Lecture 26: Cervical screening and pathology

Question 1

Metaplasia

Answer 1

replacement of one differentiated cell type with another, mature differentiated cell type

Question 2

Dysplasia

Answer 2

abnormality of development or an epithelial anomaly of growth and differentiation

not invasive!

Question 3

Neoplasia

Answer 3

New and abnormal development of cells that may be benign or malignant

Intraepithelial neoplasia = dysplasia (not invasive)

Invasiveneoplasia (neoplasm) = cancer

Question 4

What could cause this mass in the myometrium

Answer 4

1. Benign Leiomioma see pic*
   - benign SM tumours
   - common
   - Hormone receptive; regress following menopause
2. Leiomyosarcoma (invasive SM cancer)
   - Malignant smooth muscle tumour

Question 5

How can a benign leiomioma cause menorrhagia

Answer 5

If you get a sub-endometrial leiomyoma you increase the surface area of the uterine cavity → increased bleeding and shedding.

Pain as uterus contracts around large fibroids

Question 6

Whats the macroscopic difference between a leiomyosarcoma and a leiomyoma/fibroid

Answer 6

Leiomyoma: ovoid/round, circumscribed, solid creamy

Leiomyosarcoma: necrotic core/area, haemorragic areas, larger. It is heterogenous

Question 7

Whats the microscopic description of a leiomyoma

Answer 7

Leiomyoma : collection of smooth muscle cells, arranged in a new growth formation (different to SM of uterus). Cigar shaped nuclei, and pink elongated cytoplasms.

Question 8

cyclical abdominal pain indicates issues with?

Answer 8

Her period

Question 9

Potential causes of painful heavy periods

Answer 9

Leimyoma (fibroids)

Endometriosis

Primary endometrial pathology

Leiomyosarcoma unlikely

Question 10

Answer 10

A chocolate (haemorrhagic) cyst of the ovary

Question 11

What is endometriosis? What does it cause?

Answer 11

Endometrial tissue outside the lining of the uterus.

It responds to menstrual cycle hormones, leading to:

• pain
• cysts
• Tissue inflammation
• fibrosis
• infertility/ectopic pregnancy
• POTENTIALLY malignancy

Question 12

What are you looking for macroscopically to diagnose Endometriosis

Answer 12

Cyst formation, many that are ‘chocolatey’ due to haemorrhage.

Changes the structure/function of normal tissues

Question 13

What do we suspect from this?

Answer 13

-polycystic ovarian syndrome: underlying endocrine disorder cause her to be obese/infertile. Ovaries/follicule never ovulate so continued production of oestrogen.

This can cause excessive proliferation and shedding of the endometrium → heavy and irregular periods. (the irregularity makes you think she is not ovulating cyclically)

-leiomyoma

Question 14

Age variation in a thickened endometrium?

Answer 14

-Postmenopausal: no oestrogen production so there shouldn’t be proliferating/shedding at all.

If there is this is a BAD SIGN,

Question 15

How do you do a biopsy of the endometrium? What are the issues?

Answer 15

Pipelle Biopsy: little tube in uterus, suck out some endometrium. Not done under direct vision so can be incredibly difficult in obese patients.

D and C ‘Dilation and Curettage’: under direct vision in theatre under anaesthetic. Endometrium viewed and abnormal tissue scraped out.

Question 16

What is this and what would it look like microscopically

Answer 16

Endometrial adenocarcinoma.

Shaggy, thickened, heterogenic, invading into the myometrium.

Glands proliferate and become increasingly crowded and complex

Question 17

What can lead to too much eostrogen

Answer 17

• Obesity
• Exogenous oestrogen (HRT)
• Polycystic ovarian syndrome (PCOS)
• Hormone secreting tumours
• Early menarche, late menopause
• Nulliparity (pregnancy is a progestogenic state)

Question 18

cervical/PAP smear

Answer 18

1. Conventional smear: scraping spatula
2. Cytobrush (liquid based cytology): brush, send to lab, do liquid based tests

Question 19

What is cytology? Issues?

Answer 19

Diagnosis by examining the structure of individual or groups of cells.

Usually no architecture present

Question 20

What sort of things is the cytologist looking for in the cervical smear specimen

Answer 20

• Nuclei:cytoplasm ratio
• Nuclei enlargement
• Nuclei variation

Is it normal, low grade dysplasia or high grade dysplasia

Question 21

What happens if you have a smear, and see high-grade dysplastic lesion??

Answer 21

1. Abnormal smears are refered to gynaecologist for colposcopy (examination of cervix with a specialised microscope).
2. Cervix can be ‘painted’ with acetic acid to highlight abnormal areas
3. A biopsy is taken of the suspicious areas and sent to the lab

Question 22

What happens to the biopsy of the high-grade dysplastic region?

Answer 22

It is looked at microscopically (histology) and it is decided/confrimed what CIN stage the tissue is at.

CIN I: some cytoplasm still present, most of the issue down further below.

CIN III: Full thickness abnormality, lots of cytoplasm lost, darker nuclei

Question 23

Whats the treatment for the abnormal area? Follow up?

Answer 23

Area is surgically removed (Iletz or cone biopsy)

Followup: regular or annual cervical smears

Question 24

What is this? why is this so bad?

Answer 24

Cervical Cancer. Because of its anatomical location it can easily invade into important surrounding structures (rectum, bladder etc)

Question 25

What are the important risk factors asosociated with developing cervical cancer

Answer 25

• Not have cervical smear tests regularly (3years)
• Smoking can increase risk of persistant HPV

Question 26

What is a Mucinous Cystadenoma

Answer 26

Epithelial tumours of the ovaries

Question 27

How can we classify Ovarian Epithelial Tumours

Answer 27

• Mucinous vs Serous
• -Serous = tubal type epithlium (pseudostratified ciliated)
• Mucinous = mucinous epithelium*
• Benign
• Borderline
• Malignant