Lower Genital Tract Precancer
Lower Genital Tract Precancer
1 The Histopathology of Lower Genital Tract Neoplasia, 1
1.1 Introduction, 1
1.2 Terminology, 1
The concept of cervical cancer precursors, 1 Biology and natural history, 2 Rationalization of histologic terminology, 3
1.3 Histopathological features of C1N or SIL, 3
Low-grade disease (mild dysplasia, СШ1, HPV-CIN1, LSIL), 3 High-grade disease (moderate or severe dysplasia, CIS, CIN 2 or 3, HSIL), 4
1.4 Cervical glandular intraepithelial neoplasia and adenocarcinoma-in-situ, 6
Cervical glandular intraepithelial neoplasia, 6 Histologic criteria for CGIN, 6
1.5 Early invasive carcinoma (microinvasive carcinoma of the cervix), 7
1.6 Vaginal intraepithelial neoplasia, 10
Adenosis, 10
Histopathology of vaginal intraepithelial neoplasia, 11
1.7 Vulval precancer, 11
Vulval intraepithelial neoplasia, 11 Paget’ s disease, 11
1.8 Related topics, 12
1.9 References and bibliography, 12
2 Human Papillomaviruses in Pathogenesis of Lower Genital Tract Neoplasia, 15
2.1 Introduction, 15
2.2 Characteristics of human papillomaviruses, 15
2.3 Manifestations of genital HPV infections, 16
Clinical infections (predominately condylomata), 17 Subclinical HPV infections, 18 Latent HPV infections, 20
2.4 Prevalence of genital HPV infections, 21
Incidence rates of HPV infections, 21
2.5 Transmission of genital HPV infections, 22
Sexual transmission, 22 Vertical transmission, 22
2.6 Risk factors for genital HPV infections, 22
2.7 HPV and cancer precursors, 23
2.8 HPV infections and the risk for cervical cancer, 23
Case reports and case series, 23 Cohort studies, 23
2.9 Natural history, 24
Natural history of cervical HPV infections, 24 CIN and HPV have an identical natural history, 24
2.10 Molecular pathways of HPV oncogenesis, 26
The normal cell cycle, 26
The effect of HPV/host cell interaction—a prerequisite for neoplasia, 27
2.11 The role of oncogenic HPV detection in the prevention of lower genital tract precancer, 28
As an adjunct to cytology in primary screening, 28
As an adjunct to colposcopy in the management of women presenting with mild or borderline dyskaryosis (ASCUS/AGUS), 29
2.12 HPV type and type variant as determinants of the natural history, 30
2.13 References and bibliography, 30
3 Examination for Cervical Precancer—Use of colposcopy, 34
3.1 Introduction, 34
3.2 Tissue basis for colposcopy, 34
The role of the epithelium, 34
The role of the stroma, 35
The role of the surface configuration, 35
3.3 The colposcopic examination, 35
The colposcope, 35 The examination, 35
Decontamination of colposcopy clinic equipment, 40
3.4 New developments in colposcopy, 41
Video colposcopy, image management and electronic databases, 41
3.5 References and bibliography, 41
4 Colposcopy of the Normal Cervix—A prerequisite to establish the diagnosis of cervical cancer, 43
4.1 Introduction, 43
4.2 Cervical epithelium: natural history, 43
4.3 Cervical epithelium: topography, 44
4.4 Cervical epithelium: colposcopic appearances, 46
Original columnar epithelium, 46 Original squamous epithelium, 46 Transformation zone, 46
4.5 Squamous metaplastic epithelium, 47
Colposcopic stages of development, 47 Histologic features of development, 48 Stimulus to development, 49
Colposcopic representations of squamous metaplastic epithelium, 50
4.6 Colposcopy of the adolescent cervix, 52
The frequency of epithelial type, 55
4.7 Cervical epithelium during pregnancy and puerperium, 56
Ultrastructure and biomechanic properties of subepithelial tissues, 57 Physiologic mechanisms operating in the cervix during pregnancy, 58
4.8 The effect of vaginal delivery on the cervical epithelium, 59
Types of epithelial injury caused by delivery, 59
4.9 The cervical epithelium during the menopause, 59
4.10 The oral contraceptives and their effect on the cervix, 61
