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Reproductive II - Exam 1 > Vulvar Vaginal and Cervical Path (Gianani) - SRS > Flashcards

Vulvar Vaginal and Cervical Path (Gianani) - SRS Flashcards

1
Q

What are 9 common infections of the female lower genital tract?

A
  1. Herpes Virus.
  2. Syphilis
  3. Lymphogranuloma Venereum
  4. Molluscum contagiosum.
  5. Trichomonas vaginalis.
  6. Gardnerella vaginalis.
  7. Ureaplasma urealyticum
  8. Mycoplasma hominis.
  9. HPV
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2
Q

What are the two types of HSV?

What do they prefer to infect?

A

HSV-1: Oropharyngeal

HSV-2: Genital mucosa and skin

(However they can each infect the others site)

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3
Q

What percent of those with HSV infections are symptomatic?

A

1/3

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4
Q

A patient comes to you with genital ulcers that have followed a progression from red papules to vesicles to painful coalescent ulcers. A cervical smear reveals the attached cytology.

Describe the findings and make the diagnosis!

A

The arrow indicates the characteristic HSV cytopathic changes: Multinucleated cells containing eosinophilic to basophilic viral inclusion with a ground glass appearance.

Herpes Virus Infection 2 (most likely)

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5
Q

What is the progression of the lesions in HSV?

What happens when the lesions resolve?

A

Red papules> vesicles > painful coalescent ulcers > Spontaneous healing 1 to 3 weeks followed by latent infection in the regional lumbosacral nerve ganglia.

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6
Q

What does MCV stand for?

A

Molluscum Contagiousum Virus

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7
Q

A 25 y/o female patient comes to you complaining of lesions in her pelvic area. You find pearly dome-shaped papules with a dimpled center containing waxy material. Attached is a gross photo and a couple of histology samples of the lesion.

Describe the findings in the two images.

What is the likely causative organism?

A

Left: Micrograph of low power appearance of dome shaped papule with dimple center (see panel B).

Right: High power magnification reveals intracytoplasmic viral inclusions (see panel C, blue arrow) .

Molluscum Contagiosum (MCV 1-4)

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8
Q

How is MCV transmitted?

A

Children: through shared articles of clothing, towels, etc

Adults: Sexually transmitted

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9
Q

What is donovanosis caused by?

A

Klebsiella granulomatis

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10
Q

What causes granuloma inguinale?

A

Klebsiella granulomatis - another name for Donovanosis

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11
Q

Untreated cases of granuloma inguinale are characterized by the development of extensive scarring, often associated with what unique feature?

A

Lymphatic obstruction and lymphedema (elephantiasis) of the external genitalia.

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12
Q

Chancroid is an acute sexually transmitted ulcerative infection caused by what organism?

A

Haemophiluc ducreyi

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13
Q

Chancroid is one of the most common causes of genital ulcers in Africa and Southeast Asia, where it probably serves as an important cofactor in the trans­mission of?

A

HIV

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14
Q

What are the two primary cells that HPV likes to infect?

A
  1. Immature basal cells of the squamous epithelial breaks
  2. immature metaplastic squamous cells at the squamocolumnar junction
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15
Q

Why is the cervix more susceptible to HPV infection than say, the vulvar skin and mucosa?

A

Has large areas of immature squamous metaplastic epithelium

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16
Q

What is the ability of HPV to be a carcinogen dependent upon?

A

Viral proteins E6 and E7, which interfere with the activity of tumor suppressor proteins that regulate cell growth and survival.

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17
Q

HPV with the viral protien E6 will cause what changes in the cellular machinery?

A

TERT - increased telomerase expression

p53 - Inhibition

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18
Q

HPV with the viral protien E7 will cause what changes in the cellular machinery?

