Depigmented genital extramammary Paget's disease: a possible histogenetic link to Toker's clear cells and clear cell papulosis

Treatment outcomes of advanced/metastatic extramammary Paget's disease in Korean patients: KCSG-RC20-06

BACKGROUND

Extramammary Paget's disease (EMPD) is rare. There are no standard treatments due to its rarity and few clinical trials.

METHODS

The objective of this multicenter study was to investigate treatment outcomes of Korean patients with advanced/metastatic EMPD. Data were collected retrospectively from 14 institutions participating in Korean Cancer Study Group (KCSG) Rare Cancer Committee.

RESULTS

A total of 37 patients were identified. Of these 37 patients, 6 received locoregional therapy as a first-line treatment. In 31 patients who received systemic chemotherapy as a first-line treatment, platinum-based chemotherapy (n = 22) achieved an objective response rate (ORR) of 45.5% and a median progression-free survival (PFS) of 7.89 months. Taxane-based chemotherapy (n = 8) achieved an objective response rate of 62.5% and median PFS of 9.73 months. In second-line chemotherapy, platinum-based chemotherapy (n = 4) had a disease control rate (DCR) of 75.0% and median PFS of 3.45 months. Taxane-based chemotherapy (n = 8) had a DCR of 75.0% and a median PFS of 8.67 months. Six patients received anti-human epidermal growth factor receptor 2 (HER2) antibody during first- and second-line chemotherapy. Overall, systemic chemotherapy combined with anti-HER2 antibody had an ORR of 100% and a median PFS of 13.31 months. The ORR and PFS with systemic chemotherapy combined with trastuzumab was better than platinum- and taxane-based chemotherapy only.

CONCLUSIONS

Due to its rarity, advanced or metastatic EMPD still has no established standard treatment. Results of our study indicate that the combination of trastuzumab with taxane has longer survival than trastuzumab monotherapy or conventional platinum- or taxane-based chemotherapy.

Toker Cell Hyperplasia in the Nipple-Areolar Complex of Transmasculine Individuals

We previously reported breast histopathologic features associated with testosterone therapy in transmasculine chest-contouring surgical specimens. During that study, we observed a high frequency of intraepidermal glands in the nipple-areolar complex (NAC) formed by Toker cells. This study reports Toker cell hyperplasia (TCH)-the presence of clusters of Toker cells consisting of at least 3 contiguous cells and/or glands with lumen formation-in the transmasculine population. Increased numbers of singly dispersed Toker cells were not considered TCH. Among the 444 transmasculine individuals, 82 (18.5%) had a portion of their NAC excised and available for evaluation. We also reviewed the NACs from 55 cisgender women who were aged <50 years old and had full mastectomies. The proportion of transmasculine cases with TCH (20/82; 24.4%) was 1.7-fold higher than cisgender women (8/55; 14.5%) but did not achieve significance (P = .20). However, in cases with TCH, the rate of gland formation is 2.4-fold higher in transmasculine cases, achieving borderline significance (18/82 vs 5/55; P = .06). Among transmasculine individuals, TCH was significantly more likely to be present in those with higher body mass index (P = .03). A subset of 5 transmasculine and 5 cisgender cases were stained for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), androgen receptor (AR), cytokeratin 7, and Ki67. All 10 cases were cytokeratin 7+ and Ki67-; 9 out of 10 cases were AR+. Toker cells in transmasculine cases demonstrated variable expression of ER, PR, and HER2. For cisgender cases, Toker cells were consistently ER+, PR-, and HER2-. In conclusion, there is a higher rate of TCH in the transmasculine than cisgender population, particularly among transmasculine individuals with high body mass index and taking testosterone. To our knowledge, this is the first study to demonstrate that Toker cells are AR+. Toker cell features display variable ER, PR, and HER2 immunoreactivity. The clinical significance of TCH in the transmasculine population remains to be elucidated.

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.

