Vulvar Disorders Flashcards
Infectious/Inflammatory Vulvar Disorders
Bartholinitis, (Bartholin cyst) and Non-neoplastic epithelial disorders (Lichen Sclerosis and Squamous cell hyperpasia)
Vulvar Tumors
Benign exophytic lesions including condyloma acuminatum, and vulvar cancers includng VIN, Squamous Neoplastic lesions, glandular neoplastic lesions, and malignant melanoma
adenitis
acute inflammation of gland (like in bartholinitis)
function of bartholin gland
provide moisture for vaginal vestibule
location of bartholin glands
located at 4 and 8 o clock on L and R side of vagina
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)
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
bacterial organisms responsible for bartholin cyst
e. coli, staph, strep, sexually transmitted pathogens -usually polymicrobial cause
non bacterial causes of bartholin cyst
obstruction of duct by inflammatory process or trauma
chronic bartholinitis
small cyst, slightly tender, but usually asymptomatic
DDx of bartholin cyst
mesopnephric cyst of the vagina, canal of nuck (hydrocele), epithelial inclusion cyst
manifestations of bartholin cyst
can by asymptomatic if small cyst, painful if large cyst or abscess, or cause local discomfort
tx options of bartholin cyst
I and D (high recurrence, do with another procedure), abx for complicated infection, excision, or marsupilization or word catheter
abx prescribed for bartholin cyst
cefixime if strep or e. coli, and clindamycin if staph
cystadentitis without abscess tx
abx and hot sitz bath 3x a day at home
asymptomatic cyst tx
none needed if less than 40. if over 40, need tx with biopsy to r/o carcinoma
opaque white, plaque like mucosal thickening on female genitals that produces itching and scaling
leukoplakia
what percents have paget’s patients have underlying adenocarcinoma?
15%
White plaques on female genitals might be d/t any of the following non-neoplastic epithelial disorders:
leukoplakia, psoriasis, lichen sclerosus, lichen simplex chronicus
rete pegs
inward projections of the epidermis into the dermis
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
Lichen sclerosus characterized by
atrophy
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
Scant mononuclear infiltrate in lichen sclerosus refers to what?
chronic inflammatory condition involving monocytes, macrophages, lymphocytes, PMS, neutrophils
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)
