Cervical, Vaginal And Vulval Pathologies

Question 1

DD of itch

Answer 1

candidiasis (albicans/non-albicans), trichomoniasis, public lice, scabies, vulval intra-epithelial neoplasia, atrophic vulvovaginitis, dermatitis (atopic ..)

Question 2

What type of cells are captured on normal ectocervix epithelium by cervical smear?

Answer 2

Exfoliating cells

Question 3

The ectocervix becomes endocervix at what point?

Answer 3

Transition zone - squamo-columnar junction

Question 4

What is a physiological change in endocervical tissue that is associated with hormonal changes in puberty?

Answer 4

Squamous metaplasia over endocervical glands, pre puberty it is glandular epithelium however after puberty it changes to metaplastic squamous epithelium

Question 5

List 2 types of inflammatory cervical pathologies

Answer 5

Cervicitis and cervical polyp

Question 6

When can cervical polyps cause bleeding?

Answer 6

If ulcerated

Question 7

How can cervicitis lead to infertility?

Answer 7

Is often asymptomatic so there can be simultaneous silent fallopian tube damage

Question 8

List 4 causes of cervicitis

Answer 8

Follicular cervicitis,
Chlamydia trachomatis,
Herpes simplex viral infection,
Non-specific acute/chronic inflammation

Question 9

What is follicular cervicitis?

Answer 9

Sub epithelial reactive lymphoid follicles present in cervix

Question 10

List 5 risk factors for CIN/cervical cancer

Answer 10

Age of first intercourse, 
Long term use of oral contraceptives, 
Not using barrier contraceptives, 
Smoking increases risk x3,
Immunosuppressed people

Question 11

Human Papillomavirus infections can cause genital warts. What tissue is infected and what does it do to the tissue?

Answer 11

Infects squamous epithelium, causes tissue to form condyloma acuminatum

Question 12

What are condyloma acuminatum?

Answer 12

Genital warts - thickened papillomatous squamous epithelium with koilocytosis

Question 13

What is koilocytosis?

Answer 13

Cytoplasmic vacuolation - clear area around nucleus

Question 14

What types of HPV cause genital warts?

Answer 14

Low risk HPV which are 6 and 11

Question 15

HPV infection can cause Cervical intraepithelial neoplasia. What types of HPV cause CIN?

Answer 15

High risk HPV - types 16 and 18

Question 16

How does CIN affect cervical tissue?

Answer 16

Infected epithelium remains flat but shows koilocytosis

Question 17

Koilocytosis caused by HPV 16/18 can not be detected in cervical smears. True/false?

Answer 17

False - it can be detected

Question 18

HPV infections can cause cervical cancer, what kind of cancer do they most commonly cause and how?

Answer 18

Invasive squamous carcinoma - virus is integrated into host DNA

Question 19

What is found in biopsy of cervix with invasive squamous carcinoma?

Answer 19

Keratin band on surface and keratin bundles beneath

Question 20

What is the timeline for HPV infection to develop into high grade CIN?

Answer 20

6 months to 3 years

Question 21

What is the timeline for high grade CIN to develop into invasive carcinoma?

Answer 21

5 to 20 years

Question 22

There is an 80% cumulative prevalence in a lifetime however most develop immunity. What increases risk of disease?

Answer 22

Persistence

Question 23

CIN 3 is synonymous to what

Answer 23

Carcinoma in situ

Question 24

CIN is dysplasia of squamous cells in transformation zone. What stage is it in terms of cervical cancer?

Answer 24

Pre-invasive stage

Question 25

Outline the 3 histological changes seen in CIN

Answer 25

Delay in maturation of basal cells so immature basal cells occupy more of epithelium, Nuclear abnormalities e.g. hyperchromasia, increased nucleocytoplasmic ratio and pleomorphism, Excess mitotic activity e.g. situation above basal layers and abnormal mitotic forms,

Question 26

Outline CIN I grading

Answer 26

Basal 1/3 of epithelium occupied by abnormal cells | E.g. raised numbers of mitotic figures in lower 1/3, surface cells quite mature but nuclei slightly abnormal

Question 27

Outline CIN II grading

Answer 27

Abnormal cells extend to middle 1/3 | E.g. mitoses in middle 1/3 and abnormal mitotic figures

Question 28

Outline CIN III grading

Answer 28

Abnormal cells occupy full thickness of epithelium | E.g. mitoses, often abnormal, in upper 1/3

Question 29

At which CIN stage does it start involving glands?

