Lower Gynecologic Tract:

Cervix, Vulva, Vagina

Christina S. Kong, M.D.

Associate Professor, Stanford Dept. of Pathology
Director, Cytopathology Service & Fellowship
Objectives
 Understand role of HPV in carcinogenesis
 Be familiar with different nomenclature systems for
cervical cancer precursor lesions and vulvar cancer
precursor lesions
 Be able to diagnose cervical precursor lesions and
distinguish from invasive carcinoma
 Understand staging of cervical carcinoma and concept of
superficial invasion
 Be aware of two distinct pathways for developing vulvar
carcinoma
Cervical Carcinoma
 Leading cause of cancer death in women
in the US (50 years ago)
 Now 8th leading cause of death
◦ 2007: New cases 11,150, deaths 3670
2nd most common cancer in women
worldwide
◦ 493,000 new cases/year; over half fatal
HPV Infection
 High-risk HPV is found in virtually all cases
of cervical dysplasia and carcinoma
 Persistent infection with high-risk HPV is
required for development of HSIL and
cervical carcinoma
 Majority of HPV infections regress
spontaneously: 50% in 8 mos, 90% in 2 yrs
HPV & Cervical Cancer
 HPV: Necessary but not sufficient cause
 HPV 16 and 18:
◦ Most common oncogenic types
◦ Identified in cells of high grade SIL (CIN 2 and
CIN 3) and invasive carcinoma
 HPV 6 and 11
◦ Associated with vulvar, perineal and perianal
condylomas, and subset of cervical LSIL
HPV Vaccine
 Gardasil®
◦ Quadrivalent vaccine against HPV 16 & 18 (high-risk) and
HPV 6 & 11 (low-risk)
 Cevarix: Vaccine against HPV 16 & 18
 Both administered as 3 shots given over 6 months
 Phase III trials:
◦ 100% effective in preventing HPV 16/18-associated HSIL
 FDA-approved for patients age 9-26
Cervical Cancer Screening & Prevention
 Screening
◦ Cervical cytology (Pap) test (false neg ~10-20%)
◦ HPV testing
 Prevention
◦ Removal of precancerous lesions
◦ HPV vaccine

Saslow 2012 Am J Clin Pathol 2012;137:516-542

 HPV Testing
 When to use:
◦ Co-testing in women > 30 years
◦ Triage
 ASC-US paps in women >20
 Triage of LSIL paps in postmenopausal women
◦ Guide management
 ASCCP Consensus Guidelines:
www.asccp.org/consensus.shtml
 HPV Testing
 Multiple FDA-approved HPV assays:
◦ Aptima HPV & HPV 16 and 18/45 (GenProbe)
 Used at Stanford
◦ HC2 HPV DNA (Qiagen)
 Original HPV assay used in ASCUS-LSIL Triage Study (ALTS)
◦ Roche cobas HPV:
 Recently approved for primary HPV screening
92% over 5 yrs

p16

J Clin Pathol 2002;55:244-265

Transformation Zone Mature squamous mucosa

Squamous metaplasia

Basal cell layer

Endocervical glands
T
Transformation Zone
 Vast majority of invasive cervical carcinomas
and their precursors develop in this region
 During the reproductive years, this zone can
be completely visualized over the anatomic
exocervix
 Accessible for examination by colposcopy and
for tissue examination by biopsy
LAST, 2012; Bethesda, 1988

Richart, 1973

Reagan, 1953

Blaustein’s 4th Ed. Figure 7.8

 High Grade
Squamous Intraepithelial Lesion (HSIL)
 Encompasses CIN2 and CIN3
 High rate of progression to invasive carcinoma
 Progression rate higher for CIN3 than CIN2
 Threshold for treatment:
◦ CIN2+ in general population
◦ CIN3+ in “young” women (low risk < 25 yrs age)
Massad 2013
 HSIL
Atypical high N:C cells
◦ CIN2:
 Involves 1/3-2/3 epithelium
◦ CIN3:
 Involves >2/3 epithelium
High mitotic figures
Architecture
◦ Crowding
◦ Disorderly arrangement
◦ Loss of polarity

