Cervical Pathology Flashcards
What is the cervix?
(3)
Neck of the womb (Uterus)
Protects sterile environment of uterus
Supports uterus
What are the two main components of the cervix?
Ectocervix
Endocervix
What is the ectocervix?
Stratified squamous epithelium
Protection against infections and mechanical insult
What is the endocervix?
(4)
Glandular epithelium
Crypts can be seen
Honeycomb pattern
Palisade
What cervical specimen types are seen in histology?
(4)
LLETZ
LEEP
Cone Biopsy
Resection
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
What is a transient population
Patient clear HPV without treatment
What does a positive HPV and cytology morphology mean
Sent for colposcopy
What does a positive HPV but negative morphology mean
Women called back after 12 months
What does a persistent HPV infection mean
Woman sent for colposcopy
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
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
What is done in colposcopy
Application of acetic acid and Iugol’s Iodine to identify areas and grade of CIN
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
What is a LEEP
Loop electrosurgical excision procedure
What is LLETZ
Large loop excision of transformation zone
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
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 does cervical pathology present?
(5)
Blood
Discharge
Irritation
Irregular contour
Asymptomatic screening
- e.g. Cervical cancer screening programme
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
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
