Vulva and Vagina Flashcards
The provided slide is a normal histological sample of what gross structure?
Labia majora
- black curved arrow: collagen in subepithelial collagen
- blue open arrow: adipose
- black open arrow: adnexal structure
How could you differentiate a histological slide of the labia majora & labia minora?
adnexal structures & adipose tissue are largely absent in the labia minora
What type of virus is HSV & which subtype is most commonly associated with genital infections?
DNA
HSV2
(cases of HSV1 are increasing)
What are the 4 types of genital herpes infections?
-
Primary
- symptomatic or non-symptomatic (3-7 days post inoculation)
- fever, malaise, tender inguinal lymph nodes painful ulcers
- ulcers heal 1-3 weeks
-
Non-primary
- acquisition of HSV-1 if already infected with HSV-2 (or vice versa)
-
Latent
- virus established in the regional lumbosacral nerve ganglia
-
Reactivation
- reactivation due to any decrease in immune function
Are primary or non-primary HSV infections more likely to be symptomatic?
primary
What demographic is most at risk to HSV infections?
neonates
Why is it recommended that a pregnant woman with active HSV infection at time of labor have a C-section?
neonatal infections can be severe / fatal
The provided image is a gross example of what condition?
HSV2 infection
- small, grouped papules or vesicles on mucosa → extending to skin
- vesicles rupture, leavign erosions (ulcers)
What condition is depicted in the provided histological slide?
HSV2 infection
- Cowdry Type A body (large, eosinophilic nuclear inclusions & clear halo)
- ulcerated epidermis
- intracellular ballooning & degradation keratinocytes
- keratinocytes that have lost intercellular connection, multinucleation, nuclear molding, ground glass appearance
- prominent acute inflammatory infiltrate
The provided image is a gross example of what condition? Where can these lesions be located?
molluscum contagionsum
genitals, lower abdomen, buttocks, inner thighs
- well-circumscribed, dome-like structure with central umbilication
- usually multiple & separate
What is the cause of molluscum contagiosum & how is it transmitted? Treatment?
pox virus
direct contact or shared articles (ie towels)
most regress within 6 months
The provided histological slides show what condition?
molluscum contagiosum
- dome-shaped papule with cup-shaped center with brightly eosinophilic cytoplasmic inclusions (“molluscum bodies”)
- downward proliferation of squamous epithelium into dermis
Genital warts is usually caused by what HPV strains?
How is it transmitted?
6 & 11
sexual contact
What condition is shown in the provided gross image?
Precancerous?
condyloma acuminatum (genital warts)
not usually precancerous
- exophytic, papillary lesions
The provided histological slides are samples of what condition? The image on the left is an example of what cell type characteristic of this condition?
condyloma acuminatum (genital warts)
- epidermal hyperplasia, hyperkeratosis, prominent granular layer
- usually little to no dysplasia
- Left: koilocytes -→
- enlarged cells with perinuclear halos
- enlarged / condensed nuclei
- multinucleate often sen
What is the most common genital warts seen in children?
verruca vulgaris
HPV2
(HPV6 / 11 is abuse until proven othrwise)
What condition is shown in the provided image?
Bartholin Duct Cyst
What is the most common vulvar cysts?
Cause?
Bartholin Duct Cysts
obstruction of the duct by inflammation
What would be the typical presentation of a patient with a Bartholin Duct Cyst?
- female in 20s
- most commonly unilateral in labia minora
- painless swelling
- enlargement of cyst may cause pain
Bartholin duct cysts have what type of epithelium?
lined by cuboidal, transitional or mucinous epithelium (may be obliterated by inflammation)
When looking at a histological slide, how could you differentiate condyloma acuminatum from molluscum contagiosum?
NO koilocytes in molluscum contagiosum
YES koilocyttes in condyloma acuminatum
What is the clinical presentation of a patient with lichen sclerosus?
- postmenopausal woman
- +/ - itchy
- white, parchment-like appearance of skin
- “tissue paper” appearance
What condition is depicted in the provided image?
Lichen sclerosus
- initially smooth, pale plaques that enlarge & coalesce to form rough, scaly patches
- severe cases, labia may become atrophic w/ constricted vaginal orifice
The provided histological slide is a sample of what condition?
Lichen Sclerosus
- band-like lymphocytic infiltrate in deeper dermis
- thinning of epidermis with degeneration of basal cells & hyperkeratosis
- sweat glands & pilosebaceous units are absent
- low cellularity of dermis
Usual Vulvar Intraepithelial Neoplasia
(U-VIN)
HPV-related?
Age most commonly affected?
Progression?
- HPV-related, usually type 16
- 30s & 40s
- progression is unlikely & may regress spontaneously
Differentiated Vulvar Intraepithelial Neoplasia
(D-VIN)
HPV-related?
