**Tips and Tricks for Early Diagnosis of Cervico-Vaginal Involvement from Extramammary Paget's Disease of the Vulva: A Referral Center Experience**

**Anna Daniela Iacobone 1,2,\* , Maria Elena Guerrieri <sup>1</sup> , Eleonora Petra Preti <sup>1</sup> , Noemi Spolti <sup>1</sup> , Gianluigi Radici <sup>1</sup> , Giulia Peveri 3,4, Vincenzo Bagnardi <sup>5</sup> , Giulio Tosti <sup>6</sup> , Angelo Maggioni <sup>7</sup> , Fabio Bottari 2,8 , Chiara Scacchi <sup>9</sup> and Mariacristina Ghioni <sup>10</sup>**


**Abstract:** Cervico-vaginal (CV) localization of extra-mammary Paget's disease (EMPD) of the vulva is extremely rare. In order to investigate the incidence risk and the pathognomonic clinical and pathological features of this condition, a retrospective analysis was conducted including 94 women treated for vulvar EMPD at the European Institute of Oncology, Milan, Italy, from October 1997 to May 2020. Overall nine patients developed CV involvement from EMPD, with a cumulative incidence of 2.5% (95% CI: 0.5–8.0%) at 5 years, 6.5% (95% CI: 1.9–15.1%) at 10 years and 14.0% (95% CI: 4.8–27.8%) at 15 years, respectively. All cases except one were firstly detected by abnormal glandular cytology. None reported vaginal bleeding or other suspicious symptoms. The colposcopic findings were heterogeneous and could sometimes be misdiagnosed. Cervical and/or vaginal biopsies were always performed for histopathological diagnosis by identification of Paget cells in the epithelium or stroma. Most patients developed invasive EMPD (5/9) of the cervix and/or vagina and underwent hysterectomy with partial or total colpectomy. CV involvement from EMPD should not be underestimated in women with a long-standing history of vulvar Paget's disease. Liquid-based cytology with immunocytochemistry represents a valuable tool for early diagnosis and should be routinely performed during the required lifelong follow-up.

**Keywords:** vulvar extramammary Paget's disease (EMPD); cervico-vaginal involvement; atypical glandular cytology; colposcopic-guided biopsy; Paget cells
