1
|
Kibbi N, Owen JL, Worley B, Wang JX, Harikumar V, Aasi SZ, Chandra S, Choi JN, Fujisawa Y, Iavazzo C, Kim JYS, Lawrence N, Leitao MM, MacLean AB, Ross JS, Rossi AM, Servaes S, Solomon MJ, Alam M. Anatomic Subtype Differences in Extramammary Paget Disease: A Meta-Analysis. JAMA Dermatol 2024; 160:417-424. [PMID: 38446447 PMCID: PMC10918581 DOI: 10.1001/jamadermatol.2024.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/28/2023] [Indexed: 03/07/2024]
Abstract
Importance Extramammary Paget disease (EMPD) is a rare, highly recurrent cutaneous malignant neoplasm of unclear origin. EMPD arises most commonly on the vulvar and penoscrotal skin. It is not presently known how anatomic subtype of EMPD affects disease presentation and management. Objective To compare demographic and tumor characteristics and treatment approaches for different EMPD subtypes. Recommendations for diagnosis and treatment are presented. Data Sources MEDLINE, Embase, Web of Science Core Collection, and Cochrane Reviews CENTRAL from December 1, 1990, to October 24, 2022. Study Selection Articles were excluded if they were not in English, reported fewer than 3 patients, did not specify information by anatomic subtype, or contained no case-level data. Metastatic cases on presentation were also excluded. Data Extraction and Synthesis Abstracts of 1295 eligible articles were independently reviewed by 5 coauthors, and 135 articles retained. Reporting was in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The analysis was cunducted in August 2019 and updated in November 2022. Findings Most vulvar EMPD cases were asymptomatic, and diagnosis was relatively delayed (mean, 25.1 months). Although most vulvar EMPD cases were intraepidermal (1247/1773 [70.3%]), radical surgeries were still performed in almost one-third of cases. Despite this aggressive surgical approach, 481 of 1423 (34%) recurred, commonly confined to the skin and mucosa (177/198 [89.4%]). By contrast, 152 of 1101 penoscrotal EMPD cases (14%) recurred, but more than one-third of these recurrences were regional or associated with distant metastases (54 of 152 [35.5%]). Perianal EMPD cases recurred in one-third of cases (74/218 [33.9%]), with one-third of these recurrences being regional or associated with distant metastasis (20 of 74 [27.0%]). Perianal EMPD also had the highest rate of invasive disease (50% of cases). Conclusions and Relevance The diagnosis and treatment of EMPD should differ based on anatomic subtypes. Considerations for updated practice may include less morbid treatments for vulvar EMPD, which is primarily epidermal, and close surveillance for local recurrence in vulvar EMPD and metastatic recurrence in perianal EMPD. Recurrences in penoscrotal subtype were less common, and selective surveillance in this subtype may be considered. Limitations of this study include the lack of replication cohorts and the exclusion of studies that did not stratify outcomes by anatomic subtype.
