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Gynaecology > Pathology - Cervical > Flashcards

Pathology - Cervical Flashcards

1
Q

What is the transformation zone?

A

squamo-columnar junction between the ECTOcervix (squamous) and ENDOcervix (columnar) epithelia

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2
Q

The position of TZ alters during life as physiological response to - (3)

A

menarche

pregnancy

menopause

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3
Q

Pathology of Cervical Erosion/ectropion/eversion

A

so common that considered normal

  • cervix enlarges under the influence of oestrogen and endocervical canal is everted
  • protrusion of delicate endocervical epithelium to external os exposes it to acid environment of vagina, leading to physiological squamous metaplasia
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4
Q

Clinical presentation of Cervical Ectropion

A

mostly asymptomatic
bleeding
excessive watery discharge

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5
Q

Cervical ectropion risk factors? (3)

A
  1. teenagers
  2. menopause
  3. COC
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6
Q

When do symptoms of cervical ectropion disappear?

A

over time, when vaginal acidity promotes metaplasia to squamous epithelium

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7
Q

What is an important step in the investigation of cervical ectropion?

A

cervical smear to exclude cervical cancer

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8
Q

Cervical ectropion on examination?

A

red ring around os

so common that considered normal

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9
Q

What are Nabothian cysts? (pathology)

A

aka Mucinous retention cysts (so common that they are considered normal)

results from metaplasia leading to sqaumous cell cover over columnar epithelium with mucus-producing crypts within it

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10
Q

appearance of nabothian cysts?

A

multiples translucent/opaque, white or yellow lesions

ranges from 2mm to 10mm

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11
Q

Symptoms and treatment of Nabothian cysts?

A

no treatment, asymptomatic

rarely, if grow very large: cautery or cryotherapy

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12
Q

Physiological metaplasia of endocervical epithelium leads to? (2)

A

Cervical erosion/ectropion

Nabotian follicles (contains mucinous crypts)

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13
Q

Inflammatory pathology of cervix (2)

A
  1. Cervicitis

2. Cervical polyp

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14
Q

What is Cervicitis? (symptoms, complications, causes)

A
  • non-specific acute/chronic inflammation
  • often asymptomatic
  • can lead to infertility
  • follicular: sub-epithelial reactive lymphoid follicles present in cervix
  • Chlamydia (STI)
  • HSV infection
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15
Q

How may cervicitis lead to infertility?

A

due to simultaneous silent fallopian tube damage

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16
Q

what is a cervical polyp?

A

localised inflammatory outgrowth

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17
Q

Are cervical polyps pre-malignant?

A

No

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18
Q

How do cervical polyps present?

A

Incidental finding

Cause of bleeding if ulcerated

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19
Q

Most common benign neoplasms of the cervix? (how common)

A

4% of gynae population
polyps

may be endocervical or cervical

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20
Q

Endocervical polyps - which age group and what do they look like?

A

4th - 6th decade of life

cherry red lesions which may be single or multiple

may appear as apedunculated lesion on a stalk of varying length

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21
Q

Cervical polyps on examination

A

single, smooth grey-white lesions that bleed easily if touched

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22
Q

Neoplastic lesions of the cervix

A

CIN (pre-malignant)

Cervical cancer - squamous or adenocarcinoma

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23
Q

Who is Harald Zur Hausen?

A 
German Virologist 
1983:identified HPV 16
1984:identified HPV 18 
HPV-driven Cervical Disease  
75% of Cervical Cancer
2008: Nobel Prize for Medicine
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24
Q

Structure of HPV

A

circular, double stranded DNA, protected by capsid proteins

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25
Q

Risk factors for CIN/cervical cancer (4)

A
  1. persistence of high risk HPV (16, 18, 31, 33, 35, 45, 48)
  2. vulnerability of SC junction in early reproductive life
  3. smoking: 3x risk
  4. Immunosuppression
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26
Q

What increases the vulnerability of SC junction

A

young age of first intercourse

long term use of oral contraceptives

Non-use of barrier contraception

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27
Q

What increases your risk of acquiring persistent HPV?

