Depigmented extramammary Paget's disease

Pathologically Confirmed Subcutaneous Fat and Lymphovascular Invasion of a Hypopigmented Area in Extramammary Paget Disease

Extramammary Paget disease (EMPD) is a rare adenocarcinoma that usually occurs in areas of the body that are rich in apocrine sweat glands. Great depth of tumor invasion is a well-known risk factor for worse prognosis. Paget cells usually are limited to the epidermis, whereas invasive EMPD, which infiltrates the dermis, is relatively rare. It is even rarer for the tumor to spread beyond the dermis. Only 3.1% of patients with EMPD of the penis and scrotum have exhibited infiltration of the subcutaneous fat layer. We report a case of a 62-year-old male with EMPD that invaded the subcutaneous fat layer. He presented with a several-year history of a slowly expanding erythematous plaque with the hypopigmented area on the left penoscrotum. One month before presentation, the patient had undergone punch biopsy at another hospital and diagnosed with EMPD. He had no personal history of urogenital cancers. The patient was treated with Mohs micrographic surgery, and negative margins were achieved after four stages. The histopathologic findings revealed Paget cells scattered throughout the epidermis. At the hypopigmented area, Paget cells extended to the subcutaneous fat layer with lymphovascular invasion. There was no evidence of recurrence at seven months postoperatively. Herein, we describe a case of hypopigmented EMPD that infiltrated the subcutaneous layer, which rarely has been reported in Korea.

Hypopigmentation in Extramammary Paget Disease Is an Important Prognostic Factor for High Recurrence Rate and Poor Surgical Outcome

BACKGROUND

Several studies have reported the presence of hypopigmentation in extramammary Paget disease (EMPD). However, an in-depth analysis regarding its clinical implication is lacking.

OBJECTIVE

To evaluate the clinical characteristics of EMPD in the Korean population and to determine the implication of hypopigmentation on clinical outcomes.

METHODS

We retrospectively reviewed 124 cases of EMPD who underwent surgical treatment from a single tertiary hospital from December 2005 to March 2019. Baseline characteristics of the patients and hypopigmentation patterns were analyzed. Moreover, the number of stages of Mohs micrographic surgery (MMS) and recurrence rate were evaluated in relation to the hypopigmentation.

RESULTS

A total of 67.7% (n = 84) of the patients showed hypopigmentation. The adjusted odds ratio for recurrence in the hypopigmented group was 5.980, which was statistically significant (95% confidence interval = 1.347-26.553, p-value = 0.019). Furthermore, the average number of MMS stages was 2.92 in the hypopigmentation group, compared with 1.82 in the nonhypopigmentation group (p-value = .0016).

CONCLUSION

Hypopigmented lesions may disguise the tumor margin, thus raising the recurrence rate after surgery and the number of stages of MMS. The hypopigmentation status must be considered when deciding the surgical margin.

Extramammary Paget Disease of the Scrotum: A Contemporary Clinicopathologic Analysis of 20 Cases in the United States

Extramammary Paget disease (EMPD) often involves apocrine gland-bearing locations including vulva and perianal area. EMPD of the scrotum is rare. Twenty patients were identified from the pathology files of 4 institutions between 2000 and 2018. Patients were 63- to 87-year-old (mean: 73 y) with a history of symptoms of between 4 months and 10 years. Two patients had a history of prostate cancer. Follow-up was available in 11 patients for a median of 71 months (range: 8 to 126 mo). Nine of 11 patients (82%) had positive margins, and 73% required reexcisions. Three patients had a focal dermal invasion, 1 of whom reportedly died of another etiology 25 months post diagnosis and 2 were disease-free at 24 and 68 months. No patient had inguinal lymphadenopathy. Two patients were alive with disease. Immunohistochemically, GATA3 and GCDFP15 were expressed in 6/6 cases, CK7 in 8/8 cases, and androgen receptor in 13/13 cases. HER2 was positive in 5/12 cases. PSA was positive in 1 patient who had a history of prostate cancer, whereas other prostate markers (NKX3.1 and prostein) were negative, and CK7 and GCDFP15 were positive, rendering primary EMPD diagnosis. Twelve other cases were negative for PSA and NKX3.1. In conclusion, EMPD of the scrotum has an insidious onset and its nonspecific symptoms can be misdiagnosed as dermatitis or fungal infection. Although localized EMPD has a favorable prognosis, the invasive disease is rare and did not predict metastasis or progression. Margins are frequently positive requiring reexcision. Occasionally, cases can be positive for PSA leading to diagnostic pitfalls.

Extramammary Paget's disease: a review of the literature

Extramammary Paget's disease (EMPD) is a rare cutaneous malignancy. The disease typically affects older individuals aged 60-80 years and is seen most frequently in postmenopausal Caucasian women and Asian men. EMPD exhibits a predilection for the genital and perianal regions and may be associated with an underlying carcinoma in adjacent organs. EMPD presents a challenge in both diagnosis and management. Often treated empirically as various dermatitides, the correct diagnosis is frequently delayed by many years. Following diagnosis, an extensive search for an associated malignancy should be initiated. If invasive disease is present on biopsy, a sentinel lymph node biopsy may guide further treatment. Mohs micrographic surgery appears to be superior to wide local excision when considering tissue sparing ability and disease recurrence. Nonsurgical interventions have also been investigated with varied results. Regardless of treatment method, long-term follow-up is recommended to monitor for local disease recurrence, development of internal malignancy, regional lymphadenopathy, or distant metastasis.

Acquired disorders with depigmentation: A systematic approach to vitiliginoid conditions

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

Role of Multiple Scouting Biopsies before Mohs Micrographic Surgery for Extramammary Paget's Disease

BACKGROUND

Extramammary Paget's disease (EMPD) frequently extends subclinically, resulting in high recurrence rates after surgical excision. Mohs micrographic surgery (MMS) improves cure rates but may require time-consuming reexcision of subclinical extension. A mechanism to estimate the location and extent of subclinical extension would be helpful.

OBJECTIVE

To describe and evaluate a technique for multiple scouting biopsies before MMS for EMPD.

METHOD

A retrospective review of patients at Mayo Clinic who had multiple scouting biopsies before MMS for EMPD without dermal invasion.

TECHNIQUE

The clinical extent of EMPD is identified. The scouting biopsy sites are determined and documented with photographs. The scouting biopsy specimens are sent for permanent sections. The results of the scouting biopsies help guide the extent of the initial Mohs layer. The tumor is cleared with MMS. An additional 1 mm peripheral margin of tissue is usually submitted for permanent sections.

RESULTS

Multiple scouting biopsies were done in five patients. Four of the five patients had at least one true-positive result. At least one true-negative result was obtained in all five patients. Two patients had at least one false-negative result.

CONCLUSION

Multiple scouting biopsies before MMS for EMPD without dermal invasion can be a beneficial adjuvant technique.