Cervical pathology

Question 1

Which cells of the ectocervix are scraped off in a smear sample?

Answer 1

exfoliating cells

Question 2

Which cells in the ectocervix proliferate, divide and grow?

Answer 2

basal cells (site above basement membrane)

Question 3

What is the transformation zone?

Answer 3

the squamo-columnar junction between ectocervical and endocervical epithelia moves position from pre-menarche in response to menarche, pregnancy and menopause.

ectocervix = squamous 
endocervix = columnar

the region between the initial and new squamo-columnar junctions = TZ

Question 4

Describe the process of cervical erosion.

Answer 4

Exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia.

Question 5

What are nabothian follicles?

Answer 5

dilated endocervical glands that form polypoid structures.

Question 6

Why is cervicitis a risk for infertility?

Answer 6

it can be asymptomatic but simultaneously cause silent fallopian tube damage -> infertility

Question 7

What are some causes of cervicitis?

Answer 7

chlamydia trachomatis and herpes simplex viral infection

Question 8

Cervical polyps are premalignant.

T/F?

Answer 8

FALSE

not premalignant; localised inflammatory outgrowth

Question 9

What is cervical intraepithelial neoplasia?

Answer 9

Pre-invasive stage of cervical cancer occurring at TZ.

Dysplasia of squamous cells

Question 10

What is a koilocyte?

Answer 10

squamous cell that has undergone a number of structural changes due to HPV

Question 11

Describe the appearance of a koilocyte.

Answer 11

nuclear enlargement
irregular cell membrane
hyperchromasia
perinuclear halo/vacuolisation

Question 12

What are some risk factors for CIN/cervical cancer?

Answer 12

persistence of high-risk HPV (16 & 18)
vulnerability of SC junction in early reproductive life (age at first intercourse, long term use of OCP, non-use of barrier contraception)
smoking (3x risk)
immunosuppression

Question 13

What is condyloma acuminatum and what causes it?

Answer 13

Genital warts - thickened “papillomatous” squamous epithelium with cytoplasmic vacuolation (koilocytosis)
due to low risk HPV (6, 11 etc)

Question 14

Describe the histological features of CIN.

Answer 14

Delay in maturation - basal cells occupy more of epithelium
Nuclear abnormalities - hyperchromasia, increased neocytoplasmic ratio, pleomorphism.
excess mitotic activity - situated above basal layers, abnormal mitotic forms

Question 15

Describe CIN 1.

Answer 15

Basal 1/3 of epithelium occupied by abnormal cells. Raised no. of mitotic figures in lower 1/3; surface cells quite mature, but nuclei slightly abnormal

Question 16

Describe CIN II.

Answer 16

Abnormal cells extend to middle 1/3.

Mitoses in middle 1/3; abnormal mitotic figures.

Question 17

Describe CIN III.

Answer 17

Abnormal cells occupy full thickness of epithelium.

Mitoses often abnormal in upper 1/3

Question 18

Describe what you might see on a smear test for CIN.

Answer 18

high nucleus: cytoplasm ratio
bigger cytoplasm with raisin-like nucleus
lots of cytoplasm = mild dyskariosis (less cytoplasm = severe)

Question 19

Pathogenesis of invasive squamous carcinoma of cervix.

Answer 19

develops from pre-exisiting CIN - HPV virus integrated into host DNA.
Most cases should be preventable by screening.

Question 20

List some symptoms of invasive cervical cancer.

Answer 20

abnormal bleeding - post-coital, post-menopausal, brownish or blood stained vaginal discharge, contact bleeding (friable epithelium)

pelvic pain
haematuria/UTI
ureteric obstruction/renal failure

Question 21

Where might a carcinoma of the cervix spread locally?

Answer 21

uterine body, vagina, bladder, ureters, rectum

Question 22

What is the timescale for a HPV infection progressing to high-grade CIN?

Answer 22

6 months-3 years

Question 23

What is the timescale for high grade CIN progressing to invasive cancer?

Answer 23

5-20 years.

Question 24

What is cervical glandular intraepithelial neoplasia (CGIN)?

Answer 24

pre-invasive phase of endocervical adenocarcinoma

more difficult to diagnose on smear vs. squamous since it could be growing in a gland

Question 25

Endocervical adenocarcinoma has a better prognosis than squamous carcinoma of cervix.
T/F?

Answer 25

FALSE

endocervical adenocarcinoma has worse prognosis vs. squamous

Question 26

Epidemiology of endocervical adenocarcinoma?

Answer 26

higher socioeconomic class
later onset of sexual activity
smoking
HPV again incriminated, esp. HPV 18

Question 27

What is vulvular intraepithelial neoplasia (VIN)?

Answer 27

bimodal disease that is often, but not always, HPV related (e.g. lichen sclerosis)
often synchronous cervical and vaginal neoplasia (CIN & VaIN)

Question 28

Describe the bimodal occurrence of VIN.

Answer 28

young women - often multi-focal, recurrent or persistent causing treatment problems

older women - greater risk of progression to invasive squamous carcinoma

Question 29

Describe vulvar invasive squamous carcinoma.

Answer 29

Can arise from normal epithelium or VIN; mostly well-differentiated (verrucous = extremely well differentiated type)
usually elderly women, ulcer or exophytic mass

Question 30

What is the most important prognostic factor in vulvar invasive squamous carcinoma?

Answer 30

spread to superficial inguinal lymph nodes

Question 31

What are the surgical treatment options for vulvar invasive squamous carcinoma?

Answer 31

radical vulvectomy and inguinal lymphadenopathy

Question 32

Patient presents with a crusting and painful rsh on her vulva that seems to be spreading out into her groin area. Pathology shows tumour cells in epidermis containing mucin.
Diagnosis?

Answer 32

Vulvar Paget’s disease

mostly no underlying cancer, tumour arises from sweat gland in skin

can spread extensively to thighs, anus etc.