{"id":47624,"date":"2026-08-28T21:53:57","date_gmt":"2026-08-28T13:53:57","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/pathweb\/?page_id=47624"},"modified":"2026-08-28T22:02:16","modified_gmt":"2026-08-28T14:02:16","slug":"fgtvc-2","status":"publish","type":"page","link":"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/fgtvc-2\/","title":{"rendered":"Short cases &#8211; FGT case 2 (Vulva)"},"content":{"rendered":"\n<h2>\n\t\t\tFGT Case 2 (Vulva) \t<\/h2>\n\t<p><em>Case writer: Dr Gideon Tan<\/em><\/p>\n\t<p><strong>Clinical history:<\/strong><\/p>\n<ul>\n<li>60F, with no significant past medical history, presents with a worsening, itchy skin rash in the vulvar region.<br \/>\nOn examination, there is an erythematous plaque-like rash, which is sharply demarcated from the surrounding skin.<br \/>\nA biopsy of the rash, and a subsequent excision, was performed.<br \/>\nShown here are the images from the excision specimen<\/li>\n<li>What are the histologic findings?<\/li>\n<li>What are your differential diagnoses?<\/li>\n<li>What ancillary tests would you do?<\/li>\n<li>What clinical information would be helpful in your diagnostic workup?<br \/>\n<\/li>\n<li>What single important feature would dramatically change the prognosis of this condition?<br \/>\n<\/li>\n<\/ul>\n\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/fgtv.1-1024x688.png\" alt=\"fgtv.1\" height=\"430\" width=\"640\" title=\"fgtv.1\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t\t\t\t\t\t\t<\/a>\n\t<\/figure>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/fgtv.2-1024x690.png\" alt=\"fgtv.2\" height=\"431\" width=\"640\" title=\"fgtv.2\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t\t\t\t\t\t\t<\/a>\n\t<\/figure>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/fgtv.3-1024x690.png\" alt=\"fgtv.3\" height=\"431\" width=\"640\" title=\"fgtv.3\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t\t\t\t\t\t\t<\/a>\n\t<\/figure>\n\t<p>Click picture to enlarge<\/p>\n\t<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-0\" aria-controls=\"fl-accordion--content-0\" aria-expanded=\"true\" type=\"button\">Histologic Findings <i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Collapse<\/i><\/button><\/a><p>&nbsp;<\/p>\n<table>\n<tbody>\n<tr>\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/fgtv.4-scaled.png\" target=\"_blank\" rel=\"noopener\">(opens in new tab)<\/a><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/fgtv.4-scaled.png\" rel=\"noopener\" target=\"_blank\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/fgtv.4-scaled.png\" alt=\"\" width=\"2560\" height=\"1489\" \/>(opens in new tab)<\/a><\/td>\n<\/tr>\n<tr>\n<td>&nbsp;\n<ul>\n<li>Within the epidermis, there are nests of atypical cells with abundant pale to eosinophilic cytoplasm, with enlarged pleomorphic nuclei and prominent nucleoli.<\/li>\n<li>These atypical cells are confined to the epidermis.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-1\" aria-controls=\"fl-accordion--content-1\" aria-expanded=\"false\" type=\"button\">Differential Diagnoses<i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\n\n<p>The differential diagnoses when a distinct population of atypical cells is seen within the epidermis are:<\/p>\n<ul>\n<li>Extramammary Paget disease<\/li>\n<li>Melanoma in-situ<\/li>\n<li>Squamous cell carcinoma in-situ (with a pagetoid pattern)<\/li>\n<li>Benign Toker cells<\/li>\n<\/ul>\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-2\" aria-controls=\"fl-accordion--content-2\" aria-expanded=\"false\" type=\"button\">Ancillary Tests <i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\n\n<table>\n<tbody>\n<tr>\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/fgtv.5.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/fgtv.5.png\" alt=\"\" width=\"1216\" height=\"553\" \/>(opens in new tab)<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<ul>\n<li>The tumour cells are positive for CK7.<\/li>\n<li>The tumour cells show intra-cytoplasmic mucin, highlighted by mucicarmine stain.