Male genital vitiligo

Vitiligo is a polygenetic multifactorial disease leading to melanocytic loss in skin and sometimes in hair. Genital areas may be involved and represent a specific therapeutic challenge. Surprisingly, data on male genital vitiligo remain scarce. This review aims to collate current knowledge on male genital vitiligo and to discuss the risks and benefits of the various therapeutic approaches. Male genital vitiligo is relatively frequent and often induces marked impairment of quality of life, with a specific impact on sex life. Prompt recognition of activity remains mandatory to halt disease progression, as repigmentation remains difficult to achieve in most cases. Thanks to progress in understanding of the pathophysiology of vitiligo, new therapeutic approaches are under development. Topical ruxolitinib, a JAK pathway inhibitor, is currently the product in the most advanced stage of development, with a very encouraging repigmentation rate on the face, although specific efficacy in genital area remains to be assessed. The next generation of treatments, such as topical WNT agonists, could be of great interest in genital vitiligo as they will not require combination with UV therapy and they may be able to enhance the differentiation and proliferation of melanocyte stem cells in this difficult-to-treat area.

Hormonal Environment and HER2 Status in Extra-Mammary Paget's Disease (eMPD): A Systematic Literature Review and Meta-Analysis with Clinical Considerations

Background. Extra-mammary Paget’s disease (EMPD) is a rare neoplasm of epithelial origin, whose precise incidence is not clear. Starting from what is already known, we performed a systematic review and meta-analysis to investigate in male and female patients the immunohistochemical expression of biological markers that could serve as potential prognostic/therapeutic factors, including only human epidermal growth factor receptor 2 (HER2/neu), Estrogen Receptor (ER), Progesterone Receptor (PR), and Androgen Receptor (AR). Methods. A literature search was performed of the PubMed, Scopus, and Web of Science databases for English-language studies published from January 2000 to June 2020. Results. A total of 27 studies with 713 patients assessed the role of HER2/neu, AR, ER, and PR expression in male and female with EMPD. The overall rate of HER2/neu expression was 30%, the expression’s rate for ER and AR was 13% and 40%, respectively, and the overall rate for PR was 8%. The subgroup analysis revealed that there is a different expression of molecular markers between male and female patients. Conclusions. This study revealed that AR status and HER2/neu overexpression/amplification have been shown as two fundamental pathogenetic pathways in both female and male patients affected by EMPD.

Extramammary Paget disease of the vulva

Extramammary Paget disease (EMPD) is a rare neoplasm with uncertain histogenesis, usually presenting in the anogenital area, most commonly in the vulva. The disease is characterized by slow grow and high recurrence rates. This article reviews the epidemiological, clinical, morphological, genetic and treatment features of EMPD of the vulva reported in recent years.

Acquired disorders with depigmentation: A systematic approach to vitiliginoid conditions

Acquired disorders with depigmentation are commonly encountered by dermatologists and present with a wide differential diagnosis. Vitiligo, the most common disorder of acquired depigmentation, is characterized by well-defined depigmented macules and patches. Other conditions, such as chemical leukoderma, can present with similar findings, and are often easily mistaken for vitiligo. Key clinical features can help differentiate between acquired disorders of depigmentation. The first article in this continuing medical education series focuses on conditions with a vitiligo-like phenotype. Early recognition and adequate treatment of these conditions is critical in providing appropriate prognostication and treatment.

Clear Cell Papulosis: A Rare Pediatric Dermatosis

The diagnosis and management of pediatric hypopigmented lesions can be challenging given their wide range of differentials. In this case report, we present a case of a 3-year-old Chinese boy who was initially treated for tinea versicolor but subsequently diagnosed to have clear cell papulosis. The features, diagnosis, and management of clear cell papulosis are discussed in this article to raise awareness of this condition amongst pediatricians.

