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Reproduction and Sexual Health > Pathology of the Cervix, Vulva and Vagina > Flashcards

Pathology of the Cervix, Vulva and Vagina Flashcards

1
Q

Describe the cells of a normal endocervix.

A

Single layer of ciliated mucin-secreting epithelium, sitting on a basement membrane with stroma underneath

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2
Q

List the 6 different cell layers of a normal ectocervix (out to in).

A
  1. Exfoliating cells
  2. Superficial cells
  3. Intermediate cells
  4. Parabasal cells
  5. Basal cells
  6. Basement membrane
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3
Q

Where is the ‘transformation zone’?

A

Cervix

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4
Q

Describe the transformation zone.

A

Squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia

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5
Q

In what stages of a woman life does the transformation zone alter?

A
  • Menarche
  • Pregnancy
  • Menopause
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6
Q

What is cervical erosion?

A

Exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia

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7
Q

What is the characteristic sign of cervical erosion?

A

** Nabothian follicles **

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8
Q

What is metaplasia?

A

One type of epithelium transforms into another type of epithelium

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9
Q

Can squamous metaplasia be physiological?

A

Yes

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10
Q

Cervicitis can be ____________

A

Asymptomatic

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11
Q

What is cervicitis?

A

Inflammation of the cervix

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12
Q

What complication can cervicitis lead to?

A

Infertility, due to simultaneous silent fallopian tube damage

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13
Q

What can the inflammation in cervicitis be?

A

Non-specific acute/chronic

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14
Q

In follicular cervicitis, what can be seen on the cervix?

A

Sub-epithelial reactive lymphoid follicles

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15
Q

Name 2 infections which can lead to cervicitis.

A
  • Chlamydia trachomatis (sexually transmitted).

* Herpes Simplex Viral infection.

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16
Q

What is a cervical polyp?

A

A localised inflammatory outgrowth in the cervix

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17
Q

Can a polyp cause bleeding?

A

Yes, if it is ulcerated

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18
Q

Is a polyp premalignant?

A

NO

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19
Q

What 2 neoplastic changes can occur in the cervix?

A
  • Cervical Intraepithelial Neoplasia (CIN).

* Cervical Cancer:

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20
Q

What are the 2 main types of cervical cancer?

A
  • Squamous carcinoma.

* Adenocarcinoma

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21
Q

What type of virus is HPV?

A

A DNA virus

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22
Q

What strains of HPV are responsible for 70% of all cervical cancers?

A

16 and 18

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23
Q

Between 10-30 years after being infected with HPV, a small proportion of women will go on to develop cancer

A

T

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24
Q

What HPV strains are high risk?

A

16, 18, 31, 33, 35, 45, 48

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25
Q

What increases your risk of getting HPV?

A

Multiple sexual partners

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26
Q

When is the ( squamocolumnar)SC junction of the vagina vulnerable?

A

In early reproductive life

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27
Q

What factors make the SC junction more vulnerable?

A
  • Age at first intercourse.
  • Long term use of oral contraceptives.
  • Non-use of barrier contraception.
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28
Q

Does smoking increase the risk of cervical cancer?

A

Yes, it increases risk by 3x

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29
Q

HPV causes _________ warts

A

Genital

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30
Q

What HPV types cause genital warts?

A

6 and 11

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31
Q

Is HPV 6 and 11 low or high risk?

A

Low

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32
Q

What is Condyloma Acuminatum?

A

Thickened ‘papillomatous’ squamous epithelium with cytoplasmic vacuolation (‘koilocytosis’)

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33
Q

What type of HPV causes CIN?

A

High risk HPV – types 16 and 18

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34
Q

Describe the typical histological appearance of CIN.

A

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

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35
Q

What type of cervical cancer does HPV cause?

A

Invasive squamous carcinoma.

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36
Q

What does virus integrate into?

A

Host DNA

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37
Q

What is the usual time frame in which HPV infection becomes high grade CIN?

A

6 months - 3 years

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38
Q

How long does it take for high grade CIN to develop into invasive cancer?

A

5-20 years

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39
Q

What is the cumulative prevalence of HPV in a lifetime?

A

80%

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40
Q

Most people develop immunity for HPV

A

T

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41
Q

What increases the risk of HPV disease?

A

PERSISTENCE !!!

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42
Q

What is dyskaryosis?

A

Abnormal cells with multiple nuclei seen in the cervix of someone with HPV

43
Q

What is CIN?

A

A pre-invasive stage of cervical cancer

44
Q

Where does CIN occur?

A

At the transformation zone

45
Q

CIN can involve a large area of the cervix

46
Q

Histologically, what is seen in CIN?

A

Dysplasia of squamous cells.

47
Q

How does CIN usually present?

A

Asymptomatic – detected by cervical screening.

48
Q

Describe the 3 KEY histological features of CIN.

A
  1. Delay in maturation/differentiation
  2. Nuclear abnormalities
  3. Excess mitotic activity
49
Q

Describe the excess mitotic activity seen in CIN.

A
  • Situated above basal layers

* Abnormal mitotic forms

50
Q

Describe the nuclear abnormalities seen in CIN.

A
  • Hyperchromasia (very black nuclei)
  • Nucleocytoplasmic ratio (high)
  • Pleomorphism (marked variation in cell size and shape)
51
Q

Describe the delay in maturation seen in CIN.

A
  • Immature basal cells occupying more of epithelium
52
Q

What is Koilocytosis indicative of?

53
Q

When is Koilocytosis seen?

54
Q

How is CIN graded?

A

I-III, depending on the severity of the above 3 factors (delay in maturation/differentiation, nuclear abnormalities, excess activity).

