Pathology of Cervix, Vulva and Vagina Flashcards
divisions of cervix?
ectocervix
- external surface at entrance to cervix/uterus
- lined by squamous epithelium
endocervix
- canal inside the cervix leading into the uterus
- glandular epithelium lines
what lines vagina?
squamous epithelium
layers of cells in ectocervix from top to bottom?
exfoliating cells superficial cells intermediate cells parabasal cells basal cells basement membrane
what cells of ectocervix are sampled by smear test?
exfoliating and supporting cells?
features of endocervix
columnar epitheium
cillia
what is the transformation zone?
area between old squamo-columnar junction (before menarche) and new squamo-columnar junction (post-menarche)
- junction between endo and ecto cervical epithelia
clinical relevance of transformation zone?
site of infection and cancer
what alters the position of TZ?
menarche
pregnancy
menopause
what is cervical erosion and what can it cause?
exposure of the delicate endocervical epitheium to the acidic environment of the vagina leading to squamous metaplasia
- (can lead to squamous carcinoma?)
what are nabothian follicles?
mucous filled cyst on surface of cervix
often happens when squamous epithelium grows over columnar epithelium
what is cervicitis?
non-specific acute/chronic inflammation in the cervix
often asymptomatic
can lead to infertility due to simultaneous silent fallopian tube damage
types of cervicitis?
follicular cervitis - subepithelial reactive lymphoid follicles present in cervix
chlamydia trachomatis - sexually transmitted
herpes simplex
what is a cervical polyp?
localised inflammatory outgrowth
cause of bleeding if ulcerated
not premalignant
types of neoplasia in cervix?
cervical intraepithelial neoplasia (CIN) cervical cancer (squamous carcinoma, adenocarcinoma)
biggest cause of cervical cancer?
HPV
- but can still occur due to other causes
risk factors for CIN?cervical cancer?
persistence of high risk HPV (16 and 18) - multiple partners increases risk vulnerable TZ in early reproductive life - young age at first intercourse - long term oral contraceptive use - non-use of barrier contraception smoking immunosuppression
what does low risk HPV (6 and 11) cause?
genital warts
- condyloma acuminatum: thickened papillomatous squamous epithelium with cytoplasmic vacuolation (koilocytosis)
histological features of CIN due to high risk HPV?
infected epithelium remains flat but may show koilocytosis, which can be detected in cervical smears
microscopic features of cervical cancer?
invasive squamous carcinoma
virus integrated into host DNA
broken through epithelium
time line for HPV infection?
HPV > high grade CIN = 6 months - 3 years
high grade CIN > invasive cancer = 5-20 years
features of abnormal cells on smear?
abnormal shape
larger nucleus with more mitotic figures
features of CIN?
pre-invasive stage of cervical cancer occuring at TZ can involve large area dysplasia of squamous cells not visible to naked eye asymptomatic detectable by cervical screening
progression of dysplasia and neoplasia in cervical epithelium?
koilocytosis > CIN 1 > CIN 2 > CIN 3 (abnormal cells get further and further towards the surface)
histology of CIN?
delay in maturation/differentiation (immature basal cells occupy more of epithelium) nuclear abnormalities (hyperchromasia, increased nucleocytoplasmic ratio, pleomrphism) excess mitotic activity
features of CIN 1?
basal 1/3 of epithelium occupied by abnormal cells
- raised number of mitotic figures in lower 1/3
- surface cells quite mature, but nuclei slightly abnormal
features of CIN 2?
abnormal cells extend into middle 1/3
- mitoses in middle 1/3
- abnormal mitotic figures
features of CIN 3?
abnormal cells occupy full thickness of epithelium
- mitosis, often abnormal, in upper 1/3
most common cervical cancer?
squamous cell carcinoma
staging of cervical cancer?
method about to be obsolete
symptoms of invasive cervical carcinoma?
usually none at microinvasive and early invasive stages so usually just detected at screening
abnormal bleeding (post coital, post menopausal, stained discharge, contact bleeding)
pelvic pain
haematuria/urinary infections
ureteric obstruction/renal failure
how might a squamous cervical cancer spread?
local > uterine body, vagina, bladder, ureters, rectum
lymphatic (early) > pelvic, para-aortic nodes
haematogenous (late) > liver, lungs, bone
how is squamous cervical cancer graded?
well differentiated
moderately differentiated
poorly differentiated
undifferentiated/anaplastic
what is CGIN?
cervical glandular intraepithelial neoplasia
caused by HPV
originates from endocervical epithelium
pre-invasive phase of endocervical adenocarcinoma
CGIN vs CIN?
can be associated
more difficult to pick up on screening
which has a worse prognosis, squamous or adenocarcinoma?
adenocarcinoma
what is adenocarcinoma associated with?
higher socio-economic class
later onset of sexual activity
smoking
HPV, particularly HPV 18
name 3 other HPV driven diseases?
vulvar intra-epithelial neoplasia (VIN)
vaginal intra-epithelial neoplasia (VaIN)
anal intra-epithelial neoplasia (AIN)
features of vulvar intra-epithelial neoplasia?
variable, less predictable than CIN
3 grades
bi-modal
- young women = multifocal, recurrent or persistent causing treatment problems
- older women = greater risk of progression to invasive squamous carcinoma
can be HPV related but not always
often synchronous with cervical and vaginal neoplasia
features of invasive squamous carcinoma
usually elderly women with ulcer or exophytic mass
can arise from normal epithelium or VIN
usually well differentiated
spread to inguinal nodes
features of vulvar pagets disease?
crusting rash
tumour cells in epidermis containing mucin
mostly no underlying cancer, tumour arises from sweat glands in skin
name 3 other types of vulval disease
infection (candida, vulvar warts, bartholins gland abscess)
non-neoplastic epithelial disorders (lichen sclerosis and other dermatoses)
atrophy (post-menopausal)
3 main vaginal pathologies?
VaIN
squamous carcinoma (less common than cervical and vulval)
melanoma (rare)
surgical treatment of vulvar invasive squamous carcinoma?
radical vulvectomy and inguinal lymphadenopathy
