Cervix/vagina/vulva pathology

Question 1

The external surface of the cervix that is open to the vagina is called the

Answer 1

ectocervix.

Question 2

The muscularis layer of_____ contains abundant fibrous tissue and less smooth muscle than the myometrium of the uterus.

Answer 2

cervix

Question 3

The area between the simple columnar and stratified squamous epithelium of the cervix is knows as the

Answer 3

squamocolumnar junction

or transition zone

Question 4

The squamocolumnar junction is more external during the reproductive years and the exposed columnar epithelium undergoes metaplasia converting it to _______. This area is called the transformation zone.

Answer 4

stratified squamous epithelium

Question 5

The mucosa of the cervical canal is covered by ______ that is highly folded and appears like glands on cross section. This mucosa secretes cervical mucus.

Answer 5

simple columnar epithelium

Question 6

o Mostly caused by sexually transmitted infections

Answer 6

Cervicitis

Question 7

Neoplasia

– Most epithelial lesions of cervix are caused by oncogenic strains of :

• Squamous lesions • Glandular lesions

Answer 7

Human Papilloma Virus (HPV)

Question 8

What is normally present in a pap smear?

Answer 8

squamos cells, glandular cells and small amount of inflammatory cell

Question 9

see this multinucleated cells with nuclear inclusions

Answer 9

Herpes

Question 10

Common finding: Benign mass, protruding through cervix

Glandular or metaplastic with squamous lining

Dilated glands with mucus

May bleed (ulceration or inflammation)

**No malignant potential **

Answer 10

Endocervical polyps

Question 11

Risk factors for cervical neoplasia

Answer 11

– Early age at first intercourse

– Multiple sexual partners

– Male partner with multiple previous sexual partners

– Persistent infection by high-risk strains of papillomavirus

Question 12

 Precancerous lesions of cervix, is preceded by HPV infection. Most people clear the HPV, but some persist, causing neoplasia of the cervix

Answer 12

Cervical intraepithelial neoplasia (CIN)

Question 13

 Progression to carcinoma is dependent on degree of dysplasia

 Dysplasia is characterized by nuclear atypia, increased N:C ratio, and abundant mitoses

 Subdivided into CIN 1 (low grade), CIN 2 and CIN 3 (high grade)

depending on degree of dysplastic cells:

 CIN 1:

 CIN 2:

 CIN 3:

Answer 13

 CIN 1: basal 1/3rd of epithelium with dysplastic cells

 CIN 2: 2/3rd of epithelium with dysplasia

 CIN 3: Full thickness dysplasia

Question 14

Natrual hx of Squamos intraepitheilial lesions or SILs:

Lows SILS

High SIL

Answer 14

Low will regress 60% of the time, 30% persist, 10% to HSIL

High will regress 30% adn persisit 60% and 10% carcinoma

Question 15

Distinctive feature of cervical cancer on histology

Question 16

Low grade SIL vs high grade

Answer 16

look at picture

Question 17

is the next test following a positive pap smear to evaluate for CIN

Answer 17

Colposcopy

Question 18

understand grading of CIN

Answer 18

Staging increase involvemtent

Question 19

How does CIN, SIL and dysplasia compare?

Answer 19

Question 20

Whats going on in this pap smear?

Answer 20

HSIL (CIN II)

see higher dysplasia, higher N:C ration and more nucleus present withjust a rim of cytoplasm

Question 21

Characteristic of LSIL pap smear

Answer 21

see bi-nucleate

Question 22

What markers may be seen in high risk HPV that we can stain with

Answer 22

Ki-67 or p16INK4

Question 23

Cervical Adenocarinoma in-situ AIS stains with:

Answer 23

glands have p16+

Question 24

Can have a mix of high grade and low grade and that is the only staging done for this type of cancer

Answer 24

Cervical Adenocarcinoma In-situ

HSIL is when you have p+16 devo on the outside!

Question 25

Squamous cell carcinoma 75% Adenocarcinoma and mixed 20% Small cell carcinoma 5% All caused by HPV

Answer 25

Invasive Carcinoma of the Cervix

Question 26

Invasive carcinoma of cervix develops in \_\_\_\_ – Microscopic to deeply invasive

Answer 26

transformation zone

Question 27

What cervical cancer would get ot colon and bladder?

Question 28

REcommendation for cervical cancer screen

Answer 28

• Cytology (“Pap Smear”) +/- High Risk HPV testing – Begin age 21 – Co-testing after age 30 – Guidelines change frequently • Colposcopy for screen-positive women

Question 29

Guardasil works for:

Answer 29

6,11,16,18 : Prevention of ≥CIN2 in HPV- naïve women

Question 30

Pap smear screening increases early detection of cervical squamous dysplasia which can then be treated before \_\_\_\_\_\_ Pap smears may not detect glandular abnormalities (cervical crypts)

Answer 30

it progress to carcinoma

Question 31

The quadrivalent HPV vaccine is a mixture of four HPV type-specific VLPs prepared from the L1 proteins of HPV 6, 11, 16, and 18 combined with an aluminum adjuvant.

