11
Vulva, Vagina, and Anus
Carcinoma of the Bartholin's Glands
Carcinoma of the Bartholin's glands is rare, constituting less than
1% of female genital tract neoplasms; patients have an average
age of 49.5 years.42 A number of histologic variants have been
noted, including squamous cell carcinoma, adenocarcinoma,
undifferentiated carcinoma, transitional cell carcinoma, ade-
noid cystic carcinoma, adenoacanthoma, and adenosquamous
carcinoma. Because none of the cell types are unique for Bartho-
lin's gland carcinoma, the cytologic patterns correlate with the
histologic pattern. Involvement of the superficial portion of the
skin overlying the gland may make distinction from a primary
vulvar neoplasm difficult.
Melanomas
These are uncommon malignant tumors of the vulva.43,44 The
most frequent sites of involvement include the labia majora and
labia minora. The peak incidence occurs in the sixth through
eighth decades of life. The most frequent complaint is that of
a mass in the vulvar region accompanied by bleeding or pru-
ritus. Two-thirds of the lesions are pigmented. The superficial
spreading type has been reported to be most frequent; however,
some have reported that those occurring in mucous membranes
were commonly of the lentiginous type. The prognosis corre-
lates with Clark's level and Breslow's depth of invasion.43 His-
tologically, atypical melanocytes are noted migrating through
the squamous epithelium or into the dermis. The cells occur in
loose aggregates that have a nevoid or epithelioid appearance.
Nuclear pleomorphism is prominent, with prominent macro-
nuclei. Variable amounts of melanin pigment may be noted.
The cytologic appearance of melanoma reveals large pleomor-
phic cells with varying amounts of isolated or loosely aggregated
cytoplasm. The nuclei are enlarged and round to oval. Binu-
cleation and multinucleation are often noted. Macronucleoli
are frequent. Intracytoplasmic melanin may be found in the
pigmented lesions.
Key features of melanoma in vulvar scrape
• Loose aggregates or isolated cells;
• Cellular and nuclear pleomorphism;
• Enlarged nuclei with macronucleoli;
• Binucleation and multinucleation common; and
• Intracytoplasmic melanin possibly present.
Vagina
Sample collection Methods
To avoid contamination, most cytology samples from the vagina
should be obtained before manipulation of the cervix. Excess
mucus secretion should be removed with cotton balls. In sam-
pling for adenosis, some investigators recommend a circum-
vaginal scraping of the upper vagina. An alternative method is a
four-quadrant scrape of the anterior, posterior, and lateral walls
using a downward motion to avoid cervical contamination. FNA
has been successfully used for sampling palpable lesions.45
Histology
The vagina extends from the ectocervix to the vestibule or
introitus. Recesses noted in the upper portion of the vagina
between the cervix and vagina are known as the vaginal
fornices. The vagina is lined with a stratified squamous mucosa
that is hormonally sensitive. The discussion of the role of vagi-
nal cytology for hormonal assessment is beyond the scope of
this chapter.46,47
infectious and inflammatory Diseases
A number of infections and inflammatory disease processes
may involve the vagina in addition to the vulva and these have
been discussed earlier in detail. Atrophic vaginitis results from
loss of estrogenic stimulation, leading to thinning and shrink-
age of the tissue. Cell scrapings usually reveal intermediate or
atrophic parabasal cells. Trauma may result in infections with
inflammatory reactions and repair. Emphysematosa vaginitis48
is a self-limited disease characterized by multiple gas-filled cystic
cavities in the vaginal wall. The cavities usually have no discern-
ible cell lining, although multinucleated giant cells or inflam-
matory cells may be found. The etiology of this process is not
completely understood, but it is often seen in pregnant women
or patients with impaired immunity. Cytologic scrapes usually
reveal inflammatory cells with occasional giant cells and repara-
tive changes.49 Malacoplakia infrequently involves the female
genital tract (Fig. 11.11A).50 Exfoliative cytology or FNA reveals
isolated histiocytes with an occasional characteristic Michaelis-
Gutmann body (Fig.11.11B).51 Papanicolaou smear of a vaginal
lesion in a patient with Behcet's disease may show markedly
atypical keratinocytes that may mimic SCC.52,53
Vaginal Smears from Posthysterectomy Patients
Vaginal vault smears are used to detect the presence of vaginal
intraepithelial neoplasia (VaIN) or carcinoma in patients who
have had hysterectomy for cervical intraepithelial neoplasia
(CIN) or carcinoma. The value of vaginal smears after hyster-
ectomy for benign disease has not been fully established.54,55
The cost-effectiveness of routine vaginal smears for endometrial
cancer surveillance has also been questioned.56
The presence of nonatypical glandular cells in vaginal smears
from posthysterectomy patients appear to be of little clinical
consequence and not indicative of adenocarcinoma.55 The ori-
gin of these cells cannot always be satisfactorily explained.16 In
most cases, the possible sources include the cervix in cases of
supracervical hysterectomy, vaginal endometriosis, mesonephric
duct remnants and cysts, vaginal adenosis, rectovaginal fistula
(Fig. 11.12), fallopian tube prolapse, goblet cell metaplasia, and
cytologic effects following the use of 5-fluorouracil.14,55,57 Exfo-
liated reparative squamous basal and parabasal cells can also
mimic glandular cells.14
cysts
The majority of vaginal cysts are inclusion cysts lined with squa-
mous mucosa and containing keratinous debris. They are usually
traumatic in origin. The remainder of vaginal cysts are usually
of mullerian origin and are lined with columnar or cuboidal
mucus-secreting cells. They are usually located along the antero-
lateral vaginal wall. Mesonephric (Gartner's) duct cysts are typi-
cally found in the lateral walls of the vagina along the tract of
vestigial remains of the mesonephric ducts.58,59 Scrapes of such
lesions usually result in only normal-appearing squamous epi-
thelial cells. Needle aspiration may provide a worthwhile clue
about the origin and nature of the lesion. Endometriosis of the
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