Female Genital Tract- Vulva

Question 1

A large variety of organisms can infect the female genital tract. Infections with some microorganisms, such as___________,____________ and ____________ are extremely common and may cause significant discomfort with no serious sequelae.

Answer 1

Candida, Trichomonas, and Gardnerella,

Question 2

Others, such as _____________ and ____________, are major causes of female infertility.

Answer 2

Neisseria gonorrhoeae and Chlamydia infections

Question 3

and others still, such as_______ AND __________, are implicated in preterm deliveries.

Answer 3

Ureaplasma urealyticum and Mycoplasma hominis infections

Question 4

Infections of the Lower Genital Tract

Genital herpes simplex virus infection is common and involves, in the order of frequency, the_________, _________ AND ______-

Answer 4

cervix, vagina, and vulva

Question 5

. HSVs are DNA viruses that include two serotypes, HSV-1 and HSV-2.

HSV-1 typically results in __________, whereas

HSV-2 usually ____________; however, depending on the sexual practices HSV-1 may be detected in the genital region and HSV-2 may cause oral infections as well (see also Chapter 8 ). The frequency of genital herpes has increased dramatically in the past decades, particularly in teenagers and young women. By the age of 40, 20% of women are seropositive for antibodies against HSV-2. [10]

Answer 5

oropharyngeal infection

involves genital mucosa and skin

Question 6

___________is an ascending infection that begins in the vulva or vagina and spreads upward to involve most of the structures in the female genital system, resulting in pelvic pain, adnexal tenderness, fever, and vaginal discharge.

Answer 6

PID

Question 7

_____________continues to be a common cause of PID, the most serious complication of gonorrhea in women.

Chlamydia infection is another well-recognized cause of PID. Besides these two organisms, infections after spontaneous or induced abortions and normal or abnormal deliveries (called puerperal infections) are important causes of PID.

In these situations the infections are typically polymicrobial and may be caused by staphylococci, streptococci, coliform bacteria, and Clostridium perfringens.

Answer 7

Gonococcus

Question 8

With gonococcus, inflammatory changes start to appear approximately____________ after inoculation.

Answer 8

2 to 7 days

Question 9

_____________ is the most common site of initial involvement.

Answer 9

Endocervical mucosa

Question 10

Gonococcal inflammation may also begin in the ___________. From any of these sites, the organisms may spread upward to involve the fallopian tubes and tubo-ovarian region.

The non-gonococcal bacterial infections that follow induced abortion, dilation and curettage of the uterus, and other surgical procedures of the female genital tract are thought to spread from the uterus upward through the lymphatics or venous channels are thought to spread from the uterus upward through the lymphatics or venous channels
rather than on the mucosal surfaces. Therefore, these infections tend to produce less mucosal
involvement but more reaction within the deeper layers of the organs.

Answer 10

Bartholin gland and other vestibular, or periurethral, glands

Question 11

Morphology. PID gonoccocus

Wherever it occurs, gonococcal disease is characterized by ______________

Smears of the inflammatory exudate disclose the intracellular gram-negative diplococcus; however, definitive diagnosis requires culture, or detection of gonoccocal RNA or DNA.

If spread occurs, the endometrium is usually spared for unclear reasons.

Once the infection reaches the tubes, an acute suppurative salpingitis ensues.

The tubal mucosa becomes congested and diffusely infiltrated by neutrophils, plasma cells, and lymphocytes.

Gonococcal lipopolysaccharide and inflammatory mediators such as TNF cause epithelial injury and sloughing of the plicae. The tubal lumen fills with purulent exudate that may leak out of the fimbriated end.

The infection may further spill over to the ovary to create a salpingo-oophoritis. Collections of pus within the ovary and tube (tubo-ovarian abscesses) or tubal lumen (pyosalpinx) may occur ( Fig. 22-4 ).

Answer 11

marked acute inflammation largely confined to the superficial mucosa.

