Vulva, vagina & female urethra
Squamous carcinoma and precursor lesions

Topic Completed: 1 May 2014

Minor changes: 26 August 2020

Copyright: 2002-2020,, Inc.

PubMed Search: HSIL vulva

Priya Nagarajan, M.D., Ph.D.
Sara B. Peters, M.D., Ph.D.
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Cite this page: Nagarajan P, Peters SB. HSIL. website. Accessed October 26th, 2020.
Definition / general
  • See also VAIN
  • Newer terminology is VIN III
  • Bowen disease refers to high grade dysplasia of squamous epithelium or vulvar intraepithelial neoplasia grade III and is characterized by full thickness atypia
  • Previously used:
  • Currently used:
    • High grade vulvar intraepithelial neoplasia
    • Vulvar intraepithelial neoplasia, grade III
    • Squamous cell carcinoma in situ
    • Basaloid variant of vulvar intraepithelial neoplasia (J Cutan Pathol 1980;7:244)
    • Usual or classic vulvar intraepithelial neoplasia
  • Often involves labia majora but can be multifocal affecting various parts of vulva
  • May involve other squamous epithelia such as cervical, vaginal and anal mucosae
  • Human papillomavirus (HPV) 16 infection is more common than type 18 and other high risk human papillomavirus (HPV) types (Int J Cancer 2009;124:1626)
  • Risk factors include young age of first intercourse, multiple sexual partners, immunodeficiency and smoking
Clinical features
  • Lesions present as flat erythematous, pale or pigmented patches or a combination of the three and are often asymptomatic
  • May be subtle clinically; diluted acetic acid helps identify these patches (Arch Gynecol Obstet 2015;292:387)
  • Made by clinical examination and confirmed by histologic examination
Prognostic factors
Case reports
  • Untreated lesions only rarely undergo spontaneous resolution and may become invasive tumors
  • Objective of therapy is to prevent progression to invasive carcinoma
  • Various surgical and medical therapies may be combined for better outcome (Cochrane Database Syst Rev 2014;(3):CD007928, Cochrane Database Syst Rev 2011;(4):CD007924)
  • Surgical therapy: frequently complicated by recurrence (due to the multifocal nature of the disease) and includes:
    • Wide local surgical excision (commonly used)
    • Ablative therapies include carbon dioxide laser or cavitron ultrasonic surgical aspiration (CUSA), electrocoagulation, cryotherapy
  • Medical therapy:
    • Topical imiquimod, 5-fluorouracil creams
    • Systemic cidofivir
    • Photodynamic therapy
Clinical images

Images hosted on other servers:

Papules and plaques in genital and perianal area



Vulval disease

Gross description
  • Pale whitish, erythematous or pigmented patches and plaques
  • Presence of nodular areas should raise the possibility of invasive carcinoma
Microscopic (histologic) description
  • Epidermis is frequently acanthotic but may be normal, with an overlying hyperkeratotic or parakeratotic scale or an erosion
  • Background lymphoplasmacytic infiltration of submucosa is common
  • Loss of epithelial maturation with full thickness atypia
  • Cells are relatively small and monomorphic with high nuclear to cytoplasmic ratio, hyperchromatic and pleomorphic nuclei
  • Koilocytic changes are not prominent although nuclear membrane irregularity is often present
  • Mitotic activity is prominent and atypical mitotic figures are not uncommon
  • Dysplastic changes also involve adnexal epithelium
  • Dyskeratosis and acantholysis may be present and can be prominent
  • Rarely, intraepidermal nesting of clonal atypical cells may be seen, producing the so called Borst-Jadassohn phenomenon
Microscopic (histologic) images

Contributed by Priya Nagarajan, M.D., Ph.D.

Bowen disease

Bowen disease

Images hosted on other servers:

Basaloid subtype, p16


Cytology description
  • Routine Pap smears are not usually useful as a screening tool for vulvar pathologies
Positive stains
Negative stains
Molecular / cytogenetics description
  • Human papillomavirus (HPV) 16 positive
  • Presence of human papillomavirus (HPV) may be demonstrated by in situ hybridization (ISH) or polymerase chain reaction (PCR)
  • Human papillomavirus (HPV) genotyping may be useful when ISH or PCR identifies common human papillomavirus (HPV) types (Clin Exp Dermatol 2007;32:304)
  • Karyotyping and cytogenetic analyses are rarely performed
  • Subtelomeric deletion of 11p has been identified in one case (Cancer Genet Cytogenet 1997;93:109)
  • Often aneuploid
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