Collapse
Affiliation(s)
- Nour Kibbi
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Joshua L. Owen
- Dermatology Service, Audie L Murphy VA Medical Center, San Antonio, Texas
- Division of Dermatology, University of Texas Health San Antonio, San Antonio
| | | | - Jake X. Wang
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vishnu Harikumar
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Sumaira Z. Aasi
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Sunandana Chandra
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jennifer N. Choi
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Christos Iavazzo
- Department of Gynecologic Oncology, Metaxa Cancer Hospital, Piraeus, Greece
| | - John Y. S. Kim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Naomi Lawrence
- Division of Dermatology, Cooper Hospital, Rowan University, Camden, New Jersey
| | - Mario M. Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of OB/GYN, Weill Cornell Medical College, New York, New York
| | - Allan B. MacLean
- Department of Gynaecology, University College, London, United Kingdom
| | - Jeffrey S. Ross
- Departments of Pathology and Urology, Upstate Medical University, Syracuse, New York
- Medical Director, Foundation Medicine, Inc, Boston, Massachusetts
| | - Anthony M. Rossi
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sabah Servaes
- Department of Radiology, West Virginia University Children’s Hospital, Charleston, West Virginia
| | - Michael J. Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Murad Alam
- Department of Dermatology, Ehime University, To-on, Japan
- Department of Otolaryngology–Head and Neck Surgery and Surgery (Organ Transplantation), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
2
|
Caruso G, Barcellini A, Mazzeo R, Gallo R, Vitale MG, Passarelli A, Mangili G, Pignata S, Palaia I. Vulvar Paget’s Disease: A Systematic Review of the MITO Rare Cancer Group. Cancers (Basel) 2023; 15:cancers15061803. [PMID: 36980691 PMCID: PMC10046936 DOI: 10.3390/cancers15061803] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/07/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Giuseppe Caruso
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Amelia Barcellini
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy
| | - Roberta Mazzeo
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
- Correspondence:
| | - Roberta Gallo
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Maria Giuseppa Vitale
- Department of Oncology and Hematology, University Hospital of Modena, 41100 Modena, Italy
| | - Anna Passarelli
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCSS, “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Giorgia Mangili
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCSS, “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| |
Collapse
|
3
|
Della Corte L, Cafasso V, Conte C, Cuomo L, Giampaolino P, Lavitola G, Bifulco G. Medical and Surgical Strategies in Vulvar Paget Disease: Let's Throw Some Light! J Pers Med 2023; 13:jpm13010100. [PMID: 36675761 PMCID: PMC9861591 DOI: 10.3390/jpm13010100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/19/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy
- Correspondence:
| | - Valeria Cafasso
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy
| | - Carmine Conte
- Department of General Surgery and Medical-Surgical Specialties—Institute of Obstetrics and Ginecology, A.O.U. Policlinico Rodolico—San Marco, University of Catania, 95124 Catania, Italy
| | - Lara Cuomo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy
| | | | - Giada Lavitola
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy
| | - Giuseppe Bifulco
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy
| |
Collapse
|
4
|
O'Neill D, Evans M, Nunns D, El-Ghobashy A. Vulval extra-mammary Paget's disease: the master of disguise revealed. Br J Hosp Med (Lond) 2022; 83:1-12. [DOI: 10.12968/hmed.2021.0536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- Danielle O'Neill
- Department of Gynaecology Oncology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Matthew Evans
- Department of Pathology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - David Nunns
- Department of Gynaecology Oncology, Nottingham University Hospitals Trust, Nottingham, UK
| | - Alaa El-Ghobashy
- Department of Gynaecology Oncology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| |
Collapse
|
5
|
Wang D, Wang P, Li C, Zhou Z, Zhang L, Zhang G, Wang X. Efficacy and safety of HpD-PDT for Extramammary Paget's Disease refractory to conventional therapy: A prospective, open-label and single arm pilot study. Photodiagnosis Photodyn Ther 2021; 37:102670. [PMID: 34883272 DOI: 10.1016/j.pdpdt.2021.102670] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Extramammary Paget's Disease (EMPD) is an intraepithelial cancer that is prone to recurrence and sometimes refractory to therapy. A few EMPD cases have been treated with Photodynamic therapy (PDT), which reported high complete remission (CR) rates and low recurrence with hematoporphyrin derivatives (HpD) The aim of this study was to further explore the efficacy and safety of HpD-PDT for EMPD patients. METHODS Open-label, single arm, pilot study was designed to investigate the role of HpD-PDT in EMPD. The HpD sensitizer was given intravenously at a dose of 3 or 5 mg/kg 48 h before light irradiation with a laser 630 nm red light at a dose level of 150-200 J/cm2. Clinical parameters involving gender, age, disease course, previous treatment, tumor thickness, long diameter of lesion, TNM staging, EMPD staging, HpD dosage, Visual Analogue Scale (VAS) score, 1st month visit result, subsequent treatment, follow up period and endpoint outcomes were collected to evaluate efficacy and safety of the intervention. RESULTS Eleven patients with pathologic confirmed EMPD were treated with HpD-PDT. The thickness of skin lesions which were located in vulva, penis, scrotum, and perianal area is 0.8∼6.7 mm (mean thickness 2.9 mm). All patients were followed up for an average of 17.4 months (12∼27 months). Complete remission (CR) rate and partial remission (PR) rate at the 1st month were 90.1% (10/11) and 9.1% (1/11) respectively. At the end of follow-up, 72.7% of the subjects (8/11) showed CR. Pain, infection, photosensitivity and uroschesis are recorded as adverse events (AEs) in this population, and no event of hepatic impairment was reported. After treatment, all the eleven patients showed different degrees of scar in the treatment site, but none of them had any structural or functional abnormalities. CONCLUSIONS According to our study, HpD-PDT in EMPD is able to offer acceptable disease outcomes including relatively high CR rate, with good cosmetic and functional outcomes, and could be considered a potential recommended therapy for patients with EMPD. TRIAL REGISTRATION Chinese Clinical Trial Register (ChiCTR-1900024965).
