Vulva Flashcards
Lichen Sclerosus
- Immune mediated
- Fibroinflammatory condition
- Male version: Balanitis xerotica obliterans
Clinical:
* Commonly postmenopausal
* Intensly pruritic
* Can become excoriated
- Increased risk of:
- Differentiated VIN (HPV independant)
- SCC
Macro:
* Irregular, ill-definied, hypopigmented patches
* Multiple, bilateral, sometimes symmetrical
* Advanced stages: skin is shiny and wrinkled (Cigarette paper)
* Atrophic labia
Micro:
* Lichenoid inflammatory reaction
* Hyalinasation and homogenisation of superficial dermal collagen.
* Displacement of inflammatory cells downwards
* Atropic epidermis
IHC:
* p53 +ve
* p16 -ve (HPV stain)
Bartholin Gland Cyst
- Vagina
*** Posteriolateral ** - Inferior thrid
Clinical:
* Blockage of gland
* Inflammation
* Trauma
* Childbirth
* Infection - Chlamydia, Gonorrhoea
Micro:
* **Transitional or squamous **epithelium
* Adjacent mucinous Bartholin glands are present in cyst wall
* Surrounding inflammation
Gartner Duct Cyst
- Vaginal cyst in children
- Anteriolateral
- 11 o’clock and 1 o’clock
Cause:
* Remnant of mesonephric duct (Wolffian Duct)
* Fails to regress —> forms Gartner duct cyst
Micro:
* ** Cuboidal to low columnar** non-mucinous epithelial
Aggressive Angiomyxoma
- Rare
- Locally aggressive
- Mesenchymal neoplasm
Clinical:
* Unique to soft tissues of the lower genital tract, pelvis and perineum
* Often large, >10cm
* Rapid growth may occur during pregnancy
* Most commonly in women of reproductive age
- Local recurrance in 30-40%
- Distant mets/death rare
- GnRH agonist therapy –> recurrent or unresectable disease.
Macro:
* Poorly circumscribed/Infiltrative
* Gelatenous cut surface
* Recurrent tumours may be more fibrotic
Micro:
* Poorly marginated
* Hypocellular
* Copious myxoid matrix
* Bland spindled cell
* Medium to large sized, hyalinised blood vessels
* Condensation of fibrillary collagen around vessels
IHC:
Myogenic markers:
* Desmin
* SMA
* Calponin
* MSA
- May be focal
- Highlight perivascular myoid bundles
- ER, PR
- HMGA2 (90%) –> highly sensitive but not specific
Angiomyofibroblastoma
- Rare benign tumour
- Painless mass
- <5mm
- Occasionally pedunculated
- No potential for recurrence
Macro:
* Well-circumscribed
* Non-encapsulated
* Tan-white cut surface
Micro:
* Alternating zones of hyper and hypocellularity
* Abundant thin-walled blood vessels
* Blank spindled, plasmacytoid and epithelioid stromal cells.
* Variable oedematous to collagenous matrix.
* Scattered lymphos and mast cells
IHC:
* Vimentin +
* Desmin +
* ER, PR +
* SMA variable
* CD34 variable
Hidradenoma Papilliferum
- Benign
- Often an asymptomatic nodule
- Almost always found in the vulva/perianal region
- Virtually identical to intraductal papilloma of the breast.
Micro:
* Sharply circumscribed
* Maze-like glandular and papilary architecture
* No connection to overlying epithelium
* Glands: Inner layer of cuboidal cells, outer layer of myoepithelial cells.
* Mitotic figures are rare
IHC:
Myoepithelial cells:
* S-100
* SMMS
* P63
Extramammary Paget’s Disease
- Vulva is the most common site
- Local recurrences are common
- Pruritic, erythematous lesions
- Considered to be in-situ adenocarcinoma
- Probably arises from multipotential cells located in the basal layer of epidermis
Micro:
* Large, pale tumour cells
* Often ,istalen for melanoma
IHC:
Intracytoplasmic mucin:
* Mucicarmine +ve
* PAS
* Alcian blue
Three types:
Primary cutaneous VPD (Type 1)
* CEA+
* CK7+
* GCDFP-15+
Secondary to intestinal malignancy (Type 2)
* CEA+
* CK20+
* CDX2+
* MUC2+
Secondary to urological malignancy (Type 3)
* CEA+
* p63+
* CK7 +/-
* CK20 +
* Uroplakin-III +ve
* GATA-3 +
Condyloma Acuminatum
- Benign
- Verrucous papillary lesion
- Caused by HPV
- Usually low risk types –> HPV6 and HPV11 are most prevalent types
Micro:
* Acanthosis
* Papilomatosis
* Parakeratosis
* Hypergranulosis
* Hyperkeratosis
* Thick rete ridges
* Koilocytic change
Squamous Intraepithelial Lesion (SIL) / Vulval Intraepithelial Neoplasm (VIN)
- Precursor lesion of HPV-associated Vulvar carcinoma
- Reproductive age women
- High Grade SIL is most frequent type
- More common in people with HIV
Risk factors:
* Smoking
* Oral contraception
* Herpes infection
* HPV infection elsewhere
Aetiology:
- HSIL: high risk types –> HPV 16 and **18, 31, 33, 45 **
- LSIL: low risk types –>** 6, 11** and **High risk types **
Prognosis:
* most LSIL regress spontaniously
* 9% HSIL progress to SCC if untreated
LSIL (VIN1)
- Low risk HPVs –> 6, 11
Micro:
* Koilocytosis/HPV cytopathic effect in upper two thirds of epithelium
* Proliferation of basal/parabasal-like cells –> lower third if epithelium
* Mitotic figures limited to lower third of epithelium
HSIL (VIN2 and 3)
- High risk HPV –> 16, 18
Micro:
* VIN 2 –> loss of maturation lower two thirds
* VIN 3 –> loss of maturation full thickness
* Atypical mitotic figures are readily identifiable
* Koilocytosis –> within or adjacent
IHC:
* P16 –> strong, block-like
* P53 –> scattered suprabasally, lack of staining in basal layer
Basaloid/Warty SCC
Imiquimod and other antivirals
Differentiated Type Vulvar Intraepithelial Neoplasia (dVIN)
- Precursor lesion of HPV independent vulvar squamous cell carcinoma.
- Post-menopausal women
Cause:
* Chronic inflammatory dermatoses
* Lichen sclerosis
* Lichen simplex chronicyus
Micro:
* Mild to moderate atypical cells in basal and parabasal layers.
* Lacks full thickness atypia
* Enlarged squamous cells with eosinophillic cytoplasm
* Vesicular nuclei, prominent nucleoli
* Acanthosis, parakeratosis, anastomosis of rete ridges
Molecular:
* HPV ISH negative
* Mutations in TP53 - basal/parabasal over expression or absent
* Also can have TP53 wildtype variant - scattered expression
- More likely to progress to invasive carcinoma than usual VIN
- Shorter latency to become invasive
IHC:
* P53 overexpression in lower third of epithelium
* Ki67 confined to basal levels
* p16 -ve
Keratinising SCC
Role of immune checkpoint inhibition
Vaginal Polyp
- Women of childbearing age
- Often found during pregnancy
Macro:
* Soft, polypoid/papillary mass
* Usually lower third of vagina
* Usually <4cm
Micro:
* Squamous epithelium
* Plump, cytologically atypical myofibroblasts
* Bizarre multinuclei giant cells may also be present
* Mitotic activity is generally low.
IHC:
Stromal cells:
* Vimentin
* Desmin
* ER
* PR
