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b.
Vulvar
Intraepithelial Neoplasia (VIN)
à
i.
Just
one of several types of Intraepithelial Neoplasia (Cervial
Intrapeithelial Neoplasia is CIN; Perianal
Intraepithelial Neoplasia is PAIN which is probably
painful; vaginal is VAIN)
ii.
Most are related to HPV since HPV likes squamous epithelium of the female genital
tract i.e. common in the vulva, vagina, cervix and
perianal region
iii.
They
have not broken through the basement membrane and has no
metastatic potential
iv.
Requires liberal biopsy *You have seen this
terminology used several times now. Current
gynecologists are trained to “biopsy liberally” as a lot
of things present similarly histologically.
v.
Classification
1.
Low
grade vs. high grade
(consists of 2 & 3, considered to be the most clinically
significant of the three and treated similarly)
2.
Classification based on what is seen microscopically
à
a.
VIN 1
(lower 1/3 of epithelium)
b.
VIN 2
(2/3 of epithelium)
c.
VIN 3
(entire epithelium)
vi.
Presentation is highly variable = single/multiple lesions, macular, popular, variable color,
may itch
vii.
Histologically = increase in the Rini pegs,
darkness due to maturation abnormality in which cells do
not develop (cells are not uniform and appear small and
dark).
viii.
Classic
VIN
à
1.
Recurs/persists in 7-22% of cases
2.
Occult
invasion in 6-7% (up to 19% in one study series)
3.
Progression to invasion in 3-10% = greater with
inadequate or no treatment therefore treat them
4.
Risks
for subsequent invasion increases if >40yo (older)
and/or immunocompromised
5.
2-7% of
pts diagnosed prior with “vulvar dystrophy” (the old
name given to non-neoplastic disorders) actually have
VIN
6.
40% are
multifocal
7.
Various
clinical appearances = multiple red or white plaques,
pigmented, polypoid, verruciform or flat
8.
Associated with both in situ and invasive cervix and
vaginal lesions in 18-52% of the cases
ix.
HPV
field effect = if someone presents with an HPV lesion in
one place needs to be checked elsewhere
c.
Paget’s
Disease of the Vulva = non-HPV-related type of
Intraepithelial Neoplasia
i.
Itch is the most common presentation
ii.
Histologically looks similar to Paget’s disease of the breast
yet the two are different
1.
Both
result from some type of cell percolating up from
subcutaneous tissues into the epithelium
2.
That of
the breast is believed to be neoplastic cells so
considered some type of breast cancer
3.
That of
the vulva is believed to be an aberrant stem
cell that is associated with invasive cancer in 25-30%
4.
Not
always a vulvar cancer
= can also be other cancers such as sweat gland
adenocarcinoma. Or can signify that you have cancer of
the GI tract.
iii.
Associated with ~25-30% of underlying in situ or
invasive cancer (Paget’s disease has a 100% association)
iv.
Most
common in Caucasian elderly women
v.
Multifocal
vi.
Extends beyond what you can see during examination = one of the reasons
for its high recurrence
vii.
Histologically = big, pink cells that spread to the
surface (melanoma also histologically spreads so need to
distinguish with special stains)
d.
Vulvar cancer
– less common than the other cancers
i.
More
common in older women who do not go to a gynecologist or
who do not get regular examinations
ii.
Most are squamous cell carcinomas since the vulva is covered by squamous cell epithelium
iii.
They
tend to spread to the inguinal lymph nodes
iv.
Treatment in the past was a big incision known as
“Butterfly” in which they removed the entire vulva along
with the lymph nodes in the inguinal area = very bad for
women as it often required skin grafts amongst other
things; overall it was detrimental to the health of the
woman
v.
Treatment today includes a vulvectomy (removal of the affected vulva)
and/or separate excisions = women do much better
vi.
Lesions can be exophytic (going outward) or endophytic (ulcerating
inward)
vii.
Non-HPV related lesions are more common in the elderly while HPV-related
ones are more common in the younger population
II.
Vaginal conditions
a.
Inflammatory
à
often picked up on pap smears; caused by
i.
Monilla
(yeast infection)
ii.
Trichomonas – seen well with wet slide; PAP smear not
that dramatic as the do not swim around
iii.
Bacterial vaginosis due to shift in the normal vaginal
flora; discharge seen; can cause premature labor in
pregnant women
iv.
Actinomyces – associated with intrauterine devices
v.
Herpes
b.
Malignancies – occur usually if have something else
going on such as in the vulva
i.
Vaginal
intraepithelial neoplasia (VAIN) – HPV-related
ii.
Invasive Squamous cell carcinoma – to diagnose as a primary cancer must
rule out vulvar or cervical cancer first
iii.
Adenosis or trapping of glands that should not be there – normally there
are no glands in the vagina so this is rare – associated
with clear cell carcinoma caused by diethlystilbetrol
(DES) use (no longer used)
iv.
Sarcoma Botryoides (Rhabdomyosarcoma of the vagina)– pediatric smooth mm
sarcoma; usually seen in children under 5 yo; rare; once
quite deadly – better outcomes today; clinically appear
as clusters of grape
v.
Rare
tumors, metastases
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