Extramammary Paget's disease overview: Difference between revisions
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{{CMG}}{{AE}}{{Simrat}} | {{CMG}}{{AE}}{{Simrat}} | ||
==Overview== | ==Overview== | ||
Extamammary Paget's disease (EMPD) is a rare non-melanocytic [[Epidermal|intraepidermal]] skin lesion. It usually involves the [[epidermis]], but occasionally extends into the underlying dermis. It has predilection for [[apocrine gland]]-bearing areas: mostly the [[perineum]], [[vulva]], [[axilla]], [[scrotum]] and [[penis]]. Extramammary Paget's disease may be classified into two groups based on the origin of the [[Paget's cells]]. Extramammary Paget's disease may be classified into four subtypes based on site of origin and area affected. | Extamammary Paget's disease (EMPD) is a rare non-melanocytic [[Epidermal|intraepidermal]] [[skin lesion]]. It usually involves the [[epidermis]], but occasionally extends into the underlying [[dermis]]. It has predilection for [[apocrine gland]]-bearing areas: mostly the [[perineum]], [[vulva]], [[axilla]], [[scrotum]] and [[penis]]. Extramammary Paget's disease may be classified into two groups based on the origin of the [[Paget's disease|Paget's cells]]. Extramammary Paget's disease may be classified into four subtypes based on site of origin and area affected. On [[gross pathology]], [[plaque]] with an irregular border and [[erythematous]] or white [[lesion]] are characteristic findings of extramammary Paget's disease. On microscopic [[Histopathological|histopathological analysis]], the presence of Paget's cells (large cells with abundant amphophilic or [[basophilic]], finely granular [[cytoplasm]] and a large, centrally-located [[nucleus]] and prominent [[nucleolus]]) and [[Signet ring cell|signet ring cells]] are characteristic findings of extramammary Paget's disease. Extramammary Paget's disease is usually associated with [[adnexal]] [[apocrine]] [[carcinoma]], which represents infiltration of the deeper [[adnexa]] by [[epidermal]] Paget cells. Neither the direct cause nor a prominent risk factor of extramammary Paget's disease has been identified. Extramammary Paget's disease is rare and the exact [[incidence]] is unknown. Extramammary Paget's disease commonly affects individuals 50-60 years of age. [[Female|Females]] are more commonly affected with the disease than [[Male|males]]. The [[female]] to [[male]] ratio is approximately 3-4.5 to 1. It usually affects individuals of the Caucasian race, but it may occur in other races. Symptoms of extramammary Paget's disease include [[pruritis]], [[Vulva|vulvar]] pain, [[Vulva|vulvar]] [[bleeding]], and burning sensation. [[Biopsy]] is diagnostic of extramammary Paget's disease. Other diagnostic studies for extramammary Paget's disease include [[Fine needle aspiration|fine needle aspirate]] and [[Pap smear|PAP smear]]. [[Treatment Planning|Treatment]] depends on the stage at [[diagnosis]]. Treatment often includes [[surgery]] and [[chemotherapy]] with either [[5-fluorouracil]], [[imiquimod]], or combination of [[paclitaxel]] and [[trastuzumab]]. | ||
==Historical Perspective== | ==Historical Perspective== | ||
Extramammary Paget's disease was first discovered by Radcliffe Crocker in 1889. | Extramammary Paget's disease was first discovered by Radcliffe Crocker in 1889. | ||
==Classification== | ==Classification== | ||
Extramammary Paget's disease may be classified into two groups based on the origin of the Paget's cells. Extramammary Paget's disease may be classified into four subtypes based on site of origin and area affected. | Extramammary Paget's disease may be classified into two groups based on the origin of the Paget's cells. Extramammary Paget's disease may be classified into four subtypes based on site of origin and area affected. | ||
==Pathophysiology== | ==Pathophysiology== | ||
