ASF - Vulva and Vagina (Richardson) Flashcards
How do HPV-infected keratinocytes differ from normal keratinocytes?
HPV-infected cells have perinuclear clearing and binuclear, raisinoid nuclei
What is another term for condyloma acuminatum? What causes these?
Genital Warts
Typically caused by HPV 6 or 11
In what two locations can Paget’s Disease manifest?
Breast and vulva (rare)
Which patient population is at most risk for developing invasive squamous carcinoma of the labia?
Older women (over 65)
A 24-year-old female patient visits the physician at her local clinic to try to figure out why she has white lesions on her vulva. After visualizing the lesions (see below), you realize that this patient has what condition? Is it cancerous?
Condyloma acuminatum (aka genital warts)
These are typically benign lesions caused by HPV strains 6 and 11. These strains don’t normally progress to cancer.
What are the two main characteristics of lichen simplex chronicus?
Squamous hyperplasia and spongiotic dermatitis
Which patient population is at highest risk to get Paget’s Disease?
Women over the age of 70
What is the primary treatment for vaginal lichen sclerosis?
Highly potent steroid cream
A 62-year-old female visits her gynecologist complaining of a red rash that is covering the skin surrounding her vulva. On inspection, you notice a red, raised patch of skin with a scalloped (winding) border. You also notice patches of white within the red patches. What accounts for the difference in color of the lesion?
Keratin deposition
This patient has squamous carcinoma in situ (scalloped lesion with alternating red and white patches).
Leukplakia (white patches) - when keratin is spread out within epidermis
Erythroplakia (redness) - when keratin is tightly packed
What are the 3 common histiological findings of a biopsy of lichen simplex chronicus?
- Squamous hyperplasia
- Keratosis (ortho or para) - change in number of nuclei in epidermal keratin-producing cells
- Lymphocytic infiltrate of dermis
True or False: Squamous carcinoma in situ does not typically invade underlying tissues.
True
An 82-year-old female patient presents to the Gyn/Onc department to discuss options for the treatment for her cancer. When performing the physical exam, you notice patches of redness and patches of white surrounding the vulva. The patches are slightly raised, but do not feel like they are tumors. What does this patient most likely have and what primary findings would you be able to see on a histologic section?
Paget’s Disease of the Vulva
Histology should show:
Epidermal hyperplasia
White, cleared out cells (adenocarcinoma cells)
If stained with PAS, mucin droplets will be present (dark purple)
What is the most common type of female genital malignancy?
Squamous cell carcinoma
A 26-year-old female patient comes to her primary care physician complaining of an very itchy rash that started on her thighs and has since spread to her buttocks and vulva. During the physical exam, you notice that the skin is red and swollen. What is the causative agent of this patient’s condition?
Candida albicans
The patient has candidiasis.
Remember that Candida albicans is a commensal that grows in moist areas. It commonly spreads throughout the intertriginous zones (buttocks, vulva, and thigh), and it is very itchy and inflamed.
What causes hyperplasia of the squamous epithelium of the vulva that leads to lichen simplex chronicus?
Chronic irritation of the skin leads to epidermal thickening (hyperplasia) and inflammation
What is the main reason that lichen sclerosis is sometimes considered an autoimmune disease?
Buildup of activated T-cells in the dermis
These T-cells attack host dermal and epidermal cells, leading to atrophy of the epidermis and acellularity and sclerosis of the dermis.
Which strain of humanherpesvirus is responsible for causing vulvar herpes simplex infection?
HSV2 (Herpes simplex virus 2)
What are the two causes of Bartholin Gland Abscesses?
Bacterial infection and blockage of duct opening
During Spring Break, a 21-year-old female contracts a sexually transmitted infection from having unprotected sex with a random partner. The lesion appears to be a firm, painless ulcer on the fourchette. Her doctor gives her a shot of an antibacterial medicine and tells her not to have sex for the next two weeks. What medication was injected into this patient?
Penicillin
The patient has primary syphilis, an infection with Treponema pallidum. Patients with primary syphilis will be given an injection of penicillin (it not allergic), which should clear up the infection.
Failure to treat the primary infection can lead to secondary and tertiary syphilis, which have worsening symptoms.
What two immunohistochemical stains are useful in determining if a malignancy is Paget’s disease?
Carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20)
What are the 3 most common bacteria that cause inflammation/infection of the vulva?
Chlamydia trachomatis, Treponena pallidum (syphilis), gonococcus (gonorrhea)
What are two forms of benign vaginal neoplasms?
Condyloma (HPV) and leiomyoma (benign smooth muscle tumor)
What is the blue arrow pointed to? Which disease is this characteristic of?
Molluscum body
Characteristic of Molluscum contagiosum
What are the 3 types of squamous carcinoma in situ of the vulva?
- Bowen’s Disease - flat, red plaques
- Erythroplasia of Querat - plaque involving mucosa of vestibule
- Bowenoid Papulosis - verrucous wart-like lesions, typically occuring in pregnancy
A 26-year-old female presents to her gynecologist with concerns about genital warts that she has had for the past few months. She states that they didn’t bother her before, but now it looks like they are bleeding and that her skin is “dying.” On examination, you notice raised, white lesions with a central ulceration. If you were to biopsy this lesion, what would you expect to see within the tissue sample?
