamic diagnosis plus reflectance confocal microscopy to detect the margins of extramammary Paget disease lesions non-invasively reduces the postoperative tumour recurrence rate and is a valuable guide for tumour treatment.

[Micrographic controlled surgery in everyday dermatosurgery]

Micrographic controlled surgery (MCS) has become established in dermatosurgery in recent years and includes various methods to enable the histologically proven complete resection of malignant cutaneous tumors, while at the same time sparing tumor-free tissue in the immediate vicinity as much as possible. MCS is of great importance in the surgical treatment of cutaneous malignancies in so-called problem locations and aggressive tumor subtypes. Indications for MCS include basal cell carcinoma, cutaneous squamous cell carcinoma, Bowen's disease and Bowen's carcinoma, melanoma in chronic light-damaged skin with acral lentiginous melanoma, dermatofibrosarcoma protuberans (DFSP), and Merkel cell carcinoma. However, other tumor entities are also treated using MCS, such as extramammary Paget's disease and various cutaneous sarcomas. All procedures subsumed under MCS have in common the marking of the surgical specimen for topographical orientation, which provides assignment of remaining tumor remnants. Various methods of MCS (3D histology, the horizontal method or Mohs surgery) are presented in this article. Furthermore, this article aims to raise awareness of the possibilities and limitations of micrographically controlled surgery.

Fluorescein Mapping in Vulvar Paget Disease

BACKGROUND

Vulvar Paget disease often requires extensive and, in some cases, multiple resections to treat. A fluorescein-mapping procedure followed by a staged vulvectomy may be an effective technique to tailor resection and identify clinically occult lesions.

TECHNIQUE

We describe a two-step procedure; first, intravenous fluorescein sodium is injected, and the vulva is illuminated with a Wood's lamp. Representative biopsies are obtained and correlated on final pathology with the extent of disease to develop a final plan for excision. Second, using fluorescein to identify the confirmed areas of disease, the appropriate excisional procedure is performed once mapping biopsy pathology is known.

EXPERIENCE

We describe our experience with eight patients with vulvar Paget disease undergoing fluorescein mapping biopsies and staged vulvectomy. Using intravenous fluorescein sodium, all patients were found to have Paget disease beyond the visible margins of their gross lesions. No patients experienced a recurrence of Paget disease within a median follow-up time of 32 months, comparable with other directed methods of surgical resection.

CONCLUSION

We report a technique for the injection of fluorescein sodium for the visualization of vulvar Paget disease capable of providing accurate surgical margins and identification of occult satellite lesions with a high degree of safety and a favorable cost profile. This staged approach to vulvectomy could offer improved accuracy of resection for vulvar Paget disease with few drawbacks.

Sex differences in initial treatment for genital extramammary Paget disease in the United States: A systematic review

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.

The Clinical Characteristics and Prognostic Factors of Primary Extramammary Paget's Disease Treated with Surgery in Anogenital Regions: A Large Population Study from the SEER Database and Our Centre

BACKGROUND

Extramammary Paget's disease (EMPD) is a rare malignant cutaneous tumour that is commonly located in anogenital regions. The diagnosis of the disease is always delayed, and treatment is usually troublesome. This study aims to summarise the clinicopathological characteristics and the risk factors of prognosis for EMPD in anogenital regions, potentially providing evidence for the diagnosis and treatment of anogenital EMPD.

METHODS

688 patients were sourced from the Surveillance, Epidemiology and End Results (SEER) program between 1992 and 2021. In total, 176 participants from our centre from between 2011 and 2021 were included to investigate the characteristics and prognosis for EMPD in anogenital regions.

RESULTS

From the SEER program data, patient age of 65 years or older, metastasis of lymph nodes, Spanish-Hispanic-Latino race, diameter exceeding 10cm and lesions located anally were revealed as independent risk factors for shorter cancer-specific survival (CSS). However, the data from our centre highlighted that metastasis of lymph nodes and tumours extending through the epidermis are independent risk factors of shortened progression-free survival (PFS) and CSS of anogenital EMPD.

CONCLUSION

This synthesised study revealed that some characteristics are regarded as risk factors for poor clinical prognosis, which have potential value in formulating more normative and effective strategies for patients with EMPD in anogenital regions.

Mohs micrographic surgery in rare cutaneous tumors: a retrospective study at a Brazilian tertiary university hospital

BACKGROUND

Mohs micrographic surgery is an established technique in the treatment of cutaneous neoplasms. It offers higher cure rates and the main indications are non-melanoma malignant skin tumors. Few studies have been performed on the treatment of rare tumors through this technique.

OBJECTIVE

To study rare skin tumors and rare variants of basal cell carcinoma and squamous cell carcinoma submitted to Mohs micrographic surgery in a tertiary service in relation to frequency, disease-free evolution, and applicability of this surgical procedure for this group of tumors.

