Cervical Screening / Vulval Pathology

Question 1

identify the cells present within normal ectocervix?

Answer 1

Question 2

what does the endocervix normally look like histologically?

Answer 2

Question 3

what is the transformation zone and which physiological changes causes the altering of position of TZ during life?

Answer 3

squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia

position of TZ alters in response to menarche, pregnancy and menopause

Question 4

what does the squamo-columnar junction look like histologically?

Answer 4

Question 5

what is cervical erosion?

Answer 5

the exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia

Question 6

what are nabothian follicles?

Answer 6

mucous filled cyst on surface of cervix - formed when stratified squamous epithelium of ectocervix (nearest vagina) grows over columnar epithelium of endocervix (portion nearest to uterus)

Question 7

what are the symptoms and causes of cervicitis?

Answer 7

often asymptomatic but can lead to infertility due to simultaneous sildent fallopian tube damage

causes - non specific inflammation, follicular cervicitis (sub epithelial reactive lymphoid follicles present in cervix), chlamydia and HSV

Question 8

what is a cervical polyp and what is the main symptom?

Answer 8

localised inflammatory outgrowth (not premalignant)

cause of bleeding, if ulcerated

Question 9

what are the different neoplastic causes of cervical pathology?

Answer 9

cervical intraepithelial neoplasia (CIN)

cervical cancer = squamous carcinoma, adenocarcinoma

Question 10

what are the risk factors for CIN / cervical cancer?

Answer 10

high risk HPV esp 16 and 18 (sexual partners may increase risk)

vulnerability of SC junction in early reproductive lise - age at first intercourse, long term use of OCP, non use of barrier contraception

smoking - 3x risk

immunosuppression

Question 11

what strains of HPV causes genital warts and what does this look like histologically?

Answer 11

HPV 6 and 11

condyloma acuminatum = thickened “papillomatous” squamous epithelium with cytoplasmic vacuolation (koliocytosis)

Question 12

what strains of HPV causes cervical intraepithelial neoplasia (CIN) and what does this look like histologically?

Answer 12

HPV 16 and 18

infected epithelium remains flat, but may show koilocytosis, which can be detected in cervical smears

Question 13

what does cervical cancer look like histologically?

Answer 13

invasive squamous carcinoma - virus integrated into host DNA

Question 14

how long does it take for HPV infection to progress to high grade CIN?

Answer 14

6 months - 3 years

Question 15

how long does it take for high grade CIN to become invasive cancer?

Answer 15

5-20 years

Question 16

what does mild dyskaryosis with viral features (HPV) look like?

Answer 16

Question 17

what is cervical intraepithelial neoplasia (CIN) and where does it occur?

Answer 17

pre-invasive stage of cervical cancer - dysplasia of squamous cells which is not visible by naked eye and is asymptomatic

occurs at transformation zone

detected by cervical screening

Question 18

describe the progressive degrees of dysplasia and neoplasia of cervix?

Answer 18

normal squamous epithelium -> koilocytosis -> CIN1 -> CIN2 -> CIN3

Question 19

describe the general histology of CIN?

Answer 19

delay in maturation / differentiation (immature basal cells occupying more of epithelium)

nuclear abnormalities (hyperchromasia, increased nucleocytoplasmic ratio, pleomorphism)

excess mitotic activity (situated above basal layers, abnormal mitotic forms)

often koilocytosis (indicating HPV) also present, CIN is graded I-III

Question 20

descrbe the histology of CIN I?

Answer 20

basal 1/3 of epithelium occupied by abnormal cells

*raised numbers of mitotic figures in lower 1/3

*surface cells quite mature, but nuclei slightly abormal

Question 21

describe the histology of CIN II?

Answer 21

abnormal cells extend to middle 1/3

*mitoses in middle 1/3

*abnormal mitotic figures

Question 22

describe the histology of CIN III?

Answer 22

abnormal cells occupy full thicknes of epithelium

*mitoses, often abnormal, in upper 1/3

Question 23

75-95% of malignant cervical tumours are what kind?

Answer 23

invasive squamous carcinoma (2nd most common female cancer worldwide)

*develops from CIN - preventable by screening

Question 24

what are the different stages of invasive squamous carcinoma?