CIN2
HSIL
 ASC-H

 Atypical Squamous Cells, cannot exclude

HSIL
 Pap smear diagnosis – used when cells are
atypical but not diagnostic of HSIL
 Next step: colposcopy with biopsy
 HSIL (CIN2)
 Poor reproducibility
for diagnosis of CIN2
 ALT Study:
◦ CIN2: 43.4%
◦ CIN3: 77-80%
 CIN2: equivocal
diagnosis – use p16
Stoler 2001; Darragh 2012
 p16
Positive p16 stain:
 Correlates with
presence of HR-
HPV and diagnosis
of dysplasia
 Grading of
dysplasia based
primarily on H&E
morphology
 Low-grade SIL (CIN1)
Heterogeneous group of lesions:
 Poor reproducibility of diagnosis
 ALT Study on interobserver variability:
◦ 43% concordance between center pathologists
and QC pathologists
 Low-grade SIL
Low-Power:
◦ Growth pattern:
 Thickened mucosa
◦ Nuclei:
 Hyperchromatic cells in
upper layers
◦ Cytoplasm:
 Halos in upper layers
 LSIL
• Enlarged, dark
nuclei
• Binucleation
• Sharply punched
out halos
 LSIL - PAP

LSIL
 ASC-US
 Atypical Squamous Cells of Undetermined
Significance
 Pap smear diagnosis – used when cells are
atypical but not diagnostic of LSIL
 HPV triage in women >24 years
◦ HPV triage in women 21-24 years acceptable
but cytology alone at 12 months preferred
Massad 2013
Reactive Changes
 Acute and chronic cervicitis
◦ Marked inflammation can lead to reactive/
reparative changes that can appear atypical on Pap
tests
◦ STD: Gonococcus, chlamydia, mycoplasma, herpes
simplex virus (HSV)
 Endocervical polyps
◦ Benign exophytic growth in 2-5% adult women
◦ Can lead to vaginal spotting & atypical Pap test
 Low-grade SIL (CIN1)
 High rate of spontaneous regression:
◦ >90% within 24 months (Brazilian study)
◦ 70% with high-risk HPV within 4 years (Netherlands study)
◦ 91% adolescents & young women within 36 mos
 Uncommonly progresses to HSIL within first 24
months
 Management depends on prior Pap diagnosis & age

Massad 2013
Invasive Carcinoma of Cervix
 ~80% Squamous cell carcinoma
 ~15% Adenocarcinomas
 ~5% Adenosquamous and neuroendocrine
carcinomas
 Grade and type of cervical cancer has little
bearing on response to treatment or
prognosis
 Stage of disease is of greater importance
Invasive Non-keratinizing SCC
Invasive Keratinizing SCC
 Superficial Invasion
Superficially invasive Not superficially invasive

< 3 mm
< 3 mm

 < 3 mm depth of invasion

 < 7 mm horizontal spread
 FIGO stage Ia1
 Entire lesion needs to be visualized to diagnose as superficially invasive
Superficially Invasive SCC
HSIL
CIN3 involving
endocervical glands

HSIL with endocervical extension

Endocervical Adenocarcinoma In Situ
 Typically involves transformation zone
 Extends from surface into underlying
glands
 50% have concomitant HSIL
 HPV 18 most common followed by HPV 16
Endocervical Adenocarcinoma in situ
Cervical Small Cell Carcinoma
 Resembles small cell carcinoma of the lung
 Behaves aggressively with poor prognosis
 Associated with HPV 18
Cervical Small Cell Carcinoma
 Cervical Cancer Staging
Stage 0 Carcinoma in situ (CIN III, HSIL)

Stage I Carcinoma confined to cervix

1a. Preclinical carcinoma, microscopic

1a1. Superficially invasive: Stromal invasion < 3mm deep and < 7mm wide

1a2. Stromal invasion 3-5mm deep and < 7mm wide

1b. Invasive carcinoma confined to cervix and greater than stage 1a2
Carcinoma extends beyond cervix but not to pelvic wall. Carcinoma involves upper 2/3
Stage II
vagina

