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50 Cards in this Set
- Front
- Back
What should be next step when a vulvar lesion is seen or suspected? |
punch biopsy
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Lichen sclerosus
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- often chronic vulvar pruritis
- very thin, whitish epithelial area, ("onion skin" or "cigarette paper") - often responds to topical steroids |
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areas most commonly affected by lichen sclerosus
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labia majora and minora, clitorus, periclitoral epithelium and perineal body
- may have perianal halo of atrophic, whitish epithelium forming a figure of 8 confirmation - if severe, there may be loss of normal anatomy and stenosis of the vaginal introitus |
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etiology of lichen sclerosus
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unknown, but family history, autoimmune disorders including thyroid disorders and class II HLA are associations
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histological appearance of lichen sclerosus
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lichenoid pattern with band of chronic inflammatory cells (mostly lymphs), upper dermis has a zone of homogeneous, pink-staining, collagenous-like material beneath the epidermis due to cell death
- obiteration of boundaries between collagen bundles --? "hyalinized" or "glassy" appearance |
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hyperkeratosis
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increase in the number of epithelial cells -- may be seen in acanthotic areas of lichen sclerosus
- in patients with a mix of acanthosis and typical lichenoid-- the acanthosis should be treated first with 2-3 weeks of toprical steroids |
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tx of lichen sclerosus
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topical steroid (clobetasol)
- ameliorates sx but does not usually completely resolve lesions - may need indefinite intermittent treatment - acanthotic lesions typically resolve within 6 mo if tx given - lichen sclerosus doe not increase likelihood of cancer |
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therapeutically resistant acanthosis may be a sign of ..?
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squamous cell carcinoma
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lichen simplex chronicus
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"the itch that rashes"
- most patients develop this disorder secondary to an irritant dermatitis, which progresses to lichen simplex chronicus as a result of the effects of chronic mechanical irritation from scratching the irritated area - itching leads to epidermal thickening or hyperplasia and an inflammatory cell infiltrate, which leads to increased sensitivity and more itching--cycle |
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h/o of vulvar itching and/or burning that is temporarily relieved by scratching or rubbing with a washcloth
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lichen simplex chronicus
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tx of lichen simplex chornicus
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skin irritants may include laundry detergents, scented toilet paper etc-- need to get rid of these sources to break the cycle
- empiric tx with benadryl or hydroxyzine hydochloride to inhibit nightime unconcious itching, topical steroid cream - if areas of significant hyperkeratosis then give hydocortisone, triamsinolone or betamethasone - if no relief after 3 mo-- bx lesions |
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appearance of lichen simplex chronicus on exam
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skin of labia majora, minora and perineal body is diffusely red with some areas of hyperplastic or hyperpigmented plaques of red or reddish brown
- bx usually not warranted unless there is no sx relief after 3 months of tx |
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lichen planus |
DESQUAMATIVE lesion of the vagina or sometimes vulva that involves whitish, lacy bands (wickham striae) of keratosis near the reddish ulcerated lesions
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sx of lichen planus
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chronic vulvar burning and/or pruritis and insertional dypareunia, and profuse vaginal discharge
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dx of lichen planus
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- may bx if there is atypical appearance-- lesions will NOT show atypia
- vaginal discharge will show lots of acute inflammatory cells (PMNs) but no bacteria - this along with history and exam that shows patchy redness and wet prep that shows lots of WBCs |
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tx for lichen planus
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topical steroid or intravaginal 1%hydrocortisone douches
- more likely to recur than lichen simplex chronicus |
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psoriasis
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autosomal dominant disorder that affects 2% of the population
- slightly raised round or oval patches with a SILVER PLAQUE OVER AND ERYTHEMATOUS BASE -acanthotic pattern may be seen histologically - tx: UV light and corticosteroid topically |
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two categories of vulvar dermatitis
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1. eczema (a. exogenous , b. endogenous)
2. seborrheic dermatitis |
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endogenous vs exogenous eczema
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exogenous- irritant and allergic contact dermatitis
endogenous - atopic dermatitis-often also on flexor surfaces of of knees and elbows --cannot tell the difference on bx because they all have spongiotic pattern (intercellular edema within the epidermis--widening space between cells) |
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sborrheic dermatitis
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chronic inflammation of the sebaceous glands
- pale red to yellowish pink lesions that may be covered by an oily appearing, scaly crust |
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tx for vulvar dermatitis
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- remove offending agent
- perineal hygeine - 5% aluminum acetate solution several times/day--> drying - topical corticosteroid like betamethasone - benadryl at night initially to break cycle |
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vulvar vestibulitis
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acute and chronic inflammation of the vestibular glands, just underneath the vaginal introitus
- should suspect this in all patients with new onset insertional dyspareunia - unknown etiology |
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what should be suspected in all patients with new onset insertional dyspareunia?
