Pathology of Cervix, Vulva and Vagina Flashcards
What is the vagina lined by
Stratified Squamous epithelium
Describe the layers of the ectocervix from INSIDE out
BM>basal cells>parabasal cells>intermediate cells>superficial cells>Exfoliating cells
What is the transformation zone?
Squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia
Where is the transformation zone?
- just before the external OS of cervix
- lower cervix
Site for CIN
-90% IN TRANSFORMATION ZONE
What is cervical ectropion?
What may is present as?
- Endocervical cells begin to grow on the ectocervix
- Exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia
.
.
.
.
.
bleeding (before and after sex) , discharge (with streaks of blood) , dyspareunia
What are Nabothian follicles?
-mucus producing glands on the cervix - benign structures in the cervix
What are neoplastic lesions of the cervix?
- CIN (cervical Intra-epithelial neoplasia)
- Cervical cancer (Squamous CA and adenoCA)
Name inflammatory lesions of the cervix.
Cervicitis
cervical polyp
What is the % Cervical cancer is caused by HPV?
75%
What cells does HPV infect?
- epithelial cells in the cervical mucosa
- —-HPV DNA integrates into cellular genome causing CANCER
Most common HIGH risk HPV types
16 and 18
Who is at HIGH RISK of Cervical cancer
- smoking (3x risk)
- immunosuppresion
- age at first intercourse
- long term use of oral contraceptives
- non-use of barrier contraception (ask those despite use of pills)
- having multiple sex partners
Is CIN malignant?
NO
- it is still INTRA- epithelial; epithelium is intact !
- BUT it is a pre-invasive stage of cervical cancer
What do low risk HPV types cause?
Genital Warts
(types 6 and 11)
—-CONDYLOMA ACUMINATA (thickened papillomatous squamous epithelium with cytoplasmic vacuolation)
When is it considered to be malignant?
- when squamous cells break through the epithelium
Symptoms of CIN>
- asymptomatic
- detectable by cervical screening
CIN III is equivalent to _____
Squamous cell CA in-situ
When is it deemed to be cancerous?
- evidence of epithelium cells invading the basement membrane —-may grow down as endocervical crypts …?
What is the most common malignant cervical tumors?
75-95% is Invasive squamous carcinoma
2nd commonest female cancer worldwide
How does Invasive squamous Ca (ISC) of the cervix develop?
- develops from pre-existing CIN
- –should be preventable by screening
What is the diff. btwn CIN types I,II AND III?
- CIN I: presence of abnormal Mitotic cells in the basal 1/3 of epithelium
- CIN II: abnormal cells extend to MIDDLE 1/3
- CIN III: occupies FULL thickness
What are diff. forms of abnormal BLEEDING, seen as SX for invasive ca?
- POST-COITAL
- brownish/blood stained vaginal discharge
- contact bleeding (fRIABLE epithelium)
- post-menopausal
Symptoms of invasive carcinoma.
- abnormal bleeding
- pelvic pain
- hematuria/UTI
- ureteric obstruc./ renal failure
What is Cervical Glandular Intra-epithelial Neoplasia?
What does CGIN come hand in hand with?
- a pre-invasive phase of ENDOCERVICAL adenocarcinoma
- a.w CIN
A.w HPV
In which cervical cancer is screening LESS effective?
CGIN
- hard to dx on cervical smear
- SOMETIMES a.w CIN
Other HPV- driven disease?
- Vulvar Intraepithelial Neoplasia, VIN
- Vaginal Intraepithelial Neoplasia, VaIN
- Anal Intraepithelial Neoplasia, AIN
What are neoplastic lesions of the vulva?
- VIN (vulvar intraepithelium neoplasia)—-a.w Lichen sclerosis
- Paget’s disease
Is VIN a.w HPV?
- OFTEN
not always
What is VIN synchronous with?