4.11 The congenital transformation zone, 64
4.12 Summary: the normal (typical) transformation zone, 66
4.13 References, 69
5 Cytology and Screening for Cervical Precancer, 71
5.1 Introduction, 71
5.2 Cytological classifications, 71
Papanicolaou, 71
British Society for Clinical Cytology classification, 71 The Bethesda System, 72
5.3 Cytological reporting, 72
Normal cytology, 72 Smear adequacy, 73 Atrophic smears, 73 Borderline abnormalities, 74 Dyskaryotic cellular changes, 77 Cytologic indications of invasion, 79
5.4 Clinical referral, 80
5.5 Cytodiagnosis of cervical glandular intraepithelial neoplasia/adencarcinoma-in-situ, 81
High-grade CIN/AIS, 81 AGCUS/borderline glandular cells, 82 Atypical metaplasia, 82
5.6 Cytologic features of adenocarcinoma, 84
5.7 Screening for cervical cancer, 84
Introduction, 84 Cytologic screening, 84 Effectiveness, 84 Accuracy, 85
5.8 Improvements to cervical screening, 85
Improving cytological screening, 85
5.9 Sampling techniques, 85
Slide preparation—thin layer technology, 85
5.10 Cytologic interpretation, 86
Automation in screening, 86
5.11 Adjunctive tests, 88
HPV-DNA testing, 88
HPV-DNA testing as triage, 88
HPV-DNA testing as an adjunctive test to cytology, 89
Cervicography, 89
TruScan* (formerly called The PolarProbe), 90 Visual inspection-based techniques, 91 New developments, 92
5.12 Problems in cytologic screening in the postmenopausal era, 92
Alterations in function, 92 Screening in the postmenopausal era, 93
5.13 References, 94
6 Diagnosis of Cervical Precancer—The use of colposcopy, 97
6.1 Introduction, 97
6.2 Which cytologic abnormalities need further investigation? 97
6.3 Colposcopy: the initial clinical examination, 97
6.4 The rationale for the use of colposcopy in the diagnosis of cervical precancer, 97
6.5 Colposcopic appearance of the abnormal (atypical) cervical epithelium, 98
Morphology of the abnormal (atypical) epithelium, 99 Atypical vessels, 103
The vascular pattern of early invasion, 107
6.6 The classification of colposcopically abnormal (atypical) cervical epithelium, 108
6.7 Colposcopic examination of the precancerous/cancerous cervix, 109
A satisfactory or an unsatisfactory colposcopy, 109 Grading of the abnormal (atypical) colposcopic findings, 109 Unsatisfactory colposcopy: examination of the endocervical canal, 114 Colposcopic biopsy, 120
Microcolpohysteroscopic examination of the endocervical canal, 121 Other cervicoscopic appearances and pathologic findings, 123 Endocervical curettage, 125
Identification of the abnormal (atypical) epithelium: Schiller’s iodine test, 126
6.8 The concept of human papillomavirus infection and cervical precancer, 128
Colposcopic appearance of condylomatous and subclinical papillomavirus lesions, 131 Colposcopic appearances of condylomata and their differentiation from malignant lesions, 132
Further pathologic appearances of HPV and HPV/CIN-associated lesions, 133
6.9 Correlation of diagnostic methods in the detection of cervical squamous precancer, 133
Examples of the correlation of diagnostic methods, 136 In moderate-grade epithelial lesions, 138 In high-grade epithelial lesions, 138
6.10 Lack of correlation between diagnostic methods, 139
6.11 The diagnosis of early invasion, 141
Early invasive squamous cell carcinoma: colposcopic diagnosis, 141 Importance of pathology in diagnosis, 143
6.12 Preclinical invasive carcinoma (colposcopically overt/suspect): colposcopy and pathology, 147
6.13 Precancerous glandular lesions of the cervix, 149
Epidemiology, 149 Colposcopic diagnosis, 149 Relevance to management, 153
6.14 Colposcopic diagnosis of early adenocarcinoma of the cervix, 153
6.15 References, 158
7 Management of Cervical Precancer, 161
7.1 Introduction, 161
7.2 Rationale behind treatment, 161
