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    Vulva

    Background

    Vulval biopsies, excisions and vulvectomies are most commonly used in the investigation and treatment of infections, lichen sclerosis and squamous cell carcinoma. Paget’s disease, adenocarcinoma, basal cell carcinoma, Bartholin gland carcinoma and malignant melanoma are also found. Vulval cancer is rare; most commonly occurring as squamous cell carcinoma associated with human papillomavirus (HPV) in pre-menopausal women.1-4


    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.
    • Not performed
    • Performed, describe
      • Sentinel node biopsy
      • Frozen section
      • Imprints
      • Other, describe

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    All specimens must be pinned out, placed in fixative (10% buffered formalin) and fully fixed before dissection. See general information for more detail on fixation procedures.

    Orientate and identify anatomical features of the specimen; urethral and vaginal orifices, clitoris (located superiorly in midline of specimen) and lateral labia majora.

    Record additional orientation or designation provided by operating clinician.

    Identifying sutures or clips for orientation may be present particularly in partial vulvectomies and should be noted in the description.

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Feature denoted

    Describe the following features of the specimen:

    Procedure

    Describe as stated by the clinician.

    • Local excision
    • Partial vulvectomy, radically resected
    • Simple vulvectomy
    • Total radical vulvectomy
    • Anterior/total pelvic exenteration
    • Other, describe

    Anatomical components included (more than one may apply) and specimen dimensions (mm)

    Describe and measure the anatomical components present.2

    • Vulva, in three dimensions; right-left x anterior-posterior x thickness
      • Right
      • Left
      • Anterior
      • Posterior
    • Clitoris
    • Vaginal orifice
    • Labial folds
    • Other, describe

    Labial folds may not be evident in pinned out specimens from post-menopausal women.2

    Surface

    Describe the surface of the specimen.

    • Hair-bearing skin
    • Hairless skin/squamous mucosa
    • Both hair-bearing skin and hairless skin/squamous mucosa
    • Undetermined

    Specimen integrity

    • Intact and complete
    • Other, describe deficiencies

    Tumour

    • Absent; if there is no tumour, record whether a scar is present.
    • Present
      • Number; if more than one tumour, designate and describe each tumour separately2
      • Record the distance between tumours (mm)

    Multiple macroscopic tumours occur in 5% of vulva cancers.2

    Tumour size (mm)

    • In three dimensions; length x width x thickness2

    Tumours (<20mm) with a depth of invasion (<1mm) have minimal risk of metastases. 2

    Tumour site (more than one may apply)

    • Laterality
      • Right
      • Left
    • Labia minora
    • Labia majora
    • Clitoris
    • Other, specify

    Tumour growth type

    • Fungating
    • Ulcerative
    • Other, describe

    Tumour appearance

    • Colour
    • Shape
    • Contour
      • Raised
      • Flat
    • Demarcation/borders

    Margins

    • Not assessable
    • Involved, site 2
    • Clear

    Distance to margins (mm)

    • Distance of tumour to closest peripheral margin(s), specify2

    Note that where invasion occurs medially into underlying stroma, tumour may not be distinguishable from stroma and depth of invasion may not be assessable.2

    Risk of metastatic spread to the groin lymph nodes is increased where the depth of invasion/tumour thickness >1mm.2

    Adjacent skin abnormalities present (more than one may apply)

    • No
    • Yes, describe
      • White
      • Pigmented
      • Red
      • Skin-coloured
      • Thickened
      • Elevated
      • Other, describe

    The skin adjacent to SCC commonly contains VIN that is apparent as elevated white, pigmented, red or skin-coloured plaque in a clearly demarcated area.2

    Photograph the intact specimen (or other permanent record such as a drawing) to locate the tumour within the specimen and its relationship to margins.2


    Dissection

    After initial inspection and description, the specimen should be pinned out and allowed to fully fix in larger quantity of formalin before dissection.

    Paint the entire peripheral margin and deep surface of the specimen with two different coloured inks.2,3

    Serially section the specimen horizontally at 2-3mm intervals making sure the centre of the tumour is sliced. (Thin slices are particularly useful for VIN and extramammary Paget’s disease specimens; invasive tumour specimens may be sectioned at wider intervals). Section from the anterior (12 o’clock) to posterior (6 o’clock) ends ensuring that the mid-point (deepest point) of the tumour is demonstrated as indicated in the diagrams provided.2,3

    The first and last slices should be wider for ease of further dissection perpendicularly. (Radially dissect the 12 o’clock and 6 o’clock margins).2

    An annotated photograph or diagram of the dissected specimen is a useful block allocation key.2,3


    Internal Inspection

    Describe the cut surface appearance including the following items:2

    Macroscopic depth of invasion (mm) if assessable

    • Record the depth of invasion or tumour thickness into the subcutaneous fat.2
    • Not assessable

    Distance to margins (mm)

    • Distance of tumour to closest deep margin2

    If inguinal fat is attached, locate all lymph nodes.

