In the last few years, interest in vulvar disease has greatly increased. Hemangiomas are benign tumors of the vascular endothelium that. Hemangioma is a benign neoplasm that may affect the vulva, and it can cause functional or emotional disability. This article reports the case of. Abstract. Hemangioma is a benign neoplasm that may affect the vulva, and it can cause functional or emotional disability. This article reports the case of a.
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Vulvar assessment is an integral part of gynecologic examination. Vulvar abnormalities have many variations in presentation. Because multiple diagnoses may have similar gross characteristics, histologic evaluation is critical in establishing an accurate diagnosis. Histologic classification based on the tissue of origin is practical in the description of vulvar lesions. The two major categories for vulvar lesions are tumors of epithelial origin and tumors of mesenchymal origin. Condyloma Acuminatum Human papillomavirus HPV infections of the vulva are common clinical occurrences.
HPV infections are classified as either clinical or subclinical, contingent on the infectivity of the virus and the response of the affected epithelium. The typical expression is a soft, pink-white, papillary epithelial lesion. These lesions may occur singly or in clusters that may become confluent Fig. The usual vulvar locations are the prepuce, vestibule, and perineal body.
Vulvar Lobular Capillary Hemangioma: A Rare Location for a Frequent Entity
Perianal and anal loci also are seen frequently. Multiple vulvar condylomata acuminata.
Although there are more than 60 subtypes of HPV, relatively few affect the vulva. HPV 2, the virus associated with common epithelial warts, also is seen in the squamous epithelium of the vulva. Even if only clinically expressed HPV is considered, it is now one of the most common sexually transmitted diseases. Some HPV infections may progress to vulvar intraepithelial neoplasia VIN and an even smaller segment may progress further to frankly invasive squamous cell carcinoma of the vulva, but the majority of lesions are limited to the HPV cutaneus expression known as the venereal wart or condyloma.
Immunosuppressed states and pregnancy are associated with enlargement and progression of condylomatous lesions Fig. Hypertropic condylomata acuminata in a pregnant patient. Histologically, condylomata appear as epithelial papillomas with acanthosis and parakeratosis Fig. Some epithelial cells exhibit atypical nuclei and perinuclear halos that are believed to be a manifestation of HPV infection.
The underlying stroma usually hwmangioma a mild inflammatory response. Biopsies of condylomatous lesions that are resistant to treatment or that have an abnormal appearance should be performed for histologic confirmation of the diagnosis. Differentiation between condylomata and vulvar papillomatosis or other vulvar lesions can then be made. Condylomata showing acanthosis, parakeratosis and koilocytotic changes.
Treatment consists of destruction of the cutaneous manifestations of the HPV infection. Eradication of the virus from the epithelium is not clinically possible. Control of epithelial viral expression can be accomplished with topical agents such as trichloroacetic acid, bichloracetic acid, podophyllin or its derivatives, or topical 5-fluorouracil 5-FU.
Cryotherapy, laser vaporization, and electroexcision or desiccation are other methods of treatment. Intralesional or systemic administration of interferon is another therapeutic option that usually is reserved for recalcitrant lesions.
Recurrent viral cutaneous expressions usually gemangioma managed with alternative treatments or combinations of treatments. Verrucous carcinoma of the vulva appears as a large condyloma or a lesion suspicious for invasive carcinoma. The lesion, first described by Buschke and Lowenstein as a giant condyloma, 2 is associated with the HPV 6 viral subtype. Characteristically, it is localized to the vulva.
Management is best accomplished by wide excision and careful postoperative evaluation. Vulvar Intraepithelial Neoplasia Vulvar intraepithelial neoplasia is a hyperplastic squamous lesion with atypia that is confined to the epithelium.
VIN is histologically divided into three categories: VIN lesions are sufficiently atypical to be considered premalignant. These lesions appear as hyperkeratotic, raised, and frequently pigmented epithelial thickenings Fig. They usually occur in hemwngioma who are in the sixth decade or older; however, a younger age does not exclude the diagnosis.
Biopsy findings show full-thickness epithelial atypia and mitotic activity Fig. The affected areas may be asymptomatic or excoriated from scratching. Any thickened, raised, or hyperkeratotic lesion observed during gynecologic examination should be considered for biopsy, regardless of the associated symptoms. Vulvar lesions may be multifocal; therefore, multiple biopsies are suggested. Enhancement of lesions with dyes such as toluidine blue has been recommended to address the multifocal nature of these lesions.