Question 12

PID gonoccocus infection: Morphology

In the course of time the infecting organisms may disappear, leaving the sequelae of __________ and __________).

Answer 12

chronic follicular salpingitis and hydrosalpinx (dilated, fluid-filled fallopian tube

Question 13

PID : Gonococcus : Morphology

The tubal plicae, denuded of epithelium, adhere to one another and slowly fuse in a reparative, scarring process that forms glandlike spaces and blind pouches, referred to as ______________

The lumen of such tubes may be impenetrable for the oocyte, resulting in infertility or ectopic pregnancy.

Answer 13

chronic follicular salpingitis.

Question 14

PID: Gonoccocus

______________ develops as a consequence of the fusion of the fimbriae and the subsequent accumulation of the tubal secretions and tubal distention.This is another cause of post-PID infertility, since lack of flexible tubal fimbriae prevents uptake of the oocyte after ovulation.

Answer 14

Hydrosalpinx

Question 15

. PID caused by staphylococci, streptococci, and the other puerperal invaders tends to have less exudation within the lumen of the tube and less involvement of the mucosa, but a greater inflammatory response within the deeper tissue layers. These infections often **spread throughout the wall to involve the serosa and the broad ligaments, pelvic structures, and peritoneum. **

Answer 15

.

Question 16

Bacteremia is a more frequent complication of ________________than of gonococcal infections.

Answer 16

streptococcal or staphylococcal PID

Question 17

VULVA

Diseases of the_________in the aggregate constitute only a small fraction of gynecologic practice. Many inflammatory dermatologic diseases that affect skin elsewhere on the body may also occur on the this, such as psoriasis, eczema, and allergic dermatitis.

This is more prone to skin infections, because it is constantly exposed to secretions and moisture.

Answer 17

vulva

Question 18

_______________ is particularly likely to occur in the setting of immunosuppression.

Answer 18

Nonspecific vulvitis

Question 19

particular disorders to the vulva, including

Answer 19

Bartholin cyst,

non-neoplastic epithelial disorders,

benign exophytic lesions,

and tumors of the vulva.

Question 20

___________Infection of the Bartholin gland produces an acute inflammation within the gland (adenitis) and may result in an abscess.

Answer 20

Bartholin Cyst

Question 21

________________ are relatively common, occur at all ages, and result from obstruction of the duct by an inflammatory process. The resulting cysts are lined by the ductal squamous metaplastic and/or epithelium.

They may become large, up to 3 to 5 cm in diameter, and produce pain and local discomfort.

Answer 21

Bartholin duct cysts

Question 22

Bartholin duct cysts are either excised or opened permanently ______________.

Answer 22

(marsupialization).

Question 23

Non-Neoplastic Epithelial Disorders

A heterogeneous group of lesions of the vulva presents as opaque, white, plaquelike mucosal thickening that may produce itching (pruritus) and scaling. Because of their appearance, these disorders have traditionally been termed _________________- by clinicians.

Answer 23

leukoplakia

Question 24

Leukoplaka is a non-specific descriptive term, as white plaques may represent a variety of benign, premalignant, or malignant lesions including

Answer 24

(1) inflammatory dermatoses (e.g., psoriasis, chronic dermatitis); (2) vulvar intraepithelial neoplasia, Paget disease, or even invasive carcinoma; and
(3) epithelial disorders of unknown etiology.

Question 25

Excluding neoplasms and specific disease entities, nonneoplastic epithelial disorders of unknown etiology are classified into two categories:\_\_\_\_ and \_\_\_\_\_\_\_\_\_\_- The two disorders may coexist and the lesions are often multiple, making their clinical management particularly difficult

Answer 25

(1) lichen sclerosus and (2) squamous cell hyperplasia (also known as lichen simplex chronicus) .

