vulval and vaginal pathology Flashcards
(63 cards)
1
Q
describe features of a normal ectocervix?
A
- epithelium sitting on a basement membrane and is underpinned by stroma
layers from bottom to top
1. basement membrane
2. basal cells (purple layer)
3. parabasal cells
4. exfoliating cells - these cells are captured during a cervical smear
2
Q
what cells are captured during a cervical smear?
A
- exfoliating cells - squamous cells
3
Q
what lines a normal ectocervix?
A
- stratified squamous epithelium
4
Q
what lines a nomal endocervix?
A
- a single layer of glandular epithelium
5
Q
what is the most common site to become infected by HPV?
A
- transformation zone
-> go on to become CIN or glandular equivalent CGIN
6
Q
what is another word for transformation zone?
A
- squamo-columnar junction
7
Q
what are the 2 main pathologies of the cervix?
A
- inflammatory
- neoplastic
8
Q
what are some examples of inflammatory pathologies in the cervix?
A
- cervicitis -
- cervical polyp
9
Q
what are some examples of neoplastic pathologies in the cervix?
A
- cervical intraepithelial neoplasia
- cervical cancer - squamous carcinoma, adenocarcinoma, other rare tumours
10
Q
what are the risk factors for CIN/cervical cancer?
A
- high risk HPV - 16,18, 31, 33, 35, 45, 48
- many sexual partners
- vulnerability of SC junction in early repro life - age at first intercourse, long term use of oral contraceptives, non-use of barrier contraception
- smoking 3x risk
- immunosuppression -> can’t clear virus
11
Q
what are 2 types of low risk HPV?
A
- 6 and 11
- can cause genital warts
12
Q
what is condyloma acuminatum?
A
- name given to anogenital warts caused by HPV 6 and 11
- thickened ‘papillomatous’ squamous epithelium w cytoplasmic vacuolation ‘koilocytosis’ (shrunken nuclei)
- caused by HPV
13
Q
what do you see in cytology of a genital wart type presentation w HPV infection
A
- mild dyskaryosis
- multinucleation common characteristic in cells affected by HPV infection
- nuclear enlargement
- course chromatin in nuclei
14
Q
what are koilocytes
A
- halo cells
- type of epithelial cell that devleops following a HPV infection
- irregular shaped nuclei, shape or colour
15
Q
what does CIN: caused by HPV 16 and 18 show on microscopy?
A
- infected epithelium remains flat but may show koilocytosis, which can be detected in cervical smears
16
Q
HPV can cause what?
A
- genital warts: low risk HPV 6 and 11
- cervical intraepithelial neoplasia: high risk HPV 16 and 18
- cervical cancer
17
Q
what do you see on microscopy of a cervical cancer caused by HPV infection?
A
- invasive squamous carcinoma: virus integrated into host DNA
- whirls of keratin within tumour
- squamous cell carcinoma - islands of cells within stroma broken free from BM
18
Q
what is time line for a HPV infection to become a high grade CIN?
A
- 6 months -> 3 years
19
Q
what is the time line for a high grade CIN -> invasive cancer?
A
- 5 years -> 20 years
20
Q
what is cumulative prevalence of HPV infection in lifetime?
A
- 80% cumulative prevalence in lifetime
- most develop immunity…
21
Q
where does CIN most often occur?
A
- transformation zone
- pre-invasive stage of cervical cancer
22
Q
what is CIN?
A
- dysplasia of squamous cells
- not visible by naked eye but you can get a feel for it on colposcopy
- detectable on cervical screening
- asymptomatic
23
Q
histology of CIN?
A
- delay in maturation
immature basal cells occupying more of epithelium or more nuclei in top layers of epithelium - nuclear abnormalities
hyperchromasia (dark)
inc in nucleocytoplasmic ratio
pleomorphism (variable looking cells) - excess mitotic activity
situated above basal layers
abnormal mitotic forms
often koilocytosis (indicating HPV infection)
24
Q
how is CIN graded?
A
I-III depending on severity on factors including:
delay in maturation
nuclear abnormalities
excess mitotic activity
25
define CIN I?
basal 1/3 of epithelium occupied by abnormal cells
26
define CIN II
- abnormal cells extend to middle 1/3
- abnormal miotic figures
27
define CIN III
- abnormal cells occupy full thickness epithelium
- also called squamous cell carcinoma in situ
- also can show early stromal invasion
28
majority of malignant cervical tumours are?
