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Relevance. Until now, disputes among scientists about its etiology, pathogenesis, nomenclature and risk factors for the development of vulvar lichen sclerosis have not subsided, which actualizes the need for scientific research aimed at solving these problems. The aim of the study - to establish statistically significant clinical and anamnestic risk factors for vulvar lichen sclerosis. Materials and Methods. An electronic database was formed with data from 344 patients with lichen sclerosus of the vulva and 60 women without vulvar diseases aged 20-70 years on hereditary, obstetric-­gynecological, somatic and infectious history. Astatistical comparative correlation analysis of the obtained data was carried out using the Spearman correlation coefficient (R0.15), nonparametric Mann - Whitney U test and Student t test (p0.05), Chi-square tests, Phi and Cramer statistics. Results and Discussion. Statistically significant (p0.05) risk factors for the development of vulvar lichen sclerosus (R, in descending order) were established: the presence of fibrocystic mastopathy (-0.29); late menarche (15 years and older) (-0.28); onset of menopause (-0.25); recurrent vulvo-­vaginal infections (-0.18); recurrent bacterial vaginosis (-0.18); autoimmune thyroiditis(-0.16) and stage II obesity (-0.16). Also, the average number of abortions and births (1.23 and 1.49, respectively) in the group of patients with lichen sclerosis of the vulva is statistically significantly greater (p0.05) than the average value (0.27 and 1.13, respectively) in control group. Conclusion. The data obtained on the impact of obesity and autoimmune thyroiditis on the risk of developing vulvar sclerotic lichen are consistent with the results of global studies and confirm the association of the disease with autoimmune and metabolic disorders. Recurrent vulvo-­vaginal infections and dysbiotic processes in the vagina can be both acause and aconsequence of vulvar lichen. The relationship between fibrocystic mastopathy and vulvar lichen sclerosus remains debatable and requires further research. Late menarche, the onset of menopause, alarge number of abortions and childbirth can also be considered triggers for vulvar lichen sclerosus in patients with agenetic predisposition to the disease.

Background. Today, no unified clinical classification of vulvar lichen sclerosus is registered (is yet to be registered?). Isolation of pathogenetically and clinically different variants of its course enable new approaches to the treatment to be developed. Objective. To develop a pathogenetic therapy for the sclerosing variant of vulvar lichen sclerosus, taking into account its clinical and immunological characteristics. Methods. A prospective cohort study was conducted from 2018 to 2022 on the basis of Regional Clinical Hospital No. 2, Krasonodar, Russia. 292 patients aged 20 to 70 years were histologically diagnosed with vulvar lichen sclerosus. After a clinical examination using the scale for assessing subjective and objective clinical signs of vulvar lichen sclerosus, 154 patients with a sclerosing variant of the disease course were selected for the study. The control cohort consisted of 30 women of the same age category without vulvar lichen sclerosus, taking into account the exclusion criteria. The study involved a clinical assessment (in points) of objective and subjective criteria characteristic of this variant of vulvar lichen sclerosus, as well as an assessment of the level of cytokines (interleukin-20; interleukin-23; interleukin-10; tumor necrosis factor α, interferon γ) in peripheral blood of the patients from the main and control groups. One month after the immunotherapy with sodium deoxyribonucleate, the authors evaluated its clinical efficacy (using Numerical rating scale for pain (vulvodynia) and Vulvar pruritus severity scale) and immunological efficacy (repeated assessment of the level of the studied cytokines). Analysis and statistical processing of the obtained data were performed using Graph Pad Prism version 6.0 (GraphPad Software, Inc., San Diego, CA). Results. Depigmentation of the vulvar skin against the background of vulvar sclerosis and thickening features a sclerosing variant of vulvar lichen sclerosus compared to vulvar atrophy. Stenosis of the vaginal vestibule is either absent (51.3%) or predominantly corresponds to grade I, and is less specific than depigmentation and even skin atrophy. The subjective signs include a severe vulvar pruritus without or with moderately expressed (in 68.1%) vulvodynia. An immunological study showed a statistically significant increase in the level of interleukin-20 (p < 0.0001), interleukin-23 (p < 0.0001), interferon-γ (p < 0.03), tumor necrosis factor α (p < 0.009) in patients with maximal tissue sclerosis with respect to the control group, along with a statistically significant decrease in the level of anti-inflammatory interleukin-10 (p < 0.01). The immunological efficacy of sodium deoxyribonucleate was confirmed by a statistically significant (compared to baseline) decrease in interleukin-20 (p < 0.0001), interferon-γ and tumor necrosis factor α (p < 0.002), interleukin-23 (p < 0.012) without statistical differences with the control group (except for interleukin-23, the level of which decreased after therapy but remained statistically higher (p < 0.01) than in the control group). Clinical efficacy of immunotherapy was confirmed by a statistically significant (p < 0.001) reduction in vulvodynia and vulvar pruritus after the treatment. Conclusion. The obtained data demonstrate characteristic clinical features and immunological differences in relation to the norm in women with the sclerosing variant of vulvar lichen sclerosus, thereby justifying the use of sodium deoxyribonucleate in this variant with confirmed clinical and immunological efficacy.

