1
|
Janke MJ, DeBlanc J, Kobernik EK, Skala SL, Hiles GL, Kelly R, Welch KC. Comorbid Vulvar Lichen Sclerosus and High-Grade Squamous Intraepithelial Lesions: A Management Conundrum. J Low Genit Tract Dis 2022; 26:319-322. [PMID: 35972920 DOI: 10.1097/lgt.0000000000000690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to determine if treating lichen sclerosus (LS) with high-potency topical corticosteroids (TCS) increases the risk of high-grade squamous intraepithelial lesion (HSIL) recurrence in patients with comorbid vulvar LS and HSIL. METHODS This is a retrospective study of patients with comorbid vulvar LS and HSIL treated with TCS between 2015 and 2020. Patients with clinically diagnosed or biopsy-proven LS and biopsy-proven HSIL of the vulva were included. Clinical data included demographics, tobacco use, immune-modifying conditions, specimen pathology, treatment types, and HSIL recurrence. Bivariate analysis was performed to compare demographic and clinical characteristics between patients with and without HSIL recurrence. RESULTS Twenty-six patients with comorbid LS and HSIL were identified. The median age was 66.0 years and median time in treatment for LS was 5.5 years. Thirteen (50%) had recurrence of HSIL and 13 (50%) did not have recurrence. Exposure to high-potency TCS was present in 20 (77%) patients, with 17 (65%) having use of more than 1-year duration and 9 (35%) having use at the time of HSIL diagnosis. When comparing the groups with and without HSIL recurrence, there was no significant difference in high-potency TCS exposure, duration of use, or use at time of HSIL diagnosis. CONCLUSIONS High-potency TCS use for the treatment of LS did not seem to increase the risk of HSIL recurrence in patients with comorbid vulvar LS and HSIL. This suggests that high-potency TCS can be appropriately used for the treatment of LS even when HPV-associated disease is present.
Collapse
Affiliation(s)
- Monica J Janke
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI
| | - Jennie DeBlanc
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI
| | - Emily K Kobernik
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI
| | | | | | - Rebeca Kelly
- MD Anderson Cancer Center at Cooper University Hospital, Camden, NJ
| | - Kathryn C Welch
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI
| |
Collapse
|
2
|
Mendlowitz AR, Hoang LN, McAlpine JN, Sadownik LA. Differentiated Exophytic Vulvar Intraepithelial Lesions: Case Reports and Review of Literature. J Low Genit Tract Dis 2022; 26:283-286. [PMID: 35467577 DOI: 10.1097/lgt.0000000000000678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims of this article were to describe 2 patients with a pathological diagnosis of differentiated exophytic vulvar intraepithelial lesion and to summarize the literature regarding this relatively new diagnosis. MATERIALS AND METHODS The existing literature was searched on December 1, 2021, using the MEDLINE database (1966-2021), and all combinations of the following search terms were used: "differentiated exophytic vulvar intraepithelial lesion" and "differentiated vulvar intraepithelial neoplasia." RESULTS Patients were postmenopausal and reported persistent vulvar itch associated with white hypertrophic plaques. Initial biopsies did not identify differentiated exophytic vulvar intraepithelial lesion. Invasive squamous cell carcinoma was found in both cases after surgical excision. CONCLUSIONS Differentiated vulvar intraepithelial lesions and invasive squamous cell carcinoma should be considered in the differential diagnosis of vulvar itch associated with hypertrophic plaques in postmenopausal women. Excision of suspicious plaques is recommended for definitive diagnosis.
Collapse
Affiliation(s)
- Ariel R Mendlowitz
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lien N Hoang
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jessica N McAlpine
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Leslie Ann Sadownik
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
3
|
Wei KX, Hoang LN. Squamous and Glandular Lesions of the Vulva and Vagina: What's New and What Remains Unanswered? Surg Pathol Clin 2022; 15:389-405. [PMID: 35715167 DOI: 10.1016/j.path.2022.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A number of changes have been introduced into the 5th Edition of the World Health Organization (WHO) Classification of squamous and glandular neoplasms of the vulva and vagina. This review highlights the major shifts in tumor classification, new entities that have been introduced, recommendations for p16 immunohistochemical testing, biomarker use, molecular findings and practical points for pathologists which will affect clinical care. It also touches upon several issues that still remain answered in these rare but undeniably important women's cancers.
