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Home , Adenomyoma, Fibroma, Papillary hidradenoma

CONTENTS

1. Embryology of the Lower Female Genital Tract...... 1 Cervix and Vagina...... 1 ...... 3 2. Anatomy of the Lower Female Genital Tract...... 7 Cervix...... 7 Gross Anatomy...... 7 Lymphatic Drainage...... 7 Colposcopic Features and Microscopic Anatomy...... 8 Squamous ...... 8 Endocervical Glandular Epithelium...... 10 Transformation Zone...... 11 Vagina...... 16 Gross Anatomy...... 16 Lymphatic Drainage...... 16 Microscopic Anatomy...... 16 Vulva ...... 17 Gross Anatomy...... 17 Lymphatic Drainage...... 18 Microscopic Anatomy...... 19 3. Human Papillomavirus: Biology and Clinical Importance...... 23 Classification and Phylogeny...... 23 Structure and General Organization of the Papillomavirus Genome...... 23 Long-Controlling Region (LCR)...... 24 Early Genes...... 24 HPV Oncogenes: E6 and E7...... 25 The Putative Oncogene E5...... 26 Late Genes...... 27 In Vitro Models of HPV Infection...... 27 HPV Life Cycle: General Aspects...... 27 HPV Life Cycle: Productive (Vegetative) Infections...... 28 HPV Life Cycle: Abortive Infections...... 28 HPV Life Cycle: Latency...... 28 HPV Epidemiology...... 29 Oncogenic HPV Types Cause Cervical ...... 29 Acquisition and Prevalence of HPV...... 31 HPV Persistence and Progression...... 32

xi Tumors of the Cervix, Vagina, and Vulva

Progression of HPV Infection to CIN 3 and Cancer...... 35 Epidemiology of Cervical ...... 35 HPV Immunology...... 36 Evasion of Host Immune System...... 36 Host Defenses: Squamous Epithelium...... 37 Host Defenses: Immunologic Responses...... 37 Human Leukocyte Antigens...... 38 Subversion of Host Immunity...... 39 Clinical Applications of HPV Testing...... 39 Rationale for Clinical HPV Testing...... 39 Clinical HPV Assays...... 39 The ASCUS/LSIL Triage Study (ALTS)...... 40 HPV Testing for Management of Atypical Glandular Cells...... 45 HPV Testing for Quality Assurance of Cytologic Interpretations...... 46 HPV Testing for Primary Screening...... 46 HPV Testing for Post-treatment Follow-up...... 47 HPV Vaccines...... 48 Rationale for Developing HPV Vaccines...... 48 Prophylactic Vaccines...... 49 Therapeutic Vaccines...... 50 HPV Vaccine Research...... 51 4. Classification...... 59 5. Tumors of the Cervix...... 67 Squamous Lesions...... 67 Squamous ...... 67 Condyloma Acuminatum...... 67 Squamous Metaplasia...... 68 Transitional Metaplasia...... 73 Squamous Atypia...... 75 Squamous Intraepithelial Lesions...... 79 Squamous Cell ...... 105 Microinvasive ...... 105 Invasive Squamous Cell Carcinoma...... 111 ...... 121 Warty (Condylomatous) Carcinoma...... 123 Papillary Squamous Cell (Squamotransitional) Carcinoma...... 123 -Like Carcinoma...... 124 Glandular Lesions...... 128 Endocervical Polyp...... 128

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Müllerian Papilloma...... 128 Tunnel Clusters...... 128 Endocervical Glandular Hyperplasia...... 128 Microglandular Hyperplasia...... 128 Mesonephric Remnants...... 134 Mesonephric Hyperplasia...... 134 Arias-Stella Reaction...... 134 Endometriosis...... 136 Tubal, Tuboendometrioid, and Endometrioid Metaplasias...... 137 Endocervicosis...... 137 ...... 137 Intestinal Metaplasia...... 140 Atypical Oxyphilic Metaplasia...... 141 Ectopic Prostatic Tissue...... 141 Glandular Atypia...... 141 Adenocarcinoma In Situ...... 145 Adenocarcinoma...... 162 Microinvasive Adenocarcinoma (Early Invasive Adenocarcinoma)...... 163 Invasive Adenocarcinoma...... 164 Mucinous Adenocarcinoma...... 177 Endometrioid Adenocarcinoma...... 177 Well-Differentiated Villoglandular Adenocarcinoma...... 179 Endocervical Adenocarcinoma, Microcystic Type...... 186 Clear Cell Carcinoma...... 186 Minimal Deviation Adenocarcinoma...... 187 Serous Adenocarcinoma...... 191 Mesonephric Adenocarcinoma...... 191 Other Epithelial Tumors...... 197 Adenosquamous Carcinoma...... 197 Glassy Cell Adenocarcinoma...... 200 ...... 202 Adenoid Basal Cell Tumors...... 203 Neuroendocrine Tumors...... 207 Typical Tumor...... 207 Atypical Carcinoid Tumor...... 207 Small Cell Carcinoma...... 207 Large Cell Neuroendocrine Carcinoma...... 211 Undifferentiated Carcinoma...... 214 Mesenchymal Tumors...... 214

