Cervical and vulval pathology

Question 1

What is the ectocervix?

Answer 1

The outer part of the cervix that can be seen during a gynaecological exam. Ectocervix is covered with thin, flat cells called squamous cells.

Similar to skin surface except it is not keratinised

Question 2

What is the endocervix?

Answer 2

The inner part of the cervix that forms a canal connecting the vagina to the uterus.

Question 3

Where are exfoliating cells seen on cervical smear?

Answer 3

Seen on the surface of the normal ectocervix and captured when cervical smear is taken.

Question 4

What is endocervix lined with?

Answer 4

Lined with a singular layer of glandular epithelium.

Question 5

What is the squamous-columnar junction?

Answer 5

The point where the ectocervix becomes the endocervix marking the transition from the squamous epithelium.

Question 6

Inflammatory pathology examples in cervix?

Answer 6

Cervicitis - often asymptomatic: can lead to simultaneous silent fallopian tube damage.

Cervical polyp - localised inflammatory outgrowth. Cause of bleeding if ulcerated.

Question 7

Causes of cervicitis?

Answer 7

• Herpes simplex viral infection
• Non-specific acute/chronic inflammation
• Chlamydia trachomatis - sexually transmitted

Question 8

Neoplastic pathology examples in cervix?

Answer 8

• Cervical intra-epithelial neoplasia (CIN)
• Cervical cancer (squamous carcinoma, adenocarcinoma, other rare tumours).

Question 9

What is cervical intra-epithelial neoplasia (CIN)?

Answer 9

A term that describes abnormal changes of the cells that line the cervix. CIN is not cancer.

But if the abnormal cells are not treated, over time they may develop into cancer of the cervix (cervical cancer).

CIN does not cause any symptoms.

Question 10

Risk factors for CIN and cervical cancer?

Answer 10

Persistence of High Risk Human Papilloma Viruses, mostly types 16,18. Other types include: HPV types 31,33,35,45,48
Many sexual partners increases risk

Vulnerability of SC Junction in early reproductive life
- age at first intercourse
- long term use of oral contraceptives
- non-use of barrier contraception

Smoking: 3 x risk

Immunosuppression

Question 11

What HPV types cause genital warts?

Answer 11

HPV types 6 and 11

Question 12

What HPV types cause CIN/cervical cancer?

Answer 12

HPV types 16 and 18

Question 13

Time frame from HPV infection to high grade CIN?

Answer 13

6 months - 3 years

Question 14

Time frame from high grade CIN to invasive cancer?

Answer 14

5 years - 20 years

Question 15

Koilocytosis meaning?

Answer 15

Mature squamous cells with recognisable nuclear and cytoplasmic alterations.
Caused by infection with human papilloma virus

Question 16

Is CIN symptomatic?

Answer 16

No it is often asymptomatic

Question 17

Features of CIN?

Answer 17

Pre-invasive stage of cervical cancer

Occurs at the transformation zone.

Can involve large area.

Dysplasia of squamous cells

Not visible by naked eye

Asymptomatic

Detectable by cervical screening

Question 18

How many stages/grades of CIN (cervical intra-epithelial neoplasia) are there?

Answer 18

3 stages

Question 19

CIN grade 1?

Answer 19

CIN 1 is a low-grade lesion that has a low potential for progression to malignancy and a high potential for regression

Basal 1/3rd of epithelium occupied by abnormal cells. Raised number of mitotic figures in lower 1/3.

Question 20

CIN grade 2?

Answer 20

Abnormal cells extend to middle 1/3 and mitoses in middle 1/3

Question 21

CIN grade 3?

Answer 21

Abnormal cells occupy full thickness of epithelium.
Mitoses, often abnormal in upper 1/3

Question 22

Invasive squamous carcinoma is a common malignant cervical tumour. true/false?

Answer 22

True

Accounts for 75-95% of malignant cervical tumours

Question 23

What is the 2nd most common female cancer worldwide?

Answer 23

Invasive cervical squamous carcinoma

Question 24

Invasive cervical squamous carcinoma develops from pre-existing CIN, therefore most cases should be preventable by screening. true/false?

Answer 24

True

Cervical smear itself is not enough to diagnose CIN. Cervical smear can tell if patient has abnormal cells. After this calposcopy may be carried out, the calposcopy can show abnormal areas of the cervix and how abnormal the cells are.

Question 25

Symptoms of invasive carcinoma?

Answer 25

Usually none at microinvasive and early invasive stages (detected at screening)

Abnormal bleeding
- Post coital
- Post menopausal
- Brownish or blood stained vaginal discharge
- Contact bleeding – friable epithelium

Pelvic pain

Haematuria / urinary infections

Ureteric obstruction / renal failure

Question 26

Spread of squamous carcinoma?

Answer 26

Local = uterine body, vagina, bladder, ureters, rectum

Lymphatic = early: pelvic, para-aortic nodes

Haematogenous = late: liver, lungs, bone

Question 27

How is squamous carcinoma graded?

Answer 27

Well differentiated
Moderately differentiated
Poorly differentiated
Undifferentiated / anaplastic

Question 28

What is Cervical Glandular Intraepithelial Neoplasia (CGIN)?

Answer 28

Changes to the glandular cells that line the inside of the cervix (endocervix).

Without treatment, these cells could develop into a type of cervical cancer called adenocarcinoma.

CGIN is less common than CIN but is treated similarly.

Question 29

If CIN is the pre-invasive phase of squamous carcinoma. What is the pre-invasive phase of adenocarcinoma?

Answer 29

CGIN (Cervical Glandular Intraepithelial Neoplasia)

Question 30

Features of CGIN?

Answer 30

Origin from endocervical epithelium

CGIN is preinvasive phase of endocervical adenocarcinoma

More difficult to diagnose on cervical smear than squamous

Screening less effective

Sometimes associated with CIN

Question 31

What percentage of cervical cancers are endocervical adenocarcinoma?

Answer 31

5-25%

Question 32

Some other examples of HPV driven disease?

Answer 32

Vulvar Intraepithelial Neoplasia, VIN
Vaginal Intraepithelial Neoplasia, VaIN
Anal Intraepithelial Neoplasia, AIN

Graded 1,2 or 3 depending on degree of atypia and maturational disorder. Grade 3 is equivalent to SCC in situ.

Question 33

Vulvar invasive squamous carcinoma?

Answer 33

Usually elderly women, ulcer or exophytic mass.

Can arise from normal epithelium or VIN (vulvar intra-epithelial neoplasia)

Mostly well differentiated (verrucous are an extremely well differentiated type).

Spread to inguinal lymph nodes, which is most important prognostic factor.

Surgical treatment – radical vulvectomy and inguinal lymphadenectomy.
90% 5 year survival – node negative
<60% 5 year survival – node positive