外阴营养不良、外阴鳞状上皮细胞癌凝集素标记免疫组化分析

目的：探讨外阴营养不良增生型,硬化苔藓型表皮细胞和外阴鳞状上皮细胞癌等细胞膜结构与凝集素受体结合表达特征及它们三者之间的关系。方法：对慢性外阴营养不良表皮增生型,苔藓硬化型及外阴鳞状上皮细胞癌3种状态下的细胞进行了8种凝集素免疫组织化学标记,分析,比较。结果：外阴营养不良增生型表皮各层细胞细胞膜与刀豆凝集素（ConA),扁豆凝集素（LCA）,花生凝集素（PNA）,蓖麻凝集素（RCA－1）和大豆凝集素（SBA）结合强度弱,其表皮细胞细胞核膜与ConA,PNA和麦胚凝集素（WGA）有中等强度结合,外阴营养不良硬化苔藓型表皮各层细胞细胞膜与ConA,RCA-1 SBA和WGA结合强度弱,而与LCA不结合,其12例中的8例与荆豆凝集素（UEA－1）发生较弱的结合,外阴鳞状上皮细胞癌癌细胞与8种凝集素均结合,其12例中的7例其癌细胞膜与双花扁豆凝集素（DBA）弱结合,癌细胞膜与UEA－1强结合,但癌巢中央细胞团不与UEA－1结合,癌细胞细胞核膜与ConA,LCA,RCA-1呈强结合。结论：凝集素标记免疫组织化学染色可作为诊断,鉴别诊断外阴营养不良增生,硬化苔藓型和外阴鳞状上皮细胞癌新的指标,具有恶变潜能的增生型外阴营养不良与外阴鳞状上皮细胞癌,两者细胞核膜凝集素标记有相似之处,提示在外阴组织的癌变过程中,细胞核膜凝集素标记的异常表达是一个早期标识,糖基和糖蛋白代谢的异常可能是细胞发生癌变最早期的表现之一。     

p53 immunostaining in lichen sclerosus is related to ischaemic stress and is not a marker of differentiated vulvar intraepithelial neoplasia (d-VIN)

AIM: To analyse p53 immunoreactivity in 207 biopsy specimens of lichen sclerosus (LS) and "differentiated vulvar intraepithelial neoplasia" (d-VIN), a postulated precursor lesion for LS-associated vulvar squamous cell carcinoma (SCC), which is characterized by atypical basal keratinocyte proliferations with p53+ basal/suprabasal keratinocyte nuclei. METHODS AND RESULTS: Forty early, 78 classic, 30 hypertrophic vulvar LS, 26 paediatric vulvar and penile LS, 33 vulvar LS-associated SCC and 30 vulvar/penile control specimens were examined for p53 expression and the presence of d-VIN. Nuclear p53 staining was observed in 175/207 LS biopsy specimens. Eighty percent of early and 69% of paediatric LS showed discontinuous/continuous p53 staining in basal keratinocytes. Classic LS showed no p53 staining in 17%, discontinuous basal keratinocyte staining in 20%, continuous basal keratinocyte staining in 58%, basal/suprabasal staining in 5%. Hypertrophic LS revealed basal keratinocyte staining in 32% and basal/suprabasal staining in 61%. p53 staining was associated with sclerosis of blood vessels and dermis, lymphoid infiltrates, vasculitis and hypertrophic LS. d-VIN was seen in 2% of LS alone and in 24% of LS-associated SCC. CONCLUSION: d-VIN in LS is rare, while p53 staining is common and best explained as an ischaemic stress response due to poor oxygenation, vasculitis and inflammation rather than as a marker of a precancerous lesion in LS.     