Collapse
Affiliation(s)
- Kelly X Wei
- MD Undergraduate Program, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lynn N Hoang
- Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
| |
Collapse
|
4
|
Barron CR, Paczos TA, Varghese S, Smoller BR. Acantholytic Squamous Cell Carcinoma Arising From Lichen Sclerosus: A Rare Case Affecting Vulvar Skin. Int J Gynecol Pathol 2022; 41:122-125. [PMID: 34015795 DOI: 10.1097/pgp.0000000000000794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present the case of an 82-year-old female with acantholytic squamous cell carcinoma affecting vulvar skin. The patient had a history of perineal lichen sclerosus for 5 years before presentation. She was referred to a dermatologist for intractable severe pain associated with the lesions. Biopsies showed an infiltrative squamous cell carcinoma with histology consistent with the acantholytic subtype. Acantholytic squamous cell carcinoma is a rare histologic variant characterized by dyscohesive keratinocytes with pseudoglandular formation and dyskeratosis. It is associated with sun-damaged skin and most commonly occurs in the head and neck of elderly men. Few cases have been reported at nondermal sites and non-sun-exposed dermis. The patient underwent a radical vulvectomy and bilateral inguinal node dissection. The 1.6 cm tumor was diffusely acantholytic and pseudoglands were present. The tumor cells were diffusely positive for p63 immunohistochemical stain. As expected at this site, there was no solar elastosis identified histologically. However, vulvar intraepithelial neoplasia and chronic lichen sclerosus were apparent. This case represents a rare histologic subtype of squamous cell carcinoma in an unusual site associated with lichen sclerosus instead of solar elastosis.
Collapse
Affiliation(s)
- Cynthia R Barron
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York (C.R.B., T.A.P., S.V., B.R.S.)
| | | | | | | |
Collapse
|
5
|
Dryden SM, Reshko LB, Gaskins JT, Silva SR. Verrucous carcinoma of the vulva: Patterns of care and treatment outcomes. Cancer Rep (Hoboken) 2022; 5:e21591. [PMID: 35075817 PMCID: PMC9575509 DOI: 10.1002/cnr2.1591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/30/2021] [Accepted: 11/10/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Verrucous vulvar carcinoma (VC) is an uncommon and distinct histologic subtype of squamous cell carcinoma (SCC). The available literature on VC is currently limited to case reports and small single institution studies. AIMS The goals of this study were to analyze data from the National Cancer Database (NCDB) to quantitate the incidence of VC and to investigate the effects of patient demographics, tumor characteristics, and treatment regimens on overall survival (OS) in women with verrucous vulvar carcinoma. METHODS AND RESULTS Patients diagnosed with vulvar SCC or VC between the years of 2004 and 2016 were identified in the NCDB. OS was assessed with Kaplan-Meier curves and the log-rank test. Construction of a Cox model compared survival after controlling for confounding variables. The reported incidence of SCC of the vulva has significantly increased since 2004 (p < .0001). In contrast, the incidence of VC has remained stable (p = .344) since 2004. Compared to SCC, VC was significantly more likely to be diagnosed in older women (p < .0001) and treated with surgery alone (p < .0001). However, on propensity score weighted analysis there was a trend toward improved 5-year OS in women with VC compared to those with SCC (63.4% vs. 57.7%, p = .0794). Multivariable Cox survival analysis showed an improvement in OS in VC patients treated with both primary site and regional lymph node surgery compared to primary site surgery alone (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI] 0.46-0.97, p = .0357). CONCLUSION Verrucous carcinoma is more likely to present in older women. Regional lymph node surgery in addition to primary site surgery significantly improves OS in VC patients.
