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

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

BACKGROUND

Surgery is the standard treatment for genital extramammary Paget disease (gEMPD).

OBJECTIVE

To determine if gEMPD treatments and outcomes differ by sex and US region.

METHODS

A systematic review was performed of all English-language studies on initial gEMPD treatment in Medline via PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov. At least 2 reviewers performed title and abstract review and data extraction. Surgical categories included total skinning procedures, partial skinning procedures, Mohs micrographic surgery (MMS), or unspecified surgery. Chi-squared tests of association were used for comparisons.

RESULTS

A total of 60 studies comprising 302 (79.7%) female and 77 (20.3%) male patients met criteria. Women were most often initially recommended partial skinning procedures. In all, 74 (24.5%) women and 0 men underwent a total skinning procedure. Men were more likely to be offered MMS than women (40.3% vs 1.9%, P < .0001), despite men having a significantly greater extent of disease involving the perineum and perianal skin (21.1% vs 1.7%, P < .0001). Treatment recommendations varied by US region.

LIMITATIONS

Only 20 states were represented.

CONCLUSION

Women are more frequently offered total skinning procedures for gEMPD while men are more frequently offered MMS. MMS offers less recurrence and morbidity than total skinning procedures and should be recommended equally to both female and male patients with gEMPD.

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Non-Operative Options for Loco-regional Melanoma

Malignant melanoma is the 5th most common cancer and stage IV melanoma accounts for approximately 4% of new melanoma diagnoses in the United States. The prognosis for regionally advanced disease is poor, but there have been numerous recent advances in the medical management of melanoma in-transit metastases. The goal of this paper is to review currently accepted treatment options for in-transit metastases and introduce emerging therapies. Therapies to be discussed include limb perfusion and infusion, immunotherapy, checkpoint inhibitors, and radiation therapy.

Integrative bioinformatics approaches to map key biological markers and therapeutic drugs in Extramammary Paget's disease of the scrotum

Extramammary Paget’s disease (EMPD) is an intra-epidermal adenocarcinoma. Till now, the mechanisms underlying the pathogenesis of scrotal EMPD is poorly known. This present study aims to explore the knowledge of molecular mechanism of scrotal EMPD by identifying the hub genes and candidate drugs using integrated bioinformatics approaches. Firstly, the microarray datasets (GSE117285) were downloaded from the GEO database and then analyzed using GEO2R in order to obtain differentially expressed genes (DEGs). Moreover, hub genes were identified on the basis of their degree of connectivity using Cytohubba plugin of cytoscape tool. Finally, GEPIA and DGIdb were used for the survival analysis and selection of therapeutic candidates, respectively. A total of 786 DEGs were identified, of which 10 genes were considered as hub genes on the basis of the highest degree of connectivity. After the survival analysis of ten hub genes, a total of 5 genes were found to be altered in EMPD patients. Furthermore, 14 drugs of CHEK1, CCNA2, and CDK1 were found to have therapeutic potential against EMPD. This study updates the information and yields a new perspective in the context of understanding the pathogenesis of EMPD. In future, hub genes and candidate drugs might be capable of improving the personalized detection and therapies for EMPD.

Advances in non and minimal-invasive transcutaneous delivery of immunotherapy for cancer treatment

Cancer research has focused on figuring out what was the difference between cancer cells and the tissues within which cancer arose and developing targeted treatments for those differences. With FDA-approved treatments for more ten different cancers and more than thousand new clinical trials, immunotherapy has recently emerged as the most promising area of cancer research by improving efficacy and controlling the adverse effects. Transcutaneous delivery drug delivery offers a number of advantages for the patient because of not only its noninvasive and convenient nature but also factors such as avoidance of first-pass metabolism and prevention of gastrointestinal degradation. The purpose of this review was to highlight technological recent approaches to non and minimal-invasive delivery of immunotherapy for cancer treatment. Finally, some practical considerations and discussions for future studies in the field of transdermal immunomodulation are also included.

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

BACKGROUND

Extramammary Paget's disease (EMPD) is a rare malignancy with unclear pathophysiology that occurs predominantly on apocrine-rich skin. Surgery is the treatment of choice; however, procedures tend to be extensive and associated with a high rate of recurrence.

