Photodynamic therapy for extramammary Paget’s disease: A systematic review of the literature

The use of photodynamic therapy in medical practice

Cancer therapy, especially for tumors near sensitive areas, demands precise treatment. This review explores photodynamic therapy (PDT), a method leveraging photosensitizers (PS), specific wavelength light, and oxygen to target cancer effectively. Recent advancements affirm PDT's efficacy, utilizing ROS generation to induce cancer cell death. With a history spanning over decades, PDT's dynamic evolution has expanded its application across dermatology, oncology, and dentistry. This review aims to dissect PDT's principles, from its inception to contemporary medical applications, highlighting its role in modern cancer treatment strategies.

Hematoporphyrin injection mediated photodynamic therapy for secondary squamous cell carcinoma of arsenical keratosis: A case report

Hematoporphyrin injection (HpD) mediated photodynamic therapy (PDT) has demonstrated efficacy in treating various types of Bowen's disease, including basal-cell carcinoma, squamous cell carcinoma, extramammary Paget's disease, and actinic keratosis. We present a case of a male patient who developed squamous cell carcinoma as a result of repeated instances of arsenic-induced keratosis on both his hands and feet. Due to the involvement of the joint in both hands, the patient declined the conventional surgical resection treatment since it could potentially impact normal physiological function. Instead, the patient chose to undergo hemoporphyrin photodynamic therapy. After the treatment, the rash was entirely eliminated and there were no restrictions in the movement of the joint. Nevertheless, a local recurrence was detected throughout the two-year monitoring period. Arsenical keratosis carries a substantial likelihood of recurring. However, we believe that hemoporphyrin photodynamic therapy is effective in treating this condition.

Complete remission of perineal extra-mammary Paget's disease by curative-intent radiotherapy using volumetric modulated arc therapy in a patient older than 90 years

ABSTRACT

Localized extra-mammary Paget's disease (EMPD) is mainly treated with surgical resection. Curative radiation therapy (CRT) is an alternative to surgery. Electron beams and conventional X-ray methods have been used in patients with EMPD for radiotherapy. The present report describes the case of a very elderly patient with perineal EMPD who was treated with definitive radiotherapy consisting of 60 Gy in 30 fractions. Surgery was deemed too difficult because of his age and comorbidities. We adopted volumetric modulated arc therapy as the radiotherapy modality, a recent, advanced form of intensity-modulated radiation therapy. Grade 3 dermatitis was observed as an acute phase adverse event, and he achieved a complete response and maintained remission for over one-year post-treatment. Our radiotherapy treatment protocol resulted in good clinical outcomes; therefore, it may be a candidate for inoperable patients with EMPD.

A Review of the Dermatologic Clinical Applications of Topical Photodynamic Therapy

Topical photodynamic therapy is a widely approved therapy for actinic keratoses and low-risk nonmelanoma skin cancers with a rapidly growing range of emerging indications for other cutaneous diseases. This review summarizes the best-available evidence to provide a clinical update for dermatologists on the approved and emerging indications of photodynamic therapy. The body of evidence suggests that photodynamic therapy is superior or noninferior to other available treatment modalities for actinic keratoses, low-risk basal cell carcinomas, Bowen's disease, skin field cancerization, chemoprevention of keratinocyte carcinomas in organ transplant recipients, photoaging, acne vulgaris, and cutaneous infections including verrucae, onychomycosis, and cutaneous leishmaniasis. There is emerging evidence that photodynamic therapy plays a role in the management of actinic cheilitis, early-stage mycosis fungoides, extramammary Paget disease, lichen sclerosis, and folliculitis decalvans but there are no comparative studies with other active treatment modalities. Common barriers to topical photodynamic therapy include procedural pain, costs, and the time required for treatment delivery. There is significant heterogeneity in the photodynamic therapy protocols reported in the literature, including different photosensitizers, light sources, number of treatments, time between treatments, and use of procedural analgesia. Topical photodynamic therapy should be considered in the management of a spectrum of inflammatory, neoplastic, and infectious dermatoses. However, more comparative research is required to determine its role in the treatment algorithm for these dermatologic conditions and more methodological research is required to optimize photodynamic therapy protocols to improve the tolerability of the procedure for patients.

Case report: Hematoporphyrin injection (HpD) photodynamic therapy for the treatment of groin extramammary Paget's disease in an elderly male patient

Hematoporphyrin Derivative-Photodynamic Therapy (HpD-PDT) is a modality for cancer treatment, particularly suitable for challenging sites or elderly patients who can benefit from its minimally invasive and selective nature. We report a case of groin extramammary Paget's disease (EMPD) in a male patient with a lesion located in the right mons pubis. The patient was deemed unsuitable for surgical treatment due to his advanced age, underlying health conditions, extensive rash area, and the specific location of the groin lesion. He opted for hematoporphyrin photodynamic therapy instead of traditional wide local excision. The tumors were successfully treated, with no recurrence observed during the follow-up period. We suggest that hematoporphyrin photodynamic therapy may be an effective alternative to conventional surgery for the treatment of extramammary Paget's disease.

