Published online: 2021-10-06

GebFra Science | Review

2020 WHO Classification of Female Genital Tumors

WHO-Klassifikation 2020 für Tumoren des unteren
weiblichen Genitales

Authors
Anne Kathrin Höhn 1, Christine E. Brambs 2, Grit Gesine Ruth Hiller 1, Doris May 3, Elisa Schmoeckel 3, Lars-Christian Horn 1

Affiliations
1 Arbeitsgruppe Mamma, Gynäko- & Perinatalpathologie, Deutsche Version unter:
Institut für Pathologie, Universitätsklinikum Leipzig AöR, https://doi.org/10.1055/a-1545-4279
Leipzig
2 Frauenklinik, Kantonsspital, Luzern, Schweiz AB STR AC T
3 Pathologisches Institut der Ludwig-Maximilians-Universität The 2020 WHO classification is focused on the distinction be-
München, München tween HPV-associated and HPV-independent squamous cell
carcinoma of the lower female genital organs. Differentiating
Key words according to HPV association does not replace the process of
p16 immunohistochemistry, HPV, Silva pattern grading; however, the WHO classification does not recom-
mend any specific grading system. VIN are also differentiated
Schlüsselwörter according to whether they are HPV(p16)-associated. HPV-in-
p16‑Immunhistochemie, HPV, Silva Pattern dependent adenocarcinoma (AC) of the cervix uteri has an un-
favorable prognosis. Immunohistochemical p16 expression is
received 16. 4. 2021 considered to be a surrogate marker for HPV association.
accepted after revision 5. 7. 2021 HPV-associated AC of the cervix uteri is determined using the
prognostically relevant Silva pattern.
Bibliography
Geburtsh Frauenheilk 2021; 81: 1145–1153
ZU SAM ME N FA SS UN G
DOI 10.1055/a-1545-4279
ISSN 0016‑5751 In der WHO-Klassifikation 2020 steht die Unterscheidung von
© 2021. The Author(s). HPV-assoziierten und HPV-unabhängigen Plattenepithelkar-
This is an open access article published by Thieme under the terms of the Creative zinomen des unteren weiblichen Genitales im Vordergrund.
Commons Attribution-NonDerivative-NonCommercial-License, permitting copying
and reproduction so long as the original work is given appropriate credit. Contents Die Unterscheidung der HPV-Assoziation ersetzt das Grading
may not be used for commercial purposes, or adapted, remixed, transformed or nicht, für welches jedoch kein Gradingsystem empfohlen wird.
built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Auch bei der VIN erfolgt die Trennung nach HPV-(p16-)Asso-
Georg Thieme Verlag KG, Rüdigerstraße 14,
ziation. HPV-unabhängige Adenokarzinome (AC) der Cervix
70469 Stuttgart, Germany
uteri sind prognostisch ungünstiger. Als Surrogatmarker für
eine HPV-Assoziation gilt der immunhistochemische Nachweis
Correspondence
von p16. Beim HPV-assoziierten AC der Cervix uteri erfolgt die
Dr. med. Anne Kathrin Höhn
prognostisch relevante Angabe des sog. Silva-Patterns.
Arbeitsgruppe Mamma-, Gynäko- & Perinatalpathologie,
Institut für Pathologie, Universitätsklinikum Leipzig AöR
Liebigstraße 26, 04103 Leipzig, Deutschland
[email protected]

Höhn AK et al. 2020 WHO Classification … Geburtsh Frauenheilk 2021; 81: 1145–1153 | © 2021. The author(s). 1145
 GebFra Science | Review

Vulvar intraepithelial neoplasia (VIN)

WHO 2020: HPV-associated WHO 2020: HPV-independent

Syn.: L- or H-SIL, VIN 1 or VIN 2/3 Less common form of VIN
Most common form of VIN Older women
Younger women Often associated with lichen sclerosus
p16 block staining (Darragh et al. 2013) [12] p16-negative
p53 wild-type staining (Tessier-Cloutier et al. 2020) [14] Aberrant p53 expression

Morphological variants

Differentiated VIN Exophytic differentiated VIN lesion Vulvar acanthosis with altered
(d-VIN) (DEVIL) differentiation (VAAD)

Vulvar aberrant maturation (VAM) (Heller et al. 2021) [4]

Prognosis

Spontaneous regression possible (especially VIN 1) No spontaneous regression

Slower rate of progression VIN → squamous cell carcinoma Faster rate of progression VIN → squamous cell carcinoma
Longer time interval VIN → squamous cell carcinoma Shorter time interval VIN → squamous cell carcinoma

▶ Fig. 1 Clinicopathological characteristics of the 2020 WHO classification of vulvar precancerous lesions [1 – 4, 12, 14].