OBJECTIVE

To review the current literature on EMPD regarding treatment and prognosis.

MATERIALS AND METHODS

Literature review using PubMed search for articles related to EMPD.

RESULTS

Extramammary Paget's disease classically presents as a slowly growing red plaque, which often mimics an inflammatory condition leading to significant delay in diagnosis. Diagnosis requires histopathologic examination and is often supported by immunohistochemical analysis. Once a diagnosis of EMPD is made, the patient must be risk-stratified and evaluated for an underlying malignancy.

CONCLUSION

Standard of treatment is surgery, with data suggesting that Mohs micrographic surgery may have superior clinical outcomes and lower recurrence rates. Alternatives such as photodynamic therapy and topicals have been explored and may be appropriate in certain situations. Patients with EMPD generally have a good prognosis with a 5-year overall survival rate of 75% to 95%.

The diagnosis and management of extramammary Paget's disease

INTRODUCTION

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

Extramammary Paget's disease of the scrotum with complete response to imiquimod and photodynamic therapy

Extramammary Paget's disease (EMPD) is a rare intraepithelial neoplasm with an extremely variable clinical course. The objective of this study was to determine if combination imiquimod and photodynamic therapy could induce remission of EMPD. A 69-year-old man with EMPD was treated with topical imiquimod 5% cream at night for 5 days per week for 1 month, followed by 2 months of 5% imiquimod for three nights a week. For the following 6 months, monthly 5-aminolevulinic acid photodynamic therapy was added. After 6 months, imiquimod was discontinued and the patient continued to be treated with quarterly photodynamic therapy. Treatment resulted in significant improvement in the appearance of the lesion, and pathology revealed no evidence of residual disease. The patient has had no clinical signs of disease for >5 years. We conclude that topical imiquimod 5% cream and photodynamic therapy may aid in the treatment of some patients with EMPD.

Imiquimod in dermatology: an overview

Imiquimod is an immune response modifier commercially available as a 3.75 and 5% cream. Topical imiquimod stimulates the innate and adaptive immune responses and induces cytokine production. This allows its use for the treatment of a wide variety of benign and malignant skin conditions due to its potential antiviral, antitumor, and immunoregulatory effects. Currently, topical imiquimod is US Food and Drug Administration (FDA)-approved for the treatment of anogenital warts, actinic keratosis, and superficial basal cell carcinomas. However, it has also shown a beneficial effect in the treatment of many other skin disorders. In this review, we describe existing evidence on the mechanism of action of topical imiquimod, its FDA-approved indications, off-label uses, and side effects.

Viral and Nonviral Uses of Imiquimod: A Review

Background:

Imiquimod is a topical immunomodulator that is indicated for the treatment of external genital and perianal warts. This drug has been recently approved for the treatment of actinic keratoses and superficial basal cell carcinoma. There is a growing body of evidence for its effectiveness in treating a variety of other skin conditions.

Objective:

This review examines the role of imiquimod 5% cream in the treatment of skin diseases such as actinic keratoses, basal cell carcinoma, Bowen's disease, lentigo maligna, and extramammary Paget's disease.

Methods:

Published literature containing the words “Imiquimod” or “Aldara” was reviewed and summarized.

Results:

This agent has demonstrated indirect antiviral and antitumor effects in animal models. Although the exact mechanism of action is unknown, imiquimod is an agonist for toll-like receptor (TLR) 7 and is thought to act by inducing cytokines, such as interferon alpha (IFN-α), interleukin-12 (IL-12), and tumor necrosis factor alpha (TNF-α). These cytokines trigger the immune system to recognize the presence of a viral infection or tumor and the associated lesion is ultimately eradicated. Side effects are generally well tolerated with local skin reactions reported most frequently.

Conclusion:

Imiquimod has been shown to be a safe and effective treatment for a variety of skin conditions.

Topical imiquimod in the treatment of extramammary Paget's disease: A 10 year retrospective analysis in an Asian tertiary centre

Extramammary Paget's disease (EMPD) is a rare intraepithelial adenocarcinoma usually found in apocrine-rich areas. Although surgery remains standard treatment, topical imiquimod has emerged as a promising drug for the treatment of EMPD in recent years. We present our experience in treating EMPD in Asian skin successfully with topical imiquimod 5% cream, over the past 10 years in our tertiary institution.