328例女阴营养不良的病理分析

主张采用1975年国际外阴疾病研究协会上通过的女阴营养不良的命名及其分类。此法简易可行,能反映疾病的本质及其生物学行为。本文对内蒙古地区328例女阴营养不良作了病理分析,发现增生性营养不良156例(47.6%),萎缩性营养不良113例(34.6%),发病率偏高于国内其他地区,好发年龄均在20～30岁之间。病理所见,不仅上皮组织中有明显的营养不良改变,在真皮层内的结缔组织、神经组织及皮肤附属器亦均出现程度不等的变性、萎缩和消失。认为这些均系血管改变的结果。     

Specific intraepithelial localization of mast cells in differentiated vulvar intraepithelial neoplasia and its possible contribution to vulvar squamous cell carcinoma development

van de Nieuwenhof H P, Hebeda K M, Bulten J, Otte‐Holler I, Massuger L F A G, de Hullu J A & van Kempen L C L T
(2010) Histopathology 57, 351–362
Specific intraepithelial localization of mast cells in differentiated vulvar intraepithelial neoplasia and its possible contribution to vulvar squamous cell carcinoma development Aims: The aetiology of vulvar squamous cell carcinomas (SCC) that are not causally associated with high‐risk human papillomavirus remains largely elusive. The aim of this study was to analyse the inflammatory response in its presumed precursor lesions, lichen sclerosus (LS) and differentiated vulvar intraepithelial neoplasia (dVIN), and provide evidence that dVIN is a likely precursor of vulvar SCC. Methods and results: Immunohistochemical analyses for CD4+, CD8+, CD20+, CD68+, S100+ and tryptase‐positive immune cells were performed and quantified in LS (n = 7), dVIN (n = 19), SCC (n = 11), and normal vulvar tissue (n = 8). The subepithelial inflammatory response in dVIN and SCC was comparable, but absent in LS. Abundant intraepithelial mast cells were observed in dVIN only, and confirmed by electron microscopy, toluidine blue staining and cKIT expression. Adjacent keratinocytes displayed increased proliferation as determined by MIB‐1 positivity. Electron microscopy revealed intraepithelial mast cell degranulation. Intraepithelial mast cells were not or infrequently observed in vulvar hyperplasia (n = 13), condylomata acuminata (n = 5), keratinocytic intraepidermal neoplasia of sun‐exposed skin (n = 15), epidermal hyperplasia of head and neck (n = 12), and psoriasis (n = 3). Conclusions: These data indicate that dVIN can be recognized by intraepithelial mast cells and that they might promote the progression of dVIN to SCC.     

Morphometric analysis of nuclear/cytoplasmic ratios in normal and perineoplastic vulvar skin

Analysis of vulvar skin adjacent to squamous carcinoma has demonstrated abnormal deoxyribonucleic acid (DNA) content in histologically unremarkable specimens. Analysis of DNA by microdensitometry is time-consuming. Morphometric analysis by point counting was used to compare the nuclear/cytoplasmic ratios of normal vulvar skin and skin adjacent to malignancy. This showed elevated ratios in the latter specimens although there was no linear relationship to increasing ploidy.     

PD-L1 expression in vulvar cancer: a systematic review and meta-analysis

Programmed cell death ligand-1 (PD-L1) expression in cancer may predict clinical response to immunotherapeutic treatment with PD-1/PD-L1 inhibitors. Within the vulvar cancer field, PD-L1 expression has only been assessed by a few studies. We conducted a meta-analysis to examine the prevalence of PD-L1 positivity in vulvar cancer. PubMed, Embase, and Cochrane were searched for articles reporting on PD-L1 expression in vulvar cancer. Study selection and data extraction were performed independently by two authors. We extracted data on PD-L1 prevalence in vulvar cancer according to combined positive score (CPS) and tumour proportion score (TPS). Cutoff values for positivity were ≥1 or ≥10 for CPS and ≥1% and ≥5% for TPS. Random-effects models were used to estimate pooled PD-L1 prevalence, with 95% confidence intervals (CIs). Tests of between-study heterogeneity were evaluated by the I² statistics. Sources of heterogeneity were explored by subgroup analyses and meta-regression. In total, 19 studies were included. Pooled PD-L1 prevalence in vulvar cancer was 83.4% (95% CI: 70.8–91.3; I² = 80.0) and 53.9% (95% CI: 37.4–69.6; I² = 93.0) according to CPS and TPS, respectively. Based on TPS, human papillomavirus (HPV)-associated vulvar squamous cell carcinomas (SCC) showed a lower PD-L1 prevalence (39.9%; 95% CI: 13.3–74.2) compared with HPV-independent SCC (62.6%; 95% CI: 33.7–84.6), but meta-regression showed no significant variation in PD-L1 prevalence by HPV status. PD-L1 prevalence was similar in advanced (44.9%; 95% CI: 29.8–61.1) and localized vulvar cancer (56.7%; 95% CI: 18.9–76.7). In conclusion, PD-L1 expression in vulvar cancer is frequent but between-study heterogeneity was high. Based on a subgroup of heterogenous studies, we found no strong variation in PD-L1 prevalence according to HPV status and stage.     

