Gynaecology: Cervix and vulva Flashcards
Two parts of cervix? What epithelium lines each?
Ectocervix: SSNK
Endocervix: Mucin secreting glandular epithelum
Where do ectocervis and endocervis join together?
Transformation zone
True/false: Aim of cervical screening is to pick up cancer
False, aim is to pick up pre-malignant lesions (cervical intraepithelial neoplasia/CIN)
Result: negative
Recall in 3-5 years
Result unsuitable: repear 3 months
Result: Borderline nuclear changes
Repeat 6 monts
Result: Mild dyskaryosis (CIN 1)
Repeat 6 months
Result: Moderate dsykaryosis (CIN2) or multiple CIN1 results
Refer to colposcopy
Result: CIN3
rEFER TO COLPOSCOPY
What is used to screen smear slides?
Cytoscreener, pathologist only reports abnormal smears
Cytology: Enlarged nuceli due to HPV infection
Koilocytosis
Difference between CIN and CGIN?
CGIN affects cervical glandular epithelium. CIN affects squamous epithelium
Histology: Slightly enlarged basa cell nuclei in cervical SSNK epithelium
Koilocytosis (Hallmark of HPV infection)
Histology: Abnormal enlarged nuclei up to lower third of epithelium
CIN 1
Histology: Abnormal cells going up half way up the squamous epithelium
CIN 2
Histology: Abnormal cells occupying full epithelial thickness. Lots of mitotic figures, crowded nuclei indicating little maturation
CIN 3
Different grades of glandular lesions?
Low grade CGIN
High grade CGIN
Histology: Lots of nuclei within glandular cells, apoptotic bodies and mitotic figues
H grade CGIN
3 management options for pre-invasive lesions?
- Ablate (freeze or cauterise)
- Excise (loop or cone biopsy)
- Cytological and colposcopic followup
How long is follow up period for cervical cancer?
Close monitoring for 10 years
Risk factors for cervical lesions/cancer?
- HPV (especially 16 and 18) in over 99% of cancers!!
- Other infections eg chlamydia, HSV
- Early age of intercourse
- Multiple sexual partners
- Smoking
- OCP(?glandular lesions)
True/false: Cervical erosions are premalignant
False, normal physiological change with increased hormone levels
Two most common types of cervical cancer
Squamous carcinoma (85%)
Adenocarcinoma
Stage 1 cervical Ca
Microinvasive carcinoma
Stage 2 cervical Ca
Spread beyond the cervix but not into pelvic side wall
Stage 3 cervical Ca
Spread to pelvic side wall or lower third of vagina
Stage 4 cervical Ca
Spread beyond the pelvis
Treatment of microinvasive cervical cancer?
Cone or loop biopsy and check the margins
Regular smears
If older lady, hysterectomy
Tx of Stage 1 tumours larger than microinvasive but confined to cervix
Radical hysterectomy (all of the ligaments and the upper vagina are removed in addition to just the uterus as in simple hysterectomy)
Small percentage of patients with radical hysterectomy will get post op chemoradiation (ONLY if close margins or adverse prognostic features)
Tx if cancer has spread beyond cervix
No surgery
Chemoradiation
How is cervical cancer staged?
MRI scan
Pelvic exam under anaesthesia
Cytoscopy
Adverse prognostic features of cervical cancer?
Size
Differentiation
Surgical margins
Lymphovascular spread
Lymph node involvement
5 yr survival for stage 1 cervical cancer?
90-95%
5 yr survival for stage 4 cancer
<20%
What epithelium lines vulva?
Keratinising stratified squamous epithelium
Lichen sclerosis and squamous cell hyperplasia are categories of what?
Vulval Dystrophy
Present with pain, itching, leukoplakia
What can vulval dystrophy progress to ?
Invasive squamous carcinoma
Histology: Sclerosis/fibrosis within dermis of vulva, with atrophic surface epithelium
Lichen sclerosis
What virus is associated with VIN?
VIN (vulva intraepithelial neoplasia) linked to HPV
True/false: VIN less common than CIN
True, mostly found while investigating CIN
Two types of VIN in vulva?
Bowenoid/undifferentiated: younger, associated with HPV, CIN, low risk of invasion
Simplex/differentiated: Rarer, older people, NO HPV ASSOCIATION, higher risk of invasion
Two types of vulval INVASIVE squamous carcinoma? (Similar to VIN but don’t confuse them)
Bowenoid/undifferentiated: LESS COMMON due to low risk of Bowenoid VIN progressing, younger patients, HPV
Simplex/differentiated: Mosre common, no HPV, associated with lichen sclerosis and squamous cell hyperplasia (vulva dystrophies), older pt
Stage 1 Vulval cancer
Confined to vulva, <2cm
Stage 2 vulval tumour
Tumour confined to vulva but >2cm
Stage 3 Vulval tumour
Spread to lower urethra, vagina, or anus
AND/OR
Lymph node involvement
Stage 4 vulval tumour
Metastasis including to pelvis
Tx of stage 1 vulval cancer?
Surgical excision of tumour and inguinal lymph nodes
Tx of advanced vulval Ca?
Chemoradiation
Histology: Adenocarcinoma confined to the squamous epithelium of the vulva
Paget’s disease of vulva
Arises in squamous epithelium due to a stem cell becoming glandular.
Where does Paget’s disease of vulva come from?
Thought to be stem cell
Usually primary but can be secondary from an adenocarcinoma from colon, rectum, bladder, or cervix
Symptoms of Paget’s disease of vulva
Itch, redness, eczema, ulceration
Tx of Paget’s disease of vulva?
Surgical excision
Exclude another primary orign
Often reoccurs even if margin is clear
Can become invasive adenocarcinoma
What is vaginal adenosis?
Presence of galndular epithelium in vagina. Linked to DES drug
