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Pathology - Cervical Flashcards

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1
Q

What is the transformation zone?

A

squamo-columnar junction between the ECTOcervix (squamous) and ENDOcervix (columnar) epithelia

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2
Q

The position of TZ alters during life as physiological response to - (3)

A

menarche

pregnancy

menopause

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3
Q

Pathology of Cervical Erosion/ectropion/eversion

A

so common that considered normal

  • cervix enlarges under the influence of oestrogen and endocervical canal is everted
  • protrusion of delicate endocervical epithelium to external os exposes it to acid environment of vagina, leading to physiological squamous metaplasia
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4
Q

Clinical presentation of Cervical Ectropion

A

mostly asymptomatic
bleeding
excessive watery discharge

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5
Q

Cervical ectropion risk factors? (3)

A
  1. teenagers
  2. menopause
  3. COC
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6
Q

When do symptoms of cervical ectropion disappear?

A

over time, when vaginal acidity promotes metaplasia to squamous epithelium

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7
Q

What is an important step in the investigation of cervical ectropion?

A

cervical smear to exclude cervical cancer

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8
Q

Cervical ectropion on examination?

A

red ring around os

so common that considered normal

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9
Q

What are Nabothian cysts? (pathology)

A

aka Mucinous retention cysts (so common that they are considered normal)

results from metaplasia leading to sqaumous cell cover over columnar epithelium with mucus-producing crypts within it

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10
Q

appearance of nabothian cysts?

A

multiples translucent/opaque, white or yellow lesions

ranges from 2mm to 10mm

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11
Q

Symptoms and treatment of Nabothian cysts?

A

no treatment, asymptomatic

rarely, if grow very large: cautery or cryotherapy

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12
Q

Physiological metaplasia of endocervical epithelium leads to? (2)

A

Cervical erosion/ectropion

Nabotian follicles (contains mucinous crypts)

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13
Q

Inflammatory pathology of cervix (2)

A
  1. Cervicitis

2. Cervical polyp

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14
Q

What is Cervicitis? (symptoms, complications, causes)

A
  • non-specific acute/chronic inflammation
  • often asymptomatic
  • can lead to infertility
  • follicular: sub-epithelial reactive lymphoid follicles present in cervix
  • Chlamydia (STI)
  • HSV infection
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15
Q

How may cervicitis lead to infertility?

A

due to simultaneous silent fallopian tube damage

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16
Q

what is a cervical polyp?

A

localised inflammatory outgrowth

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17
Q

Are cervical polyps pre-malignant?

A

No

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18
Q

How do cervical polyps present?

A

Incidental finding

Cause of bleeding if ulcerated

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19
Q

Most common benign neoplasms of the cervix? (how common)

A

4% of gynae population
polyps

may be endocervical or cervical

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20
Q

Endocervical polyps - which age group and what do they look like?

A

4th - 6th decade of life

cherry red lesions which may be single or multiple

may appear as apedunculated lesion on a stalk of varying length

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21
Q

Cervical polyps on examination

A

single, smooth grey-white lesions that bleed easily if touched

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22
Q

Neoplastic lesions of the cervix

A

CIN (pre-malignant)

Cervical cancer - squamous or adenocarcinoma

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23
Q

Who is Harald Zur Hausen?

A 
German Virologist 
1983:identified HPV 16
1984:identified HPV 18 
HPV-driven Cervical Disease  
75% of Cervical Cancer
2008: Nobel Prize for Medicine
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24
Q

