Mammary and extramammary Paget's disease

The Role of Line-Field Confocal Optical Coherence Tomography in Detecting Extramammary Paget Disease Recurrences: A Pilot Diagnostic Study

Extramammary Paget disease (EMPD) is an uncommon adenocarcinoma of apocrine gland-rich areas, presenting significant diagnostic challenges due to its nonspecific clinical appearance and frequent misidentification as benign, inflammatory skin conditions. Traditional diagnostic methods such as biopsy are invasive and uncomfortable, often required repeatedly due to high recurrence rates. Dermoscopy and non-invasive imaging techniques have been used but provide limited diagnostic accuracy due to their constraints in depth penetration and resolution. Recent advancements in imaging technologies, such as line-field confocal optical coherence tomography (LC-OCT), show promise in enhancing diagnostic precision while minimizing invasive procedures. LC-OCT merges high-resolution imaging with deep penetration capabilities, capturing detailed horizontal and vertical skin images akin to histopathology. This study evaluated the diagnostic performance of LC-OCT in detecting EMPD and its recurrence in 17 clinically suspicious anogenital regions, belonging to six patients. Data were collected prospectively at the patient's bedside by an LC-OCT expert with poor training for EMPD, and, then, reviewed retrospectively by an independent LC-OCT expert with adequate training for EMPD and no concerns about time. The prospective examination yielded 64.7% accuracy (11 true results out of 17 total cases), 71.4% sensitivity (10 true positives out of 14 actual positives), and 33.3% specificity (1 true negative out of 3 actual negatives). The retrospective analysis achieved 94.1% accuracy (16 true results out of 17 total cases), 100% sensitivity (14 true positives out of 14 actual positives), and 66.7% specificity (2 true positives out of 3 actual positives), with the only false positive case being a difficult-to-diagnose concomitant presentation of a lichen sclerosus et atrophicus. Despite the need for specialized training, our results suggest that LC-OCT represents a valuable tool for accurately identifying EMPD and improving its management by reducing unnecessary biopsies. Further studies are needed to standardize its clinical application.

Modified clock mapping biopsy sec. Della Corte-Bifulco in the preoperative assessment of excisional surgery for vulvar Paget's disease

We have developed a biopsy technique aimed at preoperative evaluating the extent of Paget's vulvar disease in order to plan subsequent radical vulvar surgery. The aim is to find all possible lesion sites that are not visible macroscopically, to obtain a clear evaluation of the disease spread and to tailor the radical surgical procedure to remove even microscopic lesions, avoiding recurrences and excessively destructive surgery, adopting as conservative an approach as possible. We used this procedure for the first time to establish the radicality of the surgical intervention in a 68-year-old patient initially suffering from a single invasive vulvar Paget's lesion.

Extramammary Paget Disease of Oral Mucosa: Case Report with Literature Review

Extramammary Paget disease (EPMD) of the oral mucosa is an unusual and extremely rare condition, with fewer than ten cases documented. Here, we report a case of EMPD extensively involving oral mucosa and underlying salivary ducts in a 72-year-old male and review published clinical, histologic, immunophenotypic, and prognostic features of this rare entity.

Dense Lichenoid Inflammation in Paget Disease: A Diagnostic Pitfall

ABSTRACT

Mammary Paget disease is a rare form of breast cancer, which typically presents as an eczematous plaque on the nipple or surrounding skin. It is often a clinical diagnosis that is confirmed with skin biopsy. Histologic hallmarks of mammary Paget disease include large, pleomorphic, malignant, ductal epithelial cells within the epidermis. Chronic lichenoid inflammation may be seen in the papillary dermis but is not diagnostic. Because mammary Paget disease often overlies ductal carcinoma in situ or invasive carcinoma of the breast, prompt bilateral mammography is warranted. We report a case of Paget disease of the nipple with negative breast imaging that was originally misdiagnosed due to a dense lichenoid infiltrate obscuring the neoplasm.

Primary perianal Paget's disease: three cases

Perianal Paget's disease (PPD) is a rare intraepidermal neoplastic disease, presenting with nonspecific symptoms, such as pruritis ani or eczema. Perianal Paget's disease may present as a primary lesion or as a paramalignant phenomenon. Uniform evidence-based treatment strategies have not been defined for this rare condition, and currently, different treatment methods are suggested. This case report presents three cases of perianal Paget's disease with three different treatments and outcomes. Pathogenesis, treatment, and the importance of a strict follow-up program are discussed.

Contribution of histone variants to aneuploidy: a cancer perspective

Histone variants, which generally differ in few amino acid residues, can replace core histones (H1, H2A, H2B, and H3) to confer specific structural and functional features to regulate cellular functions. In addition to their role in DNA packaging, histones modulate key processes such as gene expression regulation and chromosome segregation, which are frequently dysregulated in cancer cells. During the years, histones variants have gained significant attention as gatekeepers of chromosome stability, raising interest in understanding how structural and functional alterations can contribute to tumourigenesis. Beside the well-established role of the histone H3 variant CENP-A in centromere specification and maintenance, a growing body of literature has described mutations, aberrant expression patterns and post-translational modifications of a variety of histone variants in several cancers, also coining the term "oncohistones." At the molecular level, mechanistic studies have been dissecting the biological mechanisms behind histones and missegregation events, with the potential to uncover novel clinically-relevant targets. In this review, we focus on the current understanding and highlight knowledge gaps of the contribution of histone variants to aneuploidy, and we have compiled a database (HistoPloidyDB) of histone gene alterations linked to aneuploidy in cancers of the The Cancer Genome Atlas project.

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.