xiii Tumors of the Cervix, Vagina, and Vulva

Mesodermal Stromal Polyp (Pseudosarcoma Botryoides)...... 214 ...... 215 Other Benign Mesenchymal Tumors...... 215 ...... 215 Endometrioid Stromal , Low Grade...... 216 Undifferentiated Endocervical Stromal Sarcoma...... 216 (Embryonal )...... 216 Dermatofibrosarcoma Protuberans...... 217 Alveolar Soft-Part Sarcoma...... 217 Osteosarcoma...... 221 Other Malignant Mesenchymal Tumors...... 221 Mixed Epithelial and Mesenchymal Tumors...... 221 Papillary Adenofibroma...... 221 ...... 221 Adenosarcoma...... 222 Malignant Mixed Mesodermal Tumor ()...... 222 Wilms Tumor...... 226 Miscellaneous Tumors...... 227 Melanocytic Nevus...... 227 Blue Nevus...... 227 Malignant ...... 228 Glomus Tumor...... 228 Lymphoma and Leukemia...... 229 Germ Cell Tumors...... 232 Mature (Dermoid )...... 232 Yolk Sac Tumor...... 232 Secondary Tumors...... 234 Tumor-Like Lesions...... 234 Epidermal Metaplasia...... 234 Lymphoma-Like Lesion (Pseudolymphoma)...... 236 Decidual ...... 236 Placental-Site Nodule...... 236 Amputation (Traumatic) Neuroma...... 236 Postoperative Spindle Cell Nodule...... 236 Glial Polyp...... 237 6. Tumors of the Vagina...... 255 Squamous Lesions...... 255 Squamous Papilloma...... 255 Condyloma Acuminatum...... 255

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Transitional Metaplasia...... 255 Squamous Atypia...... 256 Squamous Intraepithelial Lesions...... 256 Squamous Cell Carcinoma...... 259 Verrucous Carcinoma...... 261 Warty (Condylomatous) Carcinoma...... 261 Papillary Squamous (Squamotransitional) Cell Carcinoma...... 262 Glandular Lesions...... 262 Adenosis...... 262 Atypical Adenosis...... 266 Endometriosis...... 266 Endocervicosis...... 266 Cysts...... 268 Müllerian Papilloma...... 268 Endometrioid, Endocervical, and Intestinal Type ...... 269 Clear Cell Adenocarcinoma...... 269 Mesonephric Carcinoma...... 273 Other Epithelial Tumors...... 273 Adenosquamous Carcinoma...... 273 Miscellaneous Tumors...... 273 Mesenchymal Tumors...... 274 Mesodermal Stromal Polyp...... 274 Leiomyoma...... 274 Superficial Cervicovaginal Myofibroblastoma...... 276 ...... 276 Other Benign Mesenchymal Tumors...... 276 Leiomyosarcoma...... 276 Sarcoma Botryoides (Embryonal Rhabdomyosarcoma)...... 277 Endometrioid Stromal Sarcoma...... 280 Other Malignant Mesenchymal Tumors...... 280 Mixed Epithelial and Mesenchymal Tumors...... 280 ...... 280 Mixed Tumor Resembling ...... 281 Adenosarcoma...... 281 Malignant Mixed Mesodermal Tumor (Carcinosarcoma)...... 281 Miscellaneous Tumors...... 281 Melanocytic Nevus...... 281 Blue Nevus...... 282 Malignant Melanoma...... 282

