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The symptoms and histopathological characteristics were similar to those of mammary Paget disease, first described by James Paget in 1874.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The disease is an extremely rare form of intraepithelial adenocarcinoma that may be accompanied by other malignant neoplasms.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We report all cases of EMPD diagnosed during a 5-year period at a tertiary referral hospital.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical and histologic characteristics of patients with EMPD are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. We recorded 10 cases (4 on the vulva, 3 in the perianal region, 2 on the right groin [<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A], and 1 on the gluteal cleft [<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B]) in 4 men and 6 women aged between 50 and 79 years. In all cases there was a diagnostic delay of between 1 and 5 years, and the patients received treatment that was ineffective for fungal infections in 5 cases (50%), chronic inflammatory disease (eczema and lichen simplex) in 5 cases (50%), Bowen disease in 1 case (10%), lichen sclerosus et atrophicus in 1 case (10%), and leukoplakia in 1 case (10%). The diagnosis of EMPD was confirmed in all cases by histopathologic study of the skin biopsy, and treatment was by radical removal of the lesion with wide margins. EMPD was in situ in 6 patients (60%) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A), and dermal invasion was detected in 4 patients (40%) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The disease persisted after surgery in 4 patients (66.7%) with EMPD in situ and in 3 patients (75%) with invasive disease. In addition, recurrence was detected in 1 case of EMPD in situ (16.7%) and in 1 case of invasive EMPD (25%); further surgery was necessary in both cases. A second neoplasm was detected in 4 patients: 2 (33.3%) with EMPD in situ had melanoma in situ (1 patient) and porocarcinoma and basal cell carcinoma (1 patient); 1 patient (25%) with invasive disease had chronic B-cell lymphoproliferative disorder; and 1 patient (25%) had low-grade papillary urothelial carcinoma. Two patients (20%), both with the invasive form, died from metastasized disease, one at 10 months and the other at 2 years. In the remaining 8 patients (80%), no recurrence was observed during a follow-up period ranging from 9 months to 4.5 years.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Hospital Universitario Virgen de las Nieves, Granada, Spain is a tertiary referral hospital serving a population of 439&nbsp;035 people, among whom 10 patients were diagnosed with EMPD from 2009 to 2013. EMPD is a very infrequent neoplasm whose exact incidence is unknown, although it accounts for no more than 6.5% of all Paget diseases and only a few hundred cases have been published in the literature.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> EMPD generally affects whites aged between 50 and 80 years, mainly women at a ratio of 2.4:1, as in our series, although in Asians it usually affects men.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> There are 2 theories on the origin of EMPD. According to the first, EMPD is considered an abnormal differentiation of the epidermal cells of the basal layer (primary EMPD); therefore, Paget disease would be considered an adenocarcinoma that is independent of a second neoplasm. According to the second theory, EMPD is an epidermal metastasis of an underlying carcinoma (secondary EMPD), although solitary lesions would remain unexplained.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a> At least 6 cases of familial EMPD have been identified.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The clinical symptoms are insidious and often minor in the initial stages, with the result that patients do not request medical care until several years have passed, thus delaying diagnosis and treatment for a mean period of 2 years.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,9</span></a> The lesions consist of infiltrated brownish or erythematous plaques that are generally solitary with well-defined borders. They are occasionally edematous and exudative and can cause pruritus, pain, and a burning sensation. They may also be asymptomatic (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The surface is sometimes rough, and there may be erosions, crusts, or lichenification.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The lesions rarely present as infiltrated nodules, vegetating lesions, or locoregional lymphadenopathies.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Unlike mammary Paget disease, EMPD is associated with underlying adnexal carcinoma in 24%-33% of cases and visceral cancer in 12%-15% of cases, including tumors of the gastrointestinal tract and urinary tract, mainly in organs with a contiguous lining and more commonly in the perianal region.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,10</span></a> Associated tumors generally include those affecting the breast, bladder, and cervix, although they can also affect the rectum, colon, prostate, ovaries, urethra, vagina, endometrium, and kidneys.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> We observed an association with skin cancer in 2 cases, one with urothelial involvement and the other with hematologic involvement. The neoplasm is found mainly at sites rich in apocrine glands, such as the external genitalia, the perianal region, the groin, and the axillas,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> although it can also be found anywhere on the skin or mucosae.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The most common site is the vulva (65%), as in the cases we report, although this figure only represents 2% of all primary vulvar tumors.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9</span></a> The second most common site is the perianal region (20%), and the third is the male genitalia (14%).