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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. | ||
= | =Benign disease= | ||
This is grab bag of non-neoplastic stuffs. | This is grab bag of non-neoplastic stuffs. | ||
| Line 296: | Line 135: | ||
*[http://webpathology.com/image.asp?case=540&n=1 Bartholin cyst (webpathology.com)]. | *[http://webpathology.com/image.asp?case=540&n=1 Bartholin cyst (webpathology.com)]. | ||
*[http://webpathology.com/image.asp?n=2&Case=540 Bartholin cyst - high mag. (webpathology.com)]. | *[http://webpathology.com/image.asp?n=2&Case=540 Bartholin cyst - high mag. (webpathology.com)]. | ||
=Neoplasms (non-malignant)= | |||
A short DDx:<ref>{{Ref WMSP|456}}}}</ref> | |||
*[[Granular cell tumour]]. | |||
*[[Leiomyoma]]. | |||
*[[Fibroepithelial polyp]]. | |||
*[[Extramammary Paget's disease]]. | |||
==Hidradenoma papilliferum== | |||
*[[AKA]] ''papillary hidradenoma''.<ref>Hidradenoma papilliferum. Stedman's Medical Dictionary. 27th Ed.</ref> | |||
===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> | |||
*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: | |||
*[[WC]]: | |||
**[http://commons.wikimedia.org/wiki/File:Papillary_hidradenoma_-_low_mag.jpg Papillary hidradenoma - low mag. (WC)]. | |||
**[http://commons.wikimedia.org/wiki/File:Papillary_hidradenoma_-_very_high_mag.jpg Papillary hidradenoma - very high mag. (WC)]. | |||
*www: | |||
**[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. | |||
=Vulvar neoplasia= | |||
==Classic vulvar intraepithelial neoplasia== | |||
*Abbreviated ''classic VIN'' or ''cVIN''. | |||
===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]]. | |||
*[[Extramammary Paget disease]]. | |||
*[[Dermatomycosis]] (fungal infection) - esp. [[candidiasis]]. | |||
Images: | |||
*[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=== | |||
<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== | |||
*Abbreviated ''dVIN''. | |||
*[[AKA]] ''VIN simplex''.<ref name=pmid15910611>{{Cite journal | last1 = Ruhul Quddus | first1 = M. | last2 = Xu | first2 = C. | last3 = Steinhoff | first3 = MM. | last4 = Zhang | first4 = C. | last5 = Lawrence | first5 = WD. | last6 = Sung | first6 = CJ. | title = Simplex (differentiated) type VIN: absence of p16INK4 supports its weak association with HPV and its probable precursor role in non-HPV related vulvar squamous cancers. | journal = Histopathology | volume = 46 | issue = 6 | pages = 718-20 | month = Jun | year = 2005 | doi = 10.1111/j.1365-2559.2005.02036.x | PMID = 15910611 }}</ref> | |||
===General=== | |||
Epidemiology: | |||
*Associated with [[lichen sclerosus]]. | |||
*Seen in older women. | |||
Note: | |||
*'''Not''' associated with [[HPV]].<ref name=pmid10716158>{{Cite journal | last1 = Yang | first1 = B. | last2 = Hart | first2 = WR. | title = Vulvar intraepithelial neoplasia of the simplex (differentiated) type: a clinicopathologic study including analysis of HPV and p53 expression. | journal = Am J Surg Pathol | volume = 24 | issue = 3 | pages = 429-41 | month = Mar | year = 2000 | doi = | PMID = 10716158 }}</ref> | |||
===Microscopic=== | |||
Features:<ref name=pmid21057461>{{Cite journal | last1 = van de Nieuwenhof | first1 = HP. | last2 = Bulten | first2 = J. | last3 = Hollema | first3 = H. | last4 = Dommerholt | first4 = RG. | last5 = Massuger | first5 = LF. | last6 = van der Zee | first6 = AG. | last7 = de Hullu | first7 = JA. | last8 = van Kempen | first8 = LC. | title = Differentiated vulvar intraepithelial neoplasia is often found in lesions, previously diagnosed as lichen sclerosus, which have progressed to vulvar squamous cell carcinoma. | journal = Mod Pathol | volume = 24 | issue = 2 | pages = 297-305 | month = Feb | year = 2011 | doi = 10.1038/modpathol.2010.192 | PMID = 21057461 }}</ref> | |||
