Analysis of Clonality and HPV Infection in Benign, Hyperplastic, Premalignant, and Malignant Lesions of the Vulvar Mucosa
 |
|
|
|
|
|
|
|
|
 |
 |
 |
 |
 |
 |
 |
 |
|
Background
Squamous cell carcinoma of the vulva progresses through similar stages as squamous cell carcinoma of the cervix and vagina. The earliest stages progress through squamous dysplasia, termed vulvar intraepithelial neoplasia (VIN). VIN present with a raised surface and about 1/4 of these are pigmented. About 1/2 are white and the remainder vary in color from pink, to gray, to red.
VIN CHARACTERIZATION I Mild dysplasia II Moderate dysplasia III Severe dysplasia and Carcinoma in situ Squamous cell carcinomas have been divided into a superficially invasive type and invasive type. Superficial types may present with an ulcer, a macule, or papule. Clinically, it is not possible to separate the precursor lesion of VIN from superficial invasion. Deeply invasive tumors are usually solitary, with less than 10% having multifocal tumors. It is a large mass or ulcer in most cases, typically occurring on the labia majora or minora. Occasionally, these tumors may produce a parathyroid hormone substance resulting in hypercalcemia. VIN is found adjacent to 60-80% of superficially invasive squamous cell carcinomas and 25% of deeply invasive carcinomas.
OUTLINE
EPIDEMIOLOGY CHARACTERIZATION INCIDENCE 1.5/100,000 women in US for squamous cell carcinoma
Increases with increasing age to 20/100,000
PATHOGENESIS CHARACTERIZATION HUMAN PAPILLOMA VIRUS 40% of squamous cell carcinoma cases are associated with this infection
Departments of *Pathology and Molecular Medicine ‡Obstetrics and Gynecology, Charles University, 2nd Medical School, Faculty Hospital Motol †Department of Experimental Virology, National Reference Laboratory for Papillomaviruses, Institute of Hematology and Blood Transfusion, Prague, Czech Republic.
The term vulvar intraepithelial neoplasia (VIN) introduced in 1986 incorporates 3 grades of usual VIN (u-VIN I-III) and the differentiated VIN (d-VIN). Although u-VIN is etiologically associated with the human papillomavirus (HPV) infection, d-VIN represents an alternative HPV negative pathway of vulvar carcinogenesis. In 2004, the u-VIN I category was abandoned and u-VIN II and III were merged. Further, an alternative Bethesda-like terminology scheme presenting the term vulvar intraepithelial lesion was proposed recently.
To analyze the impact of HPV profiles of vulvar precancerous lesions for their classification and to assess the presumable efficacy of the prophylactic HPV vaccination, 269 vulvar excisions representing lichen sclerosus, lichen simplex chronicus, condylomata acuminata, d-VIN, all grades of u-VIN and squamous cell carcinomas were subjected to the HPV typing by use of GP5+/6+ polymerase chain reaction and reverse line blot hybridization.
The results showed different HPV profiles, and also differing frequency of multiple-type HPV infection and the age structure in patients with u-VIN II and III. The biologic heterogeneity within the u-VIN II category was also demonstrated. u-VIN I was distinguished as a rare disorder associated with high-risk HPV infection.
We conclude that the original VIN terminology proposed in 1986 seems to be appropriate for the classification of vulvar squamous dysplastic lesions. The spectrum of HPV types found in vulvar squamous cell carcinomas indicates that the efficacy of HPV vaccination in preventing vulvar cancer might be diminished in the studied population, because the recently developed prophylactic vaccines are targeted against a limited number of HPV types.
Departments of *Pathology double daggerGynecology and Obstetrics, The Johns Hopkins Medical Institutions, Baltimore, MD daggerDepartment of Pathology, University of Virginia Health System, Charlottesville, VA.
It has been proposed that low-grade vulvar and vaginal lesions (VIN 1 and VaIN 1) are flat condylomas and should be designated as such. Moreover, their relationship to high-grade lesions (VIN 3 and VaIN 3) is unclear. Accordingly, this study was undertaken to address these issues by comparing the distribution of human papillomavirus (HPV) types in vulvar and vaginal intraepithelial lesions.
We identified 33 cases of VIN 1, 34 cases of VIN 3, 17 cases of VaIN 1, and 16 cases of VaIN 3. In addition, 36 cases of low-grade squamous intraepithelial lesion (LSIL) in the cervix and 116 cases of cervical high-grade squamous intraepithelial lesion were used for comparison. Polymerase chain reaction analysis was performed using both the Roche PGMY and DDL SPF 10 systems. In cases where HPV was detected, the majority of low-grade and high-grade lesions contained a single HPV type. However, a minority of cases were found to have multiple HPV types. Of the VIN 1 cases, a low-risk virus was seen in 22 (67%), with HPV 6 or 11 accounting for 14 (42%). A high-risk virus was detected in 14 (42%) of cases of which 2 (6%) contained HPV 16. Of the VIN 3 cases, all had high-risk HPV of which 31 (91%) were found to have HPV 16. Of the VaIN 1 cases, 6 (35%) were found to have low-risk HPV types. HPV 6 or 11 were not found in these cases. High-risk virus was seen in 13 (76%) VaIN 1 cases, with 1 (6%) containing HPV 16. HPV was detected in 15 of 16 (94%) VaIN 3 lesions, all of which had high-risk types. HPV 16 was found in 8 (50%). In contrast, 2 (6%) of cervical LSIL had low-risk HPV (HPV 6 and 11), whereas 34 (94%) of LSIL cases had high-risk HPVs.
Of the cervical high-grade squamous intraepithelial lesion cases, 100% had high-risk HPVs of which 87 (75%) were found to have HPV 16. The findings demonstrate that a significant number of low-grade vulvar and vaginal lesions contain high-risk HPV types, supporting their designation as low-grade intraepithelial lesions rather than flat condylomas. The low frequency of HPV 16 in VIN 1 compared with VIN 3 suggests they are distinct lesions or that HPV 16 is critical in the progression to VIN 3.