Answer 31

Guardasil

Question 32

 Comprises 20% of all cervical cancers  Carcinoma arising in the endocervical glands.  More difficult to sample for by pap smear due to the crypts/folds in the cervical canal

Answer 32

Adenocarcinoma of the cervix

Question 33

Vulvitis – Bacterial, fungal, viral infections – HSV, HPV, gonococcus, Syphilis Contact dermatitis Molluscum contagiosum

Answer 33

Inflammatory disorders

Question 34

Premenarchal or postmenopausal Painful, pruritic (itchy) vag lips, Thin epidermis **(shinny)**

Answer 34

Lichen Sclerosus : benign

Question 35

pathogenesis of lichen sclerosus

Answer 35

Fibrotic dermis, loss of appendages, chronic inflammatory cell infiltrate Sclerotic hypocellular dermis

Question 36

• Secondary to chronic irritation: Underlying inflammatory dermatosis and can appear as leukoplakia see: Epithelial thickening

Answer 36

Lichen Simplex Chronicus

Question 37

Hyperkeratosis, Dermal chronic inflammation No known predilection for malignancy

Question 38

o Precancerous lesion of the vulva o Associated with high risk types of HPV.  Subdivided into VIN 1 (low grade), VIN 2 and VIN 3 (high grade) depending on degree of dysplastic cells – same as cervix

Answer 38

Vulvar intraepithelial neoplasia (VIN)

Question 39

You see leukoplakia on pt vagian, whats your next step?

Answer 39

Biopsy required to rule out: Inflammatory dermatosis, lichen sclerosis, vulvar dysplasia and carcinoma

Question 40

Low grade squamous intraepithelial lesion and condylomas (VIN-1) High grade squamous intraepithelial lesion (VIN 2-3) Invasive Squamous cell carcinoma Adenocarcinoma – (skin appendages and Bartholin glands) Paget’s disease (extramammary). Basal cell carcinoma Malignant Melanoma

Answer 40

all examples of precancerous or malignant lesions

Question 41

Papillary, raised or flat on anogenital surfaces, single or multiple, small or very large **Koilocytosis** (perinuclear cytoplasmic vacuolization and wrinkled nuclear contours)

Answer 41

Condyloma Accuminata: VIN-1 (warty lesion)

Question 42

HPV associated with condyloma accuminata

Answer 42

HPV associated, subtypes: 6 and 11

Question 43

Vulvar Intraepithelial Neoplasia, High grade (VIN-2 &VIN-3) and HPV associated, subtypes 18 &16 are all:

Answer 43

Precursor lesions in vulva

Question 44

What do we see in full thickness vulvar dysplasia

Answer 44

Full thickness dysplasia – Nuclear atypia – High Nuclear/Cytoplasmic raio – Abundant mitosis

Question 45

o 90% of vulvar malignancies are invasive squamous cell cancer o Occurs in the menopausal age group o 2 distinct subtypes: that which is preceded by vulvar dysplasia (VIN) and that preceded by reactive changes (ie lichen sclerosus)

Answer 45

Invasive squamous cell carcinoma

Question 46

Invasive squamous cell carcinoma : 90% of vulvar malignancies are

Answer 46

invasive squamous cell cancer

Question 47

o Seen as red scaly plaques on the labia o Characterized by large pale glandular cells in the epidermis

Answer 47

Paget’s disease (extramammary)

Question 48

Carcinoma of vulva: Preceded by VIN; multifocal, poorly differentiated Higher incidence in smokers, immunodeficiency

Answer 48

High risk HPV associated

Question 49

Carcinoma of vulva • Preceded by reactive changes, mainly Lichen sclerosis • Well differentiated, keratinizin

Answer 49

seen in older people, not HPV releated

Question 50

Stain to differntiate Pagets of vulva

Answer 50

Positive with mucin stain or low molecular cytokeratin (CK7)

Question 51

o Related to maternal DES exposure while in-utero o Vaginal Adenosis is seen with DES exposure and can lead to clear cell carcinoma

Answer 51

 Clear cell carcinoma of vagina

Question 52

o Seen in infants and young children o Seen as soft polypoid masses in the vagina o Can also be seen in the urinary Bladder and bile ducts o Characterized by primitive cells.

Answer 52

Sarcoma botryoides (embryonal rhabdomyosarcoma)

Question 53

Differnce btwn low grade and high grade Vaginal Intraepithelial Neoplasia

Answer 53

– Low grade squamous Intraepithelial Lesion • VAIN-1:Mild dysplasia – High Grade Squamous Intraepithelial Lesion * VAIN-2: Moderate dysplasia * VAIN-2: Severe dysplasia