this lecture covered the pathology of various conditions of female genitalia. in general most of the dermatological conditions we learned about in CPD I have the same effect in the vaginal region, although may be named differently (inflammatory dermatitis = vulvitis). psoriasis, lichen simplex chronicus, lichen planus all affect the vulva and have unique histological features: psoriasis has hyperkeratosis / loss of granular cell layer / acanthosis / rete peg elongation / vascular dilation. LSC has thickened epidermis and leukocytic infiltrate. lichen planus has sawtooth rete pegs / basal cell layer degeneration / thickened granular layer / inflammatory infiltrate.
lichen sclerosus is a white thickening of the vulvar or perianal skin and associated with an increased risk for vulvular cancer. it might present with intense pruritis that may cause the patient to itch herself to the point of ulceration. LS is characterized microscopically by edematous degeneration of the basal cell layer, loss of rete pegs, dense collagen/fibrous replacement of dermis, and band like leukocytic infiltrate.
bartholin's cyst results from a blocked bartholin duct generally resulting from a previous infection and is relatively common, affecting all ages. they are 3-5 cm and the larger cysts are generally more painful. the cysts are generally lined by transitional epithelium, squamous metaplasia, or normal duct cells.
genital herpes can present in the vulvar or anal region and are generally from HSV infection. the characteristic histomorphological finding for HSV infection is the multinucleated giant cell. genital warts, otherwise known as condyloma acumata, are generally from HPV infection-- HPV strains 6 and 11 cause 90% of cases. HPV is also an STD spread by skin to skin contact. the histomorphology of genital warts are acanthosis, hyperkeratosis, and cytoplasmic vacuoles. condylomas can also be caused via syphilus, in which case it can be accompanied by vaginal discharge.
vaginosis refers to an imbalance in the bacterial flora that results in dominance of one or two species; in low pH, trichomonas may dominate and in high pH candida may dominate. histologically, one may see clue cells, which is an epithelial cell that is covered with bacteria.
vulvar intraepithelial neoplasm results in hyperpigmented skin plaques that can appear red, white, yellow, or multipigmented. although VIN is associated with a primary squamous neoplasm and high risk HPV strains (16, 18, 31, 45), it can often regress spontaneously in young women. risk for progressing to invasive cancer increases with age over 40 or so.
vulvar carcinoma makes up 3% of female genital cancers and is mostly squamous cell carcinoma (85%) and adenocarcinoma (15%). they are classified further by HPV involvement: on a histological level, poorly differentiated cells are positive for HPV, while well differentiated, keratinizing cells are negative for HPV. potential for metastasis depends on size and depth of tumor as well as lymphatic involvement-- if VC does metastasize, it might involve the iliac, inguinal, peri-aortic, pelvic lymph nodes and go to the lungs or liver.
cervical cancer is the 5th most common cancer of women in the world and the 8th most common cancer of american women. it is caused by HPV infection and has increased likelihood in women who have risky sexual activity at a young age or have the high risk HPV strains (16, 18, 31, 45). oral contraceptives and tobacco are also associated as risk factors for cervical cancer. the extent of spread of cervical cancer is classified in four stages: stage I is confined to the cervix, stage II can extend to the upper 2/3 of the vagina, stage III to the pelvis, and stage IV beyond the pelvis and metastasis to other areas.
questions
various conditions...
1. what is inflammatory dermatitis of the vulva called?
2. vulvitis might be seen with patients with what skin conditions?
3. what are the histomorphological features of vulvar psoriasis? ††
4. what is lichen simplex chronicus?
5. what are the histological features of LSC?
6. what is widespread LSC called? what might it be a complication of? √√
7. what is lichen planus?
8. what age group of women does vulvular/vaginal lichen planus usually affect?
9. what are the histological features of lichen planus? †√
lichen sclerosus...
10. what is lichen sclerosus?
11. LS is associated with an increased risk for...
12. what are some other clinical features of LS?
13. what are the histological features of LS? √√
bartholin's cyst...
14. how common is a bartholin's cyst and what age does it affect? √
15. what is the etiology of a bartholin's cyst? √
16. what is the general size of the bartholin's cysts? √
17. larger bartholin's cysts are... √
18. bartholin's cysts are lined by what types of cells? √√
genital herpes and warts...
19. which regions may genital herpes present in? √
20. primary infections present with... X
21. what characteristic histologic feature is shown with HSV infection? √
22. what is the scientific name for genital warts? †
23. what is the etiology of genital warts? √
24. HPV strains 6 and 11 cause... †
25. HPV strains 16 and 18 cause... †
26. how is HPV spread? √
27. what are the histological features of genital warts? †
28. what is condyloma latum of syphilus and what is it caused by?
29. what might CLS be accompanied by?
vaginosis...
30. what is bacterial vaginosis?
31. what are clue cells in the context of bacterial vaginosis?
32. what are two microorganisms commonly associated with bacterial vaginosis?
33. how does vaginal pH correspond to the type of microorganism that dominates the vaginal flora?
vulvar intraepithelial neoplasia...
34. what is the appearance of a vulvar intraepithelial neoplasia?
