Resection Specimens

Wide local excisions

• these are treated like a skin ellipse. The deep and lateral margins are inked and representative blocks taken to show the lesion in relation to them. Especially with VIN, it may be difficult to assess the presence of a lesion grossly as this can be very subtle. The presence of a previous biopsy site may assist in this regard.

Hemivulvectomies and radical vulvectomies - procedure and description

• hemivulvectomies (or partial vulvectomies) require orientation by the surgeon. If this is not done it may be necessary to contact the surgeon before sectioning is performed.

• a total vulvectomy looks like an ellipse of skin with a central defect corresponding to the vaginal vault. The specimen is orientated. The clitoris is present superiorly and in the midline. The hair-bearing labia majora are present laterally. Inguinal fat, when present, is on the superior aspect of the specimen and to both sides (Figure 26.2).

• if a gross lesion is seen this may be photographed.

• the specimen is inked including the free lateral and deep margins.

• the length, width and depth of the specimen are measured (cm). Diagrams may be necessary and help in reporting.

• if inguinal fat is present on one or both sides this is carefully sectioned, looking for lymph nodes. These are separated and labelled as from the right or left side.

• the presence of any gross lesion is noted and measured in three dimensions (cm). The distances to the nearest resection margins are measured and detailed.

• the presence of any other smaller lesions is documented similar to the main lesion.

Blocks for histology (Figure 26.2)

• multiple blocks are taken of all lesions seen grossly.

• transverse blocks are taken to show the relationship of the lesion to the nearest margins including the lateral, deep and vaginal margins. The margins are labelled on the slide.

• also submit representative blocks of grossly normal skin.

• longitudinal sections of clitoris and any relevant lesion are taken.

• all lymph nodes are serially sectioned and completely submitted. The right and left sided lymph nodes are separated.

Histopathology report

• the site (right, left, labia majora/minora, clitoris) and gross characteristics of the tumour are stated, e.g., polypoid, ulcerated.

Right inguinal Mons pubis soft tissue

Posterior fourchette

Perineum

Posterior fourchette

Perineum

Left inguinal soft tissue

Labia majora

Urethral meatus

Labia minora

Vaginal opening and margin

1. Orientate

2. Paint the lateral and deep external margins

3. Serially slice the inguinal fat

4. Transverse slice the tumour in relation to vulvovaginal limits

Longitudinal section of tumour, clitoris and urethral meatus

Serially section the inguinal fat to look for nodes and tumour deposits

Transverse sections of tumour in relation to vulvovaginal limits (lateral and deep)

Longitudinal section of tumour, clitoris and urethral meatus

Serially section the inguinal fat to look for nodes and tumour deposits

Transverse sections of tumour in relation to vulvovaginal limits (lateral and deep)

Figure 26.2. Orientation and blocking of a radical vulvectomy specimen.

Transverse sections of normal looking contralateral vulva

Figure 26.2. Orientation and blocking of a radical vulvectomy specimen.

• tumour measurements - the width of tumour in two dimensions (cm) is given.

• tumour type - the vast majority of malignant tumours are squamous carcinomas although rarer morphological subtypes may occur.

• tumour differentiation - squamous carcinomas are classified as well, moderately or poorly differentiated.

• depth of invasion - the depth of invasion is measured from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest aspect of the tumour.

• the nature of the invasive component - whether the invasive squamous carcinoma is confluent or exhibits a "finger-like" growth pattern may be of prognostic importance.

• the presence or absence of the following are noted:

- adjacent VIN (and its grade), signs of HPV infection or associated vulval dystrophy.

- lymphovascular permeation.

- lymph node involvement (site, number involved, intraparenchymal or extracapsular extension).

- VIN or tumour at the skin or vaginal margins, or, if clear, the minimum distance (mm) from them.

- tumour at the deep margin, or, if clear, the minimum distance (mm) from it.

- involvement of other structures such as the vagina or anus.

FIGO/TNM Staging pTis carcinoma in situ.

pT1 tumour confined to vulva/perineum < 2 cm in greatest dimension.

a. stromal invasion < 1 mm.

b. stromal invasion > 1 mm.

pT2 tumour confined to vulva/perineum > 2 cm in greatest dimension. pT3 tumour invades lower urethra/vagina/anus.

pT4 tumour invades any of: bladder mucosa/rectal mucosa/upper urethral mucosa/pubic bone.

Regional nodes: femoral and inguinal.

pN0 no regional lymph node metastasis. pN1 unilateral regional lymph node metastasis. pN2 bilateral regional lymph node metastasis.

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