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vulvar vestibulitis
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dx of vulvar vestibulitis
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physical exam before speculum insertion - touch over glans (4 and 8 oclock with a wet cotton tip)-- brings out pain
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tx for vulvar vestibulitis
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eliminate environmental factors, temporary sexual abstinence, cortisone or lidocaine jelly
- may surgically excise the glands - low dose TCAs or fluoxetine - calcium citrate to remove oxalic acid crystals from the urine |
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sebaceous or inclusion cysts
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small, smooth nodular masses arising from the inner suface of labia majora and minora that contain cheesy sebaceous material
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hidradenoma
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rare lesion arising from the sweat glands of the vulva
- almost always benign - usually on inner surface of labia majora - tx = excision |
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vaginal intraepithelial dysplasia (VIN) 1
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mild dysplasia, low grade lesion that is limited to the lower epidermis
- occurs most often in condyloma acuminata - likely not a cancer precursor - dx by bx - tx = same as for condylomas |
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VIN 2 and 3 = VIN usual type
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high-grade, HPV related lesions
- true neoplasia with high predilection for progression to severe neoplasia and carcinoma if untx - Almost 60% of women with VIN3 will also have CIN (10% of women with CIN 3 will have VIN or VAIN) |
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risk factor for VIN
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smoking
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presentation of VIN
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vulvar pruritis, chronic irritation and raised mass lesions
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VIN usual type three categories histologically
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warty, basaloid, or mixed
- all have atypia in the lower 1/3 to 1/2 of the epithelial layer |
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tx of VIN usual type
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completely remove all involved areas of skin- wide local excision or laser ablation
- non surgical options- corticosteroids, 5-FU, and imidazoquinolones (imiquimod) |
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VIN, differentiated type
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- VIN - caricinoma in situ
- hyperkertotic plaque, warty papule or and ulcer seen primarily in older women - often associated with SCCs or lichen sclerosis - not HPV related - short VIN stage before progression to cancer |
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paget disease of vagina/vulva
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- extensive intraepithelial disease that grossly appears as fiery red background mottled with whitish hyperkeratotic areas
- histo- large pale cells of apocrine origin - associated with skin cancer - associated with higher incidence of internal cancer especially breast and colon |
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tx for paget disease of vagina/vulva
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- wide local excision or simple vulvectomy
- recurrences more common than with VIN --> wider margins |
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vulvar carcinoma
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5% of gyn malignancies
- usually occurs in postmenopausal women 70-80 and presents with pruritis - may have red or white ulcerative exophytic lesion (usually on posterior 2/3 of labia majora) - associated with smoking |
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where does vulvar carcinoma metastasize to?
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regional lymph nodes including inguinal and femoral nodes
- anterior 1/3 of vagina may go to deep pelvic nodes |
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Staging of vulvar cancer
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0 - carcinoma in situ
1- tumor confined to vulva/perineum <2 cm I A- stromal invasion < 1mm I B- stromal invasion > 1 mm II tumor confined to vulva/perineum > 2 cm III - tumor of any size which invades lower urethra, vagina, anus and/or unilateral lymph nodes IV A- tumor invades ipper urethra, bladder, rectal mucosa, or is fixed to bone or bilateral LNs IV B- distant metastasis including pelvic LNs |
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tx of vulvar cancer
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mostly surgical although trying to avoid radical vulvectomy with b/l LN dissections if possible
- post op radiation for people with 2 or more positive nodes - chemo of limited value |
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most common non-squamous cell carcinoma of the vulva?
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melanoma (3-4% of melanoma in females occurs on genitals)
- appears as raised, irritated pigmented pruritic lesions |
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how should any new bartholin mass in a woman > 40 be treated?
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excision, although cancer is unlikely
- bartholin cancer requires radical vulvectomy and b/L lymph node dissection, with reccurrences common |
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inclusion cysts
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- usually on the posterior lower vaginal surface and arising from imperfect approximation of vaginal tears during childbirth or episiotomies
- often cheesy content - excise if sx |
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VAIN
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vaginal intraepithelial neoplasia
- 3 types 1. VAIN 1- involves basal epithelial layers 2. VAIN 2- involves upper 2/3 of vagina 3. VAIN 3- involves more of vag epithelium -- CIS |
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what % of patients with VAIN have either vulvar or cervical ca?
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50-66%
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what % of women who undergo hysterectomy for CINIII ultimately develop VAIN?
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1-2%, which is why some say pap smears of vaginal cuff should be done yearly
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dx and tx of VAIN
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dx- colpo and bx of lesions
tx- VAIN 1 and 2- no tx needed VAIN 3- laser ablation, local excision, and 5-FU cream. If fail these then vaginectomy |
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staging and tx of vaginal cancer
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nonsurgical staging.
radiation = mainstay of tx |
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tx of vaginal clear cell carcinoma
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usually this is confined to upper 1/2 of vagina so tx = hysterectomy, pelvic node disection, + radiation after
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sarcoma botryoides
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aka embryonal rhabdomyosarcoma- rare tumor that presents a mass of grape-like polyps protruding from the introitus of ped's patient
- may present with bloody d/c - tx = combination chemo to shrink tumor then surgical resection |