For the patient in the preceding question, biopsy revealed an invasive apocrine gland neoplasm. The deep margins included striated muscle infiltrated by neoplastic cells. Appropriate management includes which of the following?

c. Abdominoperineal resection only

Wide local excision is the treatment of choice in the absence of invasive carcinoma. Because of the high incidence of local recurrence and residual tumor, it is vitally important to obtain an adequate resectional margin. Grossly, the extent of involvement is ill defined, and multiple punch biopsies may be required to determine the extent of involvement. For more advanced lesions with underlying carcinoma, an abdominoperineal resection is indicated. Inguinal lymph node dissection is performed only if groin lymph nodes are clinically positive for metastasis. Because of the commonly delayed diagnosis (average, 4 years), about 25% of patients with perianal Paget’s disease have metastases when they seek treatment. The sites of metastases, in order of frequency, are inguinal and pelvic lymph nodes, liver, bone, lung, brain, bladder, prostate, and adrenal gland. The prognosis is poor once metastasis has occurred.