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ATLAS OF TUMOR PATHOLOGY

Third Series
Fascicle 4

TUMORS OF THE
CERVIX, VAGINA, AND VULVA

by

ROBERT J. KURMAN, M.D.
Departments of Pathology
and Gynecology and Obstetrics
Johns Hopkins Hospital
Baltimore, Maryland 21287

HENRY J. NORRIS, M.D.
Department of Gynecologic and Breast Pathology
Armed Forces Institute of Pathology
Washington, D.C. 20306

and

EDWARD J. WILKINSON, M.D.
Department of Pathology
University of Florida College of Medicine
Gainesville, Florida 32610

Published by the
ARMED FORCES INSTITUTE OF PATHOLOGY
Washington, D.C.

Under the Auspices of
UNIVERSITIES ASSOCIATED
FOR RESEARCH AND EDUCATION
IN PATHOLOGY, INC.
Bethesda, Maryland
1992

Accepted for Publication
1990

Available from the American Registry of Pathology
Armed Forces Institute of Pathology
Washington, D.C. 20306-6000
ISSN 0160-6344
ISBN 11-881041-02-6

ATLAS OF TUMOR PATHOLOGY

EDITOR
JUAN ROSAI, M.D.
Department of Pathology
Memorial Sloan-Kettering Cancer Center
New York, New York 10021-6007

ASSOCIATE EDITOR
LESLIE H. SOBIN, M.D.
Armed Forces Institute of Pathology
Washington, D.C. 20306-6000


EDITORIAL ADVISORY BOARD

Jeffrey Cossman, M.D.
Georgetown University School of Medicine
Washington, D.C. 20007

Ronald A. DeLellis, M.D.
Tufts University School of Medicine
Boston, Massachusetts 02111

Glauco Frizzera, M.D.
Armed Forces Institute of Pathology
Washington, D.C. 20306-6000

Leonard B. Kahn, M.D.
Long Island Jewish Hospital
New Hyde Park, New York 11042

Richard L. Kempson, M.D.
Stanford University Medical School
Stanford, California 94305

Paul Peter Rosen, M.D.
Memorial Sloan-Kettering Cancer Center
New York, New York 10021

Robert E. Scully, M.D.
Harvard Medical School and
Massachusetts General Hospital
Boston, Massachusetts 02114

Steven G. Silverberg, M.D.
The George Washington University
School of Medicine
Washington, D.C. 20037

Sharon Weiss, M.D.
University of Michigan School of Medicine
Ann Arbor, Michigan 48109-0602


EDITORS' NOTE

The Atlas of Tumor Pathology has a long and distinguished history. It was
first conceived at a Cancer Research Meeting held in St. Louis in September
1947 as an attempt to standardize the nomenclature of neoplastic diseases.
The first series was sponsored by the National Academy of Sciences-National
Research Council. The organization of this Sisyphean effort was entrusted to
the Subcommittee on Oncology of the Committee on Pathology, and Dr. Arthur
Purdy Stout was the first editor-in-chief. Many of the illustrations were
provided by the Medical Illustration Service of the Armed Forces Institute of
Pathology, the type was set by the Government Printing Office, and the final
printing was done at the Armed Forces Institute of Pathology (hence the
colloquial appellation "AFIP Fascicles"). The American Registry of Pathology
purchased the Fascicles from the Government Printing Office and sold them
virtually at cost. Over a period of 20 years, approximately 15,000 copies
each of nearly 40 Fascicles were produced. The worldwide impact that these
publications have had over the years has largely surpassed the original goal.
They quickly became among the most influential publications on tumor
pathology ever written, primarily because of their overall high quality but
also because their low cost made them easily accessible to pathologists and
other students of oncology the world over.

Upon completion of the first series, the National Academy of Sciences-National
Research Council handed further pursuit of the project over to the
newly created Universities Associated for Research and Education in Pathology
(UAREP). A second series was started, generously supported by grants from the
AFIP, the National Cancer Institute, and the American Cancer Society. Dr.
Harlan I. Firminger became the editor-in-chief and was succeeded by Dr.
William H. Hartmann. The second series Fascicles were produced as bound
volumes instead of loose leaflets. They featured a more comprehensive
coverage of the subjects, to the extent that the Fascicles could no longer be
regarded as "atlases" but rather as monographs describing and illustrating in
detail the tumors and tumor-like conditions of the various organs and
systems.

Once the second series was completed, with a success that matched that of the
first, UAREP and AFIP decided to embark on a third series. A new editor-in-chief
and an associate editor were selected, and a distinguished editorial
board was appointed. The mandate for the third series remains the same as for
the previous ones, i.e., to oversee the production of an eminently practical
publication with surgical pathologists as its primary audience, but also
aimed at other workers in oncology. The main purposes of this series are to
promote a consistent, unified, and biologically sound nomenclature; to guide
the surgical pathologist in the diagnosis of the various tumors and tumor-like
lesions; and to provide relevant histogenetic, pathogenetic, and
clinicopathologic information on these entities. Just as the second series
included data obtained from ultrastructural (and, in the more recent
Fascicles, immunohistochemical) examination, the third series will, in
addition, incorporate pertinent information obtained with the newer molecular
biology techniques. As in the past, a continuous attempt will be made to
correlate, whenever possible, the nomenclature used in the Fascicles with
that proposed by the World Health Organization's International Histological
Classification of Tumors. The format of the third series has been changed in
order to incorporate additional items and to ensure a consistency of style
throughout. This includes the dropping of the 's possessive in eponymic
terms, in accordance with the WHO and the International Nomenclature of
Diseases. Close cooperation between the various authors and their respective
liaisons from the editorial board will be emphasized to minimize unnecessary
repetition and discrepancies in the text and illustrations.

