Squamous Intraepithelial Neoplasia Vulvar Intraepithelial Neoplasia

There are two distinct types of vulvar intraepithelial neoplasia (VIN). One is related to HPV, the usual type of VIN, and is discussed here (Fig. 29A-D). VIN

Table 26 Lipoma

Clinical

Diagnosis Symptoms appearance

Differential diagnosis

Therapy

Lipoma Usually Soft mass Bartholin's duct None, excision, none lesion cyst, fibrolipoma, liposuction angiolipoma (variants)

Figure 27 Ectopic nipple: this example of ectopic mammary tissue is seen on the thigh.

unrelated to HPV, differentiated VIN, is discussed below. Usual VIN has a wide variety of clinical appearances and may appear as red, white, dark, flat, raised, or ulcerated lesions. Lesions may be multifocal or confluent. These HPV-related lesions are more common and more often recurrent in patients with immune suppression, or who smoke cigarettes. Terminology is variable, and encountered terminologies may include the three-tiered VIN 1,2,3, or the two-tiered low- and high-grade squamous intraepithelial lesion. Whether VIN 1 exists or is actually the same as a reactive lesion or condyloma is controversial, and recently the International Society for the Study of Vulvovaginal Disease (ISSVD) has adopted a terminology that only includes VIN as a high-grade lesion (see below). Histologically, VIN may have a warty or basaloid configuration (52). Warty lesions have a prominent HPV cytopathic effect with koilocytosis, but are distinguished from condyloma acuminatum by the degree of maturation abnormality. Basaloid lesions resemble the smaller cells of the basal epithelial layer with hyperchromatic nuclei, which as part of the maturation abnormality, extend up above the basal layer (above the lower third). Patterns may be mixed as well. In cases of low-grade lesions where diagnosis is uncertain, positive Ki-67 (MIB-1) immunostaining above the basal layer is helpful in confirming the diagnosis (53). Immunostaining above the basal layer is also seen in high-grade lesions, which occasionally may be confused with atrophy (54) (Table 29).

ISSVD terminology for squamous VIN 2-3, high-grade VIN (2003)

1. VIN, usual type a. VIN, warty type b. VIN, basaloid type c. VIN, mixed (warty/basaloid) type

2. VINr differentiated typea aThe occasional example of VIN that cannot be classified into either of the above VIN categories (usual type and differentiated type) may be classified as VIN, unclassified type. The rare VIN of pagetoid type may be classified as such, or placed in this category.

Table 27 Ectopic Nipple

Clinical

Differential

Diagnosis

Symptoms

appearance

diagnosis

Therapy

Ectopic nipple

Usually none

Usually

Other pigmented lesions.

Excision if

recognizable

If ectopic breast tissue,

warranted

other mass lesions

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