Histopathological work-up and interpretation of sentinel lymph nodes removed for vulvar squamous cell carcinoma

Aims:  To evaluate the work-up of sentinel lymph nodes (SLNs) removed for vulvar pT1–pT2 squamous cell carcinoma (SCC). Inguinal lymphadenectomy yields metastases in only 30% of cases. Patients with missed inguinal disease, however, have a risk of dying from systemic disease. SLN dissections reduce morbidity, but work-up should reliably identify metastatic disease.
Methods and results:  All SLNs removed from 38 patients with pT1–pT2 SCC and clinically negative inguinal lymph nodes were submitted for frozen section analysis. When negative, SLN were formalin-fixed, sectioned entirely at 330-μm intervals to produce three slides per millimetre [two haematoxylin and eosin (H&E) stained slides; one slide for immunohistochemistry]. If screening of H&E-stained sections was negative, all remaining slides were subjected to immunohistochemistry with an antibody to cytokeratin. Twenty-five of 38 patients (66%) were pN0, 7/38 (18%) had metastases on frozen sections/H&E stains. Immunohistochemistry detected micrometastases in two patients and single tumour cells and anucleate cell structures in four patients. In 12/13 patients the SLN metastases, including all single-cell deposits, were from lichen sclerosus (LS)-associated SCC. Twelve of 13 patients with metastases had a pT2 SCC.
Conclusions:  Micrometastases and single tumour cell deposits in SLNs are typical of LS-associated vulvar SCC. Single tumour cell deposits in SNLs should be regarded as 'positive'. Identification requires serial sectioning and immunohistochemical analysis of all removed SLNs.     

外阴上皮内瘤变与人乳头状瘤病毒感染的相关性

目的 探讨人乳头状瘤病毒(HPV)在外阴上皮内瘤变(VIN)中的感染情况及与p53、Ki-67蛋白表达的关系.方法 用原位杂交法(ISH)检测HPV6/11、16/18、31/33型在55例VIN及10例外阴正常皮肤组织中的表达.同时用免疫组化SP法检测p53、Ki-67蛋白的表达.结果 HPVl6/18、31/33、6/11在VINⅢ中的阳性表达率分别为60%(6/10)、20%(2/10)和0%(0/10);在VIN Ⅱ中为53.57%(15/28)、39.28%(11/28)和10.71%(3/28);在VIN Ⅰ中为17.65%(3/17)、5.88%(1/17)和29.41%(5/17);正常对照组没有表达.p53、Ki-67蛋白在VINHI中的阳性表达率分别为70%(7/10)和90%(9/10);在VINⅡ中为78.57%(22/28)和78.57%(22/28);在VIN Ⅰ中为64.71%(11/17)和35.29%(6/17);在正常对照组没有表达.经统计学分析,VINⅢ、Ⅱ组中的HPVl6/18感染与正常组差异有显著性(P＜0.05);VINⅡ组的HPV31/33感染与正常组差异有显著性(P＜0.05);VINⅢ、Ⅱ组p53、Ki-67及VIN Ⅰ组p53阳性表达率与正常组差异有显著性(P＜0.05);VIN Ⅰ组Ki-67阳性表达率与VINⅡ组相比差异有显著性(P＜0.05).结论 VIN的发生与HPV感染有关,尤其与HPVl6/18、31/33型感染密切相关.VIN与外阴癌感染的HPV型别相同.在VIN的发生发展中,HPV感染以及p53突变可能起重要的作用.     