A
  1. p21 - inhibition, leading to increased cyclin D/CDK4 which inhibits RB-E2F
  2. Direct inhibition of RB-E2F
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19
Q

What are some examples of organisms that infect the lower genital tract and have a tendancy to ascend to the upper genital tract? ( STD:2, non STD: 4)

A

STD

  1. Neisseria gonorrhoeae (STD).
  2. Chlamydia trachomatis (STD).

Non-STD (usually post abortion, or tampon related)

  1. Staphylococci,
  2. streptococci,
  3. coliforms
  4. Clostridium perfrigens (infections after abortions or delivery
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20
Q

Pelvic inflammatory disease (PID) is an infection that begins in the vulva or vagina and spreads upward to involve most of the structures in the female genital system, resulting in pelvic pain, adnexal tenderness, fever, and vaginal discharge. What are two long term consequences of this condition?

A
  1. Infertility
  2. Ectopic pregnancy
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21
Q

Your patient presents with white plaques and macules in the pelvic area. You obtain a sample and see the attached image.

What do you see happening here?

What is this?

A

Lichen Sclerosus

  1. marked thinning of the epidermis
  2. excessive keratinization
  3. sclerotic changes of the superficial dermis
  4. bandlike lymphocytic infiltrate in the underlying dermis
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22
Q

In what patients is lichen sclerosus most common?

A

Elderly (post menopausal) women (but can occur in all age groups)

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23
Q
A
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24
Q

Describe the stages of syphilis?

A

Primary - painless ulcers usually in the genital area arise in the first 3 months of infection.

Secondary - occurs within 2 months after the resolution of the ulcer.

Tertiary - presents years to decades after the initial infection and manifests with cardiac, neurological and dermatological features.

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25
Q

A 60 something y/o female shows up to you for neurological deficits. She relates to you an episode from many years ago where she had painless ulcers that came on after a liason with a random stranger.

What other systems are at risk in this patient?

A

In addition to the neurological deficits she may also see cardiac, and dermatological features.

(Syphilis)

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26
Q

What are some common features of secondary syphilis?

A

Non-specific features including…

  1. Pharyngitis
  2. fever
  3. mucocutaneous lesions
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27
Q

What is the most important factor in the development of cervical cancer?

A

High risk HPV strains (16 especially and 18)

Must know this

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28
Q

What are some other cancers that HPV is responsible for?

A

squamous cell carcinomas arising at many other sites, including:

  1. vagina
  2. vulva
  3. penis
  4. anus
  5. tonsil
  6. other oropharyngeal locations.
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29
Q

What are the two main types of vulvar SCC?

A

1st type: Basaloid and warty carcinomas

2nd type: Keratinizing squamous cell carcinoma

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30
Q

Which type of vulvar SCC is associated with HPV?

In what patient population is this most common?

A

1st type: Basaloid and warty carcinomas are related to HPV (HPV16),

Most common in young women, but overall less common.

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31
Q

2nd type vulvar SCC is Keratinizing squamous cell carcinoma, and is not HPV related. In what people is this more common?

A

Older women (is the more common overall type of vulvar SCC)

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32
Q

What are the two types of vulvar Intraepithelial Neoplasia (VIN)?

A

1st Type: Classic VIN.

2nd Type: Differentiated VIN.

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33
Q

Which type of VIN?

presents either as a discrete white (hyperkeratotic) or a slightly raised, pigmented lesion. Microscopically, it is characterized by epidermal thickening, nuclear atypia, increased mitoses, and lack of cellular maturation.

A

Classic VIN

34
Q

Which type of VIN?

characterized by marked atypia of the basal layer of the squamous epithelium and normal-appearing differentiation of the more superficial layers. with invasive keratinizing squamous cell carcinomas containing nests and tongues of malignant squamous epithelium with prominent central keratin pearls.

A

Differentiated VIN

35
Q

What type of VIN?

A

Vulvar intraepithelial neoplasia, differentiated type. Nuclear atypia is confined to the basal portion of the epithelium.

36
Q

What type of VIN?

A

Vulvar intraepithelial neoplasia, classic type. Nuclear enlargement, nuclear hyperchromasia, apoptosis, and mitotic activity are present in all levels of the epithelium.

