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Kibbi N, Owen JL, Worley B, Wang JX, Harikumar V, Aasi SZ, Chandra S, Choi JN, Fujisawa Y, Iavazzo C, Kim JYS, Lawrence N, Leitao MM, MacLean AB, Ross JS, Rossi AM, Servaes S, Solomon MJ, Alam M. Anatomic Subtype Differences in Extramammary Paget Disease: A Meta-Analysis. JAMA Dermatol 2024; 160:417-424. [PMID: 38446447 PMCID: PMC10918581 DOI: 10.1001/jamadermatol.2024.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/28/2023] [Indexed: 03/07/2024]
Abstract
Importance Extramammary Paget disease (EMPD) is a rare, highly recurrent cutaneous malignant neoplasm of unclear origin. EMPD arises most commonly on the vulvar and penoscrotal skin. It is not presently known how anatomic subtype of EMPD affects disease presentation and management. Objective To compare demographic and tumor characteristics and treatment approaches for different EMPD subtypes. Recommendations for diagnosis and treatment are presented. Data Sources MEDLINE, Embase, Web of Science Core Collection, and Cochrane Reviews CENTRAL from December 1, 1990, to October 24, 2022. Study Selection Articles were excluded if they were not in English, reported fewer than 3 patients, did not specify information by anatomic subtype, or contained no case-level data. Metastatic cases on presentation were also excluded. Data Extraction and Synthesis Abstracts of 1295 eligible articles were independently reviewed by 5 coauthors, and 135 articles retained. Reporting was in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The analysis was cunducted in August 2019 and updated in November 2022. Findings Most vulvar EMPD cases were asymptomatic, and diagnosis was relatively delayed (mean, 25.1 months). Although most vulvar EMPD cases were intraepidermal (1247/1773 [70.3%]), radical surgeries were still performed in almost one-third of cases. Despite this aggressive surgical approach, 481 of 1423 (34%) recurred, commonly confined to the skin and mucosa (177/198 [89.4%]). By contrast, 152 of 1101 penoscrotal EMPD cases (14%) recurred, but more than one-third of these recurrences were regional or associated with distant metastases (54 of 152 [35.5%]). Perianal EMPD cases recurred in one-third of cases (74/218 [33.9%]), with one-third of these recurrences being regional or associated with distant metastasis (20 of 74 [27.0%]). Perianal EMPD also had the highest rate of invasive disease (50% of cases). Conclusions and Relevance The diagnosis and treatment of EMPD should differ based on anatomic subtypes. Considerations for updated practice may include less morbid treatments for vulvar EMPD, which is primarily epidermal, and close surveillance for local recurrence in vulvar EMPD and metastatic recurrence in perianal EMPD. Recurrences in penoscrotal subtype were less common, and selective surveillance in this subtype may be considered. Limitations of this study include the lack of replication cohorts and the exclusion of studies that did not stratify outcomes by anatomic subtype.
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Affiliation(s)
- Nour Kibbi
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Joshua L. Owen
- Dermatology Service, Audie L Murphy VA Medical Center, San Antonio, Texas
- Division of Dermatology, University of Texas Health San Antonio, San Antonio
| | | | - Jake X. Wang
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vishnu Harikumar
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Sumaira Z. Aasi
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Sunandana Chandra
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jennifer N. Choi
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Christos Iavazzo
- Department of Gynecologic Oncology, Metaxa Cancer Hospital, Piraeus, Greece
| | - John Y. S. Kim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Naomi Lawrence
- Division of Dermatology, Cooper Hospital, Rowan University, Camden, New Jersey
| | - Mario M. Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of OB/GYN, Weill Cornell Medical College, New York, New York
| | - Allan B. MacLean
- Department of Gynaecology, University College, London, United Kingdom
| | - Jeffrey S. Ross
- Departments of Pathology and Urology, Upstate Medical University, Syracuse, New York
- Medical Director, Foundation Medicine, Inc, Boston, Massachusetts
| | - Anthony M. Rossi
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sabah Servaes
- Department of Radiology, West Virginia University Children’s Hospital, Charleston, West Virginia
| | - Michael J. Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Murad Alam
- Department of Dermatology, Ehime University, To-on, Japan
- Department of Otolaryngology–Head and Neck Surgery and Surgery (Organ Transplantation), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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2
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Rudnicki Y, Stapleton SM, Batra R, Gan T, Mathis KL, Kelley SR. Perianal Paget's-an aggressive disease. Colorectal Dis 2023. [PMID: 36945125 DOI: 10.1111/codi.16549] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/23/2023]
Abstract
AIM Perianal Paget's disease (PAPD) is a rare disorder with a predisposition to anal and colorectal malignancies and an unclear prognosis. Our previous 25-year series demonstrated a non-aggressive nature. This study aims to describe our updated institutional experience. METHODS This is a retrospective review of all patients diagnosed with primary PAPD from 1991 to 2021. A prospectively maintained institutional database was searched which included demographics, clinical and pathological manifestations, treatment methods, recurrence, oncological outcome and mortality. RESULTS Thirty patients were diagnosed with PAPD. Fifteen were women (50%); the average age at diagnosis was 71 ± 10.7 years, and the average lesion size was 3.7 ± 2.6 cm. At diagnosis, 12 (40%) were harbouring invasive anal adenocarcinoma. Eight (27%) developed adenocarcinomas concurrent with PAPD recurrence at a mean interval of 9 ± 4.4 years (range 1.9-14.8). The Kaplan-Meier curve estimated overall survival of 93%, 86%, 82%, 65% and 56% at 1, 3, 5, 10 and 15 years, respectively. Median survival was 16 years. Six (20%) had disease-related mortality. Initially, nine (30%) were treated with abdominoperineal resection (APR), 15 (50%) underwent local resection, three (10%) were treated with radiotherapy, two (7%) received only topical therapy and one (3%) chose observation. Fifteen (50%) experienced recurrence of PAPD, two after undergoing APR. Five (17%) had persistent disease until death. Only 10 (33%) did not experience PAPD recurrence, seven of whom underwent APR. The mean follow-up time was 9.2 ± 6.2 years. CONCLUSIONS Perianal Paget's disease is an aggressive entity with high rates of synchronous anal adenocarcinoma at diagnosis and development of metachronous adenocarcinoma later in life.