METHODS

This was a retrospective observational study including rare skin tumors and less common variants of basal cell carcinoma and squamous cell carcinoma treated using Mohs micrographic surgery, between October 2008 and April 2021.

RESULTS

During the study period, 437 tumors were treated using Mohs micrographic surgery, and 22 (5%) rare skin tumors were selected. The tumors comprised three dermatofibrosarcomas protuberans, two atypical fibroxanthomas, two spiradenomas, two hypercellular fibrohistiocytomas, one primary cutaneous adenocarcinoma, one trichoblastoma, one porocarcinoma, one chondroid syringoma, one cutaneous angiosarcoma, one Merkel cell carcinoma, and one sebaceous carcinoma. Six other cases of rare basal cell carcinoma variants with trichoepitheliomatous differentiation, metatypical basal cell carcinoma, and clear cell squamous cell carcinoma were included. There were no cases of recurrence after an average of six years of follow-up.

STUDY LIMITATIONS

This is a retrospective study on rare neoplasms carried out in a single referral center, and this surgical technique isn't widely available in the public service.

CONCLUSION

This retrospective case series showed that Mohs micrographic surgery is an appropriate treatment for rare skin tumors. They corresponded to 5% of the tumors treated by the technique during a 12-year-period, with no recurrences identified.

Local Recurrence Rates of Extramammary Paget Disease Are Lower After Mohs Micrographic Surgery Compared With Wide Local Excision: A Systematic Review and Meta-Analysis

BACKGROUND

Extramammary Paget disease (EMPD) is a rare, slow growing neoplasm that presents most commonly in the anogenital region of older adults.

OBJECTIVE

To analyze the difference in local recurrence rates of EMPD in patients treated with wide local excision (WLE) versus Mohs micrographic surgery (MMS).

MATERIALS AND METHODS

A systematic review of the literature and meta-analysis were performed. Inclusion criteria were adults greater than 18 years of age with a diagnosis of EMPD who have undergone surgical intervention and had follow-up data. Studies were independently reviewed by 2 coinvestigators with discrepancies resolved by the principal investigator.

RESULTS

Twenty-seven studies met the inclusion criteria. Patients had a 2.67 times higher chance of local recurrence after WLE than MMS (95% confidence interval [CI]:1.47, 4.85; p = .001). Meta-analysis of single-arm studies revealed a 7.3% local recurrence rate after MMS (95% CI: 0.039, 0.107; p < .001) versus a 26.3% recurrence rate after WLE (95% CI: 0.149, 0.376; p < .001). After excluding recurrent tumors, the odds ratio for recurrence in WLE versus MMS was 2.3 (95% CI: 0.285, 18.43, p = .435).

CONCLUSION

There is a clinically and statistically increased risk of local recurrence of EMPD after WLE compared with MMS.

Nomograms for predicting the prognosis of patients with penoscrotal extramammary Paget’s disease: A retrospective study in the SEER database and two medical centers

Background

Extramammary Paget’ s disease (EMPD) is a rare cutaneous malignant tumor, and the prognostic factors associated with penoscrotal EMPD remains unclear. The purpose of this study is to investigate prognostic factors and construct nomograms to predict the outcome of patients with EMPD located in the penis or scrotum.

Methods

From the Surveillance, Epidemiology and End Results (SEER) database, we extracted 95 patients with primary EMPD located in the penis or scrotum as the training cohort. Forty-nine penoscrotal EMPD patients were included from two medical centers as the external validation cohort. Univariate and multivariate Cox regression model were applied to investigating risk factors of cancer-specific survival (CSS) and overall survival (OS). Based on the results of multivariate Cox regression analysis, the nomograms were constructed for predicting CSS and OS of patients with penoscrotal EMPD. The concordance index (C-index), receiver operating characteristic (ROC) curves and calibration curves were applied to evaluate the practicability and accuracy of the nomograms.

Results

In the training cohort, multivariate Cox regression analysis showed that marital status and tumor stage were independent factors of CSS, and marital status, tumor stage and surgery are associated with OS independently in patients with penoscrotal EMPD. Based on these results, we developed nomograms to predict CSS and OS respectively. The C-index values were 0.778 for CSS, and 0.668 for OS in the training set, which displayed the good discriminations. In the external validation set, the C-index values were 0.945 for CSS, and 0.703 for OS. The areas under the curve (AUC) values of nomogram predicting 1-, 3-, and 5-year CSS were 0.815, 0.833, and 0.861 respectively, and 0.839, 0.654, and 0.667 for nomogram predicting 1-, 3-, and 5-year OS respectively. In the validation set, the AUC values of nomogram predicting 1-, 3-, and 5-year CSS were 0.944, 0.896, and 0.896 respectively, and 0.777, 0.762 and 0.692 for nomogram predicting 1-, 3-, and 5-year OS respectively. Additionally, the internal calibration curves also proved that our nomograms have good accuracy.

Conclusions

By incorporating marital status, tumor stage and/or surgery, our nomograms can efficiently predict CSS and OS of patients with penoscrotal EMPD.