Background. In recent years, there has been an increase in the incidence of vulvar precancer (lichen sclerosus), as well as vulvar cancer. Since this disorder is rare, treatment planning and therapy itself are often suboptimal, which results in a high recurrence rate. Treatment of patients with local recurrence is even more difficult. Improper therapy often leads to fatal outcomes.Aim. To develop an innovative therapeutic approach to local recurrent vulvar cancer that includes combination (intraarterial and systemic) chemotherapy and surgery.Materials and methods. This pilot study included two patients with a second episode of local recurrent vulvar cancer. The first patient was denied special treatment, whereas the second one was offered abdominoperineal resection of the rectum. At the first stage, the patients received combination chemotherapy; at the second stage, they had combination reconstructive surgeries.Results. Combination chemotherapy was highly effective as demonstrated by the reduction of the recurrent tumor to a resectable size. Combination and reconstructive surgeries allowed us to preform radical treatment and preserve functions of the adjacent organs.Conclusion. Combination treatment was highly effective in patients with local recurrent vulvar cancer, when the tumor was located near the urethra, vagina, and anus or invaded them. Combination chemotherapy ensured good tumor regression, while surgery gave hopes for a favorable outcome.

Background. Lichen planus (LP) is a chronic dermatosis, which can affect vulva. Currently, there are no sufficient data about clinical picture of vulvar LP and a valuation combined lesion on the vulva, oral mucous and smooth skin in patients with different forms of LP. Aims. Is to study the features of the vulvar LP clinical picture. Materials and methods. A cross-sectional (simultaneous) uncontrolled study of 46 patients with vulvar LP was performed. We assessed the structure of vulvar LP, the duration and the manifestation of disease, localization of lesions, the involvement of the skin and oral mucosa. LichenSclerosus-Square was used to assess the area of lesions in vulvar LP. Results. The erosive form dominated in the structure of vulvar LP morbidity, which was diagnosed in 73,9% of cases. The process in erosive and hypertrophic form of LP was more common than in the typical form of LP. Distinctive features of the erosive form of the disease were the involvement of the inner surfaces of the labia minora and the vestibule (73,5% и 70,6%, p 0,001). The erosive LP is also characterized by a damage of normal vulvar architectonics (58,8%, p = 0,007). Lesions in typical LP affected labia majora (66,7%) and labia minora (33,4%), and to a lesser extent the commissure posterior (16,7%). The involvement of labia majora was found in all patients with hypertrophic form LP. The involvement of inguinal folds distinguished the hypertrophic form from other forms of LP and was observed in 33,4% of patients. Vulva lesions without the involvement of the skin and mucous membranes of other localizations were more typical for patients with erosive and hypertrophic LP (35,4% и 33,3%). Almost half of the patients (47,0%) with erosive LP had the involvement of mucous membranes, 29,0% of them were diagnosed with vulvovaginal-gingival syndrome. In 14.7% of cases, vulvovaginal-gingival syndrome combined with lesions in the scalp (vulvovaginal-gingival-pillar syndrome). Conclusions. We have identified clinical features of different forms of vulvar LP, which can be used for differential diagnosis.