Outcomes and prognostic factors of surgically treated extramammary Paget's disease of the vulva

OBJECTIVE

Extramammary Paget's disease (EMPD) of the vulva is a rare disease which predominantly presents in postmenopausal Caucasian women. As yet, no studies on Asian female patients with EMPD have been performed. This study aimed to identify the clinical features of patients with vulvar EMPD in Korea, and to evaluate the risk factors of recurrence and postoperative complications in surgically treated EMPD.

METHODS

We retrospectively reviewed 47 patients with vulvar EMPD who underwent wide local excision or radical vulvectomy. The clinical data and surgical and oncological outcomes following surgery were extracted from medical records and analyzed. Univariate and multivariate analyses for predicting recurrence and postoperative complications were performed.

RESULTS

21.3% of patients had complications after surgery, and wound dehiscence was the most common. 14.9% of patients experienced recurrence, and the median interval to recurrence from initial treatment was 69 (range 33-169) months. Vulvar lesions larger than 40 mm was the independent risk factor of postoperative complications (odds ratio [OR]=7.259; 95% confidence interval [CI]=1.545-34.100; p=0.012). Surgical margin status was not associated with recurrence in surgically treated vulvar EMPD patients (OR=0.83; 95% CI=0.16-4.19; p=1.000).

CONCLUSION

Positive surgical margin is a frequent finding in the patients with vulvar EMPD, but disease recurrence is not related with surgical margin status. Since EMPD is a slow growing tumor, a surveillance period longer than 5 years is required.

Immunohistochemical and clinicopathological study regarding nardilysin on extramammary Paget's disease

It has been reported that nardilysin (NRDC), a metalloendopeptidase which regulates various growth factors and cytokines, is associated with malignancies in a conflicting manner, in which it promoted gastric, hepatocellular, and colorectal cancers and suppressed pancreatic ductal adenocarcinoma. However, it has not been investigated how NRDC is associated with cutaneous malignancies for now. Immunohistochemical staining has revealed that NRDC expression is observed in all extramammary Paget's disease (EMPD) cases. Notably, other cutaneous malignancies including basal cell carcinoma, squamous cell carcinoma, and eccrine porocarcinoma, did not show increased NRDC expression in immunohistochemistry. EMPD typically presents several types of lesions including nodules, and positive staining of NRDC on EMPD was observed regardless of the type of lesions. Examination using samples taken from nodular lesions showed that some cases showed heterogenous NRDC expression within each lesion. We also found that NRDC staining was weaker in the marginal parts of EMPD lesion than in the central parts in several cases, and tumor cells tend to be distributed beyond the macroscopic skin lesions in these cases. It was speculated that decreased NRDC expression in the marginal zones of the skin lesions may be associated with the ability of tumor cells to produce the cutaneous manifestation of EMPD. This study suggests that NRDC may be associated with EMPD like other malignancies reported previously.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HER2 Negative Mammary Paget's Disease or In Situ Melanoma? A Case Report and Review of the Literature

Mammary Paget's disease (MPD) is a rare histological condition, accounting for 1-4% of female breast cancers, which may appear either independently (1.4-13% of the cases), or in association with an in situ or invasive ductal carcinoma (approximately 90% of the cases). The purpose of this article is to highlight the histopathological challenges related to the microscopical polymorphism of this disease and the utmost importance of immunohistochemistry in the thorough process of Paget's disease differential diagnosis. Moreover, the primary objective of this review of literature was to corroborate the existing data concerning the potential peculiar immunohistochemical profile that mammary Paget's disease might express. We report the case of a 44-year-old female patient, histopathologically diagnosed with HER2-negative MPD accompanying an invasive mammary carcinoma. The histopathological and immunohistochemical approach is derived from the exigency of excluding the possibility of synchronous tumors-a mammary invasive carcinoma, accompanied by another component with MPD phenotypic mimicry. The unexpected negative HER2 reaction is conducted to a primary focus on excluding a malignant melanoma in situ. The absence of MelanA and S100 immunoexpression and lack of pigmentation and clinical aspects infirmed it. Bowen's disease was invalidated by its rare presentation in the breast cutaneous tissue and the absence of individual risk factors suggestive of an existing immunosuppressive status. In the case of similar morphoimmunohistochemical aspects, significant expression of Ki-67 signals MPD, an immunoreactivity that helped distinguish the cellular population from Toker cells. The great similarity of MPD with other benign and malignant cutaneous tumors might determine delay or misdiagnosis. Thus, the utmost importance of immunohistochemistry is reflected in its prognostic significance and geared towards extending the therapeutic arsenal.

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.

Vulvar Paget’s Disease: A Systematic Review of the MITO Rare Cancer Group

Vulvar Paget’s disease (VPD) is a rare form of cutaneous adenocarcinoma of the vulva, which accounts for about 1–2% of all vulvar neoplasms and mainly affects post-menopausal women. The clinical presentation is usually non-specific and mimics chronic erythematous skin lesions; therefore, the diagnosis is often difficult and delayed. Although VPD is typically diagnosed at a locally advanced stage and has a high recurrence rate, the prognosis is overall favorable with a 5-year survival of nearly 90%. Due to the limited and poor-quality evidence, there is no global consensus on optimal management. Therefore, we performed a systematic review of the literature through the main electronic databases to deepen the current knowledge of this rare disease and discuss the available treatment strategies. Wide surgical excision is recommended as the standard-of-care treatment and should be tailored to the tumor position/extension and the patient’s performance status. The goal is to completely remove the tumor and achieve clear margins, thus reducing the rate of local recurrences. Non-surgical treatments, such as radiotherapy, chemotherapy, and topical approaches, can be considered, especially in the case of unresectable and recurrent disease. In the absence of clear recommendations, the decision-making process should be individualized, also considering the new emerging molecular targets, such as HER2 and PD-L1, which might pave the way for future targeted therapies. The current review aims to raise awareness of this rare disease and encourage international collaboration to collect larger-scale, high-quality evidence and standardize treatment.