Extramammary Paget’s Disease Versus Lichen Sclerosus

Burning, itching and dyspareunia are typical symptoms of many genital diseases. These subjective complaints can be misdiagnosed because of different clinical presentations. We present a case report of a postmenopausal woman treated for genital warts over a period of three years followed by the development of leukoplastic lesions in the whitish area clinical classified as Lichen sclerosus (LS). Histology of this lesion revealed carcinoma in situ. After radical surgical removal, vulvar Paget’s disease was histologically verified. LS and extramammary Paget's disease (EMPD) belong to a group of uncommon dermatoses which mainly affect the skin of the genitals in postmenopausal women. Ulceration, erosions and leukoplastic lesions can signalize the development of squamous cell carcinoma in association of lichen sclerosus, on the other hand, they can be the sign of EMPD after a long period of time using different topical agents. The importance of reaching the correct diagnosis is essential and can influence current patient investigations and invasive or non-invasive treatment.

Clear Cell Papulosis: Report of a Case With Unique Clinical and Histologic Findings

Clear cell papulosis is a rare, self-limited, benign disease of early childhood, characterized by white macules and flat papules over the milk line. Histopathologically, it is characterized by scattered clear cells throughout the basal and/or suprabasal epidermal layers, which-as clear cells of Toker of the nipple do-typically express cytokeratin 7. They also exhibit other markers expected for adenoid differentiation, such as low-molecular weight cytokeratins, carcinoembryonic antigen, epithelial membrane antigen, and mucin. The age of onset, distribution of lesions, histopathology, and its benign behavior nature help to exclude clinically similar conditions, either benign or malignant. The authors report a case of clear cell papulosis in a 7-year-old Brazilian girl in whom lesions were observed on the legs and histologically formed by solid and adenoid aggregates of clear cells, in a similar fashion than clear fetal cells of Toker.

Diagnostic utility of p63 expression in the differential diagnosis of pagetoid squamous cell carcinoma in situ and extramammary Paget disease: a histopathologic study of 70 cases

Pagetoid squamous cell carcinoma in situ (PSCCIS) is characterized by cytologically atypical cells, with abundant, pale-staining cytoplasm arranged singly and in nests within the epidermis (pagetoid distribution). The growth pattern of PSCCIS may simulate extramammary Paget disease (EMPD), and in some cases, it is difficult to differentiate the 2 entities based on histomorphology alone. In this study, biopsy samples from 30 cases of PSCCIS and 40 cases of primary EMPD were examined using immunohistochemical staining for p63. In cases where the boundaries between the pagetoid cells and surrounding keratinocytes were difficult to assess, an eosin counterstain was applied to highlight the cytoplasm of the lesional cells. The immunohistochemical results were analyzed using Fisher exact test. The results showed that all 30 cases of PSCCIS exhibited strong nuclear positivity for p63 in the neoplastic cells, when compared with 0 of 40 cases of primary EMPD (P < 0.0001). In summary, p63 is a useful marker in differentiating PSCCIS from primary EMPD. The authors propose the addition of p63 immunostain in the panel of markers when evaluating pagetoid cutaneous neoplasms.

Clear-cell papulosis: a rare entity that may be misconstrued pathologically as normal skin

We describe a case of multiple, discrete, hypopigmented macules in the suprapubic and axillary region in a healthy 3-year-old girl. The lesions first appeared at approximately 9 months of age and increased in number over time. Initial histopathologic examination by an outside dermatopathologist at 1 year of age was reported as showing nonspecific histologic changes. A repeat biopsy at 3 years of age showed large intraepidermal clear cells that expressed CKAE1/CAM5.2, CK7, and BRST2. These findings are diagnostic for clear-cell papulosis, a rare condition that primarily affects children. Without great clinical and pathologic suspicion, this is a diagnosis that can often be overlooked because the histologic findings are virtually identical to those of normal skin.