<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9</span></a> Exceptionally, the tumor is found in the axillas or groin, as in 2 of the cases reported here, in which the disease was invasive, probably because the atypical location of the lesion meant that diagnosis was delayed.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9</span></a> Since this neoplasm is rare, there is no established protocol for its diagnosis, treatment, and follow-up, thus making it a challenge in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Diagnosis is based on symptoms and histopathology. Skin biopsy reveals cells with an abundant, pale cytoplasm, large pleomorphic nuclei, and, occasionally prominent nucleoli; the nuclei are sometimes eccentric and resemble signet rings (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The differential diagnosis should include more common diseases such as eczematous lesions, lichen simplex chronicus, lichen sclerosus et atrophicus, lichen planus, inverse psoriasis, candidal intertrigo, erythroplasia of Queyrat, Bowen disease, superficial spreading amelanotic melanoma, and familial benign pemphigus.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a> The treatment of choice is extensive surgical removal, although the disseminated nature and poorly defined margins of this tumor lead to recurrence in 16%-44% of cases<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>; therefore, Mohs micrographic surgery is increasingly used and can reduce the recurrence rate to 8%-28%.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6</span></a> At our center, local persistence after surgery was recorded in 7 cases (70%) and recurrence in 2 (20%). Alternative approaches include carbon dioxide laser treatment, topical imiquimod, cryotherapy, radiotherapy, and photodynamic therapy, although the recurrence rate is very high (50%-60%).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,12,13</span></a> Systemic chemotherapy with 5-fluorouracil, mitomycin C, docetaxel, and etoposide is used in inoperable cases, although few complete responses have been achieved.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5,9</span></a> During the EMPD workup, every attempt should be made to rule out associated neoplasms and identify signs of recurrence, which affects up to 35% of patients with EMPD in situ and 67% of invasive cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Screening for associated neoplasms should include gynecologic and abdominal ultrasound, colonoscopy, and mammography. EMPD remains in situ in more than 65% of cases, as with the patients in the present study, in whom the survival rate was greater than 90% at 5 years and spontaneous regression was occasionally observed after partial surgical removal.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a> Survival decreases dramatically in invasive disease or in the presence of associated tumors, as in the 2 patients who died in the present series. The low incidence of this disease and its nonspecific clinical picture should alert us to the need for high clinical suspicion in order to avoid delays in diagnosis and therapy, which can worsen the prognosis in these patients.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:9 [
        0 => array:3 [
          "identificador" => "xres418521"
          "titulo" => "Abstract"
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              "identificador" => "abst0005"
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        1 => array:2 [
          "identificador" => "xpalclavsec401980"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres418520"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
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        3 => array:2 [
          "identificador" => "xpalclavsec401979"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case Descriptions"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conflicts of Interest"
        ]
        8 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-01-21"
    "fechaAceptado" => "2014-05-22"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec401980"
          "palabras" => array:3 [
            0 => "Extramammary Paget disease"
            1 => "Adenocarcinoma"
            2 => "Rare tumor"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec401979"
          "palabras" => array:3 [
            0 => "Enfermedad de Paget extramamaria"
            1 => "Adenocarcinoma"
            2 => "Tumor raro"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Extramammary Paget disease (EMPD) is a very rare form of intraepithelial adenocarcinoma. We report the cases of EMPD diagnosed in a referral hospital over a 5-year period from 2009 to 2013. Ten cases of EMPD were diagnosed in 4 men and 6 women aged between 50 and 79 years. Erroneous clinical diagnoses led to diagnostic delays of 1 to 5 years in all cases. Six patients had in situ lesions and dermal invasion was observed in the other 4 cases. Four patients had a second neoplasm and 2 of the patients with invasive EMPD died. Because EMPD is rare and its clinical presentation is nonspecific, a high degree of clinical suspicion is required to avoid delays in diagnosis and treatment.</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La enfermedad de Paget extramamaria (EPEM) es una forma extremadamente rara de adenocarcinoma intraepitelial. Presentamos los casos de EPEM diagnosticados en los &uacute;ltimos 5 a&ntilde;os en un hospital de referencia (2009-2013). Se trata de 10 casos, 4 varones y 6 mujeres, con edades comprendidas entre los 50-79 a&ntilde;os. Todos ellos sufrieron un retraso diagn&oacute;stico de uno a 5 a&ntilde;os debido a sospechas diagn&oacute;sticas err&oacute;neas. Seis casos correspondieron a EPEM <span class="elsevierStyleItalic">in situ</span> y en 4 exist&iacute;a invasi&oacute;n d&eacute;rmica. Existi&oacute; una segunda neoplasia en 4 pacientes y 2 con EPEM invasiva fallecieron. La baja incidencia de esta enfermedad y su cl&iacute;nica inespec&iacute;fica nos debe alertar sobre la necesidad de establecer una alta sospecha cl&iacute;nica para evitar retrasos diagn&oacute;sticos y terap&eacute;uticos.</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Blasco-Morente G, Mart&iacute;n-Castro A, Garrido-Colmenero C, Tercedor-S&aacute;nchez J. Enfermedad de Paget extramamaria: 10 casos. Actas Dermosifiliogr. 2015;106:61&#8211;65.</p>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 846
