Pathology of Cervix, Vulva and Vagina

Question 1

divisions of cervix?

Answer 1

ectocervix
- external surface at entrance to cervix/uterus
- lined by squamous epithelium
endocervix
- canal inside the cervix leading into the uterus
- glandular epithelium lines

Question 2

what lines vagina?

Answer 2

squamous epithelium

Question 3

layers of cells in ectocervix from top to bottom?

Answer 3

exfoliating cells 
superficial cells
intermediate cells
parabasal cells
basal cells
basement membrane

Question 4

what cells of ectocervix are sampled by smear test?

Answer 4

exfoliating and supporting cells?

Question 5

features of endocervix

Answer 5

columnar epitheium

cillia

Question 6

what is the transformation zone?

Answer 6

area between old squamo-columnar junction (before menarche) and new squamo-columnar junction (post-menarche)
- junction between endo and ecto cervical epithelia

Question 7

clinical relevance of transformation zone?

Answer 7

site of infection and cancer

Question 8

what alters the position of TZ?

Answer 8

menarche
pregnancy
menopause

Question 9

what is cervical erosion and what can it cause?

Answer 9

exposure of the delicate endocervical epitheium to the acidic environment of the vagina leading to squamous metaplasia
- (can lead to squamous carcinoma?)

Question 10

what are nabothian follicles?

Answer 10

mucous filled cyst on surface of cervix

often happens when squamous epithelium grows over columnar epithelium

Question 11

what is cervicitis?

Answer 11

non-specific acute/chronic inflammation in the cervix
often asymptomatic
can lead to infertility due to simultaneous silent fallopian tube damage

Question 12

types of cervicitis?

Answer 12

follicular cervitis - subepithelial reactive lymphoid follicles present in cervix
chlamydia trachomatis - sexually transmitted
herpes simplex

Question 13

what is a cervical polyp?

Answer 13

localised inflammatory outgrowth
cause of bleeding if ulcerated
not premalignant

Question 14

types of neoplasia in cervix?

Answer 14

cervical intraepithelial neoplasia (CIN)
cervical cancer (squamous carcinoma, adenocarcinoma)

Question 15

biggest cause of cervical cancer?

Answer 15

HPV

- but can still occur due to other causes

Question 16

risk factors for CIN?cervical cancer?

Answer 16

persistence of high risk HPV (16 and 18)
- multiple partners increases risk
vulnerable TZ in early reproductive life
- young age at first intercourse
- long term oral contraceptive use
- non-use of barrier contraception
smoking
immunosuppression

Question 17

what does low risk HPV (6 and 11) cause?

Answer 17

genital warts

- condyloma acuminatum: thickened papillomatous squamous epithelium with cytoplasmic vacuolation (koilocytosis)

Question 18

histological features of CIN due to high risk HPV?

Answer 18

infected epithelium remains flat but may show koilocytosis, which can be detected in cervical smears

Question 19

microscopic features of cervical cancer?

Answer 19

invasive squamous carcinoma
virus integrated into host DNA
broken through epithelium

Question 20

time line for HPV infection?

Answer 20

HPV > high grade CIN = 6 months - 3 years

high grade CIN > invasive cancer = 5-20 years

Question 21

features of abnormal cells on smear?

Answer 21

abnormal shape

larger nucleus with more mitotic figures

Question 22

features of CIN?

Answer 22

pre-invasive stage of cervical cancer occuring at TZ
can involve large area
dysplasia of squamous cells
not visible to naked eye
asymptomatic
detectable by cervical screening

Question 23

progression of dysplasia and neoplasia in cervical epithelium?

Answer 23

koilocytosis > CIN 1 > CIN 2 > CIN 3 (abnormal cells get further and further towards the surface)

Question 24

histology of CIN?

Answer 24

delay in maturation/differentiation (immature basal cells occupy more of epithelium)
nuclear abnormalities (hyperchromasia, increased nucleocytoplasmic ratio, pleomrphism)
excess mitotic activity

Question 25

features of CIN 1?

Answer 25

basal 1/3 of epithelium occupied by abnormal cells - raised number of mitotic figures in lower 1/3 - surface cells quite mature, but nuclei slightly abnormal

Question 26

features of CIN 2?

Answer 26

abnormal cells extend into middle 1/3 - mitoses in middle 1/3 - abnormal mitotic figures

Question 27

features of CIN 3?

Answer 27

abnormal cells occupy full thickness of epithelium | - mitosis, often abnormal, in upper 1/3

Question 28

most common cervical cancer?

Answer 28

squamous cell carcinoma

Question 29

staging of cervical cancer?

Answer 29

method about to be obsolete

Question 30

symptoms of invasive cervical carcinoma?

Answer 30

usually none at microinvasive and early invasive stages so usually just detected at screening abnormal bleeding (post coital, post menopausal, stained discharge, contact bleeding) pelvic pain haematuria/urinary infections ureteric obstruction/renal failure

Question 31

how might a squamous cervical cancer spread?

Answer 31

local > uterine body, vagina, bladder, ureters, rectum lymphatic (early) > pelvic, para-aortic nodes haematogenous (late) > liver, lungs, bone

Question 32

how is squamous cervical cancer graded?

Answer 32

well differentiated moderately differentiated poorly differentiated undifferentiated/anaplastic

Question 33

what is CGIN?

Answer 33

cervical glandular intraepithelial neoplasia caused by HPV originates from endocervical epithelium pre-invasive phase of endocervical adenocarcinoma

Question 34

CGIN vs CIN?

Answer 34

can be associated | more difficult to pick up on screening

Question 35

which has a worse prognosis, squamous or adenocarcinoma?

Answer 35

adenocarcinoma

Question 36

what is adenocarcinoma associated with?

Answer 36

higher socio-economic class later onset of sexual activity smoking HPV, particularly HPV 18

Question 37

name 3 other HPV driven diseases?

Answer 37

vulvar intra-epithelial neoplasia (VIN) vaginal intra-epithelial neoplasia (VaIN) anal intra-epithelial neoplasia (AIN)

Question 38

features of vulvar intra-epithelial neoplasia?

Answer 38

variable, less predictable than CIN 3 grades bi-modal - young women = multifocal, recurrent or persistent causing treatment problems - older women = greater risk of progression to invasive squamous carcinoma can be HPV related but not always often synchronous with cervical and vaginal neoplasia

Question 39

features of invasive squamous carcinoma

Answer 39

usually elderly women with ulcer or exophytic mass can arise from normal epithelium or VIN usually well differentiated spread to inguinal nodes

Question 40

features of vulvar pagets disease?

Answer 40

crusting rash tumour cells in epidermis containing mucin mostly no underlying cancer, tumour arises from sweat glands in skin

Question 41

name 3 other types of vulval disease

Answer 41

infection (candida, vulvar warts, bartholins gland abscess) non-neoplastic epithelial disorders (lichen sclerosis and other dermatoses) atrophy (post-menopausal)

Question 42

3 main vaginal pathologies?

Answer 42

VaIN squamous carcinoma (less common than cervical and vulval) melanoma (rare)

Question 43

surgical treatment of vulvar invasive squamous carcinoma?

Answer 43

radical vulvectomy and inguinal lymphadenopathy