Carcinoma extends to pelvic wall. On rectal exam, no cancer-free space between the tumor
Stage III
and pelvic wall. Carcinoma involves lower 1/3 vagina

Carcinoma extended beyond true pelvis or involves mucosa of bladder or rectum. Metastatic
Stage IV
disease present.
Treatment of Cervical Carcinoma
 Hysterectomy with lymph node dissection
for most invasive carcinomas
 Exceptions:
◦ Superficially invasive carcinoma: Cone biopsy
◦ Advanced disease: Chemotherapy and radiation
therapy
VULVA
 Vulva Terminology
LAST WHO 2003 ISSVD 2004 SYNONYMS
Low-grade SIL Condyloma Condyloma N/A
(condyloma/VIN1) acuminatum acuminatum
VIN 1 N/A Flat condyloma,
mild dysplasia
VIN 2 Moderate
dysplasia
High-grade SIL VIN 3 VIN, usual type Severe dysplasia,
(VIN2-3) CIS, Bowen’s
N/A Carcinoma in situ VIN, differentiated N/A
(simplex type) (simplex) type
(VIN3)
Vulva: Condyloma Acuminatum
 Benign but difficult to eradicate
 Associated with HPV 6 and 11
 Mimics: Fibroepithelial polyp, squamous
papilloma
 Treatment: Ablation or excision
 Vulvar Condyloma
 Hyperplastic,
hyperkeratotic
squamous
epithelium with
koilocytes covering
fibrous stalks
Vulva: Leukoplakia
Opaque white plaque, may be itchy
 Inflammatory dermatoses
 VIN, Paget disease, invasive carcinoma
 Epithelial disorders of unknown etiology
◦ Lichen Sclerosus
◦ Squamous cell hyperplasia (lichen simplex
chronicus)
 Vulvar Intraepithelial Neoplasia
 HPV related:
◦ High grade squamous intraepithelial lesion (VIN2-3)
 Non HPV-related
◦ Differentiated (simplex) type
HSIL (VIN2-3)
 Most common in reproductive-age women
 Risk factors same as for cervical SIL
 Strong association with high-risk HPV,
especially HPV16 (70% cases)
 Frequently multicentric in vulva with
associated vaginal or cervical lesions in 10-
30% patients
 HSIL (VIN2-3)
 2/3 to full thickness atypia
◦ Disorganization
◦ High N:C ratios with dark,
irregular nuclei
◦ Numerous and abnormal
mitotic figures
◦ Dyskeratotic cells
 Can extend down
pilosebaceous units
 Lichen Sclerosus
 Postmenopausal most common but occurs in all
age groups
 Etiology: Unknown
 High degree of metabolic activity
 Not pre-malignant but associated with non-HPV
related SCC
 Treatment: Topical steroids may arrest and
sometimes reverse process
 Lichen Sclerosus
Histology:
 Thinned epidermis
with loss of rete
 Smudged edematous
collagen in dermis
 Band-like
inflammatory infiltrate
in deep dermis
 Squamous Hyperplasia
Clinical:
 Non-specific condition
related to rubbing of skin
due to itching
Histology:
 Thickened epidermis, often
hyperkeratotic
 Elongated, wide rete
 Dermal inflammatory
infiltrate
VIN, differentiated (simplex) type
 Post-menopausal women (average age 76)
 Associated with lichen sclerosus, not HPV-
related
 Typically identified adjacent to well-
differentiated vulvar carcinomas
 Infrequently identified prospectively
 No counterpart in the cervix
Hart Int J Gynecol Pathol 2001;20:16-30
Medeiros et al. Adv Anat Pathol 2005;12:20-26
Differentiated (Simplex) VIN
 Elongated, narrow rete ridges
 Abnormal maturation
◦ Enlarged keratinocytes with abundant,
markedly eosinophilic cytoplasm in mid-to-
superficial layers
 Nuclear atypia of the basal cell layer

