Lecture Cervical Screening and Pathology Flashcards
Metaplasia
“meta” = change
“plasia” new formation
change/replacement of one differentiated cell type toanother mature differentiated cell type (normal –> normal)
- Barrets oesophagus (squamous –> mucinous (to block reflux acid))
- Chronic smoker (glandular –> squamous epi)
Dysplasia
“dys” bad
“plasia” new formation
abnormality of development or epithelial abnormality of growth and differentiation
= Not invading past BM –> therefore cannot spread –> cannot metastasize –> remains “intra epithelial”
- Want to find on cervical smears
Neoplasia
“neo” new
“plasia” formation
New and abnormal development of cells that are benign OR malignant
- Intra (within) epithelial neoplasm (dysplasia)
- Invasive neoplasia (cancer)
Menorrhagia
heavy periods
Dysmenorrhoea
painful periods
Benign Lyomoyoma/Fibroid uterus
Circumscribed (well defined outline) myometrial masses
- lyomyoma (beingin) or lyomyosarcoma (malignant)
Nodular + cream + solid
Lyomyoma –> well circumsribed –> submucosal/subepithelial –>
1. Increased surface area of endometiral cavity –> excessive bleeding and shedding –> menorrhagia
2. contraction around defined nodules –> painful periods –> dysmenorrhea
Tumours of the Muscular Uterine Wall
- Leiomyoma (fibroid) –> Benign Smooth muscle tumour:
- common.
- hormone receptive –> shrinking/regressing after menopause
- oval/round, solid, cream, clear cut surface - Leiomyosarcoma : Malignant Tumour of smooth muscle
- heterogenous cut surface –> necrotic core
- haemorhagic, softer, bigger, protrudes into endometrial cavity
Histology: pink + elongated cells with Cigarette shaped nuclei
Potential causes of cyclical abdominal pain
Fibrosis/Lyomyoma
Lymomyosarcoma
endometriosus
Primary endometrial pathway
Endometriosis
Cherry red/dark brown nodules on peritoneal surface –> slightly cystic bleeding in tissues
Chocolate cyst –> expanded ovary due to a cystic structure which contains brown material –> replaces the ovary
Endometriosis is a problem when it starts reacting to menstrual hormones
Endometriosis –> endometiral tissue lining uterus found outside of uterus –> continues original cellular functions –> responds to ovarian hormones in foreign location –> starts “proliferating and shedding” like normal cyclical ovarian lining during menstruation–> creates nodules of bleeding and fibrosis in perineum –> pain, inflammation and destruction –> structures can stick together (fallopian tubes) –>
1. potential risk of inferitility with stuck fallopian tubes
2. endometrial tumours outside of uterus
Histology:
- 3x components (glands, stroma, changes in surroundign tissue)
What do chocolate cysts suggest?
Endometriosis
Three Histological components of Endometriosus
- Endometrial type glands
- Endometrial type stroma
- Changes in surrounding tissues –> responding to foreing endometrial tissue
- Fibrosis (inflammatory reaction of local tissue to foreign tissue)
- Haemocyderin-containing macrophages (containing blood which has been shed around)
Where does endometriosis commonly occur
Most commonly in ovaries
Also in uterine ligaments, rest of gynae tract, bowel, peritoneum, urinary tract
Rarely lungs, pleura, bone, upper GIT
When is endometriosis a problem?
