Classic vulvar intraepithelial neoplasia: Difference between revisions

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~~#redirect~~ [[~~Vulva#Classic_vulvar_intraepithelial_neoplasia~~]]

{{ Infobox diagnosis

| Name = {{PAGENAME}}

| Image = Vulvar_intraepithelial_neoplasia3_1.jpg

| Width =

| Caption = Classic vulvar intraepithelial neoplasia. [[H&E stain]].

| Synonyms = usual vulvar intraepithelial neoplasia

| Micro = increased [[NC ratio]], multinucleation, lack of maturation to surface (not very useful -- unlike in the cervix), +/-non-basal mitoses, +/-atypical mitoses

| Subtypes =

| LMDDx = [[vulvar squamous cell carcinoma]], [[condyloma acuminatum]], [[dermatomycosis]]

| Stains =

| IHC = p16 +ve, p53 -ve, Ki-67 - suprabasal staining

| EM =

| Molecular =

| IF =

| Gross =

| Grossing =

| Site = [[vulva]]

| Assdx = [[vulvar squamous cell carcinoma]], other [[HPV]] lesions

| Syndromes =

| Clinicalhx = young women

| Signs =

| Symptoms =

| Prevalence = uncommon

| Bloodwork =

| Rads =

| Endoscopy =

| Prognosis =

| Other =

| ClinDDx =

| Tx =

}}

'''Classic vulvar intraepithelial neoplasia''', abbreviated '''classic VIN''', is a pre-neoplastic lesion of the [[vulva]] strongly associated with the [[human papilloma virus]].

It is also known as '''usual vulvar intraepithelial neoplasia''', abbreviated '''uVIN'''.<ref name=pmid24399036>{{Cite journal | last1 = Reyes | first1 = MC. | last2 = Cooper | first2 = K. | title = An update on vulvar intraepithelial neoplasia: terminology and a practical approach to diagnosis. | journal = J Clin Pathol | volume = | issue = | pages = | month = Jan | year = 2014 | doi = 10.1136/jclinpath-2013-202117 | PMID = 24399036 }}</ref> Despite being called "usual", it is less common than the other form of [[vulvar intraepithelial neoplasia]] ([[differentiated vulvar intraepithelial neoplasia]]).

==General==

Epidemiology:

*Classic VIN, like CIN, is associated with [[HPV]] and seen in younger women.

*May be multifocal, i.e. associated with cervical ([[CIN]]) or vaginal ([[VAIN]]) lesions;<ref>{{Cite journal | last1 = Pai | first1 = K. | last2 = Pai | first2 = S. | last3 = Gupta | first3 = A. | last4 = Rao | first4 = P. | last5 = Renjhen | first5 = P. | title = Synchronous vulvar intraepithelial neoplasia (VIN) of warty type and cervical intraepithelial neoplasia (CIN): case report. | journal = Indian J Pathol Microbiol | volume = 49 | issue = 4 | pages = 585-7 | month = Oct | year = 2006 | doi = | PMID = 17183865 }}</ref> multifocality has a strongly association with immunosuppression.<ref name=pmid16713062>{{Cite journal | last1 = Ait Menguellet | first1 = S. | last2 = Collinet | first2 = P. | last3 = Houfflin Debarge | first3 = V. | last4 = Nayama | first4 = M. | last5 = Vinatier | first5 = D. | last6 = Leroy | first6 = JL. | title = Management of multicentric lesions of the lower genital tract. | journal = Eur J Obstet Gynecol Reprod Biol | volume = 132 | issue = 1 | pages = 116-20 | month = May | year = 2007 | doi = 10.1016/j.ejogrb.2006.04.011 | PMID = 16713062 }}</ref>

Classic VIN is graded like cervical pre-cancerous lesions:

*VIN I.

**DDx: [[condyloma acuminatum]].<ref name=pmid15870532>{{Cite journal | last1 = Rufforny | first1 = I. | last2 = Wilkinson | first2 = EJ. | last3 = Liu | first3 = C. | last4 = Zhu | first4 = H. | last5 = Buteral | first5 = M. | last6 = Massoll | first6 = NA. | title = Human papillomavirus infection and p16(INK4a) protein expression in vulvar intraepithelial neoplasia and invasive squamous cell carcinoma. | journal = J Low Genit Tract Dis | volume = 9 | issue = 2 | pages = 108-13 | month = Apr | year = 2005 | doi = | PMID = 15870532 }}</ref>

**Uncommon.

*VIN II.

**Not common.

*VIN III.

**Commonly seen.

==Microscopic==

Features:

*Increased [[NC ratio]].

*Multinucleation.

*Lack of maturation to surface (not very useful -- unlike in the cervix).<ref>LAE. February 2009.</ref>

**May have "vertical streaming" - the long axis of the cells are perpendicular to the free surface & basement membrane.

*Apical mitoses.