Finally, comparison of the distribution of HPV in the vagina and vulva suggests that VaIN is more closely related to cervical intraepithelial neoplasia than to VIN.
Yutaka Ueda, MD, etal.
To elucidate the pathogenesis of vulvar carcinomas, we studied clonality and human papillomavirus (HPV) infection in vulvar epithelial diseases. Monoclonal composition was demonstrated in all 9 invasive tumors (squamous cell carcinoma [SCC], 6; basal cell carcinoma, 1; malignant melanoma, 2), 15 of 20 cases of vulvar intraepithelial neoplasia (VIN), 7 of 9 cases of Paget disease, 2 of 6 cases of lichen sclerosus (LS), and 2 of 3 cases of squamous cell hyperplasia (SCH); high-risk type HPV was revealed in 5 of 6 SCCs and 17 of 20 VINs.
These observations might imply that a subset of cases of LS and SCH result from a neoplastic proliferation, similar to VINs but not related to infection with high-risk type HPV.
In 1 case of SCC with concurrent VIN 3 in an adjacent lesion, both lesions showed the same pattern of X chromosome inactivation and the presence of HPV-16 in episomal and integrated forms, suggesting that monoclonal expansion triggered by high-risk type HPV integration is an early event for carcinogenesis of HPV-associated SCC.LANGERHANS CELLS
Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Background: Decreased numbers of Langerhans cells (LCs) in the cervix of human immunodeficiency virus (HIV)-infected women are believed to contribute to the progression of human papilloma virus (HPV)-related squamous intraepithelial lesions. However, this impairment of local immunity has not been well studied in the vulva. The objective of this study was to compare the S100+ LC density in high-grade vulvar intraepithelial neoplasia (VIN) in HIV-positive and HIV-negative women.
Methods: HIV-positive and HIV-negative patients with high-grade VIN, 48 (55%) and 40 (45%), respectively, were identified by retrospective chart review. Smoking status of patients was noted. The mean LC count per high-power field (HPF) was determined using S100 immunohistochemical staining. In situ hybridization was performed to detect HPV DNA types 16 and 18.
Results: Mean S100+ LC counts for HIV-positive and HIV-negative patients were 5.82 and 9.86 per HPF, respectively (p = 0.0026). LC counts in HIV-positive and HIV-negative patients were compared between smoking and nonsmoking groups (HIV-positive p = 0.4812, HIV-negative p = 0.2821).
Conclusions: HIV-positive patients with high-grade VIN had significantly lower LC counts compared with HIV-negative patients. This suggests that local vulvar immunity as evaluated by S100+ LCs is impaired in HIV-positive women, possibly contributing to the progression of HPV-related vulvar lesions.p16/RB/Cyclin D1
- Santos M,
- Landolfi S,
- Olivella A,
- Lloveras B,
- Klaustermeier J,
- Suarez H,
- Alos L,
- Puig-Tintore LM,
- Campo E,
- Ordi J.
Departments of *Pathology daggerObstetrics and Gynecology, Hospital Clinic-Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), University of Barcelona double daggerDepartment of Pathology, Hospital Princeps d'Espanya, L'Hospitalet de Llobregat, Barcelona, Spain.
Two types of vulvar squamous cell carcinomas (VSCCs) are recognized according to their relationship to human papillomavirus (HPV). Basaloid or warty carcinomas are considered HPV-associated tumors, whereas differentiated keratinizing neoplasms are considered non-HPV-associated. Recently, immunohistochemical detection of p16 and p53 has been proposed to differentiate these 2 types of VSCCs.
We conducted a histologic study with immunohistochemical evaluation of p16 and p53 and HPV detection and typing by polymerse chain reaction using 2 different sets of primers in 92 cases of VSCCs to evaluate the usefulness of immunohistochemistry in the classification of VSCCs and to describe the clinico-pathologic characteristics of both types of VSCCs. HPV was detected in 16/92 (17.4%) specimens, HPV16 being identified in 75% of positive cases. A significant number of discrepancies between histology and HPV detection were observed, with 37.5% of HPV-positive tumors being keratinizing and 9.2% of HPV-negative carcinomas showing basaloid or warty features. Diffuse positivity for p16 and p53 was observed in 100% and 6.2% of HPV-positive tumors and in 2.3% and 64.5% of HPV-negative neoplasms, respectively.
The sensitivity and specificity of p16 immunostaining to detect HPV-associated carcinomas (100% and 98.7%, respectively) were better than those of histologic criteria (93.8% and 35.5%) and of p53 negative stain (62.5% and 93.4%). Vulvar intraepithelial neoplasia grade 3 of basaloid/warty type was identified in 53.8% HPV-positive tumors, including 3 keratinizing tumors. All these cases were p16 positive and p53 negative. Vulvar intraepithelial neoplasia grade 3 of differentiated type was observed in 45.6% of HPV-negative cases; 90.8% of them were positive for p53 but all were negative for p16. No differences in age, stage, or development of recurrence were observed between HPV-positive and negative tumors.
In summary, the current morphologic criteria to discriminate HPV-positive and negative VSCCs have a significant overlap. Immunostaining for p16 is a reliable marker for HPV-positive VSSCs, which improves the results of histologic classification.
Alterations of the p16/Rb/cyclin-D1 pathway in vulvar carcinoma, vulvar intraepithelial neoplasia, and lichen sclerosus.Lerma E, Esteller M, Herman JG, Prat J.
Department of Pathology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.
Hum Pathol 2002 Nov;33(11):1120-5 Abstract quote Three different alterations in the p16/pRb/cyclin-D1 pathway (p16(INK4a)-promoter hypermethylation and expression of pRb and cyclin-D1) were investigated in a series of 38 cases of vulvar carcinoma (VC), 13 cases of vulvar intraepithelial neoplasia (VIN), and 21 cases of lichen sclerosus (LS).