Endometriosis is a specific problem when it responds to menstrual hormones --> Bleeds into adjacent tissue during menstruation --> causes: 1. Pain 2. Cysts 3. Tissue inflammation --> fibrosis 4. Infertility/ectopic pregnancy Can give rise to malignancy
Potential causes of abnormal bleeding
- Polycycstic ovaries due to excessive oestrogenic signal stimulation –> proliferation fo endometrium –>
a) outgrow blood supply –> regularly sheds
b) hyperplasia (preneoplastic state) –> endometrial carcinoma - incidental endometriosis (not related to obesity(
- Lyomyomas
- Underlying endocrine disorder –> causes obesity/non-ovulation –> problem with endometrium
Endometrial investigations
- US: good for solid and cystic structures (can observe nodules and compare relative thickness of endometrium of uterine walls)
- age dependant –> post menopausal woman should have thick endometrial wall –> as no proliferative hormones being released - Biopsy
a) pipelle –> no direct vision –> suction tube takes sample of uterus
Note: difficult in obese –> often end up in getting cervical sample
b) Dilation and Curettage –> in operating theatre –> dilate cervix –> insert instrument into uterus –> direct vision to look at uterus –> take sample of specific area
- more information and large tissue sample size
Difference b/w proliferative endometrium and endometrial carcinoma
- Proliferative endometrium: activity occurring in bottom third. hasn’t broken the BM
-hyperplasia pre-invasive –> neoplastic due to over stimulation of oestrogen 00> slightly thickened but no extension into myometrium - Endometrial Carcinoma: Actiivty occuring througout entire 3/3 of endometrium
- glands proliferated –> increasingly crowded, irregular and complex glandular structures
- lined by cells with cytological features
Note: Large irregular complex glandular structures of endometrial carcinoma –> clump into large clusters –> likely to break off –> Youth: abnormal bleeding. 50+: post menopausal bleeding
Surgically removed specimen of total abdominal hysterectomy and bilateral salphino-oophorectomy
Normal myometrium: about 0.5 cm thick endometrium
Endometrial carcinoma: shaggy, cream, irregular endometrium –> spikes illustrate it starting to invade into underlying myometrium
What is the primary endometrial pathology for younger woman?
Oestrogen driven pathology
Consequences of excessive oestrogen exposure over a lifetime
Note: Oestrogen exposure changes with lifetime
- Obestiy
- Exogenous oestrogen (hormone replacement therapy –> HRT or Tamoxifen for breast cancer)
- Polycystic ovarian syndrome (PCOS)
- Hormone secreting tumours
- Early menarche, late menopause –> someone with late menarche
- Nulliparity (as pregnancy is a progestogenic state)
Oestrogen in relation to cell cycle
- Oestrogen drives Proliferative stage (first half of the cycle
MENSTRUATION - Progesterone drives Secretory stage
- too much oestrogen causes over stimulation of endometrium –> endometrium becomes to thick –> outgrows blood supply –> endometrium breaks down –> irregular/non/cyclical bleeding –> may develop mutation –> neoplasia (hyperplasia or cancer)
Cytology
Diagnosis: examine the structure of individual or groups of cells (e.g. nucleus size) No architecture present Specimens obtained via: - cervical smear brushings - fine need aspiration
Smear process for low grade neoplasm (CIN)
- PAP smear (conventional or cytobrush for cytology)
- Cytology
If low grade: - smear in 12 months
Cytological changes in tumorous cells
nuclear:cytoplasmic ratio enlargement of nucleus hyper-chromatic variation b/w nucleuses of the group irregularly shaped nucleus pleomorphic different size and shape ***Look at pics
Another name for Low grade dysplasia CIN I
CIN I cervical intraepithelial neoplasia grade I
Low grade squamous intraepithelial lesions
Smear process for high grade neoplasm
- PAP smear (conventional or cytobrush)
- cytology
- referred to gynaecologist for colposcopy–> painted with acetic acid –> biopsy sent to lab
- Pathologist reads biopsy
- Treatment/removal of area (LLETZ/CONE biopsy)
- Annual smears
Colposcopy
- paint cervix with vinegar/acetic acid
2. abnormal areas highlighted
Where does HPV infection occur?
Transformation zone
Glandular endocervical epi –> squamous ectocervical epi.
Histological Biopsy of high grade squamous intraepithelial carcinoma CIN III
full thickness abnormality
cytoplasm lost
darker nuclei
- check for invasion past BM
Lletz cone biopsy
lazer removal of transformation zone of cervix
histology of malignant nests of squamous cells
pink
lots of cytoplasm
form keratin
What is the most important risk factor for cervical cancer
- Never having a smear!!
or not having smears regularly - smoking: increase risk of persistent HPV + cervical cancer + immunosupression
Teratoma/Dermoid cyst
germ cell tumour
composed of a variety of cells from endo, ecot and mesoderm
- solid, cystic structure, containing hair and sebaceous material
- yellow, cream ares (adipose tissue), fatty, slimy,
Ovarian neoplasm
can be some of the biggest tumours in the body
Mucinous cyst adenoma
benign cystic tumours pain or mass lesion unilateral can be very large
Mucinous vs serous
mucinous = mucinous epithelium serous = TUBAL epithelium (pseudostratified ciliated)
Necrotic tumoues
large and necrotic
uglier
solid/cream/firm/partially necrotic
Serous Carcinoma
- Sporadic cancers
2. BRCA mutation
