vulval and vaginal pathology Flashcards
describe features of a normal ectocervix?
- epithelium sitting on a basement membrane and is underpinned by stroma
layers from bottom to top
1. basement membrane
2. basal cells (purple layer)
3. parabasal cells
4. exfoliating cells - these cells are captured during a cervical smear
what cells are captured during a cervical smear?
- exfoliating cells - squamous cells
what lines a normal ectocervix?
- stratified squamous epithelium
what lines a nomal endocervix?
- a single layer of glandular epithelium
what is the most common site to become infected by HPV?
- transformation zone
-> go on to become CIN or glandular equivalent CGIN
what is another word for transformation zone?
- squamo-columnar junction
what are the 2 main pathologies of the cervix?
- inflammatory
- neoplastic
what are some examples of inflammatory pathologies in the cervix?
- cervicitis -
- cervical polyp
what are some examples of neoplastic pathologies in the cervix?
- cervical intraepithelial neoplasia
- cervical cancer - squamous carcinoma, adenocarcinoma, other rare tumours
what are the risk factors for CIN/cervical cancer?
- high risk HPV - 16,18, 31, 33, 35, 45, 48
- many sexual partners
- vulnerability of SC junction in early repro life - age at first intercourse, long term use of oral contraceptives, non-use of barrier contraception
- smoking 3x risk
- immunosuppression -> can’t clear virus
what are 2 types of low risk HPV?
- 6 and 11
- can cause genital warts
what is condyloma acuminatum?
- name given to anogenital warts caused by HPV 6 and 11
- thickened ‘papillomatous’ squamous epithelium w cytoplasmic vacuolation ‘koilocytosis’ (shrunken nuclei)
- caused by HPV
what do you see in cytology of a genital wart type presentation w HPV infection
- mild dyskaryosis
- multinucleation common characteristic in cells affected by HPV infection
- nuclear enlargement
- course chromatin in nuclei
what are koilocytes
- halo cells
- type of epithelial cell that devleops following a HPV infection
- irregular shaped nuclei, shape or colour
what does CIN: caused by HPV 16 and 18 show on microscopy?
- infected epithelium remains flat but may show koilocytosis, which can be detected in cervical smears
HPV can cause what?
- genital warts: low risk HPV 6 and 11
- cervical intraepithelial neoplasia: high risk HPV 16 and 18
- cervical cancer
what do you see on microscopy of a cervical cancer caused by HPV infection?
- invasive squamous carcinoma: virus integrated into host DNA
- whirls of keratin within tumour
- squamous cell carcinoma - islands of cells within stroma broken free from BM
what is time line for a HPV infection to become a high grade CIN?
- 6 months -> 3 years
what is the time line for a high grade CIN -> invasive cancer?
- 5 years -> 20 years
what is cumulative prevalence of HPV infection in lifetime?
- 80% cumulative prevalence in lifetime
- most develop immunity…
where does CIN most often occur?
- transformation zone
- pre-invasive stage of cervical cancer
what is CIN?
- dysplasia of squamous cells
- not visible by naked eye but you can get a feel for it on colposcopy
- detectable on cervical screening
- asymptomatic
histology of CIN?
- delay in maturation
immature basal cells occupying more of epithelium or more nuclei in top layers of epithelium - nuclear abnormalities
hyperchromasia (dark)
inc in nucleocytoplasmic ratio
pleomorphism (variable looking cells) - excess mitotic activity
situated above basal layers
abnormal mitotic forms
often koilocytosis (indicating HPV infection)
how is CIN graded?
I-III depending on severity on factors including:
delay in maturation
nuclear abnormalities
excess mitotic activity
define CIN I?
basal 1/3 of epithelium occupied by abnormal cells
define CIN II
- abnormal cells extend to middle 1/3
- abnormal miotic figures
define CIN III
- abnormal cells occupy full thickness epithelium
- also called squamous cell carcinoma in situ
- also can show early stromal invasion
majority of malignant cervical tumours are?
- invasive squamous carcinoma
- 2nd most common female cancer worldwide
when are invasive squamous carcinomas usually found: what age and what stage?
- early stage and in younger women
- however some are rapidly progressive tumours
- found from pre-existing CIN -> therefore most are preventable by screening
what is staging for cervical cancer?
- Figo staging
what are some symptoms of invasive carcinoma?
- abnormal bleeding
post coital
post menopausal
brownish or blood stained vaginal discharge
contact bleeding - friable epithelium - pelvic pain
- haematuria/urinary infections
- ureteric obstruction/renal failure
spread of squamous carcinoma?
