Pathology of Cervix, Vulva and Vagina Flashcards
What is the ectocervix? What epithelium is it composed of?
Vaginal portion of the cervix, seen on internal examination
What is the endocervix?
Lowermost portion of the uterus
Describe the lining of the ectocervix
Non-keratinising stratified squamous epithelium with basal and parabasal cells
Describe the lining of the endocervix
Simple columnar epithelium that secretes mucous via cilia
What is the transformation zone? What happens to the position of this zone?
Squamocolumnar junction between ectocervical and endocervical epithelia
Alters during menarche, pregnancy and menopause
What is the clinical significance of the transformation zone?
Most common place on the cervix for abnormal cells to develop
How does cervical erosion occur?
Exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia
How are Nabothian follicles formed?
When stratified squamous epithelium of the ectocervix grows over the simple columnar epithelium of the endocervix
State the two main types of pathology of the cervix and give examples
Inflammatory (cervicitis, polyp)
Neoplastic (CIN, squamous or adenocarcinoma)
What is cervicitis?
Non-specific acute or chronic inflammation resulting in subepithelial reactive lymphoid follicles in the cervix
How can cervicitis cause infertility in the long-term?
Simultaneous silent fallopian tube damage
What are the most common causes of cervicitis?
Commonly, a sexually-transmitted infection
Chlamydia trachomatis
Herpes simplex virus
Cervical polpys are premalignant. True/ False?
False
What is a cervical polyp? How do they present?
Localised inflammatory outgrowth
Bleeding if ulcerated
List risk factors for neoplastic changes of the cervix
Persistence of HPV (many sexual partners)
Vulnerability of SCJ (age of 1st intercourse, use of oral contraceptives, avoidance of barrier contraceptives)
Smoking
Immunosuppression
List the main presentations of HPV, in order of risk
Genital warts
Cervical intra-epithelial neoplasia
Cervical cancer
What types of HPV are associated with genital and vulvar warts?
Type 6
Type 11
What types of HPV are associated with cervical neoplasia?
Type 16
Type 18
Describe the pathological appearance of genital warts
Thickened papillomatous squamous epithelium Cytoplasmic vacuolation (koilocytosis)
Describe the pathological appearance of CIN
Infected flat epithelium
Signs of koilocytosis
Outline the timeline of progression of HPV to cervical cancer
HPV –> CIN: 6 months to 3 years
CIN –> cervical cancer: 5-20 years
What is the main risk factor for progression of HIV to cervical cancer?
Persistant exposure to HPV infection
What is cervical intra-epithelial neoplasia?
A preinvasive stage of cervical cancer occuring at transformation zone which involves dysplasia of squamous cells
How is CIN typically detected?
Asymptomatic
Detected by cervical screening
List the key histological factors that identify the severity of cervical intra-epithelial neoplasia
Delay in maturation/differentiation of immature basal cells
Nuclear abnormalities (hyperchromasia, increased N:C ratio, pleomorphism)
Excess mitotic activity above basal layer (abnormal mitotic forms)
How is CIN graded?
How deep the cell changes go into the surface of the cervix: CIN 1,2,3
Describe the pathological appearance of CIN1
Basal third of epithelium occupied by abnormal cells
Describe the pathological appearance of CIN2
Abnormal cells extend to middle third of epithelium
Describe the pathological appearance of CIN3
Abnormal cells occupy full thickness of epithelium
Outline the prevalence of the main types of malignant cervical tumours
Invasive squamous carcinomas: 75-95%
Endocervical adenocarcinoma: 5-25%
List the stages of invasive squamous carcinoma
1A1: depth up to 3mm, width up to 7mm 1A2: depth up to 5mm, width up to 7mm 1B: confined to cervix 2: spread to adjacent organs 3: Involvement of pelvic wall 4. Distant mets or involvement of rectum or bladder
List symptoms of early invasive squamous carcinoma
Usually asymptomatic
List symptoms of late invasive squamous carcinoma
Abnormal bleeding (PCB, PMB, IMB)
Brownish or blood-stained vaginal discharge
Pelvic pain
Haematuria, urinary problems
Ureteric obstruction, acute renal failure
List common sites of local spread in SCC
Uterine body Vagina Bladder Ureters Rectum
List common sites of lymphatic spread in SCC
Pelvic nodes
Paraortic nodes
List common sites of haematogenous spread in SCC
Liver
Lungs
Bone
What are the grading classifications used in SCC?
Well differentiated
Moderately differentiated
Poorly differentiated
Indifferentiated/ anaplastic
State the two main types of cervical glandular lesions
Cervical glandular intra-epithelial neoplasia (CGIN)
Endocervical adenocarcinoma
What is cervical glandular intra-epithelial neoplasia?
Preinvasive phase of endocervical adenocarcinoma originating from the endocervical epithelium
List risk factors for endocervical adenocarcinoma
Young women
Later onset of sexual activity
Smoking
HPV 18
Adenocarcinoma and squamous carcinoma of the cervix can occur simultaneously. True/ False?
True
Known as adenosquamous carcinomas
List management options for cervical cancer
Surgery (LLETZ for early cancer, hysterectomy)
Radiotherapy (external beam, brachytherapy)
Chemotherapy (neoadjuvant, concomitant, palliative)
List other types of HPV driven disease
Vulvar intrapeithelial neoplasia (VIN)
Vaginal intraepithelial neoplasia (VaIN)
Anal intraepithelial neoplasia (AIN)
Define the bimodal presentation of VIN
Young women: multifocal, recurrent, persistant
Older women: great risk of progression
Describe Paget’s disease of the vulva?
Skin cancer derived from glandular cells on the skin of the vulva characterised by a red, crusting, itchy rash
What is vulvar invasive squamous carcinoma?
A well differentiated malignant tumour, typically found in elderly women, presenting as an ulcer or exophytic mass
What is an important prognostic factor in vulvar invasive squamous carcinoma?
Spread to inguinal lymph nodes
Outline the management of vulvar invasive squamous carcinoma
Radical vulvectomy
Inguinal lymphadenectomy
What infection is a common form of vulvar disease, particularly in diabetics?
Candida
What is a Bartholin’s gland abscess?
Bartholin’s gland, located on either side of the opening of the vagina, becomes obstructed forming a cyst that can become infected and painful
List other types of non-neoplastic epithelial disorders that con form on the vulva
Lichen sclerosis (itchy white patches) Lichen planus (itchy rash) Psoriasis
What group of women typically get vulvar atrophy?
Post-menopausal women
List the main types of vaginal neoplastic pathology
Vaginal intraepithelial neoplasia
Squamous carcinoma
Melanoma
What group of women typically get invasive squamous carcinoma of the vagina?
Elderly women
How might vaginal melanoma present?
Pigmented lesion, similar to a polyp
What is the first-line treatment for 1A1 disease?
Local excision(LLETZ) +/- pelvic lymph node dissection
What is the first-line treatment for 1A2-1B1 stage disease?
> 2cm, not desiring fertility = hysterectomy
(non-surgical = chemoradiation)
<2cm, desiring fertility = radical trachelectomy
What is the first-line treatment for 1B2-2A stage disease?
Radical hysterectomy +lymphadenectomy
What is the first-line treatment for 2B-4A stage disease?
Chemoradiation
What is the first-line treatment for 4B stage disease?
Combination chemotherapy
What is the first-line treatment for a pregnant women at any stage?
MDT care
Delivery at 35 weeks