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            "Tamanyo" => 192773
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, Case 1: Erythematous, exudative plaque measuring 10<span class="elsevierStyleHsp" style=""></span>&times;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>cm, with moderate infiltration and well-defined borders on the right groin corresponding to invasive extramammary Paget disease. B, Case 3: Erythematous plaque with a whitish exudate measuring 6<span class="elsevierStyleHsp" style=""></span>&times;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm, moderate infiltration, and well-defined borders in the gluteal cleft corresponding to extramammary Paget disease in situ.</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 625
            "Ancho" => 1703
            "Tamanyo" => 308251
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A, Case 9: infiltration of the epidermis with no involvement of the dermis by cells with abundant, eosinophilic cytoplasm and evident nucleoli (Paget cells) grouped in nests (hematoxylin-eosin, original magnification &times;<span class="elsevierStyleHsp" style=""></span>4). *Occasional formation of small glands (&times;<span class="elsevierStyleHsp" style=""></span>20). B, Case 2: presence of Paget cells in the epidermis and dermis (hematoxylin-eosin, original magnification &times;<span class="elsevierStyleHsp" style=""></span>4). CK immunostaining with low- and high-molecular-weight keratins (AE1 and AE3) showing positivity in the epidermis, follicular epithelium, and (more intense) in Paget cells, with invasion of the reticular dermis by individual cells and small groups of cells (&times;<span class="elsevierStyleHsp" style=""></span>4). CK indicates cytokeratin.</p>"
        ]
      ]
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: CE, chronic eczema; CI, candidal intertrigo.</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="char" valign="top" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right groin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right groin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gluteal cleft&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perianal region and lymphadenopathy in right groin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perianal region&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perianal region&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Physical examination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="10" align="center" valign="top">Moderately infiltrated erythematous plaque with well-defined borders</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exudative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exudative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hyperkeratotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eroded&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Desquamative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exudative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eroded&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eroded&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Desquamative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Course, y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Previous diagnoses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CI, CE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CE, Bowen disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lichen sclerosus et atrophicus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Leukoplakia, lichen simplex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Previous treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical corticosteroids, antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Emollient cream&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical corticosteroids and emollient cream&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Dermal invasion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Definitive treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="6" align="center" valign="top">Radical surgical removal with a 3-cm margin</td><td class="td" title="table-entry  " align="left" valign="top">Radical vulvectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right hemivulvectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radical vulvectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulvar tumor removal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Persistence/recurrence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2/1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3/1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Associated neoplasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low-grade urothelial papillary carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chronic B-cell lymphoproliferative disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Porocarcinoma, basal cell carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Melanoma in situ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Death within 2 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Death within 10 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4.5 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1.5 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4.5 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab655958.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Clinical and Histologic Characteristics of Patients With Extramammary Paget Disease.</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
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E-Case Report
Extramammary Paget Disease: A Report of 10 Cases
Enfermedad de Paget extramamaria: 10 casos
G. Blasco-Morentea,
Autor para correspondencia
gonzaloblascomorente@gmail.com

Corresponding author.