Collapse
Affiliation(s)
- Dixin Wang
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Peiru Wang
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chunxiao Li
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhongxia Zhou
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Linglin Zhang
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guolong Zhang
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiuli Wang
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China.
| |
Collapse
|
6
|
Staged pelvic exenteration followed by oblique fleur-de-lis rectus abdominis myocutaneous (OFRAM) flap and keystone flap reconstruction for extramammary Paget’s disease. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01844-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
7
|
Troiani T, Napolitano S, Brancaccio G, Belli V, Nappi A, Miro C, Salvatore D, Dentice M, Caraglia M, Franco R, Giunta EF, De Falco V, Ciardiello D, Ciardiello F, Argenziano G. Treatment of Cutaneous Melanoma Harboring SMO p.Gln216Arg Mutation with Imiquimod: An Old Drug with New Results. J Pers Med 2021; 11:jpm11030206. [PMID: 33799349 PMCID: PMC8000647 DOI: 10.3390/jpm11030206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 12/13/2022] Open
Abstract
Melanoma is the most lethal form of skin cancer and its incidence is growing worldwide. In the last ten years, the therapeutic scenario of this disease has been revolutionized by the introduction of targeted therapies and immune-checkpoint inhibitors. However, in patients with many lesions and bulky tumors, in which surgery is no longer feasible, there is a need for new treatment options. Here we report, for the first time to our knowledge, a clinical case where a melanoma patient harboring the SMO p.Gln216Arg mutation has been treated with imiquimod, showing a complete and durable response. To better explain this outstanding response to the treatment, we transfected a melanoma cell line (MeWo) with the SMO p.Gln216Arg mutation in order to evaluate its role in response to the imiquimod treatment. Moreover, to better demonstrate that the antitumor activity of imiquimod was due to its role in suppressing the oncogenic SMO signaling pathway, independently of its immune modulating function, an in vivo experiment has been performed. This clinical case opens up a new scenario for the treatment of melanoma patients identifying a new potentially druggable target.
Collapse
Affiliation(s)
- Teresa Troiani
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (S.N.); (V.B.); (E.F.G.); (V.D.F.); (D.C.); (F.C.)
- Correspondence: ; Tel.: +39-(081)-5666628
| | - Stefania Napolitano
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (S.N.); (V.B.); (E.F.G.); (V.D.F.); (D.C.); (F.C.)
| | - Gabriella Brancaccio
- Dermatology Unit, Department of Mental and Physical Health and Prevention Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (G.B.); (G.A.)
| | - Valentina Belli
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (S.N.); (V.B.); (E.F.G.); (V.D.F.); (D.C.); (F.C.)
| | - Annarita Nappi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.N.); (C.M.); (M.D.)
| | - Caterina Miro
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.N.); (C.M.); (M.D.)
| | - Domenico Salvatore
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy;
| | - Monica Dentice
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.N.); (C.M.); (M.D.)
| | - Michele Caraglia
- Biochemistry Unit, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 81100 Naples, Italy;
| | - Renato Franco
- Pathology Unit, Department of Mental and Physical Health and Prevention Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 81100 Naples, Italy;
| | - Emilio Francesco Giunta
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (S.N.); (V.B.); (E.F.G.); (V.D.F.); (D.C.); (F.C.)