Extramammary Paget disease - clinical appearance, pathogenesis, management

Extramammary Paget disease is a rare malignant neoplasm. With regard to the pathogenesis, two prognostically different forms can be distinguished. The primary form of extramammary Paget disease is an in situ carcinoma of the apocrine gland ducts. In contrast, the secondary form is characterized by an intraepithelial spread due to an underlying carcinoma of the skin or other organ systems. Extramammary Paget disease occurs in older patients. The predilection sites include the entire anogenital skin and less often the axillary region. We present five different patients with this disease, thereby demonstrating its variation in clinical morphology. The lesion usually presents as an erythematous sharply defined spot. The polygonal borders, caused by the centrifugal growth of the tumor, may provide a diagnostic clue. The treatment of choice for extramammary Paget disease remains Mohs' microscopic surgery. However, radiotherapy or topical applications may be alternative treatment options in selected cases. In patients with the secondary form of extramam-mary Paget disease, treatment of the primary tumor is the main approach.

Lesions of anogenital mammary-like glands: an update

Long considered to be ectopic breast tissue representing the caudal remnants of the milk ridges, anogenital mammary-like glands are nowadays thought to represent a normal constituent of the anogenital area. Lesions involving these glands, benign or malignant, epithelial or stromal manifest a striking similarity to their mammary counterparts. This review addresses the recent literature on lesions of anogenital mammary-like glands and our personal experience with various lesions related to these structures. Discussed are the normal anatomy and histology of these glands as well as the clinical presentation, histopathological and immunohistochemical features, molecular biological aspects, and differential diagnosis of various lesions involving anogenital mammary-like glands, including lactating adenoma, hidradenoma papilliferum, hidradenocarcinoma papilliferum, fibroadenomas, phyllodes tumor, pseudoangiomatous stromal hyperplasia, extramammary Paget disease, and other carcinomas. In addition, "nonspecific" epithelial or stromal changes some of which can be likened to similar changes occurring in a range of benign breast disease, including sclerosing adenosis, columnar cell lesions, ductal lesions and various metaplastic changes affecting epithelium and myoepithelium are discussed. Although lesions of anogenital mammary-like glands are often discussed in many dermatopathology textbooks in the context of cutaneous adnexal neoplasms we advocate that the best approach to the diagnosis of these lesions is to relate them to analogous well recognized lesions occurring in the breast, that is, through the eyes of a breast pathologist. This will enable their recognition, precise classification and should introduce greater uniformity in how they are reported in the literature so that more meaningful clinicopathological comparisons and correlations may be made.

Frequent expression of the breast differentiation antigen NY-BR-1 in mammary and extramammary Paget's disease

While mammary Paget's disease (MPD) is clearly linked to breast cancer, the histogenesis of extramammary Paget's disease (EMPD) is controversial. Recently NY-BR-1, a differentiation antigen expressed in the breast and in skin adnexal structures was identified. Its protein expression is restricted to normal and neoplastic breast epithelium and to adnexal tumors of the skin. In this study, we examine NY-BR-1 expression by immunohistochemistry in 24 MPD cases with synchronous ductal carcinoma in situ or invasive breast cancer. Results were compared with 26 cases of EMPD of men (n= 4) and women (n= 22) as well as in apoeccrine glands of the axilla and mammary-like glands of the anogenital region. We found NY-BR-1 positivity in 18 of 24 MPD (75%) and in 21 of 26 EMPD (80.8%). All apoeccrine glands of the axilla and mammary-like glands of the anogenital region were NY-BR-1-positive. NY-BR-1 expression is a common finding in MPD and in EMPD. When considering the diagnosis of Paget's disease, NY-BR-1 is a useful diagnostic marker. Furthermore NY-BR-1 positivity in apoeccrine glands of the axilla and anogenital region suggests a potential histogenetic link between these structures and Paget's disease.

Development and validation of a questionnaire to evaluate how a cosmetic product for oily skin is able to improve well-being in women

BACKGROUND

Skin diseases are known to negatively affect self-image and to have detrimental psychosocial effects. Oily skin is a cosmetic skin problem that women often describe as 'invalidating'.

OBJECTIVE

To develop and validate a questionnaire to assess the psychological and psychosocial effects of oily skin condition in women and the outcome of a targeted cosmetic skincare treatment.