Paraffin blocks from 72 patients were selected for investigation of DNA methylation patterns in the CpG island of p16(INK4a) by methylation-specific polymerase chain reaction. Immunohistochemical studies for pRb and cyclin-D1 were performed using the standard avidin-biotin-peroxidase complex method. Epigenetic silencing of p16(INK4a) was detected in 68% of VC, 69.2% of VIN, and 42.8% of LS cases. Lack of pRb protein was found in 21% of VC, 0% of VIN, and 0% of LS cases. Overexpression of cyclin-D1 was found in 21% of VC, 30.8% of VIN, and 0% of LS cases.
We conclude (1) that p16(INK4a) epigenetic inactivation most likely represents an early event, insufficient for malignant transformation, that may occur in clinically benign lesions such as LS; (2) that lack of pRb was only detected in fewer than one quarter of the carcinomas and could be considered a late secondary event; and (3) that cyclin-D1, which was overexpressed in VC and VIN, could contribute to the malignant transformation in association with p16 hypermethylation.
GROSS APPEARANCE/
CLINICAL VARIANTSCHARACTERIZATION Bowenoid papulosis Raised papular or verruocoid lesions of VIN Erythroplasia of Queyrat Clinically red lesions of VIN
HISTOLOGICAL TYPES CHARACTERIZATION VULVAR INTRAEPITHELIAL NEOPLASIA (VIN) Dysplasia characterized by epithelial cells with enlarged and hyperchromatic nuclei, high mitotic activity, and dyskeratosis
May involve the skin appendages in 50% of cases
Abnormal mitoses consistently present in VIN 2 and 3
VIN I Dysplasia in lower 1/3 of epithelium VIN II Dysplasia in 1/2 to 2/3 of epithelium VIN III Dysplasia greater than 2/3 of epithelium
Carcinoma in situ used if there is full thickness change
Variants of VIN Small uniform cells with hyperchromatic and coarse nuclear chromatin Larger cells with greater pleomorphism with koilocytotic changes near the surface Large pleomorphic keratinocytic population with minimal nuclear hyperchromasia ACANTHOSIS
Vulvar Acanthosis With Altered Differentiation: A Precursor to Verrucous Carcinoma?
Nascimento AF, Granter SR, Cviko A, Yuan L, Hecht JL, Crum CP.
*Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School; and daggerDepartment of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
Am J Surg Pathol. 2004 May;28(5):638-643. Abstract quote
Verrucous carcinoma (VC) of the vulva is a rare variant of squamous cell carcinoma (SCC) of the vulva that afflicts older women and is characterized by a well-differentiated morphology with minimal nuclear atypia. The pathogenesis of VC is uncertain and a putative role for human papillomavirus (HPV) is doubtful.
We analyzed 9 vulvar VCs from 7 patients diagnosed as VC of the vulva over the past 10 years at Brigham and Women's Hospital and Beth Israel Deaconess Medical Center. The patients ranged from 75 to 93 years in age (median, 83 years). One also involved the vagina and another coexisted with a keratinizing SCC. VC was associated with lichen sclerosus in 1 case; 7 others contained lichen simplex chronicus with verrucous architecture. In 7 cases, a distinctive noninvasive squamous epithelial proliferation, exhibiting a triad of marked acanthosis with variable verruciform architecture, loss of the granular cell layer with superficial epithelial cell pallor, and multilayered parakeratosis.
We have designated these changes vulvar acanthosis with altered differentiation. In 5 of the 9 lesions, formalin-fixed, paraffin-embedded material was available for polymerase chain reaction analysis of HPV nucleic acids and all scored HPV negative. In conclusion, VC is a rare HPV-negative neoplasm that may be associated with other HPV-negative SCCs or its precursors, shares similar morphologic risk factors (lichen sclerosus and lichen simplex chronicus), and is frequently associated with an unusual intraepithelial lesion that can be distinguished from both classic and differentiated forms of vulvar intraepithelial neoplasia.
The possibility that vulvar acanthosis with altered differentiation is a precursor to, or a risk factor for, vulvar carcinoma, merits further study.BOWENOID PAPULOSIS In the current WHO classification, this is not designated as a separate disease. Most investigators feel this is a variant of VIN
Clinically, these lesions are usually multiple and resmble seborrheic keratoses
Heterogeneity of human papillomavirus DNA in a patient with Bowenoid papulosis that progressed to squamous cell carcinoma.Park KC, Kim KH, Youn SW, Hwang JH, Park KH, Ahn JS, Kim YG, Kim SD, Lee DY, Choe JH, Chung JH, Cho KH.
Department of Dermatology, Seoul National University College of Medicine, Korea.
Br J Dermatol 1998 Dec;139(6):1087-91 Abstract quote Bowenoid papulosis (BP) of the genitalia, characterized by the histological findings of a squamous cell carcinoma, follows a largely benign clinical course. The detection of oncogenic human papilloma viruses (HPV) from BP points to an aetiological role of these viral infections.
A 47-year-old man with multiple genital skin lesions was seen over a 10-year period with the diagnosis of BP. Recently, he attended again with a recurrent genital tumour that was diagnosed as squamous cell carcinoma. His genital lesions progressed and became polymorphic in appearance, from a wart-like tumour to a reddish invasive plaque. To screen for the presence of different HPV sequences from different skin lesions and to correlate each HPV type with distinct clinical manifestations, polymerase chain reaction and single-strand conformational polymorphism (PCR-SSCP) were performed.
PCR-SSCP revealed the presence of several types of HPV from different genital lesions. Sequencing results disclosed that he had a mixed infection of HPV6b, HPV16, HPV18 and HPV33, respectively. Interestingly, the clinical findings were fairly well correlated with the oncogenic potential of HPV found from each lesion.
