Extensive Invasive Extramammary Paget's Disease: Surgical Treatment
A 70-year-old Causasian male patient of good general health presented with a persistent scaling erythematous lesion on his groins with ill-defined margins. He reported no itching or other subjective symptoms. The lesions were slow growing for more than 5 years. Topical treatment with corticosteroids or anti-mycotics had not improved the cutaneous appearance. His personal and family medical history was unremarkable.\nOn examination we observed an extensive erythematous lesion of groins, perineum and proximal parts of scrotal skin with peripheral scaling and central oozing []. Inguinal lymph nodes were not palpable.\nLaboratory investigations were unremarkable except a slightly increase level of carcinoembryonal antigen (CEA) of 2.2 μg/L. Microbial swabs were taken for bacterial cultures but remained sterile. We took a diagnostic biopsy from the left groin in the centre of the lesions. It was suggesting Paget's disease.\nDiagnostic ultrasound for lymph nodes demonstrated some enlarged nodes. A control was suggested. The ultrasound control 6 weeks later was normal. Screening for second tumour including skin (total body investigation including dermoscopy), lung (computerized tomography), prostate (digital examination, ultrasound and prostate-specific antigen), and GIT (coloscopy) remained negative.\nTreatment and course: We performed complete surgical excision with delayed Mohs techniques []. The histopathological work-up revealed a Paget carcinoma (apocrine adenocarcinoma) surrounded by intraepidermal Paget's disease []. The invasive part was completely excised with the 1st surgery. Paget's disease was noticed in minor parts of the surgical margins. Therefore, re-excision of the margins was done twice with delayed Mohs technique, i.e., complete examination of all margins. Controls demonstrated no Paget's residues. The distance between surgical border and anal verge was 2 cm. Wound bed was prepared by repeated topical CO2 application under plastic foil for 20 min. Hereby granulation was improved. The resulting defect was closed by split-skin mesh-graft and the scrotum was partially reconstructed by extension of scrotal skin []. The healing was uneventful and the outcome was functionally and esthetical very good [].\nDuring follow-up of three months the patient was relapse-free. A regular follow-up every 3 months during the first year and twice a year for a total of five years is planned.