55
Q

CIN I can be diagnosed if …

A

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.
56
Q

CIN II can be diagnosed if …

A

Abnormal cells extending to the middle 1/3rd.

  • Mitoses in middle 1/3rd.
  • Abnormal mitotic figures.
57
Q

CIN III can be diagnosed if …

A

Abnormal cells occupy full thickness of epithelium.

  • Mitoses, often abnormal in upper 1/3rd.
58
Q

Full thickness atypia, general lack of cytoplasm, very high nucleus to cytoplasmic dysplasia.
Would show severe dyskaryosis on smear.

What does this describe?

59
Q

Invasive squamous carcinoma accounts for 75-95% of all malignant cervical tumours

60
Q

Invasive squamous carcinoma is the __nd most common female cancer worldwide

61
Q

Who are invasive squamous carcinomas usually detected in?

A

Young women

62
Q

What does invasive squamous carcinoma develop from?

63
Q

The fact that ISC is developed from CIN is good because it means lots of cases are preventable, why?

A

CIN can be picked up on smears

64
Q

Why is the staging of ISC important?

A

Treatment and prognosis is different for every stage

65
Q

Outline the staging of ISC.

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.
66
Q

When is there usually no symptoms of invasive carcinoma?

A

At microinvasive and early invasive stages (detected at screening).

67
Q

What symptoms may invasive carcinoma present with?

A

ABNORMAL BLEEDING !!!

  • Pelvic pain.
  • Haematuria/urinary infections.
  • Ureteric obstruction/renal failure.
68
Q

In what situations, might someone with invasive carcinoma notice abnormal bleeding?

A
  • Post-coital.
  • Post-menopausal.
  • Brownish or blood-stained vaginal discharge.
  • Contact bleeding – friable epithelium.
69
Q

Locally, where can squamous carcinoma spread to?

A
  • Uterine body
  • Vagina
  • Bladder
  • Ureters
  • Rectum
70
Q

Other than local spread, how else can squamous carcinoma spread?

A

Lymphatic - early - pelvic, para-aortic nodes.

Haematogenous - late - liver, lungs, bone.

71
Q

Name a glandular lesion seen in the cervix.

A

Cervical Glandular Intraepithelial Neoplasia (CGIN)

72
Q

A CGIN is an adenocarcinoma

73
Q

Where does CGIN arise from?

A

Endocervical epithelium

74
Q

What is CGIN?

A

A preinvasive phase of endocervial adenocarcinoma

75
Q

What is more difficult to diagnose on smear?

A. CGIN
B. CIN

76
Q

If something is not easy to detect on smear, what does this mean?

A

Screening is less effective

77
Q

Describe the histological appearance of high grade CGIN.

A

Cells lose polarity – nuclei are no longer found along the base only

78
Q

What % of cervical cancers is endocervical adenocarcinoma responsible for?

79
Q

Compared with the prognosis of squamous carcinoma, adenocarcinoma is …..

80
Q

List 3 risk factors for the development of endocervical adenocarcinoma.

A
  • Higher socioeconomic class.
  • Later onset of sexual activity.
  • Smoking.
81
Q

HPV __ causes endocervical adenocarcinoma

82
Q

Give 3 examples of other HPV driven diseases.

A
  • Vulvar Intraepithelial Neoplasia, VIN.
  • Vaginal Intraepithelial Neoplasia, VaIN.
  • Anal Intraepithelial Neoplasia, AIN.
83
Q

What is Paget’s disease?

A

Vulvar intraepithelial neoplasia (VIN).

84
Q

VIN is described as ‘bimodal’ - describe this.

A

Can affect both YOUNG women and OLDER women

85
Q

VIN is ________

86
Q

Describe VIN affecting young women.

A

Often multifocal, recurrent or persistent, causing treatment problems.

87
Q

Describe the main concern associated with VIN affecting older women.

A

Greater risk of progression to invasive squamous carcinoma.

88
Q

What can VIN progress into?

A

Invasive squamous carcinoma

89
Q

What is VIN often, but not always associated with?

90
Q

What is VIN often synchronous with?

A

Cervical and vaginal neoplasia (CIN and VaIN).

91
Q

Who does Vulvar Invasive Squamous Carcinoma usually affect?

A

Elderly women

92
Q

What does Vulvar Invasive Squamous Carcinoma usually present as?

A

Ulcer or exophytic mass

93
Q

What can Vulvar Invasive Squamous Carcinoma arise from?

A

Normal epithelium or VIN

94
Q

Where does VISC usually spread to?

A

Inguinal lymph nodes

95
Q

What is the most important prognostic factor of VISC?

A

Spread to inguinal lymph nodes

96
Q

How is VISC treated?

A

Surgery – radical vulvectomy and inguinal lymphadenectomy

97
Q

How does Vulvar Paget’s Disease present?

A

As a crusting rash

98
Q

Where are tumour cells found in vulvar Paget’s?

99
Q

What do tumour cells found in the epidermis of vulvar paget’s contain?

100
Q

What do the tumours of vulvar pagets arise from?

A

Sweat gland on the skin

101
Q

Give examples of infections which can affect the vulva.

A
  • Candida (esp in diabetics).
  • Vulvar wards (HPV 6 + 11).
  • Bartholin’s gland abscess (blockage of gland duct).
102
Q

Give examples of non-neoplastic epithelial disorders affecting the vulva.

A
  • Lichen sclerosis.

* Other dermatoses – lichen planus, psoriasis.

103
Q

When may vulval atrophy occur?

A

Post-menopause

Reproduction and Sexual Health (51 decks)

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