Answer 24

stage 1A1 - depth up to 3mm, width up to 7mm

stage 1A2 - depth up to 5mm, width up to 7mm (low risk of lymph node metastases)

stage 1B - confined to the cervix

stage 2 - spread to adjacent organs (vagina, uterus, etc)

stage 3 - involvement of pelvic wall

stage 4 - distant metastases or involvement of rectum or bladder

Question 25

what are the symptoms of invasive cervical carcinoma?

Answer 25

abnormal bleeding - post coital, post menopausal, brownish or blood stained vaginal discharge, contact bleeding (friable epithelium) pelvic pain haematuria / urinary infections ureteric obstruction / renal failure

Question 26

describe the spread of cervical squamous carcinoma?

Answer 26

local = uterine body, vagina, bladder, ureters, rectum lymphatic = early = pelvic, para-arotic nodes haematogenous = late = liver, lungs, bone

Question 27

how is cervical squamous carcinoma graded?

Answer 27

well differentiated moderately differentiated poorly differentiated undifferentiated / anaplastic

Question 28

where do cervical glandular intraepithelial neoplasia (CGIN) arise from and what is it the preinvasive phase of?

Answer 28

arise from endocervical epithelium CGIN is preinvasive phase of endocervical adenocarcinoma

Question 29

what is the difference in ease of diagnosis of CIN vs CGIN?

Answer 29

CGIN is more difficult to diagnose on cervical smear than squamous carcinoma therefore, screening less effective

Question 30

what does high grade CGIN look like histologically?

Answer 30

Question 31

endocervical adenocarcinoma makes up what % of cervical cancer?

Answer 31

5-25% \*iincreasing incidence, particularly in young women

Question 32

some cervical cancer are mixed type (adenosquamous) which arise from common cell of origin - true or false?

Answer 32

true

Question 33

what has a worse prognosis - endocervical adenocarcinoma or squamous carcinoma?

Answer 33

cervical adenocarcinoma

Question 34

in which people is adenocarcinoma more common?

Answer 34

higher SE class later onset of sexual activity smoking HPV again incriminated, particularly HPV18

Question 35

what does adenocarcinoma look like histologically?

Answer 35

Question 36

name 3 other HPV-driven diseases?

Answer 36

vulvular intraepithelial neoplasia, VIN vaginal intraepithelial neoplasia, VaIN anal intraepithelial neoplasia, AIN

Question 37

what disease is vulval intraepithelial neoplasia associated with?

Answer 37

pagets disease \*crusting rash, tumour cells in epidermis which contain mucin \*mostly no underlying cancer, tumour arises from sweat gland in skin

Question 38

in older women, VIN causes greater risk of progression to what?

Answer 38

invasive squamous carcinoma

Question 39

VIN is always HPV related - true or false?

Answer 39

false - often HPV related but not always

Question 40

who does vulvar invasive squamous carcinoma arise in and how does it present?

Answer 40

elderly women ulcer or exophytic mass

Question 41

how does vulvar invasive squamous carcinoma arise?

Answer 41

from normal epithelium or VIN \*they are mostly well differentiated (verrucous are an extremely well differentiated type)

Question 42

what is the treatment of vulvar invasive squamous carcinoma?

Answer 42

surgical - radical vulvectomy and inguinal lymphadenectomy \*90% 5 year survival - node negative \*\<60% 5 year survival - node positive

Question 43

what infections can cause vulval disease?

Answer 43

candida (particularly diabetics) vulvar warts (HPV 6 and 11) bartholin's gland abscess (blockage of gland duct)

Question 44

what non neoplastic epithelial disorders can cause vulval disease?

Answer 44

lichen sclerosis other dermatoses - lichen planus, psoriasis

Question 45

what causes atrophic vulval diseases?

Answer 45

post-menopausal

Question 46

name 3 types of vaginal pathology?

Answer 46

VaIN - vaginal intraepithelial neoplasia - may also have cervical and vulval lesions squamous carcinoma - less common than cervical and vulval counterparts, a disease of elderly melanoma - rare, may appear as a polyp