7.3 Colposcopic and pathologic characteristics of CIN lesion: a prerequisite to treatment, 161
The limits and nature of the abnormal (atypical) epithelium, 161 Glandular involvement, 162 Endocervical extension, 163
7.4 Colposcopically directed biopsy, 163
7.5 Which lesions to treat, 164
High-grade lesions: CIN 2 to 3/HSIL, 164 Low-grade lesions: CIN 1 /LSIL, 164
7.6 Prerequisites for treatment, 165
7.7 Methods of treatment, 165
Local destructive techniques, 165
7.8 Excision techniques for treating CIN, 173
Special problems of endocervical extension, 174 The cold knife cone biopsy, 174 Laser cone biopsy, 178
Loop diathermy excision and cone biopsy, 181
7.9 Management of extension of the abnormal (atypical) transformation zone, 187
Technique, 187
7.10 Follow-up after treatment, 187
7.11 Hysterectomy in the treatment of CIN, 188
7.12 Summary: the optimal method of CIN treatment and of follow-up, 190
Follow-up of CIN management, 190
7.13 Long-term complications of CIN treatment, 190
Stenosis and constriction, 190
Surgical treatment and reconstruction following stenosis, 193 Excessive eversion of the columnar epithelium (post-treatment), 194 Subsequent pregnancy, 194 Recurrence, 194
7.14 Precancer in pregnancy, 197
Management of invasive cervical cancer during pregnancy, 197
Management of the abnormal smear in pregnancy, 197
Colposcopic examination, 198
Biopsy under colposcopic direction, 198
Treatment, 199
Interpretation of a biopsy specimen during pregnancy, 201
7.15 Precancer in the HIV-positive patient, 201
CIN/SIL (squamous intraepithelial lesions) in HIV-infected women, 202 Risk factors for the development of CIN in HIV-infected women, 202 HPV-HIV coinfection, 202
Screening for cervical disease in HIV-affected women, 203 Treatment of CIN in НГѴ-infected women, 203 Summary, 203
7.16 Management of early invasive squamous carcinoma of the cervix (FIGO stage I), 203
History of «microinvasion», 203
Adenocarcinoma-in-situ and early invasive adenocarcinoma of the cervix, 206 Stage lb cancer of the cervix, 207 Recommended treatment: summary, 209
7.17 References, 209
8 Vaginal Intraepithelial Neoplasia, 214
8.1 Introduction, 214
8.2 Natural history of VAIN, 214
8.3 Etiology, 215
8.4 Clinical presentation, 215
Vaginoscopy, 215
VAIN seen as an extension of the cervical atypical transformation zone, 215 VAIN as seen in association with HPV lesions, 216
8.5 VAIN following hysterectomy, 218
Presentation after hysterectomy: value of cytology, 218
8.6 Biopsy of the VAIN lesion, 221
8.7 Pathology of VAIN: is it a precancerous lesion?, 221
8.8 Vaginal precancer and cancer: part of the lower genital tract neoplastic syndrome, 222
Pathology, 222
Non-malignant lesions masquerading as vaginal neoplasia, 225
8.9 Treatment of VAIN, 227
Use of the COz laser, 228 Partial vaginectomy, 228 Local excision, 229
8.10 References, 231
9 Vulvar Intraepithelial Neoplasia, 233
9.1 Introduction, 233
9.2 Epidemiology and pathogenesis, 233
Prevalence and incidence, 233 Association between VIN and CIN, 234 Viral etiology, 235
Sexually transmitted diseases as etiologic factors, 236 Human immunodeficiency virus and VIN 3,236 Smoking risk, 237
9.3 Natural history of VIN: the rationale for treatment?, 237
9.4 Pathology, 239
Differential diagnosis of VIN, 240
9.5 Clinical presentation, 241
Vulvoscopy: magnified illumination of the vulva with a colposcope, 242 Collins toluidine blue test, 243
9.6 Biopsy of the vulva, 244
9.7 Clinical appearances of VIN, 245
White lesions, 246 Red lesions, 248 Dark lesions, 249
9.8 VIN affecting the pilosebaceous unit, 251
9.9 Early invasive carcinoma of the vulva, 252
Clinical features, 253
Risk of nodal spread: depth and volume measurements, 254 Assessment of the pathologic specimen, 254 Diagnosis, 255
Recurrence of early invasive vulvar carcinoma, 256