Scrotal Extramammary Paget’s Disease in an Elderly Caucasian Male

Extramammary Paget’s disease (EMPD) is a rare dermatologic malignancy affecting regions with a dense population of apocrine glands within the intraepithelial tissue, including the vulva, perineum, axilla, scrotum, and penile regions. Clinical presentation varies from being asymptomatic to burning, painful, and pruritic lesions. As a result, it could be misdiagnosed for other dermatologic diseases. Our case report discloses a patient with an erythematous pruritic lesion that was initially treated with topical antifungal therapy. After failed treatment, a biopsy revealed EMPD of the scrotum. With no standard guidelines in the treatment of EMPD, there are different treatment modalities for the disease. Mohs micrographic surgery currently is the preferred treatment modality presenting with the lowest rates of recurrence. With early diagnosis and treatment, the five-year survival rate for patients with primary EMPD is 87%. Therefore, there should be a high level of clinical suspicion for EMPD in patients presenting with pruritic lesions in areas with apocrine glands that have failed initial medical treatment.

The Paget Trial: topical 5% imiquimod cream for noninvasive vulvar Paget disease

BACKGROUND

Vulvar Paget disease is an extremely rare skin disorder, which is most common in postmenopausal women. Most vulvar Paget disease cases are noninvasive; however, it may be invasive or associated with an underlying vulvar or distant adenocarcinoma. The current treatment of choice for noninvasive vulvar Paget disease is wide local excision, which is challenging because of extensive intraepithelial spread and may cause severe morbidity. Recurrence rates are high, ranging from 15% to 70%, which emphasizes the need for new treatment options. Imiquimod, a topical immune response modifier, has been shown to be effective in a few studies and case reports, and is a promising new treatment modality.

OBJECTIVE

To prospectively investigate the efficacy, safety, and effect on quality of life of a standardized treatment schedule with 5% imiquimod cream in patients with noninvasive vulvar Paget disease.

STUDY DESIGN

The Paget Trial is a multicenter prospective observational clinical study including 7 tertiary referral hospitals in the Netherlands. A total of 24 patients with noninvasive vulvar Paget disease were treated with topical 5% imiquimod cream 3 times a week for 16 weeks. The primary efficacy outcome was the reduction in lesion size at 12 weeks after the end of treatment. Secondary outcomes were safety, clinical response after 1 year, and quality of life. Safety was assessed by evaluation of adverse events and tolerability of treatment. Quality of life was investigated with 3 questionnaires taken before, during, and after treatment.

RESULTS

Data were available for 23 patients, 82.6% of whom responded to therapy. A complete response was reported in 12 patients (52.2%), and 7 patients (30.4%) had a partial response. A histologic complete response was observed in 10 of the 12 patients with a complete response. Patients experienced side effects such as fatigue (66.7%-70.9%) and headaches (16.7%-45.8%), and almost 80% needed painkillers during treatment. Eight patients (34.8%) adjusted the treatment protocol to 2 applications a week, and 3 patients (13.0%) stopped treatment because of side effects after 4 to 11 weeks. Treatment improved quality of life, whereas a slight, temporary negative impact was observed during treatment. Two patients with a complete response developed a recurrence within 1 year after treatment. Follow-up showed 6 patients with a noninvasive recurrence after a median of 31 months (14-46 months) after the end of treatment.

CONCLUSION

Topical 5% imiquimod cream can be an effective and safe treatment alternative for noninvasive vulvar Paget disease, particularly when compared with treatment with surgical excision.

Current Management and Treatment of Extramammary Paget's Disease

OPINION STATEMENT

Extramammary Paget's disease (EMPD) is a rare neoplastic disease affecting areas rich in apocrine glands in the elderly. EMPD clinically resembles a benign inflammatory skin disease, and ill-defined tumor borders can lead to misdiagnosis and incomplete excision. Several prognostic factors have been reported, including nodule formation, tumor thickness, tumor invasion, lymphovascular invasion, and a perianal location, which are characteristic of primary tumors. EMPD typically presents as an in situ tumor spreading horizontally within the epidermis and then invading into the dermis as it transitions to a vertical growth phase. For this reason, tumor thickness, rather than tumor size, is correlated with patient prognosis. The best treatment for resectable EMPD is complete surgical removal of the tumor. EMPD sometimes has unclear tumor borders, and it can unexpectedly spread beyond its clinical boundaries. Surgical resection in such cases is often associated with tumor-positive margins, which can result in recurrence. However, surgical excision with wide margins may deteriorate patients' organ functions and quality of life. Mohs micrographic surgery may be ideal for controlling the surgical margins and minimizing the sacrifice of normal tissue, but this technique is not always feasible because of constraints associated with the medical environment. No standard treatment for unresectable or metastatic EMPD has been established. Although conventional chemotherapy has been used as the first-line treatment, it frequently causes adverse events, and consequently, targeted therapy will become more valuable in the near future.