On gross pathology, plaque with an irregular border and [[erythematous]] or white lesion are characteristic findings of extramammary Paget's disease. On microscopic histopathological analysis, [[Paget's cells]] which are large cells with abundant amphophilic or [[basophilic]], finely granular cytoplasm, the nucleus which is usually large, centrally situated, and sometimes contains a prominent nucleolus, and signet ring cells are characteristic findings of extramammary Paget's disease. Extramammary Paget's disease arises from | On [[gross pathology]], [[plaque]] with an irregular border and [[erythematous]] or white [[lesion]] are characteristic findings of extramammary Paget's disease. On microscopic [[Histopathological|histopathological analysis]], [[Paget's cells]] which are large cells with abundant amphophilic or [[basophilic]], finely granular [[cytoplasm]], the [[nucleus]] which is usually large, centrally situated, and sometimes contains a prominent [[nucleolus]], and signet ring cells are characteristic findings of extramammary Paget's disease. Extramammary Paget's disease arises from keratinocytic [[stem cells]] or from [[apocrine gland]] ducts. Approximately 25% (range 9-32%) of the cases of extramammary Paget's disease are associated with an underlying in situ or invasive [[neoplasm]]. Extramammary Paget's disease is usually associated with [[adnexal]] [[apocrine]] [[carcinoma]], which represents infiltration of the deeper [[adnexa]] by [[epidermal]] [[Paget's disease|Paget cells]]. | ||
==Causes== | ==Causes== | ||
The cause of extramammary Paget's disease has not been identified. | The cause of extramammary Paget's disease has not been identified. | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Extramammary Paget's disease must be differentiated from [[basal cell carcinoma]], [[Bowen's disease]], cutaneous [[candidiasis]], [[intertrigo]], [[irritant contact dermatitis]], [[lichen simplex chronicus]], plaque [[psoriasis]], [[tinea cruris]], [[seborrhoeic dermatitis]], lichen sclerosis, anogenital intraepithelial neoplasia, [[melanoma]], [[histiocytosis]], [[mycosis fungoides]], [[leukoplakia]], [[squamous cell carcinoma]], condylomata accuminata, [[Crohn's disease]], and [[hidradenitis suppurativa]]. | Extramammary Paget's disease must be differentiated from [[basal cell carcinoma]], [[Bowen's disease]], cutaneous [[candidiasis]], [[intertrigo]], [[irritant contact dermatitis]], [[lichen simplex chronicus]], plaque [[psoriasis]], [[tinea cruris]], [[seborrhoeic dermatitis]], lichen sclerosis, anogenital intraepithelial neoplasia, [[melanoma]], [[histiocytosis]], [[mycosis fungoides]], [[leukoplakia]], [[squamous cell carcinoma]], condylomata accuminata, [[Crohn's disease]], and [[hidradenitis suppurativa]]. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Extramammary Paget's disease is rare, and its exact incidence is unknown. Extramammary Paget's disease commonly affects individuals 50-60 years of age. Females are more commonly affected with the disease than males. The female to male ratio is approximately 3-4.5 to 1. It usually affects individuals of the Caucasian race, but it may occur in other races. | Extramammary Paget's disease is rare, and its exact incidence is unknown. Extramammary Paget's disease commonly affects individuals 50-60 years of age. [[Female|Females]] are more commonly affected with the disease than [[Male|males]]. The female to male ratio is approximately 3-4.5 to 1. It usually affects individuals of the Caucasian race, but it may occur in other races. | ||
==Risk Factors== | ==Risk Factors== | ||
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==Screening== | ==Screening== | ||
According to the United States Preventive Services Task Force, screening for extramammary Paget's disease is not recommended among the general population. | According to the United States Preventive Services Task Force, screening for extramammary Paget's disease is not recommended among the general population. | ||
==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
