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Cervical Vulval Pathology Flashcards

1
Q

Label this histology slide or the cervix

State which part of the cervix it is

and is it normal

A

a) exfoliating cells
b) superficial cells
c) intermediate cells
d) parabasal cells
e) basal cells
f) basement membrane

Normal ectocervix

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2
Q

What type of epithelium is this?

Where is it found in the cervix?

Is it normal?

A

Columnar epithelium

Normal endocervix

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3
Q

What is the transformation zone?

A

Transformation zone is the squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia

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4
Q

Is the transformation zone found in the same part of an individual’s cervix throughout her life?

A

No. The position of the transformation zone alters during life as physiological response to:

  • menarche
  • pregnancy
  • menopause
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5
Q

When does the transformation zone move?

A

Physiological response to:

  1. menarche
  2. pregnancy
  3. menopause
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6
Q

With regards to pathology; what’s important about the transformation zone?

A

Transformation zone is where 90% of cervical intraepithelial neoplasias are found

It is liable to infection and pre-malignant changes

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7
Q

What is clinically important to remember about the transformation zone?

A

TZ is where cervix is most liable to infection and pre-malignant changes and :. this is where we want smear test to come from

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8
Q

What can be seen on this histology slide?

A

The transformation zone!

It’s a squamo-columnar junction- hence the big “drop-off”

  • squamous epithelium is a couple of layers thick but columnar is just the one layer thick
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9
Q

What does cervical erosion describe?

A

physiological metaplasia of cervix!

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

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10
Q

Why/when does the vagina become more acidic?

What happens as a result?

A

Hormonal changes at the time of menarche make the vagina more acidic

The result is cervical erosion:

  • protective mechanism where columnar epithelium undergoes physiologial metaplasia to become squamous
  • like when a lung columnar epithelium of a smoker undergoes metaplasia to squamous as a protective mechanism except that would be lung cancer and not physiological
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11
Q

What are the types of pathology seen in the cervix?

(very broadly speaking)

A

Inflammatory and

Neoplastic

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12
Q

What are the two inflammatory conditions you need to know?

A

Cervicitis

Cervical polyp

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13
Q

For cervicitis discuss:

  1. symptoms
  2. acute/chronic inflammation?
  3. aetiology
  4. complications
A
  1. often asymptomatic
  2. non-specific acute/chronic inflammation
    • follicular cervicitis- sub epithelial reactive lymphoid follicles present in cervix
    • chlamydia trachomatis- sexually transmitted
    • herpes simplex viral infection
  4. can lead to infertility due to simultaenous silent fallopian tube damage
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14
Q

for cervical polyp discuss:

  1. symptoms
  2. what is it
  3. premalignant/non-premalignant?
A
  1. if ulcerated can cause bleeding
  2. localised inflammatory outgrowth
  3. not premalignant
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15
Q

What types of neoplasia can occur in the cervix?

A
  1. Cervical Intraepithelial Neoplasia
  2. Cervical Cancer
    • squamous carcinoma
    • adenocarcinoma
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16
Q

Which types of HPV are most associated with cervical cancer?

A

HPV 16 and HPV 18

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17
Q

What percentage of cervical cancer is associated with HPV?

A

75%

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18
Q

What is CIN and what is the difference between CIN and Cervical Cancer?

A

CIN stands for Cervical Intraepithelial Neoplasia

Because CIN is intraepithelial it is not cancer. Cancer is malignant by definition and therefore has to invade the basement membrane.

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19
Q

What are some of the risk factors for CIN/Cervical Cancer?

A
  • persistance of high risk HPV
    • many sexual partners increases risk
  • vulnerability of SC Junction in early reproductive life
    • age at first intercourse
    • long term use of oral contraceptives
    • non-use of barrier contraceptive
  • smoking 3x risk
  • immunosuppression
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20
Q

What strains of HPV are most associated with genital warts?

A

6 and 11

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21
Q

Describe the histological changes seen in genital warts

A
  • Condyloma acuminatum:
    • thickened “papillomatous” squamous epithelium with cytoplasmic vacuolation (“koiocytosis”)
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22
Q

What does this histology slide show?

