Extramammary Paget's disease (EPD) is a rare malignancy occurring mainly in apocrine gland-bearing regions. Surgical excision is the treatment of choice. This may be very difficult or even impossible if the disease is widespread or located in a critical anatomical site. We report on the successful treatment of a 71-year-old man with EPD in the suprapubic region with CO2 laser guided by photodynamic diagnosis.
The topical application of δ-aminolevulinic acid (ALA) induces porphyrin formation in the skin, preferentially in tumor tissues. Irradiation of the porphyrin-enriched tumor tissue with Wood’s light leads to emission of a brick-red fluorescence. This principle may be used as a diagnostic procedure which may be termed photodynamic diagnosis (PDD). In ALA-PDD, tumors and precancerous lesions of the skin reveal a homogeneous, intensive red fluorescence. Psoriatic lesions also show a strong but inhomogeneous porphyrin fluorescence. ALA-induced porphyrin fluorescence in preoperative planning is a valuable method to determine the peripheral borders of a given tumor. The histopathological extensions of the tumors correlate well with the borders detected by the tumor-specific fluorescence. The main indications of PDD are the delineation of clinically ill-defined skin tumors and the control of the efficacy of other tumor therapies. Photodynamic therapy (PDT) utilizes exogenously applied or endogenously formed photosensitizers and their activation by light to induce cell death via formation of singlet oxygen and other free radicals. PDT is highly efficient in the treatment of solar keratoses and superficial basal cell carcinomas. Initial squamous cell carcinomas also show good response to ALA-PDT. During the last decade, numerous studies on PDT for dermatologic diseases were published, the more important ones are reviewed here.
We treated a large superficial basal cell carcinoma (ca. 10 x 6 cm) on the right breast in a 48-year old woman with photodynamic therapy (PDT). Fractionated PDT was performed by topical application of delta-aminolevulinic acid (delta-ALA, 20%) with subsequent red light (570-750 nm; 180 J/ cm2) in three sessions. Nearly total remission of the tumor resulted; however, a few residual neoplastic islands partly infiltrating the nipple-areola complex could be detected by photodynamic diagnosis (PDD). These fluorescent areas were marked, excised, and the defect was closed by a rotation advancement flap. Total excision of the tumor was verified histologically. By combining PDT and surgery, this large tumor was treated with excellent cosmetic results. This case demonstrates the efficiency of topical PDT with adjunctive plastic surgery controlled by PDD even in large tumors.
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