The following article summarizes the significant changes of

Introduction clinical relevance in the current WHO classification for tumors of
The WHO Classification of Female Genital Tumors is the fourth the female genitals in a way that is relevant in practice.
volume in the fifth edition of the WHO series on the classification
of human tumors, and was fundamentally revised in 2020 due to
new histomorphological data and, in particular, molecular pathol-
Vulvar Tumors
ogy data. In comparison with the 2013 edition, the scope of the With reference to vulvar intraepithelial neoplasias (VIN), the dis-
work has doubled in length. The WHO classification is now primar- tinction between HPV-associated and HPV-negative neoplasia has
ily constructed on the basis of new (molecular) pathology data. been retained. In terms of nomenclature, HPV-associated VIN cor-
However, data of therapeutic and diagnostic relevance, insofar as responds to low (VIN 1) and high-grade SIL (VIN 2 and 3; ▶ Figs. 1
they are available, are certainly also incorporated. The WHO Blue and 2).
Books represent an important foundation for a globally uniform In cases of VIN where no HPV is detected, the term HPV-inde-
diagnostic standard. In Germany, the guidelines of the AWMF (As- pendent VIN has been introduced [1, 2]; ▶ Fig. 1 showing a vari-
sociation of the Scientific Medical Societies) recommend using able morphology:
the current WHO classification for the pathological findings re- ▪ The differentiated VIN with its horizontal spread (d-VIN) is a
port. The obligation to use the diagnostic histopathological stan- precursor lesion that is allocated to a more aggressive,
dards and terminology according to the current WHO classifica- ▪ the differentiated exophytic VIN lesion (DEVIL) to a less ag-
tion is described in all of the guidelines relating to gynecological gressive (keratinizing) squamous cell carcinoma and the
malignancies with the verb “should”, this being the highest level ▪ vulvar acanthosis with altered differentiation (VAAD) is allo-
of recommendation. While the WHO classification sets out termi- cated to verrucous carcinoma as a precursor/risk lesion [2, 3].
nology and criteria for diagnosis, the TNM classification of malig-
nant tumors as well as the FIGO classification (Fédération Interna- Within this context, it is important to note that different types of
tionale de Gynécologie et dʼObstétrique) are used for staging, i.e., lesions may coincide with each other [1, 2, 4]. Due to morpholog-
determining the extent and spread of the gynecological tumors. ical similarities or overlaps [3], DEVIL and VAAD are also covered
by the umbrella term of aberrant maturation of the vulvar squa-

1146 Höhn AK et al. 2020 WHO Classification … Geburtsh Frauenheilk 2021; 81: 1145–1153 | © 2021. The author(s).
 ▶ Fig. 2 Precancerous lesions (VIN) and vulvar carcinoma. a HPV-associated VIN (usual VIN; u-VIN), b and c non-keratinizing, HPV-associated
squamous cell carcinoma of the vulva with a plump pattern of invasion and p16 positivity (so-called block staining; see text), d HPV-independent
VIN (d-VIN), e and f keratinizing squamous cell carcinoma of the vulva with a netlike pattern of invasion and aberrant p53 expression (see text).

