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THROUGH THE LENS
Year : 2018  |  Volume : 9  |  Issue : 6  |  Page : 471-473  

Vulvar extramammary Paget's disease secondary to urothelial carcinoma presenting with a small painful erosion of the vulva


1 Department of Dermatology, National Cheng Kung University Hospital, Tainan, Taiwan
2 Department of Pathology, National Cheng Kung University Hospital, Tainan, Taiwan

Date of Web Publication5-Nov-2018

Correspondence Address:
J Yu-Yun Lee
Department of Dermatology, National Cheng Kung University Hospital, Tainan
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_98_18

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How to cite this article:
Chen YC, Wu CL, Lee J Y. Vulvar extramammary Paget's disease secondary to urothelial carcinoma presenting with a small painful erosion of the vulva. Indian Dermatol Online J 2018;9:471-3

How to cite this URL:
Chen YC, Wu CL, Lee J Y. Vulvar extramammary Paget's disease secondary to urothelial carcinoma presenting with a small painful erosion of the vulva. Indian Dermatol Online J [serial online] 2018 [cited 2018 Dec 12];9:471-3. Available from: http://www.idoj.in/text.asp?2018/9/6/471/245020



A 75-year-old female presented to our clinic complaining of a very painful lesion in the vulva area for more than 1 month. Examination revealed a 1-cm, round erythematous erosion on the left vulva [Figure 1]. KOH smear revealed presence of pseudohyphae and budding yeast forms, indicating candidiasis. The symptoms improved after topical antifungal treatment. A skin biopsy specimen of the erosion revealed an extensive intraepidermal infiltration of atypical cells with hyperchromatic pleomorphic nuclei [Figure 2]. The tumor cells were melan-A (‒), weakly CK7 (+) [Figure 3], strongly CK20 (+) [Figure 4], GATA3 (+) [Figure 5], and uroplakin (UP)-III(-) [Figure 6]. A diagnosis of Extramammary Paget's Disease (EMPD) was made and secondary EMPD was suspected. Further questioning revealed urinary frequency in recent month. Urine cytology reported presence of suspicious malignant cells. Cystoscopy showed papillary tumors in the bladder neck, extending to the urethra. Pathology of the bladder tumor showed extensive infiltration of pleomorphic transitional cells, findings consistent with infiltrative urothelial carcinoma. Computer tomography revealed lymph node metastasis and right obturator muscle involvement. The patient was enrolled in a clinical trial 2 months after first presentation.
Figure 1: A 1-cm erythematous erosion (arrow heads) on the left vulva without a visible tumor

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Figure 2: Biopsy of the vulvar lesion reveals an extensive infiltration of atypical cells, singly and in nests, throughout the epidermis. The tumor cells have enlarged hyperchromatic, pleomorphic nuclei and moderately abundant cytoplasm (H and E stain, ×200)

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Figure 3: The tumor cells are CK7 (+) (immunohistochemistry, ×400)

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Figure 4: The tumor cells are CK20 (+) (immunohistochemistry, ×400). The expression of CK20 is stronger than that of CK7

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Figure 5: The tumor cells are GATA3 (+) (immunohistochemistry, ×200)

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Figure 6: The tumor cells are Uroplakin (UP)-III (‒) (immunohistochemistry, ×200)

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EMPD is a rare intraepithelial adenocarcinoma most commonly affecting the external genitalia, followed by perianal and axillary areas.[1] Distinction between primary versus secondary EMPD is essential for treatment planning. Vulva pain is more commonly observed in primary EMPD that has dermal invasion or an underlying adenocarcinoma, than in secondary EMPD.[2] Immunophenotyping of pagetoid cells helps to determine the origin of the tumor. In the study by Perrotto et al., primary EMPD was shown to be CK7 (100%+)/CK20 (22%+)/BRST-2 (48%+).[3] In comparison, secondary EMPD were CK7 (100%+)/CK20 (50%+)/BRST-2 (25%+). In all of the CK20+ cases, the expression of CK20 was weaker than that of CK7. Other markers that have been applied in EMPD include DX2, which is positive in 80% of the EMPD of anorectal origin, and GATA3, which is positive in primary and secondary vulvar Paget's disease (VPD)[3] and urothelial carcinoma (67%).[4] In the present case, the expression pattern of CK7/CK20 was unusual for EMPD in that the tumor showed a stronger expression of CK20, and negative expression of UP-III. Although UP-III is more specific for urothelial carcinoma, the sensitivity is low in high-grade tumors,[5] as illustrated in the present case.

VPD secondary to urothelial carcinoma (urothelial VPD) is extremely rare. Seven cases have been reported previously, five had urothelial carcinoma preceding the lesion of vulvar EMPD and two had vulvar EMPD diagnosed 14 years and 6 years, respectively, before diagnosis of urothelial carcinoma. The urethral orifice showed tumor involvement in six cases, but no visible tumor in one. Our patient is unique in that she presented with a recent-onset of painful small vulvar erosion without obvious involvement of the urethral orifice and that there was no history of a prior diagnosis of malignancy. The diagnoses of VPD and urothelial carcinoma were made at the same time. Of all eight cases of urothelial VPD, CK7 was positive in six of six cases, CK20 positive in four of five cases, and UP-III positive in three of four cases. Our case illustrates the importance of including urothelial carcinoma in the differential diagnosis of VPD, even when there is no obvious tumor of urethral orifice or a prior diagnosis of urothelial carcinoma. In such cases, the underlying urothelial carcinoma can be treated appropriately and a vulvectomy can potentially be averted.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Chen Y-H, Wong T-W, Lee JY-Y. Depigmented genital extramammary Paget's disease: A possible histogenetic link to Toker's clear cells and clear cell papulosis. J Cutan Pathol 2001;28:105-8.  Back to cited text no. 1
    
2.
Parker LP, Parker JR, Bodurka-Bevers D, Deavers M, Bevers MW, Shen-Gunther J, et al. Paget's Disease of the Vulva: Pathology, Pattern of Involvement, and Prognosis. Gynecol Oncol 2000;77:183-9.  Back to cited text no. 2
    
3.
Perrotto J, Abbott JJ, Ceilley RI, Ahmed I. The Role of Immunohistochemistry in Discriminating Primary From Secondary Extramammary Paget Disease. Am J Dermatopathol 2010;32:137-43.  Back to cited text no. 3
    
4.
Higgins JP, Kaygusuz G, Wang L, Montgomery K, Mason V, Zhu SX, et al. Placental S100 (S100P) and GATA3: Markers for Transitional Epithelium and Urothelial Carcinoma Discovered by Complementary DNA Microarray. Am J Surg Pathol 2007;31:673-80.  Back to cited text no. 4
    
5.
Brown HM, Wilkinson EJ. Uroplakin-III to distinguish primary vulvar Paget disease from Paget disease secondary to urothelial carcinoma. Hum Pathol 2002;33:545-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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