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endo/repro test 2 > Pathology of the Vulvar/Vagina > Flashcards

Pathology of the Vulvar/Vagina Flashcards

1
Q

Persistent/progressive inflammatory dermatosis of unknown etiology

A

Lichen sclerosus

AKA Chronic atrophic vulvitis AKA Lichen sclerosus et atrophicus

with predilection for vulva; may be perianal Very thin, white, itchy skin

Usually age 40 years or older (more common after menopause)

Rare in children, may involute spontaneously at puberty

May be familial; associated with autoimmune diseases

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2
Q

Lichen sclerosus:

  1. Associated risk with what cancers?
A

Benighn:

  1. NOT A PREMILIGNANT! But ass. with

VIN > squamous cell carcinoma 9% developed VIN, 21% developed invasive squamous cell carcinoma (mean 4 years later)

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3
Q

Non-specific condition resulting from rubbing or scratching to relieve pruritis

  1. underlying causes?
A

Lichen simplex chronicus AKA squamous cell hyperplasia

include specific infection (e.g. candida) and irritants.

May be idiopathic Generally considered a benign (not premalignant) lesion, but sometimes seen near areas of with squamous cell carcinoma

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4
Q

Gross features of Lichen simplex chronicus

A

Gross:

thick, scaly plaques with erythema, well demarcated from surrounding skin;

associated with excoriation, lichenification

Micro:

irregular acanthosis, orthokeratosis and parakeratosis; dermal fibrosis, hyperplasia of small dermal nerve trunks within dermal scars TX: topical steroid or topical calcineurin inhibitor

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5
Q

vaginitis can be: What are the pH ranges of these disorders?

1.

2.

3.

A
  1. bacterial vaginosis: pH>4.5
  2. vulvovaginal candidiasis: <= 4.5 (normal)
  3. trichomonas >4,5
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6
Q

characteristics of the vaginal discharge that should be noted during examination:

1.

2.

3.

4.

A

Color

Viscosity

Adherence to vaginal walls

Presence of an odor.

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7
Q

A discharge specimen should be collected from the ____ of the vagina

A

lateral wall

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8
Q

Diagnosis of VD can be concluded by what lab findings?

  1. pH
  2. Special cells
  3. Special test. What chemical is used?
  4. Discharge
A
  1. pH >4.5, which is most sensitive but least specific sign.
  2. The presence of 20% clue cells (bacterial clumping upon the borders of epithelial cells) on wet mount examination.
  3. Positive amine, “whiff” or “fishy odor” test (liberation of biologic amines with or without the addition of 10% KOH). 4. Homogeneous, nonviscous, milky-white discharge adherent to the vaginal walls.
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9
Q

Bacterial clumping upon the borders of epithelial cells are called __. This indicates what infection?

A

Clue cells

Bacterial Vaginosis

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10
Q

Homogeneous, nonviscous, milky-white discharge adherent to the vaginal walls

A

BV

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11
Q

Gold standard for BV diagnosis

A

Gram Stain

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12
Q

What does a normal Gram stain of vaginal discharge show?

A
  1. lactobacillus (long Gram-positive rods) only or lactobacillus with few Gardnerella morphotypes.
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13
Q

What findings are indicative of BV on a smear (wet mount)?

A

When a more mixed flora is present and lactobacillus is absent or present in low numbers

Will see granular appearance and shaggy looking cytoplasm from clue cells

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14
Q

Embyrological developement of vagina:

upper 2/3

Lower 1/3

A
  1. paramesonephric ducts AKA Mullerian ducts
  2. lower third of vagina derived from urogenital sinus.
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15
Q

Findings that indicate Trichomonas

  1. Wet mount
  2. pH
A
  1. Motile trichomonads seen in a saline wet mount (most common method)! This is required!
  2. pH>4,5
  3. NAAT (nulceic acid amp test)
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16
Q

Strawberry cervix

A

Trichomonas

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17
Q

Sensitivity, specitivity of the following tests in order

culture vs OSOM vs. wet mount vs. Affirm

A

culture> OSOM/Affirm> wet mount

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18
Q

Presence of any persistent Mullerian type columnar glandular epithelium in vagina

A

Adenosis

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19
Q

Explain the etilogy of Adenosis

A

•Normally during development stratified squamous epithelium in the lower third of the vagina that is derived from the urogenital sinus migrates upward and replaces the columnar type epithelium in the upper 2/3 of the vagina that was derived from Mullerian ducts

