Week 6- cervical-vulval pathology Flashcards
What is the normal structure of the ectocervix?
Surface layer is called exfoliating cells
Then superficial and intermediate cells
Then parabasal cells
Basal cells
Basement membrane.
This is the normal structure of the endocervix.
What is the transition zone?
The sqaumo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia.
What does the position of the transition zone alter in?
Menarche
Pregnancy
Menopause
This is the squamocolumnar junction
What is cervical erosion?
Exposure of delicate endocervical epithelium on the ectocervix causes the acid environment of vagina to cause a physiological squamous metaplasia.
Formation of Nabothian follicles- these are small fluid filled cysts that occur in response to growth of the squamous epithelium over the columnar epithelium in the endocervix.
(Endocervix grows down into the ectocervix which is in the acidic environment of the vagina. This then causes squamous metaplasia)
What inflammatory causes can cause change to the cervix?
Cervicitis
Cervical polyps.
What is cervicitis?
What causes it?
Inflammation of the cervix. Often can be asymptomatic- however can lead to infertility due to silent fallopian tube damage.
Could be due to:
- follicular cervicitis- sub-epithelial reactive lymphoid follicles present in the cervix.
- Chlamydia
- Herpes
What is a cervical polyp?
What symptoms may occur?
Is it malignant?
A localised inflammatory outgrowth
Can cause bleeding
No its benign and NOT pre-malignant.
What neoplastic causes can cause pathology of the cervix?
Cervical intraepithelial neoplasia
Cervical cancer- this can be squamous carcinoma or adenocarcinoma.
What percentage of cervical cancer has HPV as its driving cause?
75%
What are some risk factors for cervical intraepithelial neoplasia and cervical cancer?
HPV infection- particularly types 16 and 18.
Vulnerability of squamo-columnar junction in early reproductive life-e.g. age at first intercourse, long term contraceptives, non-use of barrier contraception
Smoking
Immunosuppression
Which HPV’s cause genital warts?
Describe the changes that occur to the epithelial layer.
HPV type 6 and 11.
Condyloma Acuminatum- means changes that occur to the epithelial membrane in HPV. It becomes thickened, papillomatous squamous epithelium with cytoplasmic vacuolation.
Describe the epithelial changes in cervical intraepithelial neoplasia. Which HPV types are associated with these changes?
Infected epithelium remains flat, but may show koilocytosis (squamous epithelial cells undergo structural changes due to HPV), which can be detected in cervical smears.
HPV types 16 and 18.
Describe what occurs with the viral DNA and cervical cancer?
Virus integrates with the host DNA.
How long can it take from being infected with HPV to having CIN?
6 months to 3 years.
How long does it take for a high grade CIN to change to an invasive cancer?
5-20 years.
Which age group are most likely to be infected by HPV?
15-25 year olds.
What increases the risk of disease?
Persistently acquiring the virus.
Most people do develop immunity.
What is CIN?
Where does it occur?
How can you detect for this?
The pre-invasive stage of cervical carcinoma. Dysplasia (abnormal cells) of squamous cells occurs.
It occurs at the transformation zone
It isnt visible by the naked eye but can be detected for in cervical screening.
NOTE- koilocytosis is the presence of koilocytes. These are squamous cells that have changed due to HPV infection.
Describe the histology of CIN?
Delay in maturation/differentiation-immature basal cells occupy more of the epithelium
Nuclear abnormalities-hyperchromasia, increased nuclear:cytoplasmic ratio (nucleus got bigger), pleomorphism
Excess mitotic activity-situated above basal layers. Abnormal mitotic forms.
How is CIN classified? Describe these classifications
CIN I-Basal 1/3rd of epithelium occupied by abnormal cells. Raised mitosis in lower 1/3. Surface cells quite mature but nuclei abnormal
CIN II-Abnormal cells extend to middle third. mitoses in middle 1/3. Abnormal mitotic figures.
CIN III-Abnormal cells occupy full thickness of epithelium. Mitoses, often abnormal in upper 1/3.