DDx:

*[[Condyloma acuminatum]].

*[[Vulvar squamous cell carcinoma]], esp. warty type.

*[[Extramammary Paget disease]].

*[[Dermatomycosis]] (fungal infection) - esp. [[candidiasis]].

===Images===

Image:Vulvar_intraepithelial_neoplasia3_1.jpg | VIN III. (WC)

Image:Vulvar_intraepithelial_neoplasia3_2.jpg | VIN III. (WC)

</gallery>

*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150314/figure/F3/ VIN I - koilocytes (nih.gov)].<ref name=pmid21702970/>

*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150314/figure/F4/ VIN I (nih.gov)].<ref name=pmid21702970>{{Cite journal | last1 = Kotsopoulos | first1 = IC. | last2 = Tampakoudis | first2 = GP. | last3 = Evaggelinos | first3 = DG. | last4 = Nikolaidou | first4 = AI. | last5 = Fytili | first5 = PA. | last6 = Kartsiounis | first6 = VC. | last7 = Gerasimidou | first7 = DK. | title = Implication of human papillomavirus-66 in vulvar carcinoma: a case report. | journal = J Med Case Rep | volume = 5 | issue = | pages = 232 | month = | year = 2011 | doi = 10.1186/1752-1947-5-232 | PMID = 21702970 | PMC = 3150314 }}</ref>

*[http://www.flickr.com/photos/euthman/2658773592/ VIN III (flickr.com)].

*[http://www.brown.edu/Courses/Digital_Path/systemic_path/female/warty_VIN.html VIN (brown.edu)].

==IHC==

*Classic VIN: p16 +ve, p53 -ve.

*Differentiated VIN: p16 -ve, p53 +ve.<ref name=pmid20062014>{{Cite journal | last1 = Pinto | first1 = AP. | last2 = Miron | first2 = A. | last3 = Yassin | first3 = Y. | last4 = Monte | first4 = N. | last5 = Woo | first5 = TY. | last6 = Mehra | first6 = KK. | last7 = Medeiros | first7 = F. | last8 = Crum | first8 = CP. | title = Differentiated vulvar intraepithelial neoplasia contains Tp53 mutations and is genetically linked to vulvar squamous cell carcinoma. | journal = Mod Pathol | volume = 23 | issue = 3 | pages = 404-12 | month = Mar | year = 2010 | doi = 10.1038/modpathol.2009.179 | PMID = 20062014 }}</ref>

Note:

*p16 can be thought of as a poor man's HPV test.

===Sign out===

====VIN I====

<pre>

VULVA, BIOPSY:

- CLASSIC VULVAR INTRAEPITHELIAL NEOPLASIA (VIN) I (MILD DYSPLASIA).

- NEGATIVE FOR INVASIVE MALIGNANCY.

</pre>

====VIN II====

<pre>

LEFT LABIUM MINUS, PUNCH BIOPSY:

- CLASSIC VULVAR INTRAEPITHELIAL NEOPLASIA (cVIN) II (MODERATE DYSPLASIA).

- LICHEN SCLEROSUS.

COMMENT:

Immunostains:

POSITIVE: p16 (strong, diffuse - lower 2/3 of the epithelium).

NEGATIVE: HMB-45, S-100, p53 (weak, patchy, superficial squamous cells).

PROLIFERATION (Ki-67): increased, marks superficial squamous cells (compatible with

high-grade lesion).

</pre>

=====Micro=====

The sections show a punch biopsy of skin. Compact hyperkeratosis and hypergranulosis is

present. The epidermis is edematous, has moderately atypical cells in the lower two thirds

of the epithelium and mitotic activity. Several suprabasal mitoses are present. Apoptotic

keratinocytes are present. Granular yellow pigment (hemosiderin?) is present in the

epidermis. The epidermis is not significantly thickened. The lesional cells extend

to the lateral edges of the tissue.

====VIN III====

<pre>

VULVA, EXCISION:

- CLASSIC VULVAR INTRAEPITHELIAL NEOPLASIA (VIN) III (SEVERE DYSPLASIA)

WITH FOCAL ULCERATION.

- MARGIN FOCALLY POSITIVE FOR VIN III.

- NEGATIVE FOR INVASIVE MALIGNANCY.

</pre>

==See also==

*[[Vulva]].

*[[Differentiated vulvar intraepithelial neoplasia]].