xv Tumors of the Cervix, Vagina, and Vulva

Yolk Sac Tumor...... 283 Mature Cystic Teratoma...... 283 ...... 283 Villous ...... 283 Malignant Lymphoma and Other Lymphohistiocytic Lesions...... 283 Primitive Neuroectodermal Tumor...... 284 Secondary Tumors...... 284 Tumor-Like Lesions...... 284 Postoperative Spindle Cell Nodule...... 284 Vault Granulation Tissue...... 285 Prolapsed Fallopian Tube...... 285 Malakoplakia...... 286 Lymphoma-Like Lesion...... 286 7. Tumors of the Vulva...... 293 Squamous Lesions...... 293 Squamous Papilloma (Vestibular Papilloma, Micropapillomatosis Labialis)...... 293 Fibroepithelial Polyp...... 293 Condyloma Acuminatum...... 294 Seborrheic Keratosis...... 297 Epidermolytic Acanthoma...... 298 Keratoacanthoma...... 299 Folliculosebaceous Cystic Hamartoma...... 300 ...... 300 Vulvar Intraepithelial Neoplasia (Vulvar Squamous Intraepithelial Neoplasia)..... 300 Squamous Cell Carcinoma...... 311 Invasive Squamous Cell Carcinoma, Stage IA (T1a,N0,M0)...... 311 Invasive Squamous Cell Carcinoma, Stage IB (T1b and higher)...... 312 Basaloid Carcinoma...... 320 Warty (Condylomatous) Carcinoma...... 321 Squamous Cell Carcinoma with Tumor Giant Cells...... 323 Spindle Cell Squamous Cell Carcinoma/Squamous Cell Carcinoma with Sarcomatoid Features...... 324 Adenoid Squamous Cell Carcinoma...... 324 Lymphoepithelioma-Like Carcinoma...... 324 Verrucous Carcinoma...... 324 Basal Cell Carcinoma...... 327 Adenoid Basal Cell Carcinoma...... 328 Metatypical Basal Cell Carcinoma...... 328 ...... 328

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Basal Cell Carcinoma Mixed with Squamous Cell Carcinoma (Mixed Carcinoma).... 329 Benign Glandular Lesions...... 329 Papillary (Hidradenoma Papilliferum)...... 329 Nodular (Clear Cell) Hidradenoma...... 330 ...... 331 Mixed Tumor of the Vulva (, Chondroid Syringoma)...... 332 ...... 333 Proliferating Trichilemmal Tumor ()...... 333 Adenoma of Minor Vestibular Glands...... 334 Intraepithelial : Paget Disease and Paget-Like Lesions...... 334 Primary Cutaneous (Intraepithelial) Paget Disease (Type 1 Paget Disease)...... 334 Primary Cutaneous (Invasive) Paget Disease (Type 1 Paget Disease)...... 337 Paget Disease Secondary to Rectal or Anal Adenocarcinoma (Type 2 Paget Disease)... 337 Paget-Like Disease Secondary to Urothelial Neoplasia: Pagetoid Urothelial Intraepithelial Neoplasia (Type 3 Paget Disease: Pagetoid Transitional Cell Neoplasia, Pseudo-Paget Disease)...... 337 Differential Diagnosis of Paget Disease and Paget-Like Lesions...... 339 Neoplastic Glandular Lesions...... 339 Bartholin Gland Tumors...... 339 Malignant Mixed Tumor...... 343 Mammary Gland-Like Adenocarcinoma and Other Mammary-Like Tumors Arising in the Vulva...... 343 Adenocarcinoma of Cloacogenic Origin (Mucinous Adenocarcinoma Arising in the Surface Epithelium of the Vulva)...... 344 Carcinoma of Sweat Gland Origin...... 344 Mucinous with Neuroendocrine Differentiation...... 344 Mucinous Adenocarcinoma with Focal Squamous and Neuroendocrine Differentiation...... 345 Benign Mesenchymal Tumors...... 345 /Fibrolipoma...... 345 Intradermal Spindle Cell (Pleomorphic) Lipoma of the Vulva...... 346 -Like Tumor of the Vulva...... 346 Nevus Lipomatosis Superficialis...... 346 Hemangioma...... 346 Capillary Hemangioma (Strawberry Hemangioma, Juvenile Hemangioma)...... 346 Cavernous Hemangioma...... 347 Acquired Hemangioma...... 347 Angiokeratoma...... 347 ...... 347 Lymphoid Hamartoma...... 347