If left untreated, the disease is usually progressive. Common complications of extramammary Paget's disease include [[recurrence]] of the tumor and metastasis. Depending on the extent of the [[tumor]] at the time of diagnosis, the prognosis may vary. The prognosis for primary | If left untreated, the disease is usually progressive. Common complications of extramammary Paget's disease include [[recurrence]] of the [[tumor]] and [[metastasis]]. Depending on the extent of the [[tumor]] at the time of diagnosis, the [[prognosis]] may vary. The [[prognosis]] for primary extramammary Pagets's disease confined to the [[Epidermis (skin)|epidermis]] is excellent. However, invasive primary extramammary Paget's disease carries a poor [[prognosis]], particularly if lymphovascular invasion is present. | ||
==Diagnosis== | ==Diagnosis== | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
Symptoms of extramammary Paget's disease include [[pruritis]], vulvar pain, vulvar bleeding, and burning sensation. | Symptoms of extramammary Paget's disease include [[pruritis]], [[Vulva|vulvar]] pain, [[Vulva|vulvar]] bleeding, and burning sensation. | ||
===Physical Examination=== | ===Physical Examination=== | ||
Common physical examination findings of extramammary Paget's disease include well demarcated, [[erythematous]] or [[ | Common physical examination findings of extramammary Paget's disease include well demarcated, [[erythematous]] or leucoplakic [[Plaque|plaques]] present on the [[skin]], characteristic ‘cake-icing’ appearance of [[Vulva|vulval]] extramammary Paget's disease ([[Erythema|erythematous]] changes associated with white islands and bridges of hyperkeratotic [[epithelium]]), and [[lymphadenopathy]]. | ||
===Chest X Ray=== | ===Chest X Ray=== | ||
Chest x-rays may be performed to detect metastases of extramammary Paget's disease to the lungs. | [[X-rays|Chest x-rays]] may be performed to detect [[Metastasis|metastases]] of extramammary Paget's disease to the [[Lung|lungs]]. | ||
===CT=== | ===CT=== | ||
Chest, abdomen, and pelvic CT scan may be helpful in the diagnosis of extramammary Paget's disease. CT scan can confirm the exact location of the cancer and show the organs nearby, as well as [[lymph nodes]] and distant organs where the cancer might have spread. | [[Chest]], [[abdomen]], and [[Pelvis|pelvic]] [[Computed tomography|CT scan]] may be helpful in the diagnosis of extramammary Paget's disease. [[Computed tomography|CT scan]] can confirm the exact location of the [[cancer]] and show the [[Organ (anatomy)|organs]] nearby, as well as [[lymph nodes]] and distant [[Organ (anatomy)|organs]] where the [[cancer]] might have spread. | ||
===MRI=== | ===MRI=== | ||
Chest, abdomen, and pelvic MRI scan may be helpful in the diagnosis of EMPD. | [[Chest]], [[abdomen]], and [[Pelvis|pelvic]] [[Magnetic resonance imaging|MRI scan]] may be helpful in the diagnosis of EMPD. | ||
===Other Imaging Findings=== | ===Other Imaging Findings=== | ||
Other imaging studies for EMPD include [[bone scan]], [[ultrasound scan]], [[PET scan]], [[cystoscopy]], [[sigmoidoscopy]], [[colonoscopy]], [[mammography]], and [[colposcopy]], which demonstrates [[metastases]] and underlying invasive carcinomas. | Other imaging studies for EMPD include [[bone scan]], [[ultrasound scan]], [[PET scan]], [[cystoscopy]], [[sigmoidoscopy]], [[colonoscopy]], [[mammography]], and [[colposcopy]], which demonstrates [[metastases]] and underlying [[Carcinoma|invasive carcinomas]]. | ||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
Biopsy is diagnostic of extramammary Paget's disease. Other diagnostic studies for extramammary Paget's disease include fine needle aspirate and | Biopsy is diagnostic of extramammary Paget's disease. Other diagnostic studies for extramammary Paget's disease include [[Fine needle aspiration|fine needle aspirate]] and [[Pap smear]]. | ||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
