PART TWO
Diagnostic Cytology
infectious and inflammatory Diseases
A number of infectious and inflammatory diseases may involve
the vulva. Proper specimen collection and culturing are often
necessary for complete identification of a causative agent. Many
venereal and nonvenereal processes have characteristic morpho-
logic appearances that on Papanicolaou smears suggest the caus-
ative agent. Viral infections such as herpes simplex and human
papillomavirus
(HPV)
have
readily identifiable
cytopathic
effects. Other viral infections such as molluscum contagiosum
(Figs. 11.1A, 11.1B), cytomegalovirus, varicella, herpes zoster
(Fig. 11.2), variola, Epstein-Barr virus, and vaccinia may less
commonly involve the vulva. Mycotic vulvar infections are usu-
ally secondary to
Candida albicans
or
Candida tropicalis.
Unusual
fungal organisms include
Torulopsis glabrata
and the superficial
dermatophytic mycoses, including tinea cruris, tinea versicolor,
and tinea circinata. Deep mycotic infections of the vulva (blasto-
mycosis, sporotrichosis, coccidioidomycosis, and actinomycosis)
are rare. Parasitic infections such as trichomoniasis, amebia-
sis, and schistosomiasis usually involve the vagina as well as
the vulva. The diagnosis can easily be made by identifying the
organism on a cytologic preparation or in a biopsy specimen.
Bartholin's gland infections are caused by various anaerobic
and aerobic bacterial organisms. Both ductal and acinar ele-
ments may be infected, resulting in a blockage of secretion and
causing the formation of an abscess that may be diagnosed by
FNA with appropriate cultures.
Inflammatory and dermatologic diseases of the vulva include
vulvar vestibulitis syndrome, Behcet's syndrome, Crohn's disease,
malacoplakia, contact dermatitis, psoriasis, pemphigus vulgaris,
bullous pemphigoid, lichen planus, and erythema multiforme.6,7
Scraping the base of a vulvar or vaginal lesion in a patient with
pemphigus vulgaris may yield intermediate squamous cells, and
isolated or loose aggregates of acantholytic cells,8,9 characterized
by round-to-oval, central, large nuclei; with regularly distrib-
uted, coarsely granular chromatin; and prominent nucleoli
(Fig. 11.3). These cells may mimic dysplastic or malignant cells.
The definitive diagnosis of pemphigus vulgaris necessitates a
biopsy and immunofluorescence studies.10
Key features of pemphigus vulgaris on vulvar scrape
• Intermediate squamous cells isolated or in loose
aggregates;
• Acantholytic cells;
• Round-to-oval central nuclei;
• Regularly distributed chromatin with prominent
nucleoli; and
• Biopsy and immunoflorescence studies are necessary
for diagnosis.
Non-neoplastic Epithelial Disorders of the Vulva
Non-neoplastic epithelial disorders of the vulvar skin have
traditionally been subdivided into lichen sclerosis, and other
dermatoses (including lichen simplex chronicus, candidiasis,
lichen planus, psoriasis, seborrheic dermatitis, and allergic con-
tact dermatitis). The variable clinical appearances of the lesions,
degree of hyperplasia, and extent of disease process offer little
indication about whether an underlying vulvar intraepithelial
neoplasia (VIN) is present. A biopsy is necessary for a definitive
diagnosis.
Many of these dermatoses have been previously grouped
under the term "squamous cell hyperplasia." While this term
may be an appropriate histopathologic descriptor, more spe-
cific subtyping better reflects the clinicopathologic and man-
agement implications.11-14 Although these lesions are generally
considered "non-neoplastic," they may be associated or coexist-
ent with neoplastic lesions. The cytologic findings from vulvar
scraping of any of the above non-infectious skin disorders of the
vulva are indistinguishable. These scrapes yield varying degrees
of nucleated and anucleated squames, parakeratotic cells, and
hyperkeratosis2 (Figs. 11.4A, 11.4B). The squamous cells retain-
ing their nuclei may demonstrate reactive changes such as slight
nuclear enlargement; however, significant degrees of nuclear
atypia and pleomorphism are not observed unless an underly-
ing VIN is present. Caution should be exercised in coming to a
conclusion about the pathologic significance of squames, para-
keratosis, and hyperkeratosis as they may similarly be obtained
from normal skin.
274
Fig. 11.1 Molluscum contagiosum of the vulva.
(A) Histology of
M olluscum contag iosum
(H&E X200); (B) cytology of
M olluscum
bodies with dense
eosinophilic cytoplasm (Papanicolaou XLP).
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