Medeiros et al. Adv Anat Pathol 2005;12:20-26

Differentiated (Simplex) VIN
Invasive Vulvar Carcinoma
 Uncommon: Accounts for 3% of all genital
invasive carcinomas
 90-95% squamous cell carcinomas
 Others: Basal cell carcinomas,
adenocarcinomas, melanomas, metastases
 Older women: 2/3 over age 60
Vulva: Invasive SCC
 HPV-dependent:
◦ Warty or basaloid SCC
◦ Associated with HSIL (VIN2-3)
 HPV-independent:
◦ Well-differentiated keratinizing SCC
◦ Associated with differentiated (simplex) VIN
and lichen sclerosus
 Rare variant: Verrucous carcinoma
Verrucous Carcinoma
 Rare, special variant of SCC
 Slow-growing, minimal metastatic potential
 Histology:
◦ Exophytic, hyperkeratotic fronds
◦ Cytologically bland squamous epithelium
◦ Well-circumscribed pushing border with chronic
inflammation
Verrucous Carcinoma
Vulva: Glandular Lesions
 Vulva contains modified sweat glands and
may have ectopic breast tissue
 Tumors with counterparts in the breast:
◦ Papillary hidradenoma
◦ Extramammary Paget disease
Papillary Hidradenoma
 Tumor of apocrine glands
 Similar to intraductal papilloma of breast
 Solitary nodule on labia majora
 May ulcerate and simulate carcinoma clinically
Papillary Hidradenoma: histology

Tubular ducts lined by non-ciliated Underlying flattened myoepithelial

columnar cells layer
Extramammary Paget Disease
 Erythematous weeping lesion, usually on labia
majora
 Mucin producing cells in epidermis and
sometimes within sweat glands
 In situ carcinoma, rarely progresses to
invasive carcinoma
 Treated with wide local excision, frequently
recur
Extramammary Paget Disease
VAGINA
Vagina
Primary lesions of the vagina are rare
 Developmental anomalies
◦ Adenosis, Gartner duct cyst, endometriosis
 Benign tumors
◦ Stromal polyps, leiomyomas, hemangiomas
 Malignant tumors
Vagina: Malignant Tumors
 Most common malignancy: Secondary
involvement by carcinoma of cervix or vulva
 Primary vaginal carcinoma: 1% of malignant
neoplasms of female genital tract
◦ Squamous cell carcinoma
◦ Clear cell adenocarcinoma
◦ Embryonal Rhabdomyosarcoma
Vagina: Squamous Cell Carcinoma
 Greatest risk factor:
◦ Previous carcinoma of cervix or vulva
◦ 1-2% with cervical CA develop vaginal CA
 Associated with high-risk HPV
 Arise from vaginal intraepithelial neoplasia
(VAIN)
Clear Cell Carcinoma
(associated with DES exposure)
Embryonal Rhabdomyosarcoma
 Sarcoma botryoides: Presents as grape-like
mass protruding from vagina
 Clinical: Infants and children < 5 yrs
 Tumor differentiates as skeletal muscle
 Excellent prognosis these days with
combination therapy
Embryonal Rhabdomyosarcoma
 Take-home Points
HSIL
 Good interobserver agreement
for CIN3
 Requires treatment, except
CIN2 can be followed in
“young” women
 High N:C ratio cells with
crowding & disorganization
 Use p16 to confirm CIN2
LSIL
 Poor interobserver agreement
 High rate of spontaneous
regression and low rate of
progression to HSIL within first
24 months
 Scan for atypical nuclei in the
upper layers
Take-home Points
 Cervical carcinoma is staged by depth of invasion and
extent of spread; superficially invasive SCC can be treated
less aggressively
 Vulvar cancer precursor lesions are divided into HPV-
related HSIL (VIN2-3) and non-HPV related differentiated
(simplex) VIN
 Vaginal tumors are uncommon and usually the result of
secondary involvement by cervical or vulvar carcinoma in
adults