Pathology of Cervix, Vulva and Vagina

Question 1

what is the ectocervix

Answer 1

on the outside

lined by squamous epithelium

Question 2

what is the endocervix

Answer 2

on the inside

lined by glandular epithelium

Question 3

what cells like the vagina

Answer 3

squamous epithelium

Question 4

what layers make up a normal ectocervix

Answer 4

basement membrane 
basal cells 
parabasal cells 
intermediate cells 
exfoliating cells 

(smear test just scrapes off the surface cells)

Question 5

what is the transformation zone of the cervix

Answer 5

area between old squamous-columnar junction and new squamocolumnar junction

(see one note for explanation)

Question 6

when does the transformation zone position change

Answer 6

menarche
pregnancy
menopause

Question 7

what is the squamous-columnar junction

Answer 7

area where the the ectocervical (squamous) and endocervical (columnar) epithelium meet

Question 8

what can lead to physiological squamous metaplasia

Answer 8

exposure of delicate endocervical epithelium to acid envorment of the vagina

Question 9

what are nabothian follicles

Answer 9

dilated endocervical glands - entirely benign

Question 10

what is cervicitis

Answer 10

inflammation in the cervix

can lead to infertility due to simultaneous silent Fallopian tube damage

Question 11

causes of cervicitis

Answer 11

non-specific acute/chronic inflammation

follicular cercititic - sub epithelial reactive lymphoid follicles in cervix

chlamydia

Herpes

Question 12

what is a cervical polyp

Answer 12

localised inflammatory outgrowth

not premalignant

can cause bleeding in ulcerated

Question 13

what are neoplastic changes in the cervix

Answer 13

Cervical intraepithelial neoplasia (CIN)

Cervical cancer (squamous carcinoma, adenocarcinoma)

Question 14

what strands of HPV are high risk for causing cervical malignancy

Answer 14

HPV 16

HPV 18

Question 15

how does HPV cause cervical cancer

Answer 15

HPV replicated inside cervical cells

cause changes in cellular genome leading to cancer

Question 16

risk factors for cervical cancer

Answer 16

high risk HPV virus

age at first intercourse

long term use of oral contraceptives

non-use of barrier contraception

smoking (3x risk)

immunosuppression

Question 17

what is intraepithelial neoplasia

Answer 17

lower genital tract cell changes

Question 18

what does a low risk HPV genital wart look like

Answer 18

thickened ‘papillomatous’ squamous epithelium with cytoplasmic vacuolation (koilocytosis)

(called condyloma acumninatum)

Question 19

what does high risk HPV (16 and 18) look like (CIN)

Answer 19

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

Question 20

what does HPV infection cervical cancer look like

Answer 20

invasive squamous cancerima

virus integrated into his DNA

epithelium no longer flat?

Question 21

how long does it take for HPV infection to lead to high grade cervical intraepithelial neoplasia

Answer 21

6months - 3 years

Question 22

how long does it take high rate cervical intraepithelial neoplasia (CIN) to become invasive cancer

Answer 22

5-20 years

Question 23

where does CIN occur

Answer 23

transformation zone

(dysplasia of squamous cells)

asymptomatic

detectable by cervical screening

Question 24

what does CIN look like histologically

Answer 24

delay in maturation/differentiation
(immature basal cells occupy more epithelium)

nuclear abnormalities

excess mitotic activity

Question 25

what does koilocytosis indicate

Answer 25

HPV infection

Question 26

what is CIN 1

Answer 26

1/3 of epithelium occupied by abnormal cells

Question 27

what is CIN 2

Answer 27

abnormal cells extend to middle 1/3 of epithelium

Question 28

What is CIN 3

Answer 28

abnormal cells occupy full thickness of epithelium

Question 29

what cancer can CIN lead to

Answer 29

invasive squamous cell carcinoma

Question 30

what are symptoms of invasive carcinoma

Answer 30

usually none at microinvasive and early invasive stages abnormal bleeding - post coital - post menopausal - brownish or blood stained vaginal discharge - contact bleeding pelvic pain haemoturia/urinary infections ureteric obstruction/renal failure

Question 31

how do you grade squamous carcinoma

Answer 31

well differentiated moderately differentiated poorly differentiated undifferentiated/anaplasic

Question 32

what is cervical glandular intraepithelial neoplasia

Answer 32

origin from endocervical epithelium preinvasive phase of endocervical adenocarcinoma screening less effective, more difficult to diagnose also caused by HPV virus

Question 33

what is endocervical adenocarcinoma

Answer 33

cancer arising from glandular endocervix worse prognosis than squamous carcinoma increasing incidence particularly in young women

Question 34

risk factors of adenocarcinoma

Answer 34

HPV - particularly HPV 18 smoking later onset of sexual activity

Question 35

what are the other HPV driven diseases

Answer 35

vulval intraepithelial neoplasia (VIN) vaginal intraepithelial neoplasia (VaIN) anal intraepithelial neoplasia (AIN)

Question 36

what are the two types of vulval intraepithelial neoplasia

Answer 36

HPV related Non-HPV related (often related to inflammatory diseases)

Question 37

treatment for VIN

Answer 37

surgical removal | will lead to invasive squamous carcinoma and spread to inguinal lymph nodes

Question 38

what surgery is done for vulvar invasive squamous carcinoma

Answer 38

radical vulvectomy and inguinal lymphadenectomy

Question 39

what is vulvar Paget's disease

Answer 39

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

Question 40

what other vulvar diseases can you get

Answer 40

candida vulvar warts Bartholin's gland abscess lichen sclerosis lichen plants psoriasis post menopausal atrophy

Question 41

what pathology do you get in the vagina

Answer 41

VaIN - vaginal intraepithelial neoplasia Squamous carcinoma (less common) disease of elderly Melanoma - rare, may appear as polyp