Extramammary Paget's Disease of the Vulva and Concomitant Premalignant/Malignant Vulvar Lesions: A Potential Challenge in Diagnosis and Treatment

The aim of the present study was to evaluate the incidence of concomitant vulvar cancers or premalignant lesions in women surgically treated for extramammary Paget's disease of the vulva (EMPDV) through a multicenter case series. The medical records of all women diagnosed with and treated for EMPDV from January 2010 to December 2020 were retrospectively analyzed. Women with EMPDV and synchronous vulvar cancer, vulvar intraepithelial neoplasia (VIN) and/or lichen sclerosus (LS) at the histology report were included in the study. A total of 69 women eligible for the present study were considered. Concomitant vulvar lesions occurred in 22 cases (31.9%). A total of 11 cases of synchronous VIN (50%) and 14 cases (63.6%) of concomitant LS were observed. One patient (4.5%) had synchronous vulvar SCC (FIGO stage 1B). Women with EMPDV and concomitant premalignant/malignant vulvar lesions had a significantly higher rate of invasive EMPDV and wider lesions with an extravulvar involvement. The specific meaning of the association between EMPDV, VIN, SCC and LS remains unclear. The potential overlapping features between different vulvar lesions highlight the importance of dedicated gynecologists and pathologists in referral centers.

Electron radiotherapy for EMPD of penis and scrotum

ABSTRACT

Electron beams represent an important treatment modality for providing an accurate dose of therapy to superficial cancers. This case reports important findings of dermal invasion in patients with extramammary Paget's disease (EMPD) using microscopic measurements and electron beam coverage. EMPD is a rare cutaneous adenocarcinoma generally arising in the anogenital region. Surgery is still a curable treatment option for patients with EMPD, whereas radiation therapy (RT) is an alternative for inoperable cases and is necessary in cases where surgery is not performed. This case report describes our experience and reviews the relevant literature on the feasibility of electron RT according to the dermal invasion length. An 80-year-old patient was diagnosed with EMPD and presented for definite radiation treatment. We observed no grade 3 toxicities during electron RT, and at the last follow-up visit, no signs of relapse were observed. There are no reports of electron irradiation as a feasible treatment option for EMPD considering the epidermal invasion length.

Medical and Surgical Strategies in Vulvar Paget Disease: Let's Throw Some Light!

BACKGROUND

Vulvar Paget's disease (VPD) is defined as a neoplasm of epithelial origin, mostly in postmenopausal women. Due to the extreme rarity of VPD, limited data about recommended treatment options are available. Surgical excision has been the treatment of choice although in the recent decade medical treatments have been proposed.

METHODS

A systematic computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane Library), from 2003 to September 2022, in order to analyze all medical and surgical strategies used for the treatment of VPD.

RESULTS

Thirty-four articles were included in this review with findings as follows: 390 patients were treated with medical or other conservative treatment while 2802 patients were treated surgically; 235/434 (54%) patients had a complete response, 67/434 (15%) a partial response, 10/434 (2.3%) a stable disease, 3/434 (0.7%) disease progress, 3/434 (0.7%) died of the disease, 55/434 (13%) died of other causes during follow up while 7/434 (1.6%) had to stop topical treatments with 5% imiquimod cream because of side effects; 239/434 patients (55%) had a recurrence and 11/434 (2.5%) were lost to follow-up. The length of follow-up was variable, according to the different studies analyzed.

CONCLUSION

VPD is a chronic disease with a high recurrence rate and low mortality. There are no significant differences in recurrence rates in patients who undergo surgery and those who do not and the margin status at the time of primary surgery and recurrence. Several surgical and medical approaches providing both local control of the disease and minimal tissue damage have been developed. Clock mapping, a recent preoperative vulvo-vaginal workup tool, can predict the invasiveness and the extension of VPD. However, to date, due to the different treatment options available and in the absence of a global consensus, it is critical to tailor treatments to individual patient characteristics and biopsy histopathologic findings, to ensure the best type of therapy.

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.

Penoscrotal defect reconstruction using loco‐regional flaps in treatment of extramammary Paget's disease: Experience and suggestion of a simplified algorithm

BACKGROUND

Reconstruction of penoscrotal defects resulted from margin-controlled excision of extramammary Paget's disease (EMPD) remains challenging, due to its unpredictably varying extents. The present study aimed to investigate outcomes of reconstruction of penoscrotal defects following radical excision of EMPD and to introduce a simplified algorithm for selecting reconstruction strategies.

METHODS

Patients with penoscrotal EMPD who were treated with wide excision and subsequent reconstruction from 2009 to 2020 were reviewed. Their demographics, operation-related characteristics, and postoperative outcomes were evaluated.

RESULTS

In total, 46 patients with a mean age of 64.9 years (range, 44-85 years) were analyzed. An average size of defects was 129.6 cm² (range, 8-900 cm² ). The most frequently involving anatomical subunit was scrotum, followed by suprapubic area and penile shaft. Twenty-six patients had defects spanning multiple subunits. The most commonly used reconstruction methods for each anatomical subunit were internal pudendal artery perforator (IPAP) flaps and/or scrotal flaps for scrotal defects, superficial external pudendal artery perforator (SEPAP) flaps for suprapubic defects, and skin grafts for penile defects. In all but four cases, successful reconstruction was achieved with combination of those reconstruction options. No major complications developed except for one case of marginal flap necrosis. All patients were satisfied with their aesthetic and functional results.