To its everlasting credit, the participation and commitment of the AFIP to
this venture is even more substantial and encompassing than in previous
series. It now extends to virtually all scientific, technical, and financial
aspects of the production.

The task confronting the organizations and individuals involved in the third
series is even more daunting than in the preceding efforts because of the
ever-increasing complexity of the matter at hand. It is hoped that this
combined effort — of which, needless to say, that represented by the authors
is first and foremost — will result in a series worthy of its two illustrious
predecessors and will be a suitable introduction to the tumor pathology of
the twenty-first century.

Juan Rosai, M.D.
Leslie H. Sobin, M.D.


ACKNOWLEDGMENTS

The publication of this Fascicle has depended on the assistance of many
individuals to whom the authors are greatly indebted. We are especially
grateful to Dr. Robert E. Scully and Dr. Richard L. Kempson for their
thoughtful review and comments on the entire text. In addition, we wish to
thank Dr. Stanley J. Robboy for his critical review of the chapter on
embryology, Dr. Peter M. Howley and Dr. Keerti V. Shah for their critique of
the chapter on human papillomaviruses, and Dr. K. Kendall Pierson and Dr. F.
Mack Sexton for their review of the chapter on vulvar tumors. Drs. I. Keith
Stone, Nancy Sexton Hardt and David L. Dolson provided clinical support for
the preparation of the vulvar chapter. We also wish to thank Mr. Raymond Lund
at the Johns Hopkins Hospital and Mr. Jeffrey Knee at the University of
Florida for their supervision of the photomicrography. Mrs. Sue Skierkowski,
Mrs. Sandra Fortier, and Ms. Trina King typed the manuscript, and to them we
are most grateful. The classification of tumors of the uterine cervix,
vagina, and vulva used in this Fascicle is based on the classification
proposed by the International Society of Gynecological Pathologists under the
auspices of the World Health Organization. The classification of vulvar
neoplasms was developed in conjunction with the International Society for the
Study of Vulvar Disease. Finally, there are many other individuals who played
an important role in the publication of this Fascicle who we have not
specifically mentioned. To all of these people we wish to express our thanks.

Robert J. Kurman, M.D.
Henry J. Norris, M.D.
Edward J. Wilkinson, M.D.


Permission to use copyrighted illustrations has been granted by:

American College of Obstetricians and
Gynecologists:
Obstet Gynecol 44:735-48, 1974. For figures 155
and 156.
Obstet Gynecol 45:638-46, 1975. For figure 326.
Obstet Gynecol 48:571-8, 1976. For figure 61.
Obstet Gynecol 62:720-7, 1983. For figure 114.

American Medical Association:
Arch Pathol 90:473-9, 1970. For figure 236.
Arch Pathol Lab Med 106:250-4, 1982. For figure
136.
JAMA 202:637-9, 1967. For figure 161.

American Society for Microbiology:
J Virol 58:225-9, 1986. For figure 27.

Blackwell Scientific Publications Ltd:
Histopathol 12:167-76, 1988. For figures 206 and
207.

Butterworth Publishing Company:
Principles and Techniques of Surgical Pathology,
1983. For figures 7 and 22.

Cahners Publishing Company:
Am J Med 85(Suppl 2A):155-8, 1988. For figure 23.

CV Mosby Company:
Am J Obstet Gynecol 58:924-42, 1949. For figures
82 and 83.
Clinical Gynecologic Oncology, 3rd. ed., 1989. For
figure 6.

Institute for Clinical Science:
Ann Clin Lab Sci 4:222-53, 1974. For figure 211.

JB Lippincott Company:
Am J Clin Pathol 46:420-6, 1966. For figure 230.
Cancer 54:869-75, 1984. For figures 203 and 204.
Cancer 67:1599-1607, 1991. For figure 30.
Clin Obstet Gynecol 34:651-61, 1991. For figure 264.

McGraw-Hill, Inc.:
Human Embrology, 1946. For figure 1.

Raven Press Ltd. New York:
Am J Surg Pathol 7:39-52, 1983. For figure 25.
Histology for Pathologists, 1992. For figures 18
and 19.
Int J Gynecol Pathol 10:107-25. For figures 261
and 276.

Royal College of Surgeons of England:
Ann R Coll Surg Engl 3:189-209, 1948. For figures
20 and 21.

Springer-Verlag New York, Inc.:
Blaustein's Pathology of the Female Genital Tract,
3rd ed. For figures 14, 32, 44, 45, 46, 71, 195,
227, 246.

W.B. Saunders Company:
Human Pathol 14:831-3, 1983. For figure 4.
Human Pathol 17:488-92, 1986. For figure 196.
Obstet Gynecol Clin North Am 14:451-69, 1987.
For figure 26.
Semin Diagn Pathol 7:158-72, 1990. For figure 29.
The Pathology of Incipient Neoplasia, 1986. For
figure 54.

Williams and Wilkins Company:
Langman's Medical Embryology, 5th ed., 1985.
For figures 2 and 5.

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