Vulvar Disorders Flashcards by Fatema Arastu

Infectious/Inflammatory Vulvar Disorders

Bartholinitis, (Bartholin cyst) and Non-neoplastic epithelial disorders (Lichen Sclerosis and Squamous cell hyperpasia)

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Vulvar Tumors

Benign exophytic lesions including condyloma acuminatum, and vulvar cancers includng VIN, Squamous Neoplastic lesions, glandular neoplastic lesions, and malignant melanoma

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adenitis

acute inflammation of gland (like in bartholinitis)

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function of bartholin gland

provide moisture for vaginal vestibule

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location of bartholin glands

located at 4 and 8 o clock on L and R side of vagina

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infection of bartholin gland can result in 1 of 2 things:

adenitis (acute inflammation of the gland) or abscess (infected cyst, usually 1-8 cm)

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remnants of male embryonic structures that are in the differential diagnosis of bartholin cyst

mesonephric cyst of the vagina and canal of nuck (hydrocele-fluid filled sac in scrotum- residua of wolffian duct that can form in vaginal vault or can go to perineum and come out looking like bartholin cyst

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bacterial organisms responsible for bartholin cyst

e. coli, staph, strep, sexually transmitted pathogens -usually polymicrobial cause

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non bacterial causes of bartholin cyst

obstruction of duct by inflammatory process or trauma

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chronic bartholinitis

small cyst, slightly tender, but usually asymptomatic

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DDx of bartholin cyst

mesopnephric cyst of the vagina, canal of nuck (hydrocele), epithelial inclusion cyst

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manifestations of bartholin cyst

can by asymptomatic if small cyst, painful if large cyst or abscess, or cause local discomfort

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tx options of bartholin cyst

I and D (high recurrence, do with another procedure), abx for complicated infection, excision, or marsupilization or word catheter

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abx prescribed for bartholin cyst

cefixime if strep or e. coli, and clindamycin if staph

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cystadentitis without abscess tx

abx and hot sitz bath 3x a day at home

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asymptomatic cyst tx

none needed if less than 40. if over 40, need tx with biopsy to r/o carcinoma

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opaque white, plaque like mucosal thickening on female genitals that produces itching and scaling

leukoplakia

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what percents have paget’s patients have underlying adenocarcinoma?

15%

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White plaques on female genitals might be d/t any of the following non-neoplastic epithelial disorders:

leukoplakia, psoriasis, lichen sclerosus, lichen simplex chronicus

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rete pegs

inward projections of the epidermis into the dermis

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Smooth white plaques or papules in vulvar region in post menopausal women complaining of dyspareunia and itching. Labia are atrophied and stiff. Vaginal orifice is constricted. Dx?

Lichen sclerosus

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Lichen sclerosus characterized by

atrophy

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histopathology of lichen sclerosus

Epidermis changes- Hydropic degeneration of basal cells, thinning of epidermis, superficial hyperkeratosis, disappearance of rete pegs. Dermis- dermal fibrosis. Scant perivascular mononuclear infiltrate

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Scant mononuclear infiltrate in lichen sclerosus refers to what?

chronic inflammatory condition involving monocytes, macrophages, lymphocytes, PMS, neutrophils

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the primary skin disease of vulva in post menopausal women

lichen sclerosus

Can lichen sclerosus become malignant?

Yes. It is an epithelial disorder that can become SCC. FOLLOW CLOSELY!

Pathogenesis of lichen sclerosus

autoimmune disorder- activated T cells, presence of other autoimmune diseases

You are seeing a postmenopausal women with symptoms that sound like lichen sclerosus. What other autoimmune disorders do you ask her about in history?

DM, thyroid dz (esp hypo), vitiligo, pernicious anemia

acanthrosis

thickening epidermis

histological changes in lichen simplex chronicus

Acanthrosis, hyperkeratosis, expansion of stratum granulosum.

how to differentiate lichen sclerosus vs. lichen simplex chronicus

biopsy

Can lichen simplex chronicus be malignant?

No increase predisposition to cancer

Benign vulvar lesions that are exophytic (raised)

condyloma latum, condyloma acumnatum, fibroepithelial polyp

Looks like "cauliflower" lesion on vulva

condyloma acuminatum

how to differentiate between condyloma latum and condyloma acuminatum?

BIOPSY! but often can tell from appearance. condyloma latum- raised w/ FLAT top. acuminatum- cauliflower appearance. imp. to distinguish because tx is different

90% of all warts caused by...

HPV 6, 11

cause of condyloma acumnatum

sexually transmitted via HPV 6, 11

histopahtologic changes in condyloma acuminatum

"tree like" cores of stroma covered by squamous epithelium, and koilocytic atypia- halo around nuclei

koilocytic atypia

viral cytopathic change that causes halo around nuclei- found in condyloma acuminatum

if you see koilocytic atypic on path report of patient with condyloma acuminatum, should you take it seriously?

Yes, F/U frequently with patient becuase these cells tend to be dysplastic and found in potentially pre-CA lesions

verrucous gross appearing raised lesion on vulva that looks wart-like. may resemble cauliflower, or tree-like

condyloma acuminatum

condyloma acuminatum may involve what areas

vulvar, perineal, perianal, and vaginal regions

is condyloma acuminatum precancerous?

