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SBCP Pathology > Gynae Pathology > Flashcards

Gynae Pathology Flashcards

1
Q

Describe the epithelium of the cervix.

A

Outer part is the ectocervix lined by squamous epithelium.
Inner part is the endocervix lined by glandular epithelium. These cells secrete mucin.
The transformation zone is the junction of the ectocervix and the endocervix.

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2
Q

What is the clinical significance of the

transformation zone?

A

Pre-malignant and malignant lesions tend to arise at this location.

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3
Q

Describe the histology of the ectocervix.

A

Stratified squamous non-keratinising epithelium. Numerous layers of cells piled on top of each other with movement from cuboidal and young to squamous and old. This has a protective function.
At the base the nuclei are close together and as you move towards the surface the nuclei are further apart.
Nuclei small and look the same.

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4
Q

Describe the histology of the endocervix.

A

Single layer of glandular epithelium. The nuclei are at the base of the cell and the cells contain abundant pale staining mucous.

This epithelium lines the surface and dips down into the stroma.

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5
Q

What is the aim of cervical screening?

A

The detection of premalignant conditions which if untreated could go on to develop into invasive cancer.

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6
Q

Which pre-malignant changes in the cervix are picked up on cervical screening?

A

Cervical Intraepithelial Neoplasia (CIN).

(Most pre-invasive abnormalities affect the squamous epithelium. Rarely get pre-invasive lesions involving the endocervical glands).

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7
Q

What is the next stage for each of these results from a cervical smear.

  • Negative
  • Unsuitable
  • Borderline nuclear changes
  • Mild dyskaryosis
  • Moderate dyskaryosis
  • Severe dyskaryosis.
A

-Negative: means normal smear. Continue with routine screening every 3-5 years.
-Unsuitable: e.g. not enough cells on the slide, a lot of blood, a lot of inflammatory cells. Repeat asap in 3 months.
- Borderline nuclear changes: unknown if changes are pre-malignant or reactive. Repeat after 6 months.
-Mild dyskaryosis: repeat after 6 months. If noticed on 2 consecutive smears then refer to gynaecologist. (Often regresses back to normal within 6 months).
-Moderate dyskaryosis &
-Severe dyskaryosis:
Refer to a gynaecologist as a significant lesion may be present.

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8
Q

What is dyskaryosis of a cervical smear?

How is it classified?

A

Dyskaryosis is the presence of abnormal nuclei in a cervical smear.

It is classified as follows:
CIN I is mild dyskaryosis.
CIN II is moderate dyskaryosis.
CIN III is severe dyskaryosis.

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9
Q

Describe the histological appearance of koilocytosis?

What does this finding indicate?

A

Slightly enlarged nuclei.

It is a manifestation of HPV infection within the cervix.

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10
Q

Describe the cytological appearance of:

  • CIN I
  • CIN II
  • CIN III
A
  • CIN I: Nuclei are enlarged and nuclear chromatin is abnormal with a speckled appearance.
  • CIN II: The nucleus occupies approximately 2/3 of the cell and nuclear chromatin is abnormal with a speckled appearance.
  • CIN III: The nucleus is very big compared to the size of the cell. There are alternate dark and light coloured areas within the nucleus indicating abnormal chromatin.
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11
Q

Name the pre-malignant conditions of the cervical epithelium.

A

Squamous epithelium - Cervical Intraepithelial Neoplasia (CIN).

Glandular - Cervical Glandular Intraepithelial Neoplasia (CGIN).

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12
Q

How are squamous pre-malignant lesions classified?

A

Koilocytosis
CIN I
CIN II
CIN III

USA:
Low grade squamous intraepithelial lesion (LSIL) - koilocytosis and CIN I (similar histological appearance and management).
High grade squamous intraepithelial lesion (HSIL) - CIN II and CIN III (similar histological appearance and management).

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13
Q

Describe the histological appearance of koilocytosis.

A

In the basal layers (columnar cells) thee nuclei are slightly enlarged.

The nuclei towards the surface (squamous cells) are much larger and very irregular in shape.

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14
Q

Describe the histological appearance of CIN I.

