Vulva
This article addresses the basics of vulva, from a pathologic perspective.
Neoplasms of the vulva
Low grade pre-cancerous lesions (VIN) are typically HPV positive, while high grade pre-cancerous lesions and cancer are less often HPV positive.[1]
Most common malignancy of vulva:
- Invasive squamous cell carcinoma.
Precursor lesion:
- 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.
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).[2]
- 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.
Lichen sclerosus
- AKA chronic atrophic vulvitis - vulvar lesion.
- AKA balanitis xerotica obliterans (BXO) - penile lesion.[3]
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:[4]
- Loss of rete ridges.
- Severe hyperkeratosis.
- Fibrosis of dermis with loss of adnexal structures - key feature.
- Inflammation - often with eosinophils.
Bartholin cyst
General
- Common.
Micro
- Cyst with squamous or urothelial epithelium.[5]
Hidradenoma papilliferum
General
- Dermal thingy; hidradenoma = tumour of sweat duct epithelium.[6]
- AKA papillary hidradenoma.[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:
Notes:
- No attachment to epidermis.
- No nuclear changes suggestive of malignancy.
See also
- Gynecologic pathology.
- Uterus.
- Cervix - cervical intraepithelial neoplasia (CIN).
- Vagina.
- Anus - anal intraepithelial neoplasia.
References
- ↑ 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.
- ↑ Finkbeiner AE (January 2003). "Balanitis xerotica obliterans: a form of lichen sclerosus". South. Med. J. 96 (1): 7–8. PMID 12602704.
- ↑ URL: http://www.pathologyoutlines.com/vulva.html#lichensclerosis. Accessed on: 19 April 2011.
- ↑ http://pathologyoutlines.com/vulva.html#bartholincyst
- ↑ URL: http://medical-dictionary.thefreedictionary.com/hidradenoma. Accessed on: 14 April 2011.
- ↑ Hidradenoma papilliferum. Stedman's Medical Dictionary. 27th Ed.
- ↑ 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.