Not typically

4th most common site of gynecologic neoplasia

vulva

most common vulvar carcinoma

squamous vulvar carcinoma

What infections are associated with squamous cell changes of vulva, vagina, and cervix possibly causing carcinoma?

HPV 16 and 18 infections

risk factors/associations with vulvar carcinomas

smoking, coffee intake, females 30-90

list the types of vulvar carcinomas from most frequent to least

squamous (90%), malignant melanoma (5%), sarcoma, basal cell, adenocarcinoma, paget's disease, and 4% are undifferentiated

precursor of vulvar squamous cell carcinoma

VIN

2 types of VIN

Usual and differentiated

categories of usual and differentiated VIN

VIN, USUAL TYPE: Warty type, basaloid type, and mixed type. VIN, DIFFERENTIATED TYPE: Simplex type

Out of the 2 VIN'S, which is a high grade squamous lesion?

VIN, differentiated type (simplex)- progresses to cancer. More aggressive. (although both types can progress to SCC)

90% of basaloid and warty type VIN lesions are positive for

HPV 16, 18, 31

Vin, usual type lesions are often multifocal and multicentric occurring in these areas:

interlabial folds, posterior fourchette, and perineum

10-30% of people who have VIN, usual type lesions also have what lesions?

vaginal or cervical HPV related lesions

histological characteristics of VIN, basaloid type

atypical immature parabasal type cells, hyperchromatic nuclei, increased mitosis, flat smooth surface, and thickened epithelium

histological characteristics of VIN, warty type

abnormal maturation of cells from basal cell on outward, increased mitosis in these layers (including basal layer), condylomatous appearance and spiking surface

VIN differentiated or usual more common?

USUAL type. Differentiated consists of less than 5%

3 differences between VIN differentiated usual

VIN differentiated- unifocal, unicentric, NOT associated wtih HPV, and has little or no atypia above the basal layers. VIN, usual- multifocal, multicentric, mostly caused by HPV 16, 18, and 31

age group of those who get VIN, differentiated

post menopausal, above 60 years often

90% of vulvar malignancies d/t

SCC (following VIN)

VIN differentiated a/s what epithelial disorder?

lichen sclerosus

2 types of vulvar SCC's

Keratinizing, differentiated (simplex type) or Classic warty, or Bowenoid type

Risk factors for VIN, usual type

reproductive age women, male partner with multiple sexual partners, multiple sexual partners, young age at first intercourse, smoking, immunodeficiency

difference between Vulvar SCC keratining vs. classic warty type

keratinizing (simplex type)- not related to HPV, precursor is VIN differentiated (simplex) Classic warty- HPV related, precursor is VIN usual type

Lichen sclerosis progression if it becomes malignant

VIN differentiated to VIN II, III to VIN, keratinizing SCC

where is atypia located in keratinizing SCC

in basal layer of squamous epithelium

what vulvar disorders can undergo malignant transformation to keratinizing SCC?

lichen sclerosus, squamous cell hyperplasia, and differentiated VIN

keratinizing SCC metastatic spread linked to

size, depth, and lymph involvement

keratinizing SCC can metastasize to what areas?

inguinal, pelvic, iliac, and periaortic LN

keratinizing SCC dissemination to

lungs and liver

keratinizing SCC prognosis

less than 2 cm- 70% avg 5 year survival. if more than 2 cm and lymph node involvement- less than 10% 5 year survival rate

HPV association differences between Classic warty SCC vs. its precursor VIN, Usual type

VIN, usual type- most are caused by HPV 16, 18, 31. Classic warty SCC a/w HPV 16, 18, 33

age groups affected in the 2 types of vulvar SCC

keratinizing- older women. Bowenoid or classic warty SCC- younger women

variant of SCC with condyloma-cauliflower appearance, but no response to HPV treatment. Grows slows, and rarely metastasizes to lymph nodes. Dx and Tx?

Verrucous SCC. Tx: excision with good borders (radiation results in increased invasiveness and mets)

incidence of malignant melanoma

less than 5%

incidence of vulvar malignant melanoma vs. cutaneous melanoma

MM occurs often in 60's-70's, cutaneous in 40's

5 year survival of vulvar MM

less than 32%

prognosis of vulvar MM depends on

depth of invasion. If Deeper than 1 mm, 60% chance of mortality

incidence of Vulvar BCC

less than 2% of vulvar cancers

age group likely to see vulvar BCC

post menopause

This type of vulvar carcinoma is not associated with HPV, is usually non metastatic, and a/w high incidence of antecedent malignancy elsewhere

vulvar BCC

tx of vulvar BCC

excision

vulvar glandular neoplastic lesions

papillary hidradenoma and extramammary paget Dz

glandular neoplastic lesions arise from what kind of tissue?

ectopic breast tissue

papillary hidradenoma appearance

identical in appearance to intraductal papillomas of the breast

papillary projections from papillary hidradenoma with 2 layers of cells:

columnar secretory cells and myoepithelial cells (characteristic of sweat glands and sweat gland tumors)

when does extramammary paget disease present?

post menopause 60-70's in caucasians

Patient describes vulvar lesion that is itchy, red, crusted, sharply demarcated, and appears like a map. Upon palpation, you note submucosal thickening or nodule. Located on labia majora

extramammary paget disease

extramammary paget disease is confined to what areas

epidermis of skin, hair follicles, and sweat glands (pagets of breasts affects ducts)