A

Koilocytes towards the surface with larger nuclei and irregular shape.

The cells in the lower 1/3 epithelium are very enlarged and abnormal. Abnormal cells confined to this lower 1/3.

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15
Q

Describe the histological appearance of CIN II.

A

Enlarged, abnormal cells extend 2/3 way up the squamous epithelium.

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16
Q

Describe the histological appearance of CIN III.

A

Abnormal cells occupy the full epithelial thickness.

There is no maturation - normal stratified squamous epithelium has columnar cells at the base and and squamous cells at the surface.

There are mitotic figures present.

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17
Q

How are glandular pre-malignant lesions classified?

A

Glandular dysplasia/Low grade CGIN.

Adenocarcinoma in situ/ High grade CGIN.

18
Q

Describe the histological appearance of high grade CGIN (adenocarcinoma in situ).

A

There is loss of the pale staining mucin from normal endocervical glandular epithelium.
Nuclei heap on top of each other.
Apoptotic bodies indicate individual cell death.
Mitotic figures present.

19
Q

What is the significance of a CIN diagnosis?

A
  • Risk of progression to invasive cervical cancer.
    CIN I - risk quite low and many cases will regress if untreated.
    CIN III - risk high
    However risk is variable as some CIN III may even regress to normal.
  • Slow progression from low grade lesion to invasion (10-15 years for CIN I to develop into invasive cancer).

However - can’t predict which will regress and which will progress so treat ALL when they are picked up.

20
Q

How are preinvasive lesions managed?

A

Gynaecologist looks at cervix with colposcope and takes a biopsy of the abnormal areas. Decide on:
- Ablation by freezing or cauterisation for low grade lesions.
- Excision of high grade lesions by cone or loop biopsy.
(Sent for histopathologist who confirms no incase cancer and then follow up smear at 6 months then every year for 10 years)
-Cytoloical +/- colposcopic follow up

21
Q

Describe the aetiology of preinvasive lesions and invasive cervical cancer.

A
  • HPV
    Low risk type (6 and 11 associated with koilocytosis and CN I)
    High risk type (16 and 18 associated with low and high grade lesions with potential to become invasive cancer)
  • Early age at first intercourse and multiple partners are risk factors for HPV infection as it is spread by sexual contact
  • Smoking - synergistic effect with HPV
  • Oral contraceptives ????? (glandular lesions)
22
Q

Name types of invasive cervical cancer.

A
  • Squamous carcinoma (85%)
  • Adenocarcinoma (10-15% but incidence increasing)
  • Rarer subtypes e.g. small cell carcinoma, adenosquamous carcinoma.
23
Q

Briefly describe the stages of cervical cancer:

  • Stage I including Ia
  • Stage II
  • Stage III
  • Stage IV
A
  • Stage I - cancer is confined to the cervix.
    Ia - micro invasive carcinoma. Max depth 5mm and length 7mm.
  • Stage II - carcinoma extends beyond the cervix but not to pelvic wall. Involves vagina but not lower 1/3.
  • Stage III - carcinoma extends to the pelvic wall and involves the lower 1/3 vagina.
  • Stage IV - cancer has spread beyond the pelvis or has clinically involved the mucosa of the bladder or rectum.
24
Q

Describe the histology of a Grade Ia microinvasive squamous carcinoma.

A

CIN III confined within the basement membrane.

Spot of cells has come of the epithelium involved by CIN III and invaded the underlying tissues. At this stage it is <1mm in size.

25
Q

Describe the histological appearance of squamous carcinoma of the cervix.

A

Squamous carcinoma invades the cervical stroma.

26
Q

Describe the histological appearance of:

  • Adenocarcinoma of the cervix
  • Adenosquamous carcinoma of the cervix.
  • Small cell carcinoma of the cervix.
A

Consult textbook.

27
Q

What is the treatment for each of these stages of Cervical Cancer?

  • Stage 1A1
  • Other Stage 1
  • > Stage 1
A
  • Stage 1A1: Cone/loop biopsy (histopathologist ensures margins are clear of tumour) or simple hysterectomy (older patient happy to have her uterus removed).
  • Other Stage 1: Radical hysterectomy (remove ligaments surrounding uterus and upper vagina)and pelvic lymphadenectomy + chemoradiation depending on status of margins.
  • > Stage 1: Chemoradiation.
28
Q

What is the Prognosis for Stage Ia and Ib cervical cancer?