Objectives. Hematoma of the vulva – extravasation of blood into the soft tissues of the external genitalia without lysis of the skin tissue. As a rule, nonobstetric hematomas of the vulva are associated with genital trauma and are very rarely presented in the specialized literature. Case presentation. Until now, there is a lack of consensus and clinical recommendations in the specialized literature regarding the treatment of traumatic hematoma of the vulva, and the treatment tactic is based on the case-by-case principle. Taking into account the rarity of traumatic hematoma of the vulva, we present our own clinical case. Patient S.I., 17 years old, came to the inpatient department of the IMSP Mother and Child Institute with vulva trauma that occurred after falling on a hard object. Upon admission, she complained of violent, expanding pain in the region of the labia majora on the right, the presence of a tumor formation in the region of the external genitalia that presented difficulties in movement. In the region of the labia majora on the right, a 10x6 cm hematoma is determined, cyanotic in color, suddenly painful on palpation with transposition to the left, which completely closes the entrance to the vagina, clitoris and urethra. Over 40 min. from admission under general anesthesia with spontaneous breathing, with a longitudinal incision along the right labia majora from its inner side, ≈ 50 ml of clotted blood was drained. For the purpose of hemostasis, three vicryl sutures were applied. She was discharged in satisfactory condition on the fourth postoperative day. Conclusions. Traumatic hematomas of the vulva present a rather rare phenomenon and are presented sporadically in the specialized literature. In the case of large and expanding hematomas of the vulva, surgical treatment is the method of choice. The surgical intervention involves the opening and evacuation of the hematoma of the vulva, the achievement of definitive hemostasis in the remaining cavity and adequate drainage.

Extramammary Paget's disease (EMPD) is a rare variant of adenocarcinoma, the most common localization of which is a vulva. Clinical manifestations are nonspecific and can be initially diagnosed as manifestations of other dermatoses, which makes early diagnosis difficult. The most effective diagnostic method is a pathomorphological and immunohistochemical examination of the skin biopsy. We present a clinical case of EMPD in a 42-year-old HIV-infected female patient.

Sclerosing lichen (SL) of the external genitalia is a chronic slowly progressive disease with pronounced focal atrophy of the skin of the perineum and visible mucous membranes of the vulva and has two main peaks of clinical manifestations: childhood and perimenopausal age. It is associated with an increased risk of developing vulvar cancer, even though it is not a malignancy in itself. The true precursor of SL-associated cancer is intraepithelial vulvar neoplasia (VIN). The diagnosis is usually clinical, but in some cases a biopsy may be performed, especially to rule out VIN or cancer. In this study, 180 patients with SL vulva were examined on the basis of two clinical bases (National Cancer Institute, MC "Verum"). After examining the patients, the diagnosis was made on the basis of examination, complaints, advanced biochemical blood test, detailed blood test, hormonal examination and ultrasound. In most cases, the diagnosis of SL vulva is clinical. As a result of a number of examinations of patients of reproductive age in patients with SL vulva, it was found that SL vulva is a consequence of thyroid disease (82.2%) of different types compared with patients in the control group (32.7%). The diagnosis of SL vulva was established in young patients mainly with AIT (48.6%) and with AIT accompanied by hypothyroidism or nodular thyroid disease (27%). When comparing the diagnostic findings of thyroid disease in patients with SL vulva and the control group, no significant differences were found. Therefore, timely detection of latent forms of AIT, hypothyroidism, nodular goiter, adequate treatment of thyroid dysfunction will allow to normalize changes in the reproductive system and prevent the formation of pathological lesions of the reproductive organs of women.

Research objective: to determine the characteristics of nutritional status (NS) in women of reproductive age with typical clinical signs of lichen sclerosus of the vulva (LSV) using key NS parameters. Materials and methods. The study included 75 women with average age 31.3 ± 1.3 years. 50 women were diagnosed with LSV and NS disorders (main group), and 25 women were practically healthy (control group). Information about all patients was collected through direct interviews, clinical examination and study of medical records. The presence of anogenital pruritus, soreness or burning, dryness, dyspareunia, urinary disturbances, perianal and/or intestinal symptoms, inflammatory bowel disease, thyroid dysfunction and tenderness, and other comorbidities were recorded. NS evaluated using anthropometric, laboratory and clinical studies. Body mass index, index of nutritional risk (nutritional deficiency), vitamins, micro- and macroelements value, scatological parameters were determined in all patients, and the intestinal microflora was examined. Results. The results of the study showed a disorder of NS in most patients with LSV by all studied parameters in comparison with the control group. Thus, it was found that 60% of patients with LSV had abnormal body mass index as well as NS was observed in 72% of patients. In addition, patients with LSV also had a higher deficiency of vitamins D and B12, and some important micro- and macronutrients. The results of the coprological study showed the neutral fats in feces, unchanged muscle fibers, extracellular and intracellular starch, decreased levels of bifidobacteria and lactobacilli in 68–74% of patients and opportunistic bacteria and fungi in 30–46% of women in the main group. Conclusions. Thus, the results of this study indicate the association between the abnormal NS and LSV. However, further research is needed to assess the course of the underlying disease and to analyze the metabolic pathways that lead to disorders of lipid, carbohydrate and protein metabolism in target patients, to select of the correct nutrients and alternative treatments.