9.10 Lichen sclerosus, 258
Clinical presentation, 258 Histopathology, 258 Management, 258
9.11 Paget’s disease (non-squamous intraepithelial neoplasia), 260
Clinical presentation, 261 Histopathology, 261 Management, 261
9.12 Vulvar lesions masquerading as cancer or precancer, 261
Syphilis, 262 Behcet’s disease, 263 Condylomata acuminata, 264 Granuloma inguinale, 265 Lichen planus, 266 Subclinical epithelial changes, 266
9.13 Skin and accessory appendages that are important for the management of VIN, 268
9.14 Management of VIN, 270
Rationale for treatment, 270 Treatment options and procedures, 271 Which approach for treating VIN 3? 284
9.15 Treatment of early invasive vulvar carcinoma, 285
Is lymphadenectomy necessary? 285 Results, 285
9.16 References, 285
10 Perianal and Anal Intraepithelial Neoplasia, 290
10.1 Epidemiology, 290
10.2 Etiology, 290
10.3 Association with other genital intraepithelial neoplastic d iseases, 291
10.4 Examination, 291
10.5 Presentation, 292
10.6 Lesions masquerading as intraepithelial neoplasia, 293
10.7 Anal canal involvement, 293
10.8 Treatment, 295
Laser vaporization, 296 Localized surgical excision, 296 Extensive surgical excision, 298
10.9 References, 299
11 Genital Tract Adenosis, 300
11.1 Developmental anatomy, 300
11.2 Developmental anomalies caused by DES, 300
Experimental evidence, 300 Epidemiology, 301 Clinical findings, 301 Pathology, 303 Treatment, 303
11.3 References, 304
12 Infective and Other Conditions Causing Confusion in Diagnosis of Lower Genital Tract Precancer, 305
12.1 Introduction, 305
12.2 Trichomonas vaginalis, 305
12.3 Candidiasis, 305
12.4 Herpes genitalis infection, 306
Clinical presentations, 306 Herpes simplex cytology, 306
Colposcopic and histologic appearances of infection, 307 Vulvar lesions, 308
12.5 HPV infection, 309
12.6 Cervical deciduosis in pregnancy, 312
12.7 Polypoid lesions of the cervix, 312
Clinical presentation and management, 312
12.8 References, 315
1.1 Introduction, 1
1.2 Terminology, 1
The concept of cervical cancer precursors, 1 Biology and natural history, 2 Rationalization of histologic terminology, 3
1.3 Histopathological features of C1N or SIL, 3
Low-grade disease (mild dysplasia, СШ1, HPV-CIN1, LSIL), 3 High-grade disease (moderate or severe dysplasia, CIS, CIN 2 or 3, HSIL), 4
1.4 Cervical glandular intraepithelial neoplasia and adenocarcinoma-in-situ, 6
Cervical glandular intraepithelial neoplasia, 6 Histologic criteria for CGIN, 6
1.5 Early invasive carcinoma (microinvasive carcinoma of the cervix), 7
1.6 Vaginal intraepithelial neoplasia, 10
Adenosis, 10
Histopathology of vaginal intraepithelial neoplasia, 11
1.7 Vulval precancer, 11
Vulval intraepithelial neoplasia, 11 Paget’ s disease, 11
1.8 Related topics, 12
1.9 References and bibliography, 12
2 Human Papillomaviruses in Pathogenesis of Lower Genital Tract Neoplasia, 15
2.1 Introduction, 15
2.2 Characteristics of human papillomaviruses, 15
2.3 Manifestations of genital HPV infections, 16
Clinical infections (predominately condylomata), 17 Subclinical HPV infections, 18 Latent HPV infections, 20
2.4 Prevalence of genital HPV infections, 21
Incidence rates of HPV infections, 21
2.5 Transmission of genital HPV infections, 22
Sexual transmission, 22 Vertical transmission, 22
2.6 Risk factors for genital HPV infections, 22
2.7 HPV and cancer precursors, 23
2.8 HPV infections and the risk for cervical cancer, 23
Case reports and case series, 23 Cohort studies, 23
2.9 Natural history, 24
Natural history of cervical HPV infections, 24 CIN and HPV have an identical natural history, 24
2.10 Molecular pathways of HPV oncogenesis, 26
The normal cell cycle, 26
The effect of HPV/host cell interaction—a prerequisite for neoplasia, 27
2.11 The role of oncogenic HPV detection in the prevention of lower genital tract precancer, 28