Question 26

This lesion is characterized by **thinning of the epidermis and disappearance of rete pegs, hydropic degeneration of the basal cells, superficial hyperkeratosis, and dermal fibrosis with a scant perivascular, mononuclear inflammatory cell infiltrate** ( Fig. 22-5 ). The lesions appear clinically as **smooth, white plaques or papules that in time may extend and coalesce**. The surface is smoothed out and sometimes **resembles parchment.** When the entire vulva is affected, the **labia become somewhat atrophic and stiffened,** and the vaginal orifice is constricted. It occurs in a**ll age groups but is most common in postmenopausal women.** It may also be **encountered elsewhere on the skin.** The pathogenesis is uncertain, but the **presence of activated T cells in the subepithelial inflammatory infiltrate and the increased frequency of autoimmune disorders in these women suggests an autoimmune reaction** may be involved.

Answer 26

LICHEN SCLEROSUS Note : Although the lesion is **not pre-malignant** by itself, women with symptomatic **lichen sclerosus** have a somewhat** increased chance of developing squamous cell carcinoma in their lifetime**. [13] Non-Neoplastic Epithelial Disorders 1946

Question 27

Previously called **hyperplastic dystrophy**, o**r lichen simplex chronicus, squamous cell hyperplasia** is a nonspecific condition **resulting from rubbing or scratching of the skin to relieve pruritus**. It is **marked by epithelial thickening**, **expansion of the stratum granulosum, and significant surface hyperkeratosis**. It appears clinically as an area of leukoplakia. The epithelium may show **increased mitotic activity in both the stratum basalis and spinosum**. Leukocytic infiltration of the dermis is sometimes pronounced. The **hyperplastic epithelial changes show no atypia** (see Fig. 22-5B ). There is generally **no increased predisposition to cancer, but suspiciously**, **lichen simplex chronicus is often present at the margins of established cancer of the vulva.**

Answer 27

SQUAMOUS CELL HYPERPLASIA

Question 28

There is generally **no increased predisposition to cancer,** but suspiciously\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is often present at the margins of established cancer of the vulva.

Answer 28

, lichen simplex chronicus

Question 29

\_\_\_\_\_\_\_\_\_\_\_\_ or wartlike conditions of the vulva may be caused by an **infection or are of unknown etiology**.

Answer 29

Benign Exophytic Lesions

Question 30

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, a papillomavirus-induced lesion, also called a **genital wart**, and \_\_\_\_\_\_\_\_\_\_\_\_\_(described in Chapter 8 ) are consequences of sexually transmitted infections.

Answer 30

Condyloma acuminatum syphilitic condyloma latum

Question 31

Vulvar fibroepithelial polyps, or skin tags, are similar to skin tags occurring elsewhere on the skin. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ are benign **exophytic proliferations covered by nonkeratinized squamous epithelium**, which develop on **vulvar mucosal surfaces and may be single or numerous (vulvar papillomatosis**). The etiology of fibroepithelial polyps and squamous papillomas is unknown; however, these lesions are not related to any known infectious agent.

Answer 31

Vulvar squamous papillomas

Question 32

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ are sexually transmitted, benign lesions that have a **distinct verrucous gross appearance** ( Fig. 22-6A ). Although they **may be solitary, they are more frequently multifoca**l: they **may involve vulvar, perineal, and perianal regions as well** as the **vagina and, less commonly, the cervix**. The lesions are identical to those found on the penis and around the anus in males ( Chapter 21 ).

Answer 32

CONDYLOMA ACUMINATUM Condylomata acuminata

Question 33

In CONDYLOMA ACUMINATUM On histologic examination, they **consist of branching, treelike cores of stroma covered by squamous epithelium with characteristic viral cytopathic change**s referred to as __________ ( Fig. 22-6B ).