Toluidine blue should stain the areas of nuclear concentration that are bulvar with VIN III; however, most lesions are hyperkeratotic, and the keratin surface prevents penetration of the dye to the epithelial nuclei. A more effective approach is application of a dilute acetic acid solution to the vulva.
In this manner, subtle epithelial changes are more easily identified. Carcinoma in situ showing hyperkeratotic pigmented epithelial thickening. Carcinoma in situ showing epithelial atypia throughout the epithelial layer. The use of 5-FU or systemic interferon has had marginal compliance and success.
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Close follow-up to assess recurrence is suggested. It occurs in patients in the second, third, and fourth decades of life. It is expressed as multiple papillomatous lesions that may involve more than one area of the vulva.
Biopsy findings show epithelial atypia with koilocytotic changes of HPV. Progression to an invasive malignancy occurs in rare cases, such as hemangiom immunosuppressed or immunocompromised patients. Management is conservative unless premalignant changes are present. Premalignant lesions are treated in a manner similar to VIN. Basal Cell Carcinoma Basal cell carcinomas usually are asymptomatic until they are large enough to be noticed by the patient or until ulceration and bleeding develop.
The tumor is firm with rolled borders, and most often is found on the labia majora of postmenopausal women. Management consists of wide excision of the tumor with adequate margins. Evaluation for metastases should be considered if the excised specimen shows invasion of subcutaneous fat, tumor thickness greater than vilvar cm, or involvement of the urethra or vagina. Histologically, these tumors have peripheral palisading of the basal cells at the epithelial margins. The remainder of the tumor has closely packed, uniform cells, with basophilic nuclei and scant cytoplasm.
Mitotic figures are frequent. These tumors are locally invasive; therefore, thorough study of the entire lesion is necessary. The margins in particular should be evaluated and reported for adequacy. Margins of less than 4 mm are at higher risk for recurrence. Acrochordon Fibroepithelial polyps are common in the vulvar epithelium.
They are referred to as skin tags. There is no malignant potential for this lesion. They are soft, hemangio,a, polypoid structures. Skin appendages and hair are not characteristic of acrochordon. Therapy is local excision of symptomatic lesions. Histologically, the acrochordon is described as a fibrovascular stalk with mature hyperkeratotic squamous epithelium.
Epidermal appendages are infrequent, and the vascular pattern may be enhanced. Hidradenoma Hidradenomas are tumors of the apocrine sweat glands. Some may have an origin in the eccrine sweat glands.
They usually are less than 1 cm in diameter, and they occur on the medial aspect of the labia majora Fig. The lesions are firm and freely movable. Ulceration and pain may develop if the lesion connects with the epithelial surface. Treatment is surgical excision. Hidradenoma of the vulva. Histologically, the hidradenoma has cystic spaces that are lined with columnar cells.
The lesion is further characterized by many complex folds, papillary structures, and pronounced glandular proliferation Fig. This lesion may vukvar confused with adenocarcinoma. The distinguishing features of the hidradenoma include the lack of pleomorphism, stacking up of cells, and nuclear conformity. Syringoma Syringomas are small, benign hamartomas of the eccrine sweat hemangimoa. Usually, multiple lesions are present, and they may occur at more than one site on the body.
The lesions are asymptomatic, and no treatment is needed unless pain or pruritus develops. Microscopically, these are tumors vuvar dilated sweat gland ducts, and cysts lined with benign cuboidal cells Fig. A minimal inflammatory response is present unless the cysts rupture.
Two percent have pigmented changes with premalignant characteristics. Benign pigmented lesions are classified as lentigines, vulvar melanosis, and nevi. Lentigines are small 1 to 4 mmwell-circumscribed macules. Histologically, lentigines are similar to junctional nevi. There is hyperplasia in the epidermis, and increased melanin in the basal layer of skin. Nuclear atypia is not seen in the hyperplastic tissue.
Vulvar melanosis is a lesion that is larger than lentigo and has an irregular border. Histologically, increased numbers of melanocytes and dermal melanophages are present.