Difference between revisions of "Vulva"
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*[http://www.flickr.com/photos/euthman/2658773592/ VIN III (flickr.com)]. | *[http://www.flickr.com/photos/euthman/2658773592/ VIN III (flickr.com)]. | ||
*[http://commons.wikimedia.org/wiki/File:Vulvar_intraepithelial_neoplasia3_2.jpg VIN III (WC)]. | *[http://commons.wikimedia.org/wiki/File:Vulvar_intraepithelial_neoplasia3_2.jpg VIN III (WC)]. | ||
*[http://www.brown.edu/Courses/Digital_Path/systemic_path/female/warty_VIN.html VIN (brown.edu)]. | |||
==Differentiated vulvar intraepithelial neoplasia== | ==Differentiated vulvar intraepithelial neoplasia== | ||
Revision as of 23:16, 10 March 2012
This article addresses the basics of vulva, from a pathologic perspective.
Malignant neoplasms overview
Most common malignancies
Most common malignancies of vulva:[1]
- Invasive squamous cell carcinoma.
- Malignant melanoma.
Vulvar squamous cell carcinoma
Main article: Squamous cell carcinoma
Like SCC elsewhere.
- Microinvasion: <=1 mm stromal invasion, tumour size <=2 cm (T1a).[2]
- Depth from DE junction.
Note:
- Tumour thickness != depth of invasion.
Precursor lesions for SCC
- Vulvar intraepithelial neoplasia (VIN).
VIN can be divided into:
- Classic VIN, and
- Differentiated VIN.
- Differentiated VIN is mostly irrelevant as it is basically never seen alone, i.e. it usually accompanies cancer.
Low grade pre-cancerous lesions (VIN) are typically HPV positive, while high grade pre-cancerous lesions and cancer are less often HPV positive.[3]
Classic vulvar intraepithelial neoplasia
Epidemiology
- Classic VIN, like CIN, is associated with HPV and seen in younger women.
General
- Classic VIN is graded like cervical pre-cancerous lesions:
- VIN I.
- Not common.
- VIN II.
- Not common.
- VIN III.
- Commonly seen.
- VIN I.
DDx:
- Condyloma (genital wart).
- Most caused by HPV.
Microscopic
Features:
- Increased NC ratio.
- Multinucleation.
- Lack of maturation to surface (not very useful -- unlike in the cervix).[4]
- Apical mitoses.
Images:
Differentiated vulvar intraepithelial neoplasia
Epidemiology
- Associated with lichen sclerosus.
- NOT associated with HPV and seen in older women.
Microscopic
Features:
- NOT graded like classic VIN.
- Acanthosis (thickening of stratum spinosum) + elongation of rete ridges.
IHC for VIN
- Classic VIN: p16+, p53-.
- Differentiated VIN: p16-, p53+.
ASIDE: p16 can be thought of as a poor man's HPV test.
Neoplasms (non-malignant)
A short DDx:[5]
Hidradenoma papilliferum
General
- Dermal thingy; hidradenoma = tumour of sweat duct epithelium.[7]
- Looks like intraductal papilloma of the breast.[8]
Microscopic
Features:
- Cystic spaces.
- Epithelium with apocrine differentiation (as demonstrated by apocrine snouts).
- Well-circumscribed.
Images:
- WC:
- www:
Notes:
- No attachment to epidermis.
- No nuclear changes suggestive of malignancy.
Other
This is grab bag of non-neoplastic stuffs.
Condyloma acuminatum
- AKA genital wart.
General
- Due to HPV.
Note:
- Related to verruca vulgaris (common wart).
Microscopic
Features:
- Koilocytes.[9]
- Cells with an enlarged nucleus and perinuclear clearing.
- Papillomatosis.[10]
- Papillomatosis = surface elevation due to dermal papillae enlargement.[11]
- +/-Parakeratosis.
Images:
- Condyloma acuminatum - low mag. (WC).
- Condyloma acuminatum - very high mag. (WC).
- Condyloma acuminatum - 2 (WC).
- Condyloma acuminatum - 3 (WC).
Lichen sclerosus
- AKA chronic atrophic vulvitis - vulvar lesion.
- AKA balanitis xerotica obliterans (BXO) - penile lesion.[12]
General
- Associated with differentiated vulvar intraepithelial neoplasia - important.
- Approximately 50% of vulvar cancer associated with lichen sclerosus.
Clinical:
- Pruritis -> leads to scratching.
- Chronic condition.
- Usu. post-menopausal women.
- May lead to labial fusion.
Treatment:
- Steroids - high dose initially, then a maintenance therapy to prevent relapse.
Notes:
- Mixed vulvar dystrophy = lichen sclerosus + squamous cell hyperplasia.[13]
Microscopic
Features:[14]
- Loss of rete ridges.
- Severe hyperkeratosis.
- Hyperkeratosis = stratum corneum thickened.
- Fibrosis of dermis with loss of adnexal structures - key feature.
- May appear pale - directly deep to the epidermis.[15]
- Inflammation - often with eosinophils.
DDx:
- Morphea profunda - deep fibrosis.
Images:
- WC:
- www:
Bartholin cyst
General
- Common.
- May become infected.
Treatment:
- Drainage.
- Marsupialization.
Microscopic
Features:
- Cyst with squamous or urothelial epithelium.[16]
Images:
See also
- Gynecologic pathology.
- Uterus.
- Cervix - cervical intraepithelial neoplasia (CIN).
- Vagina.
- Anus - anal intraepithelial neoplasia.
References
- ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 459. ISBN 978-0781765275.
- ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Vulva_11protocol.pdf. Accessed on: 9 March 2012.
- ↑ De Vuyst H, Clifford GM, Nascimento MC, Madeleine MM, Franceschi S (April 2009). "Prevalence and type distribution of human papillomavirus in carcinoma and intraepithelial neoplasia of the vulva, vagina and anus: a meta-analysis". Int. J. Cancer 124 (7): 1626–36. doi:10.1002/ijc.24116. PMID 19115209.
- ↑ LAE. February 2009.
- ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 456. ISBN 978-0781765275. }}
- ↑ Hidradenoma papilliferum. Stedman's Medical Dictionary. 27th Ed.
- ↑ URL: http://medical-dictionary.thefreedictionary.com/hidradenoma. Accessed on: 14 April 2011.
- ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1067. ISBN 0-7216-0187-1.
- ↑ Huang, Z.; Yang, S.; Li, Q.; Yan, P.; Li, L. (Feb 2001). "[Evaluation the pathological diagnostic values of koilocyte in condyloma acuminatum].". Zhonghua Liu Xing Bing Xue Za Zhi 22 (1): 58-60. PMID 11860848.
- ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 204. ISBN 978-0781765275.
- ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1230. ISBN 0-7216-0187-1.
- ↑ Finkbeiner AE (January 2003). "Balanitis xerotica obliterans: a form of lichen sclerosus". South. Med. J. 96 (1): 7–8. PMID 12602704.
- ↑ Kini, U. (Jun 1997). "Squamous cell carcinoma of the vulva in association with mixed vulvar dystrophy. A brief report with review of literature.". Indian J Cancer 34 (2): 92-5. PMID 9491669.
- ↑ URL: http://www.pathologyoutlines.com/vulva.html#lichensclerosis. Accessed on: 19 April 2011.
- ↑ URL: http://www.webpathology.com/image.asp?n=2&Case=538. Accessed on: 25 August 2011.
- ↑ http://pathologyoutlines.com/vulva.html#bartholincyst