Answer 29

CIN III

Question 30

Invasive squamous carcinoma causes 75-95% of malignant cervical tumours. It is the ___ commonest female cancer worldwide?

Answer 30

2nd commonest

Question 31

What staging is used for cervical cancer and what is it based off?

Answer 31

Figo staging - based off stromal invasion and then subdivided by size

Question 32

List 7 symptoms of invasive carcinoma

Answer 32

Abnormal bleeding: post coital, post menopausal, brownish/blood stained vaginal discharge, contact bleeding, Pelvic pain, Haematuria/urinary infections, Ureteric obstruction/renal failure

Question 33

Outline the pattern of local spread of squamous carcinoma?

Answer 33

Uterine body -> vagina -> bladder -> ureters -> rectum

Question 34

Outline the pattern of lymphatic spread of squamous carcinoma and when it occurs

Answer 34

Occurs early, | pelvic -> para-aortic nodes

Question 35

Outline the pattern of haematogenous spread of squamous carcinoma and when it occurs

Answer 35

Occurs late, | Spreads to liver, lungs and bone

Question 36

How are squamous carcinomas graded?

Answer 36

Well differentiated, Moderately differentiated, Poorly differentiated, Undifferentiated/anaplastic

Question 37

Where does cervical glandular intraepithelial neoplasia originate from?

Answer 37

From endocervical endothelium

Question 38

CGIN is more difficult to diagnose on cervical smear than squamous so screening is less effective. It is also only sometimes associated with CIN. True/false?

Answer 38

True

Question 39

CGIN is preinvase phase of what type of endocervical cancer?

Answer 39

Endocervical adenocarcinoma

Question 40

How are adenocarcinomas graded?

Answer 40

Well/moderate/poorly differentiated

Question 41

Endocervical adenocarcinoma accounts for 5-25% of cervical cancer. List 4 risk factors

Answer 41

Higher social economic class, Later onset of sexual activity, Smoking, HPV

Question 42

Which HPV type is particularly associated with endocervical adenocarcinoma?

Answer 42

HPV 18

Question 43

Vulval intraepithelial neoplasia is the precursor for what kind of cancer?

Answer 43

HPV driven SCC

Question 44

Differentiated vulval intraepithelial neoplasia is precursor of what cancer?

Answer 44

HPV independent vulval SCC

Question 45

Which type of vulval neoplasia (VIN or dVIN) has higher risk of invasive malignancy and often has a background of inflammatory dermatoses such as lichen sclerosus?

Answer 45

DVIN

Question 46

VIN is bimodal in its epidemiology. Explain this

Answer 46

Occurs in young women and older women

Question 47

Vulvar invasive squamous carcinoma usually arises in what 3 cases?

Answer 47

In elderly women, Ulcer, Exophytic mass

Question 48

What is most important prognostic factor for vulvar invasive squamous carcinoma?

Answer 48

Spread to inguinal lymph nodes

Question 49

Vulvar invasive squamous carcinoma has 90% 5 year survival rate if ______ negative and <60% 5 year survival if ______ positive.

Answer 49

90% if node negative, | <60% if node positive

Question 50

What is surgical treatment for vulvar invasive squamous carcinoma?

Answer 50

Radical vulvectomy and inguinal lymphadenectomy

Question 51

What is vulvar Paget’s disease?

Answer 51

Rare vulvar lesion - intraepithelial vulvar adenocarcinoma

Question 52

How does vulvar Paget’s disease present?

Answer 52

Crusting rash, often sharp demarcation and is pruritic or painful

Question 53

Vulvar Paget’s disease can be primary or secondary. Primary arise from intraepidermal glandular cells or pluripotent cells of folliculoebaceous or eccrine units. Where do secondary tumours arise from?

Answer 53

Colorectal or urothelial neoplasms

Question 54

List 3 types of vulval infections

Answer 54

Candida, Vulvar warts (HPV 6 & 11) Bartholin’s gland abscess

Question 55

List 3 types of skin diseases you can get in vulva, which is most common?

Answer 55

Lichen sclerosis most common, less so lichen planus and psoriasis

Question 56

Vaginal squamous carcinoma is less common than cervical and vulval squamous carcinoma and is a disease of the elderly. Primary tumours are most common type. True/false?

Answer 56

False - everything true except primary tumours are rare!