Pathology of the Cervix, Vulva and Vagina

Question 1

What is the Transformation zone (TZ)?

Answer 1

Squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia

Question 2

What physiological things can alter the position of the TZ?

Answer 2

Menarche
Pregnancy
Menopause

Question 3

What is cervical erosion?

Answer 3

Exposure to delicate endocervical epithelium to acid environment of the vagina which leads to physiological squamous metaplasia

Question 4

What is Cervicitis?

Answer 4

Often asymptomatic

Can lead to infertility due to simultaneous silent fallopian tube damage

Question 5

What is follicular cervicitis?

Answer 5

Sub. epithelial reactive lymphoid follicles present in cervix

Question 6

What is Chlamydia trachomatis?

Answer 6

STI

Question 7

What is a Cervical polyp?

Answer 7

Localised inflam outgrowth
Cause of bleeding if ulcerated
Not premalignant

Question 8

What are types of cervical cancer?

Answer 8

Squamous carcinoma
Adenocarcinoma
Cervical Intraepithelial Neoplasia

Question 9

What are risk factors for CIN/cervical cancer?

Answer 9

HPV
Age at first intercourse
Long term oral contraceptive
Non-use of barrier contraception
Smoking
Immunosuppresion

Question 10

What HPV cause genital warts?

Answer 10

6 and 11

Question 11

What are genital warts?

Answer 11

Condyloma acuminatum: thickened papilomatous squamous epithelium with cytoplasmic vacuolation (koilocytosis)

Question 12

What HPV causes CIN?

Answer 12

16 and 18

Question 13

WHat is CIN?

Answer 13

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

Question 14

What is cervical cancer?

Answer 14

Invasive squamous carcinoma: virus integrated into host DNA

Question 15

Describe CIN?

Answer 15

Pre-invasive stage of cervical cancer
Occurs at the TZ
Can involve large areas
Dysplasia of squamous cells
Not visible to naked eye
Asymptomatic
Detectable on cervical smear

Question 16

Describe CIN I

Answer 16

basal 1/3 of epithelium occupied by abnormal cells
Raised numbers of mitotic figures in lower 1/3
Surface cells quite mature, but nuclei slightly abnormal

Question 17

Describe CIN II

Answer 17

Abnormal cells extend to middle 1/3
Mitoses in middle 1/3
Abnormal mitotic figures

Question 18

Describe CIN III

Answer 18

Abnormal cells occupy full thickness of epithelium

Mitoses, often abnormal, in upper 1/3

Question 19

Describe Invasive Squamous Carcinoma (ISC)

Answer 19

75-95% of malignant cervical tumours
2nd commonest female cancer
Develop from pre-existing CIN so should be preventable by screening

Question 20

What is the 5 year survival rate for cervical cancer in Scotland?

Answer 20

70.1%

Question 21

What is stage 1A1 ISC?

Answer 21

depth up to 3mm, width up to 7mm

Question 22

What is stage 1A2 ISC?

Answer 22

depth up to 5mm
width up to 7mm
Low risk of metastases

Question 23

What is stage 1B ISC?

Answer 23

Confined to the cervix

Question 24

What is stage 2 ISC?

Answer 24

Spread to adjacent organs (vagina, uterus etc.)

Question 25

What is stage 3 ISC?

Answer 25

Involvement of pelvic wall

Question 26

What is stage 4 ISC?

Answer 26

Distant metastases or involvement of rectum or bladder

Question 27

What are symptoms of invasive carcinoma?

Answer 27

``` usually none at microinvasive and early invasive stages (detected at screening) Abnormal bleeding Pelvic plain Haematuria/Urinary infections Ureteric obstruction/Renal failire ```

Question 28

Describe the bleeding seen in invasive carcinoma?

Answer 28

Post coital Post-menopausal Brownish or blood stained vaginal discharge Contact bleeding - friable epithelium

Question 29

Where does squamous carcinoma metastasise to via local spread?

Answer 29

``` Uterine body Vagina Bladder Ureters Rectum ```

Question 30

Where does squamous carcinoma metastasise to via lymphatic spread? (early)

Answer 30

Pelvic | para-aortic nodes

Question 31

Where does squamous carcinoma metastasise to via haematogenous spread? (late)

Answer 31

Liver Lungs Bone

Question 32

How is squamous carcinoma graded?

Answer 32

Well differentiated Moderately differentiated Poorly differentiated Undifferentiated / anaplastic

Question 33

What is CGIN?

Answer 33

Cervical Glandular Intraepithelial Neoplasm

Question 34

Describe Cervical Glandular Intraepithelial Neoplasm

Answer 34

Origin from endocervical epithelium Preinvasive phase of endocervical adenocarcinoma Screening less effective Can be assoc. with CIN

Question 35

What has a worse prognosis; Squamous carcinoma or Endocervical adenocarcinoma?

Answer 35

Endocervical adenocarcinoma

Question 36

What are risk factors for Adenocarcinoma?

Answer 36

Higher S.E. class Later onset sexual activity Smoking HPV, esp. 18

Question 37

Name 3 other HPV driven diseases

Answer 37

Vulvar Intraepithelial Neoplasia (VIN) Vaginal Intraepithelial Neoplasia (VaIN) Anal Intraepithelial Neoplasia (AIN)

Question 38

What does Vulvar Intraepithelial Neoplasia have an association with?

Answer 38

Paget's disease

Question 39

Describe VIN in young women?

Answer 39

Often multifocal | Recurrent or persistent causing treatment problems

Question 40

Describe VIN in older women?

Answer 40

Greater risk of progression to invasive squamous carcinoma

Question 41

What is VIN often synchronous with?

Answer 41

Cervical and vaginal neoplasia (CIN and VaIN)

Question 42

Describe Vulvular Invasive Squamous carcinoma

Answer 42

Usually elderly women Ulcer or exophytic mass Can arise from normal epithelium or VIN

Question 43

Where does Vulvular Invasive Squamous carcinoma spread to?

Answer 43

Inguinal lymph nodes

Question 44

What is the treatment of Vulvular Invasive Squamous carcinoma?

Answer 44

Surgical - radical vulvectomy and inguinal lymphadecnectomy

Question 45

What is the 5 year survival of Vulvular Invasive Squamous carcinoma for node +ve and node -ve?

Answer 45

Node +ve = <60% | Node -ve = 90%

Question 46

Describe Vulvar Paget's disease

Answer 46

Crusting rash Tumour cells in epidermis, contain mucin Mostly no underlying cancer, tumour arises from sweat gland in skin