Vagina

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

Low grade pre-cancerous lesions of the vagina (VAIN) are typically HPV positive, while high grade pre-cancerous lesions and cancer are less often HPV positive.[1]

Normal vagina

Microscopic

  • Non-keratinized squamous epithelium.

Note:

  • Pieces of vagina are often submitted in the context of uterine prolapse.
    • In this context the squamous epithelium may be keratinized (due to irritation).

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Not quite normal

VAGINA, BIOPSY:
- SUPERFICIAL VAGINAL MUCOSA WITH PARAKERATOSIS.
- NEGATIVE FOR DYSPLASIA.
VAGINAL VAULT, BIOPSY:
- SQUAMOUS EPITHELIUM WITH COMPACT KERATIN, PARAKERATOSIS AND HYPERGRANULOSIS.
- NEGATIVE FOR DYSPLASIA.
- NEGATIVE FOR MALIGNANCY.
Micro

The sections show squamous epithelium with compact keratin, parakeratosis and hypergranulosis. The nuclei mature normally to the surface. No significant nuclear atypia is identified. Mitotic activity is not readily apparent. Minimal intracellular edema is present. No significant inflammation is identified. A very small amount of fibrous subepithelial tissue is present.

Vaginal cysts

DDx:[2][3]

Vaginal inclusion cyst

General

  • Most common vaginal cyst.[2]
  • Usually due to trauma (surgical or birth).

Microscopic

Features:[3]

  • Cyst lined by non-keratinized squamous epithelium.
  • +/-Inflammation.

DDx:

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CYST WALL, VAGINA, EXCISION:
- CONSISTENT WITH BENIGN VAGINAL INCLUSION CYST.
- SQUAMOUS MUCOSA WITH FOCAL KERATINIZATION.
- NEGATIVE FOR MALIGNANCY.

Viral infections

General

  • Cannot differentiate HSV1, HSV2, VZV using H&E.[5]

Microscopic

Features:[5]

  • Keratinocytes enlargement + acanthosis.
    • Intraepidermal vesicles & bullae.
  • Nuclear changes - 3 Ms:
    1. Moulding of nuclei.
    2. Margination of chromatin.
    3. Multinucleation.
  • Nuclei have "steel gray" colour.

Images:

Other

Vaginal mucosa with irritation

Rectocele, cystocele, vaginal mucosa and vaginal repair redirect here.

General

  • Seen in the context of vaginal repairs for rectocele or cystocele.

Microscopic

Features:

  • Squamous mucosa with hyperkeratosis.
  • Negative for atypia.
  • Negative for inflammation.

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Vaginal Mucosa, Excision During Vaginal Repair:
	- Squamous mucosa with compact keratin layer.
	- NEGATIVE for significant inflammation.
	- NEGATIVE for dysplasia and NEGATIVE for malignancy.

Vaginal cancer

  • Squamous cell carcinoma - most common cancer of the vagina.
    • Precursor lesions are similar to the cervix[6] and are often HPV associated - see vaginal intraepithelial neoplasia (VAIN).
  • Malignant melanoma - rare.
  • Adenocarcinoma of the vagina.
    • Primary adenocarcinoma is very rare.

Notes:

  • Tumours of uncertain origin that involve the:
    • Cervix and vagina are usually considered to be cervical primaries.[8]
    • Vulva and vagina are usually considered to be vulvar primaries.[8]

Images:

Vaginal intraepithelial neoplasia

  • Abbreviated VAIN.

General

VAIN is graded like cervical lesions used to be:

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

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VAGINAL VAULT, BIOPSY:
- SEVERE VAGINAL INTRAEPITHELIAL NEOPLASIA (VAIN 3), SEE COMMENT.

COMMENT:
The biopsy shows some maturation; however, focally, large cells, dyskeratotic cells 
and keratinization are present. The lamina propria/epithelial interface sampled is 
well-demarcated.
VAGINAL VAULT, BIOPSY:
- SEVERE VAGINAL INTRAEPITHELIAL NEOPLASIA (VAIN 3).
VAGINA, BIOPSY:
- MODERATE VAGINAL INTRAEPITHELIAL NEOPLASIA (VAIN 2).
VAGINA, BIOPSY:
- MILD VAGINAL INTRAEPITHELIAL NEOPLASIA (VAIN 1).

Micro

VAIN 3

The sections shows squamous epithelium with large atypical cells in the upper third of the epithelium. Mitotic activity is seen in the upper third of the epithelium. Dyskeratotic cells are present. Compact keratin and parakeratosis are present.

The lamina propria/epithelial interface sampled is well-demarcated.

VAIN 2

A. The sections shows squamous epithelium with large atypical cells in the lower two-thirds of the epithelium. Mitotic activity is seen in the lower half of the epithelium. Dyskeratotic cells are present. Compact keratin and parakeratosis are present. Some maturation to the surface is present.

The lamina propria/epithelial interface sampled is well-demarcated.

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. 2.0 2.1 URL: http://www.nlm.nih.gov/medlineplus/ency/article/001509.htm. Accessed on: 6 July 2010.
  3. 3.0 3.1 3.2 Kondi-Pafiti, A.; Grapsa, D.; Papakonstantinou, K.; Kairi-Vassilatou, E.; Xasiakos, D. (2008). "Vaginal cysts: a common pathologic entity revisited.". Clin Exp Obstet Gynecol 35 (1): 41-4. PMID 18390079.
  4. Apostolis, CA.; Von Bargen, EC.; DiSciullo, AJ.. "Atypical presentation of a vaginal epithelial inclusion cyst.". J Minim Invasive Gynecol 19 (5): 654-7. doi:10.1016/j.jmig.2012.03.027. PMID 22935309.
  5. 5.0 5.1 URL: http://missinglink.ucsf.edu/lm/DermatologyGlossary/herpes_simplex.html. Accessed on: 30 August 2011.
  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. 8.0 8.1 URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Vagina_11protocol.pdf. Accessed on: 4 April 2012.