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Vaginal adenosis, posterior wall
Vaginal red granular patch
Contributed by Leonel Maldonado, M.D.
Vaginal wall lesion biopsy
Vaginal wall lesion biopsy
Glands in vaginal mucosa
Mucinous glands below epithelium
Contributed by Leonel Maldonado, M.D.
Benign appearing glandular cells
Vaginal adenosis diffuse, rare case
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Ultrasound and MRI
MRI
Perineal, MRI
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Paravaginal, intraoperative
Perineal, intraoperative
Vulvar, preoperative
Vulvar, pre and postoperative
Contributed by @Andrew_Fltv on Twitter
Aggressive angiomyxoma
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Cut surface
Contributed by David B. Chapel, M.D. and @Andrew_Fltv on Twitter
Infiltrative growth
Entrapped adipose tissue
Extravasated red blood cells
Thick walled vessels
Myoid bundles
Entrapped nerve
Bland cytology
Aggressive angiomyxoma
HMGA2
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FISH, karyotype
Histopathology
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Hart line
Female urethra: embryology and anatomy
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Labia majora
Vestibule
Contributed by Pooja Srivastava, M.D.
Labia majora overview
Labia minora overview
Vagina overview
Vagina epithelium
Vagina lamina propria
Vagina muscular layer
Normal histology of vagina
Anatomy of female urethra
Histology of female urethra
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Vaginal ultrasound
Vaginal MRI
Vulvar MRI
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Intraoperative images
Preoperative image
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Gross specimen
Contributed by David B. Chapel, M.D.
Alternating cellularity
Spindle cells
Epithelioid cells
Multinucleated cells
Contributed by José Alberto Fonseca Moutinho, M.D.
Nevus
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Irregular dots on the periphery of the lesion
Pigmented lesion
Contributed by Anna Sarah Erem, M.D. and Gulisa Turashvili, M.D., Ph.D.
Atypical melanocytic proliferation
Atypical melanocytic proliferation
Atypical genital nevi
Atypical nevi and nevi of special sites by Dr. Phillip McKee
Atypical nevi and melanoma by Dr. Steven Wang
Contributed by Mehrane Nazeran, M.D. and Hugo Horling, M.D.
Papillary architecture
p16
Infiltrating carcinoma
Solid and glandular pattern
Cribriform growth
Glandular pattern
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Irregularly shaped and ulcerated tumor
Well limited plaque with a pigmented border
Multiple indurated nodules
Contributed by Lucy Ma, M.D. and Priya Nagarajan, M.D., Ph.D.
Nodular growth and cribriform tumor nests
Basaloid cells with mucin production
Retraction artifact
Basaloid lobules with palisading
Cleft formation between basaloid tumor lobules & stroma
Basaloid lobules - conspicuous peripheral nuclear palisade
Cleft formation between basaloid tumor lobules & stroma
p40 - CK5/6 dual stain
BerEP4
BCL2
p16
BCC 101 by Dr. Jerad Gardner
Reporting BCC by Dr. Catriona McKenzie, pathCast
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Inguinal cellular angiofibroma
Scrotal cellular angiofibroma
Contributed by David B. Chapel, M.D.
Well circumscribed tumor
Hyalinized vessels
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Karyotype and RB1 FISH
RB1 FISH
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Fig 1: not involving urethra or clitoris
Fig 2: not originating from cervix
Case #363
CK7
EMA
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Fig 3
Fig 4: papillae and acini in tubulocystic pattern
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Pap stain
Histopathology vagina - clear cell carcinoma
Contributed by Matthias Choschzick, M.D.
Condyloma acuminatum
Condyloma and HPV
Koilocytosis
Dysplasia
Contributed by José Alberto Fonseca Moutinho, M.D.
Melanocytic lesion
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Dysplastic nevi defined based on clinical criteria
Contributed by Anna Sarah Erem, M.D. and Gulisa Turashvili, M.D., Ph.D.
Mild cytologic atypia
Shouldering
Nest fusion
Grade 2 cytologic atypia
Melanoma in dysplastic nevi
Dysplastic nevus: 5 minute pathology pearls by Dr. Jerad Gardner
Dysplastic nevi by Prof. Naseem Ahmed
Melanoma arising in a dysplastic nevus by Drs. Philip H. Mckee and Antonina Kalmykova
Histopathology and dermoscopy of severely dysplastic nevus / in situ melanoma by Dr. Sasi Kiran Attili
Dysplastic nevus: fact or fiction by Prof. Cliff Rosendahl
Junctional dysplastic lentiginous nevus by Dr. Ian McColl
Dysplastic nevus by Dr. Sonam Kumar Pruthi
Dysplastic nevus by Audiopedia
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Endometroid adenocarcinoma
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MRI, proximal type
Ultrasound, proximal type with lung metastases
CT, proximal type with lung metastases
CT, proximal type with lung metastases
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Proximal type, preoperative
Proximal type, intraoperative
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Proximal type,
excision specimen
Contributed by David B. Chapel, M.D. and Priya Nagarajan, M.D., Ph.D.
