Cervical Pathology Flashcards by Aífe Hayden

What is the cervix?
(3)

Neck of the womb (Uterus)

Protects sterile environment of uterus

Supports uterus

How well did you know this?

Not at all

Perfectly

What are the two main components of the cervix?

Ectocervix
Endocervix

How well did you know this?

Not at all

Perfectly

What is the ectocervix?

Stratified squamous epithelium

Protection against infections and mechanical insult

How well did you know this?

Not at all

Perfectly

What is the endocervix?
(4)

Glandular epithelium

Crypts can be seen

Honeycomb pattern

Palisade

How well did you know this?

Not at all

Perfectly

What cervical specimen types are seen in histology?
(4)

LLETZ
LEEP
Cone Biopsy
Resection

How well did you know this?

Not at all

Perfectly

How is cervical cancer screening carried out?

Brush cervix with plastic broom

Cells washed in a liquid medium

Use liquid based cytology

Vile sent to laboratory for HPV testing (DNA or RNA testing)

We use 6400 DNA testing

Transient HPV infection (HPV DNA) but it hasn’t integrated into host cells -> no risk of developing cancer associated -> need to triage these tests so we don’t have to recall too many women -> this is why we use the morphology assessment

Transient population -> patient clears HPV without treatment

Positive HPV and cytology morphology positive for colposcopy

Positive HPV but negative morphology -> women called back after 12 months

If HPV still persistent then may be sent on for colposcopy

How well did you know this?

Not at all

Perfectly

What is a transient population

Patient clear HPV without treatment

How well did you know this?

Not at all

Perfectly

What does a positive HPV and cytology morphology mean

Sent for colposcopy

How well did you know this?

Not at all

Perfectly

What does a positive HPV but negative morphology mean

Women called back after 12 months

How well did you know this?

Not at all

Perfectly

What does a persistent HPV infection mean

Woman sent for colposcopy

How well did you know this?

Not at all

Perfectly

What happens if assessment of cervix deems changes in cervix

If changes are seem then there is removal of cervix tissue via colposcopy for histology

How well did you know this?

Not at all

Perfectly

What is colposcopy?
(7)

Visualising of the cervix by a colposcopist using a colposcope, tissue may be removed if required. They will perform appropriate treatment.

Colposcopist will visualise the cervix using a colposcope

Application of acetic acid and iodine to define lesion and area of abnormality

Acetic acid shows us regions of more protein in areas of disease

Iodine brings out normal tissue -> normal tissue high in glycogen

Contours are associated with high grade

Frilled edge associated with low grade

How well did you know this?

Not at all

Perfectly

What is done in colposcopy

Application of acetic acid and Iugol’s Iodine to identify areas and grade of CIN

How well did you know this?

Not at all

Perfectly

What is the procedure behind colposcopy?
(5)

Laser/Cryocautery -> ablation of abnormal area

Punch biopsy -> removal of small pieces of tissue

LEEP

LLETZ

Cone biopsy -> all involve larger fragment of tissue

How well did you know this?

Not at all

Perfectly

What is a LEEP

Loop electrosurgical excision procedure

How well did you know this?

Not at all

Perfectly

What is LLETZ

Large loop excision of transformation zone

How well did you know this?

Not at all

Perfectly

What is done with cervical dissections

These samples would be inked so you know where the margins are

Every single piece of tissue is processed

How well did you know this?

Not at all

Perfectly

Give some examples of cervical pathology
(9)

Infections
Endometriosis
Cervical Intraepithelial Neoplasia
Squamous cell carcinoma
Cervical Glandular intraepithelial Neoplasia
Endocervical adenocarcinoma

Adeno-squamous carcinoma
TEM/SMILE
Metastatic

How well did you know this?

Not at all

Perfectly

How does cervical pathology present?
(5)

Blood
Discharge
Irritation
Irregular contour

Asymptomatic screening
- e.g. Cervical cancer screening programme

How well did you know this?

Not at all

Perfectly

Comment on the epidemiology of cervical cancer
(3)

4th most common cancer for women worldwide

6th most common for women in Europe

90% of all cases in low/middle income countries

How well did you know this?

