Pathology of cervix, vulva and vagina Flashcards
What are the different types of the cervix?
Ectocervix
Endocervix
Transitional Zone
What lines the ectocervix and endocervix respectively?
Ectocervix; squamous epithelium
Endocervix; glandular epithelium
What makes up the epithelium of the cervix?
Basement membrane Basal cells Parabasal cells Intermediate cells Superficial cells Exfoliating cells
What is the TZ zone of the cervix?
Squamo-columnar junction between ectocervix and endocervical epithelia
What will physiological things in life alters the position of the TZ?
Menarche
Pregnancy
Menopause
What is a cervical erosion?
Exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia
What is a nabothian follicle?
Dilated endocervical glands which form a polypoid structure
Entirely benign
What is cervicitis?
Asymptomatic
Can lead to infertility due to simultaneous silent fallopian tube damage
Non-specific acute/ chronic inflammation
What is follicular cervicitis?
Sub epithelial reactive lymphoid follicles present in cervix
What are the different types of inflammatory pathology of the cervix?
Cervicit Follicular cervicitis Chlamydia trachomatis Herpes Simplex Viral Infection Cervical polyp
What is a cervical polyp?
Localised inflammatory outgrowth
Cause of bleeding if ulcerated
Not premalignant
What are the neoplastic pathologies of the cervix?
Cervical Intraepithelial Neoplasia (CIN)
Cervical cancer; squamous or adenocarcinoma
What are the high risk HPV strains?
16
18
(31,33,35,45,48)
What are risk factors for CIN?
High risk HPV
Vulnerability of SC junction in early reproductive age
Smoking
Immunosuppression
What increases the risk of vulnerability of SC junction in early reproductive age?
Age at first intercouse
Long term use of oral contraception
Non use of barrier contraception
How does HPV cause cervical cancer?
Infects epithelial cells in the cervical mucosa
HPV DNA integrates into the cellular genome resulting in cancer
What strains of HPV cause genital warts?
6 and 11
What is a condyloma acuminatum?
Thickened papillomatous squamous epithelium with cytoplasmic vacuolation
Condyloma acuminata refers to anogenital warts caused by human papillomavirus (HPV). The most common strains of HPV that cause anogenital warts are 6 and 11
What is a koilocytosis?
A type of epithelial cell that develops following a human papillomavirus (HPV) infection. Koilocytes are structurally different from other epithelial cells
Why is a CIN not a cancer?
Not broken through the basal layer
Describe the appearance of CIN?
Infected epithelium remains flat, but may show koilocysosis which can be detected in cervical smears
Describe a CIN 3?
Squamous cell carcinoma in situ
What is the time lines for HPV and high grade CIN infection?
HPV infection can transform into high grade CIN in 6 months to 3 years
High grade CIN can transform to invasive cancer within 5-20 years
What is CIN?
Pre-invasive stage of cervical cancer Occurs in TZ Can involve large area Dysplasia of squamous cell Not visible by naked eye Asymptomatic Detectable by cervical screening
What is the histology of CIN?
Delay in maturation/ differentiation; immature basal cells occupy more epithelium
Nuclear abnormality; hyperchromasia, increased nucleocytoplasmic ratio, pleomorphism
Excess mitotic activity; situated above basal layers, abnormal mitotic figures
How is CIN graded?
1 to 3
Describe CIN 1
Basal 1/3rd of epithelium occupied by abnormal cells
Raised number of mitotic figures in lower 1/3rd
Surface cells quite mature, but nuclei slightly abnormal
Describe CIN 2
Abnormal cells extend to middle 1/3rd
Mitoses in middle 1/3rd
Abnormal mitotic figures
Describe CIN 3
Abnormal cells occupy full thickness of epithelium
Mitosis, often abnormal in upper 1/3rd
What is the commonest form of cervical cancer?
Invasive squamous carcinoma
What will squamous carcinoma of the cervix arise from?
Pre-existing CIN therefore most cases should be preventable by screening
What is the staging system of invasive squamous carcinoma?
FIGO
If lymph nodes involved; a lymphadenectomy will be done
If tumour spread past cervix; radiochemo
What are the symptoms of invasive carcinoma?
Abnormal bleeding; post coital, post menopausal, brown or red stained vaginal discharge, contact bleeding
Pelvic pain
Haematuria/ urinary infections
Ureteric obstruction/ renal failure
Where will squamous carcinoma of the cervix spread locally?
Uterine body Vagina Bladder Ureters Rectum
Where will squamous carcinoma of the cervix spread lymphatically?
Early to pelvic and para-aortic nodes
Where will squamous carcinoma of the cervix spread hematogenously?
Late; liver, lungs and bone
How is squamous carcinoma of the cervix graded?
Well differentiated
Moderately differentiated
Poorly differentiated
Undifferentiated/ anaplastic
What is CGIN?
Cervical Glandular Intraepithelial Neoplasia
Origin from endocervical epithelium
Pre-invasive phase of endocervical adenocarcinoma
What is the epidemiology of endocervical adenocarcinoma?
5-25% of cervical ca Increased incidence, particularly in young women Worse prognosis than squamous carcinoma Higher SE class Later onset of sexual activity Smoking HPV 18 incriminated
What are other HPV driven disease in the genital tract?
Vulvar intraepithelial neoplasia
Vaginal intraepithelial neoplasia
Anal intraepithelial neoplasia
What is dyskaryosis?
Abnormal nucleus found in a cervical smear sample
Who does vulvar intraepithelial neoplasia affect?
Bimodal;
Young women; multifocal, recurrent, persistent
Older women; greater risk of malignant transformation
What is VIN usually synchronous with?
CIN
VaIN
Who does vulvar invasive squamous carcinoma tend to affect?
Elderly women
Presents with an ulcer or exophytic mass
What is the most important prognostic factor for vulvar invasive squamous carcinoma?
Spread to inguinal lymph nodes
What is the treatment for vulvar invasive squamous carcinoma?
Radical vulvectomy
Inguinal lymphadenectomy
What is vulvar paget’s disease?
Crusting rash
Pinky balloon cells; mucinous cells involving epidermis
Can spread along vulva, thigs, anus and vagina
Tumour arises from sweat gland in skin
What infections can affect the vulva?
Candida; diabetics
Vulvar warts (6 & q11)
Bartholin’s gland abscess
What are non-neoplastic epithelial disorders of the vulva?
Lichen sclerosis
Lichen planus
Psoriasis
Who can vulvar atrophy affect?
Post menopausal women; treat with topical oestrogen
What pathology can affect the vagina?
VaIN
Squamous carcinoma
Melanoma; appears as a polyp
What is the management of women with a borderline dyskaryosis at a cervical smear?
Lab perform a reflex high HPV test on cytology;
If HPV +ve, woman referred for colposcopy within 6 weeks
If HPV -ve; returned to routine screening
What is the management of women with high grade dyskaryosis/ suspected invasive cancer at a cervical smear?
Referred to colposcopy for app within 2 weeks
What is colposcopy?
Cervix is assessed in detail using colposcopy
What is the colposcopist looking for at colposcopy?
Abnormal changes in cervix which may indicate pre-cancerous changes (CIN)
How is CIN identified at colposcopy?
Acetic acid can be applied and abnormal areas turn white
If iodine applied; normal tissue stains dark brown and precancerous will not stain
What happens following an inadequate cervical cytology sample/
Repeat cervical cytology no less than 3 months after
If 3 consecutive cervical cytology samples are inadequate, the woman should be referred to colposcopy for an app within 6 weeks