A

many sexual partners

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28
Q

What does low risk HPV infection cause in the cervix?

A

(6 and 11)

Genital Warts

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29
Q

What are genital warts? (pathology)

A

condyloma acuminatum:

thickened papillomatous squamous epithlium with cytoplasmic vacuolation (“koilocytosis”)

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30
Q

What does high risk HPV infection cause in the cervix?

A

CIN
(16 and 18)

Cervical cancer

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31
Q

Pathology of CIN

A

infected epithelium remains flat, but may show koilocytosis, which can be detected in cervical smears

32
Q

What is a koilocyte?

A

A Koilocyte is a squamous epithelial cell that has undergone a number of structural changes, which occur as a result of infection of the cell by HPV

33
Q

Cellular changes of a koilocyte

A
  1. Nuclear enlargement x2-3
  2. Irregularity of the nuclear membrane contour
  3. darker staining nucleus (Hyperchromasia)
  4. A clear area around the nucleus(perinuclear halo)

Collectively, these types of changes are called a cytopathic effect;

34
Q

What is the definition of cervical cancer

A

invasive sqaumous carcinoma (virus integrated into host DNA)

35
Q

How long does it take for HPV infection to become a high grade CIN

A

6m - 3yrs

36
Q

How long does it take for a high grade CIN to become invasive cancer?

A

5 - 20 years

37
Q

How do polyps present?

A
  • asymptomatic
  • abnormal bleeding (PCB, IMB, Menorrhagia)
  • infertility (if grows big enough to obstruct external os)
  • malignancy is rare (1/200)
38
Q

Management of polyps

A

removed and sent to histology

if asymptomatic, twist them off

If >2cm x 1cm, refer

persistent lesions, D&C, electrosurgical excision, hysterscopic polypectomy

39
Q

Complications with removal of polyp and how to treat them

A

Vagally stimulated bradycardia - atropine

haemorrhage - cautery

40
Q

What may mimic the appearance of a large polyp

A

appearance of healed cervix following cone biopsy

41
Q

Symptoms of cervicitis?

A

none
abnormal yellow-green discharge
PCB
dysuria

42
Q

Signs of cervicitis

A

green/yellow/opaque mucopurulent discharge

endocervical friability (bleeds easily)

43
Q

Common culprits of cervicitis

A

gonorrhoea, chlamydia, HPV, HSV, trichomonas

44
Q

Treatment of cervicitis

A

anti-microbial

guided by swab results

45
Q

Prevalence of HPV infection by age group/lifetime

A

15-25 yrs = 30-50%
25 - 35 yrs = 10 -20%
>35 yrs = 5 - 15%

80% cumulative prevalence in lifetime

46
Q

If there is an 80% cumulative lifetime prevalence, why isnt cervical cancer THAT common?

A

most develop immunity

persistence increases risk of disease

47
Q

What is CIN and where does it occur?

A

pre-invasive stage of cervical cancer

occurs at TZ

can involve a large area

48
Q

Histology of CIN (4)

A

dysplasia of squamous cells (koilocytosis = HPV often present)

  1. delay in maturation/differentiation - immature basal cells occupy more of epithelium
  2. nuclear abnormalities
  3. excess mitotic activity
    - situated above basal layers
    - abnormal mitotic forms
49
Q

Clinical presentation of CIN

A

not visible to naked eye

asymptomatic

50
Q

How is CIN detected

A

C screening

51
Q

Histological staging of CIN (+ mitotic figures, maturation, nuclear feature)

A

Depth of abnormal cells and mitoses, abnormal mitotic figures

CIN 1 = basal 1/3 (raised no. of mitotic figures, surface cells quite mature, but nuclei slightly abnormal)

CIN II - extends to middle 1/3

CIN III - full epithelial thickness occupancy

52
Q

Histological nuclear abnormalities of CIN (3)

A
  • hyperchromasia
  • increased nucleocytoplasmic ratio
  • pleomorphism
53
Q

Natural history of CIN 1 lesions (% regress, persist, progression to CIN3, progression to invasion)

A

regress = 57%
persist = 32%
Progress to CIN 3 = 11 %
Progress to invasion = 1/100

