Idiopathic Lichenoid and Granulomatous Vulvitis: A Distinct Clinicopathological Entity.

ABSTRACT: The combination of lichenoid and granulomatous inflammation is uncommon in vulval biopsies. We present a series of 5 patients with lichenoid and granulomatous vulvitis, presenting with clinical changes resembling lichen sclerosus. Despite detailed clinicopathological investigation and follow-up, there was no apparent association with an underlying recognized cause. All 5 cases occurred in postmenopausal women and displayed a distinctive histological pattern of superficial band-like inflammation with granulomas "anchored" to the dermoepidermal junction. There was no evidence of deeper granulomatous inflammation. Despite repeated biopsies over 2 years in 2 patients, neither developed typical histological features of lichen sclerosus. We postulate that idiopathic lichenoid and granulomatous vulvitis may represent a distinct clinicopathologically defined vulvar dermatosis.

Foamy gland changes in gastric-type endocervical neoplasia.

Foamy gland (FG) change is a distinctive morphological alteration most widely recognised in adenocarcinomas of the prostate and pancreas, and characterised by cells showing prominent cytoplasmic microvacuolation often with deceptively bland nuclear appearances. To our knowledge, FG alteration has not been described in endocervical neoplasia. We report four patients with gastric-type endocervical neoplasms (3 invasive and 1 in situ) in which FG change was present in 30-80% of the tumour cells. The mean age was 56.5 years (range 45-66 years) and three patients, one of whom also had post-coital bleeding, had atypical glandular cells detected on cervical cytology. Three cases showed a pure gastric phenotype and benign gastric-type changes including pyloric metaplasia, tunnel clusters and/or lobular endocervical glandular hyperplasia were also present. These cases were MUC6 positive and p16 negative on immunohistochemistry while HPV was not detected. One adenocarcinoma showed a mixed histological pattern including usual-type endocervical carcinoma and gastric-type adenocarcinoma: only the latter component expressed MUC6 and this case was p16 and HPV18 positive. This report expands the morphological spectrum exhibited by gastric-type endocervical lesions and the range of anatomical sites in which neoplasms with FG features may be encountered.

Endometrial Synovial-like Metaplasia Associated With Levonorgestrel-releasing Intrauterine System.

The levonorgestrel-releasing intrauterine system (L-IUS) is widely used in contraception and in the treatment of menorrhagia, dysmenorrhea, adenomyosis, and endometriosis. L-IUS is also increasingly considered in the management of endometrial neoplasia and its precursors. Histologic changes in the endometrium can be due to the effects of high-dose progestogen or may be caused by the local irritant or mechanical effects of an intrauterine foreign body. In the present study, we describe a novel endometrial alteration associated with L-IUS that most closely resembles synovial metaplasia reported at other extra-articular anatomic sites. Eleven cases were identified with a mean age of 49.6 yr. In most patients L-IUS was used for management of menorrhagia or endometrial hyperplasia. Endometrial synovial-like metaplasia was always a focal finding and was associated with areas of surface epithelial erosion. The synovial-like cells showed a distinctive palisaded arrangement with orientation perpendicular to the endometrial surface. Multinucleate cells were present in 2 cases, but granulomas were not identified. The synovial-like cells were vimentin immunoreactive and a variable proportion of cells expressed CD68. Only focal CD10 staining was seen and there was no expression of estrogen receptor, progesterone receptor, or cytokeratin. In summary, L-IUS may be associated with a distinctive synovial-like metaplastic alteration which most likely represents a stromal reaction to an intrauterine foreign body following endometrial surface erosion. The synovial-like cells appear to comprise histiocytes and modified fibroblasts or stromal cells similar to this process in other sites.

Asynchronous glands in secretory pattern endometrium: clinical associations and immunohistological changes.

AIMS: The significance and pathogenesis of irregular or asynchronous maturation within endometrial glands remains uncertain. The aim of this study was to investigate differences in epithelial hormone receptor immunoreactivity and stromal cell calretinin, CD34 and p16 expression in morphologically normal secretory endometrium and in asynchronous (non-secretory) endometrial glands (AEGs). METHODS AND RESULTS: Nineteen consecutive endometrial specimens showing AEGs were examined. The mean age of the patients was 42.8 years, and the most common presenting symptom was menorrhagia. Immunohistological expression of oestrogen receptor (ER) α, of ERß and of progesterone receptor (PR) were compared in normal secretory glands and in AEGs. Stromal cell expression of calretinin, CD34 and p16 was also investigated. In contrast to normal secretory glands, the epithelial cells lining AEGs were usually ERα/PR-positive and showed significantly increased ERß expression. Altered calretinin and CD34 expression within functional layer stromal cells was seen in five and two cases, respectively, but there were no differences in stromal cell immunoreactivity around AEGs. CONCLUSIONS: The most common clinical symptom associated with AEGs in this study was menorrhagia. Aberrant hormone receptor expression in AEGs suggests a localized, possibly clonal, defect in epithelial maturation. There were no immunophenotypic changes to suggest that AEGs are related to a primary endometrial stromal deficiency.

Is the detection of endometrial nerve fibers useful in the diagnosis of endometriosis?

Laparoscopy is currently considered to be the gold standard investigation in patients suspected to have endometriosis, but this is an invasive and relatively costly procedure and there may be significant delays in diagnosis. As the eutopic endometrium is recognized to be abnormal in patients with endometriosis, it has been suggested that endometrial sampling could provide an indirect diagnostic approach. In particular, recent reports have suggested that the presence of nerve fibers within the endometrial functional layer could represent a specific and sensitive marker of concurrent peritoneal endometriosis. However, such studies have been performed in select patient groups and using novel sampling and analytic techniques that are not used routinely in clinical pathology laboratories. The present study was performed upon conventional endometrial biopsies from 68 patients who underwent laparoscopy for suspected endometriosis. The biopsies were stained immunohistochemically for the neural marker PGP 9.5 and examined in a blinded manner. Endometrial functional layer nerve fibers were identified in 15 (22%) biopsies overall including 9/47 (19%) cases with histologically confirmed peritoneal endometriosis and 6/21 (29% cases) without endometriosis. There was no correlation between the presence of functional layer nerve fibers and the presenting symptoms, endometrial histology, or current hormonal therapy. In our experience, endometrial functional layer nerve fibers assessment performed using standard immunohistochemical techniques on routine biopsy specimens proved neither sensitive nor specific for the diagnosis of endometriosis. Pathologists and gynecologists considering this diagnostic approach should carefully consider the methodological factors that may influence its reliability.

Prostatic-type tissue in the lower female genital tract: a morphologic spectrum, including vaginal tubulosquamous polyp, adenomyomatous hyperplasia of paraurethral Skene glands (female prostate), and ectopic lesion in the vulva.

The investigators report a series of prostatic-type lesions occurring in the lower female genital tract. The cases included a 4.5-cm mass representing hyperplasia of the glandular and stromal tissue of paraurethral Skene gland, a small ectopic prostatic lesion in the vulva, and 4 tubulosquamous vaginal polyps. All lesions were immunopositive for prostate-specific antigen and/or prostatic acid phosphatase. A brief discussion of the earlier published material is included.