Cervical, vulval pathology Flashcards
Define the ectocervix and the endocervix
- Ectocervix = The lower part of the cervix, known as the vaginal portion of the cervix (orectocervix), bulges into the top of the vagina.
- Endocervix = or endocervical canal, is a tunnel through the cervix, from the external os into the uterus.
What is the linning of the ectocervix and the endocervix ?
- The ectocervix is linned by stratified squamous epithelium
- The endocervix is linned by simple columnar epithelium
Define what the transformation zone is
Squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia
Does the transformation zone stay in the same place and if not why?
It does not, it moves about throughout life due various factors:
- Menarche
- Pregnancy
- Menopause
Define metaplasia
Transformation of one differentiated cell type to another differentiated cell type.
What can cervical erosion/ectropion lead too and how does it occur ?
- It occurs due to exposure of delicate endocervical (endocervix) epithelium to acid environment of vagina because glandular cells (or columnar epithelium), are present on the ‘outside’ of the vaginal portion of the cervix.
- Leading to physiological squamous metaplasia
- Nabothian follicles (mucus-filled cysts on the surface of the cervix) - often form when squamous (statified) metaplasia occurs where columnar epithelium once was
What is the presentation of cervical erosion/ectropion ?
There is a red ring around the cervical os because columnar epithelium has this appearance
It is prone to bleeding, excess mucus production and to infection
What are the 2 main inflammatory cervical pathologies ?
Cervicitis and cervical polyps
Define what cervicitis is and what are its causes
It is inflammation of the cervix whcih can lead to infertility due to simultaneous silent fallopian tube damage and can be caused by
Causes include:
- non-specific acute/chronic inflammation.
- Follicular cervicitis – sub epithelial reactive lymphoid follicles present in cervix.
- Chlamydia Trachomatis – sexually transmitted
- Herpes Simplex Viral Infection
What are the signs/symptoms of cervicitis ?
Many women dont have symptoms and it may only be found on routine exammination
Possible symptoms include:
- Grayish or pale yellow vaginal discharge
- Abnormal vaginal bleeding, such as bleeding after sex or between periods
- Pain during sex
- Difficult, painful, or frequent urination
- Pelvic or abdominal pain or fever, in rare cases
What is a cervical polyp ?
These are pendunculated benign tumours of the endocervical epithelium
Describe the presentation of a cervical polyp
- Pedunculated (elognated sac of tissue)
- May cause increased mucus discharge and/or postcoital bleeding
Define neoplasia
Neoplasia is the abnormal growth and proliferation of abnormal cells - these can be benign or malignant
What are the 2 main neoplastic pathologies seen in the cervix?
- Cervical intraepithelial neoplasia (CIN)
- Cervical cancer
What are the 2 main types of cervical cancer ?
- Adenocarcinoma
- Squamouscarcinoma
What are the risk factors for developing CIN/Cervical carcinoma ?
Persistence of High Risk Human Papilloma Viruses, mostly types 16,18 (there are other types, these 2 account for roughly 75% of cases)
Vulnerability of SC Junction in early reproductive life:
- age at first intercourse (earlier the higher risk)
- long term use of oral contraceptives - once used for 5 years the risk increases
- non-use of barrier contraception
Smoking: 3 x risk
Immunosuppression
Describe the progression of infection with high risk HPV (16&18) if not cleared from the body
- HPV infection ==> causing High grade CIN roughly 6 months - 3 years later
- High Grade CIN ==> results in Invasive Cancer roughly 5 -20 years later
Note 90% of women who are infected with HPV there cells heal (i.e. not all with CIN progress to cervical cancer, increased grade of CIN makes progression more likely though)
What is CIN ?
Pre-invasive stage of cervical cancer
It is defined as the replacement of the normal cervical mucosa by neoplastic cells, but there is still an intact basement membrane
Where does CIN occur ?
Occurs at the transformation zone. - so this is talking about the cervical intraepithelial neoplasia (CIN) whcih can give rise to squamous carcinoma (slight difference convered later for pre-cursor for adenocarcinoma)
How is CIN detected ?
Cervical screening as it is asymptomatic so wont be able to detect it anyother way
What are the histological features of CIN?
Due to classic morphological features of malignancy:
Delay in maturation/differentiation:
- immature basal cells occupying more of epithelium
Nuclear abnormalities:
- hyperchromasia - more intensely staining nucleus than normal
- increased nucleocytoplasmic ratio
- pleomorphism - variation in size and shape of cells
Excess mitotic activity
- situated above basal layers
- abnormal mitotic forms
Appreicate this pic of HPV infection causing mild dyskaryosis (CIN 1)
Dyskaryosis = An abnormality of nuclei seen in exfoliated cells, often cells from the uterine cervix, in which the cytoplasm remains unchanged but the nuclei exhibit hyperchromatism, irregularity or enlargement, or an increase in number.
How is CIN graded ?
It is graded from 1 to 3 on the proportion of in thirds of the epithelium whcih is occupied by abnormal cells
CIN I - 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.
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, often abnormal, in upper 1/3.
What classification of CIN is shown ?
CIN 1
Compare to the normal ectocervix its easier to see this way
What classification of CIN is shown ?
CIN 2
What classification of CIN is shown ?
CIN 3 - not how the basement membrane is still intake hence grade 3 and not invasive carcinoma
