Pathology of the Cervix, Vulva, Vagina

Question 1

What causes cervicitis?
Which infection is the most concerning?

Answer 1

Mostly caused by STIs (C. trachomatis, N. gonorrhea)
HPV infection important due to high risk types

Question 2

What is this?

Answer 2

Cervical polyps

Question 3

What are cervical polyps?
What are they characterized by?

Answer 3

Benign polyps arising from endocervical glands
Characterized by glandular or metaplastic squamous epithelium

Question 4

What causes neoplasms of the cervix?

Answer 4

Typically HPV in cause
Immature cells of transformation zone more susceptible to HPV
Pap smear samples transformation zone

Question 5

What is this?
What distinguishes eachs stage?

Answer 5

Progression from normal to cervical intraepithelial neoplasia

Subdivided into CIN 1 (low grade), CIN 2 and CIN 3 (high grade)

CIN 1: Basal 1/3rd of epithelium with dysplastic cells
CIN 2: 2/3rd of epithelium with dysplasia
CIN 3: Full thickness dysplasia

Question 6

What is the importance of CIN?
What causes it?
What are the pathological characteristics?
What are the diagnostic steps to screen for it?

Answer 6

Precancerous lesions of cervix

CIN is preceded by HPV infection
Typically HPV is cleared but persisting HPV causing neoplasia of the cervix

Nuclear atypia, increased nuclear/cytoplasmic ratio, abundant mitoses

Colposcopy is the next test following a positive pap smear to eval for CIN

Question 7

What is this?
How common is it?
How are the outcomes?

Answer 7

Squamous cell carcinoma of the Cervix

75% of cervical cancer
Markedly decreased mortality rates due to use of pap smears

Question 8

What glandular lesion of the cervix exists?

How frequent is it?
How does it arise?
What is the clinical issues?

Answer 8

Adenocarcinoma of the cervix

Comprises 20% of all cervical cancer
Carcinoma arising in the endocervical glands
More difficult to sample by pap smear due to the crypts/folds in the cervical canal

Question 9

What is the pathogenesis of HPV?

Answer 9

HPV infection occurs in the most immature squamous cells of the basal layer, replication of HPV DNA takes place in more differentiated overlying squamous cells
Squamous cells at this stage of maturation do not normally replicate DNA, but HPV-infected squamous cells do, as a consequence of expression of two potent oncoproteins encoded in the HPV genome called E6 and E7
E6 and E7 proteins bind and inactivate two critical suppressors, p53 and Rb, respectively
High-risk HPV strains: 16 and 18, account for 70% of cases of CIN and cervical carcinoma

Question 10

What is the screening for HPV?

Answer 10

21 to 65 with cytology every 3 years or 30 to 65 with cytology and HPV testing every 5 years

Question 11

What can cause vulvitis?
What is veulvar vestibulitis?

Answer 11

Infection of vulva can be from bacterial, fungal, viral organisms
Eg: Gonorrhea, syphilis, HSV, HPV, candida, molluscum contagiosum
Vulvar vestibulitis – Non-specific chronic inflammation of the mucosal surfaces of the vulva

Question 12

What is this?

Answer 12

Lichen sclerosus

Question 13

Which age group is at risk for lichen sclerosus?
How does skin appear?
What risk is it associated with?
What features are with it?

Answer 13

Occurs in premenarchal and postmenopausal age group
Skin is very pruritic and thin: “parchment paper” appearance
1-5% develop squamous cell carcinoma
Fibrotic dermis, loss of skin appendages, chronic inflammatory cell infiltrate

Question 14

What is this?

Answer 14

Lichen simplex chronicus

Question 15

What is lichen simplex chronicus secondary to?
How does it appear?
What is it characterized by?
What is its risk for carcinoma?

Answer 15

Secondary to chronic inflammation and itching
Appears thickened (hyperkeratotic) and with white plaques (leukoplakia)
Characterized by thickened epithelium with chronic inflammation
No known predilection for carcinoma

Question 16

What is this?
What is it associated with?
How is it graded?

Answer 16

VIN - Precancerous lesion of the vulva

Associated with high risk types of HPV

VIN 1-3 (Same grading as cervix)

Question 17

What is this?
How frequent is it?
Who is at risk?
What are the subtypes?

Answer 17

Invasive squamous cell carcinoma of vulva
90% of vulvar malignancies are invasive squamous cell cancer
Occurs in the menopausal age group

Subtypes:
Preceded by VIN
Preceded by reactive changes (lichen sclerosis)

Question 18

What is the many other type of vulvar carcinoma? What does it arise from?

Answer 18

Adenocarcinoma
From the Bartholin glands

Question 19

What is this?
How does it manifest?
What is it characterized by?

Answer 19

Paget’s disease (extramammary)
Red scaly plaques on the labia
Characterized by large pale glandular cells in the epidermis

Question 20

What causes vaginitis?

Answer 20

Bacterial, fungal, viral, parasitic infections

Question 21

What is the vaginal precursor to squamous dysplasia?
How frequent is it?
What can it progress to?

Answer 21

HPV associated vaginal intraepithelial neoplasia – precursor lesion
Subdivided into VAIN 1 (low grade), VAIN 2, VAIN 3

More rare than VIN/CIN

VAIN progresses to invasive squamous carcinoma

Question 22

What carcinoma is related to DES?
What is its precursor?

Answer 22

Clear cell carcinoma of the vagina

Related to maternal DES exposure while in-utero
Vaginal adenosis is seen with DES exposure and is a precursor

Question 23

What is this?
Who does it affect?
What type of mass?
Where else can it be seen?
What is it characterized by?

Answer 23

Sarcoma botryoides (embryonal rhabdomyosarcoma)

Infants, young children < 5 yo.
Soft polyploidy masses in the vagina
Also be seen in the urinary bladder and bile ducts
Characterized by primitive cells