Age most commonly affected?
Progression?
Not HPV-related
60-70s
Progression is likely
80-90% progress to SCC over 23 months
Which of the provided images is an example of U-VIN & which is an example of D-VIN?
- Left: U-VIN
- atypical parakeratosis -/+ koilocytosis
- peripheral palisading and hypercellularity
- mitotic figures are common
- Right: D-VIN
- epithelial thickening with parakeratosis & elongated, anastamosing rete ridges
- enlarged, hypereosinophilic keritinocytes
- abundant keratin & keratin pearls
- atypia is concentrated at basal layer
Describe the typical gross presentation of U-VIN.
- usually multiple lesions
- flat or exophytic
- varying pigmentations
- most commonly affects
- labia majora/minora
- posterior fourchette
- clitoris
- mons pubis
- perineal
- perianal skin
Is the provided histological slide more likely a sample from U-VIN or D-VIN?
U-VIN
Describe the typical gross presentation of D-VIN.
- usually a solitary lesion
- flat or exophytic
- usually hypopigmented
- most commonly affects
- labia majora/minora
- posterior fourchette
- clitoris
- mons pubis
- perineal
- perianal skin
Answer the following questions with regards to HPV-dependent Vulvar Squamous Cell Carcinoma (VSCC):
- Makes up what percent of all VSCC?
- Most common in women of what age?
- Association with what other conditions?
- Positive / negative for p16?
- Positive / negative for p53 mutations?
- 30%
- 35-65 yrs
- associated with U-VIN & HPV
- Positive p16
- Negative for p53 mutations
Answer the following questions with regards to HPV-independent Vulvar Squamous Cell Carcinoma (VSCC):
- Makes up what percent of all VSCC?
- Most common in women of what age?
- Association with what other conditions?
- Positive / negative for p16?
- Positive / negative for p53 mutations?
- 70%
- 55-85 (older)
- Associated with lichen sclerosus & D-VIN
- Negative for p16
- Positive for p53 mutations
What condition is shown in the provided image?
Vulvar Squamous Cell Carcinoma
- white, firm mass with raised borders
- endophytic or exophytic
- flat or ulcerated
- may be multiple tumors
- few mm to cm
Squamous cell carcinoma constitutes what percent of all vulvar cancers? What percent of all female genital cancers?
95% vulvar cancers
5% female genital cancers
What risk factors are associated with vulvar squamous cell carcinoma?
increased # sexual partners
cigarette smoking
immunodeficiency
genital granulomatous disease
What is the clinical presentation of a patient with vulvar squamous cell carcinoma?
- slow-growing papule, nodule or plaque
- commonly ulcerates
- pain, pruritus, +/- bleeding
What features of the provided image help you identify the condition? What is the condition?
Invasive Squamous Cell Carcinoma
- irregularly shaped & sized sheets, cords, nests and trabeculae
- Keratin pearls
- Desmoplastic stroma
What pathology is depicted by the provided gross image?
Papillary hidradenoma
- well-circumscribed, skin-colored nodules
- solid or cystic
- may be ulcerate (trauma)
What is a Papillary hidradenoma?
benign gland-forming tumor with apocrine differentiation
Papillary hidradenoma are most commonly found in what demographic? Treatment?
30-50
White
excision is curative
The provided histological slide is from a sample of what condition?
Papillary hidradenoma
- intradermal, well-circumscribed, nonencapsulated mass
- complex growth of branching, interconnected, anastomosing tubules
- +/- papillary structure
- double cell layer “snouts” (right)
What condition is shown in the provided gross sample?
Extramammary Paget Disease
- ill-defined, scaly raised red plaque/rash
- millimeters to centimeters
What is Extramammary Paget Disease?
intraepidermal carcinoma
can be primary (90%) or secondary (associated with extracutaneous malignancy)
What is the most common vulvar adnexal malignancy?
Extramammary Paget Disease
What is the clinical presentation of Extramammary Paget Disease?
- middle-aged
- white
- moist, red, eczematous-appearing plaque/ulcer on labia majora, labia minora, or perianal skin
Extramammary Paget Disease is commonly misdiagnosed as what condition?
inflammatory process (dermatitis)
How can you differentiate a histological sample of melanoma & Extramammary Paget Disease?
Extramammary Paget Disease will stain bright pink with mucicarmine stain due to the intracytoplasmic mucin inside the tumor.
What pathology is depicted by the provided histological slides? The image to the right is an a mucicarmine stain.
Extramammary Paget Disease
- Left
- nests / single cells of large pale cells within the epidermis
- may extend into adnexa (hair follicles & eccrine glands)
- Right
- positive for mucicarmine stain
- (-) for melanoma stain
What pathology is shown in the provided histological slide?