| | - Vincenzo De Falco
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (S.N.); (V.B.); (E.F.G.); (V.D.F.); (D.C.); (F.C.)
| | - Davide Ciardiello
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (S.N.); (V.B.); (E.F.G.); (V.D.F.); (D.C.); (F.C.)
| | - Fortunato Ciardiello
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (S.N.); (V.B.); (E.F.G.); (V.D.F.); (D.C.); (F.C.)
| | - Giuseppe Argenziano
- Dermatology Unit, Department of Mental and Physical Health and Prevention Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (G.B.); (G.A.)
| |
Collapse
|
8
|
Snast I, Sharon E, Kaftory R, Noyman Y, Oren-Shabtai M, Lapidoth M, Hodak E, Mimouni D, Mazor S, Levi A. Nonsurgical Treatments for Extramammary Paget Disease: A Systematic Review and Meta-Analysis. Dermatology 2020; 236:493-499. [PMID: 32289785 DOI: 10.1159/000506832] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 02/27/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Surgery is commonly regarded as the mainstay of treatment of extramammary Paget disease (EMPD); however, nonsurgical approaches have gained popularity in recent years. OBJECTIVES To review the published evidence for the efficacy and safety of nonsurgical modes of therapy for EMPD. METHODS A systematic review and meta-analysis of nonsurgical EMPD treatments was performed. The primary outcome was complete response (CR); secondary outcomes were clinical regression by ≥50%, adverse events, and recurrence rate. RESULTS The systematic review included 43 observational studies (341 patients; 7 prospective cohort studies, 19 retrospective cohort studies, and 17 cases series) evaluating 5 treatment modalities. Imiquimod (13 studies, 110 patients) administered at variable doses ranging from daily to twice weekly for 2-56 weeks demonstrated CR of 54% (95% CI, 40-67%; I2 = 37%) and had a satisfactory safety profile. In 14 heterogeneous studies (122 patients) evaluating photodynamic therapy (PDT), only 36% (95% CI, 22-53%; I2 = 52%) of patients achieved CR. Radiotherapy (12 studies, 67 patients) showed CR of 97%, but was associated with local and systemic side effects. Ablative lasers and topical fluorouracil and calcipotriene lacked adequate evidence of efficacy. CONCLUSIONS Imiquimod and radiotherapy are the most appropriate nonsurgical modalities for EMPD treatment given their good efficacy and safety profile. PDT has limited efficacy but may be appropriate in selected clinical settings.
Collapse
Affiliation(s)
- Igor Snast
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel, .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Eran Sharon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Breast Surgery Clinic, Rabin Medical Center, Petah Tikva, Israel
| | - Ran Kaftory
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehonatan Noyman
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Meital Oren-Shabtai
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Lapidoth
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmilia Hodak
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Mimouni
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sigal Mazor
- Department of Community Dentistry, School of Dental Medicine, Hebrew University-Hadassah, Medical Center, Jerusalem, Israel
| | - Assi Levi
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
9
|
Abstract
Extramammary Paget's disease (EMPD) is a rare and lethal intraepithelial malignancy that remains poorly understood. No standardized guidelines or consensus statements exist with regards to the diagnostic evaluation, therapeutic approaches and follow-up management. Complete surgical excision with negative margins has been accepted as the mainstay of treatment for EMPD to decrease the risk of local recurrence and to maximize durable cure. Non-invasive therapies, such as laser therapy, photodynamic therapy, radiotherapy and topical chemotherapy have been utilized, but are best reserved for non-surgical candidates. While the debate on the surgical approach between wide local excision (WLE) and Mohs micrographic surgery (MMS) continues, several studies have demonstrated the ability of WLE to be performed safely and effectively and to yield equally satisfactory outcomes with similar rates of recurrence to MMS. Patients undergoing surgical excision often require complex closures with skin grafting or local flaps to close genital defects. We aim to provide an up-to-date review of the current knowledge of EMPD. In addition to discussing the clinical presentation and prognostic outcomes, we focus and elaborate on the diagnostic approaches and treatment alternatives available. This information may serve as a primer for the urologist who may be called upon to treat this malignancy primarily or to provide wound coverage secondarily.