37
Q

What do you see in this biopsy taken from a patients vulva?

What are the key features to hone in on?

A

Keratinizing Squamous cell Carcinoma of the Vulva.

  • note the prominent keratin pearl formation and central whorls of keratinization
38
Q

What type of vulvar carcinoma is this?

A

Basaloid carcinoma of the vulva (invasive)

39
Q

What are the two types of glandular neoplastic lesions of the vulva?

A
  1. Papillary hydroadenoma
  2. Extramammary Paget disease
40
Q

What are some developmental anomalies of the vagina that we covered?

A
  1. Septate or double vagina
  2. Adenosis
41
Q

What neoplastic process is adenosis associated with?

A

Clear cell carcinoma of the vagina

42
Q

What in utero exposure are both septate vagina and adenosis linked with?

What else does this linked thing predispose patients to?

A

diethylstilbestrol (DES)

Also predisposes to Clear cell carcinoma via adenosis.

43
Q

What does VAIN stand for?

A

Vaginal intraepithelial neoplasia

44
Q

Where do cancers in the lower 2/3 of the vagina metastasize to?

A

Inguinal nodes

45
Q

Where do lesions in the upper 1/3 of the vagina tend to metastasize to?

A

Regional iliac nodes

46
Q

What are vitually all primary carcinomas of the vagina associated with?

A

High risk HPVs

47
Q

Based on the gross image and the histo what does this woman have?

A

Sarcoma botryoides - grow as polypoid, bulky, rounded masses with a grape cluster appearance/consitency.

48
Q

Ident the blanked structures in this cervix histology slide.

A
49
Q

Vaginal pH is maintained below 4.5 by what?

What else can this produce?

A

Lactobacilli production of lactic acid.

Can also produce H2O2 at low pH, if pH becomes alkaline this decreases.

50
Q

What are some example organisms that can produce significant acute or chronic cervicitis? 4

A
  1. gonococci
  2. chlamydiae
  3. mycoplasmas
  4. HSV
51
Q

What are the grades of CIN?

A

Cervical intraepithelial neoplasia (CIN)

CIN I

CIN II

CIN III

52
Q

Identify the levels of dysplasia associated with the CIN stages.

A

CIN I: Mild dysplasia

CIN II: Moderate dysplasia

CIN III: Severe Dysplasia

CIN III: Carcinoma in situ

53
Q

Why are CIN III/Carcinoma in situ dealt with severely?

A

Because they will go onto invasive cancer

54
Q

Identify the CIN stage

A

CIN III - diffuse atypia, loss of maturation, and expansion of the immature basal cells to the epithelial surface

55
Q

Identify CIN stage

A

CIN II: progressive atypia and expansion of the immature basal cells above the lower third of the epithelial thickness.

56
Q

Identify the CIN stage.

A

CIN I: koilocytic atypia

57
Q

What percent of LSIL follows each course…

  1. Regress
  2. Persist
  3. Progress
A
  1. Regress: 60%
  2. Persist: 30%
  3. Progress: 10% to HSIL
58
Q

What percent of HSIL follows each course…

  1. Regress
  2. Persist
  3. Progress
A
  1. Regress: 30%
  2. Persist: 60%
  3. Progress: 10%
59
Q

What is shown in this sample taken from a patients cervix?

A

Squamous cell carcinoma of the cervix: Microinvasive squamous cell carcinoma with invasive nest breaking through the basement membrane of high-grade squamous intraepithelial lesion.

60
Q

What is shown in this biopsy taken from a patients cervix?

A

Squamous cell carcinoma - Invasive carcinoma composed of nests and tongues of malignant squamous epithelium.

61
Q

What is this cervical lesion?

A

Invasive adenocarcinoma of the cervix

62
Q

What is a stage 0 cervical cancer?

A

Carcinoma in situ (CIN III, HSIL)

63
Q

What is a stage 1 cervical carcinoma, broadly?