, A. Martín-Castrob, C. Garrido-Colmeneroa, J. Tercedor-Sáncheza
a Unidad de Gestión Clínica, Dermatología Médico Quirúrgica y Venereología, Hospital Universitario Virgen de las Nieves, Granada, Spain
b Anatomía Patológica, Hospital Universitario Virgen de las Nieves, Granada, Spain
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            "entidad" => "Unidad de Gestión Clínica, Dermatología Médico Quirúrgica y Venereología, Hospital Universitario Virgen de las Nieves, Granada, Spain"
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        "titulo" => "Enfermedad de Paget extramamaria: 10 casos"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, Case 1: Erythematous, exudative plaque measuring 10<span class="elsevierStyleHsp" style=""></span>&times;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>cm, with moderate infiltration and well-defined borders on the right groin corresponding to invasive extramammary Paget disease. B, Case 3: Erythematous plaque with a whitish exudate measuring 6<span class="elsevierStyleHsp" style=""></span>&times;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm, moderate infiltration, and well-defined borders in the gluteal cleft corresponding to extramammary Paget disease in situ.</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0020" class="elsevierStylePara elsevierViewall">Extramammary Paget disease (EMPD) was first described by Crocker in 1889 as a localized carcinoma affecting the penis and scrotum in a 60-year-old goldsmith. The symptoms and histopathological characteristics were similar to those of mammary Paget disease, first described by James Paget in 1874.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The disease is an extremely rare form of intraepithelial adenocarcinoma that may be accompanied by other malignant neoplasms.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We report all cases of EMPD diagnosed during a 5-year period at a tertiary referral hospital.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical and histologic characteristics of patients with EMPD are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. We recorded 10 cases (4 on the vulva, 3 in the perianal region, 2 on the right groin [<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A], and 1 on the gluteal cleft [<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B]) in 4 men and 6 women aged between 50 and 79 years. In all cases there was a diagnostic delay of between 1 and 5 years, and the patients received treatment that was ineffective for fungal infections in 5 cases (50%), chronic inflammatory disease (eczema and lichen simplex) in 5 cases (50%), Bowen disease in 1 case (10%), lichen sclerosus et atrophicus in 1 case (10%), and leukoplakia in 1 case (10%). The diagnosis of EMPD was confirmed in all cases by histopathologic study of the skin biopsy, and treatment was by radical removal of the lesion with wide margins. EMPD was in situ in 6 patients (60%) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A), and dermal invasion was detected in 4 patients (40%) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The disease persisted after surgery in 4 patients (66.7%) with EMPD in situ and in 3 patients (75%) with invasive disease. In addition, recurrence was detected in 1 case of EMPD in situ (16.7%) and in 1 case of invasive EMPD (25%); further surgery was necessary in both cases. A second neoplasm was detected in 4 patients: 2 (33.3%) with EMPD in situ had melanoma in situ (1 patient) and porocarcinoma and basal cell carcinoma (1 patient); 1 patient (25%) with invasive disease had chronic B-cell lymphoproliferative disorder; and 1 patient (25%) had low-grade papillary urothelial carcinoma. Two patients (20%), both with the invasive form, died from metastasized disease, one at 10 months and the other at 2 years. In the remaining 8 patients (80%), no recurrence was observed during a follow-up period ranging from 9 months to 4.5 years.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Hospital Universitario Virgen de las Nieves, Granada, Spain is a tertiary referral hospital serving a population of 439&nbsp;035 people, among whom 10 patients were diagnosed with EMPD from 2009 to 2013. EMPD is a very infrequent neoplasm whose exact incidence is unknown, although it accounts for no more than 6.5% of all Paget diseases and only a few hundred cases have been published in the literature.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> EMPD generally affects whites aged between 50 and 80 years, mainly women at a ratio of 2.4:1, as in our series, although in Asians it usually affects men.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> There are 2 theories on the origin of EMPD. According to the first, EMPD is considered an abnormal differentiation of the epidermal cells of the basal layer (primary EMPD); therefore, Paget disease would be considered an adenocarcinoma that is independent of a second neoplasm. According to the second theory, EMPD is an epidermal metastasis of an underlying carcinoma (secondary EMPD), although solitary lesions would remain unexplained.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a> At least 6 cases of familial EMPD have been identified.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The clinical symptoms are insidious and often minor in the initial stages, with the result that patients do not request medical care until several years have passed, thus delaying diagnosis and treatment for a mean period of 2 years.