Difference between revisions of "Vulva"

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Vulva (view source)

Revision as of 15:43, 8 March 2016

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→‎Condyloma acuminatum: split out
 
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=====Micro=====
=====Micro=====
The sections show squamous mucosa with a mild chronic inflammatory infiltrate that consists predominantly of lymphocytes. There is mild nuclear enlargement and intracellular edema. The nuclear membranes are regular. No nuclear hyperchromasia is apparent. No mitotic activity is readily apparent.
The sections show squamous mucosa with a mild chronic inflammatory infiltrate that consists predominantly of lymphocytes. There is mild nuclear enlargement and intracellular edema. The nuclear membranes are regular. No nuclear hyperchromasia is apparent. No mitotic activity is readily apparent.
====Hyperkeratotic====
<pre>
VULVA, BIOPSY:
- SQUAMOUS MUCOSA WITH MILD HYPERGRANULOSIS AND A THIN COMPACT LAYER OF KERATIN.
- NO SIGNIFICANT INFLAMMATION.
- NEGATIVE FOR DYSPLASIA.
</pre>
=====Micro=====
The sections show a small piece of squamous mucosa with mild hypergranulosis and a compact keratin layer. The epithelial component is not significantly thickened but contains rare intraepithelial lymphocytes and has minimal edema. The subepithelial tissue has rare scattered lymphocytes and a mild prominence of small blood vessels. No subepithelial fibrosis is appreciated. The epithelium has no atypia. No mitotic figures are readily apparent.


=Benign disease=
=Benign disease=
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==Condyloma acuminatum==
==Condyloma acuminatum==
*[[AKA]] ''genital [[wart]]''.
*[[AKA]] ''genital [[wart]]''.
===General===
{{Main|Condyloma acuminatum}}
*Due to [[human papillomavirus]] (HPV).
**Transmission: sexual, non-sexual, horizontal (mother to child).<ref name=Ref_APBR280>{{Ref APBR|280 Q29}}</ref>
***Should raise the suspicion of child abuse.
 
Note:
*Related to [[verruca vulgaris]] (common wart).
*The Bethesda system includes this in [[LSIL]].<ref>{{Ref GP|143}}</ref>
 
Clinical DDx:
*[[Molluscum contagiosum]].<ref>URL: [http://emedicine.medscape.com/article/781735-differential http://emedicine.medscape.com/article/781735-differential]. Accessed on: 5 July 2013.</ref>
 
===Microscopic===
Features:
*Koilocytes.<ref name=pmid11860848>{{Cite journal  | last1 = Huang | first1 = Z. | last2 = Yang | first2 = S. | last3 = Li | first3 = Q. | last4 = Yan | first4 = P. | last5 = Li | first5 = L. | title = [Evaluation the pathological diagnostic values of koilocyte in condyloma acuminatum]. | journal = Zhonghua Liu Xing Bing Xue Za Zhi | volume = 22 | issue = 1 | pages = 58-60 | month = Feb | year = 2001 | doi =  | PMID = 11860848 }}</ref>
**Cells with an enlarged nucleus and perinuclear clearing.
*Papillomatosis.<ref>{{Ref WMSP|204}}</ref>
**Papillomatosis = surface elevation due to dermal papillae enlargement.<ref>{{Ref PBoD|1230}}</ref>
*+/-Parakeratosis.
 
DDx:
*[[Classic vulvar intraepithelial neoplasia]] - architecture different.
 
====Images====
<gallery>
Image:Condyloma_acuminatum_-_low_mag.jpg | Condyloma acuminatum - low mag. (WC)
Image:Condyloma_acuminatum_-_very_high_mag.jpg | Condyloma acuminatum - very high mag. (WC)
Image:Anal_condyloma_%282%29.jpg | Condyloma acuminatum - 2. (WC)
Image:Anal_condyloma_%284%29.jpg | Condyloma acuminatum - 3. (WC)
</gallery>
 
===Sign out===
<pre>
SKIN LESION ("VULVAR WART"), VULVA, EXCISION:
- CONDYLOMA ACUMINATUM (GENITAL WART).
</pre>
 
<pre>
LABIA MINORA, BIOPSY:
- CONDYLOMA/LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION (LSIL).
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
====Seborrheic keratosis-like====
<pre>
SKIN LESION, PERINEUM, BIOPSY:
- SEBORRHEIC KERATOSIS-LIKE CONDYLOMA ACUMINATUM (GENITAL WART).
</pre>
 
====Without viral cytopathic changes====
<pre>
VULVAR LESIONS (x3), EXCISION:
- SQUAMOUS HYPERPLASIA WITH HYPERORTHOKERATOSIS WITHOUT VIRAL CYTOPATHIC EFFECT,
  COMPATIBLE WITH CONDYLOMA (x3).
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Micro====
The sections show a polypoid fragment of skin with epithelium on three sides, acanthosis, hyperkeratosis and parakeratosis. Koilocytic changes (mild nuclear enlargement, perinuclear clearing) are seen focally. There is mild basilar nuclear enlargement and hyperchromasia.  The epithelium matures to the surface and a granular layer is present.
 
=====Seborrheic keratosis-like=====
The sections show skin with acanthosis with papillomatous features (round bulbous rete ridges, acanthosis with penetrating fibrovascular cores) pseudohorn cysts, parakeratosis and hyperkeratosis.  There is no significant basal nuclear atypia. There are no mitoses and no melanocytic nests. There is mild dermal inflammation. There is no solar elastosis. Pigment incontinence is present focally.


==Lichen sclerosus==
==Lichen sclerosus==
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===Sign out===
===Sign out===
====Compatible with Bartholin cyst====
====Compatible with Bartholin cyst====
<pre>
Submitted as "Bartholin's cyst wall - left", Excision:
- Connective tissue with overlying urothelium that is focally
  denuded and associated with a lymphohistiocytic response,
  compatible with Bartholin's cyst.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.
</pre>
=====Block letters=====
<pre>
<pre>
VAGINA, CYST WALL, BIOPSY:
VAGINA, CYST WALL, BIOPSY:
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*Abbreviated ''classic VIN'' or ''cVIN''.
*Abbreviated ''classic VIN'' or ''cVIN''.
*[[AKA]] ''usual VIN'' or ''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>
*[[AKA]] ''usual VIN'' or ''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>
===General===
{{Main|Classic vulvar intraepithelial neoplasia}}
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]].
*[[Extramammary Paget disease]].
*[[Dermatomycosis]] (fungal infection) - esp. [[candidiasis]].
 
Images:
*[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://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)].
 
===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 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>


==Differentiated vulvar intraepithelial neoplasia==
==Differentiated vulvar intraepithelial neoplasia==
Michael
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