Module 3: Gentials: Cervix and Vagina Flashcards
Now these cards are about pathologies of the cervix. First what is the endo and ectocervix lined by?
Ectocervix: lined by hormonally responsive stratified squamous epithelium
Endocervix: lined by simple columnar epithelium
Next just a quick review: What is acute cervicitis?
Endocervix:
- -gonococcal, chlamydia, trichomonas, herpes
- postpartum, post D and C
- -purulent vaginal discharge
What is chronic cervicitis?
Non-specific and incidental
- -lymphocytes and plasma cells normally present in wall
- -granularity, thickening
- -retention (nabothian cysts)
What is squamous metaplasia? slide 5
Irritation at puberty by lactic acid
- -conversion from columnar to stratified squamous
- -physiological
- -no HPV
- forms the transformation zone: squamocolumnar junction
Moving on to carcinoma in situ of the cervix. What are the HPV strains of concern?
HPV 16 and 18
–E6 and E7 inactivating p53 and Rb
What is the histology for carcinoma in situ?
Both still have koilocytes
CIN I: lower 1/3rd dysplasia
CIN II: lower 2/3rd dyplasia
CIN III: dysplasia throughout without koilocytes but BM in tact – this is actually carcinoma in situ
–note on cytology II and III are group together as HSIL and I is LSIL
Increased dysplasia shows what on histology?
High nuclear: cytoplasmic ratio
more basophilic nucleus (hyperchromatism)
What is the best diagnostic test for cervical carcinoma in situ?
Colposcopy and biopsy to look for BM intact
What are the futures of micro invasive cervical cancer?
Microinvasive: 5mm deep and 7mm wide
no invasion of blood vessels or lymphatics
Cone Biopsy: taking out the total squamocolumnar junction for tx
What are the features of fully invasive cervical cancer?
Fully Invasive: greater than 5mm deep and 7mm wide; invasion of lymph and blood vessels
What is the most important predisposing factor for invasive cervical cancer?
multiple sexual partners
multi party
early age at first sexual intercourse
immunodeficient
What is the presentation for invasive cervical cancer?
Postcoital bleeding most common
Leukoria:
Dyspareunia: painful intercourse
What does histology show for invasive cervical cancer?
Keratin pearls abundant for well differentiated: better dx
note there is moderate and poorly differentiated
What are the complications for invasive cervical cancer?
Most common cause of death is renal failure as a result of bilateral hydronephrosis as a result of invasion of the bladder
Constipation from rectal invasion
Invasion of vagina
Metastasis to inguinal lymph nodes
What does a pap cytology show?
Naturally in the cervix, squamous cells mature from bottom to top as they accumulate glycogen
- -Smaller Nucleus: most mature/largest = superficial cells (pap smear)
- Biggest nucleus/mitotically active = least mature = parabasal cells
What is the Schiller’s Test?
test for non-glycogen/highly mitotic areas — site of carcinoma
–paint cervix with iodine and look for unstained pale patches
What is the P16 stain in regards to cervical cancer ?
if completely negative than not CIN
–marker of staining for high risk HPV
Moving on to the low risk HPV strains 6 and 11. What are features? what do they cause?
No dysplasia: due to lack of insertion into the host genome
–raised painless warts around the vagina called Condyloma acuminatum
What are the gross and histology features, slide 8, of Condyloma Acuminatum?
Gential Warts: cauliflower shaped that is raised, dry and scaly
Histology: Koilocytes with epidermal hyperplasia and hyperkeratosis (thickening of the stratum corneum) and parakeratosis (Stratum spinosum). no dysplasia (acathosis)
What are symptoms of Condyloma Acuminatum?
Itching and burning of the vulva but no vaginal discharge and no pain
What is used to visualize the warts in Condyloma Acuminatum?
Acetic Acid
What are the complications of Condyloma Acuminatum?
No chance of malignant transformation
–papillomas in the larynx (benign) if baby comes through the birth canal
Finally genital herpes is caused by which HSV strains?
HSV2 mainly but can be caused by HSV1 (oral sex)
- -latent in the sacral nerve ganglion
- -primary infection is worse than the reactivation
What is the main mode of transmission of genital herpes?
Genital Fluids
–sexually and vertically transmitted (placenta or vaginal birth)
Why is vaginal birth contraindicated in patients with genital herpes?
Baby get conjunctivitis and temporal lobe encephalitis so must do a C -section
What is the presentation for patients with genital herpes?
Initial painful filled vesicles that ruptures to become ulcers in the vulvar region
–can become latent in sacral neurons and reactivate when stressed
What is seen on Tzank smear for patients with genital herpes?
Intracellular cowdry type A bodies and multinucleated syncytial giant cells
–note PCR most accurate (b/c this is a virus)
can also do serology for IgG and IgM
What are complications of genital herpes?
Immunocompetent = pain Immunocompromised = temporal lobe encephalitis and in babies vertical transmission
What are the three M’s for any herpes?
Multinucleation
Margination of the chromatin pushed to the periphery
Molding of the cells
The next vaginal issue to be discussed are Gartner’s Duct Cysts. What are some general features?
Benign Remnants of mesonephric ducts Anterolateral wall of vagina 1-2cm Mimics carcinoma clinically
Next is vaginal adenosis, what are some features?
Seen in young girls (10yrs) whose mother got diethyl stilbesterol (DES) during pregnancy to prevent abortion
What are histological features of vaginal adenosis?
Cells forming endocervical glands in vaginal wall
- -may progress to clear cell adenocarcinoma years later
- -benign and clinically mimics carcinoma
Next is Sarcoma Botryoides (Embryonal Rhabdomyosarcoma). What are the features?
Girls less than 5 years old
- –polypoid friable mass (bunch of grapes) hanging in the vagina
- -highly malignant, malignant rhabdomyoblasts, cambium layer, fibromyxomatous stroma
What is the histology for Sarcoma Botryoides?
Rhabdomyoblasts (precursors of skeletal muscle)
–requires surgery and chemotherapy
Next is squamous carcinoma of the vagina, what are the features?
Primary is super rare
- -usually due to a secondary cause of carcinoma from other parts of the female genital tract
- -poor prognosis for either
- -pelvic and inguinal nodes are based on location
Finally the last topic of this card deck is Bartholinitis. What are the features?
Acute inflammation on inferior part of labium major – bartholin glands (which open into vaginal introitus)
How does an abscess formation happen with Bartholinitis?
Blocking due to inflammation — abscess formation
- -strep, staph, gonococci and e.coli
- -drainage and marsupialization
How do patients with Bartholinitis present?
Severe discomfort during intercourse
How often should a women get a pap smear? what if it is abnormal?
once every 3 years if normal
and every 6 months if abnormal
What are the two type of cervical cancer?
Endocervical (dysplastic glands)
Ectocervical (keratin pearls)
both HPV 16 and 18
Besides cervical cancer, what other cancers can HPV 16 and 18 cause?
Anal
Penile
Vulva
Oral