Melanoma
- atypical melanocytes spread throughout full thickness of epidermis
- positive for melanoma marker
- negative mucicarmine stain
The provided images are normal histology of what aspect of the female reproductive organs?
vagina
- 4 epithelial layers
- basal layer (black solid arrow)
- parabasal layer (blue open arrow)
- intermediate cells (white open arrow)
- superficial cells (blue curved arrow)
What are predisposing factors to a vaginal Candida infection?
diabetes mellitus
antibiotic use
pregnancy
immunocompromised
What is the clinical presentation of vulvovaginal Candidiasis?
vulvovaginal pruritus, erythema, swelling
curd-like, white, vaginal discharge
What pathology is confirmed from the provided slides that came from vaginal discharge?
Vulvovaginal Candidiasis
- Left (KOH prep)
- budding yeast (curved arrow)
- hyphae & pseudohyphae (open arrow)
- Right (Thin Prep Papanicolaou stain)
- pseudohyphae (blue arrow) piercing epithelial cells
What pathology is shown in the provided image?
Vulvovaginal Candidiasis
- worm-like things present in teh epidermis
- often have vertical orientation
- organisms reside on/within the epidermis & do not invade the mucosa
Which infectious organism is shown on the provided slide?
Trichimonas vaginalis
- unicellular, flagellate, protazoan parasite
- motile organism with flagella
What is the clinical presentation of a patient with Trichimonas vaginalis?
- Asymptomatic - acute/chronic vaginitis
- pruritus, painful urination, painful intercourse
- yellow, frothy vaginal discharge
- marked dilation of cervical mucosa w/ fiery red appearance (strawberry cervix).
Which infectious organism is shown in the provided image?
Gardenerella vaginalis
“clue cells”
- squamous cells covered with coccobacilli with extensions to the cell edges
- velvety coat or shaggy appearance
- coccobacilli form faint granular blue background on traditional pap smears
What are risk factors for developing a Gardnerella vaginalis bacterial infection?
new sexual partner
antibiotic use
IUD
douching
What is the clinical presentation of a patient with a Gardnerella vaginalis infection?
thin, green/gray, malodorous discharge
more noticeable after intercourse
What is the clinical presentation of a patient with Vaginal Intraepithelial Neoplasia (VaIN)? Treatment?
usually asymptomatic – may present with condyloma-like lesion
Usually regresses – excellent prognosis
What pathology is shown in the provided image?
Vaginal Intraepithelial Neoplasia (VaIN)
variable white discoloration with sharp borders (acetowhite) upon application of acetic acid to cervix
What are features of the provided images indicative of VaIN?
- Left (low-grade)
- koilocytotic changes in superficial squamous epithelium
- expanded basal layer with increased mitoses
- Right (high-grade)
- high cellularity, loss of maturation & atypia in all layers
- cells with high nuclear:cytoplasm ratio
- p16 positive
What pathology is shown in the image of the provided gross sample?
Squamous Cell Carcinoma
- endophytic & exophytic growth with hemorrhagic, friable appearance
- most often affect posterior wall of upper ½ of vagina
What are risk factors for developing squamous cell carcinoma?
Greatest: previous carcinoma of cervix or vulva
high-risk HPV
non-HPV venereal infection
smoking
immunosuppression
numerous sexual partners
Squamous cell carcinoma of the cervix or vulva usually arise from what condition & most commonly affect which demographic of women?
usually arises from VaIN
postmenopausal women
What is the clinical presentation of a patient with vulvar/cervical squamous cell carcinoma?
vaginal bleeding
pain/discomfort (esp during sex)
abnormal cells on papsmear
Tumors in the lower ⅔ of the vagina metastasize to which lymph nodes? What about tumors in the uppermost ⅓ of the vagina?
- lower ⅔: inguinal lymph nodes
- upper ⅓: iliac lymph nodes
The provided image is a histological slide of what condition?
Squamous Cell Carcinoma
- Left
- non-keratinizing, basaloid & warty SCC
- most commonly associated with HPV
- Right
- keratinizing
- more often seen non-HPV related cancers
What condition is shown in the provided image?
Embryonal rhabdomyosarcoma
(sarcoma botryoides)
- polyploid, rounded, bulky masses with appearance of flusters of grapes
Embryonal rhabdomyosarcoma most commonly affects what demographic? Treatment?
infants & girls under 5 yrs
surgery & chemotherapy - tend to invade locally
The provided slides are histological samples of what condition?
Embryonal Rhabdomyosarcoma
- tumor cells are small with oval nuclei & small protrusions on one end that make them look like “tennis rackets”
- Tumor cells are crowded just beneath vaginal epithelium in “cambium layer”
- In deeper regions, cells are less numerous & lie within a edematous, fibromyxoid stroma with inflammatory cells