Extramammary Paget’s disease (EMPD) is a rather rare variant of adenocarcinoma, most often localized in the anogenital area or perineum. The aim of our study was to determine the prognostic significance of histological variants of primary EMPD in relation to the risk of tumor recurrence. Material and methods. 202 samples of primary EMPD were taken from 158 patients. Sections stained with hematoxylin and eosin were examined. Results and discussion. 23 patients (14.6 %) had recurrent EMPD. The study revealed that «glandular», «pigmented», «signet ring», «acantholytic» morphological variants of EMPD, as well as syringocystadenocarcinoma papilliferum in situ–like changes and the presence in the dermis of structures similar to eccrine syringoma, are associated with the development of disease recurrence. Conclusion. The «signet-ring» and «pigment» morphological variants of EMPD have the highest predictor value in relation to the risk of disease recurrence. The «signet ring-cell» variant of primary EMPD is the only one that influences the time of the first recurrence of the disease.

Aim: to evaluate the quality of life parameters dynamics in patients with vulvar cancer I and II stages during postoperative rehabilitation.Materials and Methods. A prospective comparative randomized study included 47 women with vulvar cancer I–II stages, aged 38 to 70 years, with an average age of 56.3 ± 3.9 years. Patients were randomized into 2 groups: 24 of them underwent postoperative rehabilitation and 23 were included in the comparison group. Quality of life and sexual function, as well as psycho-emotional state were assessed using a set of questionnaires: quality of life of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, Functional Assessment of Cancer Therapy-General (FACT-G) with an extension for vulvar cancer, Female Sexuality Index (FSFI) and WAM (well-being, activity, mood).Results. Patient who receiving postoperative rehabilitation even during the first three months, a reliable positive dynamics of all parameters of FSFI and EORTC, except cognitive function, was noted. At the same time, in the patients not undergoing postoperative rehabilitation program there was no reliable difference in the results of the questionnaires, except for FSFI, but the severity of changes was significantly less than in the patients of the research group. Dynamics in the EORTC parameters in women in postoperative rehabilitation averaged 14.8 points with 7.8 points in the comparison group. In the FACT-G questionnaire, the dynamics were even more pronounced with 19.9 and 6.8 points respectively. There was a reliable positive trend in improving the quality of sexual life and a decrease in the percentage of women suffer from pain and discomfort during sexual intercourse: from 25,0 % (n = 6) to 4,2 % (n = 1) in the study group and from 21,7 % (n = 5) to 13,0 % (n = 3) in the comparison group. Improvement in sexual desire and satisfaction during the year was noted in 5 (20.8 %) women in the study group and only 2 (8.7 %) in the comparison group.Conclusion. The developed program of postoperative rehabilitation of patients with vulvar cancer, which includes individual and group psychotherapy, "anti-cancer diet therapy", dosed physical activity, dynamic correction of vaginal biocoenosis showed high efficiency already during the first 6 months. All patients with vulvar cancer in the postoperative period should receive active rehabilitation aimed at correction of psycho-emotional state and sexual function, which will improve the quality of life and improve further prognosis.

The prospective randomized study involved 60 patients with chronic dystrophic diseases of the vulva. The clinical efficacy of cycloferon in the complex treatment of the patients and its on the psychological and functional state and the dynamics of the life quality were investigation.

