2: Cervical screening and vulval pathology

Question 1

Which type of epithelium lines the vaginal end of the cervix?

Answer 1

Squamous epithelium

Question 2

What is the vaginal end of the cervix called?

Answer 2

Ectocervix

Question 3

What is the uterine end of the cervix called?

Answer 3

Endocervix

Question 4

Which type of epithelium is found in the endocervix?

Answer 4

Columnar, glandular epithelium

Question 5

What is the transformation zone of the cervix?

Answer 5

Transition between squamous (vaginal end; ectocervical) and columnar (uterine end; endocervical) epithelium

Question 6

Where does cervical cancer arise?

Answer 6

Squamo-columnar junction / Transformation zone

Question 7

What causes the squamo-columnar junction to rise?

Answer 7

Menarche

Pregnancy

Menopause

Question 8

The vagina is an (acidic / alkaline) environment.

Answer 8

acidic

Question 9

What process occurs when the endocervix is opposed to the acid of the vagina?

Answer 9

Squamous metaplasia

Inflammation causes columnar epithelium to change into squamous epithelium

Question 10

What is cervicitis?

Answer 10

Inflammation of the cervix

Question 11

Which sexually transmitted infection, causing cervicitis, can lead to infertility?

Answer 11

Chlamydia

Question 12

What is a cervical polyp?

Answer 12

Abnormal inflammatory growth in the cervix

Question 13

Are cervical polyps malignant?

Answer 13

No

And most don’t become malignant

Question 14

What is CIN?

Answer 14

Cervical intraepithelial neoplasia

Precursor to cervical cancer

Question 15

What are the two most common forms of cervical cancer?

Answer 15

Squamous carcinoma

Adenocarcinoma

Question 16

Which specific viruses are associated with a percentage of cervical cancers?

Answer 16

HPV 16

HPV 18

Question 17

Which percentage of cervical cancers are caused by HPV 16 & 18?

Answer 17

70 - 75%

This means that 25 - 30% aren’t and you have to stay vigilant

Question 18

What are risk factors for cervical cancer?

Answer 18

HPV infection (particularly 16 and 18)

Long-term oral contraceptive use

Smoking (big one)

Immunosuppression

Question 19

What is a sign of HPV infection on histology?

Answer 19

Koilocytosis

Dyskaryosis (nuclear abnormalities) in an epithelial cell, giving them a HALO appearance

Question 20

What causes CIN to be reclassified as cancer?

Answer 20

Breaks through basement membrane

Question 21

What is the pre-invasive stage of cervical cancer called?

Answer 21

Cervical intraepithelial neoplasia (CIN)

Question 22

Is CIN symptomatic?

Answer 22

No

Not visible to the human eye

Question 23

By which process do the nuclei of cervical cells become enlarged, signalling CIN?

Answer 23

Koilocytosis

Question 24

What are some nuclear signs of CIN?

Answer 24

Hyperchromasia - stain dark black

Increased nucleus:cytoplasm ratio

Pleomorphism - variable appearance between cells

Question 25

How is **CIN classified?**

Answer 25

**CN I - III** more invasive as you go up

Question 26

What is **CIN III** also known as?

Answer 26

**"Carcinoma-in-situ"** Impending malignancy

Question 27

At which layer of squamous epithelium should mitosis be occurring?

Answer 27

**Basal layer** If it's happening above this then suspect CIN

Question 28

What is the **most common type of cer****vical cancer?**

Answer 28

**Squamous carcinoma**

Question 29

Why isn't **squamous carcinoma** as common in the UK as it used to be?

Answer 29

**Cervical screening program**

Question 30

Why can't every cervical cancer be prevented by HPV vaccination?

Answer 30

**Vaccinated HPV subtypes (6, 11, 16 and 18) only responsible for around 70% of cancers**

Question 31

What are the **symptoms** of **high stage cervical cancer?**

Answer 31

**Abnormal bleeding** **Pelvic pain** **Renal symptoms** (suggests obstruction of ureters) **Red flag cancer symptoms** - fever, night sweats, unexpected WL

Question 32

What investigations are done for suspected **cervical cancer**?

Answer 32

**Cervical screening** (to catch dysplasia early) If abnormal, refer for **Colposcopy** If high stage, **MRI pelvis / other scans** to look for metastasis

Question 33

Which **precursors** of cervical cancer develop from the a) **ectocervix** b) **endocervix**?

Answer 33

**a) CIN** (cervical intraepithelial neoplasia) **b) CGIN** (cervical GLANDULAR intraepithelial neoplasia)

Question 34

Which **invasive forms** of cervical cancer develop from the a) ectocervix b) endocervix?

Answer 34

**a) Squamous carcinoma** **b) Adenocarcinoma**

Question 35

Which risk factor causes **most** cases of **cervical cancer**?

Answer 35

**HPV infection**

Question 36

Which skin disease is implicated in **vulval intraepithelial neoplasia (VIN)** seen in older women?

Answer 36

**Lichen sclerosus**

Question 37

Why is **VIN** a sinister diagnosis?

Answer 37

**Vulva is closely associated with superficial inguinal nodes** So spread occurs easily

Question 38

Which rare skin disease presents as a red, crusting rash and signals the presence of **glandular tumours** in the epidermis of the vulva?

Answer 38

**Paget's disease** different from the bone one

Question 39

What is **dyskaryosis**?

Answer 39

**Nuclear abnormalities in a cell, e.g** pleomorphism, high nucleus:cytoplasm ratio, hyperchromatosis (dark staining) **caused by acid damage, HPV infection, i.e damage to the cell**

Question 40

What is **koilocytosis**?

Answer 40

**Dyskaryosis of an epithelial cell due to HPV infection**

Question 41

What does a **koilocyte** look like?

Answer 41

**Darkly stained halo cell**

Question 42

What is a **Nabothian cyst?**

Answer 42

**A cyst formed when ectocervix (squamous) grows over the top of endocervix (columnar)**

Question 43

Which **lifestyle factor** is highly associated with **cervical cancer**?

Answer 43

**Smoking**

Question 44

How long does it take for **initial HPV infection** to develop into **high-grade CIN?**

Answer 44

**Up to 3 years**

Question 45

How long does it take for **high grade CIN** to develop into **invasive cervical cancer?**

Answer 45

**Up to 20 years**

Question 46

**CIN classification** depends on the ___ of epithelium occupied by abnormal cells.

Answer 46

**thickness** CIN I - one third, CIN II - two thirds, CIN III - full thickness, impending malignancy

Question 47

Which type of pre-malignant tumour arises from the **endocervix?**

Answer 47

**Endocervix is made up of columnar glandular epithelium** So it develops **CGIN** (cervical glandular intraepithelial neoplasia) Which can develop into **adenocarcinoma**

Question 48

Which forms of **cervical cancer** are most common?

Answer 48

**Squamous carcinoma** (75%) **Adenocarcinoma** (5-25%)