T5: Cervical and vulval pathology Flashcards
What are risk factors for Cervical intraepithelial neoplasia (CIN)?
Warts are caused by HPV. Over 40 types of HPV can affected the genital areas.
Risk factors for the development of cervical epithelial neoplasia:
- HPV infection - same for males and females
- Multiple sexual factors
In the female: - First coitus at age less than 17 years - Long term Oral contraceptive pill use - Early pregnancy - High parity - defined as having ≥5 pregnancies of ≥20 weeks of gestation - Low socio-economic status - STD's: Herpes, gonorrhoea, chlamydia - Smoking - Immunosuppression, including HIV seropositivity (HIV seropositivemeans that a person has detectable antibodies toHIV)
Which type(s) of HPV causes cancer?
HPV 16 and 18 These are mainly cancer causing types. 75% case cervical cancer and 50% cause vaginal and vulvar cancer.
Which type(s) of HPV does not cause cancer?
HPV 6 and 11 this is low risk HPV - 90% cause anogenital warts, mainly non-cancer causing
What is the role of Liquid-based cytology?
Liquid based cytology to detect abnormalities of cervix. If abnormalities are found the patient is referred to colposcopy.
What is the role of colposcopy?
A colposcopy is a simple procedure used to look at the cervix, the lower part of the womb at the top of the vagina. Colposcopy to diagnose cervical intraepithelial neoplasia (CIN) and to differentiate high-grade lesions from low-grade abnormalities.
What is the transformation zone?
The transformation zone is the area between the original and new squamocolumnar junction where the columnar epithelium has been or is being replaced by new metaplastic squamous epithelium. This may be wide or narrow based upon the patients:
- Age
- Parity status
- Prior infections
- Exposure to hormones
The transformation zone is prone to oncogenic effects of HPV - it is the site of cervical intraepithelial neoplasm.
How is CIN graded in a Pap smear?
CIN I - Low Grade
CIN II
CIN III - High grade
The nucleo-cytoplasmic ratio is replaced, the nuclear outline becomes more irregular and the chromatin quality changes in neoplasm. If the HPV infection persist it leads to an invasive malignancy or carcinoma.
What are the morphological changes seen in CIN I-III?
CIN I - Maturation is seen in the upper 2/3rds of the epithelium. Some degree of nuclear abnormality is seen. Normal mitotic figures (MF) may be increased and abnormal mitosis supports diagnosis.
CIN II - Cytoplasmic maturation is seen in the upper 1/3rd. Nuclear atypic is more marked than in CIN I. MF’s are increased and atypical mitosis is common.
CIN III - Maturation may be absent or confined only to superficial layers. Nuclear atypic is severe, through full epithelial thickness. MF’s are seen at all levels of epithelium.
What is the role of p16?
P16 is used to confirm the diagnosis of CIN and differentiate it from squamous metaplasia and reparative changes. It is an immunohistology stain that shows block positive p16 expression used in sensitive and specific diagnosis of transforming HPV infection. This is mainly for CIN 2 and above.
How is CIN stage related to disease progression?
In less than 1% with CIN, there is progression to cancer. 60% regress to normal. The rest either persist or progress to the next stage.
In CIN II, 5% progress to cancer. 40% regress to normal and the rest either persist or progress to the next stage.
In CIN III, 30-40% progress to the next stage.
How is Cervical squamous carcinoma staged?
FIGO Staging is used - Cervical cancer stage ranges from stages I (1) through IV (4).
Stage I- Cancer is confined to the cervix. 1a is diagnosed only by microscopy whereas 1b is a clinically visible lesion. A histopathologist is more interested in diagnosing 1a.
Stage II - Cancer has spread beyond the cervix but not spread to the pelvic wall or beyond the 1/3rd of the vagina
Stage III - Cancer has spread to the pelvic wall or beyond the 1/3rd of the vagina
Stage III - Cancer has metastasised
All of the stages are subdivided. The earlier the letter, the less advanced the cancer.
Give other cervical tumours.
- Adenosquamous carcinoma
- Adenoid basal carcinoma
- Adenoid cystic carcinoma
- Neuroendocrine tumours
Metastatic lesions
What is the difference between uVIN and dVIN?
- uVIN : Usual type / Undifferentiated/ Classic
• Graded VIN 1-3
• HPV related
• Younger women; <40 yrs age - Recurs after local Rx in 50% cases.
- Recurrence correlated to smoking, multifocality and positive margins.
- Progression to squamous cell carcinoma seen in 5-6% of treated women and 10-15% of untreated women.
- Spontaneous regression may occur, particularly in pregnant or postpartum women.
- dVIN : Differentiated type
• Not graded
• Not HPV related
• Older women
• Greater risk of progression to invasive SCC than uVIN.
Third of dVIN lesions progressed and within a short period (mean 28 months).
- dVIN : Differentiated type
What is the behaviour of uVIN?
• Associated with VIN
• Can be associated with inflammatory dermatosis like Lichen sclerosus.
• Clinically seen as exophytic mass like lesions +/- ulceration
10% lesions multifocal.
What is the behaviour of dVIN?
- Greater risk of progression to invasive SCC than uVIN.
* Third of dVIN lesions progressed and within a short period (mean 28 months).
