Chapter 16 - Cervix & Vagina Flashcards
Name two types of cervical biopsies.
For what indication are they performed?
ECC (smallest) and LEEP/cone (ink!)
Usually done to evaluate for squamous or glandular dysplasia.
Describe the normal histology of the ectocervix. How does it vary with age?
Nonkeratinized squamous epithelium continuous with surrounding vaginal wall. While plump and full of glycogen in younger women, in postmenopausal women it may be thin and atrophic.
Describe the normal histology of the transitional zone.
What is the signifiance of squamous metaplasia here?
Abrupt transition from squamous to mucous-secreting columnar epithelium.
Squamous metaplasia results from irritation/inflammation, and can only be called above the transition zone and in the presence of normal endocervical component
Describe the normal histology of the endocervical glands.
Branching and complex glands that are pale with a dark outline of crescent-shaped nuclei. Squamous metaplasia can occur here and replace the glands.
Describe the appearance of the cervical stroma.
It is very fibrotic, and may feature numerous normal cysts and glandular proliferations.
What are the morphologic features of LSIL?
Viral cytopathic effect involving primarily the upper cell layers of the epithelium.
Koilocytes, with wrinkled hyperchromatic nuclei and perinuclear halo. Binucleation is common.
Maintenance of basal layer. Mitoses in lower 1/3 only.
What are the morphologic features of HSIL?
Dysplastic changes with higher N/C ratio.
Atypia in all cell layers, with boulder nuclei and many mitoses (CIN2 in middle third, CIN3 full-thickness).
HSIL can grow into endocervical glands (report this!)
What benign entity can be mistaken for HSIL? What are its morphologic features?
Immature squamous metaplasia, featuring:
Well-defined cell borders & low N/C ratio, pinker than HSIL, birds-egg nuclei, surface mucin.
“Boiling mud” look?
What immunostaining can differentiate HSIL from immature squamous metaplasia?
Ki67 (proliferation; positive only in basal layer in metaplasia)
p16 (HPV; negative or at most focal in metaplasia)
Describe the morphologic features of reactive cervical epithelium.
Regularly spaced nuclei with prominent nucleoli and smooth contours
Maturing uper layers without atypia
Spongiotic edema
Neutrophils
What are the features of squamous invasion in the cervix?
Same as in other sites:
Deep keratinization & desmoplastic stromal response
Large nucleoli
Blurred/sawtooth interface between epithelium and stroma, loss of palisading basal layer
How is squamous microinvasion defined, and what is its significance?
Invasion to a depth of less than 3 mm, which has a better prognosis.
What is the differential diagnosis for squamous invasion?
Pseudoepitheliomatous hyperplasia
Glandular involvement by HSIL
Placental site nodules
How can invasive squamous carcinoma be distinguished from glandular involvement by HSIL?
Look for remnants of columnar epithelium, a smooth rounded contour to the gland, and lack of individual cells in the stroma. All suggest glandular involvement.
What is a placental site nodule?
Describe their morphology.
A remote remnant of pregnancy.
Look for aggregates of trophoblastic cells that look bizarrely atypical, found in hyaline nodules.
What is an endocervical polyp?
A polyp with fibrotic stroma and normal glands or epithelium. May have cysts, inflammation, or tubal metaplasia.
What is a nabothian cyst?
What are tunnel clusters?
Nabothian cyst is a large dilated mucous-filled gland lined with columnar epithelium.
Tunnel clusters are lobular groups of complex branching glands also with columnar epithelium.
What is the significance and morphology of microglandular hyperplasia?
It is associated with OCP use.
Looks like a proliferation of small back-to-back glands with cuboidal/columnar cells with mucin vacuoles. It is cribriformed but pink.
Describe the morphologic features of endometriosis.
Dense blue palisaded columnar glands without mucus (endometrium!), with edematous stroma. Look for red blood cells or hemosiderin.
Name 3 glandular lesions in the cervix.
Reactive atypia
Adenocarcinoma in situ (AIS)
Invasive adenocarcinoma
Describe the morphologic features of cervical adenocarcinoma in situ.
Close clusters of dark glands
Tall, pseudostratified & hyperchromatic nuclei with nucleoli.
Papillary or cribriform architecture (beware stromal invasion)
Mucin
Ki67++, P16 diffusely positive
Describe the morphologic features of invasive cervical adenocarcinoma.
Cell clusters diving into the stroma with desmoplastic response.
Glands that are significantly deeper and back-to-back.
How can endocervical adenocarcinoma be distinguished from endometrial adenocarcinoma?
Immunohistochemistry; endocervical should be p16+, while the endometrial should be ER+/PR+.
Describe the role of HPV in vaginal and vulvar disease.
HPV causes squamous lesions which follow the same progression as in the cervix. VIN1-3.
What is bowenoid papulosis?
A clinical term to refer to VIN3, or vaginal/vulvar carcinoma in situ.
Describe the morphologic features of condyloma acuminatum.
An exophytic, verrucous lesion with subtle LSIL-changes. Epithelium predominates over stroma, otherwise consider a skin tag.
Describe the gross and histologic morphologic features of lichen sclerosus.
Gross: Flat, white, shiny patch.
Histo: Pale swath of collagen beneath a thin epidermis.
Describe the morphologic features of lichen simplex chronicus.
What should be considered before making this diagnosis?
Epidermal thickening and hyperkeratosis over a chronically inflamed dermis.
Diagnosis of exclusion; first rule-out fungal infection and squamous dysplasia!
Describe the morphology and clinical significance of Paget’s disease, extramammary type.
Large atypical carcinomatous cells percolating through a benign epidermis.
Unlike in the breast, its presence does not reflect an underlying cancer. Melanoma must be considered in a differential, however.
Squamous metaplasia at the transition zone (arrow)
Endocervical glands
Arrow: Apical mucin glands and basal nuclei
LSIL
Arrows: Koilocytes
HSIL
Immature squamous metaplasia
Left: Squamous dysplasia
Arrow: Nested irregular cells
Arrowhead: Prominent nucleoli
Right: Reactive changes
Arrow: Small, dense nucleoli
Invasive squamous cell carcinoma
Arrow: Huge & pleomorphic cells
Arrowhead: Ragged border & infiltrating cells
Placental site nodule
Arrow: Decidualized periphery
Arrowhead: Mostly small and oval nuclei with smudgy chromatin
Microglandular hyperplasia
Arrow: Mucinous cells
Arrowhead: Squamous metaplasia
Endometriosis
Arrow: Endometrial epithelium
Arrowhead: Bloody endometrial stroma
Endocervical adenocarcinoma in situ
Arrow: Intestinal-type goblet cells
Arrowhead: Residual normal gland
Circle: Mitoses
VIN3.
Arrow: Large atypical cells
Arrowhead: Hyperkeratosis and parakeratosis
Condyloma.
Arrow: Hyperkeratotic squamous epithelium
Arrowhead: Prominent fibrovascular cores
Lichen sclerosus
Arrow: Dense, pale, homogenous collagen band
Paget’s disease, extramammary type
Arrowhead: Nonsquamous paget cells