Development of squamous cell carcinoma by two high-risk human papillomaviruses (HPVs), a novel HPV-67 and HPV-31 from bowenoid papulosis.Yoneta A, Yamashita T, Jin HY, Iwasawa A, Kondo S, Jimbow K.
Departments of Dermatology and Urology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo 060-8543, Japan.
Br J Dermatol 2000 Sep;143(3):604-8 Abstract quote We report a patient with bowenoid papulosis (BP) involving two high-risk human papillomaviruses (HPVs) and the development of invasive squamous cell carcinoma (SCC).
Our patient showed verrucous lesions on the penis, perianal area and groin that had been noted over the previous 8 years and had recurred after all therapeutic approaches. The perianal and left inguinal lesions revealed invasive SCC on histology. HPV-31 and HPV-67 sequences were detected by polymerase chain reaction from BP lesions of the perianal area and the shaft of the penis. HPV-31 has already been reported in BP as a high-risk HPV for the development of SCC, but HPV-67 is a novel one that has never been reported in BP. As HPV-67 has sequence homology to HPV-52 and HPV-58, it belongs to the family of HPV-16, a high-risk HPV group.
Thus our patient showed two high-risk HPVs, i.e. HPV-31 and the novel HPV-67, which may be directly involved in the development of SCC.
Isolated human papillomavirus 18-positive extragenital bowenoid papulosis and idiopathic CD4+ lymphocytopenia.
Purnell D, Ilchyshyn A, Jenkins D, Salim A, Seth R, Snead D.
Department of Pathology, Walsgrave Hospitals NHS Trust, Coventry CV2 2DX, U.K.
Br J Dermatol 2001 Mar;144(3):619-21 Abstract quote We report a case of isolated extragenital bowenoid papulosis (BP) in a young man with an idiopathic low CD4 count. The lesions occurred on the dorsal aspect of his left middle finger and were not associated with genital involvement. Polymerase chain reaction studies of a biopsy demonstrated human papillomavirus 18.
As far as we are aware, this is the first documented case of BP (genital or extragenital) associated with idiopathic CD4 lymphocytopenia.
Extragenital bowenoid papulosis associated with atypical human papillomavirus genotypes.Papadopoulos AJ, Schwartz RA, Lefkowitz A, Tinkle LL, Janniger C, Lambert WC.
Dermatology, Pediatrics and Pathology, New Jersey Medical School, Newark, New Jersey, USA.
J Cutan Med Surg 2002 Mar-Apr;6(2):117-21 Abstract quote BACKGROUND: Bowenoid papulosis typically appears as grouped violaceous or red-brown papules in the genital or perianal regions and clinically resembles condylomata acuminata. Isolated extragenital bowenoid papulosis is rare and has been reported in only a few case reports.
OBJECTIVES: A 51-year-old immunocompetent, healthy woman had two solitary papules on the elbow; a 41-year-old HIV-positive man had a solitary cutaneous plaque on the abdomen. No genital, periungual, or other extragenital sites of involvement were noted in either patient. The diagnosis was confirmed histologically in both cases. Lesional skin from the female patient was tested with the Digenehybrid HPV DNA assay and was positive for a mixture of low-risk HPV subtypes (6, 11, 42, 43, 44). Lesional skin from the male patient was tested with polymerase chain reaction (PCR). Consensus primers targeted for the HPV L1 region, which is a highly conserved sequence common to more than 20 HPV subtypes encoding a viral capsid protein, were used. PCR using the consensus primers was positive, but type-specific probes for HPV types 6, 11, 16, 18, 45, 31, 33, 35, and 39 were negative.
CONCLUSIONS: To our knowledge, our male patient represents the first case of isolated bowenoid papulosis of the abdominal skin. Isolated upper-extremity bowenoid papulosis in our female patient is also a unique case in both location and involvement of low-risk HPV types (6, 11, 42, 43, 44), which have not been previously associated with extragenital bowenoid papulosis.
SQUAMOUS CELL CARCINOMA Measuring the depth of invasion should be taken from the granular layer or surface if nonkeratinized to the deepest point of invasion
Report should include:
Depth of invasion in millimeters (mm)
Thickness of tumor in mm
Method of measurement of the depth and thickness
Presence or absence of vascular space involvement
Diameter of tumor (as measured from the specimen)
Clinical measurement of the tumor diameter if available1A carcinoma
Defined as a single lesion measuring 2 cm or less in diameter and with a depth of invasion of 1 mm or lessPatients with multiple sites are excluded
Department of Pathology, University of Florida College of Medicine, Gainesville, FL.
Early invasive vulvar squamous cell carcinoma (SCC) with less than 1.0 mm of invasion (FIGO stage IA) has been shown to have a minimal risk of lymph node metastasis and is associated with an excellent prognosis.
The prognostic significance of other histologic parameters other than depth of invasion, however, remains controversial. Seventy-eight consecutive cases of vulvar SCC having a depth of invasion of 5.0 mm or less were reviewed and the clinical outcome compared with the type of surgical excision, the presence of concurrent lymph node metastases, the depth of tumor invasion, the tumor thickness, the tumor horizontal spread, the estimated tumor volume, tumor histologic subtype, tumor histologic grade, tumor pattern of invasion, tumor multifocality, presence of perineural invasion, presence of angiolymphatic invasion and the presence of precursor lesions, including the type of vulvar intraepithelial neoplasia and presence of lichen sclerosus.
The only histologic feature for predicting concurrent lymph node metastasis was tumor depth of invasion. The 3 most important features of stage IA tumors in predicting tumor recurrence were the depth of invasion, presence of SCC at the surgical margins, and the histologic grade.
- Histopathologic study of thin vulvar squamous cell carcinomas and associated cutaneous lesions: a correlative study of 48 tumors in 44 patients with analysis of adjacent vulvar intraepithelial neoplasia types and lichen sclerosus.
Chiesa-Vottero A, Dvoretsky PM, Hart WR.