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Affiliation(s)
- Yaron Rudnicki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sahael M Stapleton
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rishi Batra
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Tong Gan
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Law C, Eykman E, Pennington T, Ip J, Pincott S. Perianal extramammary Paget's disease: a diagnosis worth considering. ANZ J Surg 2020; 90:E135-E136. [PMID: 32353214 DOI: 10.1111/ans.15933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/13/2020] [Accepted: 04/09/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Cameron Law
- Colorectal and General Surgical Department, Northern Beaches Hospital, Sydney, New South Wales, Australia.,Gastro-Intestinal Surgical Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Elizabeth Eykman
- Colorectal and General Surgical Department, Northern Beaches Hospital, Sydney, New South Wales, Australia
| | - Thomas Pennington
- Colorectal and General Surgical Department, Northern Beaches Hospital, Sydney, New South Wales, Australia
| | - Julian Ip
- Colorectal and General Surgical Department, Northern Beaches Hospital, Sydney, New South Wales, Australia
| | - Stuart Pincott
- Colorectal and General Surgical Department, Northern Beaches Hospital, Sydney, New South Wales, Australia
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Snast I, Sharon E, Kaftory R, Noyman Y, Oren-Shabtai M, Lapidoth M, Hodak E, Mimouni D, Mazor S, Levi A. Nonsurgical Treatments for Extramammary Paget Disease: A Systematic Review and Meta-Analysis. Dermatology 2020; 236:493-499. [PMID: 32289785 DOI: 10.1159/000506832] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 02/27/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Surgery is commonly regarded as the mainstay of treatment of extramammary Paget disease (EMPD); however, nonsurgical approaches have gained popularity in recent years. OBJECTIVES To review the published evidence for the efficacy and safety of nonsurgical modes of therapy for EMPD. METHODS A systematic review and meta-analysis of nonsurgical EMPD treatments was performed. The primary outcome was complete response (CR); secondary outcomes were clinical regression by ≥50%, adverse events, and recurrence rate. RESULTS The systematic review included 43 observational studies (341 patients; 7 prospective cohort studies, 19 retrospective cohort studies, and 17 cases series) evaluating 5 treatment modalities. Imiquimod (13 studies, 110 patients) administered at variable doses ranging from daily to twice weekly for 2-56 weeks demonstrated CR of 54% (95% CI, 40-67%; I2 = 37%) and had a satisfactory safety profile. In 14 heterogeneous studies (122 patients) evaluating photodynamic therapy (PDT), only 36% (95% CI, 22-53%; I2 = 52%) of patients achieved CR. Radiotherapy (12 studies, 67 patients) showed CR of 97%, but was associated with local and systemic side effects. Ablative lasers and topical fluorouracil and calcipotriene lacked adequate evidence of efficacy. CONCLUSIONS Imiquimod and radiotherapy are the most appropriate nonsurgical modalities for EMPD treatment given their good efficacy and safety profile. PDT has limited efficacy but may be appropriate in selected clinical settings.
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Affiliation(s)
- Igor Snast
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel, .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Eran Sharon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Breast Surgery Clinic, Rabin Medical Center, Petah Tikva, Israel
| | - Ran Kaftory
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehonatan Noyman
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Meital Oren-Shabtai
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Lapidoth
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmilia Hodak
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Mimouni
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sigal Mazor
- Department of Community Dentistry, School of Dental Medicine, Hebrew University-Hadassah, Medical Center, Jerusalem, Israel
| | - Assi Levi
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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5
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Abstract
Extramammary Paget disease is an intraepidermal adenocarcinoma, most often limited to the epidermis, with typical cases affecting genital skin. When limited to the epidermis, primary extramammary Paget disease is not life-threatening, but invasive disease may portend a poor prognosis. Surgical excision remains the mainstay of treatment of extramammary Paget disease, and Mohs micrographic surgery is the surgical treatment of choice. Alternative treatments include topical 5-fluorouracil and imiquimod, photodynamic therapy, laser vaporization, chemotherapy, and radiation therapy but data are limited. Implementation of cytokeratin 7 immunostain has increased the ability to detect extramammary Paget disease on frozen section.
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Affiliation(s)
- Bradley G Merritt
- Department of Dermatology, University of North Carolina-Chapel Hill, 410 Market Street, Suite 400, Chapel Hill, NC 27516, USA
| | - Catherine A Degesys
- Department of Dermatology, University of North Carolina-Chapel Hill, 410 Market Street, Suite 400, Chapel Hill, NC 27516, USA.
| | - David G Brodland
- Zitelli and Brodland PC, 5200 Centre Avenue, Suite 303, Pittsburgh, PA 15232, USA; Department of Dermatology, The University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Otolaryngology, The University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Plastic Surgery, The University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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6
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Dos Santos JS, Bonafé GA, Pereira JA, Kanno DT, Martinez CAR, Ortega MM. Rare perianal extramammary Paget disease successfully treated using topical Imiquimod therapy. BMC Cancer 2018; 18:921. [PMID: 30253739 PMCID: PMC6157056 DOI: 10.1186/s12885-018-4815-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 09/13/2018] [Indexed: 11/15/2022] Open
Abstract
Background Perianal Paget’s disease (PPD) is a rare intraepithelial adenocarcinoma of the anal margin. Primary PPD likely represents intra-epithelial neoplasm from an apocrine source, whereas secondary disease may represent “pagetoid” spread from an anorectal malignancy. Case presentation Histologic CDX-2 and CK20 are hallmark markers for colorectal-derived Paget’s cells. Interestingly, our primary PPD patient presented both positive and no internal malignancy was identified. In addition, a negative CK7 marker was observed in our case in contrast with previously reported. Surgical excision is the standard treatment; however, previous studies have demonstrated good response with Imiquimod 5% cream in patients with vulval extramammary Paget disease (EMPD). The efficiency of Imiquimod treatment for PPD has not been well described. Our PPD patient was successfully treated using Imiquimod 5% cream. Conclusions This study describes a primary cutaneous PPD patient CDX-2+/CK20+/CK7- without invasion of the dermis and no associated colorectal carcinoma effectively treated using topical Imiquimod therapy, suggesting that Imiquimod might potentially be considered as a first-line treatment for PPD.
