Cervical Screening and Vulval Pathology Flashcards
Ho do the linings of the ectocervix and the endocervical canal differ?
Ectocervix - lined by squamous epithelium (same as vagina)
Endocervical Canal - lined by glandular epithelium
What cells in the squamous lining of the ectocervix proliferate?
Basal cells
- the cells mature and move upwards to surface (like in the skin)
What cells does a cervical smear test remove?
Mature surface cells of ectocervical lining
Why is there a Transformation Zone in the cervix rather than a squamo-columnar junction?
Location of squamocolumnar junction changes over time Due to: - menarche - Pregnancy - menopause
=> area between the original SC Junction and the New SC junction is the Transformation Zone
What causes erosion of the endocervical tissue causing it to undergo squamous metaplasia?
acidic environment of vagina
What are Nabothian follicles and are these benign or malignant lesions of the cervix?
- dilated endocervical glands
- form almost polypoid-like structure
- Benign
What percentage of Cervical Intraepithelial Neoplasia (a precursor to cancer) occurs in the Transformation Zone?
90%
What inflammatory pathologies can present in the cervix?
Cervicitis
- often asymptomatic
- can lead to infertility due to silent fallopian tube damage
- non-specific acute/chronic inflammation.
Cervical polyp
- localised inflammatory outgrowth,
- Cause of bleeding, if ulcerated
- Not premalignant
What can cause cervicitis?
Chemical Irritants
Infection e.g. Chlamydia, Herpes Simplex
What neoplastic pathologies can present in the cervix?
- Cervical Intraepithelial Neoplasia (CIN)
- Cancer
=> Squamous carcinoma
=> Adenocarcinoma
What is the most important risk factor for development of neoplastic pathology in the cervix?
High Risk Human Papilloma Virus (HPV) types
- 16,18 = highest
(31,33,35,45,48…)
What other risk factors exist for CIN and cervical cancer?
- many sexual partners = increased risk of acquiring high risk HPV subtypes
- younger age of first intercourse/pregnancy
- long term use of oral contraceptives
- non-use of barrier contraception
- Smoking: 3 x risk
- Immunosuppression
How do genital warts appear on histology?
- thickened “papillomatous” squamous epithelium
- Cytoplasmic vacuolation
- Koilocytosis => Nuclear enlargement (2-3x normal size) and Irregularity of the nuclear membrane contour
How does the appearance of CIN differ from that of genital warts?
- Affected epithelium remains flat (unlike wart)
- shows koilocytosis, which can be detected in cervical smears
CIN is graded from 1-3 with Grade 3 being the most severe. What is Grade 3 CIN homologous to?
Carcinoma in situ
When does CIN 3 thought to become a cancer on microscopic analysis?
When the cells break through the basement membrane to invade the stroma
How long does it usually take for HPV infection to progress to CIN 3, and how long for CIN 3 to progress to cancer?
HPV infection to High grade CIN:
=> 6 months - 3 years
High Grade CIN to Invasive Cancer
=> 5 -20 years
What is dyskaryosis and how is this analysed from a smear sample?
- nuclear abnormalities (enlarged and pleomorphic)
- Nuclear:cytoplasm ratio increase
- analysed using cytology
CIN is asymptomatic and not visible to the naked eye. TRUE/FALSE?
TRUE
Mitotic figures present in mature cells above the basal layer is abnormal and indicates CIN. TRUE/FALSE?
TRUE
- mitotic figures should only be seen in basal layer as this is only dividing layer
- if mitotic figures are present in mature cells then these are replicating when they should not be
CIN grading depends on the severity of what 3 factors?
- Delay in maturation/differentiation
- Nuclear abnormalities
- Excess mitotic activity
Describe the differences between cytology of CIN 1-3?
CIN I
- Basal 1/3 of epithelium = abnormal cells.
- Mitotic figures in lower 1/3
- Surface cells mature, but nuclei abnormal.
CIN II
- Abnormal cells extend to middle 1/3.
- Mitoses in middle 1/3
- Abnormal mitotic figures
CIN III
- Abnormal cells occupy full thickness of epithelium.
- Mitoses in upper 1/3.
What is the largest risk factor for developing cervical cancer?
Not participating in the cervical screening programme
How will the cervical screening programme be changing as of March 2020?
- instead of analysing cytology, patients will be directly tested for high risk HPV subtypes
- If these are present, patients will then go on to have cells analysed by cytology
Describe the progression of Stage 1-4 cervical cancer?
Stage 1 - confined to cervix
Stage 2 - local spread => vagina/uterus
Stage 3 - Spread to pelvic wall
Stage 4 - Distant Metastases or bladder/rectal involvement
If patients do not attend screening and cervical cancer is not picked up early, what symptoms may they have?
- Abnormal bleeding => Post coital => Post menopausal => Brownish or blood stained vaginal discharge => Contact bleeding – friable epithelium
- Pelvic pain
- Haematuria (not really - just blood staining urine)
- Ureteric obstruction / renal failure
Describe how squamous cervical cancer normally spreads?
Local - uterine body, vagina, bladder, ureters, rectum
Lymphatic - EARLY => pelvic, para-aortic nodes
Haematogenous - LATE => liver, lungs, bone
What is meant by a well-differentiated tumour?
Completely changed to appear exactly like new cell type (e.g. like squamous epithelium)
Some squamous cancers found in the cervix can keratinise. TRUE/FALSE?
TRUE
What glandular lesions can occur in the endocervical region?
- cervical glandular intraepithelial neoplasia
- from endocervical epithelium
- preinvasive phase of endocervical adenocarcinoma
- also caused by HPV
Screening is less effective for CGIN (glandular lesions of endocervix). TRUE/FALSE?
TRUE
- More difficult to diagnose on cervical smear than squamous
=> Screening less effective
Endocervical Adenocarcinoma has a worse prognosis than squamous carcinoma of the cervix. TRUE/FALSE?
TRUE
Who is more likely to get endocervical adenocarcinoma?
- Higher Socioeconomic Class
- Later onset of sexual activity
- Smoking
- HPV infection => particularly HPV18.
What other abnormalities of the reproductive tract are caused by HPV?
Vulvar Intraepithelial Neoplasia, VIN
Vaginal Intraepithelial Neoplasia, VaIN
Anal Intraepithelial Neoplasia, AIN
ALSO
PeIN (Penile Intraepithelial Neoplasia)
PaIN (para-anal)
What is the difference between vulval intraepithelial neoplasia in younger vs older women?
Young women: often multifocal/ recurrent/ persistent causing treatment problems
Older women: greater risk of progression to invasive squamous carcinoma.
Vulval intraepithelial neoplasia is associated with what other disease?
Paget’s
- crusting rash (keratin on surface)
- Tumour cells in epidermis, contain mucin.
- No underlying cancer, tumour arises from sweat gland in skin
What age group usually develop invasive cancers from VIN?
- elderly women
- well differentiated
- Spread to inguinal lymph nodes (important for prognosis)
How is Vulvar Invasive Squamous Carcinoma (derived from VIN) treated?
Surgical treatment – radical vulvectomy and inguinal lymphadenectomy
What non-neoplastic diseases can occur in the vulval epithelium?
Lichen Sclerosis
Other dermatoses
- Lichen planus
- Psoriasis
Patients with VaIN also have CIN or VIN. TRUE/FALSE?
TRUE
Patients with VaIN have much less chance of progressing to vaginal cancer than CIN/VIN do for their respective cancers. TRUE/FALSE?
TRUE
Squamous carcinoma is common in what age group?
disease of the elderly
Melanoma can rarely appear in the vagina. Describe how this may appear?
Polyp