PDD-guided tumor excision combined with photodynamic therapy in patients with extramammary Paget's disease

BACKGROUND

In recent years, photodynamic diagnosis (PDD) has been a technique that plays a pivotal role in visualizing tumor size during the assessment of surgery. Photodynamic therapy (PDT) is a developing treatment method apart from surgery, chemotherapy, radiotherapy, and immunotherapy and is approved for several types of tumors and nonmalignant diseases. The purpose of this study was to illustrate the efficiency and safety of PDD-guided tumor excision combined with ALA-PDT in patients with extramammary Paget's disease (EMPD).

METHODS

In our study, 7 cases of EMPD were treated with PDD-guided tumor excision combined with ALA-PDT. After removal of the tumor detected by PDD, each tumor region was irradiated with 177 J/cm² using a 635-nm laser for 15 min. Two to four ALA-PDT cycles were applied during and after surgery. EMPD was confirmed by biopsy.

RESULTS

PDD may forecast tumor margins in EMPD to guide surgery, and PDT has an inhibitory effect on tumor growth. There was no local recurrence in the follow-up of 2.9 years (range, 0.8-5 years). Only one patient experienced distant recurrence under the armpit. The patients with EMPD were able to complete the treatment protocol, with good results and no significant side effects.

CONCLUSIONS

The present study demonstrated an effective protocol using PDD for diagnosis and PDT for multiple therapies, showing potential as an alternative clinical treatment for EMPD.

Hypopigmentation in Extramammary Paget Disease Is an Important Prognostic Factor for High Recurrence Rate and Poor Surgical Outcome

BACKGROUND

Several studies have reported the presence of hypopigmentation in extramammary Paget disease (EMPD). However, an in-depth analysis regarding its clinical implication is lacking.

OBJECTIVE

To evaluate the clinical characteristics of EMPD in the Korean population and to determine the implication of hypopigmentation on clinical outcomes.

METHODS

We retrospectively reviewed 124 cases of EMPD who underwent surgical treatment from a single tertiary hospital from December 2005 to March 2019. Baseline characteristics of the patients and hypopigmentation patterns were analyzed. Moreover, the number of stages of Mohs micrographic surgery (MMS) and recurrence rate were evaluated in relation to the hypopigmentation.

RESULTS

A total of 67.7% (n = 84) of the patients showed hypopigmentation. The adjusted odds ratio for recurrence in the hypopigmented group was 5.980, which was statistically significant (95% confidence interval = 1.347-26.553, p-value = 0.019). Furthermore, the average number of MMS stages was 2.92 in the hypopigmentation group, compared with 1.82 in the nonhypopigmentation group (p-value = .0016).

CONCLUSION

Hypopigmented lesions may disguise the tumor margin, thus raising the recurrence rate after surgery and the number of stages of MMS. The hypopigmentation status must be considered when deciding the surgical margin.

The application of Wood's lamp combined with 5-aminolevulinic acid for defining tumor margins in patients with extramammary Paget's disease

OBJECTIVE

To evaluate the value of Wood's lamp examination combined with 5-aminolevulinic acid (5-ALA) photodynamic therapy (PDT) to determine positive tumor margins in patients with extramammary Paget's disease (EMPD) before surgery.

METHODS

We admitted 36 patients with EMPD from January 2016 to June 2019. The experimental group was the 5-ALA-PDT group, and the control group was the wide local excision (WLE) group. In the 5-ALA-PDT group, Wood's lamp examination combined with 5-ALA-PDT was used to trace the fluorescence range, and multipoint biopsy was performed according to the pathology to determine the final excision scope. We applied the standard partial expansion excision method for the WLE group, while frozen pathology assessment was applied to confirm the excision range. We measured the overall resection area of the WLE group and 5-ALA-PDT group. We analyzed the overall duration of surgery, the number of frozen pathology sections, patient satisfaction with appearance and function, the rate of functional sequelae, and the recurrence rate for both groups.

RESULTS

The results suggested that the difference in final resection margin between the WLE group and the 5-ALA-PDT group was significant. The number of frozen pathology sections, overall surgery time, and recurrence rate were significantly lower in the experimental group than in the control group (p<0.05). The occurrence rate of functional sequelae in the experimental group was lower, and patient satisfaction with appearance and function was significantly higher than that of the control group (p<0.05).

CONCLUSION

Wood's lamp examination combined with 5-ALA-PDT may predict tumor margins in EMPD.

Outcomes of mohs microgrpahic resection for cutaneous malignancy involving the scrotum

INTRODUCTION

Squamous cell carcinoma (SCC) and extramammary Paget's Disease (EMPD) of the scrotum are exceedingly rare. Given their propensity for local invasion and treatment with wide local excision, they can be highly morbid conditions. Outcomes of Mohs Micrographic Surgery (MMS) for scrotal cutaneous malignancy is not well described in current literature. We hypothesized that MMS for scrotal cutaneous malignancy would provide equivalent or improved oncologic outcomes while limiting the morbidity associated with wide excision.