Background. Lichen sclerosus (LS) is a common genital dermatosis with a malignant potential. Immunohistochemical predictors of malignancy in vulva and to a lesser extent in penile LS have been fairly well studied, but no gender comparison has been performed. The aim was to establish possible gender IHC differences in genital LS using р53, Ki-67, p16 and CK17 proteins. Material and methods. Biopsy and surgical material of penis (n=40) and vulva (n=57) with a morphological diagnosis of LS was examined. A comparative analysis of gender LS IHC characteristics was performed. Results. For the frst time it was found out that LS does not have any signifcant gender IHC differences and is often associated with p53 overexpression (labeling index >70), low Ki-67, and negative p16 and CK17 patterns. Conclusions. It is likely that the skin and the mucous membranes of penis and vulva in LS may undergo so-called «ischemic stress» of the similar degree, reflecting an increase of wild-type p53.

Our work was aimed for studying the role of systemic of IL-23 and IL-20 levels in different clinical variants of sclerotic lichen in women. The study was based on results of clinical data (anamnesis, examination, palpation, vulvoscopy) and immunological studies (determination of IL-20 and IL-23 cytokines in peripheral blood) in the patients with sclerotic lichen (114 patients aged 42.5±15.1 years). Group I included patients with atrophic variant of sclerotic lichen (n = 58); group II, with sclerotic variant of sclerotic lichen (n = 34). Group III included women with a sclero-atrophic variant of this disorder (n = 22). The control group consisted of conditionally healthy women without present, or previously documented vulvar pathology (30 persons). Criteria for inclusion were as follows: women 20 to 60 years old, the presence of a benign vulvar disease, absence of treatment with immunotropic drugs over past year. Exclusion criteria: presence of viral infection (HPV, HSV), detection of STI, presence of acute inflammatory process (including vulvitis and vaginitis), cancer diagnosis, symptoms of autoimmune disorders, pregnancy, and the patient’s reluctance to participate in the study.Predominant increase of IL-23 was revealed in all clinical groups of the examined patients, the most pronounced increase (2.7 times) was in severe sclerotic lichen (p < 0.0001). IL-23 concentration in the 2nd clinical group corresponded to the reference age-matched values. There was a significant increase in the blood content of IL-20 in subgroup 2.2 of the patients with sclerotic lichen (p < 0.0001), as well as in patients from group 3 with a mixed clinical course of its disorder (p < 0.0001). Meanwhile, the absence of pronounced vulvar tissue sclerosis in sclerotic variant of sclerotic lichen (subgroup 2.1) was accompanied only by a tendency for increased IL-20 concentration (p = 0.502), and only a trend for decrease in atrophic variant of sclerotic lichen (p = 0.288). In general, analysis of these data presumes a significant role of IL-20 and IL-23 in pathogenesis of sclerotic lichen in women. The cytokine assays in various clinical variants of this vulvar disorder may provide additional differential diagnostics (IL-20), and to assess severity of atrophic and sclerotic changes in vulvar tissues (IL-23) in women with sclerotic lichen.

The article covers different aspects of clinical manifestations, diagnosis, and treatment of vulvar, vaginal, and cervical sarcomas.

The article covers various aspects of clinical manifestations, diagnosis, and treatment of vulvar, vaginal, and cervical melanomas.

Human papillomavirus infection (HPV) is one of the most common infections today. Young women have a high risk of infection with HPV. The contagiosity of the virus reaches 80%. HPV is a cause of cervical cancer. Genital warts is one of the most common clinical manifestations of HPV, the incidence is 120–150 per 100,000 population. The aim of the study was to assess the degree of incidence of vulvar and vaginal warts, according to the official statistical forms and clinical practice. The statistical forms do not give an accurate account of the incidence of HPV due to the characteristics of reporting. According to clinical observation, signs of HPV were detected in 23,3% of female students, who underwent periodic medical examinations, and in 10,1% of patients, who addressed complaints to the gynecologist. Inosine pranobex is the most studied systemic immunomodulator used to eliminate HPV. The non-intervention open-site single-center study showed that the effectiveness of monotherapy acounted for 66,9%, which categorized inosine pranobex as a first-line drug.