54
Q

Natural history of CIN 2 lesions (% regress, persist, progression to CIN3, progression to invasion)

A

Regress = 43%
Persist = 35%
Progress to CIN 3 = 22%
Progress to invasion = 5%

55
Q

Natural history of CIN 3 lesions (% regress, persist, progression to invasion)

A

regress = 32%
Persist = 56%
Progress to invasion = >12%

56
Q

How common are cervical cancers (invasive squamous carcinoma) worldwide

A

75 -95% of malignant cervical tumours

2nd commonest female cancer worldwide

57
Q

Detection of cervical cancers (who, what stage, how progressive)

A

increasingly detected in younger women

often found in early stage

some are rapidly progressive tumours

58
Q

How are cervical cancers prevents and why

A

Develops from pre-existing CIN, therefore most cases should be preventable by screening

59
Q

epidemiology of cervical cancer in scotland

incidence 2002-2012, new cases in 2012, #, % of all cancers

A

12th commonest female malignancy

1.9% of all cancers

295 new cases in 2012

10.6% increase in incidence 2002-2012

60
Q

Epidemiology of cervical cancer (death in 2013, reduction in mortality 2003-2013, 5 year survival)

A

91 deaths in 2013

  1. 2% reduction in mortality 2003-2013
  2. 1% 5 year survival
61
Q

Highest risk age groups

A

30 - 44

25 - 49

62
Q

Staging of invasive squamous carcinoma 1A1/2/B (depth and width), 2-4 (organ involvement)

A

Stage 1A1 - depth up to 3mm, width up to 7mm

Stage 1A2 - depth up to 5mm, width up to 7mm
Low risk of lymph node metastases

Stage 1B - confined to the cervix

Stage 2 - spread to adjacent organs (vagina, uterus, etc..)

Stage 3 - involvement of pelvic wall

Stage 4 - distant metastases or involvement of rectum or bladder.

63
Q

Symptoms of invasive carcinoma (5)

A

usually none at microinvasive/early stage - detected at screening

abnormal bleeding

Pelvic pain

Haematuria/UTI

Uteretic obstruction/renal failure

64
Q

What do you mean by abnormal bleeding? (4)

A

PCB
PMB
brownish/blood stained vag discharge,
contact bleed - friable

65
Q

Spread of squamous carcinoma

A

Local - uterine body, vagina, bladder, ureters, rectum

lymphatic - early - pelvic, para-aortic nodes

haematogenous - late - liver, lungs, bone

66
Q

Grading of squamous carcinoma

A

Well differentiated
Moderately differentiated
Poorly differentiated
Undifferentiated / anaplastic

67
Q

Staging Ix in Cervical cancer

A

CT, MRI, Cystoscopy

68
Q

Management for early stage cervical cancer

A

Laparoscopic radical hysterectomy

69
Q

Management for cervical cancer

A

High dose rate brachytherapy

70
Q

Management of recurrent and stage IVB cervical cancer

A

Topotecan (+ cisplatin) = chemotherapt

71
Q

What is Cervical Glandular Intraepithelial Neoplasia (CGIN) ( origin, type of carinoma, diagnostic issues, screening, association)

A

Origin from endocervical epithelium

CGIN is pre- invasive phase of endocervical adenocarcinoma

More difficult to diagnose on cervical smear than squamous

Screening less effective

Sometimes associated with CIN

72
Q

Epidemiology of Endocervical Adenocarcinoma

A

5-25% of cervical cancer

?Increasing incidence, particularly in young women

73
Q

Prognosis of endocervical adenocarcinoma (cf squamous Ca)

A

worse

74
Q

Cell types and origin in endocervical adenocarcinoma

A

some are mixed (adenosquamous)

? arise from common cell or origin

75
Q

rIsk factors of adenocarcinoma (4)

A

Higher S.E. Class

later onset of sexual activity

smoking

HPV (particularly 18)

76
Q

HPV driven disease (5)

A 
CIN
CGIN 
VIN (Vulval)
VaIN (Vaginal)
AIN (anal)

Head and Neck

Gynaecology (7 decks)

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