Early vulvar lichen sclerosus: a histopathological challenge

Vulvar lichen sclerosus (LS), a lymphocyte-mediated chronic skin disease, begins with uncharacteristic symptoms and progresses undiagnosed to atrophy and destructive scarring. Some patients with longstanding advanced LS have an increased risk of vulvar carcinoma. Early LS is treatable, although not curable, if diagnosed early. Therefore, patients with persistent vulvar symptoms should be biopsied to establish the diagnosis. In contrast to advanced LS, the histological features in early LS are quite subtle and often more prominent in adnexal structures than in interfollicular skin. Adnexal structures show acanthosis, luminal hyperkeratosis and hypergranulosis with/without dystrophic hair and basement membrane thickening. The epidermis/mucosa shows mild irregular, occasionally psoriasiform acanthosis and focal basement membrane thickening. Early dermal changes are homogenized collagen and wide ectatic capillaries in dermal papillae immediately beneath the basement membrane. The lymphocytic infiltrate can be sparse or dense, lichenoid or interstitial with epidermal lymphocyte exocytosis and lymphocytic/lymphohistiocytic vasculitis. Dermal melanophages indicate preceding keratinocyte/melanocyte destruction. Biopsy specimens of early LS rarely display all features. Therefore, serial sections and periodic acid-Schiff reactions are necessary for their identification. Recognition and treatment of these early stages of LS may result in longstanding remission. Progression to atrophic stages with their associated morbidity and even to squamous cell carcinoma may be prevented.     

血管肌纤维母细胞瘤临床病理特征

目的：探讨血管肌纤维母细胞瘤的临床病理形态特征及鉴别诊断。方法：对2例血管肌纤维母细胞进行组织病理学、免疫组织化学研究,结合文献资料分析本病的临床表现、病理形态特点及鉴别诊断。结果：血管肌纤维母细胞瘤呈大片黏液背景、丰富薄壁海绵样血管和梭形上皮样细胞即肌纤维母细胞,后者胞质丰富,呈嗜酸性,核卵圆或杆状,两端对称变细或稍钝,瘤细胞分布有明显的疏密区,密集区聚于血管周围,成束或链状排列、疏松区弥散于黏液背景中,且瘤细胞常与胶原纤维伴行。结论：血管肌纤维母细胞瘤为良性肿瘤,好发于女性外生殖器,起源与肌纤维母细胞相关,既向纤维,又向平滑肌分化,且伴有丰富的海绵样薄壁血压和间质黏液变性。     

Collision tumor composed of mammary-type myofibroblastoma and eccrine adenocarcinoma of the vulva

Collision tumors of the vulva are uncommon. Mammary-type myofibroblastoma is a rare benign tumor arising at extramammary sites with morphological and immunophenotypic features similar to the breast counterpart. Eccrine adenocarcinoma of the vulva is rare. The authors report here a true collision tumor containing a mammary-type myofibroblastoma with intermingling components of eccrine adenocarcinoma occurring in the vulva. An 80-year-old woman presented with a subcutaneous nodule in the vulva. The tumor was well circumscribed but unencapsulated. The mammary-type myofibroblastoma and the adenocarcinoma measured 4 cm × 3.5 cm × 1.0 cm and 1.5 cm × 1.2 cm × 0.8 cm, respectively. In the overlying superficial dermis there was an eccrine adenocarcinoma. It was composed of uniform basophilic cells arranged in tubules, solid nests, and cribriform growth patterns. The eccrine adenocarcinoma infiltrated the mammary-type myofibroblastoma in the submucosa. The soft tissue lesion revealed a spindle cell proliferation composed of fascicles of myofibroblastic cells embedded in a collagenous stroma with a predominance of mast cells. Interspersed thick hyalinized collagen bundles separated the fascicles. Immunohistochemically, the spindle cell tumor strikingly stained for both CD34 and desmin. To the best of our knowledge, this is the first case report of a vulva collision tumor composed of mammary-type myofibroblastoma intermixed with primary eccrine adenocarcinoma in the English literature.     