CONCLUSIONS

Diverse penoscrotal defects following excision of EMPD could be solidly reconstructed with combination of several loco-regional options. A simplified algorithm using in combination of IPAP flap, SEPAP flap, scrotal flap, and skin graft may enable efficient and reliable reconstruction of penoscrotal EMPD defects.

Coexistence of condyloma acuminatum and extramammary Paget's disease on penis and scrotum: A rare case report

RATIONALE

Extramammary Paget's disease (EMPD) is a rare skin cancer that commonly occurs in sites rich in apocrine glands, such as perineum, vulva, axilla, scrotum, and penis. On the other hand, condyloma acuminatum (CA; also referred to as anogenital warts) is a common benign neoplasm caused by human papillomavirus. Few cases of coexistent EMPD and CA have been reported because of the rarity of the condition.

PATIENT CONCERNS AND DIAGNOSIS

A 72-year-old man with a genital mass, which appeared to be composed of multiple papillomatous masses, was referred for surgical resection. The lesion was first noticed 6 months previously and grew rapidly. CO2 ablative laser therapy was performed twice at a primary clinic, but the mass recurred.

INTERVENTION AND OUTCOMES

Excisional biopsy revealed the presence of coexistent EMPD and CA. Additional wide excision was performed, and postoperative biopsy confirmed no residual tumor. Two years after surgery, no recurrence had occurred.

LESSONS

CA can co-occur with several types of skin malignancies, and a skin malignancy coexisting with CA is difficult to diagnose visually. Therefore, even if a skin lesion in the genital region is considered to be CA, we recommend punch biopsy before treatment because it can benefit prognosiss.

Scrotal Extramammary Paget’s Disease in an Elderly Caucasian Male

Extramammary Paget’s disease (EMPD) is a rare dermatologic malignancy affecting regions with a dense population of apocrine glands within the intraepithelial tissue, including the vulva, perineum, axilla, scrotum, and penile regions. Clinical presentation varies from being asymptomatic to burning, painful, and pruritic lesions. As a result, it could be misdiagnosed for other dermatologic diseases. Our case report discloses a patient with an erythematous pruritic lesion that was initially treated with topical antifungal therapy. After failed treatment, a biopsy revealed EMPD of the scrotum. With no standard guidelines in the treatment of EMPD, there are different treatment modalities for the disease. Mohs micrographic surgery currently is the preferred treatment modality presenting with the lowest rates of recurrence. With early diagnosis and treatment, the five-year survival rate for patients with primary EMPD is 87%. Therefore, there should be a high level of clinical suspicion for EMPD in patients presenting with pruritic lesions in areas with apocrine glands that have failed initial medical treatment.

Unusual Manifestations of Vulval Paget Disease

Vulval extramammary Paget disease (vEMPD) is an uncommon epithelial malignancy that may arise within the vulva (primary vEMPD) or represent vulval skin involvement by a noncutaneous carcinoma (secondary vEMPD). Primary vEMPD is most often an in situ carcinoma arising within the epidermis but may be associated with dermal invasion (invasive vEMPD) or represent intraepidermal spread of an adenocarcinoma originating in vulval skin adnexa or anogenital mammary-like glands. The latter, termed mammary gland-like adenocarcinoma (MGLA), exhibits morphologic, immunohistochemical, and molecular features of various breast carcinomas but, as far as we are aware, the metaplastic variant of MGLA has not been reported on the vulva. We report 2 cases of metaplastic MGLA of the vulva with associated Paget disease and postulate that some cases of vulval MGLA may arise from Paget disease rather than originating in mammary-like glands. We also report a unique case of secondary vEMPD resulting from spread of urothelial carcinoma in situ that subsequently progressed to invasive urothelial carcinoma within the vulva.

Assessment of Extramammary Paget Disease by Two-Photon Microscopy

Two-photon microscopy techniques are non-linear optical imaging methods which are gaining momentum in the investigation of fixed tissue sections, fresh tissue or even for in vivo experiments. Two-photon excited fluorescence and second harmonic generation are two non-linear optical contrast mechanisms which can be simultaneously used for offering complementary information on the tissue architecture. While the former can originate from endogenous autofluorescence sources (e.g., NADH, FAD, elastin, keratin, lipofuscins, or melanin), or exogenous eosin, the latter is generated in fibrillar structures within living organisms (e.g., collagen and myosin). Here we test the ability of both these contrast mechanisms to highlight features of the extramammary Paget disease on fixed tissue sections prepared for standard histological examination using immunohistochemical markers and hematoxylin and eosin staining. We also demonstrate the label-free abilities of both imaging techniques to highlight histological features on unstained fixed tissue sections. The study demonstrated that two-photon microscopy can detect specific cellular features of the extramammary Paget disease in good correlation with histopathological results.

Vulval extra-mammary Paget's disease: the master of disguise revealed

Extra-mammary Paget's disease is a rare cancer affecting the anogenital region and can present with a myriad of symptoms. In women, the diagnosis of Paget's disease can be challenging as it mimics several other vulval conditions. It is important to promptly recognise this disease because of its potential association with synchronous tumours, such as colorectal adenocarcinoma. The mainstay of treatment is with immunomodulating therapies or surgery, but unfortunately the risk of recurrence is high and appears to be independent of treatment choice and tissue margin status. There is growing evidence to move away from traditional surgical excision to using topical therapy, such as imiquimod, as surgery can often be extensive and disfiguring with a prolonged recovery time. There is considerable psychosexual and physical morbidity associated with Paget's disease, largely owing to multiple surgical recurrences. As recurrences can occur several years after the initial presentation, long-term follow up of patients is recommended.