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Affiliation(s)
- Jéssica Silva Dos Santos
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, Department of Postgraduate Program in Health Science, São Francisco University (USF), Avenida São Francisco de Assis, 218, Jardim São José , Bragança Paulista, São Paulo, 12916-900, Brazil
| | - Gabriel Alves Bonafé
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, Department of Postgraduate Program in Health Science, São Francisco University (USF), Avenida São Francisco de Assis, 218, Jardim São José , Bragança Paulista, São Paulo, 12916-900, Brazil
| | - José Aires Pereira
- Department of Surgery and Proctology, São Francisco University (USF), Bragança Paulista, SP, Brazil
| | - Danilo Toshio Kanno
- Department of Surgery and Proctology, São Francisco University (USF), Bragança Paulista, SP, Brazil
| | | | - Manoela Marques Ortega
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, Department of Postgraduate Program in Health Science, São Francisco University (USF), Avenida São Francisco de Assis, 218, Jardim São José , Bragança Paulista, São Paulo, 12916-900, Brazil.
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Tagliaferri L, Casà C, Macchia G, Pesce A, Garganese G, Gui B, Perotti G, Gentileschi S, Inzani F, Autorino R, Cammelli S, Morganti AG, Valentini V, Gambacorta MA. The Role of Radiotherapy in Extramammary Paget Disease: A Systematic Review. Int J Gynecol Cancer 2018. [PMID: 29538255 DOI: 10.1097/igc.0000000000001237] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE/PURPOSE Extramammary Paget disease (EMPD) is a rare neoplasm of the skin generally affecting the anogenital area. Because of the low-frequency of the disease, no specific guidelines about the treatment strategy are available. Surgery is the recommended therapy for resectable and localized disease, but several other local treatments have been reported such as radiotherapy (RT). Most articles report small retrospective studies, referring to patients treated decades ago with large heterogeneity in terms of RT dose and technique. The aim of this study was to systematically review the main experiences in RT for the treatment of EMPD in the past 30 years. MATERIALS AND METHODS A systematic search of the bibliographic databases PubMed and Scopus from January 1986 to January 2017 was performed including studies published in English, Italian, Spanish, French, and German language. RESULTS According to the search strategy, 19 full-text articles, published from 1991 to 2015, fulfilled inclusion criteria and were included in the final review. All articles were retrospective analyses with no randomized controlled trials. These studies evaluated 195 EMPD patients treated with RT, delivered in several settings. A large variability in terms of RT doses, fractionation, clinical setting, and techniques was found.Radiotherapy was administered as definitive treatment for primary or recurrent disease after surgery in 18 studies with doses ranging from 30 to 80.2 Gy delivered in 3 to 43 fractions. Radiotherapy was administered as postoperative adjuvant treatment in 9 articles with doses ranging between 32 and 64.8 Gy in 20 to 30 fractions. Two studies reported the RT use in preoperative neoadjuvant setting with doses ranging between 40 and 43.30 Gy, and 2 experiences reported the RT treatment for in situ EMPD, using 39.6 to 40 Gy. Adverse events were reported in almost all but 2 articles and were grade 2 or lower.The 18 studies evaluating RT as definitive treatment for primary or recurrent disease after surgery reported a complete response rate ranging from 50% to 100%, with a variable rate of local relapse or persistent disease ranging from 0% to 80% of cases. The 9 studies evaluating RT as postoperative adjuvant treatment reported a local relapse or persistent disease rate of 0% to 62.5%. A dose-response relationship was reported suggesting doses greater than or equal to 60 Gy for gross tumor volume treatment. Local control, disease-free survival, and overall survival at 12, 20, and 60 months have been retrieved for available data, respectively.In patients with EMPD and concurrent underlying internal malignancy, the prognosis was often worsened by the latter. In this setting, literature analysis showed a potential RT palliative role for symptoms control or local control maintenance.Derma tumor invasion greater than 1 mm and lymph node metastases were reported to be important prognostic factors for distant metastases or death. CONCLUSIONS To date, literature highlights the role of RT in the management of EMPD, but with low level of evidences.
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Velenik V, Šegedin B, Anderluh F, Oblak I, Strojan P. Radiotherapy for Perianal Paget's Disease: A Case Report. TUMORI JOURNAL 2018; 94:750-3. [DOI: 10.1177/030089160809400520] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Perianal Paget's disease was first described in 1893. Since then, fewer than 300 cases have been reported in the literature. It might be associated with an underlying malignancy. Most of the patients are treated with surgical excision, which is often mutilating and of variable efficacy. In the present report, we describe the case of an 80-year-old woman with perianal Paget's disease. She was treated at our institution with radiotherapy with curative intent. The pertinent literature is reviewed, and the controversies in diagnosis and management are discussed. Conclusions Our single-case experience supports the opinion that radiotherapy is a viable treatment option with curative potential for patients with perianal Paget's disease. For the treatment of in situ disease, hypofractionated regimens to a total dose of 40–44 Gy and orthovoltage X-ray beams are recommended.