METHODS

We developed and validated a concise 18-item questionnaire [oily skin self-image questionnaire (OSSIQ)] to assess perception, behavioural, and emotional consequences associated with oily skin condition. The questionnaire was then used to assess the effects of a skincare treatment for oily skin and compare them with sebum level measurements.

RESULTS

The 18-item questionnaire clearly distinguished the oily skin group from the control group. Responsiveness, reliability, and construct validity showed satisfactory performance. The questionnaire provided a relevant assessment of the psychological benefits associated with the skincare programme.

CONCLUSION

The OSSIQ is a valid tool that can be used to monitor the benefits of cosmetic skincare treatments.

Mammary and extramammary Paget's disease

Paget's disease is an intra-epidermal adenocarcinoma seen over the nipple/areola (mammary Paget's disease) or in extramammary body zones, such as the anogenital and perineal skin and the axilla. Mammary and extramammary Paget's disease share many common clinicopathological features but also show several differences, namely, with regard to pathogenesis and association with underlying malignancies. Indeed, mammary Paget's disease is as a rule associated with an underlying breast carcinoma whereas association of extramammary Paget's disease with underlying (skin or visceral) malignancies occurs much less frequently. We review here the main clinicopathological and therapeutic features of mammary and extramammary Paget's disease.

Skin adnexal neoplasms--part 2: an approach to tumours of cutaneous sweat glands

Tumours of cutaneous sweat glands are uncommon, with a wide histological spectrum, complex classification and many different terms often used to describe the same tumour. Furthermore, many eccrine/apocrine lesions coexist within hamartomas or within lesions with composite/mixed differentiation. In addition to the eccrine and apocrine glands, two other skin sweat glands have recently been described: the apoeccrine and the mammary-like glands of the anogenital area. In this review (the second of two articles on skin adnexal neoplasms), common as well as important benign and malignant lesions of cutaneous sweat glands are described, and a summary for differentiating primary adnexal neoplasms from metastatic carcinoma is outlined, striving to maintain a common and acceptable terminology in this complex subject. Composite/mixed adnexal tumours are also discussed briefly.

Effect of standard medication on quality of life of patients with atopic dermatitis

Patients with atopic dermatitis present with debilitating symptoms, including pruritus and subsequent excoriation, which significantly reduces their quality of life (QOL). At present, the standard therapy for atopic dermatitis constitutes a topical steroid and/or a topical immunomodulator, an emollient and an oral antihistamine, although few studies have reported the effect of this treatment regimen on QOL. The current study aimed to verify the efficacy of the standard therapy for both clinical symptom severity and patient QOL, assessed using the validated Skindex-16 questionnaire. Atopic dermatitis patients receiving the standard therapy (n=771) were enrolled in the current phase IV, multicenter, 12-week, open-label study. The Rajka and Langeland scale (used to rate the severity of atopic dermatitis symptoms) and the Skindex-16 QOL questionnaire were completed at weeks 0 (baseline), 4 and 12. Of 415 patients completing the questionnaire at all time points (per-protocol population), 95.2% were prescribed the antihistamine fexofenadine HCl 60 mg. There were significant improvements in symptoms, emotions and functioning scale scores at weeks 4 and 12 compared with baseline (P<0.005). Discomfort associated with itching, as assessed by item 1 on the Skindex-16, improved over the treatment period (score decreased by >or=1 and >or=2 in 75.2% and 50.9% of patients, respectively). Significant (P<0.005) improvements from baseline in global scores were also observed at weeks 4 and 12, and for week 12 compared with week 4. Severity scores improved significantly (P<0.005) from weeks 0-4 and from weeks 4-12. The standard therapy was generally well tolerated with only mild adverse events reported (0.5%). These data suggest that patients with atopic dermatitis and associated pruritus experience significant improvements in both symptom severity and QOL when receiving standard therapy.

Baseline Quality of Life and Anxiety in Solid Organ Transplant Recipients: A Pilot Study

BACKGROUND

Solid organ transplant recipients on high doses of immunosuppression are at increased risk for the development of nonmelanoma skin cancer (NMSC).