mous epithelium (vulvar aberrant maturation; VAM; [4]) Should it not be possible to classify the tumor based on p16
(▶ Fig. 1), a term that is not included in the WHO classification. immunohistochemistry (and/or molecular HPV detection) or the
Despite the fact that this distinction as yet lacks diagnostic and presence of p53, the WHO deems the description squamous cell
therapeutic relevance [5, 6], the new WHO classification differen- carcinoma NOS to be “acceptable” (▶ Fig. 5). The WHO explicitly
tiates between HPV-associated and HPV-independent squamous points out that molecular analyses (i.e., HPV detection in situ) are
cell carcinoma due to their different pathogenesis (▶ Figs. 1 and not indicated for diagnostic evaluation.
2), and the WHO recommends supplying this information in the Patients with p16-positive squamous cell carcinoma who have
findings report. The ratio of HPV-independent to HPV-associated received radio(chemo)therapy show a higher response rate that is
squamous cell carcinoma is stated to be between 0.60 and 0.83 statistically significant compared with patients with p53-associ-
[7]. ated carcinoma [15 – 18].
Irrespective of clinicopathological differences (▶ Table 1), the In these patient groups with very different therapeutic ap-
HE-morphology does not allow for reliable differentiation be- proaches, it has now been acknowledged that p16-positive carci-
tween HPV-associated and HPV-independent (p53-associated) nomas have a better prognosis compared with those that are p53-
squamous cell carcinoma [2, 4], as it has an error rate of 20–30 % positive [5, 6, 11, 19]. The study by McAlpine et al. [20] points out
[8, 9]. The third pathogenetic concept postulated by Nooij et al. that patients with p53-positive tumors benefit from a more radi-
[10] (see below; ▶ Table 1; [5, 11]) is not included in the new cal surgical approach. Initial molecular studies show that vulvar
WHO classification as the current data are still insufficient. carcinoma with a p53 mutation and an additional PIK3CA comuta-
Immunohistochemistry showing strong nuclear and cytoplas- tion have a particularly unfavorable prognosis [7]. There also
mic p16 reactivity (so-called block staining; [12]; ▶ Fig. 2 c) points clearly exists a third pathogenetic group of p16−/p53−tumors,
towards HPV association and is defined as a “reliable (although which ranks prognostically between the p16-positive and the
not perfect)” surrogate marker by the WHO (WHO 2020, [4, 13]). p53-aberrant vulvar carcinoma [5, 11] (▶ Table 1). Whether or
Analysis using p53 immunohistochemistry may help to more ac- not the prognostically favorable low-grade squamous cell carcino-
curately diagnose VIN and vulvar squamous cell carcinoma [4] ma with verrucous morphology represents one morphological
(▶ Fig. 2 f), as staining patterns have been defined that correlate end of the p16−/p53− tumor spectrum [7] is still unclear.
well with underlying mutations [7, 14].

Höhn AK et al. 2020 WHO Classification … Geburtsh Frauenheilk 2021; 81: 1145–1153 | © 2021. The author(s). 1147
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The WHO classification explicitly mentions the possibility of

immunohistochemical HER2 detection for Morbus Paget. A
meta-analysis of 713 patients demonstrated that HER2 expression
was present in 30 % of cases, and steroid hormone receptor posi-
tivity for ER, PR and AR was present in 13 %, 8 % and 40 % respec-
tively [21]. These may serve as a basis for possible therapeutic tar-
gets.

Vaginal Tumors
When it comes to the vaginal intraepithelial neoplasia (VaIN;
▶ Fig. 4 a) and adenocarcinoma, there have been no changes.
For squamous cell carcinoma of the vagina, the detection of
▶ Fig. 3 Verrucous carcinoma of the vulva: exophytic verrucous HPV is currently of no therapeutic relevance [22]. Nevertheless,
growth of well-differentiated squamous cell epithelium with super-
the WHO recommends making this distinction for these tumor
ficial parakeratosis and a sharp demarcation, with only focal infil-
tration (arrow), from the subjacent stroma.
types as well (▶ Fig. 5).
In general, the majority of vaginal squamous cell carcinomas
are HPV-associated, especially those with a non-keratinizing mor-
phology (▶ Fig. 4 b) and tumor location in the upper or intermedi-
The WHO classification does not include grading specifica- ate third (so-called Müllerian vagina). Distal squamous cell carci-
tions. In the view of the authors, HPV association (i.e., p16 block nomas are known as introitus carcinoma and stem from the uro-
positivity; [12]) does not (yet) replace the grading process. Should genital sinus (so-called sinus vagina; [23, 24]). Lacking HPV associ-
a grading be necessary for documentation or for the DRG system, ation, these are often keratinizing squamous cell carcinomas
this can be done based on the extent of keratinization, analogous (▶ Fig. 4 c).
to the approach used thus far. For vaginal carcinomas too, the WHO points out that molecu-
It is unclear why verrucous carcinoma (▶ Fig. 3) is no longer lar analyses (i.e., HPV detection in situ) are not indicated for the
listed in the WHO classification; it is, however, mentioned in more diagnostic evaluation.
recent reviews [2, 4]. Molecular analyses also regard this tumor The WHO classification does not include grading specifica-
type separately [7]. Based on verified HRAS and PIK3CA muta- tions. In the view of the authors, HPV association (i.e., p16 block
tions, VAAD is thought to be a precursor lesion of verrucous carci- positivity; [12]) does not (yet) replace the grading process. Should
noma [3]. a grading be necessary for documentation or for the DRG system,

▶ Table 1 Pathogenetically based clinicopathological characteristics of vulvar squamous cell carcinoma [2, 4 – 6, 10, 11, 20, 42].