==References==

[[Category:Vulva]]

[[Category:Diagnosis]]

@@ Line 1: / Line 1: @@
-#redirect [[Vulva#Classic_vulvar_intraepithelial_neoplasia]]
+{{ Infobox diagnosis
+| Name       = {{PAGENAME}}
+| Image      = Vulvar_intraepithelial_neoplasia3_1.jpg
+| Width      =
+| Caption    = Classic vulvar intraepithelial neoplasia. [[H&E stain]].
+| Synonyms   = usual vulvar intraepithelial neoplasia
+| Micro      = increased [[NC ratio]], multinucleation, lack of maturation to surface (not very useful -- unlike in the cervix), +/-non-basal mitoses, +/-atypical mitoses
+| Subtypes   =
+| LMDDx      = [[vulvar squamous cell carcinoma]], [[condyloma acuminatum]], [[dermatomycosis]]
+| Stains     =
+| IHC        = p16 +ve, p53 -ve, Ki-67 - suprabasal staining
+| EM         =
+| Molecular  =
+| IF         =
+| Gross      =
+| Grossing   =
+| Site       = [[vulva]]
+| Assdx      = [[vulvar squamous cell carcinoma]], other [[HPV]] lesions
+| Syndromes  =
+| Clinicalhx = young women
+| Signs      =
+| Symptoms   =
+| Prevalence = uncommon
+| Bloodwork  =
+| Rads       =
+| Endoscopy  =
+| Prognosis  =
+| Other      =
+| ClinDDx    =
+| Tx         =
+}}
+'''Classic vulvar intraepithelial neoplasia''', abbreviated '''classic VIN''', is a pre-neoplastic lesion of the [[vulva]] strongly associated with the [[human papilloma virus]].
+It is also known as '''usual vulvar intraepithelial neoplasia''', abbreviated '''uVIN'''.<ref name=pmid24399036>{{Cite journal  | last1 = Reyes | first1 = MC. | last2 = Cooper | first2 = K. | title = An update on vulvar intraepithelial neoplasia: terminology and a practical approach to diagnosis. | journal = J Clin Pathol | volume =  | issue =  | pages =  | month = Jan | year = 2014 | doi = 10.1136/jclinpath-2013-202117 | PMID = 24399036 }}</ref> Despite being called "usual", it is less common than the other form of [[vulvar intraepithelial neoplasia]] ([[differentiated vulvar intraepithelial neoplasia]]).
+==General==
+Epidemiology:
+*Classic VIN, like CIN, is associated with [[HPV]] and seen in younger women.
+*May be multifocal, i.e. associated with cervical ([[CIN]]) or vaginal ([[VAIN]]) lesions;<ref>{{Cite journal  | last1 = Pai | first1 = K. | last2 = Pai | first2 = S. | last3 = Gupta | first3 = A. | last4 = Rao | first4 = P. | last5 = Renjhen | first5 = P. | title = Synchronous vulvar intraepithelial neoplasia (VIN) of warty type and cervical intraepithelial neoplasia (CIN): case report. | journal = Indian J Pathol Microbiol | volume = 49 | issue = 4 | pages = 585-7 | month = Oct | year = 2006 | doi =  | PMID = 17183865 }}</ref> multifocality has a strongly association with immunosuppression.<ref name=pmid16713062>{{Cite journal  | last1 = Ait Menguellet | first1 = S. | last2 = Collinet | first2 = P. | last3 = Houfflin Debarge | first3 = V. | last4 = Nayama | first4 = M. | last5 = Vinatier | first5 = D. | last6 = Leroy | first6 = JL. | title = Management of multicentric lesions of the lower genital tract. | journal = Eur J Obstet Gynecol Reprod Biol | volume = 132 | issue = 1 | pages = 116-20 | month = May | year = 2007 | doi = 10.1016/j.ejogrb.2006.04.011 | PMID = 16713062 }}</ref>
+Classic VIN is graded like cervical pre-cancerous lesions:
+*VIN I.
+**DDx: [[condyloma acuminatum]].<ref name=pmid15870532>{{Cite journal  | last1 = Rufforny | first1 = I. | last2 = Wilkinson | first2 = EJ. | last3 = Liu | first3 = C. | last4 = Zhu | first4 = H. | last5 = Buteral | first5 = M. | last6 = Massoll | first6 = NA. | title = Human papillomavirus infection and p16(INK4a) protein expression in vulvar intraepithelial neoplasia and invasive squamous cell carcinoma. | journal = J Low Genit Tract Dis | volume = 9 | issue = 2 | pages = 108-13 | month = Apr | year = 2005 | doi =  | PMID = 15870532 }}</ref>
+**Uncommon.
+*VIN II.
+**Not common.
+*VIN III.
+**Commonly seen.
+==Microscopic==
+Features:
+*Increased [[NC ratio]].