Structure of HPV

A

circular, double stranded DNA, protected by capsid proteins

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25
Risk factors for CIN/cervical cancer (4)
1. persistence of high risk HPV (16, 18, 31, 33, 35, 45, 48) 2. vulnerability of SC junction in early reproductive life 3. smoking: 3x risk 4. Immunosuppression
26
What increases the vulnerability of SC junction
young age of first intercourse long term use of oral contraceptives Non-use of barrier contraception
27
What increases your risk of acquiring persistent HPV?
many sexual partners
28
What does low risk HPV infection cause in the cervix?
(6 and 11) | Genital Warts
29
What are genital warts? (pathology)
condyloma acuminatum: | thickened papillomatous squamous epithlium with cytoplasmic vacuolation ("koilocytosis")
30
What does high risk HPV infection cause in the cervix?
CIN (16 and 18) Cervical cancer
31
Pathology of CIN
infected epithelium remains flat, but may show koilocytosis, which can be detected in cervical smears
32
What is a koilocyte?
A Koilocyte is a squamous epithelial cell that has undergone a number of structural changes, which occur as a result of infection of the cell by HPV
33
Cellular changes of a koilocyte
1. Nuclear enlargement x2-3 2. Irregularity of the nuclear membrane contour 3. darker staining nucleus (Hyperchromasia) 4. A clear area around the nucleus(perinuclear halo) Collectively, these types of changes are called a cytopathic effect;
34
What is the definition of cervical cancer
invasive sqaumous carcinoma (virus integrated into host DNA)
35
How long does it take for HPV infection to become a high grade CIN
6m - 3yrs
36
How long does it take for a high grade CIN to become invasive cancer?
5 - 20 years
37
How do polyps present?
- asymptomatic - abnormal bleeding (PCB, IMB, Menorrhagia) - infertility (if grows big enough to obstruct external os) - malignancy is rare (1/200)
38
Management of polyps
removed and sent to histology if asymptomatic, twist them off If >2cm x 1cm, refer persistent lesions, D&C, electrosurgical excision, hysterscopic polypectomy
39
Complications with removal of polyp and how to treat them
Vagally stimulated bradycardia - atropine haemorrhage - cautery
40
What may mimic the appearance of a large polyp
appearance of healed cervix following cone biopsy
41
Symptoms of cervicitis?
none abnormal yellow-green discharge PCB dysuria
42
Signs of cervicitis
green/yellow/opaque mucopurulent discharge endocervical friability (bleeds easily)
43
Common culprits of cervicitis
gonorrhoea, chlamydia, HPV, HSV, trichomonas
44
Treatment of cervicitis
anti-microbial | guided by swab results
45
Prevalence of HPV infection by age group/lifetime
15-25 yrs = 30-50% 25 - 35 yrs = 10 -20% >35 yrs = 5 - 15% 80% cumulative prevalence in lifetime
46
If there is an 80% cumulative lifetime prevalence, why isnt cervical cancer THAT common?
most develop immunity persistence increases risk of disease
47
What is CIN and where does it occur?
pre-invasive stage of cervical cancer occurs at TZ can involve a large area
48
Histology of CIN (4)
dysplasia of squamous cells (koilocytosis = HPV often present) 1. delay in maturation/differentiation - immature basal cells occupy more of epithelium 2. nuclear abnormalities 3. excess mitotic activity - situated above basal layers - abnormal mitotic forms
49
Clinical presentation of CIN
not visible to naked eye | asymptomatic
50
How is CIN detected
C screening
51
Histological staging of CIN (+ mitotic figures, maturation, nuclear feature)
Depth of abnormal cells and mitoses, abnormal mitotic figures CIN 1 = basal 1/3 (raised no. of mitotic figures, surface cells quite mature, but nuclei slightly abnormal) CIN II - extends to middle 1/3 CIN III - full epithelial thickness occupancy
52
Histological nuclear abnormalities of CIN (3)
- hyperchromasia - increased nucleocytoplasmic ratio - pleomorphism
53
Natural history of CIN 1 lesions (% regress, persist, progression to CIN3, progression to invasion)
regress = 57% persist = 32% Progress to CIN 3 = 11 % Progress to invasion = 1/100
54
Natural history of CIN 2 lesions (% regress, persist, progression to CIN3, progression to invasion)
Regress = 43% Persist = 35% Progress to CIN 3 = 22% Progress to invasion = 5%
55
Natural history of CIN 3 lesions (% regress, persist, progression to invasion)
regress = 32% Persist = 56% Progress to invasion = >12%
56
How common are cervical cancers (invasive squamous carcinoma) worldwide
75 -95% of malignant cervical tumours 2nd commonest female cancer worldwide
57
Detection of cervical cancers (who, what stage, how progressive)
increasingly detected in younger women often found in early stage some are rapidly progressive tumours
58
How are cervical cancers prevents and why
Develops from pre-existing CIN, therefore most cases should be preventable by screening
59
epidemiology of cervical cancer in scotland | incidence 2002-2012, new cases in 2012, #, % of all cancers
12th commonest female malignancy 1.9% of all cancers 295 new cases in 2012 10.6% increase in incidence 2002-2012
60
Epidemiology of cervical cancer (death in 2013, reduction in mortality 2003-2013, 5 year survival)
91 deaths in 2013 18. 2% reduction in mortality 2003-2013 70. 1% 5 year survival
61
Highest risk age groups
30 - 44 | 25 - 49
62
Staging of invasive squamous carcinoma 1A1/2/B (depth and width), 2-4 (organ involvement)
Stage 1A1 - depth up to 3mm, width up to 7mm Stage 1A2 - depth up to 5mm, width up to 7mm Low risk of lymph node metastases Stage 1B - confined to the cervix Stage 2 - spread to adjacent organs (vagina, uterus, etc..) Stage 3 - involvement of pelvic wall Stage 4 - distant metastases or involvement of rectum or bladder.
63
Symptoms of invasive carcinoma (5)
usually none at microinvasive/early stage - detected at screening abnormal bleeding Pelvic pain Haematuria/UTI Uteretic obstruction/renal failure
64
What do you mean by abnormal bleeding? (4)
PCB PMB brownish/blood stained vag discharge, contact bleed - friable
65
Spread of squamous carcinoma
Local - uterine body, vagina, bladder, ureters, rectum lymphatic - early - pelvic, para-aortic nodes haematogenous - late - liver, lungs, bone
66
Grading of squamous carcinoma
Well differentiated Moderately differentiated Poorly differentiated Undifferentiated / anaplastic
67
Staging Ix in Cervical cancer
CT, MRI, Cystoscopy
68
Management for early stage cervical cancer
Laparoscopic radical hysterectomy
69
Management for cervical cancer
High dose rate brachytherapy
70
Management of recurrent and stage IVB cervical cancer
Topotecan (+ cisplatin) = chemotherapt
71
What is Cervical Glandular Intraepithelial Neoplasia (CGIN) ( origin, type of carinoma, diagnostic issues, screening, association)
Origin from endocervical epithelium CGIN is pre- invasive phase of endocervical adenocarcinoma More difficult to diagnose on cervical smear than squamous Screening less effective Sometimes associated with CIN
72
Epidemiology of Endocervical Adenocarcinoma
5-25% of cervical cancer | ?Increasing incidence, particularly in young women
73
Prognosis of endocervical adenocarcinoma (cf squamous Ca)
worse
74
Cell types and origin in endocervical adenocarcinoma
some are mixed (adenosquamous) ? arise from common cell or origin
75
rIsk factors of adenocarcinoma (4)
Higher S.E. Class later onset of sexual activity smoking HPV (particularly 18)
76
HPV driven disease (5)
``` CIN CGIN VIN (Vulval) VaIN (Vaginal) AIN (anal) ``` Head and Neck

Gynaecology (7 decks)

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