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Cervical Vulval Pathology Flashcards

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1
Q

Label this histology slide or the cervix

State which part of the cervix it is

and is it normal

A

a) exfoliating cells
b) superficial cells
c) intermediate cells
d) parabasal cells
e) basal cells
f) basement membrane

Normal ectocervix

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2
Q

What type of epithelium is this?

Where is it found in the cervix?

Is it normal?

A

Columnar epithelium

Normal endocervix

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3
Q

What is the transformation zone?

A

Transformation zone is the squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia

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4
Q

Is the transformation zone found in the same part of an individual’s cervix throughout her life?

A

No. The position of the transformation zone alters during life as physiological response to:

  • menarche
  • pregnancy
  • menopause
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5
Q

When does the transformation zone move?

A

Physiological response to:

  1. menarche
  2. pregnancy
  3. menopause
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6
Q

With regards to pathology; what’s important about the transformation zone?

A

Transformation zone is where 90% of cervical intraepithelial neoplasias are found

It is liable to infection and pre-malignant changes

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7
Q

What is clinically important to remember about the transformation zone?

A

TZ is where cervix is most liable to infection and pre-malignant changes and :. this is where we want smear test to come from

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8
Q

What can be seen on this histology slide?

A

The transformation zone!

It’s a squamo-columnar junction- hence the big “drop-off”

  • squamous epithelium is a couple of layers thick but columnar is just the one layer thick
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9
Q

What does cervical erosion describe?

A

physiological metaplasia of cervix!

“Exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia.”

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10
Q

Why/when does the vagina become more acidic?

What happens as a result?

A

Hormonal changes at the time of menarche make the vagina more acidic

The result is cervical erosion:

  • protective mechanism where columnar epithelium undergoes physiologial metaplasia to become squamous
  • like when a lung columnar epithelium of a smoker undergoes metaplasia to squamous as a protective mechanism except that would be lung cancer and not physiological
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11
Q

What are the types of pathology seen in the cervix?

(very broadly speaking)

A

Inflammatory and

Neoplastic

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12
Q

What are the two inflammatory conditions you need to know?

A

Cervicitis

Cervical polyp

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13
Q

For cervicitis discuss:

  1. symptoms
  2. acute/chronic inflammation?
  3. aetiology
  4. complications
A
  1. often asymptomatic
  2. non-specific acute/chronic inflammation
    • follicular cervicitis- sub epithelial reactive lymphoid follicles present in cervix
    • chlamydia trachomatis- sexually transmitted
    • herpes simplex viral infection
  4. can lead to infertility due to simultaenous silent fallopian tube damage
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14
Q

for cervical polyp discuss:

  1. symptoms
  2. what is it
  3. premalignant/non-premalignant?
A
  1. if ulcerated can cause bleeding
  2. localised inflammatory outgrowth
  3. not premalignant
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15
Q

What types of neoplasia can occur in the cervix?

A
  1. Cervical Intraepithelial Neoplasia
  2. Cervical Cancer
    • squamous carcinoma
    • adenocarcinoma
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16
Q

Which types of HPV are most associated with cervical cancer?

A

HPV 16 and HPV 18

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17
Q

What percentage of cervical cancer is associated with HPV?

A

75%

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18
Q

What is CIN and what is the difference between CIN and Cervical Cancer?

A

CIN stands for Cervical Intraepithelial Neoplasia

Because CIN is intraepithelial it is not cancer. Cancer is malignant by definition and therefore has to invade the basement membrane.

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19
Q

What are some of the risk factors for CIN/Cervical Cancer?

A
  • persistance of high risk HPV
    • many sexual partners increases risk
  • vulnerability of SC Junction in early reproductive life
    • age at first intercourse
    • long term use of oral contraceptives
    • non-use of barrier contraceptive
  • smoking 3x risk
  • immunosuppression
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20
Q

What strains of HPV are most associated with genital warts?

A

6 and 11

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21
Q

Describe the histological changes seen in genital warts

A
  • Condyloma acuminatum:
    • thickened “papillomatous” squamous epithelium with cytoplasmic vacuolation (“koiocytosis”)
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22
Q

What does this histology slide show?

A

Cervical Intraepithelial Neoplasia caused by HPV 16 & 18

Circle the infected cells

  • high nuclear to cytoplasmic ratio
  • “raisiny-looking” nuclei
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23
Q

What does this histology slide show?

A

Cervical cancer

Invasive squamous carcinoma: Virus integrated into host DNA

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24
Q

What is the time range between contracting HPV and developing a high grade CIN?