Collapse
Affiliation(s)
- Sara M Dryden
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Leonid B Reshko
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Jeremy T Gaskins
- Department of Bioinformatics & Biostatistics, University of Louisville, Louisville, Kentucky, USA
| | - Scott R Silva
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky, USA
| |
Collapse
|
6
|
New Insights into the Epidemiology of Vulvar Cancer: Systematic Literature Review for an Update of Incidence and Risk Factors. Cancers (Basel) 2022; 14:cancers14020389. [PMID: 35053552 PMCID: PMC8773873 DOI: 10.3390/cancers14020389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/22/2021] [Accepted: 01/07/2022] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Vulvar cancer incidence data were sought from official sources (WHO Cancer Incidence in Five Continents) and studies reporting comparable data. With respect to risk factors, a systematic PubMed search of articles published since 1980 identified 69 original cohort and case-control studies. Information was extracted using a PRISMA predesigned data collection form. Recent advances have provided further evidence in support of the carcinogenic model centred on human papillomavirus infection with different defects of the immune function. Conversely, the model centred on the role of vulvar lichen sclerosus and the often-associated differentiated vulva intraepithelial neoplasia has continued to be understudied. Abstract The aim of this review was an update of vulvar cancer incidence rates and trends and of all known and putative risk factors for the disease. The most recent incidence data were sought from official sources (WHO Cancer Incidence in Five Continents). To obtain an estimate of time trends in some areas, we compared data from Cancer Incidence in Five Continents with the few available studies that measured incidence using comparable methods. With respect to risk factors, a systematic PubMed search identified 1585 relevant articles published between 1980 and 2021. Abstracts and full texts were screened. Sixty-nine eligible original cohort and case-control studies were selected. Information was extracted using a PRISMA predesigned form. Nineteen risk factors, or risk factor categories, were investigated by two or more original studies. Solitary, unreplicated studies addressed the putative role of eight more factors. Recent advances have provided further evidence supporting the carcinogenic model centred on human papillomavirus infection with different defects of the immune function. Conversely, the model centred on the role of vulvar lichen sclerosus and the often associated differentiated vulvar intraepithelial neoplasia has continued to be epidemiologically understudied. More research on the association between these two conditions and vulvar cancer is a priority.
Collapse
|
7
|
Höhn AK, Brambs CE, Hiller GGR, May D, Schmoeckel E, Horn LC. 2020 WHO Classification of Female Genital Tumors. Geburtshilfe Frauenheilkd 2021; 81:1145-1153. [PMID: 34629493 PMCID: PMC8494521 DOI: 10.1055/a-1545-4279] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/05/2021] [Indexed: 01/04/2023] Open
Abstract
The 2020 WHO classification is focused on the distinction between HPV-associated and HPV-independent squamous cell carcinoma of the lower female genital organs. Differentiating according to HPV association does not replace the process of grading; however, the WHO classification does not recommend any specific grading system. VIN are also differentiated according to whether they are HPV(p16)-associated. HPV-independent adenocarcinoma (AC) of the cervix uteri has an unfavorable prognosis. Immunohistochemical p16 expression is considered to be a surrogate marker for HPV association. HPV-associated AC of the cervix uteri is determined using the prognostically relevant Silva pattern.
Collapse
Affiliation(s)
- Anne Kathrin Höhn
- Arbeitsgruppe Mamma, Gynäko- & Perinatalpathologie, Institut für Pathologie, Universitätsklinikum Leipzig AöR, Leipzig
| | | | - Grit Gesine Ruth Hiller
- Arbeitsgruppe Mamma, Gynäko- & Perinatalpathologie, Institut für Pathologie, Universitätsklinikum Leipzig AöR, Leipzig
| | - Doris May
- Pathologisches Institut der Ludwig-Maximilians-Universität München, München
| | - Elisa Schmoeckel
- Pathologisches Institut der Ludwig-Maximilians-Universität München, München
| | - Lars-Christian Horn
- Arbeitsgruppe Mamma, Gynäko- & Perinatalpathologie, Institut für Pathologie, Universitätsklinikum Leipzig AöR, Leipzig
| |
Collapse
|
8
|
Abstract
Importance Vulvar intraepithelial neoplasia (VIN) represents an increasingly common, yet challenging diagnosis that shares many common risk factors with cervical intraepithelial neoplasia. However, unlike cervical intraepithelial neoplasia, effective screening and treatment strategies are much less defined for patients with VIN. Objective The objective of this article is to review the underlying risk factors leading to the development of VIN, identify special populations at risk for VIN, and outline acceptable treatment strategies. Evidence Acquisition This literature review was performed primarily using PubMed. Results Vulvar intraepithelial neoplasia can be separated into usual VIN (uVIN) and differentiated VIN (dVIN). The more common uVIN is related to underlying human papillomavirus infection, whereas dVIN occurs in the setting of other vulvar inflammatory conditions such as lichen sclerosis. Differentiated VIN carries a higher risk of progression to invasive malignancy. Extramammary Paget disease is a rare intraepithelial adenocarcinoma unrelated to uVIN and dVIN, although management is similar. Conclusions and Relevance Vulvar intraepithelial neoplasia is a preinvasive neoplasia of the vulva with few robust strategies for surveillance or management. Careful examination with targeted biopsy is warranted for suspicious lesions, and a combination of surgical and medical management can be tailored for individual patient needs.