HPV-associated HPV-independent Uncertain

p16+/p53− p16−/p53+ p16−/p53−
Frequency 40 % 50–60 % 20 %
Age 40–60 years of age 50–70 years of age 60–70 years of age
Precancerous lesion VIN 2/3 (H‑SIL) HPV-independent VIN ? (d-VIN-/VAAD-like?)
(d-VIN,? VAAD,? DEVIL)
Etiopathogenesis High-risk HPV infection p53 alteration ? (NOTCH-1/HRAS/
PIK3CA mutation?)
Biomarker expression p16 positive (block staining) p53-aberrant staining pattern p16 negative/p53 wt
Histology (Heller et al. 2020) Non-keratinizing (ca. 66 %) Keratinizing (80–90 %) Keratinizing/
non-keratinizing
Inguinal lymph node metastases 30 % 40 % 30 %
Radio(chemo)sensitivity Usually sensitive Less sensitive Possibly less sensitive
Prognosis Better Poorer Intermediate
▪ Local recurrence (Nooij et al. 2017) [10] 5.3 % 22.6 % 16.3 %
▪ 2-year DFS (Woelber et al. 2021) [11] 64 % 47 % 60 %
▪ 5-year DSS (Barlow et al. 2020) [5] 89 % 75 % 83 %
▪ Overall survival (Woelber et al. 2021) [11] 82 % 70 % 75 %

1148 Höhn AK et al. 2020 WHO Classification … Geburtsh Frauenheilk 2021; 81: 1145–1153 | © 2021. The author(s).
 ▶ Fig. 4 Precancerous lesions and carcinoma of the vagina. a HPV-associated precancerous lesion of the vagina (VAIN 3), b keratinizing squamous
cell carcinoma of the vagina with slight peritumoral desmoplasia and absence of peritumoral inflammation, c non-keratinizing squamous cell car-
cinoma of the vagina with a high degree of peritumoral inflammation.

2020 WHO classification of squamous cell carcinoma of the female genitals

No immunohistochemistry possible Immunohistochemistry (p16, p53)

HPV-PCR1

Squamous cell carcinoma, HPV-associated HPV-independent

NOS2 squamous cell carcinoma squamous cell carcinoma
“acceptable diagnosis” (WHO 2020) Vagina: proximal two thirds Vagina: distal third (sinus vagina)
(Müllerian vagina) Vulva: mostly older women, associated
Vulva: mostly younger women, with d-VIN, DEVIL; VAAD (lichen sclerosus)
associated with H-SIL (VIN 2/3) Usually non-keratinizing SCC
Usually non-keratinizing SCC p16-negative (non-block staining)
p16 block staining (Darragh et al. 2013) [12] Vulva: p53 aberrant staining
1 Vulva: p53 wild-type staining (Tessier-Cloutier et al. 2020) [14]
WHO 2020: molecular methods are not
indicated to differentiate HPV-associated (Tessier-Cloutier et al. 2020) [14] Vulva: less favorable response to
SCC from HPV-independent SCC; however, Vulva: better response to radio(chemo)therapy
they may be helpful in uncertain cases radio(chemo)therapy Less favorable prognosis
2
NOS = not otherwise specified Better prognosis

▶ Fig. 5 Clinicopathological characteristics of the 2020 WHO classification of squamous cell carcinoma of the female genitals [1, 5, 6, 8, 9, 11 – 14,
17, 18, 20, 24, 27, 44].

