Sentinel lymph node (SLN) biopsy has become an important procedure in managing malignant skin tumors. Lymphatic mapping using radioisotope (RI) and blue dye is the standard procedure in SLN mapping and has an over 90% detection rate. However, we sometime encounter cases in which it is difficult to detect SLN or cases that develop lymph node recurrence (false negatives). Therefore, we decided that the method for detecting SLN should be revised. We started a new lymphatic mapping method using indocyanine green (ICG) fluorescence from December of 2009 and collected 50 cases. As a result, SLN was successfully detected in 49 (98%) of 50 cases. ICG detected significantly more SLNs than RI, 2.20 and 1.81 per SLNs per case, respectively (P<0.05, student t-test). ICG detected additional SLNs in the same lymphatic basin detected by RI in 10 cases (20%) and additional SLNs in another lymphatic basin in 6 cases (13%). More than three quarters of such additional SLNs had primary tumors in the head/neck, trunk, and genitalia. There was no statistically significant improvement in the detection rate after adding ICG compared with 50 cases that underwent SLN biopsy without ICG (98% versus 92%), but the combination detected more SLNs (2.20 versus 1.76 SLNs per case, P<0.01,student t-test). We intend to collect more cases and track long-term outcomes to evaluate the effects of this new mapping method in SLN detection.
A 90-year-old woman presented with a 3-month history of an erythematous plaque on the vulva with superficial erosion; it measured about 7×6 cm. A biopsy performed at a nearby hospital revealed an intra-epidermal proliferation of large, pleomorphic, pale cells, distributed singly or in clusters. Most of the tumor cells stained positively with periodic acid Schiff (PAS, pancytokeratin (CAM5.2), and gross cystic disease fluid protein 15 (GCDFP15. She was diagnosed with extramammary Pagetʼs disease and referred to our hospital. Because of her age and poor physical condition, surgery was deemed inappropriate. Because of its relative ease of application, topical imiquimod 5% cream was applied three times weekly to the lesion and immediate perilesional skin. After 3 weeks of treatment, moderate inflammation with erythema and erosion developed in the treated area. The treatment was continued for a total of 6 weeks. One week after completion of the treatment, the lesion appeared to be completely healed. A posttreatment biopsy specimen also revealed resolution of the disease. To our knowledge, only a few cases of extramammary Pagetʼs disease have been reported to be treated successfully with topical imiquimod cream. We consider that topical imiquimod is a promising new treatment option for Pagetʼs disease patients who are not suitable for surgery.
From January 2001 to July 2010, we studied 101 cases (67 males and 34 females; ages between 41 and 85 years; mean age, 69.9 years) who underwent treatment at the Division of Dermatology, National Cancer Center Hospital, Japan. Tumors were located on the vulva in 89 cases, perianal region in 6 cases, and axilla in 5 cases. Multiple tumors were present in the vulva/axilla in 1 case. Surgery was the first choice of treatment if no distal metastasis was detected during preoperative examination. A sentinel lymph node biopsy or lymph node biopsy was performed when the patient showed pathological dermal invasion histopathologically and subcutaneous nodules clinically. Patients with lymph node metastasis underwent regional lymph node dissection. Significant differences were observed in 5-year survival rates; 100% of the patients with 1 or 2 metastatic lymph nodes survived for 5 years, but none of the patients with more than 3 metastatic lymph nodes did. However, the results also revealed that lymph node dissection resulted in a poor prognosis in cases of bilateral inguinal lymph node metastases or those of multiple metastases in vulval extramammary Paget’s disease. Thus, reduction surgery should be considered to prevent damage to the patient’s quality of life. A FECOM (5-FU/Epirubicin/Carboplatin/Vincristine/Mitomycin C) regimen or treatment with taxanes is often employed in cases of unresectable lymph node metastasis or distal metastasis; however, resistance to these treatments is common, and prognosis is extremely poor.