Collapse
|
9
|
Dasgupta S, de Jonge E, Van Bockstal MR, Wong-Alcala LSM, Wilhelmus S, Makkus LACF, Schelfout K, Van de Vijver KK, Smits S, Marbaix E, Koljenović S, van Kemenade FJ, Ewing-Graham PC. Histological interpretation of differentiated vulvar intraepithelial neoplasia (dVIN) remains challenging-observations from a bi-national ring-study. Virchows Arch 2021; 479:305-315. [PMID: 33682013 PMCID: PMC8364542 DOI: 10.1007/s00428-021-03070-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 12/29/2022]
Abstract
Differentiated vulvar intraepithelial neoplasia (dVIN) is a premalignant lesion that is known to progress rapidly to invasive carcinoma. Accurate histological diagnosis is therefore crucial to allow appropriate treatment. To identify reliable diagnostic features, we evaluated the inter-observer agreement in the histological assessment of dVIN, among a bi-national, multi-institutional group of pathologists. Two investigators from Erasmus MC selected 36 hematoxylin-eosin-stained glass slides of dVIN and no-dysplasia, and prepared a list of 15 histological features of dVIN. Nine participating pathologists (i) diagnosed each slide as dVIN or no-dysplasia, (ii) indicated which features they used for the diagnosis, and (iii) rated these features in terms of their diagnostic usefulness. Diagnoses rendered by > 50% participants were taken as the consensus (gold standard). p53-immunohistochemistry (IHC) was performed for all cases, and the expression patterns were correlated with the consensus diagnoses. Kappa (ĸ)-statistics were computed to measure inter-observer agreements, and concordance of the p53-IHC patterns with the consensus diagnoses. For the diagnosis of dVIN, overall agreement was moderate (ĸ = 0.42), and pair-wise agreements ranged from slight (ĸ = 0.10) to substantial (ĸ = 0.73). Based on the levels of agreement and ratings of usefulness, the most helpful diagnostic features were parakeratosis, cobblestone appearance, chromatin abnormality, angulated nuclei, atypia discernable under × 100, and altered cellular alignment. p53-IHC patterns showed substantial concordance (ĸ = 0.67) with the consensus diagnoses. Histological interpretation of dVIN remains challenging with suboptimal inter-observer agreement. We identified the histological features that may facilitate the diagnosis of dVIN. For cases with a histological suspicion of dVIN, consensus-based pathological evaluation may improve the reliability of the diagnosis.
Collapse
Affiliation(s)
- Shatavisha Dasgupta
- Department of Pathology, Erasmus MC, University Medical Centre, Postbus 2040, Be-building, 3000CA, Rotterdam, The Netherlands
| | - Elf de Jonge
- Department of Pathology, Groene Hart Ziekenhuis, Gouda, The Netherlands
| | - Mieke R. Van Bockstal
- Department of Pathology, Cliniques Universitaires Saint-Luc Bruxelles, Brussels, Belgium
| | | | - Suzanne Wilhelmus
- Department of Pathology, Pathan B.V., Laboratory for Pathology, Rotterdam, The Netherlands
| | | | - Katrien Schelfout
- Department of Pathology, Bravis Ziekenhuis, Bergen op Zoom, The Netherlands
- Department of Pathology, Ziekenhuis Geel, Geel, Belgium
| | - Koen K. Van de Vijver
- Department of Pathology, Cancer Research Institute Ghent, Ghent University Hospital, Ghent, Belgium
- Department of Pathology, Antwerp University, Antwerp, Belgium
| | - Sander Smits
- Department of Pathology, Pathan B.V., Laboratory for Pathology, Rotterdam, The Netherlands
| | - Etienne Marbaix
- Department of Pathology, Cliniques Universitaires Saint-Luc Bruxelles, Brussels, Belgium
| | - Senada Koljenović
- Department of Pathology, Erasmus MC, University Medical Centre, Postbus 2040, Be-building, 3000CA, Rotterdam, The Netherlands
| | - Folkert J. van Kemenade
- Department of Pathology, Erasmus MC, University Medical Centre, Postbus 2040, Be-building, 3000CA, Rotterdam, The Netherlands
| | - Patricia C. Ewing-Graham
- Department of Pathology, Erasmus MC, University Medical Centre, Postbus 2040, Be-building, 3000CA, Rotterdam, The Netherlands
| |
Collapse
|
10
|
Roy SF, Wong J, Le Page C, Tran-Thanh D, Barkati M, Pina A, Trinh VQH, Rahimi K. DEVIL, VAAD and vLSC constitute a spectrum of HPV-independent, p53-independent intraepithelial neoplasia of the vulva. Histopathology 2021; 79:975-988. [PMID: 34265101 DOI: 10.1111/his.14451] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/14/2021] [Indexed: 11/30/2022]
Abstract