6例分化型外阴上皮内瘤变临床病理观察

目的：探讨分化型外阴上皮内瘤变( differentiated-type vulvar intraepithelial neoplasia, dVIN)的临床病理学特征、鉴别诊断、治疗及预后。方法回顾性分析6例dVIN的临床特点、病理形态学和免疫表型特征,并复习相关文献。结果患者均为女性,年龄53~80岁,平均62岁,临床特点大多表现为外阴白斑、激惹、瘙痒、疼痛、溃疡、触血。病理组织学特征表现：基底与副基底层显著增生,上皮角下延、吻合,细胞显著异型,核仁明显,核分裂活跃,伴异常角化;中、表层细胞高度分化,细胞间桥显著,伴明显的胞质嗜酸性改变,表层角化过度与角化不全;邻近上皮真皮水肿与胶原化,带状淋巴细胞浸润,表皮增生与角化过度。免疫表型：p53在dVIN中的阳性率为83．3%(5/6),p16不表达(0/6),dVIN基底层和副基底层细胞Ki-67增殖指数>90%。4例随访时间为6~36个月,平均17个月,其中1例术后9个月死亡,1例术后6个月复发,复发和死亡的2例同时或异时伴浸润性鳞状细胞癌,其余2例术后分别随访18个月和36个月,均无复发。结论 dVIN是一种少见的高级别外阴上皮内病变,具有高的、潜在进展危险性,p53、p16及Ki-67联合使用有助于dVIN的诊断。     

侵袭性血管黏液瘤7例临床病理分析

目的探讨侵袭性血管黏液瘤(aggressive anginomyxoma,AAM)的临床病理特征与鉴别诊断。方法收集7例AAM,并与2例血管肌纤维母细胞瘤(AMFb)、1例浅表性血管黏液瘤作对照观察。免疫组织化学(采用SP法)所用抗体为vimentin、desmin、SMA、MSA、CD34、ER/PR、S-100蛋白、CK和CD68。结果7例AAM患者均为女性,23~54岁,中位年龄43·5岁。病变部位位于外阴部3例,累及阴道1例,位于盆腔及髂窝部2例,会阴累及坐骨结节1例。肿瘤直径3·5~17cm,平均7·5cm。位于皮下或较深部,呈浸润性生长,切面均质灰白或灰黄褐色,黏液胶冻样或肉质样。镜下瘤细胞幼稚,呈星形、梭形,弥漫或结节样分布,基质黏液样变性并见胶原纤维及为数众多的大小厚薄不一的血管分布其中,厚壁血管常透明变性,其周围常有增生肌纤维束,切面呈“袖套状”,间质可见肥大细胞和红细胞外渗,1例可见多核巨细胞,肿瘤边缘浸润等特点。组织化学奥辛蓝染色阳性,免疫组化:7例AAM vimentin均阳性,5例SMA和desmin阳性,4例MSA阳性,3例CD34阳性,4例中有3例ER/PR阳性,而S-100蛋白、CK、CD68均阴性,多核巨细胞CD68阳性。5例有随访,术后1~2年有3例复发,2例未见复发和转移,健在。结论侵袭性血管黏液瘤较为少见,好发于成年女性盆腔及会阴的软组织,侵袭性和复发性是其重要的临床特征。病理诊断易误诊或漏诊。免疫组化desmin、SMA、MSA、CD34等联合检测对确定AAM病变有所帮助,但与AMFb、浅表性血管黏液瘤在鉴别诊断上意义不大。     