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Affiliation(s)
- Vaneja Velenik
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Barbara Šegedin
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Franc Anderluh
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Irena Oblak
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Primož Strojan
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
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9
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Park YY, Kim M, Cheong C, Kim SK, Song SY, Chung KY, Kim NK. Perianal Paget disease: a report of 2 cases. Ann Surg Treat Res 2017; 93:336-341. [PMID: 29250514 PMCID: PMC5729129 DOI: 10.4174/astr.2017.93.6.336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/16/2017] [Accepted: 02/27/2017] [Indexed: 11/30/2022] Open
Abstract
Extramammary Paget disease (EMPD) is a rare cutaneous neoplasm. Perianal Paget disease (PPD) is a subset of EMPD manifesting perianal lesions. Two cases of PPD in Severance Hospital are described in this article. A 65-year-old female and 78-year-old male patients visited our institution because of an unhealed perianal skin lesion despite treatment for a long period with topical agents. PPD was diagnosed by skin biopsies in both cases, and the patients underwent surgical treatment. Clinical manifestations, preoperative work-ups, and surgical treatments including different reconstruction methods are described in detail. As only sporadic PPD cases have been reported and no standard treatment has been established, we hope that our experience could contribute to improving the diagnosis and treatment of PPD patients.
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Affiliation(s)
- Youn Young Park
- Division of Colorectal Surgery, Department of Surgery, Colorectal Cancer Clinic, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Moonsik Kim
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chinock Cheong
- Division of Colorectal Surgery, Department of Surgery, Colorectal Cancer Clinic, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kyum Kim
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Yong Song
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kee-Yang Chung
- Department of Dermatology and Cutaneous Biology Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Division of Colorectal Surgery, Department of Surgery, Colorectal Cancer Clinic, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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10
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Primary perianal extramammary Paget’s disease: Case report with review. JOURNAL OF DERMATOLOGY & DERMATOLOGIC SURGERY 2016. [DOI: 10.1016/j.jdds.2016.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
PURPOSE Perianal Paget's disease is a rare intraepithelial adenocarcinoma of the perianal skin and the second most common localization of extramammary Paget's disease. This study was designed to evaluate long-term outcomes in patients with perianal Paget's disease. METHODS We identified patients who were treated for perianal Paget's disease between 1981 and 2013. Patient demographics, family history, associated malignancies, treatments, histopathological features, need for re-operations, and long-term outcomes were documented. RESULTS Our study cohort consisted of 15 male and 10 female patients with a median age of 67 (40-83) years. Four patients had concurrent anorectal adenocarcinoma (two anal canal, two rectal) when perianal Paget's disease was diagnosed. Index operations performed were wide local excision (14 patients), local excision (five patients), abdominoperineal resection (four patients), and radiotherapy (two patients). Five patients developed invasive carcinoma (three anal canal, one vulvar, one perianal squamous cell carcinoma) during a median follow-up time of 60 (3-299) months. Thirteen patients were re-operated. Fifteen patients had a reconstructive procedure following excision. Overall survival was similar between the patients who were treated with wide local excision and local excision regardless of surgical margin status at index excision (P = 0.75). CONCLUSIONS Since there is a risk for developing invasive carcinoma in the anal canal and perineum in patients with perianal Paget's disease, close follow-up is needed after R0 or R1 excision. Physicians should be aware of the risk of cancers associated with perianal Paget's disease and should rule out them during management.
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12
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Effects of imiquimod on vulvar Paget's disease: a systematic review of literature. Gynecol Oncol 2015; 139:165-71. [PMID: 26193428 DOI: 10.1016/j.ygyno.2015.07.097] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 07/14/2015] [Accepted: 07/16/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine the effectiveness of topical imiquimod therapy for vulvar Paget's disease. METHODS A systematic literature search was conducted using three public search engines with entry keywords "Paget's disease" and "imiquimod". Case reports describing imiquimod treatment for vulvar Paget's disease were examined for demographics, treatment patterns, and outcome (63 cases). RESULTS Median age was 68, and nearly a half of cases were recurrent disease (50.8%) with surgical resection being the most common prior treatment modality (62.5%). All cases used 5% imiquimod and the median treatment duration was 4months. The most common initial treatment frequency was 3-4times/week (68.3%) followed by 5-7 (17.4%) and 1-2times/week (14.3%). Frequency-reduction due to adverse effects was seen in 9.5% with the initial 5-7times/week regimen being associated with the highest reduction rate (1-2, 3-4, and 5-7times/week: 0%, 2.3%, and 81.8%, p<0.01). In 46 (73.0%) cases, a complete remission (CR) to imiquimod therapy was reported, with 2, 4, and 6-month cumulative CR rates being 9.8%, 31.1%, and 71.6%, respectively. With median follow-up duration of 12months after the completion of imiquimod treatment, 2 (5.7%) of the 35 women who had a CR developed disease recurrence. Age, disease status (primary versus recurrent), and treatment frequency after dose reduction were not associated with CR rates (all, p>0.05). CONCLUSION Our results suggested that imiquimod therapy may be an effective possible treatment option for vulvar Paget's disease, especially for women who have experienced recurrence after multiple surgical resections or who are with poor surgical candidates.
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13
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Ilbawi AM, Simianu VV, Millie M, Soriano P. Wide local excision of perianal mucinous adenocarcinoma. J Clin Oncol 2014; 3:483-5. [PMID: 24590647 DOI: 10.1016/j.ijscr.2012.05.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 05/23/2012] [Indexed: 11/17/2022] Open
Affiliation(s)
- André M Ilbawi
- University of Washington School of Medicine, Seattle, WA
| | - Vlad V Simianu
- University of Washington School of Medicine, Seattle, WA
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Garibaldi E, Cattari G, Delmastro E, Siatis D, Racca M, Maggio A, Gabriele D, Frangipane E, Gabriele P. Technical and Clinical Description of a Case of Extensive Anogenital Paget's Disease Associated with anal Cancer Treated by Tomotherapy. TUMORI JOURNAL 2014; 100:e41-4. [DOI: 10.1177/030089161410000222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this paper we describe a case of extramammary Paget's disease associated with anal cancer, which was successfully treated by intensity-modulated radiotherapy using tomotherapy with a simultaneous integrated boost and daily image guidance. The main pitfall in this report is the relatively short follow-up (1 year), which means that the evaluated data is promising but not conclusive. Considering the rarity and wide extension of our patient's Paget's disease in the anogenital region, and the lack of literature reports about curative radiotherapy in this particular setting, this case report may be considered the first related to extensive extramammary Paget's disease treated by tomotherapy.
