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In this section we have spot diagnoses posted on a daily basis since June 2010, now over 1700! You can review the archived cases and read the suggested diagnoses by users and the final comment by Dr Uma Sundram, the Editor-in-Chief and main spot diagnosis host. Case are uploaded each week day by 10 a.m. UK time with the correct diagnosis will generally be posted at 8 p.m. UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

Case Number : Case 2251 - 29 January 2019 Posted By: Uma Sundram

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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70 year old woman with patch on right vulva


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dVIN (Differentiated Vulvar intraepithelial neoplasia).

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Alex-Ventura-Leon

Posted

VIN, differentiated type.

All of these lesion are considered high grade

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Dyskeratosis with satellitosis in stromalepithelial interfacce are more in keeping with autoimmune T-cell mediated reaction, so agree with dermpath1’s question: Why not LP?  

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Alex-Ventura-Leon

Posted

It´s a valid question and probably you are rigth. My first impression was dysplastic changes but now i´m not sure.

Lichen planus seems to be more reasonable.

Waiting for more comments.

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vincenzo

Posted (edited)

My question is: Why not LP?  But I’m not sure about the answer... there are clues to LP, but also to dVIN: sharp margin with adiacent epidermis and some market unicellular eosinophilic appearance up in epithelium and some light atypia in basal layer .Hypergranulosis instead is a clue to LP.  Waiting for other comments too. 

Perhaps it should be convenient a follow up because dVIN is an high grade lesion. 

Edited by vincenzo

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Found this article:https://dx.doi.org/10.1007%2Fs00428-018-2436-8.

Important clues to dVIN could be, according to these authors, MACRONUCLEOLI, ANGULATED NUCLEI, AND COBBLESTONE APPEARANCE IN BOTTOM HALF. I don't see these features, but may be it's a subjective status! What do you guys think about?

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Uma Sundram

Posted

I have an advantage over you guys as I happen to know that this patient had a high grade invasive SCC on the left vulva and this lesion, thought to be dVIN clinically, on the right vulva. Hypertrophic LP and hypertrophic LS are both good thoughts here. What catches my eye, outside of the usual LP features, is the level of extreme hyperkeratosis and the presence of diffuse cytologic atypia extending all the way to the granular layer.  A hyperchromatic basal layer is also a distinctive feature, not usually seen in typical lesions of LP, even hypertrophic ones. There is low power basaloid nuclear hyperchromasia, disorganization of the epithelial layers, and skipping of adnexal structures. These latter features, coupled with the clinical impression, favors dVIN over hypertrophic LP. If unsure, one can ask for the clinical picture, an outside expert opinion, or err on the side of atypicality with greater follow up and lower threshold for re biopsy. A lesion like this may eventually lead to anastomosing of rete pegs, which would be unusual in any LP lesion but can be seen with some frequency in dVIN.This is an extremely difficult case which is why I posted it.  I have not found stains to be particularly helpful, but GATA 3 appears to show some promise (Goyal A et al., Mod Pathol. 2018 Jul;31(7):1131-1140)

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Alex-Ventura-Leon

Posted

Excellent case and discussion Dr. Uma. Very difficult indeed.

I´ve learned a lot form all your comments. Thank you.

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