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20
Q

Diethylstilbestrol (DES): Risks of :

woman that took is

Duaghters

Sons

A

•Women that took DES

–Increased risk of breast cancer

•Daughters of mothers that took DES during pregnancy

  1. vaginal adenosis
  2. clear cell adenocarcinoma
  3. abnormalities in formation of uterus and fallopian tubes

•Sons of mothers that took DES during pregnancy

  1. increased risk of epididymal cysts
  2. cryptorchidism
  3. testicular inflammation/infection
21
Q

Clear cell adenocarcinoma

  1. Is this malignant?
  2. Mean age of pt?
  3. Increased risk in pt with ___
A
  1. yes
  2. Mean age 22 years
  3. vaginal adenosis 2/3 have history of in utero DES exposure
22
Q

A biopsy reveals malignant cells that have abundant clear cytoplasm (glycogen) arranged in a mixture of glandular, cystic, solid and papillary patterns, glands often contain hobnail cells.

A

Clear cell carcinoma

23
Q

Hobnail cells are found in what diseases? Describe morphological appearance.

1.

2.

3.

A
  1. clear cell ovarian adenocarcinoma,
  2. collecting duct carcinoma
  3. end-stage cirrhosis.
24
Q

A 2 year old girl presents to the ED with •vaginal a grape-like mass projects out of the vagina.

  1. What microscopic features would you expect to find?
  2. What markers would be positive on staining?
  3. What is th dx and tx?
A

–1. spindle-shaped tumor cells with cross-striations in cytoplasm (rhabdomyoblasts) as well as cambium layer: tumor cells crowded beneath intact vaginal epithelium

  1. Stain positively for desmin, actin, and myogenin

Embryonal Rhabdomyosarcoma

Tx: surgery combined with multidrug chemotherapy

25
Q

A woman is diagnosed with Vaginal squamous cell carcinoma.

  1. Where does this tumor arise?
  2. What predisposing factors can cause this?
  3. What is a precursor fnding that can identify the risk of developing this cancer?
A
  1. Malignant neoplasm arising in vaginal squamous epithelium
  2. HPV
  3. Get dysplasia (vaginal intraepithelial neoplasia) initially as precursor to carcinoma
26
Q

A woman is dx with Vaginal squamous cell carcinoma. Where are metastasis most likely to occur in the tiumor is found in the lower 3rd of the vagina vs. the upper 2/3?

A

lower third of the vagina metastasize to the inguinal nodes

upper two-thirds of the vagina tend to spread to regional iliac nodes

27
Q

Portion of the female genitalia that consists of the skin and mucosa external to the hymen

What type of epithelial tissue is found here?

A

Vulva

•Squamous epithelium

28
Q

Lichen Sclerosis features:

Gross

Microscopic

A

Gross: atrophic skin resembles cigarette paper (crinkly atrophy); often with loss of labia; also white/red ill-defined patches

Micro: :

hyperkeratosis; thin epidermis,

loss of rete pegs,

homogenized band of dense fibrosis at papillary dermis,

chronic inflammation around vessels that is often band like

TX: Topical steroids, calcipotriol cream, topical and systemic retinoids (acitretin), and systemic steroids.

29
Q

parakeratosis vs

A

Hyperkeratosis with retention of nuclei in

stratum corneum

ass. with psoriasis

30
Q

What is VIN?

What changes do you see if associated with HPV?

A

Vulvar Intraepithelial Neoplasia involves dysplastic changes to normal vaginal cells.

Doesn’t always lead to cancer

Koilocytic change (cells with perinuclear halos)

31
Q

VIN (Vulvar Intraepithelial Neoplasia) is dz in a 60 year old woman. The woman also has a PH for lupis. What findings would indicate whether she has classic or differentiated VIN?

A

If Differentiated:

•Atypia confined to lower layers of epithelium only (in the basal and parabasal layers)

P53 mutation

Lichen: sclerosis or simplex chronicus

NO HPV!!!

If classic then HPV is prevelant

•discrete white (hyperkeratotic) or a slightly raised, pigmented lesion.

32
Q

VIN treatment and care

A

•VIN can be treated with excision, laser ablation, or topical imiquimod (off-label use).

