Pathology cervix and screening Flashcards
What is the transformation zone of the cervix?
- squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelium
- position of this alters during life
What is cervical erosion(ectropion)?
-exposure of delicate endocervix to acidic environ. of vagina leads to physiological squamous metaplasia
What is a nabothian follicle (nabothian cyst)
squamous epithelium grows over the columnar epithelium = mucus filled cyst on cervix surface
What is cervicitis?
- caused by?
- what pathology is seen?
- clinical features?
Causes: chlamydia and herpes simplex
Pathology:
- non-specific acute inflammation
- follicular cervicitis: subepthelial reactive lymphoid fllicles present at cervix
Cervical polyp:
- is this premalignant?
- what can it cause?
- what pathology is seen?
Not premalignant
- cause of bleeding if ulcerated
- localised inflammatory outgrowth
What 3 neoplastic conditions affect the cervix?
CIN: HPV 16, 18
Cancer:
- squamous carcinoma
- adenocarcinoma
What are the risk factors for CIN/cervical cancer?
persistence of high risk HPV (16,18):
-many sexual partners increases the risk
Vulnerability of transitional zone in early reproductive life:
- early age at 1st sexual intercourse
- long term use of oral contraceptives
- non-use of barrier contraception
- Smoking (X3 the risk)
- immunosupression
What does HPV 6 and 11 cause?
Condyloma acuminatum (genital warts) -thickened papillomatous squamous epithelium with cytoplasmic vacuolation
What does HPV 16 and 18 cause? describe the epithelial changes? where does this take place?
CIN
- infected epithelium remains flat but may show koilocytosis
- occurs at the transformation zone of the cervix
- squamous cell dysplasia
What does HPV infection lead to? how long does this take?
HPV leads to high grade CIN (6mths - 3yrs)
High grade CIN can lead to invasive squamous carcinoma (5-20 years)
Describe the histology seen with CIN?
Delay in maturation/differentiation:
-immature basal cells occupy
No clear abnormalities:
- hyperchromasia
- pleomorphism
- increase in nuclear cytoplasmic ratio
Excess mitotic activity:
- situated above basal layers
- abnormal mitotic forms
Describe the morphology of CIN 1,2 and 3, what is the chance of progression to invasion?
CIN 1:
- Basal 1/3 epithelium occupied by abnormal cells
- raised no. of mitotic figures in lower 1/3
- surface cells quite mature but nuclei slightly abnormal
- 1% chance progression
CIN 2:
- abnormal cells extend to middle 1/3
- mitoses in middle 1/3
- abnormal mitotic figures
- 5% chance progression
CIN 3:
- abnormal cells occupy full thickness of epithelium
- mitoses, often abnormal, in upper 1/3
- > 12% chance progression
Invasive squamous cell carcinoma cervix:
- is this common?
- does this affect younger women?
- is this preventable?
75-95% of malignant cervical tumours
-2nd commonest female cancer worldwide
- increasingly detected in younger women, often found in early stages but some are rapidly progressive tumours
- preventable if develops from pre-exisiting CIN
What are the symptoms of squamous cell carcinoma cervix?
Asymptomatic: micro/ealry invasive (screening)
Abnormal bleeding: PCB/PMB/brownish-blood stained discharge/contact bleeding (friable epithelium)
Pelvic pain
Haematuria/UTI
Ureteric obstruction and renal failure
Where does squamous cell carcinoma cervix spread to?
Local: uterine body, vagina, bladder, uterus, rectum
Lymphatic: early = pelvic, paraortic nodes
Haemotogenous: late = liver/lungs/bone
Describe the staging of squamous cell carcinoma cervix?
FIGO staging systems ¥ Stage 1a – microscopic ¥ Stage 1b visible lesion ¥ Stage 2 a – vaginal involvement ¥ 2b parametrial involvement ¥ Stage 3 lower vagina or pelvic sidewall ¥ Stage 4 bladder/rectum or metastases
What is cervical glandular intraepithelial neoplasia (CGIN)?
- origin from?
- what can this lead to?
- is this picked up on smears?
- is this assoc. CIN?
- origin from endocervical epithelium
- pre-invasive phase of endocervical adenocarcinoma
- screening is less effective CIN
- sometimes assoc. CIN
Endocervical adenocarcinoma cervix:
- is this common?
- is the prognosis better or worse than squamous?
- what is the epidemiology?
5-25% cervical cancer, increased incidence in younger women
Prognosis -worse than squamous
Epidemiology:
- higher s.e. class
- later onset sexual activity
- smoking
- HPV esp. 18
Apart from CIN what other HPV driven disease exists?
- Vulval intraepithelial neoplasia (VIN)
- Vaginal intraepithelial neoplasia (VaIN)
- Anal intraepithelial neoplasia (AIN)
VIN:
- which disease is this assoc. with?
- is the pathology predictable or unpredictable?
- what age does this affect?
- what else is this usually synchronous with?
- What can this lead to?
Pagets disease: small no. of those with PD of vulva may develop VIN
Unpredictable pathology (3 grades)
Age affected is bimodal:
Young women - often multifocal, recurrent or persistent causing treatment problems
Older women - greater risk of progression to invasive
Usually synchronous with CIN/VaIN
Can lead to vulval invasive squamous carcinoma
What is vulval pagets disease?
Crusting rash
- tumour cells in epidermis contain mucin (they arise from sweat glands in skin)
- mostly no underlying cancer
vulval invasive squamous carcinoma:
- who does this affect?
- what is seen macroscopically?
- what is the usual pathology?
- where does this spread?
- treatment?
Affects elderly women
Macroscopically:
-ulcer or exophytic mass
Pathology:
- can arise from normal epithelium or VIN
- mostly are well differentiated
Spread:
-inguinal nodes
Treatment:
-surgical = radical vulvectomy and inguinal lymphadenectomy
VaIN:
- is this common?
- who does this effect?
Less common than CIN/VIN
-elderly women
Cervical screening:
What is done if CIN1 is detected?
-repeat smear in 6mths
Cervical screening:
What is done if CIN2 is detected?
- referred to colposcopy for LLETZ/laser ablation/cold coagulation
- then retested every 6mths for CIN and HPV
- if HPV -ve and normal smear go back to normal population
What is done if CIN3 is detected?
- referred to colposcopy for LLETZ/laser ablation/cold coagulation
- then retested every 6mths for CIN and HPV
- if HPV -ve and normal smear go back to normal population
At what age is cervical screening done?
-25-64
Describe the treatment options of cervical cancer
Surgery is for stage 1B2 or less
o Loop excision of transformation zone (LETS)
o Fertility sparing
o Wertheim
- Radiotherapy – do this OR surgery
- Chemotherapy – there is not much role for this but get it in combo with radio.
Radiotherapy for cervical cancer: how is this done?
-what planning is needed?
¥ High energy x-rays
¥ Targeted to include tumour +/- nodes
¥ External Beam – for five weeks
¥ Brachytherapy – then get this ‘concentrated’ radiotherapy
(Intrauterine tube goes into cervix with ring applicator which is loaded with a radioisotope)
Planning:
¥ EUA (examination under anaesthetic) and marker seed insertion – this helps to indicate how extensive tumour is
¥ CT planned
Describe how chemo is given for cervical cancer?
¥ Neoadjuvant
Concomittant – at same time as therapy
Palliative
Types:
• Cisplatin – 40mg/m2 weekly
• Carboplatin/paclitaxel
