Cervical diseases

Question 1

What is an endocervical polyp?

Answer 1

• Groosly an outward projection and microscopically lined by columnar or squamous epithelium (since it a poly only) with a fibrovascular core
• It usually occur in the 4-6th decade with abnormal vaginal bleeding

Question 2

Describe the microscopic photo of an endocervical polyp

Answer 2

1) Polyp lined with squamous/endocervical epithelium

2) It overlies a fibrous stroma with thick-walled vessels and cystically dilated endocervical glands

• The most important thing is the presence of ENDOCERVICAL glands

Question 3

What is a condyloma acuminatum?

Answer 3

• Genital warts, where condyloma means a MASS and acumination means POINTED

Question 4

What causes a condyloma acuminatum?

Answer 4

HPV 6 & 11 (which are the low-risk HPV that “Does not cause cancer”)

• It infects the Vulva, vaginal wall, anus and ectocervix (it loves stratified squamous cells and the basal cells)

Question 5

How does HBV spread?

Answer 5

Skin-skin contact

Question 6

What is the gross picture of a condyloma acuminatum?

Answer 6

Exophytic papillary lesion

Question 7

What is the microscopic photo of a condyloma acuminatum?

Answer 7

1) Papillary lesions

2) Hyperkeratosis (increases the keratin in the skin, if the skin has keratin)

3) Acanthosis (thickening of the epidermal cells)

4) Koliocytic changes (creates a raisinoid hyperchromatic nuclei “perinuclear halos”)

Question 7

What are the types of squamous intraepithelial lesions (SIL)/cervical intraepithelial neoplasia (CIN)?

Answer 7

1) Low-grade SIL: Mild dysplasia

2) High-grade SIL: Moderate to severe dysplasia

Question 8

What are the causes of high-grade cervical intraepithelial neoplasia?

Answer 8

HPV 16, 18, and 18 other types

Question 9

What is the gross picture of SIL?

Answer 9

• Using colonoscopy:

1) Discolored raised plaque (visually)

2) White-mosaic/cobblestone when we apply 3-5% acetic acid

3) Lugol’s iodine is used, which will make it turn bright yellow

Question 10

What is the microscopic photo of SIL?

Answer 10

1) Low-grade: Nuclear pleomorphism and hyperchromasia in the lower 1/3 of the epithelium

2) High-grade: Nuclear pleomorphism and hyperchromasia in the lower 2/3 or in the entire thickness

• In high grade, P16 immunohistochemistry is used, and if the cells had a strong and diffuse nuclear cytoplasmic positivity in the full thickness, this is a strong indication of HPV

Question 11

What is the treatment for high-grade SIL?

Answer 11

• Low-grade isnt a must to remove just keep visiting
• In high grade, we must remove and using electrosurgical excision procedure (LEEP), Conization, Laser, Cryosurgery, thermal ablation

Question 12

What is cervical glandular intraepithelial neoplasia?

Answer 12

• AKA: Adenocarcinoma in situ (it can spread if not treated)
• It is a precancerous condition of the endocervix
• In situ” means the abnormal cells haven’t spread yet — they are still in their original place, but they can turn into cancer (adenocarcinoma)
• Adenocarcinoma in situ is due to the replacement of the normal endocervical cells with Atypical epithelium

Question 13

What are the types of in situ adenocarcinoma?

Answer 13

• There are two main types depending on the HPV associated

1) HPV-Associated: Microscopically showing the “Usual type” and it shows p16 positivity on immunohistochemistry (which lights up if HPV is involved, showing a “brown blocky stain”)

2) HPV-Independent: it is less common and shows a gastric-type epithelium and p16 negative

Question 14

Describe the microscopic photo of adenocarcinoma in situ

Answer 14

• Replacement of the endocervical epithelium on the surface and the glands by abnormal Atypical epithelium

Question 15

Okay we are done with dysplasia next cards will be about cervical carcinoma

Question 16

What is the type of cervical cancer in the ectocervix?

Answer 16

Squamous cell carcinoma

Question 17

What is the type of cancer in the endocervix?

Answer 17

Adenocarcinoma

Question 18

What is the risk factors for cervical carcinoma?

Answer 18

1) Ectocervix:

1. Multiple sexual partners
2. First intercourse at a young age (before 17)
3. Persistent infection with a high-risk HPB (18 more than 16)

2) Endocervix carcinoma:

1. Obesity
2. Hypertension
3. Oral contraceptive pills
   - All of them increase the levels of estrogen

Question 19

Describe the gross features of both cervical carcinoma

Answer 19

1) Fungating exophytic mass (cauliflower like mass that protrudes into the vagina)

2) Ulcerative lesion

3) Infiltrative masses (barrel-shaped cervix)

Question 20

Describe the microscopic photo of squamous cell carcinoma

Answer 20

• Solid nests of malignant squamous cells that invade the underlying stroma
• If HPV associated it is then non-keratinizing, P16 positive
• If non-HPV associated, it is then keratinizing and caused by P53 mutation

Question 21

What is the cause of non-HPV squamous cell carcinoma?

Answer 21

P53 mutation

Question 22

What is the microscopic photo of the cervical adenocarcinoma?

Answer 22

1) HPV-Related: It could be usual ADC (malignant cells arranged in glands) or Mucinous ADC (malignant cells with mucinous secretion and signet ring (a ring with a flat top as the nucleus is pushed to one side)

2) Non-HPV associated ADC: There are three types: 1. Gastric type ADC, 2. Clear cell ADC where the nucleus protrudes beyond the boundaries of the cell (Hobnail nuclei), 3. Endometroid ADC

Question 23

How does cervical cancer spread?

Answer 23

1) Direct

2) Lymphatics

3) Hematogenous

Question 24

What is cervical cancer pap smear?

Answer 24

- Pap tests are cytological presentation of the exfoliated cells from the cervix, which are stained in the Papanicolaou method - It is done by: 1) Sample collection 2) Stain the sample using a Papanicolaou stain 3) Examine the sample using the Bethesda system

Question 25

What are the indications of pap smears?

Answer 25

1) If below 21 years no pap-smear is required regardless of sexual activity 2) If 21-29 years, then a pap smear is recommended every 3 years, and HPV testing is not recommended routinely 3) 30-65 years: Pap test every 3 years, HPV test every 5 years, and HPV/Pap co-testing every 5 years 4) If >65 years: stop screening if adequate prior history and there is no history of a high-grade cervical dysplasia

Question 26

If the psp-smear was positive, how to manage it?

Answer 26

1) Aged 21-24 with ASCUS (Atypical squamous cell of undetermined origin) or LSIL (low-grade squamous intraepithelial lesion): No need to scare them; we repeat the pap in 1 year 2) Women 25 years and older: 1- NILM (Negative for Intraepithelial Lesion or Malignancy) but HPV positive: We do HPV-subtyping; however, if High high-risk HPV, we do colposcopy 2- LSIL: Whether HPV positive or not "DONE", we do colposcopy, and if HPV is negative, we can repeat co-testing in 1 year 3) For all ages: 1) HSIL? = we do colposcopy 2) Atypical glandular cells? = Colposcopy + cervical and endometrial sampling