A primer on extramammary Paget's disease for the urologist

A Territory-Wide Follow-Up of Primary and Secondary Extramammary Paget Disease of 2 Decades: Effects of Local Disease on Survival

INTRODUCTION

Extramammary Paget disease (EMPD) is an uncommon malignant cutaneous neoplasm that are divided into primary and secondary forms. In this multicenter study, histologically proven cases of primary and secondary EMPD were reviewed for clinical outcomes with subgroup analysis for secondary EMPD.

METHODOLOGY

Cases of EMPD were identified from pathology report of the involved institutions over a period of over 2 decades. Cases of secondary EMPD were identified review of case notes, radiology, and pathology reports. Clinicopathological and outcome data were retrieved for statistical analysis.

RESULTS

A total of 109 cases were retrieved, including 19 cases of secondary EMPD, most commonly associated with colorectal (n = 6), anal (n = 5), and prostatic carcinomas (n = 3). A difference was observed between older age and secondary (vs. primary) EMPD (p = 0.016), but no differences were seen in other clinico-demographical parameters. Male sex (p = 0.018), age over 60 years (p = 0.004), and involvement of margins (resectable) (p = 0.018) were associated with shorter OS. For DSS, involvement of margins (p = 0.009) was an adverse predictor. Secondary EMPD had a shorter DSS than primary EMPD (p = 0.005). Multivariable analysis confirmed all above associations (p < 0.05). In subgroup analysis for secondary EMPD, margin involvement remained associated with shorter OS (p = 0.007) and DSS (p = 0.003).

CONCLUSIONS

Secondary EMPD is associated with poorer outcomes. Margin involvement is strong and independent indicator of shorter OS and DSS, including secondary EMPD. Resectability is a strong predictor of favorable outcome and excision with clear margins should be attempted when surgically feasible.

INTRODUCTION

Extramammary Paget disease (EMPD) is an uncommon malignant cutaneous neoplasm that are divided into primary and secondary forms. In this multicenter study, histologically proven cases of primary and secondary EMPD were reviewed for clinical outcomes with subgroup analysis for secondary EMPD.

METHODOLOGY

Cases of EMPD were identified from pathology report of the involved institutions over a period of over 2 decades. Cases of secondary EMPD were identified review of case notes, radiology, and pathology reports. Clinicopathological and outcome data were retrieved for statistical analysis.

RESULTS

A total of 109 cases were retrieved, including 19 cases of secondary EMPD, most commonly associated with colorectal (n = 6), anal (n = 5), and prostatic carcinomas (n = 3). A difference was observed between older age and secondary (vs. primary) EMPD (p = 0.016), but no differences were seen in other clinico-demographical parameters. Male sex (p = 0.018), age over 60 years (p = 0.004), and involvement of margins (resectable) (p = 0.018) were associated with shorter OS. For DSS, involvement of margins (p = 0.009) was an adverse predictor. Secondary EMPD had a shorter DSS than primary EMPD (p = 0.005). Multivariable analysis confirmed all above associations (p < 0.05). In subgroup analysis for secondary EMPD, margin involvement remained associated with shorter OS (p = 0.007) and DSS (p = 0.003).

CONCLUSIONS

Secondary EMPD is associated with poorer outcomes. Margin involvement is strong and independent indicator of shorter OS and DSS, including secondary EMPD. Resectability is a strong predictor of favorable outcome and excision with clear margins should be attempted when surgically feasible.

Challenges in treating coexisting scrotal apocrine carcinoma and gastric cancer: insights from an elderly patient: a case report and literature review

BACKGROUND

Apocrine carcinoma associated with Paget's disease is a rare malignancy that typically manifests in elderly individuals, predominantly affecting the geriatric population. It commonly arises in regions rich in apocrine glands and often exhibits an insidious onset, potentially requiring several years to be diagnosed.