MATERIALS/METHODS

This is a retrospective review and analysis of a prospectively maintained database spanning entries from 2005 to 2019. Collected data included general patient characteristics and surgical characteristics reported on a per lesion basis. MMS was performed by our institution's department of dermatology using their standard technique.

RESULTS

Overall, a total of 26 consecutive patients with 28 lesions (SCC or EMPD) were analyzed. Out of our cohort of 15 patients with 16 scrotal SCC lesions, 10 (66%) patients were current or former smokers, 4 (26%) were immunosuppressed, and 2 (13%) had HPV infections. The median preoperative and postoperative size of SCC lesions were 5.7cm [2] and 20.2cm [2] respectively. There was one (6%) oncologic recurrence of SCC of the scrotum and one (6%) local wound complication. Our cohort also included 11 patients with 12 scrotal EMPD lesions. One patient (9%) had an underlying associated malignancy (prostate cancer). The preoperative and postoperative area of lesions were 50.6cm [2] and 96.4cm [2] respectively. One (9%) EMPD lesion had a positive final margin at resection requiring reoperation. After achieving negative surgical margins, no patients in this cohort had an oncologic recurrence. 3 (26%) scrotal EMPD cases had local wound postoperative complications, only one required reoperation.

CONCLUSION

To our knowledge, this is the first case series focused on MMS for both SCC and EMPD with scrotal involvement. Our data suggests that MMS for scrotal cutaneous malignancy may improve oncologic outcomes and may decreases local post-operative reconstructive issues when compared to reported outcomes of treatment with wide local excision. When able, scrotal cutaneous malignancy patients should be referred to urologists at centers with MMS capabilities as it likely will improve their outcomes. The urologist should maintain active involvement with these patients to coordinate this complex and advanced pattern of care.

Local Recurrence Rates of Skin Tumors After Resection With Complete Circumferential Peripheral and Deep Margin Assessment-Identification of High-Risk Entities

BACKGROUND

The local recurrence rates of malignant skin tumors after micrographic controlled surgery using complete circumferential peripheral and deep margin assessment (CCPDMA) are reported to be low. However, in daily practice, tumor entities with a significantly higher recurrence rate are found.

OBJECTIVE

The aim of the investigation was to identify these high-risk tumors to develop approaches for risk stratification.

PATIENTS AND METHODS

We included different malignant tumors that were surgically treated and examined with CCPDMA using paraffin sections and H&E staining. Re-excisions were performed until the tumor was completely removed.

RESULTS

Ninety-nine thousand three hundred seventy-two tumors were included in the study; the follow-up period was 4 years (median). Eight tumor entities were identified as high-risk entities, showing a significantly higher local recurrence rate of over 20%: desmoplastic squamous cell carcinoma, desmoplastic melanoma, Merkel cell carcinoma, microcystic adnexal carcinoma, pleomorphic sarcoma, liposarcoma as well as angiosarcoma, and extramammary Paget's disease.

CONCLUSION

Complete circumferential peripheral and deep margin assessment allows complete control of the resection margins and enables skin-sparing resections with low recurrence rates for basal cell carcinomas, nondesmoplastic squamous cell carcinomas, lentiginous melanomas, and dermatofibrosarcoma protuberans. However, other tumors show significantly higher recurrence rates and therefore need to be classified as high-risk tumors.

Treatment of Extramammary Paget Disease and the Role of Reflectance Confocal Microscopy: A Prospective Study

BACKGROUND

Extramammary Paget disease (EMPD) poses treatment challenges. Invasive and noninvasive treatment modalities exist with variable success reported. Reflectance confocal microscopy (RCM) is emerging as an adjuvant diagnostic tool.

OBJECTIVE

To evaluate the treatment of EMPD patients and the role of RCM.

METHODS

Prospective study. Demographic and tumor characteristics were recorded. Handheld-RCM was performed and correlated with histology. Treatment, clearance, pathology, and follow-up were all recorded.

RESULTS

Thirty-six EMPD lesions in 33 patients were included. Mean age was 71.7 years, and 23 were men. Mean number of surgical stages needed to clear margins was 1.9 (SD, 0.9; 1.0-3.0 stages), and mean margin needed to clear was 1.8 cm. Reflectance confocal microscopy correlated well with scouting punch biopsies (kappa, 0.93; p < .001). Disruption of the dermoepidermal junction was associated with invasive EMPD versus in situ (83.3% vs 25.9%) on histology (p = .01).

LIMITATIONS

Relatively small sample size.

CONCLUSION

Extramammary Paget disease is challenging, and lesion demarcation is of the utmost importance. Using a staged surgical excision approach, the mean margins needed were 1.8 cm, less than previously reported. Nonsurgical modalities, including radiation therapy, imiquimod, or photodynamic therapy can be considered if surgery is not pursued. Reflectance confocal microscopy is a valuable noninvasive imaging modality for the management of EMPD.