Monitor for vulvar cancer every 6-12 months annualy

33
Q

Vulvar Squamous Cell Carcinoma

2 groups:

1.

2.

A

•Two main groups

  1. Keratinizing squamous cell carcinomas (65-80% of cases)
  • unrelated to HPV infection.
  • older women.
  1. Basaloid and warty carcinomas (20-35% of cases) related to infection with high risk HPV types, most commonly HPV-16.
    * These occur at younger age.
34
Q
A
35
Q

paired structures which lie deep to the posterior ends of the labia minora

A

Bartholin’s Glands

duct on each side opens between the labium minus and the hymen and is about 0.5 cm long

  • Secrete lubricating mucus
  • Normally the gland cannot be palpated
36
Q

Bartholin’s Gland Cysts

  1. often related to what infection?

Treatment:

A

Gonnorrhea

•: Word catheter, surgery, marsupialization, excision, antibiotics for infection

37
Q

This •is usually a primary malignancy involving the labia majora and is a glandular tumor of vulva.

If secondary, what dx are related?

1.

2.

A

Extramammary Paget’s Disease

15-30%:

  1. adenocarcinoma of anorectum
  2. urothelium, prostate)
38
Q

Extramammary Paget’s Disease:

What other cancer must this be differentiated from?

How can you do this?

A

melanoma

–EMPD: pankeratin+, PAS+, S100-

–Melanoma: pankeratin-, PAS-, S100+•

39
Q

Extramammary Paget’s Disease

Gross:

Micro:

Tx

A

Gross: Crusting, weeping, oozing lesion; may be erythematous

  • Micro: large pale staining tumor cells, usually in lower epidermis, in nests, glandular spaces or continuously along basement membrane; contain mucin
  • TX: Complete surgical excision
40
Q

large pale staining tumor cells, usually in lower epidermis, in nests, glandular spaces or continuously along basement membrane; contain mucin:

What tumur could this be?

What markers could verify this assumption?

A

Extramammary Paget’s Disease

+pankeratin

+PAS+

-S100

41
Q

Crusting, weeping, oozing lesion

A

Extramammary Paget’s Disease

42
Q
  • Papillary Hidradenoma
  • AKA Hidradenoma Papilliferum

Gross:

Micro

A
  • May arise from apocrine sweat glands of vulva or from ectopic breast tissue along milk line
  • Gross: Benign, small, sharply circumscribed nodule covered by normal skin, often on labia majora or interlabial folds
  • Micro: well differentiated, complex papillary glandular pattern with some stratification and pleomorphism
  • TX: Excision
43
Q

arise from apocrine sweat glands of vulva or from ectopic breast tissue along milk line

A

Papillary Hidradenoma

•AKA Hidradenoma Papilliferum

44
Q

•Condyloma acuminatum

  1. Location: Related to what viral subtypes?

A.

B.

C.

A

Sexual transmitted disease, lesions may be multiple and coalesce

  1. Location: Vulvar, vaginal, perianal, perineal
  2. HPV types 6 and 11
45
Q

•Condyloma acuminatum

Gross

Micro:

A

•Micro:

acanthosis,

hyperkeratosis,

parakeratosis,

nuclear atypia with raisin-like nuclei with perinuclear halos (“koilocytic change”).

•Multiple treatment options

46
Q

Clear cell adenocarcinoma

Symptoms?

Gross:

Micro:

Tx

A

abnormal vaginal bleeding or discharge

About 25% are asymptomatic

Gross: usually a polypoid mass that typically originates from the anterior wall of the upper two-thirds of the vagina (may involve most of vagina); usually only superficially invasive at diagnosis

Micro: malignant cells that have abundant clear cytoplasm (glycogen) and are arranged in a mixture of glandular, cystic, solid and papillary patterns, glands often contain hobnail cells.

TX: Surgery, may need radiation therapy/chemotherapy for large/extensive tumors

47
Q

usually a polypoid mass that typically originates from the anterior wall of the upper two-thirds of the vagina (may involve most of vagina); usually only superficially invasive at diagnosis

A
48
Q

malignant cells that have abundant clear cytoplasm (glycogen) and are arranged in a mixture of glandular, cystic, solid and papillary patterns, glands often contain hobnail cells.

A

Clear cell adenocarcinoma

endo/repro test 2 (8 decks)

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