This shows CIN I. The abnormal cells (there seems to be lots compressed into one small space) at the bottom.
This is CIN II. The compressed cells have moved up to the middle third.
This shows CIN III. The compressed cells have taken over the whole epithelium.
What makes up the majority of malignant cervical tumours?
Invasive squamous carcinoma. (2nd commenest female cancer worldwide).
What does invasive squamous carcinoma develop from?
Pre-exisiting CIN- therefore should be detectable and preventable through screening.
Describe the staging in invasive carcinoma?
Stage 1 A1- depth up to 3mm, width up to 7mm
Stage 1 A2- depth up to 5mm, width up to 7mm
Stage 1B-confined to the cervix
Stage 2-spread to adjacent organs e.g. uterus, vagina
Stage 3-involvement of pelvic wall
Stage 4-distant metastases or involvement or rectum or bladder.
This shows stage 1A
What are the symptoms with invasive carcinoma?
Usually none at microinvasive and early invasive stages.
Abnormal bleeding- post coital, post menopausal, brownish or blood stained vaginal discharge, contact bleeding
Pelvic pain
Haematuria/ urinary infections
Ureteric obstruction/renal failure
Where is invasive squamous carcinoma likely to invade locally?
Likely to invade the uterine body, vagina, bladder, ureters and rectum.
Where (lymphatics wise) is squamous cell carcinoma likely to spread?
Early to pelvic and para-aortic nodes
Where (in the blood) is invasive squamous cell carcinoma likely to spread?
Spreads late to liver, lungs and bone.
How do you grade squamous cell carcinoma?
Well differentiated
Moderately differentiated
Poorly differentiated
Undifferentiated/anaplastic.
What is cervical glandular intraepithelial neoplasia?
CGIN is the pre-invasive phase of endocervical carcinoma. They originate from the cervical epithelium and are therefore difficult to diagnose on smear (hard to get too).
Which has a worse prognosis- squamous carcinoma or adenosquamous?
Adenosquamous has the worse prognosis.
Who gets adenocarcinoma?
Higher socio-economic classes.
Later onset of sexual activity
Smoking
HPV-particularly 18.
What are some other HPV driven diseases?
Vulvar intraepithelial neoplasia
Vaginal intraepithelial neoplasia
Anal intraepithelial neoplasia.
What is VIN associated with?
Pagets disease (not the same as pagets disease of the bone- just has the same name).
What is vulval intraepithelial neoplasia?
Variable behaviour- graded three ways.
Has a bimodal variation- affects:
- young women-often multifocal, recurrent or persistent causing treatment problems.
- older women- greater risk of progression to invasive squamous carcinoma
There is often synchronous cervical and vaginal neoplasia.
Describe vulvar invasive squamous carcinoma?
What is the most important prognostic factor?
USually elderly women, ulcer or exophytic rash.
Can arise from normal epithelium or VIN.
Mostly well differnetiated
Spread to the inguinal lymph nodes.
How is vulvar invasive squamous carcinoma treated?
Surgical treatment- radical vulvectomy and inguinal lymphadenopathy.
What is vulvar pagets disease?
Crusting rash
Tumour cells in epidermis contain mucin
Mostly no underlying cancer- tumour arises from sweat gland in the skin.
What is colposcopy?
Examination of the cervix by a colposcope. A speculum is inserted, and the transformation zone of the cervix is painted with 5% acetic acid (or lugols iodine). This is preferentially taken up by neoplastic cells. Aceto-white areas show abnormal cells allowing a punch biopsy to be taken.
What does a cervical smear identify?
It collects cells for microscopy to show dyskariosis (abnormalities which reflect CIN).
If a women has a smear and has borderline abnormalities, what is the management?
Tested for HPV. If positive reffered for colposcopy.
If a women has a smear and has moderate-severe abnormalities, what is the management?
Colposcopy regardless of HPV status.
What is the english cervical screening criteria?
Sexually active women aged 25-64
3 yearly for women 25-50, 5 yearly until 65
