Difference between revisions of "Vulva"

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This article addresses the basics of '''vulva''', from a pathologic perspective.
This article addresses the basics of '''vulva''', from a pathologic perspective.


==Neoplasms of the vulva==
=Malignant neoplasms overview=
Low grade pre-cancerous lesions (VIN) are typically HPV positive, while high grade pre-cancerous lesions and cancer are less often HPV positive.<ref name=pmid19115209>{{cite journal |author=De Vuyst H, Clifford GM, Nascimento MC, Madeleine MM, Franceschi S |title=Prevalence and type distribution of human papillomavirus in carcinoma and intraepithelial neoplasia of the vulva, vagina and anus: a meta-analysis |journal=Int. J. Cancer |volume=124 |issue=7 |pages=1626–36 |year=2009 |month=April |pmid=19115209 |doi=10.1002/ijc.24116 |url=}}</ref>
==Most common malignancies==
Most common malignancies of vulva:<ref name=Ref_WMSP459>{{Ref WMSP|459}}</ref>
#Invasive [[squamous cell carcinoma]].
#[[Malignant melanoma]].


Most common malignancy of vulva:
==Squamous cell carcinoma==
*Invasive [[squamous cell carcinoma]].
{{Main|Squamous cell carcinoma}}
Like SCC elsewhere.


Precursor lesion:
===Precursor lesions for SCC===
*Vulvar intraepithelial neoplasia (VIN).
*Vulvar intraepithelial neoplasia (VIN).


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*''Differentiated VIN''.
*''Differentiated VIN''.
**''Differentiated VIN'' is mostly irrelevant as it is basically never seen alone, i.e. it usually accompanies cancer.
**''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.<ref name=pmid19115209>{{cite journal |author=De Vuyst H, Clifford GM, Nascimento MC, Madeleine MM, Franceschi S |title=Prevalence and type distribution of human papillomavirus in carcinoma and intraepithelial neoplasia of the vulva, vagina and anus: a meta-analysis |journal=Int. J. Cancer |volume=124 |issue=7 |pages=1626–36 |year=2009 |month=April |pmid=19115209 |doi=10.1002/ijc.24116 |url=}}</ref>


==Classic vulvar intraepithelial neoplasia==
==Classic vulvar intraepithelial neoplasia==
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ASIDE: [[p16]] can be thought of as a poor man's HPV test.
ASIDE: [[p16]] can be thought of as a poor man's HPV test.
=Neoplasms (non-malignant)=
A short DDx:<ref>{{Ref WMSP|456}}}}</ref>
*[[Granular cell tumour]].
*[[Leiomyoma]].
*[[Fibroepithelial polyp]].
*[[Paget's disease]].
==Hidradenoma papilliferum==
===General===
*Dermal thingy; hidradenoma = tumour of sweat duct epithelium.<ref>URL: [http://medical-dictionary.thefreedictionary.com/hidradenoma http://medical-dictionary.thefreedictionary.com/hidradenoma]. Accessed on: 14 April 2011.</ref>
*[[AKA]] ''papillary hidradenoma''.<ref>Hidradenoma papilliferum. Stedman's Medical Dictionary. 27th Ed.</ref>
*Looks like ''intraductal papilloma of the breast''.<ref>{{Ref PBoD|1067}}</ref>
===Microscopic===
Features:
*Cystic spaces.
*Epithelium with apocrine differentiation (as demonstrated by apocrine snouts).
*Well-circumscribed.
Images:
*[http://farm4.static.flickr.com/3019/2646470314_12fb77d3ec_z.jpg Hidradenoma papilliferum (flickr.com)].
Notes:
*No attachment to epidermis.
*No nuclear changes suggestive of malignancy.
=Other=
This is grab bag of non-neoplastic stuffs.