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Affiliation(s)
- Elisabetta Garibaldi
- Department of Radiotherapy, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) - FPO, Candiolo, Turin
| | - Gabriella Cattari
- Department of Radiotherapy, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) - FPO, Candiolo, Turin
| | - Elena Delmastro
- Department of Radiotherapy, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) - FPO, Candiolo, Turin
| | - Dimitrios Siatis
- Department of Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) - FPO, Candiolo, Turin
| | - Manuela Racca
- Department of Nuclear Medicine, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) - FPO, Candiolo, Turin
| | - Angelo Maggio
- Department of Medical Physics, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) - FPO, Candiolo, Turin
| | - Domenico Gabriele
- Department of Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) - FPO, Candiolo, Turin
| | - Elena Frangipane
- Department of Pathology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) - FPO, Candiolo, Turin
| | - Pietro Gabriele
- Department of Radiotherapy, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) - FPO, Candiolo, Turin
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Itonaga T, Nakayama H, Okubo M, Mikami R, Nogi S, Tajima Y, Sugahara S, Tokuuye K. Radiotherapy in Patients with Extramammary Paget's Disease - Our Own Experience and Review of the Literature. Oncol Res Treat 2014; 37:18-22. [DOI: 10.1159/000358161] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 11/11/2013] [Indexed: 11/19/2022]
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Kim IY, Yun SJ, Lee JS, Jung S, Jung TY, Moon KS, Jang WY. Brain metastasis from extramammary Paget's disease of the scrotum. J Clin Neurosci 2013; 21:694-6. [PMID: 24210806 DOI: 10.1016/j.jocn.2013.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 05/23/2013] [Accepted: 05/26/2013] [Indexed: 11/29/2022]
Abstract
We present to our knowledge the first patient with histopathologically proven brain metastasis from extramammary Paget's disease (EMPD) and discuss the effect of brain radiation therapy for this condition. A 68-year-old man presented to our hospital with headache and gait disturbance. Brain MRI showed multiple enhancing mass lesions, and two large cystic lesions in the left cerebellum. The patient had been diagnosed with scrotal Paget's disease 3 months previously but no further management had been performed due to his refusal. The patient underwent stereotactic aspiration and biopsy of the two large cystic lesions. A histopathological examination revealed that the tumor was a metastatic adenocarcinoma. Immunohistochemical staining revealed that the tumor cells were strongly positive for cytokeratin 7 and moderately positive for carcinoembryonic antigen and gross cystic disease fluid protein 15. These findings were similar to those of his scrotal skin lesions and were consistent with metastatic EMPD. The patient underwent brain radiation therapy with a total radiation dose of 30 Gy in 10 fractions. The patient improved neurologically so as to be self-ambulatory, and a mild improvement in the metastatic tumors was found on follow-up MRI. We had planned systemic chemotherapy, but the patient died of acute respiratory failure 2 months after radiation therapy.
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Affiliation(s)
- In-Young Kim
- Brain Tumor Clinic and Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, 160, Ilsimri, Hwasun-eup, Hwasun-gun, Chonnam 519-809, Republic of Korea; Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea.
| | - Suk-Jung Yun
- Department of Dermatology, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Ji-Shin Lee
- Department of Pathology, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Shin Jung
- Brain Tumor Clinic and Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, 160, Ilsimri, Hwasun-eup, Hwasun-gun, Chonnam 519-809, Republic of Korea; Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Tae-Young Jung
- Brain Tumor Clinic and Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, 160, Ilsimri, Hwasun-eup, Hwasun-gun, Chonnam 519-809, Republic of Korea; Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Kyung-Sub Moon
- Brain Tumor Clinic and Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, 160, Ilsimri, Hwasun-eup, Hwasun-gun, Chonnam 519-809, Republic of Korea; Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Woo-Youl Jang
- Brain Tumor Clinic and Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, 160, Ilsimri, Hwasun-eup, Hwasun-gun, Chonnam 519-809, Republic of Korea
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Mann J, Lavaf A, Tejwani A, Ross P, Ashamalla H. Perianal Paget disease treated definitively with radiotherapy. ACTA ACUST UNITED AC 2013; 19:e496-500. [PMID: 23300373 DOI: 10.3747/co.19.1144] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extramammary Paget disease (empd) is a relatively rare cutaneous disorder described as an apocrine gland tumour occurring in both a benign and a malignant form with metastatic potential. The areas of the body affected are the vulva, perianal region, penis, scrotum, perineum, and axilla, all of which contain apocrine glands. When empd affects the perianal region, it is called perianal Paget disease (ppd). All forms of empd, including ppd, are typically treated by wide surgical excision. Perianal Paget disease usually occurs later in life in patients who are often poor surgical candidates, but the available literature is scarce regarding other treatment modalities, including definitive radiotherapy. We contend that ppd can be safely and effectively treated with radiotherapy, and here, we present the case of a 75-year-old woman with ppd who was successfully so treated. A brief review of the literature concerning the diagnosis, natural history, and treatment of ppd is also included.