AIMS We aimed to characterize a large cohort of non-invasive, HPV and p53-independent verruciform lesions, such as "vulvar acanthosis with altered differentiation" (VAAD), "differentiated exophytic vulvar intraepithelial lesion" (DEVIL) and "verruciform lichen simplex chronicus" (vLSC). METHODS AND RESULTS We retrospectively identified from January 2008 until December 2020, 36 eligible patients with verruciform non-invasive lesions (n=36) and collected clinical, histological and follow-up parameters. Verruciform non-invasive lesions occurred at a median age of 71 years with a median follow-up of 33.5 months. Clinically, pruritus was only reported in patients with VAAD (n=3, 21%). Lesion color was significantly different across categories (p=0.028). Apart from the histopathological criteria already known to distinguish these entities (hypogranulosis, epithelial pallor and low-magnification architecture), no other significant criteria were discovered, and significant overlap was observed, particularly between VAAD and DEVIL. Patients with vLSC trended towards longer survival without recurrence compared to VAAD and DEVIL (P=0.082) yet showed comparable invasion-free survival interval (p=0.782). Squamous cell carcinomas (SCC) associated with either VAAD, DEVIL or vLSC displayed similar clinical, histopathological and biological parameters. In non-invasive precursor lesions, stromal edema was associated with invasion (p=0.015) and remained so upon Cox regression analysis (p=0.009). CONCLUSION Our study of HPV and p53 independent non-invasive verruciform lesions of the vulva highlights significant clinical, histopathologic and biologic overlap between VAAD, DEVIL and vLSC suggesting that these pre-invasive lesions should be viewed as a spectrum. We also show that stromal features such as edema might play an import role in progression to invasion.
Collapse
Affiliation(s)
- Simon F Roy
- Département de Pathologie, Université de Montréal, University of Montréal, Centre hospitalier de l, Montréal, Canada.,Département de Pathologie et de Biologie Cellulaire, Université de Montréal, Montréal, Canada
| | - Jahg Wong
- Département de Pathologie, Université de Montréal, University of Montréal, Centre hospitalier de l, Montréal, Canada.,Département de Pathologie et de Biologie Cellulaire, Université de Montréal, Montréal, Canada
| | - Cécile Le Page
- Département de Pathologie, Université de Montréal, University of Montréal, Centre hospitalier de l, Montréal, Canada
| | - Danh Tran-Thanh
- Département de Pathologie, Université de Montréal, University of Montréal, Centre hospitalier de l, Montréal, Canada
| | - Maroie Barkati
- Département de Pathologie et de Biologie Cellulaire, Université de Montréal, Montréal, Canada
| | - Annick Pina
- Département d'Obstétrique et Gynécologie, Université de Montréal, Centre hospitalier de l, Montréal, Canada
| | - Vincent Quoc-Huy Trinh
- Département d'Obstétrique et Gynécologie, Université de Montréal, Centre hospitalier de l, Montréal, Canada
| | - Kurosh Rahimi
- Département de Pathologie, Université de Montréal, University of Montréal, Centre hospitalier de l, Montréal, Canada.,Département de Pathologie et de Biologie Cellulaire, Université de Montréal, Montréal, Canada
| |
Collapse
|
11
|
Neville G, Chapel DB, Crum CP, Song SJ, Yoon JY, Lee KR, Kolin DL, Hirsch MS, Nucci MR, Parra-Herran C. Interobserver reproducibility of the diagnosis of differentiated exophytic vulvar intraepithelial lesion (DEVIL) and the distinction from its mimics. Histopathology 2021; 79:957-965. [PMID: 34214216 DOI: 10.1111/his.14442] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 02/05/2023]
Abstract
AIMS Most vulvar squamous cell carcinomas are human papillomavirus (HPV)-associated or TP53-mutant. A third category of HPV-independent TP53-wild-type lesions is uncommon and not fully understood. Differentiated exophytic vulvar intraepithelial lesion (DEVIL) has been characterised as a precursor of this latter category. The reproducibility of the diagnosis of DEVIL and its distinction from lesions with overlapping morphology has not been studied. Our aim was to establish the interobserver agreement in the diagnosis of DEVIL and its distinction from neoplastic and reactive conditions of the vulva on haematoxylin and eosin evaluation. METHODS AND RESULTS A set of 35 slides was evaluated by eight reviewers (two trainees and six practising gynaecological