Cervical, vulval pathology 2 Flashcards
How do invasive cervical carcinomas typically present and what do some rarely do making detection difficult?
As an unclerating mass protruding into the vagina
Note some carcinomas may grow inwards (rather than outwards to the vagina) resulting in a ‘barrel-shaped cervix’ adenocarcinomas are the most common type of carcinoma to potetially grow in this fashion, making it difficult to detect on cervical screening resulting in them potnetially being caught much later on
What is the most common type of cervical carcinoma ?
Squamous
Where do squamous cervical carcinomas arise ?
In the transformation zone developing from pre-exisiting CIN
Recall the guidelines for cervical screening in scotland
All women who are registered with a GP are invited for cervical screening:
- aged 25 to 49 – every 3 years
- aged 50 to 64 – every 5 years
- over 65 – only women who haven’t been screened since age 50 or those who have recently had abnormal tests
What are the symptoms of invasive cervical carcinomas
Usually no symptoms at microinvasive and early invasive stages (detected at screening):
- Abnormal bleeding
- Post coital
- Post menopausal
- Brownish or blood stained vaginal discharge
- Contact bleeding – friable epithelium
Pelvic pain
Haematuria / urinary infections
Ureteric obstruction / renal failure
What is the different staging of squamous cervical carcinoma ? (FIGO staging for cervical cancers)
Stage 1 - tumours confined to the cervix
- Stage 1A1 - depth up to 3mm, width up to 7mm
- Stage 1A2 - depth up to 5mm, width up to 7mm
- Low risk of lymph node metastases
- Stage 1B – clinically visible or dimensions greater than 1A
Stage 2 - spread to adjacent organs (vagina, uterus, etc..)
Stage 3 - involvement of pelvic wall
Stage 4 - distant metastases or involvement of rectum or bladder.
Describe the different areas squamous carcinoma can spread too
- Local e.g. uterine body, vagina, bladder, ureters, rectum
- Lymphatic (in early spread) e.g. pelvic, para-aortic nodes
- Haematogenous (in late spread) e.g. liver, lungs, bone
Appreciate that squamous carcinoma can be graded from:
Well-differentiated to poorly differentiated
What implications does this have on prognosis ?
Poorly differentiated carcinomas tend to have a more aggressive progression and ==> worse prognosis
What is the precursor lesion for cervical adenocarcinomas ?
Cervical Glandular Intraepithelial Neoplasia (CGIN) - note this is not graded like CIN
Where does Cervical Glandular Intraepithelial Neoplasia (CGIN) originate in the cervix ?
Endocervical epithelium ==> adenocarcinomas of the cervix typically arise from the endocarvical epithelium (columnar)
Why is it more difficult to diagnose cervical adenocarcinomas comapred to squamous ?
Becuase they arise in endocervical epithelium which is not as easily swabbed during smear test
What are the risk factors for endocervical andenocarcinoma ?
- Higher Socioeconmic Class
- Later onset of sexual activity
- Smoking
- HPV again, particularly HPV18.
Which carries the worse prognosis - adenocarcinoma or squamous carcinoma of the cervix?
Adenocarcinoma as often caught later
What type of cervical carcinoma is shown here ?
Squamous cell carcinoma of the cervix, its characterisitcs include:
- normal features of cancer but also better differentiated ones may have kertain perals seen (the swirlls of pink)
- Compared to adenocarcinoma, have more irregular cellular and nuclear shapes, more cytoplasmic density, more chromatin granularity, more hyperchromasia
What type of cervical cancer is shown
Adenocarcinoma
Increased number of glands plus normal malignant features
What is the main type of cancer affecting the vulva ?
Squamous cell carcinoma
What is the precursor lesion for vulval carcinomas and how are they graded ?
- Vulvar intraepithelial neoplasia
- Has 3 grades just like CIN
What are the two main groups of women in which Vulvar intraepithelial neoplasia can arise in ?
- Most common group is post-menopasual women greater risk of progression to invasive squamous cell carcinomas
- 2nd group is young women who it is often multifocal, recurrent or persistent causing treatment problems and typically develop basloid or warty carcinoma (squamous)
What are vulval carcinomas often associated with ?
HPV infection
If Vulvar intraepithelial neoplasia is detected what is there also going on ?
Cervical and vaginal neoplasia (CIN & VaIN).
Describe the typical presentation of vulval squamous cell carcinoma and someone with it
Usually elderly women but may present in someone considerably younger
Presents with vulval itching, irritation or pain. Women may also notice a lump, bleeding or discharge.
How is vulval carcinoma diagnosed ?
Biopsy of the lesion
What is the likely place in which an invasive carcinoma (squamous) of the vulva can spread too ?
The inguinal lymph nodes
What is the treatment of vulvar squamous cell carcinoma ?
- Lesions less than 2 cm in diameter and confined to the vulva or perineum, with stromal invasion less than or equal to 1.0 mm (FIGO stage Ia) can be managed by wide local excision only, without groin node dissection.
- Dissection of the groin nodes (unilateral or bilateral) should be performed when the depth of invasion is greater than 1 mm (FIGO stage Ib or worse) or the maximum diameter of the tumour is greater than 2 cm.
- Advanced vulval carcinoma - Wide, radical, local excision with a minimum of 15 mm diseasefree margin may be used but some tumours will require a radical vulvectomy + inguinal lymphadenectomy
What is pagets disease of the vulva and describe its presentation?
A rare, slow-growing, usually noninvasive intraepithelial (in the epidermis) adenocarcinoma
Presents as a erythematous plaque with typical white scaling + irritation, itching, and burning.
What are the other diseases to simply be aware of which can affect the vulva ?
Infections:
- Candida (Particularly diabetics)
- Vulvar warts (HPV 6 & 11)
- Bartholin’s gland abscess (blockage of gland duct)
Non Neoplastic Epithelial disorders:
- Lichen Sclerosis
- Other dermatoses
- Lichen planus
- Psoriasis
What is the take home message about vaginal carcinomas ?
- Primary tumours are very rare here and the most common type of prmiary tumour is squamous carcinomas
- Before diagnosis of a primary tumour of the vagina can be made the possibility of extension of either a vulval or cervical carcinoma into the vagina must be excluded as this is the most common.
- VaIN :Vaginal intraepithelial neoplasia is the precursor lesion and often associated with ongoing cervical and vulva lesions so check these areas
What is the treatment for vulval carcinoma ?
radical vulvectomy and inguinal lymphadenectomy.
Define what lichen sclerosus is and where is commonly affects
- It is an inflammatory condition which usually affects the genitalia and is more common in elderly females.
- Lichen sclerosus leads to atrophy of the epidermis with white plaques forming
Describe the appearance of vulval lichen sclerosus
- Ivory or porcleain-white, shiny lesions
- Commonly associated with areas of purpura
What are the signs/symptoms of vulval lichen sclerosus
- Pruritus vulva (itch) is the main symptom - worse at night, may disturb sleep
- Painful vulva
- Genital or anal bleeding
- Constipation
- Dysparenuria and sexual dysfunction
- Dysuria
Symptoms are generally due to tightening around the area
What are the potential complications of vulval lichen sclerosus ?
- Scarring of vulval skin
- Small risk of development into squamous cell carcinoma
How is vulval lichen sclerosus diagnosed ?
- 1st line = clinical diagnosis from appearance
- 2nd line = skin biopsy for histopathology to exlcude cancer
biopsy done if there if there is suspicion of cancer - new or exisiting skin lesions that are not responsive to steroid treatment
What is the management of vulval lichen sclerosus ?
1st line = steroid ointments (clobetasol proprionate) + emoillients & avoid skin irritants