Imprint cytology can be a better option for diagnosis of mammary Paget’s disease!!!: A case report with review

Mammary Paget’s disease (MPD) is a rare form of pruritic eczematous skin lesion involving the nipple areola complex usually associated with an underlying in-situ or invasive carcinoma of breast, accounting ≤ 4% of overall breast carcinoma. The patient may present with nipple discharge, eczema, plaque, or nipple destruction with or without a lump which is resistant to common remedies. Diagnosis of MPD is usually accomplished by a punch biopsy, but imprint cytology is found to be an effective modern technique yet less explored. Cytological diagnosis is advantageous over surgical excisional biopsy; advantages being easy practicability, cost-effective, quick non-invasive, and above all can lead the physician for breast-preserving surgeries in selective cases rather than more aggressive standard mastectomies. We report one such case of MPD in a 52-year-old female diagnosed on imprint cytology with the aim to emphasize that imprint cytology can be a better option to improve the treatment protocol.

Serum Cytokeratin 18 as a Metastatic and Therapeutic Marker for Extramammary Paget's Disease

Extramammary Paget's disease (EMPD) is a rare cutaneous adenocarcinoma with unfavorable prognosis once it becomes invasive. A tumor marker that reflects disease progression is required for adequate management of this disease. Cytokeratin 18 is highly expressed in many types of cancer and its soluble forms are detected by M30 (for caspase-cleaved form) and M65 (for both caspase-cleaved and intact forms) assays. Here, we report that tumor cells of EMPD in both lesional skin and lymph node metastasis are positive for CK18 immunohistochemically and the baseline serum M30 and M65 levels in metastatic EMPD patients are significantly higher than those in non-metastatic patients. In addition, serial serum M30 and M65 levels might reflect recurrence of EMPD and response to chemotherapy. These results suggest that serum CK18 levels may be a useful tumor marker for advanced EMPD.

Pulmonary Neuroendocrine Carcinomas in Situ: Do They Exist?

INTRODUCTION

Although precursor lesions of pulmonary squamous carcinoma, adenocarcinoma, and carcinoid tumor are well known and accepted entities, precursor lesions of pulmonary neuroendocrine carcinomas, i.e., small cell lung carcinoma and large cell neuroendocrine carcinoma, have never been identified. A small body of literature documenting intraepithelial involvement in cases of pulmonary neuroendocrine carcinomas begs the question of whether the intraepithelial lesion represents de novo intraepithelial neoplasia or invasion by underlying tumour.

METHODS AND MATERIALS

The literature on cases of invasive neuroendocrine carcinomas with an intraepithelial component exhibiting a neuroendocrine immunophenotype was thoroughly and critically reviewed.

RESULTS

The authors of the publications of cases of coexisting invasive and intraepithelial neuroendocrine carcinoma generally favour invasion as the explanation for the intraepithelial component. However, in practice, it is difficult or impossible to determine the direction of migration of tumor cells when there is both an invasive and intraepithelial component. Pulmonary neuroendocrine carcinomas in situ have been produced in genetically engineered mouse models.

CONCLUSIONS

Based on the illustrations in the literature of human cases and the production of pulmonary neuroendocrine carcinomas in situ in genetically engineered mice, it seems likely that these tumours also exist in humans. However, their existence and acceptance require definitive proof. Studies should be undertaken to identify bronchial and other lung biopsies with in situ carcinoma exhibiting a neuroendocrine immunophenotype and a subsequent negative resection specimen and no follow-up evidence of invasive carcinoma. Documenting such cases would provide definitive proof for the existence pulmonary neuroendocrine carcinomas in situ in humans.

Impact of Surgery on Extramammary Paget's Disease Vulva: a Case Series

Extramammary Paget's disease is a rare neoplasm that may affect the vulva. It usually presents as a pruritic red eczematous lesion with islands of hyperkeratosis that is often mistaken for other benign conditions. There are no specific guidelines for the management of this disease. Surgical excision is the standard treatment but recurrences are common in spite of extensive surgery with negative margins. We report here a series of 7 cases of Paget's disease vulva treated by primary surgery. The series highlights some of the challenges in the diagnosis and management of Paget's disease vulva.

The treatment of anogenital extramammary Paget's disease as part of a multidisciplinary approach: The use of Mohs surgery moat method with CK7

Although most cases of extramammary Paget's disease (EMPD) are localized to the intraepidermal, the extensive subclinical extension can lead to high rates of marginal recurrence with wide local excisions and topically destructive treatments. Recurrence rates of EMPD treated with Mohs micrographic surgery (MMS) without immunohistochemical staining are better but variable. Here, we describe our multidisciplinary approach for treating large EMPD tumors of the anogenital region involving critical anatomy using MMS for peripheral margin clearance (moat method) and intraoperative CK7 immunostaining. Our clinical pearls for the management of anogenital EMPD are based on 53 multidisciplinary cases treated at the author's institution between 2014 and 2020.

