Vulva and vagina

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

Low grade pre-cancerous lesions (VAIN, 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 VIN

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.

Micro. of classic VIN

  • Increased NC ratio.
  • Multinucleation.
  • Lack of maturation to surface (not very useful -- unlike in the cervix).[2]
  • Apical mitoses.

Differentiated VIN

Epidemiology

Histology

  • 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

General

  • Pruritis -> leads to scratching.

Microscopic

Features:[3]

  • Loss of rete ridges - key feature.
  • Severe hyperkeratosis.
  • Fibrosis of dermis with loss of adnexal structures[4]
  • Inflammation - often with eosinophils.

Bartholin cyst

General

  • Common.

Micro

  • Cyst with squamous or urothelial epithelium.[5]

Vagina

Normal

  • Squamous epithelium, non-keratinized.

Prolapse

  • Pieces of vagina are often submitted in the context of uterine prolapse.

Microscopic

  • Squamous epithelium - may be keratinized.

Vaginal cancer

  • Most common cancer of the vagina is squamous cell carcinoma.
  • Precursor lesions are similar to the cervix[6] and are often HPV associated - see vaginal intraepithelial neoplasia (VAIN).
  • Development of VAIN can be associated with cervical intraepithelial neoplasia and arises in up to 7.4% of patients that underwent a (total) hysterectomy for CIN2 or worse.[7]

Vaginal intraepithelial neoplasia (VAIN)

VAIN is graded like cervical lesions:

  • Mild vaginal intraepithelial neoplasia (VAIN I).
  • Moderate vaginal intraepithelial neoplasia (VAIN II).
  • Severe vaginal intraepithelial neoplasia (VAIN III).

Vaginal cysts

  • Most common is vaginal inclusion cyst.[8]
    • Usually due to trauma.

See also

References

  1. ↑ 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.
  2. ↑ LAE. February 2009.
  3. ↑ http://www.pathologyoutlines.com/vulva.html#lichensclerosis
  4. ↑ NEED REF.
  5. ↑ http://pathologyoutlines.com/vulva.html#bartholincyst
  6. ↑ Indraccolo U, Chiocci L, Baldoni A (2008). "Does vaginal intraepithelial neoplasia have the same evolution as cervical intraepithelial neoplasia?". Eur. J. Gynaecol. Oncol. 29 (4): 371–3. PMID 18714572.
  7. ↑ Schockaert S, Poppe W, Arbyn M, Verguts T, Verguts J (August 2008). "Incidence of vaginal intraepithelial neoplasia after hysterectomy for cervical intraepithelial neoplasia: a retrospective study". Am. J. Obstet. Gynecol. 199 (2): 113.e1–5. doi:10.1016/j.ajog.2008.02.026. PMID 18456229.
  8. ↑ URL: http://www.nlm.nih.gov/medlineplus/ency/article/001509.htm. Accessed on: 6 July 2010.
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