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Affiliation(s)
- J Mann
- Department of Radiation Oncology, New York Methodist Hospital, Weill Cornell Medical College, Brooklyn, NY, U.S.A
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Marcos S, Montero A, Capuz B, Martinez-Ollero J, Hernanz R, Fernández E, Polo A, Ramos A. HDR-plesiotherapy for the treatment of anogenital extramammary Paget's disease. Rep Pract Oncol Radiother 2012; 17:163-7. [PMID: 24377019 DOI: 10.1016/j.rpor.2012.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Revised: 01/07/2012] [Accepted: 03/10/2012] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Extramammary Paget disease (EMPD) is a rare condition that most commonly affects the anogenital region in the elderly. It may be associated with an underlying invasive carcinoma. Surgical excision is nowadays considered a standard treatment for extramammary Paget's disease, although this approach might not be suitable for all patients. Good rates of local control and cosmetic outcome have been achieved by using high-dose-rate (HDR) plesiotherapy in the treatment of skin tumors arising in different locations. MATERIAL AND METHODS We present the results observed in a patient with EMPD treated by HDR plesiotherapy with a custom-made mold up to a final dose of 54 Gy in 12 fractions of 450 cGy over 4 weeks. RESULTS After a follow-up of 18 months, the patient is alive and without evidence of local or distant relapse. Acute toxicity was acceptable and cosmetic result was considered as excellent. CONCLUSION This technique represents an attractive alternative for those patients who are not candidates for surgical procedures because of unacceptable risk of disfigurements or functional impairment, medical contraindications or patient preference.
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Affiliation(s)
- Soraya Marcos
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Angel Montero
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Belén Capuz
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | | | - Raúl Hernanz
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Eva Fernández
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Alfredo Polo
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Alfredo Ramos
- Department of Radiation Oncology, Universitary Hospital Ramón y Cajal, Madrid, Spain
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Kyriazanos ID, Stamos NP, Miliadis L, Noussis G, Stoidis CN. Extra-mammary Paget's disease of the perianal region: a review of the literature emphasizing the operative management technique. Surg Oncol 2011; 20:e61-71. [PMID: 20884199 DOI: 10.1016/j.suronc.2010.09.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2010] [Revised: 09/07/2010] [Accepted: 09/08/2010] [Indexed: 12/13/2022]
Abstract
The perianal skin is a common area for extra-mammary Paget's disease development. The unique clinical, histopathological, and immunohistochemical features which this medical phenomenon demonstrates, along with its rarity and frequent association with synchronous or metachronous carcinomas, present us with a treatment challenge. In order to organize the surgical treatment, it is important to determine whether the disease is localized exclusively to the perianal skin or associated with metastasis or anorectal carcinomas. Despite several controversies concerning its optimal therapeutic management, wide local excision of the skin and subcutaneous tissue in the perianal region is generally recommended for the treatment of the non-invasive form of the disease. Such an aggressive operative management usually results in a large perianal tissue defect, which can not be primarily suppressed without resultant tension and possible complications, requiring a special technique for its coverage. Various techniques have been described in the literature for the treatment of these defects, often associated with unfavourable long term results, i.e. split-thickness skin grafts and vacuum-assisted closure devices. More recently several authors have reported favourable results using various transposition or rotation local skin flaps, myocutaneous flaps of the gluteal and thigh muscles, and V-Y island flaps to cover these areas of tissue loss. In this article we present a short review of the literature concerning perianal Paget's disease with special attention to its management and a demonstration of the operative technique we prefer on patients with perianal non-invasive Paget's disease, i.e. wide local excision with a 2 cm margin in the anal mucosa and use of U and V-Y shaped perianal fatty-cutaneous island flaps for reconstruction by covering the bilateral anal skin defects.
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Wagner G, Sachse MM. Extramammary Paget disease - clinical appearance, pathogenesis, management. J Dtsch Dermatol Ges 2011; 9:448-54. [PMID: 21205169 DOI: 10.1111/j.1610-0387.2010.07581.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Gunnar Wagner
- Department of Dermatology, Bremerhaven Hospital (Reinkenheide), Bremerhaven, Germany.
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Hata M, Omura M, Koike I, Wada H, Miyagi E, Tayama Y, Odagiri K, Minagawa Y, Ogino I, Inoue T. Role of radiotherapy as curative treatment of extramammary Paget's disease. Int J Radiat Oncol Biol Phys 2010; 80:47-54. [PMID: 20951507 DOI: 10.1016/j.ijrobp.2010.01.073] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Revised: 01/13/2010] [Accepted: 01/13/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE Extramammary Paget's disease (EMPD) is a relatively rare malignancy that usually arises in the genital areas. Wide surgical excision remains the standard and most reliable curative treatment of EMPD. However, surgery is sometimes not possible, because many patients are elderly, and complete excision can be difficult owing to the tumor location. We, therefore, performed a review to determine the role of radiotherapy (RT) for EMPD. METHODS AND MATERIALS A total of 22 patients with EMPD in their external genitalia (4 men and 18 women, age 52-94 years at RT) underwent RT with curative intent. Nine patients had regional lymph node metastases. A total dose of 45-70.2 Gy (median, 60) was delivered to the pelvis, including the tumors, in 25-39 fractions (median, 33). RESULTS In all but 3 patients, the irradiated tumors were controlled during a follow-up period of 8-133 months (median, 42). Of the 22 patients, 13 developed recurrences, including local progression within the radiation field in 3 and lymph node and/or distant metastases outside the radiation field in 10, at 3-43 months after treatment. The 2- and 5-year local progression-free rates were 91% and 84%, respectively. Of the 22 patients, 7 patients had died at 33-73 months after RT. The cause of death was tumor progression in 4, infectious pneumonia in 2, and renal failure in 1 patient. The overall and cause-specific survival rates were 100% for both at 2 years and 53% and 73% at 5 years, respectively. No therapy-related Grade 3 or greater toxicity was observed. CONCLUSIONS RT is safe and effective for patients with EMPD. It appears to contribute to prolonged survival as a result of good tumor control.
