Lipoma On Vulva

Figure 21 Angiomyofibroblastoma. (A) The lesion is well circumscribed. (B) (See color insert) Bland spindle cells in a collagenous background with numerous thin-walled vessels. (C) Mixed hypocellular and more hypercellular areas, with cells tending to cluster around vessels. Source: Courtesy of James Scurry, MD, Nextpath, Newcastle, Australia.

Figure 21 Angiomyofibroblastoma. (A) The lesion is well circumscribed. (B) (See color insert) Bland spindle cells in a collagenous background with numerous thin-walled vessels. (C) Mixed hypocellular and more hypercellular areas, with cells tending to cluster around vessels. Source: Courtesy of James Scurry, MD, Nextpath, Newcastle, Australia.

Figure 22 (See color insert) Aggressive angiomyxoma: the lesion tends to be more hypocel-lular than angiomyofibroblastoma, with a myxoid background. Vessels tend to be thicker walled. The lesions are poorly circumscribed.

excision. In addition to the potential clinical impression of carcinoma because of the present of a mass, the overlying squamous epithelium often shows pseudoepithelio-matous hyperplasia, which may be mistaken histologically for a squamous cell carcinoma, particularly on superficial biopsies (Table 23) (37).

Leiomyoma

Smooth muscle neoplasms of the vulva are relatively uncommon (Fig. 24). They are usually benign, although leiomyosarcomas have been described arising in the vulva. The age range of cases is wide. Theories of origin of smooth muscle neoplasms in this region have included erectile tissue, blood vessel smooth muscle, round ligament, dartos muscle, and erector pili muscle (41). The lesions stain for smooth muscle markers immunohistochemically. The criteria for distinguishing benign from malignant tumors is less well established than in the uterine counterpart. Histology may be variable, with epithelioid cells in a plexiform pattern and myxoid change not infrequent. Features associated with recurrence or metastasis in one series (42) were size of 5.0 cm or greater, infiltrative margin, five or more mitoses per 10 HPF, and grade 2 to 3 nuclear atypia. The authors diagnosed leiomyosarcoma when at least three of these criteria were met, atypical leiomyoma when two were met, and leiomyoma for one or none. Nucci and Fletcher (17) suggest that any mitotic activity, nuclear pleomorphism, or infiltrative margin are risk factors for local recurrence, often many years later, and term a lesion with any of these features, but falling short of the definition of sarcoma, atypical (Table 24).

Table 22 Aggressive Angiomyxoma

Clinical

Diagnosis Symptoms appearance Differential diagnosis Therapy

Aggressive Mass Mass, cyst Clinical: Bartholin's cyst, or Complete angiomyxoma other cystic lesion. excision

Pathologic:

angiomyofibroblastoma, fibroepithelial polyp, myxoma, other myxoid lesions

Labial Fibroma Differential Diagnosis
Figure 24 Leiomyoma. (A) A large nodule is seen in the right labium majus. (B) Typical appearance with interlacing fascicles of bland smooth muscle cells.
Table 23 Granular Cell Tumor

Clinical

Diagnosis

Symptoms

appearance

Differential diagnosis

Therapy

Granular

Small

Firm subcu-

Bartholin's duct cyst, lipoma,

Wide

cell

painless

taneous mass

hidradenoma, fibroma.

excision

tumor

mass

< 5 cm

Squamous cell carcinoma or

sexually transmitted disease may

be suspected by the clinician if

overlying squamous epithelium is

ulcerated (39)

Table 24

Leiomyoma

Clinical Differential

Diagnosis

Symptoms

appearance diagnosis

Therapy

Leiomyoma Painless mass. Wide range of Bartholin duct Excision

Erythema, pruritus, size. Well cyst, fibroma pain also occur circumscribed.

Figure 25 Fibroma. (A) Typical pedunculated lesion. (B) The lesion is composed of fibro-blasts and abundant collagen.

Fibroma

Fibromas, while uncommon, are the most common benign neoplasm of the vulva, occurring most often in women aged 20 to 40, but have been reported across a broad age range (Fig. 25A and B). They may be small, but if over 8.0 cm, are usually pedunculated (42). They have an intact overlying squamous epithelium and are hypocellular lesions composed mainly of collagen, with a fibroblast component (Table 25) (22,42).

Lipoma

Lipomas are composed of mature adipose tissue with a thin fibrous capsule (Fig. 26A and B). They are generally asymptomatic, however may be of cosmetic concern. Rarely liposarcomas and atypical lipomas have been described. In Nucci's series (43), most resolved with excision, although one incompletely resected lesion recurred. These lesions were less circumscribed and showed varying degrees of atypia. One case was described as presenting as a Bartholin abscess (44). Recently, characteristic cytogenetic aberrations have been described as important in predicting the behaviors of lipomatous tumors (45); hence fresh tissue should be provided for cytogenetic analysis in lesions that are large and/or deep seated (Table 26).

Mammary-Like Tissue Within Vulva

Van der Putte (46) has described anogenital ''sweat'' glands that mimic the histology of breast tissue, most highly concentrated in the interlabial sulcus of the vulva. These are distinct from, but with some similarities to both apocrine and eccrine glands. Further postulated is that a variety of lesions can arise in these glands, ranging from fibrocystic change to fibroadenomas (47), hidradenoma papilliferum, and cases of

Table 25 Fibroma

Diagnosis

Symptoms

Clinical appearance

Differential diagnosis

Therapy

Fibroma

None for smaller

Pedunculated

Leiomyoma

Excision

lesions, discomfort/

mass

pain for larger

Photo Labial Tissue
Figure 26 Lipoma. (A) Lesions may be large and pedunculated. (B) Lesion is composed of well-circumscribed adipose tissue.

Paget's disease and invasive adenocarcinomas that are not of sweat gland origin. Supernumerary nipples (polythelia) or breasts (polymastia) usually occur along the milk line, and hence such a lesion can occur on the vulva. Breast tissue in a vulvar location may not be apparent prior to the hormonal stimulation of puberty or pregnancy. Ectopic breast tissue may develop the same lesions as eutopic breast tissue

(48). Polythelia may be associated with other anomalies, particularly renal or cardiac

(49). While usually a straightforward clinical diagnosis, excision of an ectopic nipple may be performed for diagnosis or cosmetic reasons (Table 27) (Fig. 27).

Neurofibroma

Neurofibromas of the vulva are rare (Fig. 28A and B). They may occur as isolated lesions, or may be part of the cutaneous manifestations of neurofibromatosis l (Von Recklinghausen's disease). The labia may be involved, as may the clitoris (50). Labial lesions are usually small, rubbery lesions that may be nodular or polypoid; however giant lesions have been described (51). Clitoral enlargement because of a neurofi-broma may mimic an intersex condition. There is a small risk of malignant transformation. Histologically, the lesions contain the elements of peripheral nerve (Schwann cells, neurons, and fibroblasts) in a disorganized pattern. The lesion is often seen in association with a peripheral nerve (Table 28).

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