Three-dimensional evaluation of subclinical extension of extramammary Paget disease: visualization of the histological border and its comparison to the clinical border.

BACKGROUND: In extramammary Paget disease (EMPD), Paget cells are sometimes detected outside the clinical border (subclinical extension). However, the spreading pattern of Paget cells in subclinical extension remains unclear. In addition, the macroscopic appearances of lesions accompanied by subclinical extension are totally unknown. OBJECTIVES: To characterize the spreading pattern of Paget cells as well as the macroscopic appearance of lesions of EMPD with subclinical extension. METHODS: Nineteen patients with primary anogenital EMPD underwent mapping biopsies and excisional surgeries; biopsy samples were then taken at the periphery of well-demarcated lesions. Samples were transparentized and subjected to whole-mount immunostaining with anticytokeratin 7 antibody to label Paget cells. The histological border was evaluated in three dimensions by two-photon microscopy. The shape and location of the histological border were compared with those of the clinical border. RESULTS: In 21 samples taken at the lesion where subclinical extension was not shown by mapping biopsy, the shape and location of the histological border were almost identical to those of the clinical border. However, two samples exhibited small foci of Paget cells outside the clinical border, showing subclinically extended satellite lesions. In the two samples taken at the lesions where subclinical extension was shown by mapping biopsy, a continuous arrangement of Paget cells extending beyond the clinical border was identified. Subclinically extended Paget cells were detected solely outside hypopigmented patches with erythema. CONCLUSIONS: In EMPD, at least two patterns of subclinical extension exist: continuous and satellite lesions. Subclinical extension might exist preferentially outside hypopigmented patches with erythema.

Less invasive technique for EC-IC bypass.

BACKGROUND: We introduce less invasive technique for superficial temporal to middle cerebral artery (STA-MCA) anastomosis, and also described an innovative technique to preoperatively identify the recipient artery using three dimensional CT angiography (3D CTA). Objective. In a period of 28 months between January 2004 and April 2006, 39 EC-IC bypass were performed for hemodynamic compromised patients (including 9 patients with Moyamoya disease) using less invasive technique. METHODS: Operative technique is as follows: 1) A parietal or frontal branch of STA and cortical arteries could be identified on the original images of 3D CTA. The most suitable segment of both the artery provided as donor and recipient arteries for EC-IC bypass. The distance between the afore-mentioned segment of donor artery (STA) and the superior border of the helix were calculated. 2) A 5 cm linear skin incision on the STA, the center of which was the point measured on preoperative 3D CTA, was made. The temporal muscle was divided in the same fashion, and a 3 cm small craniotomy was made. The recipient artery could be identified on the center of the craniotomy. End-to-side anastomosis was performed in the usual way. RESULTS: Operation times were 115-172 min (mean 154 min) and intraoperative blood loss was 20-60 ml (mean 38 ml). All bypasses were patent on the post-operative 3D CTA. CONCLUSIONS: This technique for EC-IC bypass was less invasive and cosmetically excellent. 3D CTA provides useful information for planning of the less invasive EC-IC bypass.