Answer 33

koilocytic atypia

Question 34

Condylomata acuminata are caused by \_\_\_\_\_\_\_\_\_\_\_\_\_\_principally **types 6 and 11**, and represent **productive viral infection in which HPV replicates in the squamous cells.** The virus life cycle is **completed in the mature superficial cells,** resulting in **distinct cytologic changes—koilocytotic atypia**—characterized by **nuclear enlargement and atypia as well as a cytoplasmic perinuclear halo** (see also “Cervix”). Condylomata acuminata are **not considered precancerous lesions.** Benign Exophytic Lesions 1949

Answer 34

**low oncogenic** risk HPVs,

Question 35

\_\_\_\_\_\_\_\_\_\_\_\_\_ is the most common histologic type of vulvar cancer.

Answer 35

Squamous cell carcinoma

Question 36

In terms of etiology, pathogenesis, and histologic features, vulvar squamous cell carcinomas are divided **into two groups**:

Answer 36

1. basaloid and warty carcinomas related to infection with **high oncogenic risk HPVs (30% of cases)** and 2. keratinizing squamous cell carcinomas, **not related to HPV infection (70% of cases).**

Question 37

Invasive basaloid and warty carcinomas develop from a precancerous in situ lesion called \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ This form of VIN includes lesions designated formerly as **carcinoma in situ or Bowen disease**

Answer 37

classic vulvar intraepithelial neoplasia (classic VIN).

Question 38

\_\_\_\_\_\_\_\_\_\_\_\_ is characterized by **nuclear atypia** of the **squamous cells**, **increased mitoses**, and **lack of cellular maturation** ( Fig. 22-7A ). It is analogous to cervical squamous intraepithelial lesions (SILs, see under “Cervix”). It most **commonly occurs in reproductive-age women,** and the **risk factors are the same as those associated with cervical squamous intraepithelial lesions** (e.g., young age at first intercourse, multiple sexual partners, male partner with multiple sexual partners), since **both cervical squamous intraepithelial lesions and classic VIN are related to HPV infection.**

Answer 38

Classic VIN

Question 39

\_\_\_\_\_\_\_\_\_\_\_\_\_is frequently **multicentric in the vulva**, and **10% to 30%** of patients with VIN also have **vaginal or cervical HPVrelated lesions.** The majority of cases of classic VIN are **positive for HPV 16, and less frequently for other high-risk HPV types**, like **HPV 18 or 31**. Spontaneous regression of VIN lesions has been reported, usually in younger women; the **risk of progression to invasive carcinoma is higher in women older than 45 years of age or in women with immunosuppression.**

Answer 39

VIN

Question 40

Histopathology of classic vulvar intraepithelial neoplasia (HPV positive) with \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 40

diffuse cellular atypia, immaturity, nuclear crowding, and increased mitotic activity.

Question 41

HPV-associated vulvar squamous cell carcinomas begin as \_\_\_\_\_\_\_\_\_\_\_\_\_, which present as **discrete white (hyperkeratotic), flesh-colored or pigmented, slightly raised lesions**.

Answer 41

classic VIN lesions

Question 42

Coexisting carcinomas may be _________ or indurated, frequently with ulceration.

Answer 42

exophytic or indurated

Question 43

On histologic examination, \_\_\_\_\_\_\_\_\_\_\_\_\_ ( Fig. 22-8A ) shows an infiltrating tumor characterized by **nests and cords of small, tightly packed malignant squamous cells *lacking maturation*** that **resemble immature cells from the basal layer of the normal epithelium**. The tumor **may have foci of central necrosis.**

Answer 43

basaloid carcinoma

Question 44

\_\_\_\_\_\_\_\_\_\_is characterized by exophytic, papillary architecture and prominent koilocytic atypia

Answer 44

Warty carcinoma

Question 45

Non-HPV-related keratinizing squamous cell carcinomas frequently arise in individuals with **long-standing lichen sclerosus or squamous cell hyperplasia**. The **mean age of the patients is 76** years. The **immediate premalignant lesion** is referred to as ________________________ (see Fig. 22-7B ). [14]

Answer 45

differentiated vulvar intraepithelial neoplasia (differentiated VIN) or VIN simplex