Höhn AK et al. 2020 WHO Classification … Geburtsh Frauenheilk 2021; 81: 1145–1153 | © 2021. The author(s). 1149
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2020 WHO classification of cervical adenocarcinoma (AC)

(International Endocervical Adenocarcinoma Classification; IECC1)

HPV-associated HPV-independent
Usual type Gastric AC
Clear-cell AC
Mesonephroid AC (Gartner’s duct carcinoma)
Endometrioid3

Variants p16-positive Immunohistochemistry p16-positive4

Villoglandular p16 is not absolutely necessary
Mucinous NOS for the classification; usually,
Mucinous intestinal the HE morphology is sufficient
Mucinous signet-ring cell
Invasive SMILE (i-SMILE)
1
(Endometrioid)2 The IECC Classification (Stolnicu et al. 2018) [31] has been largely adopted by the WHO.
2
Adenosquamous Is a variant of the usual type with mucus depletion. Immunohistochemical analysis to rule out cervical
Mucoepidermoid infiltration of an endometrioid endometrial carcinoma is recommended.
Adenoid basal cell 3
Primary endometrioid cervical carcinoma is extremely rare and is usually associated with endometriosis.
4
In its role as a tumor suppressor gene, p16 may also be positive in HPV-independent AC; in such cases
it is not indicative of a high-risk HPV infection.

▶ Fig. 6 Classification of adenocarcinoma of the cervix uteri in accordance with the 2020 WHO classification [1, 28, 29, 31, 32, 37]. Small image:
strong p16 positivity of a usual-type AC.

this can be done based on the extent of keratinization, analogous apeutic or prognostic differences. With regard to grading, the
to the approach used thus far. WHO classification states that there is no established grading sys-
tem. In the view of the authors, HPV association (i.e., p16 block
positivity; [12]) does not (yet) replace the grading process. Should
Tumors of the Cervix Uteri a grading be necessary for documentation or for the DRG system,
For squamous cell cervical intraepithelial neoplasia (CIN), there this can be done based on the extent of keratinization, analogous
have been no changes. to the approach used thus far.
When it comes to adenocarcinoma in situ (AIS), a distinction For adenocarcinoma (AC) of the cervix uteri, a similar distinc-
is made between various HPV-associated variants and the non- tion is made with regard to the high-risk HPV association. HPV-
HPV-associated gastric AIS (g-AIS). SMILE (stratified mucin-pro- negative AC has a significantly less favorable prognosis [28 – 30].
ducing intraepithelial lesion) as a subtype of AIS is no longer Therefore, the previous diagnostic category of AC‑NOS no lon-
listed as an independent entity. ger exists in the new edition of the WHO classification.
Epithelial precancerous lesions and carcinoma of the cervix The same applies for (primary) serous AC of the cervix uteri,
uteri are predominantly HPV-associated [25]. which are almost exclusively endometrial or isthmic endometrial
To ensure a uniform nomenclature, the WHO has classified carcinomas with cervical involvement [29, 31].
these squamous cell carcinomas in a manner analogous to the vul- The WHO classification has adopted the “International Endo-
var and vaginal carcinomas (▶ Fig. 5). cervical Adenocarcinoma Classification” (IECC; [28, 29])
For the very rare HPV-negative squamous cell carcinoma [26, (▶ Fig. 6), which was also included in the S3-Guideline for cervical
27] there is no known precancerous lesion. carcinoma reviewed in 2021 [32].
Similarly for squamous cell carcinoma of the cervix uteri, the An HPV analysis is not necessary for the diagnosis [1]. If “block-
HE-morphology alone does not allow differentiation between the type” reactivity is detected [1] (▶ Fig. 6), p16 is a reliable surro-
two forms; for this reason the WHO recommends performing p16 gate marker for HPV association. In very rare cases, p16 hyper-
immunohistochemistry but also accepts the diagnosis of squa- methylation may lead to a (false) negative immunohistochemistry
mous cell carcinoma NOS (▶ Fig. 5), as there are no existing ther- [33], an error that is estimated to occur for CIN 3 in approx. 5 % of

1150 Höhn AK et al. 2020 WHO Classification … Geburtsh Frauenheilk 2021; 81: 1145–1153 | © 2021. The author(s).
 ▶ Table 2 Frequency and prognostic relevance of the Silva pattern for HPV-associated adenocarcinoma of the cervix uteri [43].