OBJECTIVE

The objective was to assess the possible factors impacting quality of life (QOL) in solid organ transplant recipients.

METHODS

Patients were seen in a dermatology clinic integrated within the transplant center at a university-based hospital. One anxiety questionnaire and three QOL questionnaires were administered to each patient. A regression model was used to determine possible predictors of anxiety and lower QOL.

RESULTS

The baseline scores on the QOL instruments and anxiety questionnaire indicate poor organ-specific and general QOL as well as high levels of anxiety. Time since transplant was predictive of lower QOL as measured by Skindex-16 (p<.01). While not significant, number of NMSCs correlated with higher anxiety as measured by the STAI (p=.055).

CONCLUSIONS

While transplant patients enjoy longer survival, the quality of the extended life has room for improvement. Future studies will determine how QOL changes over time as these patients develop more numerous and aggressive skin cancers. Intervention with regular screening may not only lessen morbidity associated with skin cancer but may improve overall QOL in the posttransplant period.

Teledermatology research review

Teledermatology consultations can be performed using either store-and-forward or real-time technology. The best-studied aspect of teledermatology is diagnostic reliability, also known as diagnostic agreement. A good level of diagnostic reliability is achieved by dermatologists using both store-and-forward and real-time modalities and is comparable to that found between clinic-based examiners. Less information is available regarding diagnostic accuracy. Current data suggest that teledermatologists reviewing store-and-forward consults achieve accuracy comparable to that of clinic-based dermatologists. When store-and-forward consult systems are used, approximately one in four in-person clinic appointments are averted. Real-time consult systems avoid the need to schedule approximately one in two clinic visits. Store-and-forward technology results in timelier interventions for patients when compared to a conventional referral process. To date, surveys of both store-and-forward and real-time teledermatology consult modalities suggest that patients, referring clinicians, and dermatologists are all highly satisfied with teledermatology consults. Very little has been published about the economic impact of store-and-forward teledermatology, whereas several studies have evaluated real-time modalities. Teledermatology has ranged from a cost-saving strategy to an intervention that incurs greater costs than conventional care, depending on the health care setting and economic perspective. Future research focusing on diagnostic accuracy, clinical outcomes using clinical course or disease status as outcome measures, development of reliable and valid teledermatology-specific survey instruments, and economic analyses that assess cost-effectiveness will help guide future teledermatology program assessments and policy.

Correlates of health-related quality of life in women with severe facial blemishes

BACKGROUND

Facial appearance plays a large role in self-perception and interaction with others. Visible facial skin lesions are a common condition. Purpose This study assessed factors associated with health-related quality of life (HRQOL) in women with visible facial skin lesions.

METHODS

The study included 73 women with one or more of the following conditions: acne, dermatosis papulosis, hypopigmentation, lentigenes, melasma, rosacea, vascular proliferations and other facial scars. The Skindex-16 was used as a measure of HRQOL. Fear of negative evaluation (FNE) was assessed to determine whether self-perception characteristics relate to HRQOL.

RESULTS

There were strong correlations in both bivariate and multivariate analyses among increased FNE, heightened perception of QOL without the facial condition and lower overall HRQOL (P< 0.05 and P< 0.01, respectively). There were no differences in HRQOL by type of facial condition, as well as no effects of the area covered by the condition on HRQOL. Interestingly, women not using foundations represented only 10% of the study population and had better HRQOL than women who did use foundations.

CONCLUSIONS

Severe facial blemishes of any cause have a significant impact on women's QOL, and the effect of these lesions is mediated in part by psychological characteristics related to self-perception and self-presentation.

