Khaled el-Hoshy MD, Troy, Michigan, USA
on May 1, 2008
Special stains (minimum CEA) should be done. Mohs surgery,
preceded by 2 weeks of 5-FU gives excellent cure rates. Malignancy
in genito-urinary/lower GIT should be evaluated as suggested
by presenting MD.
Joel Bamford MD, SMDC & UMD Medical School, Duluth,
MN, USA on May 1, 2008
Excellent photos and current history. I presented a poster
about a man with more extensive disease. All of his flat lesions
resolved with Aldara 5 x daily over two months. This left him
with several nodules which did not clear. He then developed
allergic response to Aldara and stopped it. Subsequent radiation
was of paliative help but not curative.
Firas Altamimi MD, Basra, Iraq on May 2, 2008
Nice case. EMPD has a high rate of metastases with very poor
prognosis. Sentinal lymph node examination of this patient should
be considerd to exclude any metastases. Surgical removal by
Moh's surgery is treatment of choice. Imiquimod cream 5% apply
daily can be used.
Abbas Naji Alshammari MD, Consultant Dermatologist,
Doha, Qatar on May 2, 2008
Nice presentation and photos. To start with, treat the overlying
candidal infection both orally and topically, preferably with
mild to moderate topical steroid to calm down the irritation
and inflammation . This makes easier to see the real extent
of the disease. Then try to investigate the deeper origin and
extent of the tumour. After that can adjust the proper way of
treatment accordingly. Although Mohs surgery has its value it
has certain indications and limitations. Update us with any
new results or data please.
Hamish Dunwoodie MD, Dermatologist, Moncton, NB, Canada
on May 3, 2008
I don't see any photomicrographs of the specimen from this
patient. It is important to be 100% sure of dx since one will
commit this patient to major intervention. It might be good
to repeat the biopsy since the Candida has been cleared up.
David Elpern MD, Dermatologist, Williamstown, MA, USA
on May 3, 2008
This is a great case for discussion. I suspect that if this
woman has internal involvement with EMPD it will be difficult
to eradicate. Hers is the kind of problem that is best handled
at a tertiary centre (and you may not have that kind of service
in Malaysia). Even S'pore may not have the depth since skin
cancer is so uncommon in your area. I suppose I would repeat
the biopsy and have it confirmed by Jag or Andy and then use
Aldara but keep in mind that it will be difficult on the patient.
I would also try to find an expert in USA, Europe or Australia
to weigh in on this. Good luck and keep us posted.
Ian McColl MD, Dermatologist, Gold Coast, Australia
on May 3, 2008
It all boils down to where the tumour is coming from, vagina,
rectum, urethra etc. Little point in Mohs surgery for the outside
tumour without dealing with the tumour of origin. That said
you can get primary extramammary Pagets. In that case Mohs or
PDT directed Mohs using aminolaevulinic acid and red light to
help localise the tumour extent can be used but this will be
a big defect. Radiotherapy can certainly be palliative but she
needs scopes up all her local orifices. If the tumour is CK7pos
and CK20 neg it may just be the primary type derived from local
apocrine or eccrine stem cells and has a better prognosis after
I have used Imiquimod and PDT therapy with some success in
both males and females but never achieved a cure. These therapies
are better for local recurrence after surgery or radiotherapy.