Frequency Pelvic lymph node metastasis FIGO Stage I FIGO Stage II–IV Recurrence rate
Pattern A 20.7 % 0% 100 % 0% 0%

Pattern B 25.6 % 4.4 % 100 % 0% 1.1 %

Pattern C 53.7 % 23.8 % 83 % 17 % 23.7 %

cases [4, 34]. The choice of a suitable p16 clone is also very im-
portant for the reliable detection of p16 [35]. The p16 reactivity
in old paraffin blocks or insufficiently fixed tissues is deemed un-
reliable [31, 36]. It is also important to note that HPV-indepen-
dent AC (i.e., gastric AC) may also demonstrate p16 positivity
[37]. The p16 immunohistochemistry must be interpreted within
the context of the HE morphology.
The so-called Silva pattern, a prognostically relevant classifica-
tion of (HPV-associated) AC based on architectural criteria, has
been newly adopted into WHO classification (▶ Table 2).
It distinguishes between the prognostically more favorable
pattern A carcinoma with non-destructive invasion and the pat-
tern B and C carcinoma with destructive invasion. Distinguishing
between pattern A‑AC and AIS based on HE morphology can be
difficult (k = 0.23; [38]).
In almost all cases, endometrioid AC of the endocervix repre-
sents a mucin-depleted variant of HPV-associated AC. Immunohis-
tochemistry should be used to distinguish between benign lesions ▶ Fig. 7 Adenosarcoma of the Uterus: foliaceous tumor growth
and endometrioid endometrial carcinoma with cervical infiltration. with very cell-poor stroma (*) showing discrete accentuation of the
cell density underneath the superficial epithelium (arrows) with a
bland cytology.
Epithelial-mesenchymal Tumors
Adenofibromas of the cervix uteri that were previously listed in
the WHO classification are now considered in fact to be benign
endometrial or cervical polyps with an unusual morphology [39,
40], or alternatively adenosarcoma with “low-grade stromal mor-
phology” (▶ Fig. 7). Immunohistochemical analyses are helpful for
differential diagnosis in these cases [41].

Höhn AK et al. 2020 WHO Classification … Geburtsh Frauenheilk 2021; 81: 1145–1153 | © 2021. The author(s). 1151
 GebFra Science | Review

