JEADV
LETTER TO THE EDITOR
A case of erythroplasia of Queyrat successfully treated with combination carbon dioxide laser vaporization and surgery Editor Squamous cell carcinoma in situ on the mucosal or transitional surfaces is known as erythroplasia of Queyrat (EQ). It usually occurs on the glans penis and appears as a well-marginated erythematous patch or plaque.1 Removal of the cancer by partial or total penectomy had been regarded as standard therapy, but radical procedures may cause considerable mental distress. Therefore, development of an alternative non-invasive treatment for EQ has been important. Topical 5% imiquimod cream containing an immune-response modifier has been applied, or (a)
methylaminolaevulinic acid photodynamic therapy has been tried; however, both therapeutic effectiveness in EQ are still controversial.2–4 Herein, we report the case of an 87-year-old male with dementia suffering from EQ involving preputial area and glans that underwent combination carbon dioxide laser vaporization and surgery and had a good clinical result. An 87-year-old man, with a history of severe dementia, visited our department for penile redness and slightly bleeding. On physical examination, an asymptomatic, well defined, erythematous, shiny plaque measuring 1.0 9 2.0 cm was observed on the glans penis and extended to the frenulum and the upper part of the penile shaft (Fig. 1a). A skin biopsy specimen revealed atypical keratinocytes with dyskeratosis, hyperchromatism and pleomorphism were seen throughout the epidermis. Intraepidermal dyskeratotic cells were observed as prematurely cornified individual keratinocytes and showed eosinophilic cytoplasm with a
(b)
(c)
(d)
(e)
Figure 1 (a) Clinical presentation; erythroplasia of Queyrat (EQ) of the glans, appearing as a shiny, erythematous and slightly infiltrated plaque. (b) Histopathological findings; biopsy specimen shows acanthosis with dyskeratotic cells. Keratinocytes throughout the epidermis show a partial loss of polarity, increased mitoses and cellular atypia (H&E stain, original magnification; 9200). (c) In the procedure image; combination carbon dioxide laser vaporization at glans and so-called partial phimosiotomy. (d) Histopathological findings; biopsy specimen shows there are no tumour cells remained (H&E stain, original magnification; 9200). (e) Clinical presentation 3 months after the operation; the patient had maintained a good clinical condition without local recurrence.
JEADV 2014
© 2014 European Academy of Dermatology and Venereology
Letter to the editor
2
dense basophilic nucleus (Fig. 1b). Based on these findings, we made the final diagnosis of EQ. He underwent combination carbon dioxide laser vaporization at the glans and so called partial phimosiotomy (Fig. 1c). The laser (Bel Laser; Takarabelmont, Osaka, Japan) was used in the superpulsed waved and 10 watts of potency. We confirmed that tumour cells were not remained by intraoperative rapid diagnosis (Fig. 1d). At 3 months of follow-up, the patient had maintained a good clinical condition without local recurrence (Fig. 1e). In our case, we considered every treatment options including partial and total penectomy, topical application of imiquimod 5% cream, photodynamic therapy and these combinations; however, the patient’s background having dementia in 87-year-old male patient narrowed therapeutic resources. We speculated that he could not have used topical 5% imiquimod application continuously at his home, and he steadfastly refused total or partial penectomy; he strongly hoped that the shape of his glans should be remained. We finally chose the combination carbon dioxide laser vaporization and surgery. Although resurfacing by carbon dioxide laser has been known as good therapeutic option that resulted in an excellent cosmetic and functional status outcome for the glans penis,5,6 the lack of pathological examination with this method may raise a potential dilemma. In this respect, we emphasized that we confirmed tumour cells were negative histologically by intraoperative rapid diagnosis. In determining the extent of surgery, we cut his preputia up to coronal sulcus, and we paid attention not only to incision the glans in terms of preserving the shape but also of avoiding unnecessary bleeding. As a result, the duration of these procedures was only about 20 min, and there were not any major complications and pain complaints.
JEADV 2014
In conclusion, this is the first report of EQ that describes the usefulness and safety of the combined therapy with CO2 laser and surgical excision in the English literature. This combination may be a good treatment option in case that we deal with EQ in the elderly male with or without dementia. Y. Yamaguchi, H. Hata,* K. Imafuku, S. Kitamura, H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan *Correspondence: H. Hata. E-mail: [email protected]
References 1 Graham JH, Helwig EB. Erythroplasia of Queyrat. A clinicopathologic and histochemical study. Cancer 1973; 32: 1396–1414. 2 Micali G, Nasca MR, De Pasquale R. Erythroplasia of Queyrat treated with imiquimod 5% cream. J Am Acad Dermatol 2006; 55: 901–903. 3 Alessi SS, Sanches JA, Oliveira WR, Messina MC, Pimentel ER, Festa Neto C. Treatment of cutaneous tumors with topical 5% imiquimod cream. Clinics 2009; 64: 961–966. 4 Feldmeyer L, Krausz-Enderlin V, T€ ondury B, Hafner J, French LE, Hofbauer GF. Methylaminolaevulinic acid photodynamic therapy in the treatment of erythroplasia of Queyrat. Dermatology 2011; 223: 52–56. 5 Conejo-Mir JS, Mu~ noz MA, Linares M, Rodrıguez L, Serrano A. Carbon dioxide laser treatment of erythroplasia of Queyrat: a revisited treatment to this condition. J Eur Acad Dermatol Venereol 2005; 19: 643–644. 6 Del Losada JP, Ferre A, San Roman B, Vieira V, Fonseca E. Erythroplasia of Queyrat with urethral involvement: treatment with carbon dioxide laser vaporization. Dermatol Surg 2005; 31: 1454–1457. DOI: 10.1111/jdv.12888
© 2014 European Academy of Dermatology and Venereology