What are the subtypes?

A

Carcinoma confined to the cervix

  1. Ia
  2. Ia1
  3. Ia2
  4. Ib
64
Q

Carcinoma confined to the cervix is subclassed into the following four categories. Describe how each is different.

  1. Ia
  2. Ia1
  3. Ia2
  4. Ib
A
  1. Ia: preclinical carcinoma - diagnosed only by microscopy
  2. Ia1: Stromal invasion no deeper than 3 mm and no wider than 7 mm (Microinvasive)
  3. Ia2: Max depth of stroma deeper than 3 mm and no deeper than 5 mm from base of epithelium, horizontal invasion not more than 7 mm
  4. Ib: Histologically invasive carcinoma confined to the cervix and greater than stage Ia2
65
Q

What is considered a stage II carcinoma?

A

Carcinoma extends beyond the cervix but not to the pelvic wall.

OR Involves the vagina but not the lower third.

66
Q

What constitutes a stage III carcinoma?

A

Has extended to the pelvic wall. On rectal examination there is no cancer-free space between the tumor and the pelvic wall.

OR Tumor involves the lower third of the vagina.

67
Q

What constitutes stage IV cervical carcinoma?

A

Extended to beyond the true pelvis or has invoved the mucosa of the bladder or rectum. This stage also includes cancers with metastatic dissemination.

68
Q

Stage?

Stromal invasion no deeper than 3 mm and no wider than 7 mm (Microinvasive)

A

Ia1

69
Q

Stage:

Has extended to the pelvic wall. On rectal examination there is no cancer-free space between the tumor and the pelvic wall. Tumor involves the lower third of the vagina.

A

III

70
Q

Stage?

Carcinoma in situ (CIN III, HSIL)

A

0

71
Q

Stage?

Extended to beyond the true pelvis or has invoved the mucosa of the bladder or rectum. This stage also includes cancers with metastatic dissemination.

A

IV

72
Q

Stage?

Max depth of stroma deeper than 3 mm and no deeper than 5 mm from base of epithelium, horizontal invasion not more than 7 mm

A

Ia2

73
Q

Stage?

Carcinoma extends beyond the cervix but not to the pelvic wall. Involves the vagina but not the lower third.

A

II

74
Q

Stage?

Histologically invasive carcinoma confined to the cervix and greater than stage Ia2

A

Ib

75
Q

Stage?

preclinical carcinoma - diagnosed only by microscopy

A

Ia

76
Q

As is well known, cytologic cancer screening has significantly reduced mortality from cervical cancer. In countries where such screening is not widely practiced, cervical cancer continue to exact a high toll. What is the reason that cytologic screening is so effective?

A

Most cancers arise from precursor lesions over the course of years.

77
Q

Testing for the presence of HPV DNA in the cervical scrape is a molecular method of cervical cancer screening. HPV testing has a higher sensitivity but lower specificity, as compared to Pap test.

What patients may you consider adding this testing protocol to cervical cytology?

In what patients is this not recommended?

A
  1. May be added to screening for women 30 y/o or older
  2. Not recommended for women under 30 d/t the high incidence of infection and thus particularly low specificity of HPV test results in this age group.
78
Q

Cervical cancer screening and preventive measures are carried out in a step wise fashion. Recommendations for the frequency of Pap screening vary. When should the first smear happen?

How often for recheck?

A

Age 21 years, or within 3 years of onset of sexual activity.

Recheck every three years.

79
Q

After age 30, women who have had normal cytology results and are negative for HPV may be screened every?

A

5 years

80
Q

Women with a normal cytology result, but test positive for high-risk HPV DNA, should have cervical cytology repeated every?

A

6 to 12 months

81
Q

What is the new big deal in the treatment of cervical cancer?

In whom is this recommended?

A

Vaccination against high risk oncogenic HPVs

Recommended for…

All girls and boys by age 11 - 12 years.

Young men and women up to age 26 years.

Reproductive II - Exam 1 (12 decks)

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