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,9</span></a> The lesions consist of infiltrated brownish or erythematous plaques that are generally solitary with well-defined borders. They are occasionally edematous and exudative and can cause pruritus, pain, and a burning sensation. They may also be asymptomatic (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The surface is sometimes rough, and there may be erosions, crusts, or lichenification.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The lesions rarely present as infiltrated nodules, vegetating lesions, or locoregional lymphadenopathies.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Unlike mammary Paget disease, EMPD is associated with underlying adnexal carcinoma in 24%-33% of cases and visceral cancer in 12%-15% of cases, including tumors of the gastrointestinal tract and urinary tract, mainly in organs with a contiguous lining and more commonly in the perianal region.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,10</span></a> Associated tumors generally include those affecting the breast, bladder, and cervix, although they can also affect the rectum, colon, prostate, ovaries, urethra, vagina, endometrium, and kidneys.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> We observed an association with skin cancer in 2 cases, one with urothelial involvement and the other with hematologic involvement. The neoplasm is found mainly at sites rich in apocrine glands, such as the external genitalia, the perianal region, the groin, and the axillas,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> although it can also be found anywhere on the skin or mucosae.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The most common site is the vulva (65%), as in the cases we report, although this figure only represents 2% of all primary vulvar tumors.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9</span></a> The second most common site is the perianal region (20%), and the third is the male genitalia (14%).<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9</span></a> Exceptionally, the tumor is found in the axillas or groin, as in 2 of the cases reported here, in which the disease was invasive, probably because the atypical location of the lesion meant that diagnosis was delayed.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9</span></a> Since this neoplasm is rare, there is no established protocol for its diagnosis, treatment, and follow-up, thus making it a challenge in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Diagnosis is based on symptoms and histopathology. Skin biopsy reveals cells with an abundant, pale cytoplasm, large pleomorphic nuclei, and, occasionally prominent nucleoli; the nuclei are sometimes eccentric and resemble signet rings (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The differential diagnosis should include more common diseases such as eczematous lesions, lichen simplex chronicus, lichen sclerosus et atrophicus, lichen planus, inverse psoriasis, candidal intertrigo, erythroplasia of Queyrat, Bowen disease, superficial spreading amelanotic melanoma, and familial benign pemphigus.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a> The treatment of choice is extensive surgical removal, although the disseminated nature and poorly defined margins of this tumor lead to recurrence in 16%-44% of cases<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>; therefore, Mohs micrographic surgery is increasingly used and can reduce the recurrence rate to 8%-28%.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6</span></a> At our center, local persistence after surgery was recorded in 7 cases (70%) and recurrence in 2 (20%). Alternative approaches include carbon dioxide laser treatment, topical imiquimod, cryotherapy, radiotherapy, and photodynamic therapy, although the recurrence rate is very high (50%-60%).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,12,13</span></a> Systemic chemotherapy with 5-fluorouracil, mitomycin C, docetaxel, and etoposide is used in inoperable cases, although few complete responses have been achieved.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5,9</span></a> During the EMPD workup, every attempt should be made to rule out associated neoplasms and identify signs of recurrence, which affects up to 35% of patients with EMPD in situ and 67% of invasive cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Screening for associated neoplasms should include gynecologic and abdominal ultrasound, colonoscopy, and mammography. EMPD remains in situ in more than 65% of cases, as with the patients in the present study, in whom the survival rate was greater than 90% at 5 years and spontaneous regression was occasionally observed after partial surgical removal.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a> Survival decreases dramatically in invasive disease or in the presence of associated tumors, as in the 2 patients who died in the present series. The low incidence of this disease and its nonspecific clinical picture should alert us to the need for high clinical suspicion in order to avoid delays in diagnosis and therapy, which can worsen the prognosis in these patients.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>"