Perianal Paget's Disease

Background:

Perianal Pa get's disease is an uncommon intraepithelial neoplasm that involves areas affluent with apocrine glands, most frequently in the female external genitalia, but may also affect the perianal region.

Objective:

We present the pathologic and clinical management of a case of Paget's disease involving the perianal region, in which diagnosis was delayed for 8 years.

Conclusions:

The importance of a high index of suspicion for early diagnosis is emphasized, which should be followed by aggressive surgical treatment with wide excision and local reconstruction.

A pilot study of topical imiquimod therapy for the treatment of recurrent extramammary Paget's disease

OBJECTIVE

The objective of this prospective pilot study was to assess the clinical and histologic effects of topical imiquimod therapy on recurrent extramammary Paget's disease of the vulva.

METHODS

Patients with biopsy-proven recurrent extramammary Paget's disease presenting to the gynecology outpatient services at two participating institutions were recruited for conservative treatment with 5% imiquimod cream from 2007 to 2011. The topical cream was to be applied 3 times per week for 12weeks. Punch biopsy and photography were performed at baseline and at the 12-week time point.

RESULTS

Eight patients from two institutions were enrolled. Complete clinical and histologic response was achieved in 6 (75%) patients by the 12-week follow-up appointment. Of the two remaining patients, one had a complete clinical response but no significant histologic response; the other patient was removed from the study protocol secondary to intolerable local irritation. Two patients continue to have no evidence of disease after a median follow-up of 35months. Five are alive with disease. No patients progressed to invasive cancer while receiving therapy.

CONCLUSION

Topical 5% imiquimod cream is a safe and feasible option for women suffering from recurrent extramammary Paget's disease of the vulva, and should be considered as a viable alternative to surgical management. Given the rare nature of this disease, additional multi-institutional prospective studies should be conducted to explore the efficacy of this treatment regime.

Treatment of primary vulvar paget disease with 5% imiquimod cream

INTRODUCTION

Our objective was to evaluate the efficacy of conservative treatment with imiquimod in Paget vulvar disease.

MATERIALS AND METHODS

We describe a case series that includes 10 patients with histopathologic diagnosis of extramammary Paget disease of the vulva, who were treated with 5% imiquimod cream. Of these patients, 3 were treated for recurrent disease and 7 were treated for initial primary disease. The patients applied the cream every other day until the lesions were no longer clinically detected.They were previously instructed on how and where to apply the cream by making them use a mirror while following the physician's directions.

RESULTS

Complete clinical and histologic remission of the disease was achieved in 9 patients. The remaining patient had partial histologic response and is still under treatment. The treatment was well tolerated despite moderate irritation. No recurrences were observed during a mean follow-up of 18 months.

CONCLUSIONS

On the basis of the results, the authors consider that 5% imiquimod cream could be considered a safe and effective therapeutic option for the treatment of primary vulvar Paget disease. Further studies are needed to determine the real efficacy and safety of 5% imiquimod cream for the treatment of this infrequent disease.

Topical pharmacotherapy for skin cancer: part II. Clinical applications

The purpose of the paper is to provide an in-depth, evidence-based analysis of the clinical use of topical treatments for skin cancer. A comprehensive review of topical drugs has been performed, including 5-fluorouracil, imiquimod, diclofenac, ingenol mebutate, retinoids, resiquimod, piroxicam, dobesilate, and betulinic acid. The evaluated studies were rated according to their level of evidence level (I-V), as indicated by recent guidelines for evidence-based medicine, The Oxford 2011 Levels of Evidence. Therapeutic response is generally related to tumor type, extent, and localization, and also to patient compliance. Careful patient selection is required in order to achieve the desired goal of complete tumor clearance.

Management of Extramammary Paget's Disease: A Case Report and Review of the Literature

Extramammary Paget's Disease (EMPD) is a rare condition of the skin that often involves the vulva, perianal region, scrotum, penis, and axilla. Although prognosis is generally favorable, it can be associated with neoplasms of the bladder, urethra, prostate, and rectum. This report presents a case of scrotal EMPD that failed treatment with imiquimod 5% cream and discusses benefits and complications of available treatment options. The variation of treatment success emphasizes the importance of further research.