As an adjunct to cytology in primary screening, 28
As an adjunct to colposcopy in the management of women presenting with mild or borderline dyskaryosis (ASCUS/AGUS), 29
2.12 HPV type and type variant as determinants of the natural history, 30
2.13 References and bibliography, 30
3 Examination for Cervical Precancer—Use of colposcopy, 34
3.1 Introduction, 34
3.2 Tissue basis for colposcopy, 34
The role of the epithelium, 34
The role of the stroma, 35
The role of the surface configuration, 35
3.3 The colposcopic examination, 35
The colposcope, 35 The examination, 35
Decontamination of colposcopy clinic equipment, 40
3.4 New developments in colposcopy, 41
Video colposcopy, image management and electronic databases, 41
3.5 References and bibliography, 41
4 Colposcopy of the Normal Cervix—A prerequisite to establish the diagnosis of cervical cancer, 43
4.1 Introduction, 43
4.2 Cervical epithelium: natural history, 43
4.3 Cervical epithelium: topography, 44
4.4 Cervical epithelium: colposcopic appearances, 46
Original columnar epithelium, 46 Original squamous epithelium, 46 Transformation zone, 46
4.5 Squamous metaplastic epithelium, 47
Colposcopic stages of development, 47 Histologic features of development, 48 Stimulus to development, 49
Colposcopic representations of squamous metaplastic epithelium, 50
4.6 Colposcopy of the adolescent cervix, 52
The frequency of epithelial type, 55
4.7 Cervical epithelium during pregnancy and puerperium, 56
Ultrastructure and biomechanic properties of subepithelial tissues, 57 Physiologic mechanisms operating in the cervix during pregnancy, 58
4.8 The effect of vaginal delivery on the cervical epithelium, 59
Types of epithelial injury caused by delivery, 59
4.9 The cervical epithelium during the menopause, 59
4.10 The oral contraceptives and their effect on the cervix, 61
4.11 The congenital transformation zone, 64
4.12 Summary: the normal (typical) transformation zone, 66
4.13 References, 69
5 Cytology and Screening for Cervical Precancer, 71
5.1 Introduction, 71
5.2 Cytological classifications, 71
Papanicolaou, 71
British Society for Clinical Cytology classification, 71 The Bethesda System, 72
5.3 Cytological reporting, 72
Normal cytology, 72 Smear adequacy, 73 Atrophic smears, 73 Borderline abnormalities, 74 Dyskaryotic cellular changes, 77 Cytologic indications of invasion, 79
5.4 Clinical referral, 80
5.5 Cytodiagnosis of cervical glandular intraepithelial neoplasia/adencarcinoma-in-situ, 81
High-grade CIN/AIS, 81 AGCUS/borderline glandular cells, 82 Atypical metaplasia, 82
5.6 Cytologic features of adenocarcinoma, 84
5.7 Screening for cervical cancer, 84
Introduction, 84 Cytologic screening, 84 Effectiveness, 84 Accuracy, 85
5.8 Improvements to cervical screening, 85
Improving cytological screening, 85
5.9 Sampling techniques, 85
Slide preparation—thin layer technology, 85
5.10 Cytologic interpretation, 86
Automation in screening, 86
5.11 Adjunctive tests, 88
HPV-DNA testing, 88
HPV-DNA testing as triage, 88
HPV-DNA testing as an adjunctive test to cytology, 89
Cervicography, 89
TruScan* (formerly called The PolarProbe), 90 Visual inspection-based techniques, 91 New developments, 92
5.12 Problems in cytologic screening in the postmenopausal era, 92
Alterations in function, 92 Screening in the postmenopausal era, 93
5.13 References, 94
6 Diagnosis of Cervical Precancer—The use of colposcopy, 97
6.1 Introduction, 97
6.2 Which cytologic abnormalities need further investigation? 97
6.3 Colposcopy: the initial clinical examination, 97
6.4 The rationale for the use of colposcopy in the diagnosis of cervical precancer, 97
6.5 Colposcopic appearance of the abnormal (atypical) cervical epithelium, 98
Morphology of the abnormal (atypical) epithelium, 99 Atypical vessels, 103