Initial topical monotherapy may increase the risk of recurrence in patients with extramammary Paget's disease

Although topical therapies are used to treat extramammary Paget's disease (EMPD), reliable treatment outcomes and the effects of these therapies on subsequent surgical treatments are unclear. To assess the clinical outcomes of topical treatment of EMPD and establish the treatment guidelines the medical records of 166 patients diagnosed with EMPD were retrospectively reviewed. The recurrence rate was evaluated according to the previous use of topical agents. Thirty-four patients (34/166, 20.5%) were initially treated with topical agents such as imiquimod, 5-fluorouracil, and ingenol mebutate. Three patients (3/34, 8.8%) showed clinical response, while 31 patients required subsequent therapy owing to treatment failure. Analysis of the prognostic factors of recurrence in 166 patients revealed that initial topical treatment increased the hazard ratio (HR) in both univariate and multiple Cox proportional hazards models (HR = 3.770, 95% confidence interval [CI] = 1.768-8.037, P = 0.001, and adjusted HR = 3.628, 95% CI = 1.558-8.450, P = 0.003). Patients treated with topical agents showed significantly poorer 3-year recurrence-free survival than the nontreated group (66.3% vs 88.6%, P < 0.001). Topical treatment may be deleterious for some EMPD patients, thus increasing the recurrence risk.

Penoscrotal Paget's disease

Paget's disease (PD) denotes an initially intra-epidermal adenocarcinoma that can later invade the dermis and metastasise. Among the extramammary forms of PD (EMPD), penoscrotal presentations are rarer than the vulvar and perianal forms. Once diagnosis has been confirmed by histopathological examination, a search for associated neoplasia must be conducted, although penoscrotal EMPD is less frequently associated with underlying neoplasia than mammary PD (MPD). The associated cancer most often involves a neighbouring organ, with prostate cancer being the most common, or in some cases consists of underlying cutaneous adnexal tumours. First-line therapy consists of surgical excision. Alternatives to surgery (imiquimod, CO₂ laser vaporisation, dynamic phototherapy) may be considered in certain cases.

Paget's disease of the vulva: A challenge for the gynaecologist

Paget's disease of the vulva is a rare form of extramammary Paget's disease mainly affecting postmenopausal women. Its pathophysiology remains largely unknown. Up to fairly recently, the only treatment for this disease was surgery, often mutilating the vulva, with significant psychosexual repercussions without the assurance of complete therapeutic efficacy. New therapeutic approaches -topical treatments, radiotherapy or chemotherapy- have emerged in recent years but lack consensual guidelines. We present a literature review of the recent results published in this field.

Extramammary Paget's Disease: A Review of the Literature Part II: Treatment and Prognosis

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%.

Extramammary Paget disease of the vulva: Management and prognosis

OBJECTIVE

To evaluate the clinicopathological characteristics, management and prognosis of patients with vulvar extramammary Paget disease of the vulva (EMPD).

MATERIALS AND METHODS

The U.S National Cancer Database was accessed and patients diagnosed between 2004 and 2015 with microscopically confirmed vulvar EMPD were selected. Overall survival (OS) was calculated for patients diagnosed between 2004 and 2014, who had at least one month of follow-up. Five year OS rates were calculated following generation of Kaplan-Meier curves while comparisons were made with the log-rank test.

RESULTS

A total of 2602 patients were identified. Median age at diagnosis was 72 years (range 31-90 years) and the majority were of White race (92%), without any co-morbidities (80.9%). Personal history of another tumor was present in 36.9% of patients. In situ EMPD was diagnosed in 994 cases (38.2%) and the majority (95.1%) were managed with local excision or vulvectomy. Five-year OS was 85.8%, while presence of positive margins was not associated with worse OS (p = 0.38). Invasive EMPD was diagnosed in 1608 (61.8%) patients. Staging information was available for 1172 patients, 75.3% had early stage disease. Most patients underwent surgical treatment (91.6%); 53.6% had positive margins. Performance of lymphadenectomy was infrequent (6.8%). Moreover, immunotherapy (4.5%), chemotherapy (1.5%) and radiation therapy (2.2%) were rarely employed in the management of invasive EMPD. Patients with early stage disease (n = 766) had better OS compared to those with advanced stage (n = 278) (5-yr OS rates were 84.3% and 73.6% respectively, p = 0.015) while presence of positive margins was not associated with worse OS (p = 0.35).

CONCLUSIONS

Extramammary Paget disease is a rare vulvar tumor. Surgical excision is the main treatment option while other modalities are rarely employed. Overall survival rates are encouraging.

Laparoscopic extralevator abdominoperineal excision for the treatment of perianal Paget's disease: A case report

RATIONAL

Perianal Paget's disease (PPD) is a very rare intraepithelial adenocarcinoma. Very few cases of PPD have been reported till date, so the treatment remains controversial and more experience is needed.

