Female Genital Tract 1

Question 1

What are the layers of a normal ectocervix?

Answer 1

1. nonkeratinized stratified squamous epithelium (cell with a lot of glycogen-low ph, lactobacillus produce)
2. stroma=dense connective tissue; small amount of smooth muscle

Question 2

What cells make up the endocervix?

Answer 2

simple columnar epithelium

Question 3

What happens in the cervical transformation zone from birth to young adult to adult?

Answer 3

1. Young adult: the columnar epithelium everts
2. acidity of vagina is one factor that encourages squamous metaplastic change
3. band of squamous metaplasia lying between the original and new SCJ(squamocolumnar junction=transformation zone
   - exocervix with restored squamous columnar junction

Question 4

What are the three steps of the squamous metaplasia of transformation zone?

Answer 4

1. Early stage: reserve cells begin to proliferate
2. Later stage: proliferating reserve cells displace the glandular epithelium
3. Final step: cells mature into glycogen-rich squamous cells

Question 5

Why does the transformation zone matter?

Answer 5

site of cervical squamous carcinoma

Question 6

What are the high and low risk types of HPV, a oncogenic DNA virus?

Answer 6

High risk: 16, 18, 31, 33

Low risk: 6, 11

Question 7

What happens with low risk HPV 6, 11 episomal infection? what is the characteristic cell?

Answer 7

condyloma 
characteristic cell=koilocyte
-nuclear enlargement
-irregular nuclear membrane contour
-hyperchromasia
-perinuclear halo 

exophytic condyloma “condyloma acuminatum”

Question 8

What happens with high risk HPV 16,18 viral integration?

Answer 8

1. CIN
persistent infection
2. Higher grade CIN
3. invasive cancer
4. Metastasis

Question 9

How is HPV oncogenic?

Answer 9

1. HPV oncoproteins E6, E7 bind to Rb and p53 and neutralize their function
2. monoclonal outgrowth of squamous cells

Question 10

What is the difference between CIN1 and CIN2/CIN3?

Answer 10

CIN 1= low grade SIL

• koilocytes prominent
• basalmost layer is orderly

CIN2/CIN3=high grade SIL
-abnormal mitotic figures
-basalmost layer is jumbled
(CIN3 full thickness)

Question 11

How do you manage CIN/SIL?

Answer 11

Biopsy

• via colposcopy
• contour, color, and vascular pattern distinguish LSIL, HSIL

LSIL-observation
HSIL-surgical excision, long term follow up

Question 12

What do the bivalent vaccines protect against, what about the quadrivalent?

Answer 12

bivalent: 16, 18
quadrivalent: 16, 18, 6, 11

Question 13

Some invasive carcinoma of the cervix are from somatically acquired mutations in what tumor suppressor gene?

Answer 13

LKB1

Question 14

WHat is the peak incidence, symptoms and key risk factor for invasive carcinoma of the cervix?

Answer 14

45 yrs old
symptoms: vaginal bleeding, leukorrhea, dyspareunia, dysuria
key risk factor: high risk HPV infection
other risk factors: smoking, immunodeficiency (AIDs defining illness)

-keratin peras in well differentiated tumors

Question 15

What is the treatment for cervical carcinoma?

Answer 15

hysterectomy, lymph node dissection
-mortality strongly correlated to tumor stage
advanced disease=local invasion, obstruction of ureters and urinary bladder

Question 16

What are the different stages of cervical cancer?

Answer 16

0: carcinoma in situ
1: confined to cervix
2: extends beyond cervix but not to pelvic wall, involves vagina but not lower 1/3
3: extends to pelvic wall, involves vagina lower 1/3
4: extends beyond true pelvis or involves bladder or rectum

Question 17

How common is vulva squamous cell carcinoma? who, risk factors, precursor, presentation, metastases

Answer 17

1. 3% of all femal genital cancers
2. > 60 yrs old
3. risk factors
   - high risk hpv 16, 18
   - non hpv related: lichen sclerosus
4. precursor: vulvar intraepithelial neoplasia
5. presentation: leukoplakia
6. metastases: regional lymph nodes

Question 18

How common is vaginal squamous cell carcinoma? who, risk factors, precursor, presentation, metastases

Answer 18

1. extremely uncommon
2. > 60 yrs old
3. risk factors
   - high risk hpv 16, 18
4. precursor: vaginal intraepithelial neoplasia
5. presentation: vaginal bleeding, discharge
6. metastases: regional lymph nodes

Question 19

lichen sclerosus

Answer 19

postmenopausal women
-uncertain etiology, but suspect autoimmune
Symptoms: none, pruritus, soreness, irritation
Histology: Thinning of epidermis, fibrosis of dermis
Physical exam: leukoplakia-thin white plaques on vulva
small risk of progression to cancer

Question 20

Vulva condyloma

Answer 20

war
condyloma acuminata
HPV 6, 11
low risk of progression to cancer

Question 21

condyloma lata

Answer 21

treponema pallidum

stage 2 syphilis-teeming with spirochetes

Question 22

lichen simplex chonicus

Answer 22

associated with chronic irritation, scratching
Histology: hyperplasia of vulvar epithelium
Exam: leukoplakia; thick leathery skin
No increased risk of malignancy

Question 23

paget disease of the vulva (extramammary paget disease)

Answer 23

1. intraepidermal proliferation of malignant cells
   - can also occur in breast nipple
2. no underlying tumor
3. arise from intra-epidermal progenitor cells
4. presents as RED, scaly, crusted plaque

Histology: single cells with pale vacuolated cytoplasm with abundant glycosaminoglycans
PAS +
cytokeratin +
not S100 positive vs melanoma

Question 24

clear cell adenocarcinoma of vagina

Answer 24

• rare malignancy associated with diethylstilbestrol exposure in utero
• malignancy proliferation of glands with clear cytoplasm
• precursor lesion= vaginal adenosis-persistence of columnar epithelium in upper 1/3 vagina
• clinical examination: red, granular areas adjacent to normal pale pink vaginal mucosa

Question 25

embryonal rhabdomyosarcoma of vagina

Answer 25

• aka sarcoma botryoides
• rare primary vaginal cancer
• children