The vascular pattern of early invasion, 107
6.6 The classification of colposcopically abnormal (atypical) cervical epithelium, 108
6.7 Colposcopic examination of the precancerous/cancerous cervix, 109
A satisfactory or an unsatisfactory colposcopy, 109 Grading of the abnormal (atypical) colposcopic findings, 109 Unsatisfactory colposcopy: examination of the endocervical canal, 114 Colposcopic biopsy, 120
Microcolpohysteroscopic examination of the endocervical canal, 121 Other cervicoscopic appearances and pathologic findings, 123 Endocervical curettage, 125
Identification of the abnormal (atypical) epithelium: Schiller’s iodine test, 126
6.8 The concept of human papillomavirus infection and cervical precancer, 128
Colposcopic appearance of condylomatous and subclinical papillomavirus lesions, 131 Colposcopic appearances of condylomata and their differentiation from malignant lesions, 132
Further pathologic appearances of HPV and HPV/CIN-associated lesions, 133
6.9 Correlation of diagnostic methods in the detection of cervical squamous precancer, 133
Examples of the correlation of diagnostic methods, 136 In moderate-grade epithelial lesions, 138 In high-grade epithelial lesions, 138
6.10 Lack of correlation between diagnostic methods, 139
6.11 The diagnosis of early invasion, 141
Early invasive squamous cell carcinoma: colposcopic diagnosis, 141 Importance of pathology in diagnosis, 143
6.12 Preclinical invasive carcinoma (colposcopically overt/suspect): colposcopy and pathology, 147
6.13 Precancerous glandular lesions of the cervix, 149
Epidemiology, 149 Colposcopic diagnosis, 149 Relevance to management, 153
6.14 Colposcopic diagnosis of early adenocarcinoma of the cervix, 153
6.15 References, 158
7 Management of Cervical Precancer, 161
7.1 Introduction, 161
7.2 Rationale behind treatment, 161
7.3 Colposcopic and pathologic characteristics of CIN lesion: a prerequisite to treatment, 161
The limits and nature of the abnormal (atypical) epithelium, 161 Glandular involvement, 162 Endocervical extension, 163
7.4 Colposcopically directed biopsy, 163
7.5 Which lesions to treat, 164
High-grade lesions: CIN 2 to 3/HSIL, 164 Low-grade lesions: CIN 1 /LSIL, 164
7.6 Prerequisites for treatment, 165
7.7 Methods of treatment, 165
Local destructive techniques, 165
7.8 Excision techniques for treating CIN, 173
Special problems of endocervical extension, 174 The cold knife cone biopsy, 174 Laser cone biopsy, 178
Loop diathermy excision and cone biopsy, 181
7.9 Management of extension of the abnormal (atypical) transformation zone, 187
Technique, 187
7.10 Follow-up after treatment, 187
7.11 Hysterectomy in the treatment of CIN, 188
7.12 Summary: the optimal method of CIN treatment and of follow-up, 190
Follow-up of CIN management, 190
7.13 Long-term complications of CIN treatment, 190
Stenosis and constriction, 190
Surgical treatment and reconstruction following stenosis, 193 Excessive eversion of the columnar epithelium (post-treatment), 194 Subsequent pregnancy, 194 Recurrence, 194
7.14 Precancer in pregnancy, 197
Management of invasive cervical cancer during pregnancy, 197
Management of the abnormal smear in pregnancy, 197
Colposcopic examination, 198
Biopsy under colposcopic direction, 198
Treatment, 199
Interpretation of a biopsy specimen during pregnancy, 201
7.15 Precancer in the HIV-positive patient, 201
CIN/SIL (squamous intraepithelial lesions) in HIV-infected women, 202 Risk factors for the development of CIN in HIV-infected women, 202 HPV-HIV coinfection, 202
Screening for cervical disease in HIV-affected women, 203 Treatment of CIN in НГѴ-infected women, 203 Summary, 203
7.16 Management of early invasive squamous carcinoma of the cervix (FIGO stage I), 203
History of «microinvasion», 203