A

Cervical Intraepithelial Neoplasia caused by HPV 16 & 18

Circle the infected cells

  • high nuclear to cytoplasmic ratio
  • “raisiny-looking” nuclei
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23
Q

What does this histology slide show?

A

Cervical cancer

Invasive squamous carcinoma: Virus integrated into host DNA

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24
Q

What is the time range between contracting HPV and developing a high grade CIN?

A

HPV Infection –> High Grade CIN

  • 6 months to 3 years
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25
Q

What is the time range between developing a high grade CIN and developing an invasive cancer?

A

High Grade CIN –> Invasive Cancer

5 to 20 years

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26
Q

Circle the normal squamous cells in this slide and the abnormal ones

Describe the abnormalities

A

Mild dyskaryosis with Viral Features (HPV)

  • Normal (circled in green) squamous cells have lots of cytoplasm
  • Abnormal cells (circled in red):
    • much darker
    • can see folds in nuclear membrane
    • higher nuclear:cytoplasmic ratio
    • nucleus looks a raisin
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27
Q

What is CIN?

A

CIN is the pre-invasive stage of cervical cancer

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28
Q

Where does CIN most commonly occur?

Do CINs have a large surface area?

A

Occurs at the transformational zone

Can involve large area

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29
Q

Is CIN dysplasia or metaplasia?

A

DYSPLASIA of squamous cells

30
Q

What symptoms would somebody with CIN present with?

A

NONE

It’s asymptomatic

and hence screening is so important

31
Q

Use the appropriate terminology to describe this schematic

A
  1. Normal squamous epithelium
  2. Koilocytosis
  3. CIN I
  4. CIN II
  5. CIN III

It’s a diagram of cervical epithelium showing progressive degrees of dysplasia and neoplasia

32
Q

What is seen on the histological slide of CIN?

A
  • Delay in maturation/differentiation
    • immature basal cells occupying more of epithelium
  • Nuclear abnormalities
    • hyperchromasia
    • increased nucleocytoplasmic ratio
    • pleomorphism
  • Excess mitotic activity
    • situated above basal layers
    • abnormal mitotic forms
  • Often koilocytosis
    • indicates HPV infection
33
Q

How is CIN graded?

A

CIN is graded I-III depending on severity of:

  1. Delay maturation/differentiation
  2. Nuclear abnormalities
  3. Excess mitotic activity
34
Q

Describe a Grade I CIN

A
  • Basal 1/3 of epithelium occupied by abnormal cells
    • raised numbers of mitotic figures in lower 1/3
    • surface cells quite mature, but nuclei slightly abnormal
35
Q

Describe a Grade II CIN

A
  • Abnormal cells extended to middle 1/3
    • mitoses in middle 1/3
    • abnormal mitotic figures
36
Q

Describe a grade III CIN

A
  • Abnormal cells occupy full thickness of epithelium
    • mitoses, often abnormal, in upper 1/3
37
Q

How common is squamous carcinoma of cervical?

A
  • 75%-95% of malignant cervical tumours
  • 2nd commonest female cancer, worldwide
38
Q

Why is screening for squamous carcinoma so important?

A

Squamous carcinoma develops from pre-existing CIN, therefore most cases should be preventable by screening

39
Q

What symptoms might a woman with squamous carcinoma present with?

A
  • Usually none 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
40
Q

Where does a squamous carcinoma spread locally?

A
  • uterine body
  • vagina
  • bladder
  • ureters
  • rectum
41
Q

Where does squamous carcinoma spread lymphatically?

A
  • pelvic nodes
  • para-aortic nodes
42
Q

Where does squamous carcinoma spread haematogenously?

A
  • liver
  • lungs
  • bone
43
Q

What’s the really pink stuff?

44
Q

What does CGIN stand for?

and what does it mean?

A

Cervical Glandular Intraepithelial Neoplasia

CGIN is preinvasive phase of endocervical adenocarcinoma

45
Q

Is screening more effective for CGIN or CIN?