Extramammary Paget's Disease: Diagnosis, Pathogenesis, and Treatment with Focus on Recent Developments

Extramammary Paget's disease (EMPD) is a rare neoplasm that usually develops in apocrine gland-bearing areas, such as the vulva, scrotum, and penis. EMPD may present with a focal, multifocal, or an ectopic lesion. Clinically, EMPD lesions often exhibit infiltrative erythema, which is sometimes similar to other skin disorders such as eczema. While primary EMPD arises as intraepithelial neoplasm of the epidermis, EMPD-like lesions may occur from epidermotropic spread of malignant cells or direct extension from an underlying internal neoplasm, known as secondary EMPD. Because treatment strategies differ for primary EMPD and secondary EMPD, accurate diagnosis based on detailed histopathological evaluation is required. In the early stages, EMPD usually shows indolent growth, and most cases are diagnosed as carcinoma in situ. However, invasive lesions may result in metastases, and deep invasion is associated with high incidence of metastases. Conventional chemotherapies have been used for EMPD treatment in patients with distant metastases, but the efficacy is not satisfactory, and the prognosis for such patients remains poor. Recent studies have provided various insights into the molecular pathogenesis of the development and advancement of EMPD, which may lead to novel treatment approaches for metastatic EMPD. This review addresses the diagnosis, pathogenesis, and treatment of EMPD with focus on recent progress in understanding this disease.

Axillary Paget disease with a visible satellite: a case report and literature review

Background

Extramammary Paget disease (EMPD) is an uncommon malignancy affecting apocrine gland–bearing skin, such as vulvar, perianal, axillary and penoscrotal areas. Paget cells are sometimes detected outside clinical border in a phenomenon called subclinical extension. Satellite is one of the patterns of subclinical extension which is likely to be invisible. The standard management strategy for EMPD without distant metastasis is a complete surgical removal, sometimes called wide local excision. However, there is no consensus regarding surgical margin width to decrease the high recurrence rate. Here we describe the first macroscopically visible satellite of axillary EMPD and wide local excision of both main lesion and the satellite lesion with only 0.5 cm margin, succeeded by a short review of the literature.

Case presentation

A 48-year-old female with a red macule in the right axilla was presented to our clinic. A well-demarcated 4 cm × 3 cm erythematous plaque was observed in the right axilla, and a similar lesion measuring 0.5 cm × 0.3 cm was found 3.5 cm away from the primary site. Breast and axillary node examination was unremarkable. Biopsy of the large plaque revealed Paget disease, then we performed a local extended excision of both lesions with a 0.5 cm margin, all margins negative indicated, by frozen pathology. Pathology revealed the nature of the satellite beside the main lesion also as Paget disease. The patient is currently followed-up for 20 months and has shown no signs of recurrence, with normal shoulder motor function.

Conclusion

We have report the first visible satellite of extramammary Paget disease, indicating the necessity of an extended local resection of both the main leision and the satellite lesion. Considering the anatomical structure of axillary Paget disease, a 0.5 cm negative surgical margin indicated by frozen pathology might be sufficient to sustain the shoulder motor function.

Perianal Paget's Disease

A 78-year-old woman with a complaint of fecal incontinence was noted to have a perianal rash. Despite improvement of the incontinence with medical management, the rash persisted. She had no symptoms related to the rash, but due to its persistence after two years, she saw a dermatologist who performed a punch biopsy of the area. The biopsy revealed extramammary Paget’s disease that was positive for CAM5.2, CK7, and CDX2 and equivocal for CK20. On physical examination, she had a 2×3cm raised and erythematous lesion on the right buttock extending to the anal margin without anal canal involvement (see Figure 1 ). Subsequent work-up including upper endoscopy, colonoscopy, CT of the chest and abdomen and pelvis, and small bowel follow through was negative. This patient’s case was discussed at the multi-disciplinary conference, and wide local excision was recommended. The patient underwent wide local excision with healing via secondary intention. Closure was foregone due to the small size of the wound and the patient’s medical comorbidities. Pathological examination confirmed negative margins.

Cancer of the Vulva: A Review

BACKGROUND

Vulvar cancers, although rare, are becoming an increasingly serious threat to women's health. Cancer of the vulva accounted for 0.3% of all new cancers in the United States in 2019, with 6,070 newly diagnosed cases. This review details the epidemiology, pathogenesis, diagnosis, staging, and treatment of vulvar malignancies.

OBJECTIVE

To review cancer entities of the vulva, including vulvar intraepithelial neoplasms, squamous cell carcinoma (SCC), malignant melanoma, basal cell carcinoma, neuroendocrine tumors, and adenocarcinomas.

MATERIALS AND METHODS

Literature review using PubMed search for articles related to cancer of the vulva.

RESULTS

Vulvar intraepithelial neoplasms represent premalignant precursors to SCC of the vulva. There are several different histopathologic subtypes of SCC, and treatment is dependent on characteristics of primary tumor and lymph node involvement. Melanoma is the second most common cancer to affect the vulva, and staging is based on tumor, node, and metastatic spread.

CONCLUSION

Vulvar malignancies are rare, and diagnosis is dependent on biopsy and pathologic evaluation. Treatment for vulvar malignancies depends on histopathologic diagnosis but ranges from wide local excision with or without lymph node biopsy or dissection to radiation therapy with chemo- or immunotherapy. Overall survival varies by diagnosis.

Penoscrotal Paget's disease

Paget's disease (PD) denotes an initially intra-epidermal adenocarcinoma that can later invade the dermis and metastasise. Among the extramammary forms of PD (EMPD), penoscrotal presentations are rarer than the vulvar and perianal forms. Once diagnosis has been confirmed by histopathological examination, a search for associated neoplasia must be conducted, although penoscrotal EMPD is less frequently associated with underlying neoplasia than mammary PD (MPD). The associated cancer most often involves a neighbouring organ, with prostate cancer being the most common, or in some cases consists of underlying cutaneous adnexal tumours. First-line therapy consists of surgical excision. Alternatives to surgery (imiquimod, CO₂ laser vaporisation, dynamic phototherapy) may be considered in certain cases.