Collapse
Affiliation(s)
- Joon Yau Leong
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia PA, USA
| | - Paul H Chung
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia PA, USA
| |
Collapse
|
10
|
Lebas E, Chapelier C, Quatresooz P, Seidel L, Nikkels AF. Exploratory Assessment of Oxygen Flow-Assisted Cutaneous Administration of Methotrexate for Superficial Basal Cell Carcinoma, Mycosis Fungoides, and Extramammary Paget Disease. J Invest Dermatol 2019; 140:583-592. [PMID: 31513804 DOI: 10.1016/j.jid.2019.08.443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022]
Abstract
The molecular weight of methotrexate (MTX) makes cutaneous penetration difficult. Oxygen flow could enhance the skin permeation of MTX diluted in the proprietary LP3 carrier system. This pilot study aims to assess the efficacy, safety, and tolerance of oxygen flow-assisted LP3-MTX3% for treating superficial skin cancers. Patients with superficial basal cell carcinoma (n = 12), extramammary Paget disease (n = 5), classic mycosis fungoides (MF; n = 10), and folliculotropic MF (n = 6) were included in the study and were treated with four weekly applications of oxygen flow-assisted LP3-MTX3%. Photographs and biopsies were performed before and one month after treatment. At one month after treatment, the mean superficial basal cell carcinoma erythema-crusting-thickness clinical score, the extramammary Paget disease erythema-oozing-scaling/hyperkeratosis-pain/pruritus clinical score, and the modified composite assessment of index lesion severity classic MF and folliculotropic MF scores were improved by 77.5% ± 17.1% (P < 0.0001), 66.7% ± 22.9% (P = 0.011), 51.3% ± 32.2% (P = 0.0007), and 27.8% ± 32.0% (P = 0.086), respectively. At one month after treatment, histology revealed partial and total clearances for superficial basal cell carcinoma (1/12, 11/12), extramammary Paget disease (4/5, 1/5), classic MF (8/10, 2/10), and folliculotropic MF (6/6, 0/6). Tolerance was excellent and no pain was observed. MTX was never detectable in serum at baseline and 1, 2, 3, 8, 24, 48, and 72 hours post-treatment. In conclusion, the interesting therapeutic efficacy of oxygen flow-assisted LP3-MTX3% for treating superficial basal cell carcinoma, extramammary Paget disease, and MF lesions prompts further studies on a larger scale.
Collapse
Affiliation(s)
- Eve Lebas
- Department of Dermatology, CHU of Sart Tilman, University of Liège, Liège, Belgium
| | - Corinne Chapelier
- Department of Dermatology, CHU of Sart Tilman, University of Liège, Liège, Belgium
| | - Pascale Quatresooz
- Department of Pathology, CHU of Sart Tilman, University of Liège, Liège, Belgium
| | - Laurence Seidel
- Department of Biostatistics, CHU of Sart Tilman, University of Liège, Liège, Belgium
| | - A F Nikkels
- Department of Dermatology, CHU of Sart Tilman, University of Liège, Liège, Belgium.
| |
Collapse
|
11
|
Abstract
Cutaneous metastasis portends a poor prognosis. Therefore, a high clinical index of suspicion is necessary so that a clinician knows how to recognize the presentation of a cutaneous metastasis, while the pathologist must know the appropriate stains to order. In this review, the authors summarize the common and uncommon ways that these tumors will present. Frequently a metastatic cancer will present as a firm red nodule or as a plaque, ulcer, or papule. Less commonly they will present with a clinical clue that can alert a clinician to a likely diagnosis; these manifestations include alopecic, vesicular, blue color, sclerodermoid, acrochordon-, or pellagra-like.