<\/li>\n<\/ul>\n<p><em>The positivity for CK7 and mucin stains support Paget disease, and help to exclude a melanoma in-situ and squamous cell carcinoma in-situ. While Toker cells are positive for CK7, they do not show cytological atypia and do not contain intra-cytoplasmic mucin.<\/em><\/p>\n<p>Other ancillary tests performed which were negative:<\/p>\n<ul>\n<li>S100, SOX10, Melan A (positive in melanoma in-situ)<\/li>\n<li>p63, p40 (positive in squamous cell carcinoma in-situ)<\/li>\n<\/ul>\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-3\" aria-controls=\"fl-accordion--content-3\" aria-expanded=\"false\" type=\"button\">Important Clinical Points<i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\n<p>What clinical information would be helpful in your diagnostic workup?<\/p>\n<ul>\n<li>History of urothelial or anorectal malignancies, to exclude secondary Paget disease<\/li>\n<\/ul>\n<p>What single important feature would dramatically change the prognosis of this condition?<\/p>\n<ul>\n<li>Presence of invasion (invasive extramammary Paget disease, which is an adenocarcinoma)<\/li>\n<li>The presence of dermal invasion converts an otherwise indolent, chronic intra-epithelial disease into an adenocarcinoma with higher risk of disease metastasis. The prognosis also depends on several parameters, such as the depth of invasion.<\/li>\n<\/ul>\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-4\" aria-controls=\"fl-accordion--content-4\" aria-expanded=\"false\" type=\"button\">Diagnosis and Learning Points <i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\n\n<p><u><b>Diagnosis<\/b><\/u><\/p>\n<ul>\n<li>Extramammary Paget disease<\/li>\n<\/ul>\n<p><u><b>Learning Points<\/b><\/u><\/p>\n<ul>\n<li>Various conditions can present with a &#8220;pagetoid&#8221; pattern of spread within the epidermis\n<ul>\n<li>Extramammary Paget disease, melanoma in-situ, and squamous cell carcinoma in-situ can all present with a pagetoid pattern of spread, with individual cells or nests of cells scattered within the epidermis.<\/li>\n<li>Proper examination for morphological clues, and the use of immunohistochemical and special stains (mucin stains specifically) is important to distinguish the conditions.<\/li>\n<\/ul>\n<\/li>\n<li>Adequate sampling and proper gross assessment is important in excision specimens of extramammary Paget disease\n<ul>\n<li>It is crucial to sample the specimen adequately (if not entirely) to exclude focal invasive disease, as this greatly impacts the prognosis.<\/li>\n<li>Invasion would occur as atypical cells extending deeper, beyond the epidermis and into the dermis.<\/li>\n<\/ul>\n<\/li>\n<li>The atypical cells within the epidermis can be extremely focal and few.<\/li>\n<li>\n<ul>\n<li>Be careful not to miss them on microscopy!<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\t<a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pathology-updates-journal-clubs\" target=\"_blank\" rel=\"noopener\">Pathology Updates &#038; Journal Clubs(opens in new tab)<\/a><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/\" target=\"_blank\" rel=\"noopener\">Short Cases(opens in new tab)<\/a><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pg-patho\/\" target=\"_blank\" rel=\"noopener\">Postgrad Pathology Home(opens in new tab)<\/a>\n\n","protected":false},"excerpt":{"rendered":"<p>FGT Case 2 (Vulva) Case writer: Dr Gideon Tan Clinical history: 60F, with no significant past medical history, presents with a worsening, itchy skin rash in the vulvar region. On examination, there is an erythematous plaque-like rash, which is sharply demarcated from the surrounding skin. A biopsy of the rash, and a subsequent excision, was [&hellip;]<\/p>\n","protected":false},"author":828,"featured_media":0,"parent":47288,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-47624","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>NUS Pathweb<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/fgtvc-2\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:description\" content=\"FGT Case 2 (Vulva) Case writer: Dr Gideon Tan Clinical history: 60F, with no significant past medical history, presents with a worsening, itchy skin rash in the vulvar region. 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