- local
- lymphatic
- haematogenous
how does local spread of squamous carcinoma spread?
- uterine body, vagina, bladder, ureters, rectum
lymphatic spread of squamous carcinoma?
- early -> pelvic, para-aortic nodes
haematogenous spread of squamous carcinoma?
- late -> liver, lungs, bone
what are 2 main classifications of cervical cancer?
- squamous cell carcinoma
- adenocarcinoma
where is SCC of the cervix found?
epithelial lining of the ectocervix
where is adenocarcinoma of the cervix found?
- cancer of the glands found within the lining of the cervix
grading of squamous carcinoma?
- well differentiated
- moderately differentiated
- poorly differentiated
- undifferentiated/anaplastic
what does this image show?
- well differentiated squamous carcinoma of the cervix
what is cervical glandular intraepithelial neoplasia? (CGIN)
- seen in endocervical epithelium
- CGIN is preinvasive phase of endocervical adenocarcinoma
- more difficult to dx on cervical smear than squamous
- screening less effective
- can sometimes be associated w CIN
in high grade CGIN how much of the gland is involved?
- all of the gland is involved
how common is endocervical adenocarcinoma?
- 5-25% of cervical cancers
> some are increasing in incidence, particularly in young women
can cancers of the cervix be mixed?
- yes some are mixed - adenosquamous
what is the grading system for HPV-driven disease include VIN (vulvar itraepithelial neoplasia), VaIN (vaginal intraepithelial neoplasia), AIN (anal intraepithelial neoplasia)
- graded 1,2 or 3 based on degree of atypia and maturational disorder
- grade 3 is equivalent to SCC in situ
is VIN (vulval intraepithelial neoplasia) of usual type a precursor of hpv driven SCC?
- yes
> differentiated VIN (dVIN) is a precurosr of hpv independent vulval SCC. higher risk of invasive malignancy - often has a background of inflammatory dermatoses - lichen sclerosus
who is affected by vulvar intraepithelial neoplasia? (VIN)
- often bimodal:
young women: multifocal, recurrent or persistent causing tx problems
older women: greater risk of progression to invasive squamous carcinoma
what is the most important prognostic factor in vulvar invasive squamous carcinoma?
- if there has been spread to inguinal lymph nodes
what is vulvar invasive squamous carcinoma?
- usually elderly women, ulcer or exophytic mass
- can arise from normal epithelium or VIN
surgical treatment for a vulvar invasive squamous carcinoma?
- radical vulvectomy and inguinal lymphadenectomy
what is 5 year survival for vulvar invasive squamous carcinoma w no spread to lymph nodes?
- 90%
> node positive however <60%
how does vulvar paget’s disease present?
- crusting rash > often sharp demarcation
- pruritic/painful
- tumour cells in epidermis, contain mucin
what cells do lesions in primary vulvar paget’s disease arise from?
- intraepidermal glandular cells
- or pluripotent cells of folliculosebaceous or eccrine units
in secondary cases of vulvar paget’s disease where do cells arise from?
- colorectal neoplasms or urothelial neoplasms
what is the black circle outlining in the epidermis of the vulva?
- paget cells
- red line shows BM - therefore this image is non-ivasic pagets disese of the vulva
how do you manage paget’s disease of the vulva?
- excision of the lesion
- can sometimes extend up into the vagina or anus making excision difficult
list some infections of the vulva?
- candida - particular DM
- vulvar warts - HPV6 and 11
- bartholins glands abscess - blockage of gland duct
what are non neoplastic epithelial disorders of the vulva?
- lichen sclerosis
- other dermatoses: lichen planus, psoriasis
what can often occur to vulva in a post-menopausal women causing pain and bleeding?
- atrophy of the vulva
candida shows what on cytology?
- hyphae and spores
what does a viral wart/condyloma acuninatum show on cytology?
- papillomatous architecture (also characteristic of VIN)
- koilocytes
what does lichen sclerosus et atrophicus show on microscopy?
- epidermis
- glassy subepithelial hyalinised band
name some kind of vaginal pathologies in the vagina?
- benign - polyps, cysts
- VaIN - vaginal intraepithelial neoplasia. may also have cervical and vulval lesions
- squamous carcinoma: less common than cervical and vulval counterparts. disease of the elderly, primary tumours are rare
- melanoma: rare, may appear as a polyp
