I am writing a case report for a medical journal. I want you to help me write a conclusion paragraph based on the following information presented below:

ABSTRACT: Extramammary Paget's Disease (EMPD) is an intra-epithelial malignancy that primarily occurs where apocrine sweat glands are located. It is associated with invasive adenocarcinoma components and other secondary cancers such as colon or rectal cancers, which can occur due to the proximity of EMPD to apocrine glands near the genitals. Clinical presentations of EMPD are often demarcated plaques that appear as erosive, ulcerated, or scaly on the vulva, perineal, scrotal, perianal, and penile skin. This case report describes a 75-year-old male patient with a history of basal cell and squamous cell carcinoma, colon cancer, and bladder cancer, who had recurring EMPD near his scrotum. The patient had a wide local excision to treat his first EMPD case, followed by Mohs micrographic surgery (MMS) 10 years later when his second EMPD case developed. Two surgical attempts were made to reduce the growth of EMPD, which responded well to MMS. Since his EMPD mostly resolved, the patient was prescribed Imiquimod Aldara 5% topical cream while monitoring for colon and bladder cancer. Although the patient had a quick recovery after the recent MMS, precautionary steps still need to be taken to minimize or halt the progression of EMPD or other related cancers. The patient's EMPD manifests as a rash that involves the anogenital skin, which may be associated with an underlying gastrointestinal or prostate malignancy. Recurrence of EMPD is common in the first two years, and the prognosis is good if the disease is localized, and there is no other underlying associated cancer. EMPD is better treated with MMS than WLE. Slow MMS should be the golden standard for treating such aggressive conditions as EMPD. The patient is being referred to gastroenterology to rule out occult malignancy.

KEYWORDS: Extra Mammary Paget’s Disease, Mohs Surgery, Wide Local Excision, Case Report, (Redeveloped EMPD?), 

Case Report
INTRODUCTION: Extramammary Paget’s Disease (EMPD) is classified as an intra-epithelial malignancy that occurs most prominently where apocrine sweat glands are located [1]. This dermatological condition is associated with an invasive adenocarcinoma component as well as other secondary cancers, such as colon or rectal cancers due to its proximity to apocrine glands near the genitals [2]. Clinical presentations of EMPD are often found on the vulva, although perineal, scrotal, perianal, and penile skin, and are often demarcated plaques that perceive as erosive, ulcerated, or scaly in presentation [1].
In this case report, we describe a case of recurring EMPD on the left inguinal crease, near the scrotum, resulting in scarred bumps. The patient had a wide local excision (WLE) to treat his first EMPD case. Roughly 10 years later, his second case of EMPD was resolved with Mohs micrographic surgery (MMS). Two surgical attempts were taken to help reduce the growth and treat the patient’s EMPD. Although the patient has had a quick recovery after the recent MMS, precautionary steps still need to be taken to minimize or halt the progression of EMPD or other related cancers.

REPORT OF A CASE: A 75-year-old male patient has had recurring EMPD and extensive history of basal cell and squamous cell carcinoma, colon cancer, and bladder cancer. Since age 32, the patient has had roughly over 90 incisions for treating his various cancers. Upon reviewing the patient's medical history, he is noted to have had bladder cancer and colon polyps 12 years ago. It is noted that the colon is a rare site of origin for distant bladder metastasis. Shortly after his polypectomy, the patient developed EMPD near his scrotum. Though a direct correlation between his metastasis cannot be concluded, there is a high chance that his bladder cancer developed in his first case of EMPD, first noted to be in 2011. Urology, at Mayo Clinic, performed his WLE in his first case of EMPD in addition to performing his polypectomy. From 2011 to 2021, the patient’s EMPD had resolved and he has followed up with regular cytoscopies.
On October 2021, the patient presented to our clinic with a chief complaint of redeveloped EMPD in the same region again around his scrotum (Figure 1). This patient’s EMPD manifests with multiple, evenly-spaced erythematous purpuric papules that involve the anogenital skin. Pathology confirmed the diagnosis of EMPD. The patient’s condition started to metastasize around his scrotum around January 2022. Since this developed pathophysiology was noted, nearly a decade later from his first surgery, the patient was referred to the dermatology department of the Mayo Clinic. 
On February 2022, MMS was performed again at the left inguinal crease covering around his scrotum (Figures 2 and 3). The surgery provided immediate relief to the patient and on May 4th, 2022, Imiquimod Aldara 5% topical cream was prescribed to the groin while monitoring colon and bladder cancer. Upon the advice of the patient's urologist, the patient did not take the Imiquimod due to prostate cancer a month prior.
This type of EMPD may be associated with an underlying gastrointestinal or prostate malignancy. Though his EMPD condition is mostly resolved, he is being referred to gastroenterology to rule out occult malignancy.

DISCUSSION: Recurrence for EMPD is common in the first two years and the prognosis is good if the disease is localized and there is no other underlying associated cancer [3]. It is rare for patients to have invasive and metastatic EMPD and exhibit a poor prognosis, even when there is a good response to a first chemotherapy line [3]. Since this patient had recurring EMPD after a ten-year time frame near his scrotum, he is still potentially at risk for redeveloping the condition in the future, especially considering his vast history of various cancers.
The patient’s first case was surgically removed through a WLE in 2011, which is not the ideal way to treat EMPD; MMS is better for treating patients with EMPD [4,5]. However, the golden standard for treating patients with such an aggressive condition as EMPD should be to perform slow MMS [6]. Additionally, the patient did not have any chemotherapy done for his first case of EMPD because the urology department performed a WLE instead of what the dermatology department would have done, through MMS. Chemotherapy was also not done for his second case of EMPD as well because it was not the golden standard, compared to performing MMS. Imiquimod Aldara 5% topical cream, was given to this patient to manage his EMPD, however, since the patient had prostate cancer surgery right before his subscription, he was advised to not apply Imiquimod to his groin [7].
Since MMS was performed in his second clinical presentation of EMPD in 2022, there is a good chance that the patient’s EMPD is fully resolved. If MMS, specifically slow MMS, was performed instead of Urology performing the WLE, the patient might have not had EMPD recurrence [6]. Furthermore, slow MMS would have been a better treatment regime for the second case instead of normal MMS and could have led to more accurate excisions, leading to better removal of EMPD [8].
Since this patient has had colon and bladder cancer in the past, we want to make sure that any cancers, if developed, are detected early as treatment options may be less invasive in nature if found earlier, especially since this patient has a history of cancers near the anogenital region; therefore, this patient must be monitored not only for EMPD, but also for bladder cancer, colon cancer, and basal & squamous cell carcinoma [9]. Patients like this should be planning to get a cystoscopy to check for bladder cancer and a colonoscopy for their ruling out gastrointestinal-related cancers and check roughly every three months, even if their EMPD condition is resolved [1,9].

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