CASE PRESENTATION

An 80-year-old male was simultaneously diagnosed with scrotal apocrine carcinoma (showing Paget changes) and early-stage gastric cancer. Whole-genome exome sequencing confirmed these as independent malignancies with minimal genetic overlap, indicating that they were two primary tumors. The patient initially underwent successful surgery but experienced recurrence and metastasis. Treatment with capecitabine and paclitaxel showed promising responses, highlighting similarities between breast and apocrine carcinomas. Challenges were noted in the use of genetic testing and drug susceptibility assessments for treatment guidance. Notably, HER-2 expression in metastatic lesions, a trait of apocrine carcinoma, has remained unexplored due to negative HER-2 FISH results and a lack of available targeted therapies in China.

CONCLUSION

Elderly patients often exhibit a lesser degree of aggressiveness toward treatment following a diagnosis of malignant tumors. It is imperative to carefully consider how to strike a balance between effective treatment and maintaining a satisfactory quality of life for these patients. This case underscores the complexity of treating coexisting rare cancers in older adults and emphasizes the need for personalized treatments and continued innovation in cancer therapy. The insights gained offer significant value in understanding and managing such rare cancer cases.

Primary Extramammary Paget's Disease Following Previously Treated Secondary Extramammary Paget's Disease Over the Scrotum: A Rare Case Successfully Treated With Mohs Micrographic Surgery

Extramammary Paget's disease (EMPD) is a rare cutaneous neoplasm that can be classified as either primary or secondary, depending on the presence or absence of an associated internal malignancy. Primary EMPD arises as an intraepithelial adenocarcinoma, while secondary EMPD results from the extension of an underlying visceral malignancy. This case report presents a unique instance of primary EMPD developing 10 years after a diagnosis of secondary EMPD in the same anatomical location, a phenomenon not previously documented in the literature. The patient, initially treated for secondary EMPD with wide local excision, later developed primary EMPD, as confirmed through histopathological and immunohistochemical analysis. This rare occurrence raises questions about the potential mechanisms, including field cancerization, persistent risk factors, or a coincidental event. The case underscores the importance of long-term follow-up and surveillance for EMPD patients. Mohs micrographic surgery remains the gold standard for treating EMPD due to its high precision in margin control and lower recurrence rates compared to conventional surgical methods. This case highlights the need for meticulous diagnostic approaches and continuous monitoring to manage and understand the complexities of EMPD effectively.

A Systematic Review and Meta-Analysis of Mapping Biopsy for Primary Extramammary Paget's Disease in Reducing Recurrence Following Surgical Excision

Objective

To examine the association between the performance of mapping biopsies and surgical outcomes postexcision of extramammary Paget's disease (EMPD).

Background

Primary EMPD is a rare entity associated with poorly defined surgical margins and difficult-to-access sites of lesions. Surgical resection with clear margins remains the preferred management method. The use of mapping biopsies might be beneficial, particularly in lowering disease recurrence.

Methods

Available literature was reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology before a fixed-effect meta-analysis was performed to identify the presence of a correlation between performing mapping biopsies and positive margins on permanent sections as well as disease-free survival. Additional study results not included in the quantitative assessment were qualitatively assessed and reported.

Results

A total of 12 studies were shortlisted for final analysis. 294 patients who underwent mapping biopsies and 48 patients who did not undergo mapping biopsies were included in the assessment. Forest plot analysis revealed a pooled rate ratio of 0.50 (95% CI, 0.32-0.77) in the prevalence of positive margins in patients with mapping biopsies performed as compared to patients without. The pooled rate ratio of the prevalence of disease-free survival in patients with mapping biopsies performed as compared to patients without was 1.38 (95% CI, 1.03-1.84). Qualitative assessment of the remaining selected studies revealed equivocal results.

Conclusions

Mapping biopsies are able to improve EMPD surgical excision outcomes but given the rarity of the disease and heterogeneity of mapping biopsy procedures, further confirmation with randomized controlled trials or a larger patient pool is necessary.

The clinical effect of modified slow Mohs circular skin biopsy on penoscrotal extramammary Paget's disease

OBJECTIVE

Determining the tumor margin is the main problem in penoscrotal extramammary Paget's disease (PEMPD) surgery. This study aimed to explore the role of modified slow Mohs circular skin biopsy in determining the tumor margin in patients with PEMPD before operation.