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MESH Headings
- Aged
- Aged, 80 and over
- Disease-Free Survival
- Dose Fractionation, Radiation
- Female
- Genital Neoplasms, Female/pathology
- Genital Neoplasms, Female/radiotherapy
- Genital Neoplasms, Male/pathology
- Genital Neoplasms, Male/radiotherapy
- Humans
- Male
- Middle Aged
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/radiotherapy
- Paget Disease, Extramammary/mortality
- Paget Disease, Extramammary/radiotherapy
- Retrospective Studies
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Affiliation(s)
- Masaharu Hata
- Department of Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan.
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Treatment of recurrent vulvar Paget disease with imiquimod cream: a case report and review of the literature. Arch Gynecol Obstet 2010; 283:97-101. [PMID: 20803209 DOI: 10.1007/s00404-010-1653-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Accepted: 08/16/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Extra-mammary Paget disease is one of the rare neoplastic conditions of the skin. The most common site of involvement is the vulva and presents itself with erythematous plaques. Surgery is the most important treatment option. In the recent years, there are publications of the topical use of imiquimod cream in extra-mammary cutaneous Paget disease. We report the case of a woman with recurrent vulvar Paget disease, who underwent successful treatment with imiquimod cream. We also review the reports of other patients with vulvar Paget disease who were treated with topical imiquimod cream. CASE REPORT A 65-year-old woman presented to the Oncology Outpatient Clinic with an itchy lesion in her vulva for 2 years. In the gynecologic examination, a hyperkeratotic erythematous lesion was found starting from the right labium to involve clitoris, with a size of 4 × 3 cm. Pathology result was reported as Paget disease. She was operated and wide vulvar excision was performed with a safety margin of 2 cm. Then recurrence two times occurred. Because she refused surgery, imiquimod cream 5% was applied for treatment. CONCLUSION Imiquimod cream is an effective and safe therapeutic agent for both primary and recurring vulvar Paget disease.
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Lian P, Gu WL, Zhang Z, Cai GX, Wang MH, Xu Y, Sheng WQ, Cai SJ. Retrospective analysis of perianal Paget’s disease with underlying anorectal carcinoma. World J Gastroenterol 2010; 16:2943-8. [PMID: 20556842 PMCID: PMC2887592 DOI: 10.3748/wjg.v16.i23.2943] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze clinical and pathological characteristics of an aggressive subtype of perianal Paget’s disease (PPD) and explore its rational treatment modalities.
METHODS: PPD patients were retrospectively collected in the institutional colorectal database of the Fudan University Shanghai Cancer Center. Detailed patient histories of past medical condition, diagnosis, treatment, and pathological findings were reviewed. Surgical specimen from diagnosis and surgery were reviewed by two independent pathologists for confirmation of diagnoses. Follow up was accomplished by clinical interview by cellphone.
RESULTS: In total, eight cases of PPD were analyzed. All patients had underlying anorectal adenocarcinoma, including seven with synchronous lesions and one with metachronous lesions. Moreover, all anorectal lesions had a mucin-producing component. The median age at diagnosis was 65 (range 29-81 years), and the male/female ratio was 7:1. The Median follow-up time of all patients was 61.5 mo (range 10-204 mo). One patient treated with abdominoperineal resection (APR) died from lung metastases 10 mo after the APR operation. The other patients are still free of disease at the time of this analysis.
CONCLUSION: PPD is a rare malignancy and is easily misdiagnosed. Underlying anorectal cancer was not unusual and was a significant prognostic factor. Rational treatment of both anorectal cancer and PPD lesion is essential for long-term survival.
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Zhang N, Gong K, Zhang X, Yang Y, Na Y. Extramammary Paget's disease of scrotum—report of 25 cases and literature review. Urol Oncol 2010; 28:28-33. [DOI: 10.1016/j.urolonc.2008.07.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2008] [Revised: 06/30/2008] [Accepted: 07/02/2008] [Indexed: 11/28/2022]
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Abstract
PURPOSE Extramammary Paget's disease (EMPD) is frequently associated with adnexal or visceral synchronous or metachronous malignancies. Our purpose was to evaluate, retrospectively, the results obtained in six cases of EMPD and to review the literature. METHODS Six patients with the perianal Paget's disease had been treated in our division between March 1996 and December 2006. In three cases, the disease was confined in the epidermis; in one case, there was a microinvasion of the dermis, while in another one the dermis was infiltrated. The last case was associated to a low rectal adenocarcinoma. All patients underwent wide perianal excision and reconstruction with skin graft. We performed a transanal resection of the rectal adenocarcinoma. A review of the literature from 1990 to 2008 revealed 193 cases of perianal EMPD, 112 were intraepithelial/intradermal while 81 were associated with malignancies. Anorectal adenocarcinoma was already existing in two cases, synchronous in 48, and subsequent to diagnosis in 11. RESULTS In three cases, the disease recurred locally, but no patient developed metastatic spread. Five patients survived and are free of disease. The review of the literature allows a clear identification of the primitive EMPD and the form associated to anorectal adenocarcinoma and little information about cases associated with synchronous adnexal adenocarcinoma. The Paget's disease can relapse after radical surgery and has a capacity of metastatic spread. CONCLUSIONS Up to now, no clear guidelines have been established for the diagnosis of EMPD. The association with synchronous or metachronous carcinomas imposes a long-term follow-up with frequent clinical, radiological, and endoscopical controls.
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Hatch KD, Davis JR. Complete resolution of Paget disease of the vulva with imiquimod cream. J Low Genit Tract Dis 2008; 12:90-4. [PMID: 18369301 DOI: 10.1097/lgt.0b013e31815a58a5] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Extra mammary Paget disease (EMPD) is a neoplastic disease of apocrine gland bearing skin. Surgical excision is the standard of care for EMPD; however, it is accompanied by recurrence in more than 60% of the patients. Recently, imiquimod cream has been reported to induce complete responses in primary or recurrent EMPD. We report on 2 women with vulva EMPD who achieved biopsy-confirmed resolution of their disease after topical application of imiquimod 5% cream.