*Thickening of the stratum spinosum (acanthosis). | |||
*Elongation of rete ridges with bridging/anastomoses between rete ridges. | |||
*Nuclear atypia - esp. basal layer. | |||
*Nuclei in stratum corneum (parakeratosis). | |||
*+/-Atypical mitoses. | |||
Notes: | |||
*'''Not''' graded like classic VIN. | |||
*Mnemonic ''BAD LAP'': '''b'''asal cell atypia, '''a'''nastomosing rete ridges (bridging), '''d'''VIN, '''l'''ichen sclerosus, '''a'''canthosis, '''p'''arakeratosis. | |||
DDx: | |||
*[[Lichen sclerosus]]. | |||
*[[Lichen simplex chronicus]] (squamous hyperplasia). | |||
Images: | |||
*www: | |||
**[http://www.nature.com/modpathol/journal/v24/n2/fig_tab/modpathol2010192f3.html#figure-title Differentiated VIN (nature.com)].<ref name=pmid21057461>{{Cite journal | last1 = van de Nieuwenhof | first1 = HP. | last2 = Bulten | first2 = J. | last3 = Hollema | first3 = H. | last4 = Dommerholt | first4 = RG. | last5 = Massuger | first5 = LF. | last6 = van der Zee | first6 = AG. | last7 = de Hullu | first7 = JA. | last8 = van Kempen | first8 = LC. | title = Differentiated vulvar intraepithelial neoplasia is often found in lesions, previously diagnosed as lichen sclerosus, which have progressed to vulvar squamous cell carcinoma. | journal = Mod Pathol | volume = 24 | issue = 2 | pages = 297-305 | month = Feb | year = 2011 | doi = 10.1038/modpathol.2010.192 | PMID = 21057461 }}</ref> | |||
**[http://www.nature.com/modpathol/journal/v23/n3/fig_tab/modpathol2009179f1.html Differentiated VIN with bridging rete ridges (nature.com)].<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> | |||
*[[WC]]: | |||
**[http://commons.wikimedia.org/wiki/File:Differentiated_vulvar_intraepithelial_neoplasia_-_low_mag.jpg Differentiated VIN - low mag. (WC)]. | |||
**[http://commons.wikimedia.org/wiki/File:Differentiated_vulvar_intraepithelial_neoplasia_-_intermed_mag.jpg Differentiated VIN - intermed. mag. (WC)]. | |||
**[http://commons.wikimedia.org/wiki/File:Differentiated_vulvar_intraepithelial_neoplasia_-_deep_-_high_mag.jpg Differentiated VIN - deep - high mag. (WC)]. | |||
===IHC=== | |||
*Differentiated VIN: p16 -ve, p53 +ve.<ref name=pmid20062014/> | |||
*Classic VIN: p16 +ve, p53 -ve. | |||
Note: | |||
*p16 can be thought of as a poor man's [[HPV]] test. | |||
=Malignant neoplasms of the vulva= | |||
==Overview== | |||
Most common malignancies of vulva:<ref name=Ref_WMSP459>{{Ref WMSP|459}}</ref> | |||
#Invasive [[squamous cell carcinoma]]. | |||
#[[Malignant melanoma]]. | |||
==Vulvar squamous cell carcinoma== | |||
{{Main|Squamous cell carcinoma}} | |||
===General=== | |||
*Most common vulvar malignancy. | |||
====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.<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> | |||
===Microscopic=== | |||
Like SCC elsewhere. | |||
*Microinvasion: <=1 mm stromal invasion, tumour size <=2 cm (T1a).<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Vulva_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Vulva_11protocol.pdf]. Accessed on: 9 March 2012.</ref> | |||
*Depth from DE junction. | |||
Note: | |||
*Tumour thickness != depth of invasion. | |||
**Thickness = granular layer ''or'' surface (no granular layer present) to deepest tumour. | |||
**Depth of invasion = epithelial-stromal junction in "valley" of papillae. | |||
DDx: | |||
*[[Classic vulvar intraepithelial neoplasia]] - esp. tangential sections. | |||
*[[Differentiated vulvar intraepithelial neoplasia]]. | |||
=See also= | =See also= | ||