35. 10-30% of VIN cases are associated with...
36. VIN affects mostly women of what age?
37. what is found in 90% of VIN cases?
38. describe the prognosis of VIN in younger women.
vulvar carcinoma...
39. what are the different types of vulvar carcinoma and what are their relative percentages?
40. what are two general categories of vulvar carcinomas?
41. how does HPV involvement change the histomorphology of vulvar carcinoma?
42. what factors is the metastasis of VC due to?
43. which lymph nodes does metastasis of VC involve?
44. distant metastasis of VC usually involves...
vaginal carcinoma...
45. how common are vaginal carcinomas?
46. what type of vaginal carcinoma is associated with women whose mothers were treated with DES during pregnancy?
47. male offspring of mothers with vaginal carcinoma are at an increased risk for...
cervical cancer...
48. how prevalent is cervical cancer in the US and world?
49. what is the causative factor in nearly all cases of cervical cancer?
50. which strains of HPV are involved in cervical cancer?
51. what is the possible genetic component involved in the pathogenesis of cervical cancer?
52. what are some risk factors for cervical cancer?
53. what is the current classification system for cervical carcinoma?
koilocytosis...
54. what are the cellular changes involved in koilocytotic atypia?
55. koilocytosis atypia are made up of which cells?
56. what is a ASC-US?
57. what are the hallmarks of CIN1?
58. what are the hallmarks of CIN2?
59. what about CIN3?
60. what are the four stages of cervical cancer and what are they characterized by?
answers
1. vulvitis.
2. psoriasis, eczema, allergic dermatitis.
3. hyperkeratosis/parakeratosis
loss of granular layer
epidermal acanthosis
elongated rete pegs
vascular dilation. [hyper loss of cans makes your veins longer] [ker gran can rete vasc] [
4. a generalized skin condition characterized by lichenification due to chronic itching.
5. thickened epidermis, leukocytic infiltrate.
6. neurodermatitis, complication of atopic dermatitis.
7. a common skin condition (PPPP- purple polygonal pruritic papules) causing inflammation and maybe ulceration.
8. women of childbearing age.
9. sawtooth rete pegs, basal cell layer degeneration, thickened granular cell layer, inflammatory infiltrate. [i plainly saw the generation of inflamed grandmas]
10. white thickening of vulvar and perianal skin.
11. vulvular cancer.
12. itchiness; patient might create ulcerations. intravaginal area not affected.
13. edematous degeneration of basal cell layer, rete pegs disappear, dense collagenous fibrous tissue replaces dermis, band like lymphocytic infiltrate. [edema, disappear, dense, band] [in LS, eddie disappeared in a thick band]
14. fairly common, all ages.
15. blockage of bartholin duct usually due to preceding infection.
16. 3-5 cm.
17. more painful.
18. transitional epithelium, normal duct tissue, or squamous metaplasia.
19. vulvar or anal.
20. flu like symptoms.
21. multinucleated giant cells.
22. condyloma acuminata.
23. STD from HPV.
24. 90% of genital warts.
25. 70% of cervical cancer.
26. skin/skin contact during sex.
27. acanthosis (diffuse epidermal hyperplasia), hyperkeratosis, cytoplasmic vacuoles.
28. genital wart due to syphilis.
29. vaginal discharge.
30. infection resulting from imbalance of vaginal flora.
31. epithelial cells coated with bacteria.
32. trichomonas vaginalis, candida albicans.
33. low pH generally results in vaginosis from trichomonas, high from candida.
34. hyper-pigmented skin plaques: red, white, yellow, multipigmented.
35. primary squamous neoplasm of vagina or cervix.
36. below 40.
37. high risk HPV strains (16,18, 31, 45).
38. may spontaneously regress.
39. 85% SCC, 15% BCC / melanoma / adenocarcinoma.
40. carcinomas related to HPV or not related to HPV.
41. poorly differentiated cells positive for HPV, well differentiating keratinizing cells negative for HPV.
42. size and depth of tumor, lymphatic involvement.
43. inguinal, iliac, peri-aortic, pelvic.
44. liver or lungs.
45. not common.
46. clear cell adenocarcinoma.
47. peri-anal cancer.
48. 5th most common cancer in the world, 8th in the US.
49. HPV.
50. 16, 18, 31, 45.
51. HLA-B7.
52. early age of sexual activity
multiple sexual partners
high risk HPV strains
oral contraceptives
smoking
genital infections
multiple births [young many risky mouth smoke infect multiple] [many youth risk infecting multiple mouths by smoking]
53. the bethesda system, which groups cervical cancers into high and low grade.
54. enlarged nuclei, halo stain around nucleus.
55. intermediate and superficial squamous cells from vaginal epithelium.
56. atypical squamous cell of undetermined significance.
57. koilocytotic atypia.
58. progressive atypia in all epithelial layers.
59. carcinoma in situ- diffuse atypia, loss of maturation.
60. stage I: confined to cervix.
stage II: upper 2/3 of vagina.
stage III: extends into pelvic wall.
stage IV: beyond pelvis, metastasis.
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