xvii Tumors of the Cervix, Vagina, and Vulva

Superficial Angiomyxoma...... 347 Angiomyofibroblastoma...... 349 ...... 350 Lymphangioma...... 352 Lymphangioma Circumscriptum...... 352 ...... 353 (Atypical Solitary Fibrous Tumor)...... 353 Cellular ...... 353 Giant Cell Angiofibroma...... 353 Leiomyoma/Atypical Leiomyoma...... 354 Granular Cell Tumor...... 354 ...... 356 Schwannoma (Neurilemmoma)...... 357 Paraganglioma...... 357 Glomus Tumor...... 357 Benign Fibrous ...... 358 Atypical Fibrous Histiocytoma...... 358 Rhabdomyoma...... 358 Malignant Mesenchymal Tumors...... 358 Rhabdomyosarcoma...... 358 Botryoid Rhabdomyosarcoma...... 359 Alveolar Rhabdomyosarcoma...... 360 Embryonal Rhabdomyosarcoma...... 362 Alveolar Soft-Part Sarcoma...... 362 Leiomyosarcoma...... 363 Dermatofibrosarcoma Protuberans...... 363 Composite Tumor Consisting of Dermatofibrosarcoma Protuberans and Giant Cell Fibroblastoma...... 364 Malignant Fibrous Histiocytoma...... 364 ...... 366 Angiomyofibrosarcoma (Angiomyofibroblastoma with Sarcomatous Transformation)...... 366 Synovial Sarcoma...... 366 Epithelioid Sarcoma...... 367 Malignant Rhabdoid Tumor...... 367 Malignant Schwannoma...... 369 Lymphangiosarcoma...... 369 Angiosarcoma...... 369 Kaposi Sarcoma...... 369

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Hemangiopericytoma...... 370 ...... 370 Malignant Granular Cell Tumor...... 371 Melanocytic Tumors...... 371 Congenital Melanocytic Nevus...... 371 Common Acquired Melanocytic Nevus...... 371 Lentigo Simplex...... 371 Melanosis Vulvae...... 372 Cellular Blue Nevus...... 372 Atypical Melanocytic Nevus of Genital Type and Clark/Dysplastic Vulvar Nevus.... 372 Malignant Melanoma...... 374 Malignant Blue Nevus...... 379 Miscellaneous Tumors...... 379 Malignant Lymphoma...... 379 Tumors of Germ Cell Type...... 379 Yolk Sac Tumor (Endodermal Sinus Tumor)...... 379 Neuroendocrine and Neuroectodermal Tumors...... 379 Merkel Cell Tumor...... 379 Peripheral Neuroectodermal Tumor (Extraosseous Ewing Sarcoma)...... 381 Secondary/Metastatic Tumors...... 382 Tumor-Like Lesions...... 382 Pseudoepitheliomatous Hyperplasia...... 382 Endometriosis and Decidua...... 383 Langerhans Cell Histiocytosis/Granulomatosis (Histiocytosis X including Eosinophilic Granuloma)...... 384 Benign Xanthogranuloma...... 384 Verruciform Xanthoma...... 384 Desmoid Tumor (Extraabdominal /Aggressive Fibromatosis)...... 384 Sclerosing Lipogranuloma...... 385 (Pseudosarcomatous Faciitis/Postoperative Faciitis)...... 385 Postoperative Spindle Cell Nodule...... 386 Crohn Disease...... 387 Vulvitis Granulomatosa...... 387 Cysts ...... 387 Bartholin Duct Cyst...... 387 Mucinous Cyst...... 387 Acquired Mucinous Cyst/Mucinous Metaplasia...... 388 Epidermal Inclusion (Keratinous) Cyst...... 388 Mesonephric-Like Cyst...... 389

xix Tumors of the Cervix, Vagina, and Vulva

Ciliated Cyst...... 389 Mesothelial Cyst (Cyst of the Canal of Nuck)...... 390 Periurethral Cyst...... 390 Other Epithelial Disorders of Skin and Mucosa...... 390 Lichen Sclerosus (Lichen Sclerosus et Atrophicus)...... 390 Lichen Simplex Chronicus/Squamous Cell Hyperplasia (Formerly Hyperplastic Dystrophy)...... 393 Inflammation of the Vulvar Vestibule of Unknown Etiology: Vulvar Vestibulitis and Vulvodynia...... 395 Other Dermatoses...... 395 Index ...... 413

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