Conflict of Interest [18] Allo G, Yap ML, Cuartero J et al. HPV-independent Vulvar Squamous Cell
Carcinoma is Associated With Significantly Worse Prognosis Compared
With HPV-associated Tumors. Int J Gynecol Pathol 2020; 39: 391–399
The authors declare that they have no conflict of interest.
[19] Rasmussen CL, Sand FL, Hoffmann Frederiksen M et al. Does HPV status
influence survival after vulvar cancer? Int J Cancer 2018; 142: 1158–
References 1165
[20] McAlpine JN, Leung SCY, Cheng A et al. Human papillomavirus (HPV)-in-
[1] Lokuhetty D, White VA, Watanabe R. Female genital Tumours. 5th ed. dependent vulvar squamous cell carcinoma has a worse prognosis than
Lyon: Internal Agency for Research on Cancer (IARC); 2020 HPV-associated disease: a retrospective cohort study. Histopathology
[2] Singh N, Gilks CB. Vulval squamous cell carcinoma and its precursors. 2017; 71: 238–246
Histopathology 2020; 76: 128–138 [21] Angelico G, Santoro A, Inzani F et al. Hormonal Environment and HER2
[3] Watkins JC. Human Papillomavirus-Independent Squamous Lesions of Status in Extra-Mammary Pagetʼs Disease (eMPD): A Systematic Litera-
the Vulva. Surg Pathol Clin 2019; 12: 249–261 ture Review and Meta-Analysis with Clinical Considerations. Diagnostics
[4] Heller DS, Day T, Allbritton JI et al. Diagnostic Criteria for Differentiated (Basel) 2020; 10: 1040
Vulvar Intraepithelial Neoplasia and Vulvar Aberrant Maturation. J Low [22] Hellman K, Lindquist D, Ranhem C et al. Human papillomavirus, p16
Genit Tract Dis 2021; 25: 57–70 (INK4A), and Ki-67 in relation to clinicopathological variables and surviv-
[5] Barlow EL, Lambie N, Donoghoe MW et al. The Clinical Relevance of p16 al in primary carcinoma of the vagina. Br J Cancer 2014; 110: 1561–1570
and p53 Status in Patients with Squamous Cell Carcinoma of the Vulva. [23] Höckel M, Horn L-C, Illig R et al. Ontogenetic anatomy of the distal vagi-
J Oncol 2020; 2020: 3739075 na: relevance for local tumor spread and implications for cancer surgery.
[6] Sand FL, Nielsen DMB, Frederiksen MH et al. The prognostic value of p16 Gynecol Oncol 2011; 122: 313–318
and p53 expression for survival after vulvar cancer: A systematic review [24] Horn L-C, Höhn AK, Hampl M et al. S2k-Leitlinie Diagnostik und Therapie
and meta-analysis. Gynecol Oncol 2019; 152: 208–217 des Vaginalkarzinoms und seiner Vorstufen – Anforderungen an die Pa-
[7] Tessier-Cloutier B, Pors J, Thompson E et al. Molecular characterization thologie. Der Pathologe 2021; 42: 116–124
of invasive and in situ squamous neoplasia of the vulva and implications [25] de Sanjosé S, Serrano B, Tous S et al., RIS HPV TT, VVAP and Head and
for morphologic diagnosis and outcome. Mod Pathol 2021; 34: 508–518 Neck study groups. Burden of Human Papillomavirus (HPV)-Related Can-
[8] Cheng AS, Karnezis AN, Jordan S et al. p16 Immunostaining Allows for cers Attributable to HPVs 6/11/16/18/31/33/45/52 and 58. JNCI Cancer
Accurate Subclassification of Vulvar Squamous Cell Carcinoma Into Spectr 2019; 2: pky045
HPV-Associated and HPV-Independent Cases. Int J Gynecol Pathol [26] Li N, Franceschi S, Howell-Jones R et al. Human papillomavirus type dis-
2016; 35: 385–393 tribution in 30,848 invasive cervical cancers worldwide: Variation by
[9] Santos M, Landolfi S, Olivella A et al. p16 overexpression identifies HPV- geographical region, histological type and year of publication. Int
positive vulvar squamous cell carcinomas. Am J Surg Pathol 2006; 30: J Cancer 2011; 128: 927–935
1347–1356 [27] Casey S, Harley I, Jamison J et al. A rare case of HPV-negative cervical
[10] Nooij LS, Ter Haar NT, Ruano D et al. Genomic Characterization of Vulvar squamous cell carcinoma. Int J Gynecol Pathol 2015; 34: 208–212
(Pre)cancers Identifies Distinct Molecular Subtypes with Prognostic Sig- [28] Hodgson A, Olkhov-Mitsel E, Howitt BE et al. International Endocervical
nificance. Clin Cancer Res 2017; 23: 6781–6789 Adenocarcinoma Criteria and Classification (IECC): correlation with ad-
[11] Woelber L, Prieske K, Eulenburg C et al. p53 and p16 expression profiles verse clinicopathological features and patient outcome. J Clin Pathol
in vulvar cancer: a translational analysis by the Arbeitsgemeinschaft Gy- 2019; 72: 347–353
näkologische Onkologie Chemo and Radiotherapy in Epithelial Vulvar [29] Stolnicu S, Hoang L, Chiu D et al. Clinical Outcomes of HPV-associated
Cancer study group. Am J Obstet Gynecol 2021; 224: 595.e1–595.e11 and Unassociated Endocervical Adenocarcinomas Categorized by the In-
[12] Darragh TM, Colgan TJ, Thomas Cox J et al. The Lower Anogenital Squa- ternational Endocervical Adenocarcinoma Criteria and Classification
mous Terminology Standardization project for HPV-associated lesions: (IECC). Am J Surg Pathol 2019; 43: 466–474
background and consensus recommendations from the College of [30] Nicolás I, Saco A, Barnadas E et al. Prognostic implications of genotyping
American Pathologists and the American Society for Colposcopy and and p16 immunostaining in HPV-positive tumors of the uterine cervix.
Cervical Pathology. Int J Gynecol Pathol 2013; 32: 76–115 Mod Pathol 2020; 33: 128–137
[13] Dasgupta S, Ewing-Graham PC, Swagemakers SMA et al. Precursor le- [31] Stolnicu S, Barsan I, Hoang L et al. International Endocervical Adenocar-
sions of vulvar squamous cell carcinoma – histology and biomarkers: A cinoma Criteria and Classification (IECC): A New Pathogenetic Classifica-
systematic review. Crit Rev Oncol Hematol 2020; 147: 102866 tion for Invasive Adenocarcinomas of the Endocervix. Am J Surg Pathol
[14] Tessier-Cloutier B, Kortekaas KE, Thompson E et al. Major p53 immuno- 2018; 42: 214–226
histochemical patterns in in situ and invasive squamous cell carcinomas [32] AWMF. S3-Leitlinie zur Diagnostik, Therapie und Nachsorge der Patientin
of the vulva and correlation with TP53 mutation status. Mod Pathol mit Zervixkarzinom, 2021. Accessed January 26, 2021 at: https://www.
2020; 33: 1595–1605 awmf.org/leitlinien/detail/ll/032-033OL.html
[15] Yap ML, Allo G, Cuartero J et al. Prognostic Significance of Human Papil- [33] Nuovo GJ, Plaia TW, Belinsky SA et al. In situ detection of the hyperme-
loma Virus and p16 Expression in Patients with Vulvar Squamous Cell thylation-induced inactivation of the p16 gene as an early event in onco-
Carcinoma who Received Radiotherapy. Clin Oncol (R Coll Radiol) 2018; genesis. Proc Natl Acad Sci U S A 1999; 96: 12754–12759
30: 254–261 [34] Shain AF, Kwok S, Folkins AK et al. Utility of p16 Immunohistochemistry
[16] Lee LJ, Howitt B, Catalano P et al. Prognostic importance of human pap- in Evaluating Negative Cervical Biopsies Following High-risk Pap Test Re-
illomavirus (HPV) and p16 positivity in squamous cell carcinoma of the sults. Am J Surg Pathol 2018; 42: 69–75
vulva treated with radiotherapy. Gynecol Oncol 2016; 142: 293–298 [35] Shain AF, Wilbur DC, Stoler MH et al. Test Characteristics of Specific p16
[17] Proctor L, Hoang L, Moore J et al. Association of human papilloma virus Clones in the Detection of High-grade Squamous Intraepithelial Lesions
status and response to radiotherapy in vulvar squamous cell carcinoma. (HSIL). Int J Gynecol Pathol 2018; 37: 82–87
Int J Gynecol Cancer 2020; 30: 100–106