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Shepherd NA. Anal intraepithelial neoplasia and other neoplastic precursor lesions of the anal canal and perianal region. Gastroenterol Clin North Am 2007; 36:969-87, ix. [PMID: 17996800 DOI: 10.1016/j.gtc.2007.08.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Anal cancer is rare and this helps to explain why anal pre-neoplastic conditions are poorly understood, especially with regard to their natural history and management. Anal intraepithelial neoplasia is closely linked to human papillomavirus infection and is particularly common in homosexuals and in immunosuppressed patients, especially those with HIV/AIDS. The high regression rates of low-grade anal intraepithelial neoplasia may simply reflect inconsistent pathologic reporting. Higher grades of anal intraepithelial neoplasia may remain static for long periods of time in immunocompetent patients, but those with HIV/AIDS show early and rapid malignant transformation. In general, most anal pre-neoplastic conditions are best diagnosed by biopsy and treated by surgical excision, although local recurrence is a problem. In anal Paget's disease, it is important to ascertain, at the time of diagnosis, whether it is due to a primary in-situ apocrine-type of neoplasia of the anus or if the disease is secondary to an invasive primary carcinoma of the rectum.
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Affiliation(s)
- Neil A Shepherd
- Department of Histopathology and Cranfield Postgraduate Medical School in Gloucestershire, Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK.
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Yanagi T, Kato N, Yamane N, Osawa R. Radiotherapy for extramammary Paget's disease: histopathological findings after radiotherapy. Clin Exp Dermatol 2007; 32:506-8. [PMID: 17489988 DOI: 10.1111/j.1365-2230.2007.02425.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Several reports have suggested the efficacy of radiotherapy for treating extramammary Paget's disease (EMPD); however, these reports comprised only clinical observations, without in-depth histopathological observations. We report our experience of genital EMPD treated by radiotherapy in two elderly women, and the marked efficacy of radiotherapy, confirmed both by clinical observation and by detailed histopathological investigations. Our cases agree with the notion that radiotherapy is useful as an alternative therapy for EMPD, and should be considered particularly in elderly patients who may not tolerate surgery well.
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Affiliation(s)
- T Yanagi
- Department of Dermatology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan.
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Black D, Tornos C, Soslow RA, Awtrey CS, Barakat RR, Chi DS. The outcomes of patients with positive margins after excision for intraepithelial Paget's disease of the vulva. Gynecol Oncol 2007; 104:547-50. [PMID: 17067662 DOI: 10.1016/j.ygyno.2006.09.017] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 09/11/2006] [Accepted: 09/12/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Vulvar Paget's disease is a rare neoplasm that usually occurs in postmenopausal women. Treatment with surgical excision can be complicated by extension of microscopic disease in an irregular manner well beyond the visible margins of the lesion. The objective or our study was to analyze the outcomes of patients with primary vulvar intraepithelial Paget's disease who had positive microscopic margins after primary excision. METHODS We reviewed the records of all patients with Paget's disease of the vulva treated at our institution from 1/80 to 9/02. Patients whose sample showed stromal invasion or an underlying carcinoma were excluded. Data were collected regarding patient demographics, disease location, treatment, surgical margin status, additional treatment, and clinical outcome. RESULTS The medical records and histopathologic specimens of 28 women with intraepithelial Paget's disease of the vulva were evaluated. Surgical treatment consisted of radical vulvectomy in 3 patients (11%), simple vulvectomy in 18 patients (64%), and wide local excision in the other 7 patients (25%). Of the 20 patients with microscopically positive margins, 14 (70%) developed recurrent disease and the remaining 6 (30%) are disease free. Of the 8 patients with negative margins, 3 (38%) developed disease recurrence and the remaining 5 (63%) are disease free. With a median follow-up of 49 months (range, 3-186 months), there was no correlation between disease recurrence and margin status (P=0.20). Of the 17 patients who recurred, 14 (82%) underwent additional surgical excision and 1 patient was treated with Retin-A. The remaining 2 patients refused further treatment and were lost to follow-up. In those patients who underwent surgery for recurrence, between 1 and 3 re-excisions were performed. Of the 15 evaluable patients who were treated for recurrent disease, 12 (80%) had no evidence of persistent disease and 3 (20%) had persistent disease at a median follow-up of 63.7 months (range, 18.5-186 months). CONCLUSIONS Microscopically positive margins following surgical excision of vulvar intraepithelial Paget's disease is a frequent finding, and disease recurrence is common regardless of surgical margin status. Long-term monitoring of patients is recommended, and repeat surgical excision is often necessary.
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Affiliation(s)
- Destin Black
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Luk NM, Yu KH, Yeung WK, Choi CL, Teo ML. Extramammary Paget's disease: outcome of radiotherapy with curative intent. Clin Exp Dermatol 2003; 28:360-3. [PMID: 12823291 DOI: 10.1046/j.1365-2230.2003.01301.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Six patients with extramammary Paget's disease were treated with curative intent radiotherapy. Two of the patients had associated underlying adenocarcinoma. Radiotherapy was given as primary treatment (two patients), definitive treatment for postexcisional relapse (three patients) and adjuvant treatment (one patient). Radiotherapy techniques included high dose rate mould brachytherapy, electron beam, superficial X-ray and photon treatments. Follow-up durations after radiotherapy were 1.2-14.8 years. Complete response was obtained in five patients while one patient had a partial response. Marginal failure occurred in one complete-responder who was successfully salvaged by surgery. The two patients with underlying adenocarcinoma died of distant metastasis. Radiotherapy side effects were acute confluent wet desquamation and mild late skin atrophy. Our results confirmed the useful role of radiotherapy in the management of extramammary Paget's disease.
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Affiliation(s)
- N M Luk
- Social Hygiene Service, Department of Health, Hong Kong SAR, China.
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