pathologists). The set included DEVIL, condyloma, established vulvar precursors [high-grade squamous intraepithelial lesion (HSIL) and differentiated vulvar intraepithelial neoplasia (dVIN)] with superimposed acanthosis or verruciform growth, lichen simplex chronicus (LSC), and psoriasis. Kappa (κ) values were calculated. Overall, interobserver agreement was moderate (κ = 0.56), improving to substantial (κ = 0.7) when evaluation was performed by practising pathologists. Agreement was strong for the diagnosis of HSIL (κ = 0.88), and substantial for the diagnosis of DEVIL (κ = 0.61), condyloma (κ = 0.79), and LSC (κ = 0.72). Agreement was moderate for the diagnosis of dVIN (κ = 0.59) and psoriasis (κ = 0.53). Perfect agreement (6/6) among practising pathologists was observed in 43% of cases, and majority agreement (5/6 or 4/6) was observed in 48% of cases. CONCLUSIONS Reproducibility in the diagnosis of verruciform vulvar lesions, including the novel DEVIL, is acceptable overall. Reproducibility is higher for well-known lesions such as HSIL and condyloma than for more challenging diagnoses such as DEVIL, dVIN, and psoriasis. Agreement is higher among practising gynaecological pathologists, suggesting that training and experience improve reproducibility. Our findings support the inclusion of DEVIL as a diagnostic entity in the classification of vulvar squamous lesions.
Collapse
Affiliation(s)
- Grace Neville
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David B Chapel
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher P Crum
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharon J Song
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ju-Yoon Yoon
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth R Lee
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David L Kolin
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michelle S Hirsch
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marisa R Nucci
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carlos Parra-Herran
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
12
|
Dasgupta S, Koljenović S, van den Bosch TPP, Swagemakers SMA, van der Hoeven NMA, van Marion R, van der Spek PJ, van Doorn HC, van Kemenade FJ, Ewing-Graham PC. Evaluation of Immunohistochemical Markers, CK17 and SOX2, as Adjuncts to p53 for the Diagnosis of Differentiated Vulvar Intraepithelial Neoplasia (dVIN). Pharmaceuticals (Basel) 2021; 14:ph14040324. [PMID: 33918187 PMCID: PMC8066509 DOI: 10.3390/ph14040324] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 12/26/2022] Open
Abstract
Histological diagnosis of differentiated vulvar intraepithelial neoplasia (dVIN), the precursor of human papillomavirus (HPV)-independent vulvar squamous cell carcinoma (VSCC), can be challenging, as features of dVIN may mimic those of non-dysplastic dermatoses. To aid the diagnosis, p53-immunohistochemistry (IHC) is commonly used, and mutant expression patterns are used to support a histological diagnosis of dVIN. However, a proportion of dVIN can show wild-type p53-expression, which is characteristic of non-dysplastic dermatoses. Furthermore, recent research has identified a novel precursor of HPV-independent VSCC—the p53-wild-type differentiated exophytic vulvar intraepithelial lesion (de-VIL). Currently, there are no established diagnostic IHC-markers for p53-wild-type dVIN or de-VIL. We evaluated IHC-markers, cytokeratin 17 (CK17), and SRY-box 2 (SOX2), as diagnostic adjuncts for dVIN. For this, IHC-expression of CK17, SOX2, and p53 was studied in dVIN (n = 56), de-VIL (n = 8), and non-dysplastic vulvar tissues (n = 46). For CK17 and SOX2, the percentage of cells showing expression, and the intensity and distribution of expression were recorded. We also performed next generation targeted sequencing (NGTS) on a subset of dVIN (n = 8) and de-VIL (n = 8). With p53-IHC, 74% of dVIN showed mutant patterns and 26% showed wild-type expression. Median percentage of cells expressing CK17 or SOX2 was significantly higher in dVIN (p53-mutant or p53-wild-type) and de-VIL than in non-dysplastic tissues (p < 0.01). Diffuse, moderate-to-strong, full epithelial expression of CK17 or SOX2 was highly specific for dVIN and de-VIL. With NGTS, TP53 mutations were detected in both dVIN and de-VIL. We infer that immunohistochemical markers CK17 and SOX2, when used along with p53, may help support the histological diagnosis of dVIN.