1152 Höhn AK et al. 2020 WHO Classification … Geburtsh Frauenheilk 2021; 81: 1145–1153 | © 2021. The author(s).
[36] Nuovo AJ, Garofalo M, Mikhail A et al. The effect of aging of formalin- [41] McCluggage WG. A practical approach to the diagnosis of mixed epithe-
fixed paraffin-embedded tissues on the in situ hybridization and immu- lial and mesenchymal tumours of the uterus. Mod Pathol 2016; 29
nohistochemistry signals in cervical lesions. Diagn Mol Pathol 2013; 22: (Suppl. 1): S78–S91
164–173 [42] Knopp S, Bjørge T, Nesland JM et al. p16INK4a and p21Waf1/Cip1 ex-
[37] Carleton C, Hoang L, Sah S et al. A Detailed Immunohistochemical Anal- pression correlates with clinical outcome in vulvar carcinomas. Gynecol
ysis of a Large Series of Cervical and Vaginal Gastric-type Adenocarcino- Oncol 2004; 95: 37–45
mas. Am J Surg Pathol 2016; 40: 636–644 [43] Roma AA, Mistretta T‑A, Diaz De Vivar A et al. New pattern-based per-
[38] Parra-Herran C, Taljaard M, Djordjevic B et al. Pattern-based classifica- sonalized risk stratification system for endocervical adenocarcinoma
tion of invasive endocervical adenocarcinoma, depth of invasion mea- with important clinical implications and surgical outcome. Gynecol On-
surement and distinction from adenocarcinoma in situ: interobserver col 2016; 141: 36–42
variation among gynecologic pathologists. Mod Pathol 2016; 29: 879– [44] Höckel M, Trott S, Dornhöfer N et al. Vulvar field resection based on on-
892 togenetic cancer field theory for surgical treatment of vulvar carcinoma:
[39] Ip PP. Benign endometrial proliferations mimicking malignancies: a re- a single-centre, single-group, prospective trial. Lancet Oncol 2018; 19:
view of problematic entities in small biopsy specimens. Virchows Arch 537–548
2018; 472: 907–917
[40] Howitt BE, Quade BJ, Nucci MR. Uterine polyps with features overlapping
with those of Müllerian adenosarcoma: a clinicopathologic analysis of 29
cases emphasizing their likely benign nature. Am J Surg Pathol 2015; 39:
116–126

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