+*Multinucleation.
+*Lack of maturation to surface (not very useful -- unlike in the cervix).<ref>LAE. February 2009.</ref>
+**May have "vertical streaming" - the long axis of the cells are perpendicular to the free surface & basement membrane.
+*Apical mitoses.
+DDx:
+*[[Condyloma acuminatum]].
+*[[Vulvar squamous cell carcinoma]], esp. warty type.
+*[[Extramammary Paget disease]].
+*[[Dermatomycosis]] (fungal infection) - esp. [[candidiasis]].
+===Images===
+<gallery>
+Image:Vulvar_intraepithelial_neoplasia3_1.jpg | VIN III. (WC)
+Image:Vulvar_intraepithelial_neoplasia3_2.jpg | VIN III. (WC)
+</gallery>
+*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150314/figure/F3/ VIN I - koilocytes (nih.gov)].<ref name=pmid21702970/>
+*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150314/figure/F4/ VIN I (nih.gov)].<ref name=pmid21702970>{{Cite journal  | last1 = Kotsopoulos | first1 = IC. | last2 = Tampakoudis | first2 = GP. | last3 = Evaggelinos | first3 = DG. | last4 = Nikolaidou | first4 = AI. | last5 = Fytili | first5 = PA. | last6 = Kartsiounis | first6 = VC. | last7 = Gerasimidou | first7 = DK. | title = Implication of human papillomavirus-66 in vulvar carcinoma: a case report. | journal = J Med Case Rep | volume = 5 | issue =  | pages = 232 | month =  | year = 2011 | doi = 10.1186/1752-1947-5-232 | PMID = 21702970 | PMC = 3150314 }}</ref>
+*[http://www.flickr.com/photos/euthman/2658773592/ VIN III (flickr.com)].
+*[http://www.brown.edu/Courses/Digital_Path/systemic_path/female/warty_VIN.html VIN (brown.edu)].
+==IHC==
+*Classic VIN: p16 +ve, p53 -ve.
+*Differentiated VIN: p16 -ve, p53 +ve.<ref name=pmid20062014>{{Cite journal  | last1 = Pinto | first1 = AP. | last2 = Miron | first2 = A. | last3 = Yassin | first3 = Y. | last4 = Monte | first4 = N. | last5 = Woo | first5 = TY. | last6 = Mehra | first6 = KK. | last7 = Medeiros | first7 = F. | last8 = Crum | first8 = CP. | title = Differentiated vulvar intraepithelial neoplasia contains Tp53 mutations and is genetically linked to vulvar squamous cell carcinoma. | journal = Mod Pathol | volume = 23 | issue = 3 | pages = 404-12 | month = Mar | year = 2010 | doi = 10.1038/modpathol.2009.179 | PMID = 20062014 }}</ref>
+Note:
+*p16 can be thought of as a poor man's HPV test.
+===Sign out===
+====VIN I====
+<pre>
+VULVA, BIOPSY:
+- CLASSIC VULVAR INTRAEPITHELIAL NEOPLASIA (VIN) I (MILD DYSPLASIA).
+- NEGATIVE FOR INVASIVE MALIGNANCY.
+</pre>
+====VIN II====
+<pre>
+LEFT LABIUM MINUS, PUNCH BIOPSY:
+- CLASSIC VULVAR INTRAEPITHELIAL NEOPLASIA (cVIN) II (MODERATE DYSPLASIA).
+- LICHEN SCLEROSUS.
+COMMENT:
+Immunostains:
+POSITIVE: p16 (strong, diffuse - lower 2/3 of the epithelium).
+NEGATIVE: HMB-45, S-100, p53 (weak, patchy, superficial squamous cells).
+PROLIFERATION (Ki-67): increased, marks superficial squamous cells (compatible with
+                         high-grade lesion).
+</pre>
+=====Micro=====
+The sections show a punch biopsy of skin. Compact hyperkeratosis and hypergranulosis is
+present. The epidermis is edematous, has moderately atypical cells in the lower two thirds
+of the epithelium and mitotic activity. Several suprabasal mitoses are present. Apoptotic
+keratinocytes are present. Granular yellow pigment (hemosiderin?) is present in the
+epidermis.  The epidermis is not significantly thickened.  The lesional cells extend
+to the lateral edges of the tissue.
+====VIN III====
+<pre>
+VULVA, EXCISION:
+- CLASSIC VULVAR INTRAEPITHELIAL NEOPLASIA (VIN) III (SEVERE DYSPLASIA)
+  WITH FOCAL ULCERATION.
+- MARGIN FOCALLY POSITIVE FOR VIN III.
+- NEGATIVE FOR INVASIVE MALIGNANCY.
+</pre>
+==See also==
+*[[Vulva]].
+*[[Differentiated vulvar intraepithelial neoplasia]].
+==References==
+{{Reflist|2}}
+[[Category:Vulva]]
 [[Category:Diagnosis]]

Classic vulvar intraepithelial neoplasia: Difference between revisions

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