Infiltrative growth
Sheet-like growth
Atypia
Myxoid stroma
High grade atypia
Diffuse growth
Rhabdoid morphology
Core biopsy
Epithelioid cells
Tumor necrosis
Cytokeratin
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FISH and aCGH based detection of SMARCB1 deletion
Proximal type epithelioid sarcoma of the groin
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Labium majora mass
Labium majora polyp
Contributed by Hope Haefner, M.D.
Vulvar polyp
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Labia majora mass
Contributed by Albert Alhatem, M.D. and Debra S. Heller, M.D.
Stroma reaching the epithelium
Hypocellular stromal form
Hypercellular stromal form
Stellate cells
Multinucleated cells
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White plaque
Ulcerated nodule
Contributed by Matthias Choschzick, M.D.
HSIL, basaloid type
HSIL, p16 block staining
HSIL, increased Ki67
HSIL, warty type
LSIL
LSIL, HPV stain
Contributed by Matthias Choschzick, M.D.
HPV, p16, p53
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Ulcerative lesion, upper labia minor
Contributed by Matthias Choschzick, M.D.
Vulvar carcinoma
Contributed by Matthias Choschzick, M.D.
Nonkeratinizing SCC
Margin
Invasion depth
p16
p53
HPV RNA ISH
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Abdominal pelvic CT
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Vulvectomy
Contributed by Priya Nagarajan, M.D., Ph.D.
Verrucous carcinoma of vulva
Verrucous carcinoma of vulva
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Globoid projections
Exophytic growth
Mild atypia
Contributed by Matthias Choschzick, M.D.
Basal atypia
Basaloid differentiation
Cell pallor
No atypia
p53 expression
p53 overexpression
CK17
CK17
CK17
Table 1: Diagnostic criteria of vulvar erosive lichen planus by the International Society of the Study of Vulvovaginal Disease (ISSVD) (adapted from Br J Dermatol 2013;169:337)
| 3 out of 9 criteria needed for diagnosis |
| Well demarcated erosions or glazed erythema of introitus |
| Wickham striae on surrounding skin |
| Pain or burning |
| Scarring or loss of architecture |
| Vaginal inflammation |
| Involvement of other mucosal surfaces |
| Well defined inflammatory band in superficial connective tissue involving dermoepidermal junction |
| Inflammatory band consists of predominantly lymphocytes |
| Evidence of basal cell layer degeneration (e.g., Civatte bodies, abnormal keratinocytes or basal apoptosis) |
Table 2: Summary of minimum clinicopathologic criteria to diagnose vulvar erosive lichen planus, more specific than those proposed by ISSVD (adapted from J Low Genit Tract Dis 2020;24:317)
| All 5 criteria must be present | |
| Clinical presentation (signs) | Well demarcated glazed red macule or patch located on vestibule, labia minora or vagina* |
| Histopathological correlate | Nonkeratinized squamous epithelium, mucocutaneous junction or adjacent hairless skin |
| Band-like lymphocytic infiltrate abuts the epithelial layer | |
Basal layer with one of the following patterns
| |
| Sclerosis is absent | |
- *Supportive features
- Architectural changes include midline fusion or labia minora, adhesions between affected opposed structures
- Common comorbidities: lichen sclerosis (LS), other types of locations of lichen planus, systemic autoimmune diseases
Table 3: Clinicopathologic features of classic hypertrophic lichen planus (adapted from J Low Genit Tract Dis 2020;24:317)
| Classic lichen planus | Hypertrophic lichen planus | |
| Clinical features | Red, gray-white or purple-brown plaque or papules on hairless or hair bearing skin | Circumferential red plaque over hairless and hair bearing skin of vulva or perianal area |
| Histopathological correlate | ||
| Stratum corneum* | Hyperkeratosis | Marked hyperkeratosis |
| Granular cell layer* | Hypergranulosis | Diffuse and marked hypergranulosis |
| Rete ridge morphology | Mild to moderate acanthosis with irregular rete ridges, often sawtoothed or spiky | Marked acanthosis with deep and irregular rete ridges |
| Basal layer | Apoptotic bodies, squamatization, vacuolar change Lymphocytosis | Apoptotic bodies, squamatization, vacuolar change may be confined to rete tips / basal layer above papillary processes
Lymphocytosis |
| Dermis | Band-like applied lymphocytic infiltrate | |
| Papillary dermal fibrosis | ||
- *May be altered by excoriation, especially in hypertrophic lichen planus
Contributed by M. Luann Racher, M.D.