- often synchronous with CIN and VaIN
aRE YOUNGER or older women at risk of vulvar invasive squamous CA?
OLDER ! —greater risk of VIN to progress in to isc (but may also arise from NORMAL epithelium)
How to treat Vulvar ISC?
surgical
- —radical vulvectomy and inguinal lymphadenopathy –If node +: <60% 5 year survival
- if node (-)ve= 90% 5 year survival
How does vulvar paget’s disease present as?
- painful
- itchy d.t crusting rash
- ## oozing
Where does the vulvar paget’s disease arise from?
sweat gland in skin
What can cervicitis be caused by?
- Chlamydia Trachomatis
- Herpes Simplex Viral infection
- follicular cervicitis
What is a cervical polyp?
- a localized inflammatory OUTGROWTH
- bleeds if ulcerated
IS Cerv. polyp a premalignant lesion?
no
Can cervicitis lead to infertility?
- yes
- d.t simultaneous fallopian tube damage
What do the high risk HPV types cause?
- CIN
- —-infected epithelium remains FLAT
- —-may show koliocytosis (detected on cervical smear)
How long is the progression of HPV infection into HIGH grade CIN?
6 MONTHS- 3 YEARS
Is the progression of high grade CIN to invasive cancer fast?
- NO
- 5-20 years !
What is alarming on smear test results?
- mild dyskaryosis
- viral fts
(disproportionate nucleus to cytoplasmic ratio)
Where does CIN occur?
And what occurs?
- at the transformation zone
(may involve a LARGE area)
—-dysplasia of SQUAMOUS cells
What is seen on histology of CIN?
- delay in maturation
(immune BASAL cells occupying more of epithelium) - nuclear abnormalities (hyperchromasia/ ^ nucleocytoplasmic ratio/ pleomorphism)
- excess mitotic activity (above basal layers/ abnormal mitotic forms)
Koliocytosis seen on smear test. What does it suggest?
- HPV infection
halo around dysplastic nucleus
How does squamous carcinoma spread?
- local> surrounding organs (uterus/vagina/bladder/bowel)
- Lymphatic (pelvic and para-aortic nodes)
- Hematogenous (later stage–>LIVER/LUNGS/BONES)
How to classify squamous carcinoma?
- well-differentiated
- moderately
- poorly
- undifferent.
What is CGIN?
- cervical glandular intraepithelial neoplasia (CGIN)
- —-it is the PRE-INVASIVE phase of ENDOCERVICAL adenocarcinoma
Are the ladies most likely to be younger in endocervical adenocarcinoma or squamous carcinoma?
- adenocarcinoma
- –WORSE prognosis than squamous carcinoma
What is the epidemiology of adenocarcinoma?
- HIGHER s.e class
- later onset of sexual activity
- smoking
- HPV 18
How does Vulvar intraepithelial neoplasia present as?
- variable
- 3 grades
YOUNG women: multifocal, recurrent or PERSISTENT (rx problems)
Olderwomen: RISK of progression to INVASIVE squamous carcinoma
Are the VINs well differentiated?
And what is an important prognostic factor?
- most are well differentiated
(esp. VERRUCOUS) - spread to INGUINAL lymph nodes = prognostic factor
How does vulvar invasive squamous carcinoma present as?
- THICK, SCALY, bumpy skin
- area is VERY itchy, red, or darker/lighter
- enlarged lymph nodes
- pain on urination
- burning sensation
Name other vulvar lesions.
Infections: candida (diabetic) / vulvar warts/ bartholin’s glands abscess
- non-epithelial d.o: Lichen Sclerosis and other dermatoses (lichen planus/psoriasis)
- atrophy (post-menopause)
How common is Vaginal squamous carcinoma?
- LESS common than cervical and vulvar counterparts (disease of the elderly)
How does a vaginal melanoma appear?
- as a polyp
How does vulvar invasive squamous carcinoma appear as in an older women?
- ULCER
- EXOPHYTIC mass
