Definition/General
Clinical Features
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Gross Description
Microscopic Description
Immunohistochemistry
Molecular/Genetic
Differential Diagnosis
Sample Pathology Report
Template Format
Sample Pathology Report
Complete Report: This is an example of how the final pathology report should be structured for this condition.
Specimen Information
Vulvar excision from [site], measuring [size] cm in greatest dimension
Diagnosis
Vulvar intraepithelial neoplasia ([LSIL/HSIL])
Classification
Classification: [HSIL/LSIL], type: [usual/differentiated]
Histological Features
Shows [degree of atypia] with [architectural changes] and [keratinization pattern]
Extent of Involvement
VIN involves [thickness of epithelium] with [multifocal/unifocal] distribution
Margins
Margins: [clear/involved], closest margin [X] mm from VIN
Associated Lesions
Associated lesions: [lichen sclerosus/condyloma/none identified]
HPV Status
HPV association: [suggested by morphology and p16 staining/not determined]
Special Studies
IHC: p16: [diffuse positive/negative/patchy], p53: [wild-type/mutant pattern]
HPV ISH: [positive/negative/not performed]
[other study]: [result]
Prognostic Factors
Risk factors: VIN type, margin status, multifocality, patient age
Final Diagnosis
Vulvar intraepithelial neoplasia, [grade], [type], margins [status]