Bilateral red patch
Circumferential red patch
Excoriated erythematous plaque
Excoriated erythematous plaque
Scarring and excoriated plaques
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Glassy, reticulated, white papules and plaques
Extensive erosion and ulceration
Contributed by Anna Sarah Erem, M.D. and Gulisa Turashvili, M.D., Ph.D.
Lichenoid interface dermatitis
Civatte bodies or colloid bodies
Hypertrophic lichen planus
Civatte bodies
and clefting at
dermal epidermal
junction
Hyperkeratosis and hypergranulosis
Chronic lichenoid interface dermatitis
Lichen planus & hypertrophic lichen planus
Hypertrophic lichen planus: 5 minute pathology pearls
Lichen planus
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Cigarette paper appearance
Clitoris becomes buried under clitoral hood
Contributed by Jutta Huvila, M.D., Ph.D.
Typical lichen sclerosis
Sclerotic superficial dermis
Edema
Early lichen sclerosus
Interface change
Introduction to lichen sclerosus
Case #273
Case #273
Contributed by Anna Sarah Erem, M.D., Gulisa Turashvili, M.D., Ph.D. and José Alberto Fonseca Moutinho, M.D.
Vulvar melanoma
Vulvovaginal melanoma
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Nodule and ulcer
Large friable, gray-white growth
Vulvar melanoma
Nonpigmented primary lesion found in vagina
Contributed by Anna Sarah Erem, M.D. and Gulisa Turashvili, M.D., Ph.D.
Vulvectomy for melanoma
Contributed by Anna Sarah Erem, M.D., Gulisa Turashvili, M.D., Ph.D. and Priya Nagarajan, M.D., Ph.D.
Superficial growth pattern
Melanoma in situ
Melanoma in situ, lentiginous pattern
Vaginal melanoma
HMB45
Vulvovaginal melanoma
Vulvar melanoma, recurrent
S100
Mucosal vulvar melanoma
MelanA / MART1
Vaginal amelanotic melanoma
Vulvovaginal melanoma
by Dr. Lewis Hassell
Vaginal melanoma radiology
by Dr. Ayushi Gupta
Vaginal melanoma
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Posterior vaginal wall tumor
Contributed by Brooke Howitt, M.D.
Separation from squamous epithelium
Cytologically bland spindle cells
Discrete nests
Pancytokeratin
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Lesion on perineal area
Preoperative
Erythematosquamous
lesion
Before and after treatment
Asymmetrical brown lesion
Contributed by Lucy Ma, M.D.
Plaque-like lesion
Contributed by Priya Nagarajan, M.D., Ph.D. and Lucy Ma, M.D.
Abundant intracytoplasmic mucin
Preservation of basal keratinocytes
Large polygonal cells with pale cytoplasm
Paget cells extending upward as single cells
Adnexal structures
Infiltrating Paget cells
Large invasive nests
Subtle case
Subtle case
Secondary extramammary Paget disease
Mucicarmine positive
Extramammary Paget disease: 5 minute pathology pearls
Paget disease versus melanoma versus squamous cell carcinoma in situ
Table 1: Features distinguishing vulvar nevi, melanosis and melanoma (adapted from J Am Acad Dermatol 2014;71:1241)
| Reassuring features suggestive of a benign process | Concerning features for possible malignancy | |
| Clinical |
|
|
| Dermoscopy |
|
|
| Reflectance confocal microscopy |
|
|
Table 2: Clinical morphology for pigmented vulvar lesions (adapted from Dermatol Ther 2010;23:449)
| Papules and macules | Patches and plaques |
| Pigmented nevi (nevocellular nevi) | Physiologic hyperpigmentation |
| Dysplastic nevi | Postinflammatory hyperpigmentation |
| Malignant melanoma | Vulvar melanosis (vulvar lentiginosis) |
| Anogenital warts | Acanthosis nigricans |
| Vulvar intraepithelial neoplasia | |
| Seborrheic keratosis | |
| Basal cell carcinoma | |
| Angiokeratoma |
Table 3: Genodermatosis syndromes with vulvar melanosis (adapted from J Am Acad Dermatol 2014;71:1241)
| Genodermatosis | Areas affected | Key features | Genetic mutation |
| Peutz-Jeghers syndrome | Oral, perianal and genital area, lips, nostrils, hands, feet | Hamartomatous polyps in the gastrointestinal tract (GIT), breast, ovarian, pancreatic and GIT cancers | STK11 |