Management of penoscrotal extramammary Paget disease: case series and review of the literature

Extramammary Paget disease (empd) is a rare, slow-growing neoplasm, considered to be an adenocarcinoma of the apocrine glands. In men, the penoscrotal region is the most commonly affected area. The disease can present as carcinoma in situ or as invasive disease that can subsequently metastasize to lymph nodes and distant sites. Because of the rarity of empd, the medical literature available to guide management of the disease is limited, particularly in patients with metastases. In addition, metastatic disease may pose a diagnostic challenge, because invasive cancer of the genitourinary or gastrointestinal tract can occur in association with empd. In the present case series, we describe our experience in treating penoscrotal empd with multimodality therapy, and we review the existing literature concerning its diagnosis and management.

Treatment of vulvar Paget disease with topical imiquimod: a case report and review of the literature

BACKGROUND

Extramammary Paget's disease is a cutaneous neoplasm that presents as erythematous crusted patches and plaques reminiscent of contact dermatitis or inverse psoriasis that can be a challenge to treat in a tissue-sparing manner. The most commonly involved site for this rare disorder is the anogenital region. Surgery is considered as the gold standard therapy. In the last years, the topical use of imiquimod cream in the treatment of this condition has been reported.

MAIN OBSERVATIONS

We present a case of a 59-year-old woman with primary extramammary Paget's disease of the vulva, in which a conservative approach to therapy was desired, and who underwent complete and stable remission with imiquimod cream. We also review the previous reports of patients with extramammary Paget's disease treated with imiquimod cream.

CONCLUSIONS

Imiquimod therapy may be an alternative for primary as well as recurring extramammary Paget's disease. Treatment-associated morbidity is minimal compared with other therapies, such as surgery which may be debilitating.

[Extramammary Paget disease: successful therapy with imiquimod 5% cream]

A 90-year-old woman presented with an extensive primary form of extramammary Paget disease localized in the anogenital region. An associated carcinoma could be excluded. Due to the age of the patient, the location and extent of the tumor as well as existing comorbidities, neither a surgical nor a radio-oncological treatment were advisable. A local treatment with imiquimod 5% cream applied 3 times weekly for 2 × 3 weeks led to a clinically and histopathologically complete remission. As also shown by other authors, imiquimod appears to be a treatment option for the primary form of extramammary Paget disease.

Potential efficacy of imiquimod on immunity-related cytokines in murine skin in vivo and in human Langerhans cells in vitro

INTRODUCTION

Imiquimod, an immune-response modifier, has been proven to be clinically effective in the treatment of viral infections and skin cancers, but its mechanism of action remains poorly understood. This study aimed to assess the effects of imiquimod on the expression of three immunity-related cytokines, TNF-α, IL-1β, and IL-6.

MATERIALS AND METHODS

Female BALB/C mice were treated for seven days with topical 1% imiquimod cream; they were then killed and skin samples were snap-frozen. In the in vitro studies, both purified LCs and HaCaT cells were incubated with 5 μg/ml imiquimod for four hours. In all samples, the mRNA levels of TNF-α, IL-1β, and IL-6 were then detected by reverse transcription polymerase chain reaction, and the secretion levels were determined by an enzyme-linked immunosorbent assay.

RESULTS

Imiquimod upregulated the mRNA and protein expression levels of TNF-α, IL-1β, and IL-6 in the skin of imiquimod-treated BALB/C mice and in human LCs, compared with untreated controls (P<0.05). However, there was no significant difference in the expression of these cytokines in imiquimod-treated and untreated HaCaT cells.

CONCLUSIONS

These findings indicate that imiquimod increased the expression of TNF-α, IL-1β, and IL-6 in skin and that the target cell of imiquimod may be the LCs but is unlikely to be the epidermal keratinocytes.

Extra-mammary Paget's disease of the perianal region: a review of the literature emphasizing the operative management technique

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.

Extramammary Paget's disease of the unilateral axilla: a review of seven cases in a 20-year experience

BACKGROUND

Extramammary Paget's disease (EMPD) is an uncommon malignancy that occurs on apocrine-rich skin. EMPD of the axillary region is extremely rare and is not well documented. Objectives  The aim of the study is to review our experience with axillary EMPD with regard to initial examination, treatment, and long-term outcome.