Collapse
Affiliation(s)
- Evan Alexander Choate
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Alexander Nobori
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Scott Worswick
- Department of Dermatology, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Ezralow Tower, Suite 5301, Los Angeles, CA 90033-9174, USA.
| |
Collapse
|
12
|
Abstract
BackgroundExtramammary Paget’s disease is a rare condition, and the vulva is a common site for it to occur. Despite this, there is a paucity of literature on Paget’s disease of the vulva (VPD). A Cochrane meta-analysis could not draw any conclusions on interventions in VPD. Our aim was to review our practice and improve further management of VPD in our center.MethodsWe reviewed all the cases presented to Leeds Gynaecological Oncology Centre between 1988 and 2016. All cases identified in this interval were followed up until April 2016. All case notes and electronic patient data were retrieved to collate the data.ResultsWe identified 18 cases of VPD. The median age at presentation was 76.9 years. Primary surgery was used in 18 cases. Eight patients had wide local excision with graft reconstruction. Ten women had wide local excision with primary reconstruction. Margins were negative in 27% of the excisions. Sixty percent of patients with clear surgical margins had a recurrence, and 69% of patients with positive margins had a recurrence; there was no statistical difference between the 2 groups for recurrence (P > 0.05). Fifty-eight percent of patients who had recurrence had coexisting malignancy. Logistic regression showed no correlation of recurrence rates due to either age, margin status, or coexisting malignancies.ConclusionsPaget’s disease of the vulva is a rare condition. Our experience indicates that most cases may be amenable to surgical treatment at first presentation. Negative margin status does not reduce the chance of recurrence, and hence patients should be under follow-up for life. The benefit of radical surgery in the absence of reduced recurrences, based on margin status, is questionable. Radiotherapy and imiquimod are options for extensive lesions or recurrent settings. Coexisting malignancies are associated with VPD.
Collapse
|
13
|
Bubna AK. Imiquimod - Its role in the treatment of cutaneous malignancies. Indian J Pharmacol 2016; 47:354-9. [PMID: 26288465 PMCID: PMC4527053 DOI: 10.4103/0253-7613.161249] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 03/26/2015] [Accepted: 06/20/2015] [Indexed: 01/12/2023] Open
Abstract
Imiquimod is a synthetic imidazoquinolone amine, which has potent immune response modifier activity, when topically used. This characteristic property of imiquimod has led to its use in a number of applications in dermatology, particularly in cutaneous malignancies, where it has been found to be effective and safe. Currently, additional mechanisms for its activity in actinic keratosis, basal cell carcinoma, and invasive squamous cell carcinoma have been elucidated. Its usage for cutaneous metastasis in breast cancer has been a further addition to its therapeutic armamentarium recently.
Collapse
Affiliation(s)
- Aditya Kumar Bubna
- Assistant Professor, Department of Dermatology, Sri Ramachandra University, Porur, Chennai, Tamil Nadu, India
| |
Collapse
|
14
|
van der Linden M, Meeuwis K, Bulten J, Bosse T, van Poelgeest M, de Hullu J. Paget disease of the vulva. Crit Rev Oncol Hematol 2016; 101:60-74. [DOI: 10.1016/j.critrevonc.2016.03.008] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 01/25/2016] [Accepted: 03/03/2016] [Indexed: 01/03/2023] Open
|
15
|
|
16
|
Effects of imiquimod on vulvar Paget's disease: a systematic review of literature. Gynecol Oncol 2015; 139:165-71. [PMID: 26193428 DOI: 10.1016/j.ygyno.2015.07.097] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 07/14/2015] [Accepted: 07/16/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine the effectiveness of topical imiquimod therapy for vulvar Paget's disease. METHODS A systematic literature search was conducted using three public search engines with entry keywords "Paget's disease" and "imiquimod". Case reports describing imiquimod treatment for vulvar Paget's disease were examined for demographics, treatment patterns, and outcome (63 cases). RESULTS Median age was 68, and nearly a half of cases were recurrent disease (50.8%) with surgical resection being the most common prior treatment modality (62.5%). All cases used 5% imiquimod and the median treatment duration was 4months. The most common initial treatment frequency was 3-4times/week (68.3%) followed by 5-7 (17.4%) and 1-2times/week (14.3%). Frequency-reduction due to adverse effects was seen in 9.5% with the initial 5-7times/week regimen being associated with the highest reduction rate (1-2, 3-4, and 5-7times/week: 0%, 2.3%, and 81.8%, p<0.01). In 46 (73.0%) cases, a complete remission (CR) to imiquimod therapy was reported, with 2, 4, and 6-month cumulative CR rates being 9.8%, 31.1%, and 71.6%, respectively. With median follow-up duration of 12months after the completion of imiquimod treatment, 2 (5.7%) of the 35 women who had a CR developed disease recurrence. Age, disease status (primary versus recurrent), and treatment frequency after dose reduction were not associated with CR rates (all, p>0.05). CONCLUSION Our results suggested that imiquimod therapy may be an effective possible treatment option for vulvar Paget's disease, especially for women who have experienced recurrence after multiple surgical resections or who are with poor surgical candidates.