Collapse
Affiliation(s)
- Shatavisha Dasgupta
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands; (S.K.); (T.P.P.v.d.B.); (S.M.A.S.); (R.v.M.); (P.J.v.d.S.); (F.J.v.K.); (P.C.E.-G.)
- Correspondence:
| | - Senada Koljenović
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands; (S.K.); (T.P.P.v.d.B.); (S.M.A.S.); (R.v.M.); (P.J.v.d.S.); (F.J.v.K.); (P.C.E.-G.)
| | - Thierry P. P. van den Bosch
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands; (S.K.); (T.P.P.v.d.B.); (S.M.A.S.); (R.v.M.); (P.J.v.d.S.); (F.J.v.K.); (P.C.E.-G.)
| | - Sigrid M. A. Swagemakers
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands; (S.K.); (T.P.P.v.d.B.); (S.M.A.S.); (R.v.M.); (P.J.v.d.S.); (F.J.v.K.); (P.C.E.-G.)
- Department of Clinical Bioinformatics, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Nick M. A. van der Hoeven
- Department of Gynecology and Obstetrics, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands;
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands;
| | - Ronald van Marion
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands; (S.K.); (T.P.P.v.d.B.); (S.M.A.S.); (R.v.M.); (P.J.v.d.S.); (F.J.v.K.); (P.C.E.-G.)
| | - Peter J. van der Spek
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands; (S.K.); (T.P.P.v.d.B.); (S.M.A.S.); (R.v.M.); (P.J.v.d.S.); (F.J.v.K.); (P.C.E.-G.)
- Department of Clinical Bioinformatics, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Helena C. van Doorn
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands;
| | - Folkert J. van Kemenade
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands; (S.K.); (T.P.P.v.d.B.); (S.M.A.S.); (R.v.M.); (P.J.v.d.S.); (F.J.v.K.); (P.C.E.-G.)
| | - Patricia C. Ewing-Graham
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands; (S.K.); (T.P.P.v.d.B.); (S.M.A.S.); (R.v.M.); (P.J.v.d.S.); (F.J.v.K.); (P.C.E.-G.)
| |
Collapse
|
13
|
Jenkins TM, Mills AM. Putative precancerous lesions of vulvar squamous cell carcinoma. Semin Diagn Pathol 2020; 38:27-36. [PMID: 32948383 DOI: 10.1053/j.semdp.2020.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 01/09/2023]
Abstract
Precursor lesions of vulvar squamous cell carcinoma (VSCC) can be divided into two major biologic and prognostic groups: HPV-associated and HPV-independent VSCC. These two pathways are categorized as usual vulvar intraepithelial neoplasia (uVIN) with progression to basaloid or warty VSCC and differentiated vulvar intraepithelial neoplasia (dVIN) with progression to the more common keratinizing VSCC. While the HPV-dependent pathway to squamous cell carcinoma is well-understood, the development of squamous cell carcinoma from HPV-independent lesions is less clear. The majority of HPV-independent lesions fall into the dVIN category, and mutations in TP53 have been implicated as the driver behind their development. Other less common HPV-independent precursor lesions, termed differentiated exophytic vulvar intraepithelial lesion (DEVIL) and vulvar acanthosis with altered differentiation (VAAD), have also been characterized as precursors to keratinizing and verrucous VSCC. Inflammatory conditions of the vulva such as lichen sclerosus and lichen simplex chronicus also put patients at risk for developing VSCC. We herein evaluate the available evidence and biologic basis for these VSCC precursor lesions, among other speculated entities, and discuss their clinical, diagnostic, and prognostic features.