Expression of lipoma preferred partner in mammary and extramammary Paget disease

BACKGOUND

This study aims to identify the expression of lipoma preferred partner (LPP) in Paget disease (PD) and to further understand the pathogenesis of PD.

METHODS

Tissue microarray was used to evaluate the expression of LPP by immunohistochemistry in 40 PD patients. The results of LPP expression were combined with clinical and histopathological characteristics. Patient files were analyzed retrospectively.

RESULTS

Twenty-one cases were mammary Paget disease (MPD) and 19 extramammary Paget disease (EMPD) involving the vulva, scrotum, and penis. LPP was expressed in PD and this expression was significantly greater in MPD versus EMPD (P = .031). The expression of LPP in MPD was significantly related with age (P = .009) and expression of Ki-67 (P = .011). No statistically significant differences were observed in LPP expression as related to sex, body location, and time of PD diagnosis.

CONCLUSIONS

While LPP is expressed in both MPD and EMPD, the intensity of this expression is greater in MPD. LPP expression is positively correlated with Ki-67 and is more prevalent in middle-aged versus senior MPD patients. Further research is needed to determine its potential role in tumorigenesis and distribution.

[Pathology of the nipple-areola complex : I. Paget's disease of the nipple, variants, and differential diagnoses]

The classical Paget's disease of the nipple is histologically characterized by tumor cell infiltration originating in intraductal or invasive breast carcinoma, immunohistologically by a frequent overexpression of HER2 and clinically by eczema-like changes of the nipple and areola. Variants with different histological, immunohistological, and clinical features are observed in nonclassical forms of Paget's disease, such as isolated Paget's disease of the nipple, anaplastic Paget's disease, Paget's disease with invasion, and pigmented Paget's disease of the nipple. In the differential diagnosis of Paget's disease, benign changes have to be considered, including Toker cell hyperplasia, nipple eczema, and rare dermatoses.

Expression of laminin-5 gamma 2 chain predicts invasion of extramammary Paget's disease cell

Extramammary Paget's disease (EMPD) is a rare malignant skin neoplasm characterized by intraepidermal proliferation of tumor cells. The tumor cells of EMPD may sometimes invade into the dermis or metastasize into the regional lymph nodes. Several studies have proposed mechanisms underlying the increased invasiveness of EMPD; however, molecular markers indicating invasiveness have yet to be well characterized. Laminin-5 (Lam-5), a heterotrimer composed of three chains (α3, β3, and γ2), is a major component of the basement membrane in many tissues. One of the chains, Lam-5 γ2, is a marker of invasion, because it often develops as a monomer in malignant neoplasms. We investigated the expression of Lam-5 γ2 and its role for the invasiveness in EMPD. Paraffin-embedded specimens of EMPD obtained from 36 patients were examined immunohistochemically for Lam-5 γ2. The cases adopted into this study comprised 16 cases of intraepidermal lesions and 20 cases with dermal invasion. The basement membrane seen in normal skin disappeared in one-third of non-invasive cases and in most invasive cases. The disappearance of Lam-5 γ2 in the basement membrane and its cytoplasmic expression was more observed in the invasive cases than non-invasive cases. Expression of Lam-5 γ2 may be a biological marker to predict invasiveness of EMPD.

Extramammary Paget disease of the vulva

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

Genitourinary extramammary Paget's disease: review and outcome in a multidisciplinary setting

BACKGROUND

Extramammary Paget's disease (EMPD) is a rare malignant disease originating from the apocrine glands involving the perineum, vulva, axilla, scrotum, and penis.

OBJECTIVE

To study the clinical presentation, extent of disease, efficacy of treatment, and survival outcomes of the cases in a single institution.

METHODS

Retrospective observation data analysis of 19 EMPD cases was performed. Demographic information, clinical management records, and histopathologic data of individual cases were obtained from the inpatient hospital data registry.

RESULTS

The mean age (years) at time of diagnosis was 62.4 with equal gender distribution. Synchronous tumors were detected in 6 cases (31.5%). 18 out of 19 patients underwent definitive surgical management in the form of wide local excision (WLE) and reconstructive surgery. Positive margins were found in 11 (68.8%) cases and 7 out of these 11 cases underwent second look surgical intervention to achieve oncological clearance or adjuvant oncology treatment. Follow-up period for living patients varied depending on time of diagnosis and definitive treatment. 10 out 19 cases (52.7%) were alive at the time of the study. Among the 7 cases of mortality from cancer, 5 cases died from progression of underlying associated malignancy and only 2 cases died with advanced stage of EMPD.

CONCLUSION

EMPD can be quite aggressive, especially in the secondary form, and surgical management is challenging with a high rate of residual tumor at the surgical margin. EMPD can easily mislead the clinician and patient, leading to unnecessary delay prior to definitive effective management.

Clinical Characteristics, Treatment, and Prognostic Factors of Patients With Primary Extramammary Paget's Disease (EMPD): A Retrospective Analysis of 44 Patients From a Single Center and an Analysis of Data From the Surveillance, Epidemiology, and End Results (SEER) Database

Objective: Primary extramammary Paget's disease (EMPD) is a rare cutaneous malignancy. The aim of this article is to analyze clinical characteristics, evidence of the prognosis, and share treatment experience of primary EMPD.

Methods: We extracted 771 patients' data from the Surveillance, Epidemiology, and End Results (SEER) program between 1973 and 2013 to investigate the characteristics and prognosis of patients with EMPD. In addition, 44 patients with primary EMPD in our hospital were retrospectively reviewed for 10 years.