LETTER TO THE EDITOR
A case of erythroplasia of Queyrat successfully treated with combination carbon dioxide laser vaporization and surgery Editor Squamous cell carcinoma in situ on the mucosal or transitional surfaces is known as erythroplasia of Queyrat (EQ). It usually occurs on the glans penis and appears as a well-marginated erythematous patch or plaque.1 Removal of the cancer by partial or total penectomy had been regarded as standard therapy, but radical procedures may cause considerable mental distress. Therefore, development of an alternative non-invasive treatment for EQ has been important. Topical 5% imiquimod cream containing an immune-response modifier has been applied, or (a)
methylaminolaevulinic acid photodynamic therapy has been tried; however, both therapeutic effectiveness in EQ are still controversial.2–4 Herein, we report the case of an 87-year-old male with dementia suffering from EQ involving preputial area and glans that underwent combination carbon dioxide laser vaporization and surgery and had a good clinical result. An 87-year-old man, with a history of severe dementia, visited our department for penile redness and slightly bleeding. On physical examination, an asymptomatic, well defined, erythematous, shiny plaque measuring 1.0 9 2.0 cm was observed on the glans penis and extended to the frenulum and the upper part of the penile shaft (Fig. 1a). A skin biopsy specimen revealed atypical keratinocytes with dyskeratosis, hyperchromatism and pleomorphism were seen throughout the epidermis. Intraepidermal dyskeratotic cells were observed as prematurely cornified individual keratinocytes and showed eosinophilic cytoplasm with a
(b)
(c)
(d)
(e)
Figure 1 (a) Clinical presentation; erythroplasia of Queyrat (EQ) of the glans, appearing as a shiny, erythematous and slightly infiltrated plaque. (b) Histopathological findings; biopsy specimen shows acanthosis with dyskeratotic cells. Keratinocytes throughout the epidermis show a partial loss of polarity, increased mitoses and cellular atypia (H&E stain, original magnification; 9200). (c) In the procedure image; combination carbon dioxide laser vaporization at glans and so-called partial phimosiotomy. (d) Histopathological findings; biopsy specimen shows there are no tumour cells remained (H&E stain, original magnification; 9200). (e) Clinical presentation 3 months after the operation; the patient had maintained a good clinical condition without local recurrence.
JEADV 2014
© 2014 European Academy of Dermatology and Venereology
Letter to the editor
2
dense basophilic nucleus (Fig. 1b). Based on these findings, we made the final diagnosis of EQ. He underwent combination carbon dioxide laser vaporization at the glans and so called partial phimosiotomy (Fig. 1c). The laser (Bel Laser; Takarabelmont, Osaka, Japan) was used in the superpulsed waved and 10 watts of potency. We confirmed that tumour cells were not remained by intraoperative rapid diagnosis (Fig. 1d). At 3 months of follow-up, the patient had maintained a good clinical condition without local recurrence (Fig. 1e). In our case, we considered every treatment options including partial and total penectomy, topical application of imiquimod 5% cream, photodynamic therapy and these combinations; however, the patient’s background having dementia in 87-year-old male patient narrowed therapeutic resources. We speculated that he could not have used topical 5% imiquimod application continuously at his home, and he steadfastly refused total or partial penectomy; he strongly hoped that the shape of his glans should be remained. We finally chose the combination carbon dioxide laser vaporization and surgery. Although resurfacing by carbon dioxide laser has been known as good therapeutic option that resulted in an excellent cosmetic and functional status outcome for the glans penis,5,6 the lack of pathological examination with this method may raise a potential dilemma. In this respect, we emphasized that we confirmed tumour cells were negative histologically by intraoperative rapid diagnosis. In determining the extent of surgery, we cut his preputia up to coronal sulcus, and we paid attention not only to incision the glans in terms of preserving the shape but also of avoiding unnecessary bleeding. As a result, the duration of these procedures was only about 20 min, and there were not any major complications and pain complaints.
JEADV 2014
In conclusion, this is the first report of EQ that describes the usefulness and safety of the combined therapy with CO2 laser and surgical excision in the English literature. This combination may be a good treatment option in case that we deal with EQ in the elderly male with or without dementia. Y. Yamaguchi, H. Hata,* K. Imafuku, S. Kitamura, H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan *Correspondence: H. Hata. E-mail: [email protected]
References 1 Graham JH, Helwig EB. Erythroplasia of Queyrat. A clinicopathologic and histochemical study. Cancer 1973; 32: 1396–1414. 2 Micali G, Nasca MR, De Pasquale R. Erythroplasia of Queyrat treated with imiquimod 5% cream. J Am Acad Dermatol 2006; 55: 901–903. 3 Alessi SS, Sanches JA, Oliveira WR, Messina MC, Pimentel ER, Festa Neto C. Treatment of cutaneous tumors with topical 5% imiquimod cream. Clinics 2009; 64: 961–966. 4 Feldmeyer L, Krausz-Enderlin V, T€ ondury B, Hafner J, French LE, Hofbauer GF. Methylaminolaevulinic acid photodynamic therapy in the treatment of erythroplasia of Queyrat. Dermatology 2011; 223: 52–56. 5 Conejo-Mir JS, Mu~ noz MA, Linares M, Rodrıguez L, Serrano A. Carbon dioxide laser treatment of erythroplasia of Queyrat: a revisited treatment to this condition. J Eur Acad Dermatol Venereol 2005; 19: 643–644. 6 Del Losada JP, Ferre A, San Roman B, Vieira V, Fonseca E. Erythroplasia of Queyrat with urethral involvement: treatment with carbon dioxide laser vaporization. Dermatol Surg 2005; 31: 1454–1457. DOI: 10.1111/jdv.12888
© 2014 European Academy of Dermatology and Venereology