PATIENT CONCERNS

A 73-year-old female was admitted to several hospitals with diagnosed as "perianal eczema" in perianal lesion. After a variety of treatments, the patient's condition did not improve.

DIAGNOSES

Abdominopelvic computed tomography and rectal magnetic resonance imaging showed thickening of the soft tissue around the anus, with significant enhancement. Histologic examination revealed the state of Paget's cells.

INTERVENTIONS

Laparoscopic Extralevator Abdominoperineal Excision (ELAPE) surgery was performed at our department.

OUTCOMES

The patient recovered well. After 10 months, a check-up revealed that her perianal area was disease-free.

LESSONS

The aim of this report was to present the characteristics of PPD in order to improve its diagnosis and treatment. Laparoscopic ELAPE is a successful therapy.

Vulvar Cancer

This article reviews the epidemiology, diagnosis, and management of vulvar preinvasive lesions, squamous cell carcinoma, and melanoma. There is an emphasis on sentinel lymph node dissection for early stage disease and advances in chemoradiation for late-stage disease. A brief review of vulvar Paget disease is also included.

Extramammary Paget's disease: a review of the literature

Extramammary Paget's disease (EMPD) is a rare cutaneous malignancy. The disease typically affects older individuals aged 60-80 years and is seen most frequently in postmenopausal Caucasian women and Asian men. EMPD exhibits a predilection for the genital and perianal regions and may be associated with an underlying carcinoma in adjacent organs. EMPD presents a challenge in both diagnosis and management. Often treated empirically as various dermatitides, the correct diagnosis is frequently delayed by many years. Following diagnosis, an extensive search for an associated malignancy should be initiated. If invasive disease is present on biopsy, a sentinel lymph node biopsy may guide further treatment. Mohs micrographic surgery appears to be superior to wide local excision when considering tissue sparing ability and disease recurrence. Nonsurgical interventions have also been investigated with varied results. Regardless of treatment method, long-term follow-up is recommended to monitor for local disease recurrence, development of internal malignancy, regional lymphadenopathy, or distant metastasis.

Mohs Micrographic Surgery: Development, Technique, and Applications in Cutaneous Malignancies

Mohs micrographic surgery (MMS) is a specialized technique for treating skin malignancies that offers the highest cure rate by allowing histological evaluation of the entire peripheral and deep margins. MMS also maximally preserves as much uninvolved, normal adjacent tissue as possible, allowing for the best cosmetic and functional outcomes. When used for appropriate indications, this technique is also more cost-effective than other treatment modalities. In this article, the authors will discuss the development of MMS, the steps involved in this procedure, and the indications for this technique. They will also review the use of MMS for basal cell carcinoma, squamous cell carcinoma, melanoma in situ, and some less common skin malignancies.

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

Photodynamic Therapy is a procedure based on the interaction between a Photosensitizer, a light source with a specific wavelength and oxygen. The aim of this review is to provide a brief and updated analysis of scientific reports on the use of PDT with topical PS in the management of oncological, infectious, and inflammatory disorders involving mucosal and semimucosal areas, with a specific focus on diseases of dermatologic interest.

The diagnosis and management of extramammary Paget's disease

INTRODUCTION

Extramammary Paget's disease (EMPD) is a rare neoplastic condition that commonly affects the anogenital area in the elderly. Owing to its low incidence, limited data regarding EMPD's diagnosis and treatment have been available. This review article aims to explore the current knowledge of EMPD to improve the management of this disease. Areas covered: This review outlines the diagnosis and management of EMPD. Articles on this issue that had been published in PubMed were identified and surveyed. We provide an overview of the reported studies, focusing on the recent advances in this field. Expert commentary: A new TNM staging system specific for EMPD has been proposed in Japan; the T category was classified by tumor thickness and lymphovascular invasion, the N category by the number of metastatic lymph nodes, and the M category by systemic metastases. As new diagnostic tools for EMPD, dermoscopy and reflectance confocal microscopy have emerged. Recent reports about Mohs micrographic surgery, mapping biopsy, radiation therapy, photodynamic therapy, topical imiquimod, conventional chemotherapy, and targeted therapy are also discussed. Despite the increasing publications of EMPD, limited information on this condition is available and the accumulation of more data is required.

Extramammary Paget Disease of the Vulva: A Case Series Examining Treatment, Recurrence, and Malignant Transformation

Objectives

Extramammary Paget disease (EMPD) of the vulva is a rare lesion with a high recurrence rate ranging from 12% to 61%. The rate of underlying adenocarcinoma varies, but in the largest series was reported at 4%. Given the rarity of the disease there is a paucity of data to optimize treatment. This study aims to describe the management and recurrence patterns in a tertiary care setting and to offer suggestions for management in a modern-day setting.

Methods

Patients with pathologically confirmed EMPD treated from 2000 to 2015 were retrospectively identified using an IRB approved database. Clinical data were abstracted from the electronic medical record. Pathology underwent central review.