Department of Anatomic Pathology, Division of Pathology and Laboratory Medicine, Cleveland Clinic Foundation, Cleveland, OH.
Am J Surg Pathol. 2006 Mar;30(3):310-8. Abstract quote
A series of 48 excised thin (</=5 mm in tumor thickness) invasive squamous cell carcinomas (SCCs) of the vulva in 44 patients were studied to determine the interrelationships of tumor type with type of adjacent vulvar intraepithelial neoplasia (VIN) and lichen sclerosus.
The SCCs were of conventional keratinizing type in 38 tumors (79%), warty type in 6 (13%), and basaloid type in 4 (8%). VIN adjacent to SCC was found in 37 (77%) of the tumors. Of these, 19 were classic VIN (51%) and 18 were simplex (differentiated) VIN (49%). All 10 warty and basaloid SCCs had adjacent classic VIN. Of the 38 keratinizing SCCs, 27 (71%) had adjacent VIN, consisting of simplex VIN in 67% and classic VIN in 33%. The median age of the patients with classic VIN, simplex VIN, and no VIN were 62, 78, and 75 years, respectively. In the overall statistical analysis, the differences between the VIN types and the types of SCC were highly significant. In pairwise comparisons, significant differences in SCC type were found when the classic VIN group was compared with the simplex VIN group and when the classic VIN group was compared with the no VIN group.
In contrast, no difference was found when the simplex VIN group was compared with the no VIN group. Lichen sclerosus (LS) was present in 14 of the 44 patients (32%). All SCCs in patients with LS were of keratinizing type. Of the 30 patients without LS, the SCCs were of the keratinizing type in 20 patients (67%), the warty type in 6 patients (20%), and the basaloid type in 4 patients (13%). Only 1 of the 19 (5%) patients with classic VIN had LS compared with 9 (56%) of the 16 patients with simplex VIN and 4 (44%) of 9 patients with no adjacent VIN. Atypical LS occurred in 8 of 14 patients with LS (57%); 4 of these (50%) also had simplex VIN and none had classic VIN. Significant differences in the overall comparison were found when comparing the percentage of keratinizing SCC and percentage of LS between the groups with classic VIN, simplex VIN, and no VIN. Pairwise comparisons revealed the similarity of features between the simplex VIN group and the no VIN group, and the distinction of both of these groups from the classic VIN group. Both the simplex VIN group and the no VIN group have a significantly greater association with keratinizing SCC and LS (including atypical LS) than does the classic VIN group. Strong staining for p53 with a high labeling index was commonly found in atypical LS and simplex VIN and may be of value in confirmation of these lesions.
These findings support the theory that simplex VIN is the most likely precursor of conventional keratinizing SCC, the most common type of vulvar invasive carcinoma. Atypical LS may be closely related to simplex VIN.
- Detection of microinvasion in vulvar and cervical intraepithelial neoplasia using double immunostaining for cytokeratin and basement membrane components.
Rush D, Hyjek E, Baergen RN, Ellenson LH, Pirog EC.
Department of Pathology and Laboratory Medicine, Malcolm Randall VA Medical Center, and University of Florida College of Medicine, Gainesville, USA.
Arch Pathol Lab Med. 2005 Jun;129(6):747-53. Abstract quote
CONTEXT: Identification of early invasion in vulvar intraepithelial neoplasia 3 (VIN 3) and cervical intraepithelial neoplasia 3 (CIN 3) may be difficult with the use of routine hematoxylin-eosin staining. Presence of obscuring inflammation and tangential tissue sectioning are the most common diagnostic pitfalls.
OBJECTIVE: To examine the utility of double immunostaining for cytokeratin-collagen IV or cytokeratin-laminin in the detection of early invasion in VIN 3 and CIN 3. DESIGN: The study group consisted of 10 cases of "VIN 3, suspicious for invasion" and 10 cases of "CIN 3, suspicious for invasion." The negative control group consisted of VIN 3 (n = 15) and CIN 3 (n = 10). The positive control group consisted of cases of invasive vulvar carcinoma (n = 11) and invasive cervical carcinoma (n = 25). All cases were double immunostained for cytokeratin and collagen IV and, in a separate reaction, for cytokeratin and laminin. The continuity of the basement membrane and the presence of stromal invasion were assessed in the stained sections.
RESULTS: The staining for collagen IV and laminin yielded identical results. A well-defined, continuous basement membrane was visualized in all cases of VIN 3 and CIN 3. A discontinuous or absent basement membrane was observed around the malignant cells on the invasive tumor front in all cases of vulvar and cervical carcinoma. In 2 of 10 cases of VIN 3, suspicious for invasion and in 4 of 10 cases of CIN 3, suspicious for invasion definitive foci of microinvasion were identified with the use of double immunostaining. A well-defined, continuous basement membrane was present in the remaining cases "suspicious for invasion."
CONCLUSION: Double immunostaining for cytokeratin- collagen IV or cytokeratin-laminin is useful for evaluation of early invasion in equivocal cases of VIN 3 and CIN 3.INVASIVE SQUAMOUS CELL CARCINOMA Confluent growth should be mentioned and is defined as anastomosing cords of tumor or tumor in the dermis exceeding 1 mm3
No undifferentiated cells Undifferentiated cells <50% of tumor Undifferentiated cells >50% of tumor
Human papillomavirus-negative spindle cell carcinoma of the vulva associated with lichen sclerosus: case report and literature review.Santos-Briz A, Antunez P, Lopez-Rios F, Rodriguez-Peralto JL, Garzon A.
Departaments of Pathology, Hospital Universitario "12 de Octubre," Madrid (A.S.-B., F.L.-R., J.L.R.-P., A.G.), and Hospital Clinico Universitario, Salamanca (P.A.), Spain.
Am J Dermatopathol 2002 Apr;24(2):135-8 Abstract quote Although spindle cell carcinoma (SC) is a common neoplasm in the oral cavity, upper respiratory tract, and other head and neck areas, its occurrence in the vulva is rare.