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    "fechaRecibido" => "2014-01-21"
    "fechaAceptado" => "2014-05-22"
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            0 => "Extramammary Paget disease"
            1 => "Adenocarcinoma"
            2 => "Rare tumor"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Extramammary Paget disease (EMPD) is a very rare form of intraepithelial adenocarcinoma. We report the cases of EMPD diagnosed in a referral hospital over a 5-year period from 2009 to 2013. Ten cases of EMPD were diagnosed in 4 men and 6 women aged between 50 and 79 years. Erroneous clinical diagnoses led to diagnostic delays of 1 to 5 years in all cases. Six patients had in situ lesions and dermal invasion was observed in the other 4 cases. Four patients had a second neoplasm and 2 of the patients with invasive EMPD died. Because EMPD is rare and its clinical presentation is nonspecific, a high degree of clinical suspicion is required to avoid delays in diagnosis and treatment.</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La enfermedad de Paget extramamaria (EPEM) es una forma extremadamente rara de adenocarcinoma intraepitelial. Presentamos los casos de EPEM diagnosticados en los &uacute;ltimos 5 a&ntilde;os en un hospital de referencia (2009-2013). Se trata de 10 casos, 4 varones y 6 mujeres, con edades comprendidas entre los 50-79 a&ntilde;os. Todos ellos sufrieron un retraso diagn&oacute;stico de uno a 5 a&ntilde;os debido a sospechas diagn&oacute;sticas err&oacute;neas. Seis casos correspondieron a EPEM <span class="elsevierStyleItalic">in situ</span> y en 4 exist&iacute;a invasi&oacute;n d&eacute;rmica. Existi&oacute; una segunda neoplasia en 4 pacientes y 2 con EPEM invasiva fallecieron. La baja incidencia de esta enfermedad y su cl&iacute;nica inespec&iacute;fica nos debe alertar sobre la necesidad de establecer una alta sospecha cl&iacute;nica para evitar retrasos diagn&oacute;sticos y terap&eacute;uticos.</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Blasco-Morente G, Mart&iacute;n-Castro A, Garrido-Colmenero C, Tercedor-S&aacute;nchez J. Enfermedad de Paget extramamaria: 10 casos. Actas Dermosifiliogr. 2015;106:61&#8211;65.</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, Case 1: Erythematous, exudative plaque measuring 10<span class="elsevierStyleHsp" style=""></span>&times;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>cm, with moderate infiltration and well-defined borders on the right groin corresponding to invasive extramammary Paget disease. B, Case 3: Erythematous plaque with a whitish exudate measuring 6<span class="elsevierStyleHsp" style=""></span>&times;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm, moderate infiltration, and well-defined borders in the gluteal cleft corresponding to extramammary Paget disease in situ.</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A, Case 9: infiltration of the epidermis with no involvement of the dermis by cells with abundant, eosinophilic cytoplasm and evident nucleoli (Paget cells) grouped in nests (hematoxylin-eosin, original magnification &times;<span class="elsevierStyleHsp" style=""></span>4). *Occasional formation of small glands (&times;<span class="elsevierStyleHsp" style=""></span>20). B, Case 2: presence of Paget cells in the epidermis and dermis (hematoxylin-eosin, original magnification &times;<span class="elsevierStyleHsp" style=""></span>4). CK immunostaining with low- and high-molecular-weight keratins (AE1 and AE3) showing positivity in the epidermis, follicular epithelium, and (more intense) in Paget cells, with invasion of the reticular dermis by individual cells and small groups of cells (&times;<span class="elsevierStyleHsp" style=""></span>4). CK indicates cytokeratin.</p>"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: CE, chronic eczema; CI, candidal intertrigo.</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right groin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right groin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gluteal cleft&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perianal region and lymphadenopathy in right groin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perianal region&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perianal region&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Physical examination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="10" align="center" valign="top">Moderately infiltrated erythematous plaque with well-defined borders</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exudative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exudative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hyperkeratotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eroded&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Desquamative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exudative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eroded&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eroded&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Desquamative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Course, y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Previous diagnoses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CI, CE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CE, Bowen disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lichen sclerosus et atrophicus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Leukoplakia, lichen simplex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Previous treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical corticosteroids, antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Emollient cream&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical corticosteroids and emollient cream&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Dermal invasion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Definitive treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="6" align="center" valign="top">Radical surgical removal with a 3-cm margin</td><td class="td" title="table-entry  " align="left" valign="top">Radical vulvectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right hemivulvectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Radical vulvectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulvar tumor removal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Persistence/recurrence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2/1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3/1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0/0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Associated neoplasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low-grade urothelial papillary carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chronic B-cell lymphoproliferative disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Porocarcinoma, basal cell carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Melanoma in situ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">Follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Death within 2 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Death within 10 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4.5 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1.5 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4.5 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab655958.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Clinical and Histologic Characteristics of Patients With Extramammary Paget Disease.</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:13 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "H.R. Crocker"
                          ]
                        ]
                      ]
                    ]
                  ]
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                      "Revista" => array:5 [
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                        "volumen" => "40"
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of photodynamic therapy for mammary and extra-mammary Paget&#39;s disease: A state of the science review"
                      "autores" => array:1 [
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                          "etal" => false
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                            0 => "A.A. Nardelli"
                            1 => "T. Stafinski"
                            2 => "D. Menon"
                          ]
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                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Dermatol"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "13"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21676258"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
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              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
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                      "autores" => array:1 [
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                          "etal" => false
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                            0 => "J. Kanitakis"
                          ]
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17447970"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Enfermedad de Paget extramamaria"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J.M. S&aacute;nchez-S&aacute;nchez"
                            1 => "J.&Aacute;. Molinero-Caturla"
                            2 => "J.R. Ferreres-Riera"
                            3 => "E. Masferrer-i-Niub&ograve;"
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                        "tituloSerie" => "Semergen"
                        "fecha" => "2011"
                        "volumen" => "37"
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            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Extramammary Paget&#39;s disease: Treatment, prognostic factors and outcome in 76 patients"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:5 [
                            0 => "N. Hatta"
                            1 => "M. Yamada"
                            2 => "T. Hirano"
                            3 => "A. Fujimoto"
                            4 => "R. Morita"
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2007.08314.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "2008"
                        "volumen" => "158"
                        "paginaInicial" => "313"
                        "paginaFinal" => "318"
                        "link" => array:1 [
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