Extramammary Paget disease of the perianal region: the potential role of imiquimod in achieving disease control

Applications of photodynamic therapy in extramammary Paget's disease

Extramammary Paget's disease (EMPD) is a rare form of adenocarcinoma usually found in apocrine gland-containing cutaneous regions. EMPD affects the vulvar area most commonly, followed by the perianal area, scrotum, penis, and axillary region. In its initial form, EMPD presents as an erythematous plaque with well-defined edges, fine scaling, excoriations, exulcerations, and lichenification. Generally, a definitive diagnosis can be made through histopathological analysis. Importantly, associated malignancies should be investigated prior to treatment initiation. Photodynamic therapy (PDT) is a modern, noninvasive treatment strategy for non-oncological diseases as well as various cancers. In recent years, PDT has been widely used to treat EMPD. This present article presents a discussion of the diagnosis and treatment of EMPD as well as the usefulness of PDT in its management.

Perianal Paget's-an aggressive disease

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.

Extramammary Paget disease: five perianal case report and treatment options

We present five cases of perianal Paget disease (PPD). Two cases underwent a wide local excision (WLE) of PPD plus skin flap transfer surgery with good curative effect. One case of PPD complicated with mucinous adenocarcinoma underwent a laparoscopic abdominoperineal resection (Miles), which may be the extremes of clinical treatment of the disease. The remaining two cases passed away without surgery after they refused further treatments. This article aims to draw attention to relationship among the correct diagnosis, protection of anal function and treatment options of PPD.

Perianal Paget Disease: Different Entities With the Same Name

Extramammary Paget disease (EMPD) is a rare form of cancer that involves skin areas rich in apocrine glands. The common sites of occurrence include the vulva, perianal region, perineum, and axilla. Perianal Paget disease (PPD) is a subset of EMPD, which arises in the perianal skin. The disease commonly presents with a thickened plaque-like lesion with erythema or white scaly appearance. It is generally classified into two categories based on the origin of the tumor cells: (1) primary PPD if the tumor arises from intraepidermal cells and (2) secondary PPD if cancer originates from the underlying colorectal or urinary tract neoplasm. Due to its rarity, only a few sporadic case reports have been published in the literature, and treatment methods are yet to be standardized. In light of this, we report two PPD cases with different etiopathogenesis and staging: one involved only the perianal skin without regional or metastatic disease, and was not accompanied by visceral adenocarcinomas although there was a previous history of sigmoid adenocarcinoma; the other was probably secondary to an anal canal tumor spreading with disseminated disease involving the perianal and perineum area with bilateral inguinal, pelvic lymph node, and liver metastasis. The treatment plans and the outcomes of both cases were necessarily different from each other.

Rare perianal extramammary Paget disease successfully treated using topical Imiquimod therapy

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.