We report a case of this rare condition with immunohistochemical, ultrastructural, and human papillomavirus (HPV) testing. The neoplastic cells were positive for vimentin, keratins (AE1-AE3, keratin 902, and keratin 903), and epithelial membrane antigen. Ultrastructurally, they showed primitive junctions and tonofilaments. HPV testing by polymerase chain reaction was negative.
In addition, we review the clinicopathologic findings of the four well-documented cases of vulvar SC that have been reported previously in the English language literature.
HISTOPATHOLOGICAL VARIANTS EOSINOPHILS Eosinophils as a Marker for Invasion in Vulvar Squamous Neoplastic Lesions Gregory W Spiegel, M.D., Ph.D.
From the Department of Pathology, Roswell Park Cancer Institute, Buffalo, New York.
Int J Gyn Pathol 2002;21:108-116 Abstract quote A study of eosinophils directed against vulvar neoplastic squamous epithelium was undertaken to determine whether there were thresholds per high-power field (hpf) or 10 hpf that were a marker for invasion.
The presence of stromal and intraepithelial eosinophils in 33 cases of vulvar grade 3 squamous intraepithelial neoplasia (carcinoma in situ) (VIN 3) was compared with that in 38 cases of vulvar invasive carcinoma with any degree of invasion (ISC). In both incisional biopsy and excisional specimens, the presence of >3 eosinophils per high-power field (eos/hpf) and the presence of 5 eosinophils per 10 high-power fields (eos/10 hpf) were both significantly associated with invasion, and the presence of 20 eos/hpf and/or >50 eos/10 hpf was limited to cases with invasion. The presence of eosinophils within the neoplastic squamous epithelium was also limited to cases with invasion.
The author proposes: 1) eosinophil counts in vulvar incisional biopsy specimens of >3/hpf and/or 5/10 hpf warrant a note of caution that invasion may be present even when none is identified by conventional criteria; 2) eosinophil counts of >3/hpf and/or 5/10 hpf in excisional specimens should raise the suspicion of invasion in cases in which only VIN 3 is identified in the initial sections, and warrant additional sections and/or levels to search for invasion; 3) the above eosinophil counts provide supportive evidence for invasion in cases with equivocal invasion by conventional criteria; and 4) the presence of 20 eos/hpf and/or >50 eos/10 hpf, and the presence of intraepithelial eosinophils in conjunction with >3 eos/hpf and 5 eos/10 hpf is virtually diagnostic of invasion.
DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES BASALOID ADENOCARCINOMA Salivary Gland-Type Basal Cell Adenocarcinoma of Presumed Bartholin's Gland Origin: A Case Report Ana Félix, M.D.; Jose F. Moura Nunes, M.D.; Jorge Soares, M.D., Ph.D.
From the Departamento de Patologia Morfológica, Instituto Português de Oncologia de Francisco Gentil, Portugal.
Int J Gynecol Pathol 2002;21:194-197 Abstract quote Salivary gland-type carcinomas arising in Bartholin's gland are rare neoplasms.
We report the case of a 75-year-old female who presented with a vulvar tumor with morphological and immunophenotypical features identical to those of salivary gland basal cell adenocarcinomas. We believe that the tumor was most likely of Bartholin's gland origin, although no Bartholin's gland tissue was found adjacent to the neoplasm.
This type of malignancy with myoepithelial differentiation has not been previously reported to arise in the Bartholin's gland.
INVERTED FOLLICULAR KERATOSIS Inverted follicular keratosis of the vulvar skin: a lesion that can be confused with squamous cell carcinoma.
Roth LM, Look KY.
Department of Pathology, Indiana University School of Medicine, Indianapolis, USA.
Int J Gynecol Pathol 2000 Oct;19(4):369-73 Abstract quote
Although seborrheic keratoses of the vulva are described in textbooks, to our knowledge, inverted follicular keratosis has not been reported.
A 27-year-old woman underwent an excisional biopsy for a small lesion of the left labium majus. Squamous cell carcinoma was considered in the clinical differential diagnosis. The initial pathologic diagnosis suggested squamous cell carcinoma in situ, and the consultation diagnosis was superficially invasive squamous cell carcinoma. On pathologic examination, a symmetrical, endophytic, epithelial tumor was observed consisting of a proliferation of basaloid cells with many areas of reactive squamous cells showing numerous squamous eddies, focal reactive nuclear atypia, and occasional mitotic figures. After the pathologic diagnosis of inverted follicular keratosis was made, a history of close perineal shaving and total body tanning was obtained.
Because inverted follicular keratosis is postulated to be related to follicular injury, it is likely that the trauma of close shaving is a significant etiologic factor. There is less evidence that ultraviolet ray exposure is of etiologic importance.
METASTATIC CARCINOMAS
Metastatic tumors of the vulva: a clinicopathologic study of 66 cases.Neto AG, Deavers MT, Silva EG, Malpica A.
Am J Surg Pathol. 2003 Jun;27(6):799-804. Abstract quote Metastatic tumors involving the vulva are rare, with only a few series and case reports published in the English literature to date. In this study, we present the clinicopathologic features of 66 cases of metastatic tumors of the vulva seen at the University of Texas M. D. Anderson Cancer Center from 1944 to 2001.
The patients' age ranged from 18 to 84 years (mean 54.8 years). The most common presentations were vulvar nodules or a mass (39 cases), pain (7 cases), and ulceration (5 cases). In 46.9% of cases, the primary tumor was of gynecologic origin, whereas in 43.9% of cases the primary tumor was of nongynecologic origin. The remainder had unknown primaries. The site most frequently involved by metastasis was the labium majus (44 cases: 18 on the right, 13 on the left, 6 bilateral, and 7 unspecified side). Thirty percent of the patients received chemotherapy as treatment for the metastasis, 27% received radiotherapy, and the rest received some combination of chemotherapy, radiotherapy, and surgery. Of the 60 patients with available follow-up, 52 died of disease within 1-81 months (median 7.5 months) from diagnosis of the metastasis.