Collapse
Affiliation(s)
- Taylor M Jenkins
- University of Virginia Health System, Department of Pathology, Charlottesville, VA 22903, United States
| | - Anne M Mills
- University of Virginia Health System, Department of Pathology, Charlottesville, VA 22903, United States.
| |
Collapse
|
14
|
Larish A, Yin L, Glaser G, Moore E, Bakkum-Gamez J, Routman D, Ma D, Price D, Janus J, Price K, Chintakuntlawar A, Neben-Wittich M, Foote R, Van Abel K. Human Papillomavirus-Associated Anogenital Pathology in Females With HPV-Positive Oropharyngeal Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2020; 164:369-374. [PMID: 32663054 DOI: 10.1177/0194599820941499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We sought to determine the incidence and location of human papillomavirus (HPV)-associated anogenital disease in women with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) via a retrospective cohort study with prospective contact to update history at Mayo Clinic in Rochester, Minnesota. Females undergoing treatment for nonmetastatic HPV-positive OPSCC from 2011 to 2019 were identified. Clinical history and outcomes were abstracted from medical records. Patients without documented anogenital history were contacted, consented, and administered a survey, and external records were requested and reviewed. Seventeen of 46 patients (37.0%) had a history of anogenital HPV-associated disease, and 16 of 17 (94.1%) required procedures to diagnose or treat HPV lesions. The cervix was the most common site (16/17, 94.1%). Procedures included colposcopy (n = 6), cervical excision (n = 3), cryotherapy (n = 4), and hysterectomy (n = 3). One case of fatal cervical carcinoma was noted, diagnosed 1 year following OPSCC. Three of 17 (17.6%) had HPV-related vulvovaginal disease, and 1 of 17 had anal disease. Patients with a history of HPV-positive OPSCC may be at elevated risk for HPV-associated anogenital disease.
Collapse
Affiliation(s)
- Alyssa Larish
- Department of Obstetrics and Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Linda Yin
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Department of Obstetrics and Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie Bakkum-Gamez
- Department of Obstetrics and Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel Price
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey Janus
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katharine Price
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Robert Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
15
|
CD274 (PD-L1), CDKN2A (p16), TP53, and EGFR immunohistochemical profile in primary, recurrent and metastatic vulvar cancer. Mod Pathol 2020; 33:893-904. [PMID: 31844270 DOI: 10.1038/s41379-019-0429-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/01/2019] [Accepted: 11/06/2019] [Indexed: 01/10/2023]
Abstract
Vulvar squamous cell carcinoma can be divided by human papillomaviruses (HPV) status into two distinct clinicopathological and molecular entities. New agents targeting the tumor surface expression of programmed cell death-1/programmed cell death-ligand-1 are becoming a therapeutic option in an increasing number of carcinomas. We evaluate CD274 (PD-L1), CDKN2A (p16), tumor protein p53 (TP53), and epidermal growth factor receptor (EGFR) immunoexpression in primary tumors, recurrences and lymph node metastases and its correlations with prognosis and HPV status. We report 93 cases of vulvar squamous cell carcinoma diagnosed between 2002 and 2016 with the description of their clinicopathological features and prognosis data. Immunohistochemistry for CD274, CDKN2A, TP53, and EGFR was performed on tissue microarrays collecting from primary tumor, recurrences and lymph node metastasis. Kaplan-Meier estimator and multivariable Cox regression analysis controlling for FIGO stage and age were used. Patients who underwent surgery had a superior overall survival (HR = 0.51, 95% CI = 0.26-0.99 p = 0.04). Lymph node metastasis size ≥5 mm was associated with an inferior overall survival (HR = 1.88, 95% CI = 1.22-2.92 p = 0.004). CDKN2A expression was correlated with an inferior rate of recurrent disease (p = 0.02). In high-risk HPV DNA+ vulvar squamous cell carcinomas patients with CDKN2A- carcinomas showed a significantly worse overall survival than women with CDKN2A+ tumors (56% vs.100%, p = 0.003). TP53 expression was associated with an increased rate of recurrent disease (p = 0.0005). CD274 expression was associated with lymph node metastasis (p = 0.04). In 16 patients the CD274, CDKN2A, TP53, and EGFR expression changed between primary tumors, recurrences and lymph node metastases during tumor progression. In conclusion, a significant percentage of vulvar squamous cell carcinoma has a heterogeneous biomarker expression during tumor progression. We highlight the importance of some of these markers to be used as prognostic biomarkers. This data brings new light to future treatment using targeted therapy to EGFR or CD274 to include retesting such biomarkers in recurrence and lymph nodes metastases.
Collapse
|