A

Stage 1A - excellent prognosis, expect cure. Small % will have lymph node metastases.

Stage 1B - guarded. Prognosis generally good but depends on factors such as size, differentiation, surgical margins, lymphovascular permeation, lymph node status)

29
Q

What epithelium lines the vulvula?

A

Part of the skin - keratinising stratified squamous epithelium with underlying skin appendix structures.

30
Q

Name and describe the two vulval dystrophies.

A

Lichen sclerosis - sclerosis/fibrosis within the dermis. Surface squamous epithelium also atrophic.

Squamous cell hyperplasia.

31
Q

What is the presentation and significance of a vulval dystrophy.

A

Presentation:

  • Pruritis
  • Pain
  • Leukoplakia.

Significance:
Small risk of progression to invasive squamous carcinoma.

32
Q

Name the preinvasive lesions of the vulva. How do they present?

A 
Vulval Intraepithelial Neoplasia (VIN). 
Categorised into 
VIN I 
VIN II 
VIN III

Present in a similar way to a vulval dystrophy - pain, pruritus and leukoplakia (gross lesion). May be picked up when patient is being followed up for CIN (HPV associated).

33
Q

Name the two types of VIN and describe their differences.

A
  • Bowenoid/undifferentiated: younger, associated with HPV, multifocal, associated withCIN and VAIN, low risk of invasion.
  • Simplex/differentiated: older, no association with HPV, may be associated with vulval dystrophies, unifocal, no association with CIN, high risk of invasion.
34
Q

Describe the histological appearance of VIN III.

A

Similar to CIN III.

Atypical nuclei and mitotic figures present throughout the epithelial matrix.

35
Q

Name the different types of Vulval Squamous Carcinoma and their differences.

A
  • Bowenoid/undifferentiated: rarer (this type of VIN has low risk of developing invasive carcinoma). Associated with HPV, younger females.
  • Simplex/differentiated: more common, not associated with HPV, association with vulval dystrophy, older.
36
Q

Describe the histological appearance of Squamous Carcinoma of the Vulva.

A

Atypical squamous cells invade the vulval stroma.

37
Q

Describe the stages of vulval carcinoma.

A
  • Stage I: Tumour confined to vulva and/or perineum, <2cm.
  • Stage II: Tumour confined to vulva and/or perineum >2cm.
  • Stage III - tumour of any size with spread to lower urethra and/or vagina and/or anus and/or unilateral lymph node metastasis.
  • Stage IV: Tumour invades upper urethra/bladder mucosa/rectal mucosa/pelvic bone/ bilateral regional lymph nodes.
38
Q

What is the treatment for vulval carcinoma.

A
  • Stage 1A - surgical excision i.e. when <1mm in size there is very little chance of lymph node involvement. (Tumour spreads in a very predictable way to lymph nodes on same side, then to contralateral nodes).
  • > Stage 1A - surgical excision and groin lymph nodes.
  • Advanced - chemoradiation.
39
Q

Explain Paget’s Disease and its presentation.

A

Paget’s disease is an adenocarcinoma arising in the squamous epithelium of the vulva and is confined to the squamous epithelium of the vulva.

It can be primary (arises from stem cell with potential to develop down a squamous or glandular pattern) or secondary from internal organs (colorectum, bladder, cervix).

It presents with Pruritis, burning, eczema and ulceration.

40
Q

Describe the histological appearance of Paget’s Disease.

A

The vulval squamous epithelium is replaced by very large adenocarcinoma cells.

41
Q

How is Paget’s Disease managed?

A

Surgical excision with free margins and exclude other internal malignancy.

42
Q

What is the prognosis for Paget’s Disease?

A

Recurrences, which may be multiple, are common, even when excision margins are clear.
Dermal invasion associated with poorer prognosis. Sometimes can develop invasive adenocarcinoma.

SBCP Pathology (4 decks)

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