Metastatic tumors of the vulva are rare; however, the diagnosis of these tumors is facilitated by the knowledge of a preexistent malignancy and the lack of a mucocutaneous intraepithelial lesion.
PROGNOSIS AND
TREATMENTCHARACTERIZATION Prognostic Factors Depth of invasion and diameter of tumor important
Tumors with 5 mm depth of invasion will have 15% develop lymph node metastasis
Tumors invading between 1-2 mm have little risk of metastasis
Survival 5 year survival with lymph node mets was 78.6%
Without lymph node mets 97.9%5 year survival 87% 75% 29% Recurrence Distance between tumor and surgical margin is significant predictor for local recurrence
Margin of 8 mm or less associated with 50% local recurrence
Metastasis 18% with lymph node mets (36/190) Screening for occult nodal metastasis in squamous cell carcinoma of the vulva.
Leys CM, Hartenbach EM, Hafez GR, Mahvi DM.
Department of Surgery, University of Wisconsin Medical School, Madison 53792, USA.
Int J Gynecol Pathol 2000 Jul;19(3):243-7 Abstract quote
Metastases to inguinofemoral lymph nodes in patients with carcinoma of the vulva alter the prognosis and treatment of this disease. Our goal was to determine if immunohistochemical staining could reveal occult metastatic nodal disease not detected with routine hematoxylin and eosin staining.
We retrospectively examined a total of 110 lymph nodes from 10 patients who had undergone lymph node dissection and found to have all negative nodes. Paraffin embedded lymph nodes were immunostained with a monoclonal antibody directed against multiple low- and high-molecular weight cytokeratins. Micrometastases were not detected in any lymph nodes examined with immunohistochemistry. All positive and negative controls yielded satisfactory results.
It is concluded that immunohistochemistry with cytokeratin antibodies does not provide greater sensitivity than routine hematoxylin and eosin staining for the detection of nodal metastases in vulvar carcinoma.
TREATMENT Conservative with excision or laser ablation Vulvectomy depending upon the depth and diameter of the tumor Vulvectomy Removal of a part of the vulvar/perineal integument independent of depth Removal of the entire vulva and appropriate integument of the perineum independent of depth Depth of excision Removal of the most superficial layer with a variable amount of dermis and subcutaneous tissue Removal of the vulva to the superficial aponeurosis of the urogenital diaphragm and/or pubic periosteum IMIQUIMOD CREAM Treatment of Undifferentiated Vulvar Intraepithelial Neoplasia With 5% Imiquimod Cream A Prospective Study of 12 Cases
Jeanne Wendling, MD ;Philippe Saiag, MD, PhD ;Sophie Berville-Levy, MD ;Isabelle Bourgault-Villada,
MD, PhD;
Thierry Clerici, MD ;Micheline
Moyal-Barracco, MDArch Dermatol. 2004;140:1220-1224. Abstract quote Objective To assess the efficacy of 5% imiquimod cream on undifferentiated vulvar intraepithelial neoplasia (VIN), a disease caused by high-risk human papillomavirus.
Design Prospective, uncontrolled study.
Setting University hospital vulvar clinic.
Patients Twelve consecutive patients treated with 5% imiquimod cream for undifferentiated VIN between March 1, 1999, and May 31, 2001.
Intervention Self-application of 5% imiquimod cream, initially 3 times a week, then adjusted according to tolerance, for up to 7 months according to clinical response.
Main Outcome Measures Therapeutic response, clinically assessed by successive photographs and histologically confirmed for complete responders, was scored as complete, partial (50% decrease in lesion size), or failure. Tolerance was evaluated at each visit.
Results A total of 3, 4, and 5 patients achieved complete response, partial response (75% reduction in lesion size for all such cases), and failure, respectively. Mean duration of treatment was 3.6 months (37.3 applications), 5.0 months (50.7 applications), and 3.4 months (25.2 applications) for complete responders, partial responders, and failures, respectively. Follow-up after treatment was 5 to 18, 14 to 32, and 2 to 28 months, respectively, with 1 partial responder lost to long-term follow-up. No patient developed invasive carcinoma. All but 2 patients experienced vulvar discomfort, resulting in treatment withdrawal for 3. Two patients had flulike symptoms.
Conclusions Imiquimod cream could be a therapeutic option for undifferentiated VIN. Although poorly tolerated, this self-applied treatment could spare patients, either totally or partially, the classic painful and sometimes mutilating treatments of VIN. Controlled, randomized studies are needed to evaluate its efficacy and tolerance.
SENTINEL LYMPH NODE
Further data on the usefulness of sentinel lymph node identification and ultrastaging in vulvar squamous cell carcinoma.Puig-Tintore LM, Ordi J, Vidal-Sicart S, Lejarcegui JA, Torne A, Pahisa J, Iglesias X.
Section of Gynecologic Oncology, Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON), Hospital Clinic, Institut d'investigacions biomediques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain.
Gynecol Oncol 2003 Jan;88(1):29-34 Abstract quote OBJECTIVE: The aim was to determine the feasibility of surgical identification and pathological ultrastaging of sentinel nodes (SNs) in vulvar carcinoma and to evaluate whether SN negativity rules out the possibility of metastasis in other nodes and can therefore avoid conventional lymphadenectomy.
MATERIAL AND METHODS: In 26 patients with vulvar squamous cell carcinoma the SNs were detected using both peritumoral injection of (99m)Tc and blue dye (isosulfan or methylene) before the surgical procedure. Dissection of the SNs was followed by standard lymphadenectomy and vulvar exeresis. For pathological ultrastaging at least eight histological sections of every node separated 400 microm were evaluated using hematoxylin & eosin and immunostaining against cytokeratin.
