Failure of carbon dioxide laser treatment in three patients with penoscrotal extramammary Paget's disease

Abstract

A 64-year-old man presented with a 3-month history of a 4r6 cm eczematoid erythematous skin lesion in the penoscrotal area (Fig. 1). The lesion involved about half of the proximal penile shaft and the left scrotum; the lesion was con®rmed as extramammary Paget's disease (EPD) by skin-punch biopsy. Other studies including serum PSA, IVU, abdominal ultrasonography, gastric and colonic endoscopic examination showed no other abnormality. Using Wood's¯uorescent visualization, the EPD was identi®ed and the lesion treated with a CO 2 laser (10±60 W), resurfacing with 300±500 mJ of pulse energy. The resulting charred surface was removed by lightly abrading the surface with moist saline-soaked gauze. This process was repeated layer-by-layer using the same parameters until all remaining abnormal¯uores-cent tissue had been removed. The skin was vaporized to a depth of < 2 mm and horizontally 1 cm beyond thē uorescent area. After 10±14 days the wound healing was almost completed; at 1 month after treatment the healing of the lesion showed good granulation and nō uorescence was detectable for 2 months (Fig. 2). However, after 6 months there was a diffuse¯uorescent area at the treated site which was con®rmed as EPD by punch biopsy. The lesion was then widely excised with normal tissue for 3 cm beyond the¯uorescent lesion; the lesion was then covered by a split-skin graft from the buttock area. Case 2A 75-year-old man presented with a 4r5 cm eczematoid lesion in the penoscrotal area, diagnosed as EPD using a skin-punch biopsy. Other examinations to detect internal malignancy revealed RCC in the left kidney and the patient underwent left radical nephrectomy. The pathology revealed a clear-cell tumour of stage of T2N0M0. His Paget's disease was treated using the CO 2 laser, as described for the ®rst patient; however, eventually the lesion was excised and the wound grafted in the same way, because he had the same clinical course. Case 3A 74-year-old man who had a 3r5 cm pruritic eczematoid lesion for 2 years was diagnosed with EPD using skin-punch biopsy. No other internal malignancy was found by the other examinations described; the lesion was treated with the CO 2 laser as described. The clinical course was again the same as in the ®rst two Fig. 1. The gross appearance of penoscrotal EPD at diagnosis.

Role of Radiotherapy as Curative Treatment of Extramammary Paget’s Disease

“…Although the number of reports on the use of photodynamic therapy for EMPD is small, and its effects are limited to the superficial regions, it may be a safe and useful technique for a wide range of diseases (40,41). Also, a few reports have been published on the use of carbon dioxide lasers for EMPD; however, these were associated with a high incidence of recurrence of 67-100% in patients treated with laser alone (42,43). Fukui et al (44) reported that a combination of photodynamic therapy and carbon dioxide laser therapy achieved a complete response in all 5 EMPD patients.…”

Sequential use with imiquimod and surgery in extramammary Paget's disease

“…Many treatments have been tried for the cases of localized skin disease (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). Some of them have been used isolatedly (3)(4)(5)(6)(7)(8)(9)(10)(11)13,14) or together with surgical resection (12,(15)(16)(17)(18)(19). Imiquimod modifies the biological response and is able to stimulate the immune system, so it has an effect in all the areas even in those clinically silent (22).…”

Extramammary Paget's Disease: Extended Subclinical Growth Detected Using Three-Dimensional Histology in Routine Paraffin Procedure and Course of the Disease

“…The effect of laserd is confined to superficial layers of the skin, resulting in incomplete tumor removal. 28 Radiotherapy has not been used often as a first treatment because of high recurrence rates, although there have been cases of EMPD successfully treated using radiation. 23,24 It is an appropriate therapy for inoperable lesions or for cases with positive surgical margins, as shown in one patient in this study.…”