Vulva. Froberg. Katelyn Rogers. 03.03.10.
Emphasis is on major characteristics & pathogenic mechs of non-neoplastic dx.
Vulvar Dystrophy
(bad name)
Leukoplakia is
better
Subgroups
Vulvar Neoplasms
Papillary
Hidradenoma
Age/
occurrence
Gross
Any; most
menopausal
Smooth-surfaced,
dry, stiff, white,
atrophic vulva
Micro
Lichen sclerosus:
epidermal atrophy,
dermal fibrosis
Squamous hyperplasia:
epith thick,
hyperkeratotic (now
called lichen simplex
chronicus - LSC)
Effects
Fissures, ulcers,
infections, pruritis;
few  ca
Diagnosis
Biopsy!!!
DDx/Rx:
lichen sclerosus, lichen
simplex chronicus,
chronic dermatitis,
Paget Disease, VIN,
vulvar cancer
Localized, benign,
sweat gland
tumor, papillae of
ductal lining cells
Benign
Condylomas
(STD- related
warts)
Vulvar Carcinoma
Precursor: Vulvar
intraepithelial
neoplasia (VIN)
Extramammary
Paget Disease
Invasive
Carcinoma
Accuminatum:
caused by HPV
Lata:
symphilitic
wart
Some present w/
leukoplakia.
Progressive grades
of dysplasia I, II, II
(Bowen’s dx/CIS)
Presents as
pruritic, red,
crusted, welldelineated lesion
usu on labia
majora
Spread  pelvic
& inguinal LNs
Can bleed
occasionally.
Mimics
condyloma
Accuminatum:
koilocytosis
HPV assctd
Confined to
epidermis, hair
follicles and
sweat glands .
Believed to arise
from adnexal
structs.
Squamous cell ca
= 88%.
Bland
Benign
Concurrent
vaginal &/or
cervical CA in 20%
Rarely assctd w/
underlying invasive
cancer (as see in
breast)
Adenocarcinoma
Melanoma
Few
5% of
vulvar Ca
Can be up
the tract,
in the
vagina or
even in the
fundus of
the cervix.
Sweat glands?
Bartholin’s?
Norm: narrow
neck, cyst
Chronic inflam
scarring -
obstructs  cyst
Acute inf 
abscess
(gonococcus,
Chlamydia)
Norm: columnarlined, mucus-sec
cyst
Can form an
abscess
Often delayed bc
embarrassed.
Long survival,
but may recur
following
surgical excision.
Radical resection of
vulva, pelvic + groin
nodes
Prog: no nodes
(85% 5 y), groin
nodes (66%), pelvic
nodes (25%)
Intraepidermal
glandular cells
Exophytic Fissure
Carcinoma
Lichen-sclerosis –
atrophic adenexal
struct
Delay
Rarely
metastasizes
. Cured by
surgery.
30% 5 y
survival
Surgically drain.
Inflammation
Lobular papillae
covered by benign
epithelium.
LSC
Verrucous
SCC
Bartholin’s Gland
Can be confused
w/ melanoma.
But PAS+ shows
glands.
Nests of SCC w/
keratin whorls
Characteristics
Vulvo-Vaginal
Inflammation
-Gonorrhea in kids
-Trichomonas
(strawberry mucosa –
red)
-Moniliasis (candidiasis) :
white patches
-Herpes (vesicles)
-Senile vaginitis
(drynessulcers,
fissures) from decd E
White fungal patches on
vulva & perineum
(Candida)
Candida in keratin layer
Congenital
Lesions
Imperforate
hymen:
-Hematocolpos
(Blood filling
uterus- can be
irritating to
peritoneum)
-Reflux
Septate
(“double”) vagina
Vaginal Adenosis
Islands of cervical glds
beneath squamous
ectocervix cervical
eruption
Cause:
-rarely congenital
-most=maternal exposure
to DES
Asymp, but 0.1%  clear
cell adenocarcinoma
In E exposure, glandular
epith migrates lower into
along the cervix where
squamous epith is normally
located.
Squamous Cell Carc
Precursors: Ca cervix
or vulva; VIN
Spread: upper
vaginapelvic nodes,
lower  inguinal
Staging: like cervix
Prognosis: stage 1 =
80% 5 yr; 3-4 =
<20%
Adenocarcinoma
Clear cell type = DESrelated
Young
Cancer
Sarcoma Botryoides
Aka. Embryonic
Rhabdomyosarcom
a
Age: < 5yr
Locally destructive;
large ones
metastasize
Prognosis is good if
txd early.
Red tumor top right.
Exophytic &
ulcerated.
Rounded, grape-like
bulky mass
Glycogen filled clear
cells
Polypoid masses,
lined by squamous
epith, tumor just
beneathe.
Atrophic glands
Cambian layer of
sarcoma
Tichomoniasis (can also
be in cervix) STD
Trichomonas vaginalis
Red, granular focus of
vaginal adenosis w/in
squamous mucosa
Small blue cell
tumor may show
myoblastic or strap
cell; striations in
some
Endodermal sinus (Yolk Sac) Tumor
Rare
~ to same tumor in ovary
Synthesizes a-FP (hyaline droplets
that stain + by IHC; also inc in bld) &
alpha-1-trypsin
Prognosis is AWEFUL
A germ cell tumor.
Sheets & Schiller-Duval body (cent
bld vessel surrounded by 2 layers of
germ cells)
Questions:
For the following presentations what is the most likely diagnosis for each? Pick from the list below.
Vulvar dystrophy (leukoplakia)
Papillary Hidradenoma
Condylomas
Vulvar intraepithelial neoplasia
Extramammary Paget Disease
Invasive carcinoma
Verrucous SCC
Adenocarcinoma
Melanoma
Bartholin’s Gland infection
Vulvo-Vaginal inflammation: gonorrhea, trichomonas, candidiasis, herpes, or senile vaginitis.
Imperforate hyman
Septate vagina
Vaginal adenosis
Squamous cell carcinoma
Sarcoma Botryoides
Endodermal sinus (Yolk Sac) Tumor
1.
2.
3.
4.
5.
6.
Islands of cervical gland beneath squamous ectocervix leading to cervical eruption in a female whose mother was exposed to estrogens during pregnancy.
This is a very rare germ cell tumor that demonstrates sheets & Schiller-Duval bodies histologically. It also has an awful prognosis.
Strawberry mucosa on vaginal exam.
Patient presents with leukoplaxia and level I dysplasia. She also has a history of HPV.
Pruritic, red, crusted, well-delinieated lesion on labia majora.
Which of these is it most important to get a biopsy in order to diagnose the cause?
Answers:
1.
2.
3.
4.
5.
6.
Vaginal Adenosis
Endodermal sinus (Yolk Sac) Tumor
Vulvo-Vaginal inflammation from trichomonas
Vulvar intraepithelial neoplasia
Exgtramammary Paget Disease
Vulvar dystrophy (leukoplakia)