Purpose: The aim of the study was to evaluate the efficacy of Cicatridina® application in healing and repairing process after operative procedures concerning uterine cervix, vagina and vulva and after brachytherapy due to cervical and endometrial cancer. We also analyzed Cicatridina® effect on vaginal athrophical signs in post-menopausal women. Patients and Methods: The examined group consist of 319 women. They were divided into 2 arms. The active arm concerns 213 women who used Cicatridina®, while controlled one consists of 106 women. The effect of treatment was estimated after 6 weeks and 3 months by the visual inspection of the cervix and vagina. We also analyzed the subjective filling of patients bound to sexual intercouses by using of Visual Analogue Scale (0% – no effect; 100% – disappearance of pathological symptoms). Results: In active arm according to control one the reparation of cervix was more often: after surgery procedures (respectively after 6 weeks 93% vs 70%; after 3 months 99% vs 89%) and after brachytherapy (respectively after 3 months 86% vs 0%). In brachytherapy group the lack of discomfort during sexual intercourses was also more often in active arm (respectively 55% vs 0%). In postmenopausal women reduction of symptoms associated with atrophic vaginitis was observed only in active group (respectively after 6 weeks 43% vs 0%; after 3 months 57% vs 0%). In the group of patients after ephisiotomy due to delivery the relief of discomfort during sexual intercourses was also more often in active arm (respectively 94% vs 25%). Conclusion: Cicatridina® causes fast healing of cervix after gynecological procedures. It influences improvement of atrophical, inflammatory and after radiation therapy effects which improve quality of life and comfort of vagina after brachytherapy due to cervical and endometrial cancer. Cicatridina® causes similar effect in vagina of pos-menopausal women as locally used estrogens. Cicatridina® also causes the feeling of relief and comfort in vagina after delivery as well as fast healing after episiotomy.

The structure and trend of incidence, geographical prevalence, the comparative analysis and morphology of cancer of uterus, ovaries, vaginas and vulvas among inhabitants of Kabardino-Balkaria during 1990–2014 are presented. Rates of a gain of these new growths considerably exceed the all-Russian indicators especially concerning an endometrium carcinoma, but “rejuvenation” of diseases in Kabardino-Balkaria is not observed. Carcinomas of a body and a neck of a uterus meet among inhabitants of mountainous areas of the region than flat more often. Cancer tumors of endometrium and ovaries affect city dwellers, unlike a uterus neck more. The received results allow revealing actively patients at early stages of diseases, to hold medical examination and preventive events more effectively, to plan rational tactics of treatment of patients.

Today the most prominent results of lichen sclerosis treatment has been accumulated by laser application, as it is this type of surgical energy that has been widely used to treat vulvae pathology. However, high recurrent rate, wide areas of vulvae deformities and even high ineffectiveness trigger the necessity to seek new approaches to treatment methods with the use of alternative kinds of surgical energies. Radio-wave technology is by right the leading method in uterine cervix pathology treatment. It possesses a lot of advantages if compared to laser treatment. Since 2013 our clinic has used radiowave device «Surgitron» to treat lichen sclerosis.

We report a 69-year-old female patient with primary non-invasive isolated extra-mammary Pagetʼs disease of the vulva. EBRT resultedin full resorption of the lesion without auxiliary techniques, making EBRT to be considered as an alternative to surgery in some cases.

We report a 33-year-old female patient with primary isolated malignant vulvar Langerhans cell histiocytosis (LCH). The effectiveness of hemivulvectomy with adjuvant EBRT and chemotherapy is presented. Adequate tissue excision followed by histological study with immunohistochemistry was of critical importance for the diagnosis in our case. Unified management recommendations with multidisciplinary approach are required.

Urethral diverticulum is one of the rarest female urological diseases, which is characterized by various manifestations, ranging from an asymptomatic to severe urinary disorders, pain and dyspareunia. The aim of this work is to present a clinical observation of female urethral diverticulum with a description and discussion of its etiology, diagnosis, and treatment. Clinical observation is dedicated to 40-year-old woman with complaints of pain in the urethral area. The patient underwent ureteral stenting followed by a diverticulectomy. Vaginal diverticulectomy is the gold standard for treatment. The specialist performing such interventions should be aware for possible intraoperative complications. It seems appropriate to perform the surgical treatment of female urethral diverticulum in specialized centers with an experience in female urethral reconstruction.

Mammary-like glands are a normal anatomical component of the anogenital region and can give rise to many benign and malignant tumors that morphologically mimic the similar diseases of the breast. The literature review is complemented by a description of 199 cases of malignant tumors of mammary-like glands. The paper presents the clinical and morphological characteristics of various malignant tumors of mammary-like glands, including extramammary Paget's disease, ductal, tubulolobular, adenoid cystic adenocarcinoma, low-grade phyllodes tumor, etc.