Not at all

Perfectly

Comment on the cervical cancer epidemiology in Ireland

290 cases of cervical cancer diagnosed annually
90 deaths

What increases you risk for Cervical Cancer?
(10)

Human Papillomavirus
Sexually transmitted infections )HSV, Chlamydia, HIV)
Smoking
Party
Oral contraceptives
Early age of intercourse
Number of sexual partners/high risk partners
Socioeconomic status
Diethylstilbesterol DES
Family history

What is metaplasia?
(5)

Its not a malignant process in itself

The transformation of one type of epithelium to another

In the cervix, its the transformation of vulnerable glandular epithelium to a protective stratified squamous epithelium

Metaplasia arises in reserve cell population that usually replenish columnar epithelium

Swelling of cervix due to hormones in puberty can release acid which changes glandular epithelium

What is the transformation zone?
(3)

The area that metaplasia takes place

This is an area of instability

It’s said to ‘precisely define the field of neoplastic potential’

What is the transformation zone? (3)

The area that metaplasia takes place This is an area of instability It's said to 'precisely define the field of neoplastic potential'

What is cervical pathology

Recognised premalignant/precancerous stage in the development of squamous cell carcinoma of the cervix

What is the precancerous stage of cervical pathology? (3)

Cervical Intraepithelial Neoplasia (CIN) Cells from area of CIN are seen on cytology slide Morphological features are termed 'Dyskaryosis' on cytology

What pathology can be seen on cervical smears? (5)

Inflammation and infections Cervical intraepithelial neoplasia Invasive squamous cell carcinoma Cervical Glandular Intraepithelial Neoplasia (CGIN) - Endometrial/Ovarian/Extra-uterine Metastatic

Give four examples of infections which can be seen on a cervical smear

Actinomyces Candida Trichomonas vaginalis Herpes simplex virus II

What is Cervical Intraepithelial Neoplasia (CIN)? (4)

Evidence that CIN is a precursor of invasive squamous cell carcinoma in - patients with CIN who did not receive treatment - CIN found at the periphery of invasive cancer on histology sections - cells from CIN show similar morphology to cells from invasive Ca Spectrum of morphology which is divided into 3 stages and graded as CIN1, CIN2, CIN3

How is CIN graded?

Assessment of grade is based on the proportion of epithelium replaced by immature, crowded cells with enlarged irregular hyperchromatic nuclei

What is CIN1?

Mild dysplasia

What is CIN2

Moderate displase

What is CIN3

Sever dysplasia

What is dyskaryosis?

Used to describe all abnormal cells that have appearances which suggest derivation from CIN and invasive carcinoma of the cervix

How is dyskaryosis reported? (3)

Using reporting terminology BSCC (BAC) and Bethesda Low grade/high grade (squamous intraepithelial lesion)

How is dyskaryosis graded?

Nuclear abnormalities Nuclear:cytoplasmic ratio

What is the correlation between cytology grade and histological grade

Low grade SIL/Dyskaryosis = CIN1 High Grade SIL/Dyskaryosis = CIN2+

What are six features of dyskaryosis

Abnormal/irregular chromatin pattern Irregular nuclear membranes Irregular nuclear contours Disproportionate nuclear enlargement Hyper or hypochromasia Abnormalities in nucleoli

What is invasive squamous cell carcinoma (3)

When a lesion has breached the basement membrane The basement membrane cannot be seen on cervical smears and therefore invasion cannot be reported on cervical cytology Some features can be seen on cervical smear that may suggest invasion

What are some features of invasive squamous cell carcinoma? (5)

Windowing - irregular chromatin distribution causing 'holes' Fibre/tadpole/bizarre cells Keratinisation Diathesis Blood

What is an endocervical adenocarcinoma? (4)

Two main types: CGIN (AIS) and adenocarcinoma Cytological features recognised Association with HPV Increasing incidence and high incidence in younger women (30s)

What are some features of CGIN

Supercrowding (loss of normal architecture) Feathering Pseudostratification Rosettes

What are some extra-uterine malignancies seen in smears (4)

Ovarian carcinoma Colorectal Bladder Melanoma

What is the role of histochemistry in cervical samples? (3)

Limited application Cytology: Papanicolaou stain Histology: H+E - Specialised stains as required: (Connective tissue and infections)

Write about immunohistochemistry for cervical pathology (7)

Diagnostic panel: - Cytokeratins - adeno vs squamous - p16 - HPV - Ki67 - proliferation Metastatic markers CINTec plus - dual stain

What is Ki67 for?

Proliferation

What molecular tests are used in cervical pathology?

Histology - chromogenic ISH for HPV Cytology - pHPV tests (DNA or RNA) - Genotyping - Methylation markers

How is cervical pathology treated (4)

Colposcopy procedures If invasion, may go on for more extensive surgical removal (Trachelectomy, Hysterectomy) Chemotherapy Radiotherapy (brachytherapy)

Comment on research for cervical pathology

Cerviva - research consortium in TCD Coombe women and infants university hospital