METHODS

Thirty-six PEMPD patients were divided into the control group and the observation group according to the simple randomization method. The control group, which consisted of 16 patients, underwent wide local excision, and the observation group, which consisted of 20 patients, underwent a modified slow Mohs circular skin biopsy to determine the tumor margin before surgery. The duration of surgery, number of frozen sections, satisfaction with the appearance of the skin, tumor recurrence rate, and incidence of functional sequelae were statistically analyzed.

RESULTS

The number of frozen sections, duration of surgery, incidence of functional sequelae, and tumor recurrence rate in the observation group were lower than in the control group. The satisfaction with the appearance of the skin was higher in the observation group than in the control group, and the difference was statistically significant (P < 0.05).

CONCLUSION

Modified slow Mohs circular skin biopsy can determine the tumor margin before surgery and reduce the number of frozen sections, tumor recurrence rate, and the incidence of functional sequelae. It also increases the postoperative satisfaction of patients.

High-dose-rate brachytherapy in scrotal extramammary Paget's disease: A case report

PURPOSE

Extramammary Paget's disease (EMPD) is a rare but lethal intraepithelial malignancy without standardized guidelines concerning diagnostic or therapeutic approaches. We report a case of EMPD of the scrotum treated with excellent results using high-dose brachytherapy.

METHODS AND MATERIALS

A 76-year-old male originally presented in 2015 with pruritus and erythema of the right scrotum, biopsy proved to represent extramammary Paget's disease. He was treated for a year with topical creams without sustained relief. In July 2016 he underwent a right hemiscrotectomy which revealed stage 1 EMPD of the right scrotum and the medial thigh with positive margins but no deep invasion. Brachytherapy was selected as the most appropriate treatment option and carried out in December 2016 using HDR with a H.A.M. applicator and CT treatment planning.

RESULTS

On December 2021, at 5 years of clinical and pathological follow up, the patient remains NED with minimal skin toxicity.

CONCLUSIONS

High-Dose-Rate Brachytherapy appears to be a feasible treatment alternative as adjuvant therapy in patients with EMPD with incomplete resection.

Photodynamic therapy in the treatment of extramammary paget’s disease

Extramammary Paget’s disease (EMPD) is a rare tumor that predominantly affects the skin containing apocrine glands. Due to insufficient data on the effectiveness of different methods, there is no single therapeutic approach to the treatment of patients with EMPD and their subsequent management. The use of surgical methods, laser therapy and local cytotoxic drugs has a number of limitations. The advantages of using photodynamic therapy (PDT) in EMPD are the absence of systemic toxicity, non-invasiveness, selectivity of action, the absence of carcinogenic potential, the possibility of conducting several courses of treatment, and good cosmetic results. In our review, we analyzed those published in 2000-2022 data on the results of PDT treatment of 114 patients with EMPD. As a result of treatment, complete regression of tumor foci was achieved in 40% of patients. Most authors note that PDT is more effective for small areas (up to 4 cm2).

Pagetoid spread of urothelial carcinoma controlled without resection

Introduction

Extramammary Paget's disease is an eczematous skin condition that affects the vulva and perineum. Extramammary Paget's disease secondary to urothelial carcinoma is a rare condition that is typically treated with invasive surgical resection of the lesion.

Case presentation

An 80-year-old woman with a 7-year history of urothelial carcinoma presented with erythema of the labia majora. Immunostaining of skin biopsy specimens suggested extramammary Paget's disease secondary to urothelial carcinoma. The patient did not consent to resection of the lesion. Nine cycles of first-line platinum-based chemotherapy for metastatic urothelial carcinoma were administered. As tumor cells remained after systemic chemotherapy, pembrolizumab will be administered to the patient for treating residual extramammary Paget's disease.

Conclusion

Platinum-based chemotherapy can control extramammary Paget's disease secondary to urothelial carcinoma.

Extramammary Paget's Disease of genitourinary origin

PURPOSE OF REVIEW

Extramammary Paget's Disease (EMPD) is an uncommon intra-epithelial malignancy, affecting primarily apocrine gland-bearing skin. EMPD is often considered an orphan diagnosis given its rarity. This review provides a contemporary overview of EMPD management.