==Lichen sclerosus==
==Lichen sclerosus==
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===General===
===General===
*Common.
*Common.
===Micro===
*Cyst with squamous or urothelial epithelium.<ref>[http://pathologyoutlines.com/vulva.html#bartholincyst http://pathologyoutlines.com/vulva.html#bartholincyst]</ref>
==Hidradenoma papilliferum==
===General===
*Dermal thingy; hidradenoma = tumour of sweat duct epithelium.<ref>URL: [http://medical-dictionary.thefreedictionary.com/hidradenoma http://medical-dictionary.thefreedictionary.com/hidradenoma]. Accessed on: 14 April 2011.</ref>
*[[AKA]] ''papillary hidradenoma''.<ref>Hidradenoma papilliferum. Stedman's Medical Dictionary. 27th Ed.</ref>
*Looks like ''intraductal papilloma of the breast''.<ref>{{Ref PBoD|1067}}</ref>


===Microscopic===
===Microscopic===
Features:
Features:
*Cystic spaces.
*Cyst with squamous or urothelial epithelium.<ref>[http://pathologyoutlines.com/vulva.html#bartholincyst http://pathologyoutlines.com/vulva.html#bartholincyst]</ref>
*Epithelium with apocrine differentiation (as demonstrated by apocrine snouts).
*Well-circumscribed.
 
Images:
*[http://farm4.static.flickr.com/3019/2646470314_12fb77d3ec_z.jpg Hidradenoma papilliferum (flickr.com)].
 
Notes:
*No attachment to epidermis.
*No nuclear changes suggestive of malignancy.


==See also==
=See also=
*[[Gynecologic pathology]].
*[[Gynecologic pathology]].
*[[Uterus]].
*[[Uterus]].
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*[[Anus]] - anal intraepithelial neoplasia.
*[[Anus]] - anal intraepithelial neoplasia.


==References==
=References=
{{reflist|2}}
{{reflist|2}}


[[Category:Gynecologic pathology]]
[[Category:Gynecologic pathology]]

Revision as of 15:06, 27 April 2011

This article addresses the basics of vulva, from a pathologic perspective.

Malignant neoplasms overview

Most common malignancies

Most common malignancies of vulva:[1]

  1. Invasive squamous cell carcinoma.
  2. Malignant melanoma.

Squamous cell carcinoma

Main article: Squamous cell carcinoma

Like SCC elsewhere.

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.[2]

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.

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).[3]
  • Apical mitoses.

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:[4]

Hidradenoma papilliferum

General

  • Dermal thingy; hidradenoma = tumour of sweat duct epithelium.[5]
  • AKA papillary hidradenoma.[6]
  • Looks like intraductal papilloma of the breast.[7]

Microscopic

Features:

  • Cystic spaces.
  • Epithelium with apocrine differentiation (as demonstrated by apocrine snouts).
  • Well-circumscribed.

Images:

Notes:

  • No attachment to epidermis.
  • No nuclear changes suggestive of malignancy.

Other

This is grab bag of non-neoplastic stuffs.

Lichen sclerosus

  • AKA chronic atrophic vulvitis - vulvar lesion.
  • AKA balanitis xerotica obliterans (BXO) - penile lesion.[8]

General

  • Associated with differentiated vulvar intraepithelial neoplasia.
    • 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.

Microscopic

Features:[9]

  • Loss of rete ridges.
  • Severe hyperkeratosis.
  • Fibrosis of dermis with loss of adnexal structures - key feature.
  • Inflammation - often with eosinophils.

Bartholin cyst

General

  • Common.

Microscopic

Features:

  • Cyst with squamous or urothelial epithelium.[10]

See also

References

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ LAE. February 2009.
  4. ↑ 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. }}
  5. ↑ URL: http://medical-dictionary.thefreedictionary.com/hidradenoma. Accessed on: 14 April 2011.
  6. ↑ Hidradenoma papilliferum. Stedman's Medical Dictionary. 27th Ed.
  7. ↑ 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.
  8. ↑ Finkbeiner AE (January 2003). "Balanitis xerotica obliterans: a form of lichen sclerosus". South. Med. J. 96 (1): 7–8. PMID 12602704.
  9. ↑ URL: http://www.pathologyoutlines.com/vulva.html#lichensclerosis. Accessed on: 19 April 2011.
  10. ↑ http://pathologyoutlines.com/vulva.html#bartholincyst
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