Treatment depends on the stage at diagnosis. Chemotherapy with either 5-fluorouracil, imiquimod, or combination of paclitaxel and trastuzumab has been evaluated for the treatment of extramammary Paget's disease. | Treatment depends on the stage at diagnosis. [[Chemotherapy]] with either [[5-fluorouracil]], [[imiquimod]], or combination of [[paclitaxel]] and [[trastuzumab]] has been evaluated for the treatment of extramammary Paget's disease. | ||
===Surgery=== | ===Surgery=== | ||
Surgery is the first line treatment for extramammary Paget's disease. | [[Surgery]] is the first line treatment for extramammary Paget's disease. | ||
===Primary Prevention=== | ===Primary Prevention=== | ||
There are no primary preventive measures against extramammary Paget's disease. | There are no [[Primary prevention|primary preventive]] measures against extramammary Paget's disease. | ||
===Secondary Prevention=== | ===Secondary Prevention=== | ||
Secondary prevention strategies following extramammary Paget's disease include an annual complete physical examination, [[proctosigmoidoscopy]] and [[punch biopsy]] of any new lesion. [[Colonoscopy]] should be carried out at every two to three year intervals. | [[Secondary prevention]] strategies following extramammary Paget's disease include an annual complete physical examination, [[proctosigmoidoscopy]] and [[punch biopsy]] of any new lesion. [[Colonoscopy]] should be carried out at every two to three year intervals. | ||
==References== | ==References== | ||
Latest revision as of 13:54, 9 April 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]
Overview
Extamammary Paget's disease (EMPD) is a rare non-melanocytic intraepidermal skin lesion. It usually involves the epidermis, but occasionally extends into the underlying dermis. It has predilection for apocrine gland-bearing areas: mostly the perineum, vulva, axilla, scrotum and penis. Extramammary Paget's disease may be classified into two groups based on the origin of the Paget's cells. Extramammary Paget's disease may be classified into four subtypes based on site of origin and area affected. On gross pathology, plaque with an irregular border and erythematous or white lesion are characteristic findings of extramammary Paget's disease. On microscopic histopathological analysis, the presence of Paget's cells (large cells with abundant amphophilic or basophilic, finely granular cytoplasm and a large, centrally-located nucleus and prominent nucleolus) and signet ring cells are characteristic findings of extramammary Paget's disease. Extramammary Paget's disease is usually associated with adnexal apocrine carcinoma, which represents infiltration of the deeper adnexa by epidermal Paget cells. Neither the direct cause nor a prominent risk factor of extramammary Paget's disease has been identified. Extramammary Paget's disease is rare and the exact incidence is unknown. Extramammary Paget's disease commonly affects individuals 50-60 years of age. Females are more commonly affected with the disease than males. The female to male ratio is approximately 3-4.5 to 1. It usually affects individuals of the Caucasian race, but it may occur in other races. Symptoms of extramammary Paget's disease include pruritis, vulvar pain, vulvar bleeding, and burning sensation. Biopsy is diagnostic of extramammary Paget's disease. Other diagnostic studies for extramammary Paget's disease include fine needle aspirate and PAP smear. Treatment depends on the stage at diagnosis. Treatment often includes surgery and chemotherapy with either 5-fluorouracil, imiquimod, or combination of paclitaxel and trastuzumab.
Historical Perspective
Extramammary Paget's disease was first discovered by Radcliffe Crocker in 1889.
Classification
Extramammary Paget's disease may be classified into two groups based on the origin of the Paget's cells. Extramammary Paget's disease may be classified into four subtypes based on site of origin and area affected.