Quality of life in vitiligo patients after treatment with long-term narrowband ultraviolet B phototherapy

Long-term treatments for chronic diseases such as vitiligo need to be evaluated for their clinical efficacy. Assessment of the quality of life (QOL), however, may provide the most relevant information on the actual benefit for these patients. In this study we evaluated QOL after long-term narrowband ultraviolet (UV) B for the treatment of vitiligo. All patients, with long-term stable vitiligo vulgaris, who were treated at our clinic during the last 4 years received specifically for this study a designed QOL questionnaire, which included questions about general well-being, camouflage and psychosocial aspects; 71.4% of the patients responded. Most patients indicated an improvement on a psychological level, but an increase in camouflaging. The present study shows that, after long-term narrowband UVB phototherapy, skin appearance does not play a major role in the life of vitiligo patients, while well being only improved in a minority of patients.

Vulvar Clear Cells of Toker

Clear cells of Toker are intraepithelial cells with clear to pale staining cytoplasm and bland cytologic features found with H&E staining in approximately 10% of normal nipples. Toker cells have been hypothesized as a precursor of extramammary Paget's disease (EMPD), although Toker cells have not been identified as a normal component of genital skin. Using immunohistochemistry, we studied 11 vulvectomies for the presence of Toker cells in association with mammary-like glands of the vulva (MLG). A retrospective study of 11 vulvectomies was performed using routine hematoxylin and eosin staining, as well as immunohistochemical staining for cytokeratin 7 (CK7). Control sections of skin not involving the milk line from age-matched patients were also examined. Four of eleven vulvectomies (36%) demonstrated Toker cells with CK7 staining. Toker cells were associated with the openings of the ducts of mammary-like glands of the vulva. Toker cells were not seen in control tissues. Toker cells occur as a normal constituent of genital skin in association with mammary-like glands of the vulva. Previous morphologic, immunohistochemical, and ultrastructural evidence have pointed to Toker cells as a precursor of EMPD. The demonstration of Toker cells in genital skin strengthens the evidence of their role in the development of EMPD.

Clear Cell Papulosis of the Skin: A Case Report From Singapore

Clear cell papulosis of the skin is a rare condition; to our knowledge only 12 cases have been reported. Here, we report for the first time a case of clear cell papulosis with cytokeratin 7 expression and provide a comprehensive literature review. A 16-month-old girl presented with 3 hypopigmented lesions in the pubic region that were 3 to 9 mm in diameter; 1 lesion was papular, and the other 2 were macular. A skin biopsy revealed acanthosis with a proliferation of clear cells along the basal and suprabasal layers of the epidermis occurring in small clusters and singly. The cells had round to oval regular nuclei with abundant to moderate lightly eosinophilic to clear cytoplasm and intracytoplasmic mucin. Immunostaining produced positive results for carcinoembryonic antigen, AE1/3, epithelial membrane antigen, cell adhesion molecule 5.2, and cytokeratin 7 and negative results for gross cystic fluid disease protein, S100, and HMB-45. Clear cells of clear cell papulosis are mucin-positive and S100-negative glandular-secretory epithelial cells with histogenetic features of Toker cells of nipple and Paget cells. Immunohistochemical features support an eccrine secretory cell origin because the clear cells are consistently and strongly positive for carcinoembryonic antigen, positive for cell adhesion molecule 5.2, and negative or rarely positive for gross cystic fluid disease protein.

Depigmented extramammary Paget's disease

BACKGROUND

Depigmented extramammary Paget's disease (EMPD) has been reported in a few cases. Depigmented macules or patches may be the only presenting sign or may coexist with the classical erythematous lesions.

OBJECTIVES

To investigate the occurrence rate and clinical presentation of depigmentation in EMPD.

METHODS

All pathology-proven cases of EMPD diagnosed in our department during 1990-2003 were retrieved. The clinical photographs were reviewed for evidence of local depigmentation. The pathological diagnosis of EMPD in the whitish lesions was confirmed by positive expression of cytokeratin 7 or carcinoembryonic antigen, and/or the presence of intracytoplasmic mucin.

RESULTS

Of 19 cases of EMPD, six (30%) manifested depigmented lesions which were confirmed to be EMPD pathologically. In two patients, the hypopigmentation was associated with erythematous lesions at the initial presentation. In four others, the depigmentation developed later as local recurrence after excision, cryotherapy, photodynamic therapy or radiotherapy. The progressive enlargement of the depigmentation and the appearance of separate new white lesions in these four cases suggested that the localized depigmentation was unlikely to be simple postinflammatory hypopigmentation.