Treponema pallidum (spiral bacteria)
This patient is suffering from secondary syphilis. Primary syphilis is associated with a painless chancre. Secondary and tertiary syphilis can arise if the primary infection is not treated.
Secondary lesions appear raised, white, and with a central ulceration.
In what age-group is lichen sclerosis et atrophicus most common?
Post-menopausal women
How are Treponema pallidum, the bacteria that cause syphilis, identified under the microscope? Give the stain and the appearance of the bacteria.
Silver stain is used to stain the bacteria black so that they can be visualized under the microscope.
The bacteria are spirochetes, meaning that they are spiral in appearance.
What is ortho- and parakeratosis and which condition are they involved in?
- Orthokeratosis - keratin layer of epidermis with little to no nuclei
- Parakeratosis - keratin layer of epidermis with lots of nuclei
Involved in lichen simplex chronicus
True or False: Lichen sclerosis does not cause atrophy of the labia.
False
Lichen sclerosis is characterized by white, thin skin of the labia due to atrophy of the epidermis and hypocellularity of the dermis.
A 35-year-old female patient comes to her OB/Gyn for a yearly checkup. She tells you that she has had a rash on her vulva for a while now. On physical examination, you notice a raised, puffy, hypopigmented rash of the labia (seen below). What is the name of this condition and what are some common causes of it?
Lichen Simplex Chronicus
Causes:
- Chronic inflammation
- Constant physical irritation of skin of area
- Allergic exposure - lotions, detergents, etc. causing rash
What 3 characteristics would be noted on a histological slide of a biopsy of a patient with squamous cell carcinoma?
- Thickened epidermis
- Lymphocytes infiltrating dermis
- Cords of epidermis invading dermis
What is a condyloma lata and which specific disease is it associated with?
Condyloma lata are white, raised exophytic lesions of the skin caused by epidermal hyperplasia. These lesions typically also have central ulceration.
Associated with secondary syphilis
A 19-year-old female patient comes to your office to discuss an “ugly bump” on her labia. She says that it has caused her some pain, and that her boyfriend will not have sex with her until she gets it fixed. She is afraid that it could be cancer or an STI. During your physical exam, you notice swelling and outpouching of the labia, red, inflamed skin, and tenderness to palpation. What is your diagnosis and what treatment would you recommend?
Bartholin Gland Abscess
Treatment: Wood catheter to drain gland OR surgical removal
Bartholin Gland Abscesses occur with physical blockage of the duct opening or with bacterial infection. The abscess should be drained, or the gland should be removed.
What is the classical appearance of herpes simplex infection of the vulva?
White vesicles bilaterally of the vulva and perineum
A 22-year-old female visits her GP to discuss what she believes are genital warts. She states that she had unprotected sex with a man that she met at a club a few weeks ago. She is worried that she has HPV even though she has had the vaccine. On physical exam, you notice firm papules on the skin of the thigh and labia majora that have a central indentation. What would you expect to find on a histologic slide of this lesion?
Molluscum bodies
The patient has molluscum contagiosum, a form of poxvirus that invades the keratinocytes and produces papules.
Molluscum bodies are cytoplasmic inclusions within keratinocytes that contain highly contagious poxvirus.
Which histologic test is done by examining pus from a ruptured vesicle of a herpes simplex virus? What is it looking for?
Tzanck Smear
Looks for multinucleated giant cells, which are indicative of a herpesvirus infection
What are two common histologic findings on a biopsy of a verrucous carcinoma?
- Church spire plugging of keratin
- Elephant feet
What is the hallmark feature of Molluscum contagiosum in terms of gross pathology?
Firm, pearly papules with central umbilication
Describe the histological characteristics of a tissue sample of lichen sclerosis.
- Epidermis - atrophic and flattened
- Dermis - 3 layers
- Acellular layer - causes the whitening of skin
- Band of T-cells - lymphocytic infiltrate
- Sclerotic layer
What are commonly found in the epidermis of a patient with candidiasis?
- Neutrophils
- Candida spores
- Pseudohyphae
What is the main gross pathological characteristic associated with lichen simplex chronicus?
Areas of leukoplakia (whitening of the skin) that protrude outward due to thickened epidermis
A 70-year-old female patient comes to her OB/Gyn office complaining of a white rash on her labia. During the physical exam, you notice that the skin of the labia appears very thin and that the area is hypopigmented (seen below). On palpation, you don’t notice any swelling or raised lesions. Based on this patient’s symptoms and your exam findings, what disease process is occurring and how would you treat it?
Lichen Sclerosis
Treatment: high-potency steroid cream
Remember that LS is characterized by a whitening and atrophy of the labia that typically occurs in post-menopausal women. The lesion was said to flat and not bulging. If the “rash” were raised, it would be lichen simplex chronicus.