METHODS

A retrospective study of inpatient files with the diagnosis of axillary EMPD was made. The data were collected regarding patient demographics, symptoms, surgical treatments, and time to recurrence. Follow-up information was obtained as well.

RESULTS

Seven patients with a median age of 67.6 years were diagnosed with axillary EMPD during a 20-year period from 1989 to 2008. The male-female ratio was 1 : 1.3. All patients had a unilateral axillary occurrence, with three in the left and four in the right side. Patients typically presented with a chronic erythematous to brownish plaque with or without pruritus. All patients were treated with wide excision with margins up to 2-3 cm. There were no recurrences after surgery during the follow-up period.

CONCLUSIONS

Extramammary Paget's disease of the axillary region is a rare finding even in a large medical center. The disease process is generally a prolonged one without remarkable symptoms. The prognosis of axillary EMPD is relatively good, and long-term follow-up is recommended.

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.

Treatment of recurrent vulvar Paget disease with imiquimod cream: a case report and review of the literature

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.

Efforts to counteract locally the effects of systemic immunosupression: a review on the use of imiquimod, a topical immunostimulator in organ transplant recipients

The potent systemic immunosuppression therapy necessary to sustain a life-saving solid organ transplant is associated with an increased incidence of various infections including human papillomavirus infection and skin cancers in organ transplant recipients. Imiquimod, a topical agent that functions through local induction of a specific anti-viral or anti-tumor immune response, appears to be a promising therapeutic option that could potentially counteract in situ the effects of systemic immunosupression in this vulnerable group. Up-to-date studies using this local immune-response modifier in transplanted patients have yielded reassuring and encouraging results regarding its safety and efficacy in this population. However, in order to establish the use of imiquimod as a standard treatment option for organ transplant recipients, additional research and clinical trials are required.

Anal neoplasms

A variety of lesions comprise tumors of the anal canal, with carcinoma in situ and epidermoid cancers being the most common. Less common anal neoplasms include adenocarcinoma, melanoma, gastrointestinal stromal cell tumors, neuroendocrine tumors, and Buschke-Lowenstein tumors. Treatment strategies are based on anatomic location and histopathology. In this article different tumors and management of each, including a brief review of local excision for rectal cancer, are discussed in turn.

Extramammary Perianal Paget's Disease

Perianal Paget's disease is a rare malignancy. It is rarely isolated and often associated with an underlying adenocarcinoma. It usually presents with anal itchiness and discomfort and can be misdiagnosed as hemorrhoids. Once the diagnosis of perianal Paget's disease is granted, extensive work-up to find an underlying primary malignancy is crucial. Surgery is the standard modality of treatment of extramammary Paget's disease (EMPD) with recurrence rates of 44–60%. Other different treatment modalities including radiotherapy, laser therapy, topical and systemic chemotherapy and the new emerging, promising photodynamic therapy are in the field of study. A 76-year-old man was referred to our hospital with a one-year history of anal itchiness and intermittent rectal bleeding. Skin shave and punch biopsies from the perianal area were reported back as perianal Paget's disease with no underlying adenocarcinoma. The immunohistochemical stains were positive for cytokeratin 7 but also positive for cytokeratin 20 and CEA which indicated the essentiality of extensive investigations to find a primary malignancy. Skin exam showed no primary source. The investigations were unable to find the primary malignancy. Given the results of immunohistochemical stains we recommended local perianal Paget's disease resection. The intraoperative frozen section showed adenocarcinoma around the anal sphincter. Ten days later the patient underwent an abdominoperineal resection and the final pathology report showed extensive adenocarcinoma in three quadrants of the perianal area with focal involvement of the rectal mucosa. We recommended an adjuvant chemotherapy with FOLFOX following surgery given the bulkiness of the disease. We conclude that once perianal Paget's disease is diagnosed, an extensive work-up should be done to find the underlying primary malignancy. Immunohistochemical stains are helpful in raising the suspicion of underlying primary malignancy. Finding an underlying primary malignancy in patients with EMPD is prompt to choose the treatment modality and estimate the prognosis.