Results: Compared with patients younger than 65 years, patients diagnosed at 65–74 years [hazard ratio (HR), 2.453] and 75 years or older (HR, 5.750) had shorter survival. Patients with a primary site in the truncal skin (HR, 0.367) or scrotum (HR, 0.246) had better survival compared to those with a primary site in the perianal area. Compared with localized EMPD, EMPD with distant (HR, 18.821) and regional (HR, 2.180) metastases was associated with a worse prognosis. Patients who received radiotherapy had decreased survival, with an HR of 2.039. Patients with a higher N stage, M stage, and American Joint Committee on Cancer (AJCC) stage had a decreased prognosis (p < 0.001).

Conclusions: Older age at diagnosis, primary site in the perianal area, distant metastasis, radiotherapy, and higher N stage, M stage, and AJCC stage may result in decreased survival.

Novel ex vivo disease model for extramammary Paget's disease using the cancer tissue-originated spheroid method

BACKGROUND

Extramammary Paget's disease (EMPD) is a rare skin cancer that frequently occurs in the anogenital region in the elderly. Prognosis in patients with metastatic EMPD is poor as EMPD treatment has advanced little in recent years, primarily because no EMPD cell line has been established.

OBJECTIVE

We aimed to establish an ex vivo EMPD disease model using the cancer tissue-originated spheroid (CTOS) method, which is used to prepare and culture primary cancer cells while maintaining cell-cell contact.

METHODS

Thirteen samples from 12 EMPD patients were obtained. CTOSs were prepared and cultured using CTOS method. Histopathological examination of the CTOSs was performed. We investigated optimum medium conditions and effects of growth factors for CTOS growth. Chemo-sensitivity assays were conducted.

RESULTS

CTOSs were successfully prepared from 3 primary lesions and 2 metastatic lymph nodes. Of these, 2 CTOSs (EMPD-3 and EMPD-4) could be maintained and passaged long term ex vivo. Following transplantation of CTOSs to NOD/Scid mice, CTOS-derived xenotumors exhibited ductal formation, indicating that CTOSs retained the original tumor characteristics. Chemo-sensitivity assays revealed that docetaxel significantly inhibited EMPD-3 growth in a dose-dependent manner, whereas EMPD-4 was not clearly inhibited. These findings indicate the heterogeneity of EMPD and potential use of chemosensitivity assays with patient-derived CTOS to select the most effective drugs for each patient.

CONCLUSION

To our knowledge, this study represents the first establishment of an ex vivo-EMPD disease model involving conventional cell lines. EMPD CTOSs might be useful for developing new therapeutic strategies.

Paget's disease of scrotum and penis case report of a re-irradiation and review of the literature

Extramammary Paget's disease (EMPD) is a rare cutaneous adenocarcinoma generally arising in the anogenital region. Surgery is still considered the treatment of choice for patients with EMPD, while Radiotherapy is a common alternative for inoperable cases and it's necessary in case of lack of surgical radicality. In this article, we described our experience and a review of the literature, with a particular focus on radiation-induced toxicity and on the feasibility of re-irradiation. A 70-year-old patient with EPMD underwent adjuvant radiotherapy in 2015. After 28 months for recurrence another radiant treatment was performed. No G3 (CTCAE v4) toxicity were recorded. In the last follow-up visit at 18 months, no signs of relapse were reported. A search strategy of the bibliographic database PubMed was performed. The inclusion criteria for the articles were case report, clinical prospective, or retrospective studies with histological confirmation of EMPD of scrotum and penis; studies with patients undergoing RT; studies in the past 30 years. In most of the 14 reported studies, RT was overall well tolerated. The major observed toxicity was G3 skin toxicity in one study. To our knowledge, there are no other cases of EPMD re-irradiation in literature. Our patient showed an excellent response and tolerated very well the high doses of both the radiation treatments. This suggests that the tolerance of skin to re-irradiation following a long period between the two treatments may be comparable to the normal constraints.

Extramammary Paget's Disease and Melanoma: 2 Cases of Double Cancers

Extramammary Paget's disease (EMPD) is a rare intraepidermal neoplastic disease. There is a well-known relationship between EMPD and underlying malignancy. However, only a few cases of EMPD and cutaneous melanoma have been reported previously. In this case report we present 2 cases of such double cancers: one as a collision tumor, the other at separate sites. We discuss the pathogenesis, treatment, and importance of a thorough clinical and radiological examination and review the literature.

Polymer nanoparticle-assisted chemotherapy of pancreatic cancer

Pancreatic cancer is a lethal disease characterized by highly dense stroma fibrosis. Only 15-20% of patients with pancreatic cancer have resectable tumors, and only around 20% of them survive to 5 years. Traditional cancer treatments have little effect on their prognosis, and successful surgical resection combined with effective perioperative therapy is the main method for maximizing long-term survival. For this reason, chemotherapy is an adjunct treatment for resectable cancer and is the main therapy for incurable pancreatic cancer, including metastatic pancreatic adenocarcinoma. However, there are various side effects of chemotherapeutic medicine and low drug penetration because the complex tumor microenvironment limits the application of chemotherapy. As a novel strategy, polymer nanoparticles make it possible to target the tumor microenvironment, release cytotoxic agents through various responsive reactions, and thus overcome the treatment barrier. As drug carriers, polymer nanoparticles show marked advantages, such as increased drug delivery and efficiency, controlled drug release, decreased side effects, prolonged half-life, and evasion of immunogenic blockade. In this review, we discuss the factors that cause chemotherapy obstacles in pancreatic cancer, and introduce the application of polymer nanoparticles to treat pancreatic cancer.