| Carney complex | Oral and genital area, lips, eyelids, conjunctiva | Blue nevus, psammomatous melanotic schwannoma, myxomas (usually cardiac), endocrine neoplasms | PRKAR1A |
| Multiple lentigines syndrome (LEOPARD syndrome) | Face, neck, trunk, genital area | Delayed growth, sensorineural deafness, ECG abnormalities, ocular hypertelorism, pulmonic stenosis, abnormal genitalia | PTPN11, RAF1, BRAF |
| Bannayan-Riley-Ruvalcaba syndrome | Face, genital area | Macrocephaly, intellectual and motor deficiencies, joint hyperextensibility, pectus excavatum, scoliosis, intestinal hamartomatous polyposis, lipomas, hemangiomas | PTEN |
| Dowling-Degos syndrome | Axillae, neck, flexural folds, inguinal and genital area | Follicular papules, comedone-like lesions, perioral scar, reticulated hyperpigmentation, hypopigmented or erythematous macules | KRT5 |
Table 4: Clinical and histologic differences between atypical genital nevus and vulvar melanoma
(adapted from Hoang: Melanocytic Lesions - A Case Based Approach, 1st Edition, 2014)
| Proposed diagnosis | Atypical genital nevus of special anatomic site | Vulvar melanoma |
| Age | Premenopausal, young adult | Postmenopausal |
| Size | < 1 cm | > 1 cm |
| Delineation | Well circumscribed | Infiltrative |
| Symmetry | Present | Absent |
| Lateral extension of junctional component | Focal | Present |
| Lentiginous junctional component | Focal | Present |
| Junctional nests | Dyscohesive | Confluent |
| Retraction artefact | Present | Absent |
| Ulceration | Absent or due to trauma | Often present |
| Pagetoid upward spread | Focal, central, inconspicuous | Prominent |
| Cytologic atypia | Superficial, mild - moderate | Deep, moderate to severe |
| Dermal mitosis | Rare and superficial | Conspicuous, atypical, deep |
| Dermal maturation | Present | Absent |
| Melanin pigmentation | Coarse, uniform | Fine, irregular |
| Dermal fibrosis | Broad zone of superficial coarse dermal fibrosis | Regression type |
Contributed by José Alberto Fonseca Moutinho, M.D.
Acanthosis nigricans
Angiokeratoma
Postinflammatory
hyperpigmentation
Melanosis / lentiginosis
Physiologic pigmentation
Pigmented condyloma acuminata
Nevus
Pigmented seborrheic keratosis
Pigmented basal cell carcinoma
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Hyperpigmented, brownish macules
Angiokeratoma of Fordyce
Contributed by Emory University School of Medicine
Angiokeratoma
Genital melanocytic macule
Vulvar compound melanocytic nevus
Compound melanocytic proliferation
Blue nevus, common type
Basal cell carcinoma
Seborrheic keratosis
Atypical melanocytic nevus, genital type
Angiokeratoma by Filip Sokol
Angiokeratoma by Pathology mini tutorials
Atypical nevi and nevi of special sites by Dr. Phillip McKee
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Vulvar leiomyoma
Vaginal leiomyoma, MRI
Vaginal leiomyoma, MRI and angiography
Vaginal leiomyoma, ultrasound
Vaginal leiomyoma, MRI & CT
Vaginal leiomyosarcoma, MRI
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Vulvar leiomyoma, preoperative examination
Vulvar leiomyoma, intraoperative
Vulvar leiomyosarcoma, preoperative examination
Vaginal leiomyosarcoma, preoperative examination
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Vulvar leiomyoma, excision specimen
Vulvar leiomyoma, cut surface
Vaginal leiomyoma, cut surface
Vaginal leiomyosarcoma, gross examination
Contributed by David B. Chapel, M.D.
Vulvar leiomyoma
Vulvar leiomyosarcoma
Vulvar STUMP
Vaginal leiomyosarcoma
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Scanning and transmission electron micrographs
Contributed by Morgan Hrones, M.D. and Natalia Buza, M.D.
Mucinous cystic lining
Bland appearing cyst lining
Benign urothelial cyst
Benign urothelial lined cyst
Benign epidermal inclusion cyst
Bartholin cyst with adjacent Bartholin glands
Bartholin cyst
Bartholin gland cyst of the vulva - histopathology
Clement: 2019
Crum: 2017
Crum: 2015
Fadare: 2015
Hoang: 2015
IARC: 2020
Nucci: 2020
Nucci: 2023
Vang: 2017
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