Collapse
|
17
|
Abstract
INTRODUCTION Our objective was to evaluate the efficacy of conservative treatment with imiquimod in Paget vulvar disease. MATERIALS AND METHODS We describe a case series that includes 10 patients with histopathologic diagnosis of extramammary Paget disease of the vulva, who were treated with 5% imiquimod cream. Of these patients, 3 were treated for recurrent disease and 7 were treated for initial primary disease. The patients applied the cream every other day until the lesions were no longer clinically detected.They were previously instructed on how and where to apply the cream by making them use a mirror while following the physician's directions. RESULTS Complete clinical and histologic remission of the disease was achieved in 9 patients. The remaining patient had partial histologic response and is still under treatment. The treatment was well tolerated despite moderate irritation. No recurrences were observed during a mean follow-up of 18 months. CONCLUSIONS On the basis of the results, the authors consider that 5% imiquimod cream could be considered a safe and effective therapeutic option for the treatment of primary vulvar Paget disease. Further studies are needed to determine the real efficacy and safety of 5% imiquimod cream for the treatment of this infrequent disease.
Collapse
|
18
|
Luyten A, Sörgel P, Clad A, Gieseking F, Maass-Poppenhusen K, Lellé RJ, Harter P, Buttmann N, Petry KU. Treatment of extramammary Paget disease of the vulva with imiquimod: A retrospective, multicenter study by the German Colposcopy Network. J Am Acad Dermatol 2014; 70:644-650. [DOI: 10.1016/j.jaad.2013.12.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 11/28/2013] [Accepted: 12/03/2013] [Indexed: 01/09/2023]
|
19
|
Doyen J, Demoulin S, Delbecque K, Goffin F, Kridelka F, Delvenne P. Vulvar skin disorders throughout lifetime: about some representative dermatoses. BIOMED RESEARCH INTERNATIONAL 2014; 2014:595286. [PMID: 24511539 PMCID: PMC3910662 DOI: 10.1155/2014/595286] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 12/12/2013] [Indexed: 11/18/2022]
Abstract
The objective of this paper is to present general considerations which should be kept in mind by clinicians in charge of women with vulvar diseases. Four representative vulvar dermatoses are described. Lichen simplex chronicus is a pathological condition related to chemical and mechanical irritant agents. Detrimental effects of these irritants, in the presence of other dermatoses, have to be considered when therapeutic responses are unsatisfactory. Lichen sclerosus is the most common vulvar dermatosis in elderly. However, it should be kept in mind that it may be diagnosed at any age. Lichen planus, in spite of sharing a similar range of etiological factors with lichen sclerosus, is a very distinct entity. Finally, Paget's disease, although rare, is also described especially because of the challenge it represents both clinically and therapeutically.
Collapse
Affiliation(s)
- Jean Doyen
- Department of Gynecology and Obstetrics, Regional Hospital Citadelle, 4000 Liege, Belgium
| | - Stéphanie Demoulin
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000 Liege, Belgium
| | - Katty Delbecque
- Department of Pathology, University Hospital of Liege, 4000 Liege, Belgium
| | - Frédéric Goffin
- Department of Gynecology and Obstetrics, Regional Hospital Citadelle, 4000 Liege, Belgium
| | - Frédéric Kridelka
- Department of Gynecology and Obstetrics, Regional Hospital Citadelle, 4000 Liege, Belgium
| | - Philippe Delvenne
- Department of Pathology, University Hospital of Liege, 4000 Liege, Belgium
| |
Collapse
|