Adenocarcinoma-in-situ and early invasive adenocarcinoma of the cervix, 206 Stage lb cancer of the cervix, 207 Recommended treatment: summary, 209
7.17 References, 209
8 Vaginal Intraepithelial Neoplasia, 214
8.1 Introduction, 214
8.2 Natural history of VAIN, 214
8.3 Etiology, 215
8.4 Clinical presentation, 215
Vaginoscopy, 215
VAIN seen as an extension of the cervical atypical transformation zone, 215 VAIN as seen in association with HPV lesions, 216
8.5 VAIN following hysterectomy, 218
Presentation after hysterectomy: value of cytology, 218
8.6 Biopsy of the VAIN lesion, 221
8.7 Pathology of VAIN: is it a precancerous lesion?, 221
8.8 Vaginal precancer and cancer: part of the lower genital tract neoplastic syndrome, 222
Pathology, 222
Non-malignant lesions masquerading as vaginal neoplasia, 225
8.9 Treatment of VAIN, 227
Use of the COz laser, 228 Partial vaginectomy, 228 Local excision, 229
8.10 References, 231
9 Vulvar Intraepithelial Neoplasia, 233
9.1 Introduction, 233
9.2 Epidemiology and pathogenesis, 233
Prevalence and incidence, 233 Association between VIN and CIN, 234 Viral etiology, 235
Sexually transmitted diseases as etiologic factors, 236 Human immunodeficiency virus and VIN 3,236 Smoking risk, 237
9.3 Natural history of VIN: the rationale for treatment?, 237
9.4 Pathology, 239
Differential diagnosis of VIN, 240
9.5 Clinical presentation, 241
Vulvoscopy: magnified illumination of the vulva with a colposcope, 242 Collins toluidine blue test, 243
9.6 Biopsy of the vulva, 244
9.7 Clinical appearances of VIN, 245
White lesions, 246 Red lesions, 248 Dark lesions, 249
9.8 VIN affecting the pilosebaceous unit, 251
9.9 Early invasive carcinoma of the vulva, 252
Clinical features, 253
Risk of nodal spread: depth and volume measurements, 254 Assessment of the pathologic specimen, 254 Diagnosis, 255
Recurrence of early invasive vulvar carcinoma, 256
9.10 Lichen sclerosus, 258
Clinical presentation, 258 Histopathology, 258 Management, 258
9.11 Paget’s disease (non-squamous intraepithelial neoplasia), 260
Clinical presentation, 261 Histopathology, 261 Management, 261
9.12 Vulvar lesions masquerading as cancer or precancer, 261
Syphilis, 262 Behcet’s disease, 263 Condylomata acuminata, 264 Granuloma inguinale, 265 Lichen planus, 266 Subclinical epithelial changes, 266
9.13 Skin and accessory appendages that are important for the management of VIN, 268
9.14 Management of VIN, 270
Rationale for treatment, 270 Treatment options and procedures, 271 Which approach for treating VIN 3? 284
9.15 Treatment of early invasive vulvar carcinoma, 285
Is lymphadenectomy necessary? 285 Results, 285
9.16 References, 285
10 Perianal and Anal Intraepithelial Neoplasia, 290
10.1 Epidemiology, 290
10.2 Etiology, 290
10.3 Association with other genital intraepithelial neoplastic d iseases, 291
10.4 Examination, 291
10.5 Presentation, 292
10.6 Lesions masquerading as intraepithelial neoplasia, 293
10.7 Anal canal involvement, 293
10.8 Treatment, 295
Laser vaporization, 296 Localized surgical excision, 296 Extensive surgical excision, 298
10.9 References, 299
11 Genital Tract Adenosis, 300
11.1 Developmental anatomy, 300
11.2 Developmental anomalies caused by DES, 300
Experimental evidence, 300 Epidemiology, 301 Clinical findings, 301 Pathology, 303 Treatment, 303
11.3 References, 304
12 Infective and Other Conditions Causing Confusion in Diagnosis of Lower Genital Tract Precancer, 305
12.1 Introduction, 305
12.2 Trichomonas vaginalis, 305
12.3 Candidiasis, 305
12.4 Herpes genitalis infection, 306
Clinical presentations, 306 Herpes simplex cytology, 306
Colposcopic and histologic appearances of infection, 307 Vulvar lesions, 308
12.5 HPV infection, 309
12.6 Cervical deciduosis in pregnancy, 312
12.7 Polypoid lesions of the cervix, 312
Clinical presentation and management, 312
12.8 References, 315