cervical and vulval pathology

Question 1

Intraepithelial neoplasia

Answer 1

same as dysplasia which means its non-invasive (earliest step to malignancy).

Question 2

Human papillomaviruses (HPVs)

Answer 2

ouble stranded DNA viruses. Different types affect different tissues.
Lifecycle linked to epithelial differentiation. Genital HPVs grouped into low and high oncogenic risk

Question 3

Genital warts

Answer 3

Lower genital tract warts (condylomas = benign squamous neoplasms.

Question 4

Low grade ‘IN’s:

Answer 4

Low grade ‘IN’s: Very rarely in malignant lesions. 6 + 11 commonly cause benign genital warts.

Question 5

High risk’ HPV

Answer 5

16 + 18: High grade ‘IN’s and invasive carcinomas. HPV vaccination against this – cause 70% cervical cancers. 2 vaccines are Gardasil and Cervarix.

Question 6

Cervical intraepithelial neoplasia

Answer 6

Pre-invasive stage of cervical SCC. Detection is aim of cervical screening programme. Graded according to increasing abnormality.
CIN1 regression 60%, persistence 30% Progression to invasion 1%
CIN2 regression 40% persistence 40% Progression to invasion 5%
CIN3 regression 33% persistence 56% Progression to invasion 20% - 70%

Question 7

Cervical carcinoma

Answer 7

Transformation zone = physiological area of squamous metaplasia
Original state  Menacrche  Development of transformation zone  menopausal changes where TZ moves up into cervix so no longer able to test this part for dysplasia.

Question 8

Vulval intraepithelial neoplasia

Answer 8

Varied clinical appearances of VIN.
Classical / warty / baseloid
Graded VIN 1-3
Related to HPV infection. Younger people
Differentiated VIN
Not graded. Not HPV related
Occurs in chronic dermatoses
esp. lichen sclerosus. Older people

Question 9

Behaviour of VIN

Answer 9

35-50% recur
Positive margins predict recurrence
Progression to invasive Ca in 4-7% treated women and up to 87% of those untreated.
Invasion more likely to occur in postmenopausal/immunocompromised
Spontaneous regression may occur particularly in young, postpartum women.

Question 10

Vulval carcinoma: Squamous cell carcinoma –

Answer 10

Associated with VIN. Associated with inflammatory dermatoses. Eroded plaque or ulcer. Risk of lymph node metastasies <1mm very rare, > 4mm 40% likely.
Spreads: locally to involve vagina and distal urethra To ipsilateral inguinal LNs and To contralateral inguinal LNs, deep iliofemoral LNs (25% if inguinal nodes +ve)
Risk of lymph node mets. FIGO STAGING.

Question 11

Malignant melanoma

Answer 11

5% of vulval cancers. Mean age 50-60. Local recurrence in 1/3, spread to urethra frequent
Lymph node/haematogenous spread common. Depth of invasion correlates with LN involvement.

Question 12

Paget’s disease (Extramammary Paget’s disease) (tumours come out of glands)

Answer 12

5% Vulval cancers, mean age 80. Pruritic/burning/eczematous patch. In-situ adenocarcinoma of squamous mucosa. Tend to recur following excision. Can develop invasive adenocarcinoma. 5% regional malignant disease

Question 13

cervical screening programme

Answer 13

Available test has high sensitivity and specificity Test is not harmful. Defined pre-invasive stage
Long enough to allow intervention. Simple, successful treatment. Is not a test for cancer!
High HPV carriage rate, incl high risk types – 70-80% will be eliminated
Unnecessary LLETZ procedures can have obstetric consequences.
Colposcopy and treatment of CIN = Large Loop Excision of the Transformation Zone (LLETZ)
High risk HPV is most important causative factor as is Multiple sexual partners, Male partner with multiple partners, Young age at first intercourse, High parity, Low socioeconomic group, SMOKING, Immunosuppression