A

CIN

CGIN is more difficult to diagnose on cervical smear than squamous

although CGIN is sometimes associated with CIN

46
Q

What percentage of cervical cancer is made up of endocervical adenocarcinoma?

A

5-25% of cervical cancer

47
Q

Which has a worse prognosis, squamous carcinoma or endocervical adenocarcinoma?

A

Endocervical adenocarcinoma has a worse prognosis than squamous carcinoma

48
Q

What are the risk factors for adenocarcinoma?

A
  1. Higher S.E class
  2. Later onset of sexual activity
  3. Smoking
  4. HPV again incriminated, particularly HPV18
49
Q

What are the other HPV-driven diseases you need to know?

A
  • Vulvar Intraepithelial Neoplasia, VIN
  • Vaginal Intraepithelial Neoplasia, VaIN
  • Anal Intraepithelial Neoplasia, AIN
50
Q

What types of vulvar intraepithelial neoplasia are there?

A

Vulvar intraepithelial neoplasia (VIN)

and

Paget’s disease

51
Q

What groups of women are more likely to present with vulval intraepithelial disease (VIN)?

A

It’s bimodal:

  1. Young women
    • often mutlifocal, recurrent or persistent causing treatment problems
  2. Older women
    • greater risk of progression to invasive squamous carcinoma
52
Q

What’s the relationship between HPV and VIN?

A

VIN is often, but not always, HPV related

53
Q

What is the relationship between VIN and CIN & VaIN?

A

VIN is often synchronous with cervical and vaginal neoplasia (CIN & VaIN)

54
Q

How does vulvar invasive squamous carcinoma develop?

A

Vulvar invasive squamous carcinoma can arise from normal epithelium or VIN

55
Q

Who normally gets vulvar invasive squamous carcinoma?

What does it look like?

A

Usually elderly women

Ulcer or exophytic mass

56
Q

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

A

Inguinal lymph nodes

57
Q

What is the surgical treatment for vulvar invasive squamous carcinoma?

What are the outcomes?

A

Surgical treatment- radical vulvectomy and inguinal lymphadenectomy

If it’s left sided tumour, left inguinal nodes are removed. If it’s a medial tumour both L&R inguinal nodes are removed.

  • 90% 5 year survival- node negative
  • <60% 5 year survival- node positive
58
Q

If you see keratin on a histology slide what type of cancer is it?

59
Q

Describe the pathology of Vulvar Paget’s disease

A
  • tumour cells in epidermis, contain mucin
  • mostly no underlying cancer, tumour arises from sweat gland in skin
  • it’s like an adenocarcinoma of the skin and primarily affects vulva
60
Q

How does vulvar Paget’s disease present clinically?

A

It’s a crusting rash (keratin causes the crust)

Spreads along vulva and sometimes down the thighs; may go into anus and can spread to vagina

Painful

Itchy

Weeping, oozing

VERY RARE

61
Q

What does this slide show?

A

Paget’s disease of the vulva

NB: the keratin along the top of the slide which causes the crusty presentation

62
Q

What vulvar infections do you need to know about?

A
  1. Candida
  2. Vulvar warts
  3. Bartholin’s gland abscess
63
Q

What group of people are more likely to get a Candida infection of the vulva?

64
Q

Which strains of HPV are most associated with vulvar warts?

65
Q

How does Bartholin’s gland abscess occur?

A

Blockage of gland duct

66
Q

What non-neoplastic epithelial disorders are there?

A
  • Lichen sclerosis
  • Other dermatoses
    • lichen planus
    • psoriasis
67
Q

What three vaginal pathologies do you need to know about?

A
  1. VaIN
  2. Squampus carcinoma of vagina
  3. Melanoma
68
Q

Discuss VaIN

A

Vaginal intraepithelial neoplasia

May also have cervical and vulval lesions

69
Q

Discuss squamous carcinoma of vagina

A

Less common than cervical and vulval counterparts

A disease of the elderly

70
Q

Discuss melanoma of the vagina

A

Rare

May appear as a polyp

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