Small vulvar squamous cell carcinomas and adjacent tissues. A morphologic study

Vulvar squamous cell carcinomas are of different subtypes and degrees of differentiation, and may be associated with adjacent lichen sclerosus and/or varying degrees of dysplasia. The aim of this investigation was to study small carcinomas with a diameter of less than 2 cm in order to find a possible relation between subtypes of carcinomas and adjacent epithelial changes. Fourteen cases of small vulvar squamous cell carcinomas were totally embedded in paraffin. Serial sectioning made a detailed mapping of all different lesions possible, and a two- and three-dimensional imaging was obtained in each case. Seven patients with keratinizing squamous cell carcinomas (median age 65) had adjacent lichen sclerosus. All carcinomas were completely surrounded by areas of VIN1. VIN2 and VIN3 were not found. Seven patients without lichen sclerosus (median age 58) showed squamous cell carcinomas of the keratinizing type (n=2) or the basaloid type (n=5). Five of these cases were incompletely surrounded by varying degrees of dysplasia, mainly VIN2 and VIN3. Two different pathogenetic pathways for the development of vulvar squamous cell carcinoma are likely.     

Aberrant promoter methylation of SH3GL2 gene in vulvar squamous cell carcinoma correlates with clinicopathological characteristics and HPV infection status

Objective: This study attempted to examine the methylation status of SH3GL2 gene in different types of human vulvar lesions and its correlation with clinicopathological parameters. Methods: Immunohistochemical analysis was used to identify the expression status of SH3GL2 in vulvar squamous cell carcinoma (VSCC), vulvar intraepithelial neoplasia (VIN) and benign vulvar squamous epithelium tissues. Bisulfite genomic sequencing method was used to detect methylation status of the SH3GL2 gene. Clinicopathological correlation of the alterations was analysed by the chi-square tests. Results: Immunohistochemical analysis showed expression of SH3GL2 in VSCC was significantly downregulated than that in VIN and normal vulvar tissues. In accordance with higher frequency of methylation status in SH3GL2, statistical analysis showed methylation status of SH3GL2 was closely related to tumor TNM stage (P=0.003), but not related to age, tumor volume, tumor differentiation, lymph node metastasis and VIN grade. High-methylation status of SH3GL2 showed significant association with HPV infection status. Conclusions: Our results indicated that the methylation status of SH3GL2 gene was associated with the TNM staging and HPV infection status of VSCC, suggesting that it might play a synergistic role in the development of VSCC.     

Overexpression of p53 is correlated with stromal invasion in extramammary Paget's disease of the vulva

Molecular alterations that are associated with clinicopathological features of extramammary Paget's disease of the vulva (PDV) are poorly understood. Consequently, we have investigated whether a correlation exists between overexpression of p53 protein and various clinicopathologic features of PDV. Our study group comprises 10 primary noninvasive PDVs, 3 primary PDVs with minimal invasion, and 1 primary PDV with frank invasion. Recurrence in the form of noninvasive PDV was seen in 4 patients with previously noninvasive PDVs and in 1 patient who previously had PDV with minimal invasion. Metastases to the inguinal lymph nodes were associated with the 1 PDV with frank invasion and 1 of the PDVs with minimal invasion. An immunohistochemical study of p53 expression was performed on paraffin-embedded tissue. Negative p53 immunostaining was seen in all of the primary noninvasive PDVs as well as their recurrences. Positive p53 immunostaining was observed in the invasive as well as the intraepidermal components of all of the primary PDVs with invasion, the metastatic tumors in the inguinal lymph nodes, and the recurrent PDV associated with prior invasion, indicating a possible role of p53 in the progression of PDV. To our knowledge, our observation of p53 overexpression in the intraepidermal component of PDVs associated with invasion is the first to be reported in the literature. This observation may prove helpful in identifying stromal invasion in small biopsies. We also report for the first time an association between high nuclear grade in PDV and the propensity for inguinal lymph node metastasis.