Pathophysiology
On gross pathology, plaque with an irregular border and erythematous or white lesion are characteristic findings of extramammary Paget's disease. On microscopic histopathological analysis, Paget's cells which are large cells with abundant amphophilic or basophilic, finely granular cytoplasm, the nucleus which is usually large, centrally situated, and sometimes contains a prominent nucleolus, and signet ring cells are characteristic findings of extramammary Paget's disease. Extramammary Paget's disease arises from keratinocytic stem cells or from apocrine gland ducts. Approximately 25% (range 9-32%) of the cases of extramammary Paget's disease are associated with an underlying in situ or invasive neoplasm. Extramammary Paget's disease is usually associated with adnexal apocrine carcinoma, which represents infiltration of the deeper adnexa by epidermal Paget cells.
Causes
The cause of extramammary Paget's disease has not been identified.
Differential Diagnosis
Extramammary Paget's disease must be differentiated from basal cell carcinoma, Bowen's disease, cutaneous candidiasis, intertrigo, irritant contact dermatitis, lichen simplex chronicus, plaque psoriasis, tinea cruris, seborrhoeic dermatitis, lichen sclerosis, anogenital intraepithelial neoplasia, melanoma, histiocytosis, mycosis fungoides, leukoplakia, squamous cell carcinoma, condylomata accuminata, Crohn's disease, and hidradenitis suppurativa.
Epidemiology and Demographics
Extramammary Paget's disease is rare, and its exact incidence is unknown. Extramammary Paget's disease commonly affects individuals 50-60 years of age. Females are more commonly affected with the disease than males. The female to male ratio is approximately 3-4.5 to 1. It usually affects individuals of the Caucasian race, but it may occur in other races.
Risk Factors
There are no established risk factors for extramammary Paget's disease.
Screening
According to the United States Preventive Services Task Force, screening for extramammary Paget's disease is not recommended among the general population.
Natural History, Complications and Prognosis
If left untreated, the disease is usually progressive. Common complications of extramammary Paget's disease include recurrence of the tumor and metastasis. Depending on the extent of the tumor at the time of diagnosis, the prognosis may vary. The prognosis for primary extramammary Pagets's disease confined to the epidermis is excellent. However, invasive primary extramammary Paget's disease carries a poor prognosis, particularly if lymphovascular invasion is present.
Diagnosis
History and Symptoms
Symptoms of extramammary Paget's disease include pruritis, vulvar pain, vulvar bleeding, and burning sensation.
Physical Examination
Common physical examination findings of extramammary Paget's disease include well demarcated, erythematous or leucoplakic plaques present on the skin, characteristic ‘cake-icing’ appearance of vulval extramammary Paget's disease (erythematous changes associated with white islands and bridges of hyperkeratotic epithelium), and lymphadenopathy.
Chest X Ray
Chest x-rays may be performed to detect metastases of extramammary Paget's disease to the lungs.
CT
Chest, abdomen, and pelvic CT scan may be helpful in the diagnosis of extramammary Paget's disease. CT scan can confirm the exact location of the cancer and show the organs nearby, as well as lymph nodes and distant organs where the cancer might have spread.
MRI
Chest, abdomen, and pelvic MRI scan may be helpful in the diagnosis of EMPD.
Other Imaging Findings
Other imaging studies for EMPD include bone scan, ultrasound scan, PET scan, cystoscopy, sigmoidoscopy, colonoscopy, mammography, and colposcopy, which demonstrates metastases and underlying invasive carcinomas.
Other Diagnostic Studies
Biopsy is diagnostic of extramammary Paget's disease. Other diagnostic studies for extramammary Paget's disease include fine needle aspirate and Pap smear.
Treatment
Medical Therapy
Treatment depends on the stage at diagnosis. Chemotherapy with either 5-fluorouracil, imiquimod, or combination of paclitaxel and trastuzumab has been evaluated for the treatment of extramammary Paget's disease.
Surgery
Surgery is the first line treatment for extramammary Paget's disease.
Primary Prevention
There are no primary preventive measures against extramammary Paget's disease.
Secondary Prevention
Secondary prevention strategies following extramammary Paget's disease include an annual complete physical examination, proctosigmoidoscopy and punch biopsy of any new lesion. Colonoscopy should be carried out at every two to three year intervals.