Gynaecology: Cervix and vulva

Question 1

Two parts of cervix? What epithelium lines each?

Answer 1

Ectocervix: SSNK

Endocervix: Mucin secreting glandular epithelum

Question 2

Where do ectocervis and endocervis join together?

Answer 2

Transformation zone

Question 3

True/false: Aim of cervical screening is to pick up cancer

Answer 3

False, aim is to pick up pre-malignant lesions (cervical intraepithelial neoplasia/CIN)

Question 4

Result: negative

Answer 4

Recall in 3-5 years

Question 5

Result unsuitable: repear 3 months

Question 6

Result: Borderline nuclear changes

Answer 6

Repeat 6 monts

Question 7

Result: Mild dyskaryosis (CIN 1)

Answer 7

Repeat 6 months

Question 8

Result: Moderate dsykaryosis (CIN2) or multiple CIN1 results

Answer 8

Refer to colposcopy

Question 9

Result: CIN3

Answer 9

rEFER TO COLPOSCOPY

Question 10

What is used to screen smear slides?

Answer 10

Cytoscreener, pathologist only reports abnormal smears

Question 11

Cytology: Enlarged nuceli due to HPV infection

Answer 11

Koilocytosis

Question 12

Difference between CIN and CGIN?

Answer 12

CGIN affects cervical glandular epithelium. CIN affects squamous epithelium

Question 13

Histology: Slightly enlarged basa cell nuclei in cervical SSNK epithelium

Answer 13

Koilocytosis (Hallmark of HPV infection)

Question 14

Histology: Abnormal enlarged nuclei up to lower third of epithelium

Answer 14

CIN 1

Question 15

Histology: Abnormal cells going up half way up the squamous epithelium

Answer 15

CIN 2

Question 16

Histology: Abnormal cells occupying full epithelial thickness. Lots of mitotic figures, crowded nuclei indicating little maturation

Answer 16

CIN 3

Question 17

Different grades of glandular lesions?

Answer 17

Low grade CGIN
High grade CGIN

Question 18

Histology: Lots of nuclei within glandular cells, apoptotic bodies and mitotic figues

Answer 18

H grade CGIN

Question 19

3 management options for pre-invasive lesions?

Answer 19

1. Ablate (freeze or cauterise)
   
   1. Excise (loop or cone biopsy)
2. Cytological and colposcopic followup

Question 20

How long is follow up period for cervical cancer?

Answer 20

Close monitoring for 10 years

Question 21

Risk factors for cervical lesions/cancer?

Answer 21

1. HPV (especially 16 and 18) in over 99% of cancers!!
2. Other infections eg chlamydia, HSV
3. Early age of intercourse
4. Multiple sexual partners
5. Smoking
6. OCP(?glandular lesions)

Question 22

True/false: Cervical erosions are premalignant

Answer 22

False, normal physiological change with increased hormone levels

Question 23

Two most common types of cervical cancer

Answer 23

Squamous carcinoma (85%)

Adenocarcinoma

Question 24

Stage 1 cervical Ca

Answer 24

Microinvasive carcinoma

Question 25

Stage 2 cervical Ca

Answer 25

Spread beyond the cervix but not into pelvic side wall

Question 26

Stage 3 cervical Ca

Answer 26

Spread to pelvic side wall or lower third of vagina

Question 27

Stage 4 cervical Ca

Answer 27

Spread beyond the pelvis

Question 28

Treatment of microinvasive cervical cancer?

Answer 28

Cone or loop biopsy and check the margins Regular smears If older lady, hysterectomy

Question 29

Tx of Stage 1 tumours larger than microinvasive but confined to cervix

Answer 29

Radical hysterectomy (all of the ligaments and the upper vagina are removed in addition to just the uterus as in simple hysterectomy) Small percentage of patients with radical hysterectomy will get post op chemoradiation (ONLY if close margins or adverse prognostic features)

Question 30

Tx if cancer has spread beyond cervix

Answer 30

No surgery Chemoradiation

Question 31

How is cervical cancer staged?

Answer 31

MRI scan Pelvic exam under anaesthesia Cytoscopy

Question 32

Adverse prognostic features of cervical cancer?

Answer 32

Size Differentiation Surgical margins Lymphovascular spread Lymph node involvement

Question 33

5 yr survival for stage 1 cervical cancer?

Answer 33

90-95%

Question 34

5 yr survival for stage 4 cancer

Answer 34

\<20%

Question 35

What epithelium lines vulva?

Answer 35

Keratinising stratified squamous epithelium

Question 36

Lichen sclerosis and squamous cell hyperplasia are categories of what?

Answer 36

Vulval Dystrophy Present with pain, itching, leukoplakia

Question 37

What can vulval dystrophy progress to ?

Answer 37

Invasive squamous carcinoma

Question 38

Histology: Sclerosis/fibrosis within dermis of vulva, with atrophic surface epithelium

Answer 38

Lichen sclerosis

Question 39

What virus is associated with VIN?

Answer 39

VIN (vulva intraepithelial neoplasia) linked to HPV

Question 40

True/false: VIN less common than CIN

Answer 40

True, mostly found while investigating CIN

Question 41

Two types of VIN in vulva?

Answer 41

**Bowenoid/undifferentiated:** younger, associated with HPV, CIN, low risk of invasion **Simplex/differentiated:** Rarer, older people, NO HPV ASSOCIATION, higher risk of invasion

Question 42

Two types of vulval INVASIVE squamous carcinoma? (Similar to VIN but don't confuse them)

Answer 42

Bowenoid/undifferentiated: LESS COMMON due to low risk of Bowenoid VIN progressing, younger patients, HPV Simplex/differentiated: Mosre common, no HPV, associated with lichen sclerosis and squamous cell hyperplasia (vulva dystrophies), older pt

Question 43

Stage 1 Vulval cancer

Answer 43

Confined to vulva, \<2cm

Question 44

Stage 2 vulval tumour

Answer 44

Tumour confined to vulva but \>2cm

Question 45

Stage 3 Vulval tumour

Answer 45

Spread to lower urethra, vagina, or anus AND/OR Lymph node involvement

Question 46

Stage 4 vulval tumour

Answer 46

Metastasis including to pelvis

Question 47

Tx of stage 1 vulval cancer?

Answer 47

Surgical excision of tumour and inguinal lymph nodes

Question 48

Tx of advanced vulval Ca?

Answer 48

Chemoradiation

Question 49

Histology: Adenocarcinoma confined to the squamous epithelium of the vulva

Answer 49

Paget's disease of vulva Arises in squamous epithelium due to a stem cell becoming glandular.

Question 50

Where does Paget's disease of vulva come from?

Answer 50

Thought to be stem cell Usually primary but can be secondary from an adenocarcinoma from colon, rectum, bladder, or cervix

Question 51

Symptoms of Paget's disease of vulva

Answer 51

Itch, redness, eczema, ulceration

Question 52

Tx of Paget's disease of vulva?

Answer 52

Surgical excision Exclude another primary orign Often reoccurs even if margin is clear Can become invasive adenocarcinoma

Question 53

What is vaginal adenosis?

Answer 53

Presence of galndular epithelium in vagina. Linked to DES drug