Week 1: Path of cervix, vagina, vulva

Question 1

common HPV types associated with benign and malignant disease

Answer 1

1. Low Risk: HPV 6, 11
   - benign low grade cervical changes
   - Condylomata acuminata (genital warts)
2. High risk: HPV 16, 18
   - low grade, or high grade cervical changes
   - cervical cancer
   - anogenital and other cancers

Question 2

Terminology for HPV related squamous lesions

Answer 2

Classical-Intraepithelial system (histology)-Bethesda system (cytology)

• CIN=cervical intraepithelial neoplasia
• VAIN=vagina IN
• VIN=vulvar IN
• LSIL=low grade squamous intraepithelial lesion
• HSIL=high grade
  1. Mild dysplasia -CIN1/VAIN1/VIN1 -LSIL
  2. moderate dysplasia - CIN2 -HSIL
  3. severe dysplasia -CIN3 -HSIL
  4. Carcinoma in situ -CIN3- HSIL

Question 3

Does low grade pre invasive disease progress to high-grade pre invasive disease?

Answer 3

• probably not

- start out as high grade lesions

Question 4

Cervical squamous carcinoma

Answer 4

PATH
-CIN1: see koilocytes, large cells with perinuclear halo, indicative of HPV infection. Infection can resolve and return to normal. Can see cell maturation from top to bottom.
-CIN III: little maturation. Cells look same throughout.
-Grossly: application of a acetic acid turns cervical cancer precursor lesions white.
INVASION
-microinvasive: invasive component penetrates less than 5mm in depth and less than 7mm horizontally
-invasive sq. CA: invasion deeper than stated above (Rx. radical hysterectomy and lymph node dissection or irradiation)

Question 5

Adenocarcinoma in situ of cervix

Answer 5

• malignant appearing cells: hyperchormatic
• normal looking glands architecture
• potential to progress to invasive
• HPV 18

Question 6

Invasive adenocarcinoma of cervix

Answer 6

• similar to squamous Ca in etiology and prognosis
• clear cell adenocarcinoma related to intrauterine diethylstilbestrol (DES) exposure. Was given to pregnant women to prevent miscarriage, affects daughters who are born-higher risk of clear cell.

Question 7

Vaginal cancer

Answer 7

• most commonly an invasive lesion from the cervix
• primary lesions associated with HPV
• least common cancers of lower genital tract.

Question 8

Condyloma acuminatum

Answer 8

• epidermal manifestation of HPV infection
• anogenital warts
• 90% related to HPV 6 and 11
• most common viral sexually transmitted disease in the US
• path: acanthotic, hyperkeratotic, squamous epithelium with abundant koilocytes

Question 9

Extramammary Paget’s disease of the vulva

Answer 9

• mucinous adenocarcinoma in situ within the epidermis
• adenocarcinoma scattered between squamous cells rather than forming a discrete collection of cells
• unclear etiology
• if isolated, good prognosis
• deep seated malignancy: poor poor prognosis
• staining: + for mucin, keratins, CEA

Question 10

VIN and carcinoma of vulva

Answer 10

• mostly squamous cell Ca.
• 50-70% not assoc. with HPV. often arises in long standing lichen sclerosus (chronic inflammatory condition). Older patients
• 30-50% from HPV. slow growing, epidermal Ca historically referred to as Bowen disease.

Question 11

Unusual neoplasms of lower genital tract

Answer 11

• small cell anapestic CA
• sarcoma botryoides (embryonal rhabdomyosarcoma)
• melanoma