Scrotal inflammatory cancer

　　First, Etiology

　　The tissue origin of extramammary Paget's disease is still unclear. Tissue chemistry and immunohistochemical studies have found that the tissue origin of the disease may originate from the germinal tissue of pluripotent primordial epithelium. Some believe that extramammary Paget's disease may have the following sources:

　　1. The majority of cases originate from the epidermis itself, which may be the original pluripotent stem cells of the epidermal basal layer;

　　2. Part of the cases come from apocrine gland tumors;

　　3. Originating from intraepidermal sweat ducts;

　　4. A very small number of cases originate from tumors of adjacent organs.

　　Second, Pathogenesis

　　Scrotal Paget's disease belongs to the category of extramammary skin Paget's disease, with diagnosis based on the presence of Paget cell nests in histopathology. Paget cells are large, round cells with faintly stained cytoplasm, large and irregular nuclei, without intercellular bridges, and may contain multiple nucleoli or a giant nucleolus. The nuclei often show mitotic figures, and cell clusters are distributed in a nest-like, string-like, or island-like pattern. In the late stage of the disease, there is an increase in Paget cells, but they do not penetrate into the dermis. Subepidermal Paget cells are often separated from the dermis by the basal cell layer, and there may be inflammatory infiltration in the dermis. Sometimes, Paget cells in the tumor may appear as signet ring-shaped or glandular structures, which often indicates poor tumor differentiation and an increased risk of metastasis and infiltration.

　　Scrotal inflammatory cancer can be accompanied by local eccrine cancer at the same time. Attention should be paid to distinguish whether the inflammatory cancer spreads downward to the sweat duct to form an adenoid cancer, and primary eccrine cancer does not find Paget cells. Scrotal Queyrat erythema is an intraepidermal squamous cell carcinoma, which is also relatively easy to differentiate from Paget's disease from a histological point of view.

　　About 35% of patients with extramammary Paget's disease have concurrent cancer of accessory organs, and 27% of patients have concurrent cancer at other sites or internal organs, such as rectal cancer, prostate cancer, etc.

　　1, Rectal cancer:When rectal cancer grows to a certain extent, symptoms such as hematochezia can occur. Small amounts of bleeding are not easily visible to the naked eye, but a large number of red blood cells can be found when examining the stool under a microscope, so-called positive occult blood test in feces. When the amount of bleeding is large, blood in the stool can appear, the color is bright red or dark red. When the surface of the tumor breaks through, forming an ulcer, the necrotic tumor tissue becomes infected, purulent, mucous stools can occur.

　　2, Prostate cancer:The onset of the disease is relatively hidden and the growth is slow, so early prostate cancer may have no symptoms, and it is only found during screening that the serum PSA level is elevated and/or the rectal examination shows abnormal changes in the prostate. Once symptoms appear, they often belong to the advanced progressive stage of prostate cancer.

　　1, Local skin itching, erosion, exudation, scab formation, and still have erosion and exudation after desquamation, the range of skin lesions gradually expands.

　　2, Skin lesions are all manifested as erythematous skin lesions, slightly elevated above normal skin, with clear boundaries but irregular like a map. The surface of the lesions is rough, with scabs, erosions, or exudation visible. A few cases may have papules, hyperpigmentation. The peripheral lesions are demarcated from normal skin.

　　3, Swelling of the inguinal lymph nodes is mostly inflammatory, and biopsy is necessary to exclude tumor metastasis if necessary.

　　The origin of extramammary Paget's disease is not yet clear. Organochromic and immunohistochemical studies have found that the tissue origin of the disease may originate from the germ tissue of multipotent primitive epithelium. Therefore, there is no direct effective preventive method for the disease. Early detection, early diagnosis, and early treatment are of great significance for the prevention of the disease. Once it is confirmed that the disease is present, active chemotherapy is required.

　　The diagnosis based on scrotal skin lesions and biopsy is not difficult. For recurrent scrotal eczema and chronic skin lesions that do not heal, it is advisable to perform tissue biopsy as soon as possible. Pathological examination: The presence of Paget cells in the basal layer or below the stratum spinosum of the epidermis is the basis for diagnosis.

　　1, Fresh root of Lysimachia christinae 30 grams, Alisma orientale 15 grams, mung bean 50 grams, rock sugar 20 grams. First, boil the white root and Alisma orientale, remove the dregs and take the juice after 20 minutes. Then add the mung bean and cook until the mung bean blooms and peels off. Finally, add a little rock sugar and cook for a while before eating.

　　A high-carbohydrate diet can provide breast cancer patients with sufficient energy, reduce protein consumption, prevent hypoglycemia, and protect liver cells from damage by anesthetics. In addition, it can increase the body's resistance and provide calories to compensate for the energy consumption caused by insufficient intake after surgery in breast cancer patients.

　　1. Treatment

　　Early and timely wide local resection of the scrotum is the preferred treatment, and the resection range should extend 2 cm beyond the normal skin around the visible tumor lesions on the scrotum wall, including the epidermis, dermis, up to the tunica albuginea of the tunica vaginalis of the testis. If the deep tissue is involved, the testis and spermatic cord should be resected together. If the resection range is too large, a local flap reconstruction or scrotal reconstruction can be performed (Payne, 1994). Recently, there have been reports that in order to completely resect the lesion, intraoperative frozen biopsy or intraoperative rapid carcinoembryonic antigen staining can be used to determine the resection range (Harris, 1994).

　　Enlarged lymph nodes in the inguinal area are often caused by inflammation and may not be metastasis, so prophylactic lymph node dissection is not necessary. As with the treatment of penile cancer, anti-infection treatment should be initiated at the beginning of treatment, and if the lymph node biopsy is negative after the lesion is resected, continue anti-infection treatment. If there is still suspicion, re-biopsy, and only if the biopsy is positive, perform lymph node dissection, and at the same time, remove the ipsilateral testis and spermatic cord. The operation should be performed 2-3 weeks after the primary lesion is resected to reduce the occurrence of incisional infection, flap necrosis, and lymph fistula.

　　Radiation and chemotherapy are not sensitive to scrotal inflammatory carcinoma, so the use of radiation and chemotherapy alone, as well as the use of bleomycin and fluorouracil locally, is not effective. However, since the tumor infiltration is deep and the resection is not thorough, adjuvant use before and after surgery can enhance efficacy, reduce recurrence, and control metastasis (Inamura, 1999). There are also reports that the combination of cyclophosphamide, daunorubicin, cisplatin, and methotrexate (aminopterin) chemotherapy plus radiotherapy has achieved certain effects in palliative or concurrent adenocarcinoma in the late stage (Shinura, 1994).

　　2. Prognosis

　　The efficacy of treatment largely depends on whether the dermis is involved. Early lesions are limited to the epidermis and appendages, and if the surgery is thorough, the prognosis is good. If the lesions involve the dermis, even if regional lymph nodes have been invaded, the prognosis is poor, and the postoperative survival time rarely exceeds 5 years.