Question 46

\_\_\_\_\_\_\_\_\_\_is characterized by marked atypia of the basal layer of the squamous epithelium with apparently **normal epithelial maturation** and differentiation in the superfical layers, thus the postulated that **chronic epithelial irritation in lichen sclerosus or squamous cell hyperplasia may contribute to a gradual evolution of the malignant phenotype.**

Answer 46

Differentiated VIN

Question 47

Note: ​The putative molecular events leading to **malignant transformation in lichen sclerosus, squamous cell hyperplasia, and differentiated VIN**are under investigation. A report of**allelic imbalance in lichen sclerosus and squamous cell hyperplasia** supports the hypothesis that both conditions pose a risk for neoplasia despite the lack of morphologic evidence of atypia. **Rare cases of lichen sclerosus, differentiated VIN, and adjacent carcinoma with identical p53 gene mutations have been reported**. Overall, however,**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is an infrequent and rather late event in vulvar carcinogenesis.**

Answer 47

**p53 gene mutation**

Question 48

Carcinomas associated with **lichen sclerosus, squamous cell hyperplasia, and differentiated VIN** may **develop as nodules in a background of vulvar inflammation**. The oftensubtle emergence of cancer **may be misinterpreted as dermatitis, eczema, or leukoplakia for long periods.** The clinical manifestations are nonspecific, including local discomfort, itching, and exudation **because of superficial secondary infection, and underscore the importance of repeated examination in women with vulvar inflammatory disorders** . Histologic examination reveals infiltrating tumor characterized by nests and tongues of malignant squamous epithelium with \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 48

prominent central keratin pearls

Question 49

Risk of cancer development in VIN is principally a function of \_\_\_\_\_,\_\_\_\_\_\_\_\_\_ and \_\_\_\_\_\_\_\_\_\_\_\_\_ [16]

Answer 49

age, extent, and immune status.

Question 50

Once invasive cancer develops, metastatic spread is linked to the **size of tumor, depth of invasion, and involvement of lymphatic vessels**. The **initial spread** is to **inguinal, pelvic, iliac, and periaortic lymph nodes**. Ultimately, lymphohematogenous dissemination to the lungs, liver, and other internal organs may occur.

Answer 50

:)

Question 51

Patients with lesions **\_\_\_\_\_\_\_\_\_\_\_\_\_\_** have a **60% to 80% 5-year survival** after treatment with vulvectomy and lymphadenectomy; however, **larger lesions with lymph node involvement have a 5-year survival rate of less than 10%.**

Answer 51

**less than 2 cm in diameter**

Question 52

Rare variants of squamous cell carcinoma include \_\_\_\_\_\_\_\_\_\_\_\_( Fig. 22-9B ), which are **fungating tumors resembling condyloma acuminatum, and basal cell carcinomas** , which are identical to their counterparts in the skin. **Neither tumor is associated with papillomaviruses.** Both tumors **rarely metastasize and are successfully cured by wide excision.**

Answer 52

verrucous carcinomas

Question 53

Glandular Neoplastic Lesions

Answer 53

1. PAPILLARY HIDRADENOMA 2. EXTRAMAMMARY PAGET DISEASE

Question 54

Like the breast, the **vulva contains modified apocrine sweat glands**. In fact, the **vulva may contain tissue closely resembling breast (“ectopic breast”)** and **develop two tumors with counterparts in the breast,** namely ___________ and \_\_\_\_\_\_\_\_\_\_.

Answer 54

papillary hidradenoma and extramammary Paget disease.

