What type of cellular layer is on the vulva?
What is a bartholin cyst?
Cystic dilation of Bartholin gland (which secretes mucous-like fluid which lubricates the vulva/vagina)
- Arises due to inflammation and obstruction of gland; usually occurs in women of reproductive age; often related to infection and STI's
What is the clinical presentation of a Bartholin cyst?
Unilateral, painful cystic lesion
- Lower vestibule adjacent to vaginal canal
What is a Condyloma?
Warty neoplasm of squamous epithelium (of the vulva); often large
- Most commonly due to HPV types 6 or 11
- Characterized by koilocytic change
- Rarely progresses to carcinoma
What defines High Risk or Low Risk HPV infections?
Based on the DNA sequencing of the virus subtype
Low risk (to develop carcinoma): 6 and 11 (Causes condyloma)
High Risk (to develop carcinoma): 16, 18, 31, 33 (Causes dysplasia --> carcinoma)
What is lichen sclerosis?
Thinning of epidermis and fibrosis of underlying dermis
- Leukoplakia with parchment-like vulvar skin
- Most commonly seen in postmenopausal women
- Benign, associated with slightly increased risk of squamous cell carcinoma
What is lichen simplex chronicus?
Hyperplasia of vulvar squamous epithelium
- Leukoplakia with thick, leathery vulvar skin
- Associated with chronic irritaion and scratching
- Benign; no increased risk of squamous cell carcinoma
What is the clinical presentation of vulvar carcinoma?
Arises from squamous epithelium lining vulva
- Relatively rare
- Presents as leukoplakia (similar to lichen sclerosis or lichen simplex chronicus)
--> Biopsy required
What can lead to vulvar carcinoma?
May be HPV: High risk infxn: 16, 18, 31, 33
- Younger ages: 40-50yrs old
Non-HPV: long standing lichen sclerosis
- Older ages: 65-75yrs old
What is extramammary Paget Disease?
Malignant epithelial cell in the epidermis of the vulva
- Presents as erythematous, pruritic, ulcerated skin
- Represents carcinoma in situ, usually no underlying carcinoma
--> Can be seen in the nipple (Paget disease of the nipple)
How is extramammary Paget Disease (carcinoma) distinguished from melanoma?
Paget Cells: PAS+, keratin+, and S100-
Melanoma: PAS-, keratin-, and S100+
**PAS marks mucus, so only epithelial cells will be stained b/c they make mucus
What is adenosis?
Focal persistence of columnar epithelium in the upper 1/3 of vagina (derived from mullerian duct)
- Increased incidence in females exposed to DES in utero
What is a rare complication of DES-associated vaginal adenosis?
Clear cell adenocarcinoma
- Malignant proliferation of glands with clear cytoplams
What is embryonal rhabdomyosarcoma?
Malignant mesenchymal proliferation of immature skeletal muscle -- very rare
What is the presentation of embryonal rhabdomyosarcoma?
Bleeding and grape-like mass protruding from vagina or penis of child, usually < 5yrs old
What is the malignant cell in rhabdomyosarcoma?
- Immature cells with cytoplasmic cross-striations
- Cells stain IHC staining for desmin (indicating muscle cell) and myoglobin (indicating myoblast)
What is vaginal carcinoma and it's key risk factor?
Carcinoma arising from squamous epithelium lining the vaginal mucosa
- Usually related to high-risk HPV (16, 18, 31, 33)
- Precursor lesion is vaginal intraepithelial neoplasia (VAIN)
What is the regional lymph node spread for:
lower 2/3 of vagina?
upper 1/3 of vagina?
Lower 2/3: develops from Urogenital Sinus
--> spreads to inguinal nodes
Upper 1/3: develops from Mullerian duct
--> spreads to regional iliac nodes
What are the divisions of the cervix?
Exocervix: squamous epithelium
Endocervix: columnar epithelium
- Division is extremely clear on histology
What is HPV?
A DNA virus; sexually transmitted
Infects the lower genital tract, especially cervix in the transformation zone
- Persistent infection leads to risk for Cervical Intraepithelial Neoplasia (CIN)
What makes High-risk HPV high risk?
HPV 16, 18, 31, and 33
E6: increases destruction of p53
E7: increases destruction Rb
What is the histological presentation of Cervical Intraepithelial Neoplasia?
- Koilocytic change (due to HPV infxn)
- Nuclear atypia
- Increased mitotic activity
- Divided into grades based on extent of immature, dysplastic cells:
--> CIN I, II, and III have possibility of reversing; but when they develop into carcinoma in situ, there is no reversing
What are characteristics of cervicl carcinoma?
Invasive carcinoma that arises from cervical epithelium
- Most commonly seen in middle-aged women (40-50yrs old)
- Presents as vaginal bleeding (either randomly or post-coital)
What are key risk factors for cervical carcinoma?
High-risk HPV infection (16, 18, 31, 33)
- Secondary risk factors include:
What are the two types of cervical carcinoma?
(Both HPV driven)
What is the classic finding of advanced cervical cancer?
- Advanced Cervical cancer often invades through the anterior uterine wall into the bladder and blocks the ureters
--> can lead to post-renal failure and death
What is the gold standard for screening of cervical cancer? Why is it necesary?
- Goal is to catch dysplasia before it develops into carcinoma (takes 10-20 years for carcinoma to develop and identified dysplasia can be removed to prevent carcinoma)
What are limitations of pap smear?
- Inadequate sampling of transformation zone resulting in false negative screening
- Limited efficacy in screening for adenocarcinoma (better for squamous cell carcinoma)
What is the current immunization for HPV?
Quadrivalent vaccine: HPV 6, 11, 16, 18
Protection lasts for 5 years
Pap smears still necessary