CONCLUSIONS

Our study suggests that depigmented EMPD may not be rare. Localized depigmentation in the genital area can be an early sign of EMPD and its local recurrence. In patients with an established diagnosis of EMPD, appearance of new white lesions and continuous enlargement of depigmented patches should not be dismissed as simple treatment-induced postinflammatory hypopigmentation or another type of hypopigmented lesion without biopsy confirmation.

Clear cells of Toker in accessory nipples

BACKGROUND

Clear cells of Toker are intraepithelial cells with clear to pale staining cytoplasm and bland cytologic features found in approximately 10% of normal nipples. Toker cells have been hypothesized as a precursor of extramammary Paget's disease (EMPD), although the distribution of Toker cells outside of the nipples has not been studied. Using immunohistochemistry, we studied 20 cases of accessory nipples for the presence of Toker cells.

METHODS

A retrospective study of 20 cases of accessory nipples was performed using routine hemotoxylin and eosin staining, as well as immunohistochemical staining for CK7, CK20, EMA, and GCDFP-15.

RESULTS

Thirteen out of 20 accessory nipples (65%) demonstrated Toker cells with CK7 staining. Toker cells in six of the 13 cases were also positive for EMA. Only one case with Toker cells showed immunoreactivity for antibodies to GCDFP-15.

CONCLUSIONS

Toker cells occur outside the normal nipple epidermis in the epidermis of accessory nipples. The distribution of Toker cells along the milk line correlates with the distribution of most cases of EMPD along the milk line, especially in the groin and axillae. Further studies are necessary to define the relationship between Toker cells and EMPD.

Treatment of primary limited cutaneous extramammary Paget's disease with topical imiquimod monotherapy: Two case reports

We present two cases of primary limited cutaneous perineal and genital extramammary Paget's disease (EMPD) that were successfully treated with imiquimod 5% cream. Clinical and histologic cure was confirmed after 7.5 to 12 weeks of monotherapy. Treatment-associated morbidity is minimal compared with more invasive therapies, and self-application by the patient improves convenience and appeal. Imiquimod may offer a minimally invasive and promising therapeutic option for the treatment of limited cutaneous EMPD. The diagnosis and management of EMPD and the current literature regarding imiquimod therapy are reviewed.

Vulvar Paget disease of urothelial origin: a report of three cases and a proposed classification of vulvar Paget disease

Extramammary Paget disease is generally considered a distinct entity that can involve the genital tract skin and may be associated with underlying adenocarcinoma. Evidence is presented that vulvar Paget disease represents a heterogeneous group of epithelial neoplasms that can be similar both clinically and histopathologically. Three cases of vulvar Paget-like disease that were manifestations of urothelial carcinoma are investigated. Vulvar Paget disease can be classified based on the origin of the neoplastic Paget cells as either primary (of cutaneous origin) or secondary (of noncutaneous origin). Each classification has 3 subtypes: primary, intraepithelial cutaneous Paget disease of the usual type; intraepithelial cutaneous Paget disease with invasion, and intraepithelial cutaneous Paget disease as a manifestation of underlying skin appendage adenocarcinoma; secondary, Paget disease of anorectal origin, Paget disease of urothelial origin, and Paget disease of other origin. This subclassification is based on a review of the literature and the current study of 3 patients with Paget-like disease of urothelial neoplastic origin. The 3 subtypes of vulvar Paget disease studied here can present similarly as eczematoid skin or vulvar mucosal lesions and may appear similar on routine hematoxylin and eosin-stained slides. Immunohistochemical studies can be used to help differentiate them. The distinction between these 3 types of Paget-like lesions is essential in that the specific diagnosis has a significant influence on current treatment. The difference in surgical approach to the subtypes of vulvar Paget disease justifies classifying them into distinct lesions to avoid potential confusion and unnecessary surgery.