A

HPV Infection –> High Grade CIN

  • 6 months to 3 years
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25
What is the time range between developing a high grade CIN and developing an invasive cancer?
High Grade CIN --\> Invasive Cancer 5 to 20 years
26
Circle the normal squamous cells in this slide and the abnormal ones Describe the abnormalities
Mild dyskaryosis with Viral Features (HPV) * Normal (circled in green) squamous cells have lots of cytoplasm * Abnormal cells (circled in red): * much darker * can see folds in nuclear membrane * higher nuclear:cytoplasmic ratio * nucleus looks a raisin
27
What is CIN?
CIN is the pre-invasive stage of cervical cancer
28
Where does CIN most commonly occur? Do CINs have a large surface area?
Occurs at the transformational zone Can involve large area
29
Is CIN dysplasia or metaplasia?
DYSPLASIA of squamous cells
30
What symptoms would somebody with CIN present with?
NONE It's asymptomatic and hence screening is so important
31
Use the appropriate terminology to describe this schematic
1. Normal squamous epithelium 2. Koilocytosis 3. CIN I 4. CIN II 5. CIN III It's a diagram of cervical epithelium showing progressive degrees of dysplasia and neoplasia
32
What is seen on the histological slide of CIN?
* 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 * indicates HPV infection
33
How is CIN graded?
CIN is graded I-III depending on severity of: 1. Delay maturation/differentiation 2. Nuclear abnormalities 3. Excess mitotic activity
34
Describe a Grade I CIN
* 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 abnormal
35
Describe a Grade II CIN
* Abnormal cells extended to middle 1/3 * mitoses in middle 1/3 * abnormal mitotic figures
36
Describe a grade III CIN
* Abnormal cells occupy full thickness of epithelium * mitoses, often abnormal, in upper 1/3
37
How common is squamous carcinoma of cervical?
* 75%-95% of malignant cervical tumours * 2nd commonest female cancer, worldwide
38
Why is screening for squamous carcinoma so important?
Squamous carcinoma develops from pre-existing CIN, therefore most cases should be preventable by screening
39
What symptoms might a woman with squamous carcinoma present with?
* Usually none at microinvasive and early invasive stages (detected at screening) * 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
40
Where does a squamous carcinoma spread locally?
* uterine body * vagina * bladder * ureters * rectum
41
Where does squamous carcinoma spread lymphatically?
* pelvic nodes * para-aortic nodes
42
Where does squamous carcinoma spread haematogenously?
* liver * lungs * bone
43
What's the really pink stuff?
Keratin
44
What does CGIN stand for? and what does it mean?
Cervical Glandular Intraepithelial Neoplasia CGIN is preinvasive phase of endocervical adenocarcinoma
45
Is screening more effective for CGIN or CIN?
CIN CGIN is more difficult to diagnose on cervical smear than squamous although CGIN is sometimes associated with CIN
46
What percentage of cervical cancer is made up of endocervical adenocarcinoma?
5-25% of cervical cancer
47
Which has a worse prognosis, squamous carcinoma or endocervical adenocarcinoma?
Endocervical adenocarcinoma has a worse prognosis than squamous carcinoma
48
What are the risk factors for adenocarcinoma?
1. Higher S.E class 2. Later onset of sexual activity 3. Smoking 4. HPV again incriminated, particularly HPV18
49
What are the other HPV-driven diseases you need to know?
* Vulvar Intraepithelial Neoplasia, VIN * Vaginal Intraepithelial Neoplasia, VaIN * Anal Intraepithelial Neoplasia, AIN
50
What types of vulvar intraepithelial neoplasia are there?
Vulvar intraepithelial neoplasia (VIN) and Paget's disease
51
What groups of women are more likely to present with vulval intraepithelial disease (VIN)?
It's bimodal: 1. Young women * often mutlifocal, recurrent or persistent causing treatment problems 2. Older women * greater risk of progression to invasive squamous carcinoma
52
What's the relationship between HPV and VIN?
VIN is often, but not always, HPV related
53
What is the relationship between VIN and CIN & VaIN?
VIN is often synchronous with cervical and vaginal neoplasia (CIN & VaIN)
54
How does vulvar invasive squamous carcinoma develop?
Vulvar invasive squamous carcinoma can arise from normal epithelium or VIN
55
Who normally gets vulvar invasive squamous carcinoma? What does it look like?
Usually elderly women Ulcer or exophytic mass
56
What is the most important prognostic factor in vulvar invasive squamous carcinoma?
Inguinal lymph nodes
57
What is the surgical treatment for vulvar invasive squamous carcinoma? What are the outcomes?
Surgical treatment- radical vulvectomy and inguinal lymphadenectomy If it's left sided tumour, left inguinal nodes are removed. If it's a medial tumour both L&R inguinal nodes are removed. * 90% 5 year survival- node negative * \<60% 5 year survival- node positive
58
If you see keratin on a histology slide what type of cancer is it?
Squamous
59
Describe the pathology of Vulvar Paget's disease
* tumour cells in epidermis, contain mucin * mostly no underlying cancer, tumour arises from sweat gland in skin * it's like an adenocarcinoma of the skin and primarily affects vulva
60
How does vulvar Paget's disease present clinically?
It's a crusting rash (keratin causes the crust) Spreads along vulva and sometimes down the thighs; may go into anus and can spread to vagina Painful Itchy Weeping, oozing VERY RARE
61
What does this slide show?
Paget's disease of the vulva NB: the keratin along the top of the slide which causes the crusty presentation
62
What vulvar infections do you need to know about?
1. Candida 2. Vulvar warts 3. Bartholin's gland abscess
63
What group of people are more likely to get a Candida infection of the vulva?
Diabetics
64
Which strains of HPV are most associated with vulvar warts?
6&11
65
How does Bartholin's gland abscess occur?
Blockage of gland duct
66
What non-neoplastic epithelial disorders are there?
* Lichen sclerosis * Other dermatoses * lichen planus * psoriasis
67
What three vaginal pathologies do you need to know about?
1. VaIN 2. Squampus carcinoma of vagina 3. Melanoma
68
Discuss VaIN
Vaginal intraepithelial neoplasia May also have cervical and vulval lesions
69
Discuss squamous carcinoma of vagina
Less common than cervical and vulval counterparts A disease of the elderly
70
Discuss melanoma of the vagina
Rare May appear as a polyp

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