Results

Forty-four patients met criteria and underwent central pathology review. Forty-two patients were treated with surgical excision. Alternative treatment modalities included Mohs surgery in 3 patients and medical therapy in 20 patients. The median number of surgical procedures was 1 and the number of procedures ranged from 1 to 16. Twenty-five patients (56.8%) had recurrent disease with a median of 2 (1-6) recurrences per patient. The median disease-free interval was 28.7 months with a median follow up of 45.8 months (1.2-178.9 months). Three patients (7%) had invasive cancer and 7 patients (16%) were diagnosed with a separate malignancy at or following diagnosis of EMPD. Despite radical resection, the majority of patients had positive margins and there was no significant difference in disease recurrence between simple and radical resection (P = 0.69).

Conclusions

Patients with EMPD in this series have a high rate of recurrence. Many undergo multi-modal therapy often with multiple providers. However, patients experience relatively long disease-free intervals with a low rate of associated malignancy. We propose an algorithm for management that focuses on symptom control and minimizing morbidity of treatment intervention once invasive disease has been excluded.

Evaluation of mapping biopsies for extramammary Paget disease: A retrospective study

BACKGROUND

Extramammary Paget disease (EMPD) sometimes shows an ill-defined border and an unexpectedly extended tumor spread beyond the clinical borders. Mapping biopsy is 1 approach for complete surgical removal, but its efficacy has remained controversial.

OBJECTIVE

We sought to evaluate mapping biopsies for EMPD.

METHODS

We performed a retrospective review of 133 patients with 150 primary EMPD lesions. We histopathologically examined 1182 skin biopsy specimens (975 from mapping biopsy and 207 from lesional biopsy).

RESULTS

Only 1.6% of mapping biopsy specimens from well-defined EMPD (13 of 810) were positive. Moreover, 4.6% of mapping biopsy specimens from ill-defined EMPD (8 of 165) were positive, whereas all specimens taken from sites 2 cm or more from the clinical border were negative. For both well-defined and ill-defined EMPD, there was no significant difference in the margin status of surgical resection regardless of mapping biopsy.

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

Mapping biopsies are unnecessary for well-defined EMPD or when 2-cm margins can be achieved, whereas surgical removal with predetermined margins (1 cm for well-defined EMPD and 2 cm for ill-defined EMPD) appears to be safe. Mapping biopsies can be considered when shortening of the safe surgical margin to less than 2 cm is required in ill-defined EMPD.

The Paget Trial: A Multicenter, Observational Cohort Intervention Study for the Clinical Efficacy, Safety, and Immunological Response of Topical 5% Imiquimod Cream for Vulvar Paget Disease

Background

Vulvar Paget disease is a rare skin disorder, which is most common in postmenopausal Caucasian women. They usually present with an erythematous plaque that may show fine or typical “cake icing” scaling or ulceration that may cause itching, pain, irritation, or a burning sensation. Although most cases are noninvasive, vulvar Paget disease may be invasive or associated with an underlying vulvar or distant adenocarcinoma. The histological evidence of so-called “Paget cells” with abundant pale cytoplasm in the epithelium confirms the diagnosis. The origin of these Paget cells is still unclear. Treatment of choice is wide local excision with negative margins. Obtaining clear surgical margins is challenging and may lead to extensive and mutilating surgery. Even then, recurrence rates are high, ranging from 15% to 70%, which emphasizes the need for new treatment options. A number of case reports, retrospective case series, and one observational study have shown promising results using the topical immune response modifier imiquimod.

Objective

This study aims to investigate the efficacy, safety, and immunological response in patients with noninvasive vulvar Paget disease using a standardized treatment schedule with 5% imiquimod cream.

Methods

Topical 5% imiquimod cream might be an effective and safe treatment alternative for vulvar Paget disease. The Paget Trial is a multicenter observational cohort study including eight tertiary referral hospitals in the Netherlands. It is ethically approved by the Medical-Ethical Committee of Arnhem-Nijmegen and registered in the Central Committee on Research Involving Human Subjects (CCMO) Register by as NL51648.091.14. Twenty patients with (recurrent) noninvasive vulvar Paget disease will be treated with topical 5% imiquimod cream three times a week for 16 weeks. The primary efficacy outcome is the reduction in lesion size at 12 weeks after end of treatment. Secondary outcomes are safety, immunological response, and quality of life. Safety will be assessed by evaluation of adverse events and tolerability of treatment. To evaluate the immunological response, various immunological markers will be tested on biopsy specimens taken before, during, and after treatment. Quality of life will be assessed with three questionnaires taken before, during, and after treatment.

Results

First results are expected in the summer of 2018.

Trial Registration

ClinicalTrials.gov NCT02385188; https://clinicaltrials.gov/ct2/show/NCT02385188 (Archived by WebCite at http://www.webcitation.org/6sXygHuhP).