    Retrieved from resection specimen

    • Describe site(s)
    • Number retrieved

    Separately submitted

    • For each container, record specimen number and designation
    • Collective size of tissue in three dimensions (mm)
    • Number of lymph nodes submitted
    • Maximum diameter of each (mm)

    Lymph node resection is only undertaken where tumours are large due to likely morbidity of lower limb lymphoedema. Sentinel lymph node excision has been introduced in some centres.2

    Note any photographs taken, diagrams recorded and markings used for identification.


    Processing

    • Submit all sections of tumour demonstrating relationship with adjacent skin.

    Submit representative sections of:2

    • 12 o’clock and 6 o’clock margins, perpendicular sections.2 If circumferential sections are preferred, ensure that the surface demonstrating the outer limit is embedded downwards in a cassette (i.e. visible in first paraffin section).3
    • Entire cross section demonstrating deepest point of tumour invasion, using composite blocks if required.
    • Sections demonstrating relationship of tumour with closest margin
    • Sections demonstrating interface of tumour with adjacent skin
    • Sections demonstrating areas of tumour with different appearance (raised, ulcerated etc.)
    • Submit all sections from area from previous excision or biopsy (identified by suture or scar). Long scars, however, may be sampled rather than all submitted.2
    • Submit all tissue if possible
    • If not possible, submit representative sections particularly the most raised areas

    Sentinel lymph nodes:

    • Bisect transversely across the long axis. Submit all sections.

    Small, macroscopically uninvolved lymph nodes:

    • Bisect transversely across the long axis. Submit all sections.

    Large, macroscopically uninvolved lymph nodes:

    • Section transversely at 3mm intervals across the long axis. Submit all sections.

    Macroscopically involved lymph nodes:

    • Section transversely at 3mm intervals across the long axis. Submit sections demonstrating relationship with the capsule to allow microscopic evaluation of any possible extracapsular invasion.

    Remaining tissue should be stored with orientation maintained in case further sections are required (e.g. rolled up annotated paper or fabric corresponding to diagrammatic or photographic record).2

    Record details of each cassette.

    An illustrated block key similar to the one provided may be useful.

    Block allocation key

    Cassette id
    Site
    No. of pieces
    A
    12 o’clock margins, perpendicular sections
     
    B
    6 o’clock margins, perpendicular sections
     
    C
    Tumour, deepest point of invasion
     
    D
    Tumour and closest margin
     
    F
    Tumour and adjacent skin
     
    G-H
    Tumour, raised/ulcerated areas
     
    I+
    Lymph nodes
     
    Cassette id
    Site
    No. of pieces
    A-C
    Sections from area of previous biopsy/suture/scar
     
    Cassette id
    Site
    No. of pieces
    A-E
    All tissue or representative sections as applicable.
     
     

    Acknowledgement

    Assoc Prof James Scurry for his contribution in reviewing and editing this protocol and Dr Ken Jaaback for his contribution in reviewing and editing these diagrams.


    References

    1. Brown L and McCluggage WG. Datasets for the histopathological reporting of vulval neoplasms, The Royal College of Pathologists, London, 2010.
    2. Scurry J, Grant P, Hacker N and Stewart C. Vulva cancer structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2013.
    3. Brown L, Andrew A, Hirschowitz L and Millan D. Tissue pathways for gynaecological pathology, The Royal College of Pathologists, London, 2008.
    4. Heatley MK . Dissection and reporting of the organs of the female genital tract. J Clin Pathol 2008;61(3):241-257.

    Jump To

      Vulva 1

      Vulva anatomy

      Vulva 2

      Vulva with tumours, indicating vulvectomy sites

      Vulva 3

      Anterior vulvectomy, no macroscopic tumour identified

      Vulva 4

      Anterior vulvectomy, pins removed and margins inked

      Vulva 5

      Anterior vulvectomy, serially sectioned in the horizontal plane

      Vulva 6

      Anterior vulvectomy, all sections submitted for processing

      Vulva 7

      Wide local excision of vulval tumour

      Vulva 8

      Wide local excision of vulval tumour, indicating inked margins and dissection lines

      Vulva 9

      Vulva 9

      Vulva 10

      Wide local excision of vulval tumour, demonstrating deepest point of invasion

      Vulva 11

      Wide local excision of vulval tumour, sections for processing

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      Copyright © 2019 RCPA. All rights reserved.

      26-Mar-2019
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