Cervix, Vulva & Vagina Pathology

Question 1

Describe the histology of a normal ectocervix

Answer 1

Basement membrane underpinned in stroma, basal cells on top then paranasal cells. Nuclei get smaller and become exfoliating cells

Question 2

What does the ectocervix look like on a smear?

Answer 2

Squamous velds, small well defined nucleus with large surrounding cytoplasm

Question 3

Describe the histology of a normal endocervix

Answer 3

Single layer of glandular epithelium, lined by single cell layer of columnar epithelium

Question 4

What does the endocervix look like on a smear?

Answer 4

Cytoplasm, nuclei and cilia can be seen

Question 5

Describe the transformation zone

Answer 5

Squamo-columnar junction

Question 6

What is inflammation of the cervix called?

Answer 6

Cervicitis

Question 7

What can cause inflammation of the cervix?

Answer 7

Chlamydia
Herpes
Follicular cervicitis

Question 8

Name the neoplasm that can present in the cervix

Answer 8

Cervical intraepithelial neoplasia
Cervical intraepithelial glandular neoplasia
Squamous carcinoma
Adenocarcinoma

Question 9

State the risk factors for cervical pathology

Answer 9

High risk HPV 
Many sexual partners 
Vulnerable SC Junction 
- age of first intercourse 
- long term oral contraceptives
- non-use barrier contraception 
Smoking 
Immunosuppression (HIV/Chemotherapy)

Question 10

Describe low risk HPV

Answer 10

Type 6 and 11

Infection of squamous epithelium causes enlarged nuclei, thickened and papillomatous with cytoplasmic vacuolation

Question 11

Describe high risk HPV

Answer 11

Type 16 and 18
Cervical intraepithelial neoplasia
Pale cells with odd shaped nuclei

Question 12

What is special about squamous cells?

Answer 12

They can produce keratin

Question 13

What is CIN?

Answer 13

Pre-invasive, dysplasia of squamous cells at the transformation zone

Question 14

What nuclear abnormalities can be seen in CIN?

Answer 14

Hyperchromasia
Increased nucleocytoplasmic ratio
Pleomorphism

Question 15

What happens to the basal cells in CIN?

Answer 15

Usually the nuclei get smaller (mature) towards the surface but in CIN there is excess mitotic activity above basal layers and abnormal mitotic figures can be seen

Question 16

What is seen in CIN I?

Answer 16

Basal 1/3 of epithelium occupied by abnormal cells, surface cells mature but nuclei slightly abnormal

Question 17

What is seen in CIN II?

Answer 17

Abnormal cells extend into the middle 1/3 with mitoses and abnormal mitotic figures

Question 18

Describe CIN III

Answer 18

Abnormal cells occupy full thickness of epithelium with mitoses and abnormal cells
Squamous cell carcinoma in situ

Question 19

How is a squamous carcinoma staged?

Answer 19

IA - 3-7mm
IB - confined to cervix, >5mm
II - spread to adjacent organs 
III - involvement of pelvic floor 
IV - distant mets

Question 20

How is a squamous carcinoma graded?

Answer 20

Well
Moderately
Poor
Undifferentiated/anaplastic

Question 21

What are the symptoms of squamous carcinoma?

Answer 21

Abnormal Bleeding
Pelvic Pain
Haematuria/urinary infections
Ureteric obstruction/renal failure

Question 22

How is CIN treated?

Answer 22

I - conservative

II and III - cold coagulation or large loop excision

Question 23

How will squamous carcinoma spread?

Answer 23

Local - uterine body, vagina, bladder, ureter, rectum
Lymphatic - early (para-aortic)
Haematogenous - late (liver, lungs, bone)

Question 24

How is stage IA squamous carcinoma treated?

Answer 24

Local excision

Simple hysterectomy and pelvic lymphadenectomy

Question 25

What is the treatment for IB-IIA squamous carcinoma?

Answer 25

Radical hysterectomy and pelvic lymphadenectomy | Oophrectomy

Question 26

If a patient is unsuitable for surgery what is the alternative?

Answer 26

Radical radiotherapy and cisplatin chemotherapy

Question 27

If the cancer has spread past the cervix how is it treated?

Answer 27

Radical radiotherapy and cisplatin chemotherapy

Question 28

Describe the precursor to adenocarcinoma

Answer 28

Cervical glandular intraepithelial neoplasia | Endocervical origin - irregular gland shape lined by atypical cells with dark nuclei and mitotic figures

Question 29

What does cervical adenocarcinoma look like?

Answer 29

Glands budding to form more, atypical cellular architecture

Question 30

What are the specific risk factors for adenocarcinoma?

Answer 30

Higher SE class, later onset sexual activity, smoking, HPV 18

Question 31

Name some vulvar pathologies

Answer 31

``` Vulval intraepithelial neoplasia Vulvar invasive squamous carcinoma Vulvar Paget's disease Infections - candida, warts Lichen sclerosis Lichen Planes ```

Question 32

What are the two types of vulvar intraepithelial neoplasia?

Answer 32

Usual Type | Differentiated

Question 33

Describe VIN of usual type

Answer 33

HPV driven, graded I,II,III looks viral and similar to cervical lesions

Question 34

Describe differentiated VIN

Answer 34

High grade, not viral driven and risk of malignancy is high

Question 35

What disease can often be in the background to differentiated VIN?

Answer 35

Lichen sclerosis

Question 36

What does VIN usually cause in young women?

Answer 36

Multifocal, recurrent or persistent disease that can cause treatment problems

Question 37

What does VIN usually cause in older women?

Answer 37

Greater risk of progression to invasive squamous carcinoma

Question 38

How does vulvar squamous carcinoma present?

Answer 38

Elderly women with ulcer or exophytic mass

Question 39

Where does vulvar squamous carcinoma spread to?

Answer 39

Inguinal lymph nodes

Question 40

How is vulvar squamous carcinoma treated?

Answer 40

Radical vulvectomy | Inguinal lymphadenectomy

Question 41

What does vulvar squamous carcinoma look like on histology?

Answer 41

Irregular invasive nests of tumour with whirls of keratin

Question 42

How does vulvar paget's disease present?

Answer 42

Crusting rash often sharply demarcated that causes itching or pain

Question 43

How is vulvar paget's treated?

Answer 43

Excision

Question 44

What cells are present in primary paget's?

Answer 44

Intraepithelial glandular cells - pluripotent of folliculosebaceous/eccrine unit

Question 45

Name four vaginal pathologies

Answer 45

Polyps/cysts VaIN Squamous carcinoma Melanoma