RESULTS: We identified the SNs in 25/26 patients (96%). In 19 patients (76%) the SN was unilateral and in 6 (24%) it was bilateral. A total of 46 SNs were isolated. Metastatic carcinoma was identified in 9 SNs from 8 patients (30.8%). Thirty-eight percent (3 of 8) patients with metastatic SNs presented micrometastasis detected only in ultrastaging. Seven (3.3%) of 239 nonsentinel nodes (non-SNs) showed metastasis. No metastatic implant was detected in non-SNs when SNs were negative in patients without clinical suspicious adenopathy (100% negative predictive value).
CONCLUSION: Inguinofemoral lymph nodes can be confidently avoided when sentinel node metastases are excluded by histological ultrastaging. This may reduce the surgical morbidity of conventional inguinofemoral lymphadenectomy, without worsening vulvar cancer prognosis.
Identification of sentinel lymph nodes in vulvar carcinoma patients with the aid of a patent blue V injection: a multicenter study.
Ansink AC, Sie-Go DM, van der Velden J, Sijmons EA, de Barros Lopes A, Monaghan JM, Kenter GG, Murdoch JB, ten Kate FJ, Heintz AP.
Academic Medical Center, Amsterdam, The Netherlands.
Cancer 1999 Aug 15;86(4):652-6 Abstract quote
BACKGROUND: The aim of this multicenter study was to investigate the feasibility and negative predictive value of sentinel lymph node detection with blue dye in vulvar carcinoma patients.
METHODS: In patients with squamous cell carcinoma of the vulva without suspicious groin lymph nodes, patent blue V was injected intradermally shortly before surgery. Routine groin lymph node dissection and radical vulvectomy were performed. During the surgery, blue lymph vessels and lymph nodes were identified, and the blue lymph nodes were sent separately for histologic examination. The negative predictive value of the blue lymph nodes for the absence of metastases was assessed by histologic examination of the groin lymph node specimens.
RESULTS: Fifty-one patients in whom 93 groin lymph node dissections were performed were entered. One or more blue lymph nodes were detected in only 52 groins (56%). Nine (17%) of these were tumor positive, and 6 blue lymph nodes were the only tumor positive lymph nodes in the specimen in which they were found. There were two false-negative blue lymph nodes. The negative predictive value was 0.953.
CONCLUSIONS: It was shown in this multicenter study that sentinel lymph node detection in vulvar carcinoma patients with blue dye only is not feasible because its negative predictive value is too low. Further studies involving the use of a combination of radioactive labeled technetium and blue dye are warranted.
Sentinel lymph node procedure is highly accurate in squamous cell carcinoma of the vulva.
de Hullu JA, Hollema H, Piers DA, Verheijen RH, van Diest PJ, Mourits MJ, Aalders JG, van Der Zee AG.
Departments of Gynecologic Oncology, Pathology, and Nuclear Medicine, University Hospital Groningen, Groningen, The Netherlands.
J Clin Oncol 2000 Aug;18(15):2811-6 Abstract quote
PURPOSE: To determine the diagnostic accuracy of the sentinel lymph node procedure in patients with squamous cell carcinoma of the vulva and to investigate whether step sectioning and immunohistochemistry of sentinel lymph nodes increase the sensitivity for detection of metastases.
PATIENTS AND METHODS: Between July 1996 and July 1999, 59 patients with primary vulvar cancer were entered onto a two-center prospective study. All patients underwent sentinel lymph node procedure with the combined technique (preoperative lymphoscintigraphy with technetium-99m-labeled nanocolloid and intraoperative blue dye). Radical excision of the primary tumor with uni- or bilateral inguinofemoral lymphadenectomy was performed subsequently. Sentinel lymph nodes and lymphadenectomy specimens were sent for histopathologic examination separately. Sentinel lymph nodes, negative at the time of routine pathologic examination, were re-examined with step sectioning and immunohistochemistry.
RESULTS: In 59 patients, 107 inguinofemoral lymphadenectomies were performed (11 unilateral and 48 bilateral). All sentinel lymph nodes, as observed on preoperative lymphoscintigram, were identified successfully intraoperatively. Routine histopathologic examination showed lymph node metastases in 27 groins, all of which were detected by the sentinel lymph node procedure. The negative predictive value for a negative sentinel lymph node was 100% (97.5% confidence interval [CI], 95% to 100%). Step sectioning and immunohistochemistry showed four additional metastases in 102 sentinel lymph nodes (4%; 95% CI, 1% to 9%) that were negative at the time of routine histopathologic examination.
CONCLUSION: Sentinel lymph node procedure with the combined technique is highly accurate in predicting the inguinofemoral lymph node status in patients with early-stage vulvar cancer. Future trials should focus on the safe clinical implementation of the sentinel lymph node procedure in these patients. Step sectioning and immunohistochemistry slightly increase the sensitivity of detecting metastases in sentinel lymph nodes and should be included in these trials.
Macpherson and Pincus. Clinical Diagnosis and Management by Laboratory Methods. Twentyfirst Edition. WB Saunders. 2006.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fifth Edition. Mosby Elesevier 2008
Basic Principles of Disease
Learn the basic disease classifications of cancers, infections, and inflammation
Commonly Used Terms
This is a glossary of terms often found in a pathology report.Diagnostic Process
Learn how a pathologist makes a diagnosis using a microscopeSurgical Pathology Report
Examine an actual biopsy report to understand what each section meansSpecial Stains
Understand the tools the pathologist utilizes to aid in the diagnosisHow Accurate is My Report?
Pathologists actively oversee every area of the laboratory to ensure your report is accurateGot Path?
Recent teaching cases and lectures presented in conferences
Pathologists Who Make A Difference
Search for a Physician Specialist
Gross or Clinical Photo
Gross or Clinical Photo
Microscopic Photo
Last Updated May 5, 2008
Send mail to The Doctor's Doctor with questions or comments about this web site.
Read the Medical Disclaimer.
Copyright © The Doctor's Doctor