Efficacy of Hematoporphyrin injection (HpD) photodynamic therapy in the treatment of widespread extramammary Paget's disease

Photodynamic therapy (PDT) utilizing Hematoporphyrin Derivative (HpD) injection has been demonstrated as an efficacious treatment for various conditions, including Bowen's disease, subtypes of basal cell carcinomas, and actinic keratosis. While surgical resection is considered the primary treatment option for extramammary Paget's disease (EMPD), but some patients may not be suitable candidates for surgical intervention. ALA-PDT may have some benefits in treating EMPD in select patients, while Hematoporphyrin Derivative-Photodynamic Therapy (HpD-PDT) has demonstrated promising potential as a cancer treatment. We present one case of vulvar extramammary Paget's disease (EMPD),that is a female patient with lesions in the vulva and involving the urethra. Due to advanced age, underlying diseases, the extensive affected area, and the specific location of the vulvar lesion, the patients were unable to undergo surgical treatment. Therefore, the patient declined traditional wide local excision and instead opted for hematoporphyrin photodynamic therapy. Treatment eliminated the tumor, but it recurred locally after 1.5 years of follow-up. Localized small-scale recurrence at the affected site can be treated with surgical resection or photodynamic therapy to achieve complete clearance of the lesion. However, the patient refuses further examination and treatment. EMPD has a high recurrence rate, but we propose that hematoporphyrin photodynamic therapy is an effective alternative to conventional surgery for treating this condition, even in case of recurrence.

Photodynamic therapy in a patient with perianal extramammary Paget's disease

Extramammary Paget's disease is a rare neoplasm of apocrine gland-bearing areas of the skin. One of the most common localizations of such a tumor is the perianal area. Surgery is the most frequently reported therapy. However, it is invasive and complicated by a high recurrence rate. An alternative to surgical treatment may be non-invasive photodynamic therapy. We describe in this article the case of a 69-year-old patient with extramammary Paget's disease (a large tumor in the perianal area 22 × 18 cm) successfully treated with chlorin e6 photodynamic therapy.

Global Trends and Research Progress of Photodynamic Therapy in Skin Cancer: A Bibliometric Analysis and Literature Review

Background

Based on photochemical reactions through the combined use of light and photosensitizers, photodynamic therapy (PDT) is gaining popularity for the treatment of skin cancer. Various photosensitizers and treatment regimens are continuously being developed for enhancing the efficacy of PDT on skin cancer. Reviewing the development history of PDT on skin cancer, and summarizing its development direction and research status, is conducive to the further research.

Methods

To evaluate the research trends and map knowledge structure, all publications covering PDT on skin cancer were retrieved and extracted from Web of Science database. We applied VOSviewer and CiteSpace softwares to evaluate and visualize the countries, institutes, authors, keywords and research trends. Literature review was performed for the analysis of the research status of PDT on skin cancer.

Results

A total of 2662 publications were identified. The elements, mechanism, pros and cons, representative molecular photosensitizers, current challenges and research progress of PDT on skin cancer were reviewed and summarized.

Conclusion

This study provides a comprehensive display of the field of PDT on skin cancer, which will help researchers further explore the mechanism and application of PDT more effectively and intuitively.

Photodynamic therapy in the treatment of extramammary paget’s disease

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

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.

Efficacy and safety of HpD-PDT for Extramammary Paget's Disease refractory to conventional therapy: A prospective, open-label and single arm pilot study

BACKGROUND

Extramammary Paget's Disease (EMPD) is an intraepithelial cancer that is prone to recurrence and sometimes refractory to therapy. A few EMPD cases have been treated with Photodynamic therapy (PDT), which reported high complete remission (CR) rates and low recurrence with hematoporphyrin derivatives (HpD) The aim of this study was to further explore the efficacy and safety of HpD-PDT for EMPD patients.

METHODS

Open-label, single arm, pilot study was designed to investigate the role of HpD-PDT in EMPD. The HpD sensitizer was given intravenously at a dose of 3 or 5 mg/kg 48 h before light irradiation with a laser 630 nm red light at a dose level of 150-200 J/cm². Clinical parameters involving gender, age, disease course, previous treatment, tumor thickness, long diameter of lesion, TNM staging, EMPD staging, HpD dosage, Visual Analogue Scale (VAS) score, 1st month visit result, subsequent treatment, follow up period and endpoint outcomes were collected to evaluate efficacy and safety of the intervention.

RESULTS

Eleven patients with pathologic confirmed EMPD were treated with HpD-PDT. The thickness of skin lesions which were located in vulva, penis, scrotum, and perianal area is 0.8∼6.7 mm (mean thickness 2.9 mm). All patients were followed up for an average of 17.4 months (12∼27 months). Complete remission (CR) rate and partial remission (PR) rate at the 1st month were 90.1% (10/11) and 9.1% (1/11) respectively. At the end of follow-up, 72.7% of the subjects (8/11) showed CR. Pain, infection, photosensitivity and uroschesis are recorded as adverse events (AEs) in this population, and no event of hepatic impairment was reported. After treatment, all the eleven patients showed different degrees of scar in the treatment site, but none of them had any structural or functional abnormalities.

CONCLUSIONS

According to our study, HpD-PDT in EMPD is able to offer acceptable disease outcomes including relatively high CR rate, with good cosmetic and functional outcomes, and could be considered a potential recommended therapy for patients with EMPD.

TRIAL REGISTRATION

Chinese Clinical Trial Register (ChiCTR-1900024965).

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.

Combined methyl aminolevulinate-based photodynamic therapy and imiquimod in a patient with perianal extramammary Paget's disease

Extramammary Paget's disease (EMPD) is a rare form of intraepithelial adenocarcinoma. Complete surgical removal of localized disease is the standard treatment for EMPD but carries anaesthesia-related risks and possible postoperative functional deficits. Herein, we present a case of perianal EMPD successfully treated with topical methyl aminolevulinate-based photodynamic therapy (MAL-PDT), followed by topical imiquimod. Immunohistochemical analysis after PDT revealed high expression of Toll-like receptor 7 on keratinocytes, Paget's cells, and dermal inflammatory cells, as well as increased expression of intraepidermal Langerhans cells, dermal macrophages, and T cells. We propose that MAL-PDT may prime the enhancing effects of topical imiquimod. Combined local treatment with PDT and imiquimod may provide an alternative and non-invasive strategy for perianal EMPD.