Question 55

\_\_\_\_\_\_\_\_\_\_\_\_\_ presents as a **sharply circumscribed nodule**, **most commonly on the labia majora or interlabial folds**, and may **be confused clinically with carcinoma because of its tendency to ulcerate.**

Answer 55

Papillary hidradenoma

Question 56

On histologic examination ______________ is identical in appearance to **intraductal papillomas of the breast and consists of papillary projections** **covered with two layers of cells**: the ***top columnar, secretory cells and an underlying layer of flattened “myoepithelial cells.***” These **myoepithelial elements are characteristic of sweat glands and sweat gland tumors**

Answer 56

hidradenoma

Question 57

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ of the vulva, a well-circumscribed tumor nodule composed of benign papillary projections covered with columnar secretory epithelium and underlying myoepithelial cells.

Answer 57

Papillary hidradenoma

Question 58

This **curious and rare lesion** of the **vulva,** and sometimes the **perianal region**, is **similar in its manifestations to Paget disease of the breast** ( Chapter 23 ). As a **vulvar neoplasm**, it presents as a **pruritic, red, crusted, sharply demarcated, maplike area, occurring usually on the labia majora**. It may be accompanied by a palpable submucosal thickening or nodule.

Answer 58

EXTRAMAMMARY PAGET DISEASE

Question 59

Paget disease is a distinctive intraepithelial proliferation of malignant cells. The **diagnostic microscopic feature** is the presence of\_\_\_\_\_\_\_\_\_\_\_\_\_. These cells are distinguished by a **clear separation (“halo”)** from the surrounding epithelial cells ( Fig. 22-11 ) and a finely granular cytoplasm containing mucopolysaccharide that stains with periodic acid–Schiff (PAS), Alcian blue, or mucicarmine stains. **Ultrastructurally, Paget cells display apocrine, eccrine, and keratinocyte differentiation a**nd presumably **arise from primitive germinal cells of the mammary-like gland ducts of the vulvar skin**

Answer 59

large tumor cells lying singly or in small clusters within the epidermis and its appendages

Question 60

In **contrast to Paget disease of the nipple**, in which **100% of patients show an underlying ductal breast carcinoma**, **vulvar lesions** are \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. Paget disease is treated with wide local excision and shows a **high recurrence rate.** Typically, Paget cells spread beyond the confines of the grossly visible lesion, and therefore are frequently present beyond the margins of surgical excision. Intraepidermal Paget disease may persist for many years, even decades, without invasion or metastases. **Invasion develops rarely, and in such patients the prognosis is poor**

Answer 60

most frequently confined to the epidermis of the skin and adjacent hair follicles and sweat glands

Question 61

\_\_\_\_\_\_\_ of the vulva are rare, representing **less than 5%** of all vulvar cancers and **2% of all melanomas in women**. Their peak incidence is in the **sixth or seventh decade**; they tend to have the **same biologic and histologic characteristics as melanomas occurring elsewhere in the skin** and are capable of **widespread metastatic dissemination**. The **5-year survival rate is less than 32%**, presumably**because of delays in detection** and because the majority of these tumors **rapidly enter a vertical growth phase following inception** ( Chapter 25 ) . Prognosis is linked principally to depth of invasion, with greater than 60% mortality for lesions invading deeper than 1 mm.

Answer 61

Malignant Melanoma

Question 62

Because it is **initially \_\_\_\_\_\_\_\_\_\_\_\_\_\_**, melanoma may **resemble Paget disease**, both grossly and histologically.

Answer 62

**confined to the epithelium**

Question 63

How can you differentiate malignant melanoma from paget disease?

Answer 63

It can usually be differentiated by its uniform reactivity with antibodies to S100 protein, absence of reactivity with antibodies to cytokeratin, and lack of mucopolysaccharides, both of which are present in Paget disease.

Question 64

The ___________ is a portion of the female genital tract that is remarkably **free from primary disease**.

Answer 64

vagina Note : In the adult, **inflammations often affect the vulva and perivulvar structures** and **spread to the cervix without significant involvement of the vagina**.

Question 65

Primary lesions of the vagina are **rare;** the most serious of which is \_\_\_\_\_\_\_\_\_\_\_\_\_\_. Thus, they are discussed only briefly.

Answer 65

primary vaginal carcinoma