RECENT FINDINGS

The mainstay of EMPD treatment centers around a high index of suspicion to allow for an early and accurate diagnosis, wide local or Mohs micrographic surgical excision with care paid toward the margin status, and thoughtful consideration for lymphadenectomy in patients with clinically positive regional disease. There is currently no consensus regarding adjuvant therapies or systemic therapies although with ongoing improvements in tumor biology and genomics, including molecular pathways and alterations specific to EMPD, targeted or combinatorial therapies may be on the horizon.

SUMMARY

Clinicians caring for patients with EMPD should seek consultation from or if feasible, consider referral to high-volume, experienced centers with patients counseled and provided with frequent and close follow-up for disease recurrence or progression. Collaboration with groups such as the Global Society for Rare Genitourinary Tumors, and especially patient groups will be vital to designing trials and collaborative databases.

The application of Wood's lamp combined with 5-aminolevulinic acid for defining tumor margins in patients with extramammary Paget's disease

OBJECTIVE

To evaluate the value of Wood's lamp examination combined with 5-aminolevulinic acid (5-ALA) photodynamic therapy (PDT) to determine positive tumor margins in patients with extramammary Paget's disease (EMPD) before surgery.

METHODS

We admitted 36 patients with EMPD from January 2016 to June 2019. The experimental group was the 5-ALA-PDT group, and the control group was the wide local excision (WLE) group. In the 5-ALA-PDT group, Wood's lamp examination combined with 5-ALA-PDT was used to trace the fluorescence range, and multipoint biopsy was performed according to the pathology to determine the final excision scope. We applied the standard partial expansion excision method for the WLE group, while frozen pathology assessment was applied to confirm the excision range. We measured the overall resection area of the WLE group and 5-ALA-PDT group. We analyzed the overall duration of surgery, the number of frozen pathology sections, patient satisfaction with appearance and function, the rate of functional sequelae, and the recurrence rate for both groups.

RESULTS

The results suggested that the difference in final resection margin between the WLE group and the 5-ALA-PDT group was significant. The number of frozen pathology sections, overall surgery time, and recurrence rate were significantly lower in the experimental group than in the control group (p<0.05). The occurrence rate of functional sequelae in the experimental group was lower, and patient satisfaction with appearance and function was significantly higher than that of the control group (p<0.05).

CONCLUSION

Wood's lamp examination combined with 5-ALA-PDT may predict tumor margins in EMPD.

Survival analysis of extramammary Paget's disease (EMPD) in a tertiary hospital in Taiwan

Background

This study aimed to investigate the survival analysis of extramammary Paget’s disease (EMPD) in a Taiwanese population and to provide data for comparison with other studies in various locations and racial populations.

Methods

We retrospectively analyzed the medical records of 63 patients with EMPD who were surgically treated from 2002 to 2019 at a single institution. The primary endpoint was the 5-year overall survival rate of EMPD, and the secondary endpoint was recurrence-free 5-year survival. Independent variables included patients’ demographic data, concurrent malignancy (i.e., non-EMPD-related cancers), tumor size, distant metastasis, and surgery and/or radiation.

Results

Of all the 63 patients, 8 cases were excluded. A total of 43 patients (78.18%) were male, and 12 were female, with a mean age of 72.67 years (range 44–89 years). The most common affected anatomic site was the penoscrotal region (22 patients, 40.00%), followed by the perianal and perineal regions (17 patients, 30.91%). Among the 55 patients, 41 patients (74.55%) were diagnosed with at least one underlying disease, whereas the most common underlying disease was cardiovascular disease (30 patients, 54.55%). The overall survival rate was 80.00% at 36 months and 65.45% at the end of follow-up. EMPD with deep dermal invasion was a significant poor prognostic factor of overall survival in cause-specific hazard model (sub-hazard ratio (HR) 5.167, p = 0.0015, 95% confidence interval (CI) 1.876–14.230). Patients with regional metastasis or distant metastasis had poorer prognosis of 5-year survival (sub-HR 4.513, p = 0.0028, CI 1.683–12.103). The limitations of this study include its retrospective nature and sample size.

Conclusions

In our series, EMPD with metastasis and deep dermal invasion was the significant harmful factors in both overall 5-year survival and 5-year recurrence-free survival. The surgical excision is not associated with a low risk of local recurrence or overall survival, and long-term follow-up is still needed.