Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Sarasota Memorial Healthcare System, Sarasota, FL.
Am J Obstet Gynecol. 2023 Dec;229(6):660.e1-660.e8. doi: 10.1016/j.ajog.2023.08.018. Epub 2023 Aug 24.
Extramammary Paget's disease recurs often after traditional surgical excision. Margin-controlled surgery improves the recurrence rate for male genital disease but is less studied for female anatomy.
This study aimed to compare surgical and oncologic outcomes of margin-controlled surgery vs traditional surgical excision for female genital Paget's disease.
We conducted a prospective observational trial of patients with vulvar or perianal Paget's disease treated with surgical excision guided by Mohs micrographic surgery between 2018 and 2022. The multidisciplinary protocol consisted of office-based scouting biopsies and modified Mohs surgery followed by surgical excision with wound closure under general anesthesia. Modified Mohs surgery cleared peripheral disease margins using a moat technique with cytokeratin 7 staining. Medial disease margins (the clitoris, urethra, vagina, and anus) were assessed using a hybrid of Mohs surgery and intraoperative frozen sections. Surgical and oncologic outcomes were compared with the outcomes of a retrospective cohort of patients who underwent traditional surgical excision. The primary outcome was 3-year recurrence-free survival.
Three-year recurrence-free survival was 93.3% for Mohs-guided excision (n=24; 95% confidence interval, 81.5%-100.0%) compared to 65.9% for traditional excision (n=63; 95% confidence interval, 54.2%-80.0%) (P=.04). The maximum diameter of the excisional specimen was similar between groups (median, 11.3 vs 9.5 cm; P=.17), but complex reconstructive procedures were more common with the Mohs-guided approach (66.7% vs 30.2%; P<.01). Peripheral margin clearance was universally achieved with modified Mohs surgery, but positive medial margins were noted in 9 patients. Reasons included intentional organ sparing and poor performance of intraoperative hematoxylin and eosin frozen sections without cytokeratin 7. Grade 3 or higher postoperative complications were rare (0.0% for Mohs-guided excision vs 2.4% for traditional excision; P=.99).
Margin control with modified Mohs surgery significantly improved short-term recurrence-free survival after surgical excision for female genital Paget's disease. Use on medial anatomic structures (the clitoris, urethra, vagina, and anus) is challenging, and further optimization is needed for margin control in these areas. Mohs-guided surgical excision requires specialized, collaborative care and may be best accomplished at designated referral centers.
传统手术切除后，乳腺外派杰氏病常复发。边缘控制手术可提高男性生殖器疾病的复发率，但对女性解剖结构的研究较少。
本研究旨在比较边缘控制手术与传统手术切除治疗女性生殖器派杰氏病的手术和肿瘤学结果。
我们对 2018 年至 2022 年间接受莫氏显微外科引导的手术切除治疗的外阴或肛周派杰氏病患者进行了前瞻性观察性试验。多学科方案包括基于办公室的探查活检和改良莫氏手术，随后在全身麻醉下进行手术切除和伤口闭合。改良莫氏手术使用角蛋白 7 染色的护城河技术清除外周疾病边缘。使用莫氏手术和术中冷冻切片的混合方法评估内侧疾病边缘（阴蒂、尿道、阴道和肛门）。比较边缘控制手术和传统手术切除的患者的手术和肿瘤学结果。主要结局是 3 年无复发生存率。
莫氏引导切除的 3 年无复发生存率为 93.3%（24 例；95%置信区间，81.5%-100.0%），而传统切除为 65.9%（63 例；95%置信区间，54.2%-80.0%）（P=.04）。两组切除标本的最大直径相似（中位数，11.3 与 9.5 cm；P=.17），但莫氏引导组更常见复杂的重建手术（66.7%与 30.2%；P<.01）。改良莫氏手术普遍实现了外周边缘清除，但 9 例患者存在阳性内侧边缘。原因包括有意保留器官和术中苏木精-伊红冷冻切片无角蛋白 7 时性能不佳。术后 3 级或以上并发症罕见（莫氏引导切除为 0.0%，传统切除为 2.4%；P=.99）。
改良莫氏手术的边缘控制显著提高了女性生殖器派杰氏病手术后的短期无复发生存率。在阴蒂、尿道、阴道和肛门等内侧解剖结构上的应用具有挑战性，需要进一步优化这些区域的边缘控制。莫氏引导手术切除需要专门的、协作的护理，最好在指定的转诊中心进行。