- invasive squamous carcinoma
- 2nd most common female cancer worldwide
29
when are invasive squamous carcinomas usually found: what age and what stage?
- early stage and in younger women
- however some are rapidly progressive tumours
- found from pre-existing CIN -> therefore most are preventable by screening
30
what is staging for cervical cancer?
- Figo staging
31
what are some symptoms of invasive carcinoma?
- abnormal bleeding
post coital
post menopausal
brownish or blood stained vaginal discharge
contact bleeding - friable epithelium
- pelvic pain
- haematuria/urinary infections
- ureteric obstruction/renal failure
32
spread of squamous carcinoma?
- local
- lymphatic
- haematogenous
33
how does local spread of squamous carcinoma spread?
- uterine body, vagina, bladder, ureters, rectum
34
lymphatic spread of squamous carcinoma?
- early -> pelvic, para-aortic nodes
35
haematogenous spread of squamous carcinoma?
- late -> liver, lungs, bone
36
what are 2 main classifications of cervical cancer?
- squamous cell carcinoma
- adenocarcinoma
37
where is SCC of the cervix found?
epithelial lining of the ectocervix
38
where is adenocarcinoma of the cervix found?
- cancer of the glands found within the lining of the cervix
39
grading of squamous carcinoma?
- well differentiated
- moderately differentiated
- poorly differentiated
- undifferentiated/anaplastic
40
what does this image show?
- well differentiated squamous carcinoma of the cervix
41
what is cervical glandular intraepithelial neoplasia? (CGIN)
- seen in endocervical epithelium
- CGIN is preinvasive phase of endocervical adenocarcinoma
- more difficult to dx on cervical smear than squamous
- screening less effective
- can sometimes be associated w CIN
42
in high grade CGIN how much of the gland is involved?
- all of the gland is involved
43
how common is endocervical adenocarcinoma?
- 5-25% of cervical cancers
> some are increasing in incidence, particularly in young women
44
can cancers of the cervix be mixed?
- yes some are mixed - adenosquamous
45
what is the grading system for HPV-driven disease include VIN (vulvar itraepithelial neoplasia), VaIN (vaginal intraepithelial neoplasia), AIN (anal intraepithelial neoplasia)
- graded 1,2 or 3 based on degree of atypia and maturational disorder
- grade 3 is equivalent to SCC in situ
46
is VIN (vulval intraepithelial neoplasia) of usual type a precursor of hpv driven SCC?
- yes
> differentiated VIN (dVIN) is a precurosr of hpv independent vulval SCC. higher risk of invasive malignancy - often has a background of inflammatory dermatoses - lichen sclerosus
47
who is affected by vulvar intraepithelial neoplasia? (VIN)
- often bimodal:
young women: multifocal, recurrent or persistent causing tx problems
older women: greater risk of progression to invasive squamous carcinoma
48
what is the most important prognostic factor in vulvar invasive squamous carcinoma?
- if there has been spread to inguinal lymph nodes
49
what is vulvar invasive squamous carcinoma?
- usually elderly women, ulcer or exophytic mass
- can arise from normal epithelium or VIN
50
surgical treatment for a vulvar invasive squamous carcinoma?
- radical vulvectomy and inguinal lymphadenectomy
51
what is 5 year survival for vulvar invasive squamous carcinoma w no spread to lymph nodes?
- 90%
> node positive however <60%
52
how does vulvar paget's disease present?
- crusting rash > often sharp demarcation
- pruritic/painful
- tumour cells in epidermis, contain mucin
53
what cells do lesions in primary vulvar paget's disease arise from?
- intraepidermal glandular cells
- or pluripotent cells of folliculosebaceous or eccrine units
54
in secondary cases of vulvar paget's disease where do cells arise from?
- colorectal neoplasms or urothelial neoplasms
55
what is the black circle outlining in the epidermis of the vulva?
- paget cells
- red line shows BM - therefore this image is non-ivasic pagets disese of the vulva
56
how do you manage paget's disease of the vulva?
- excision of the lesion
- can sometimes extend up into the vagina or anus making excision difficult
57
list some infections of the vulva?
- candida - particular DM
- vulvar warts - HPV6 and 11
- bartholins glands abscess - blockage of gland duct
58
what are non neoplastic epithelial disorders of the vulva?
- lichen sclerosis
- other dermatoses: lichen planus, psoriasis
59
what can often occur to vulva in a post-menopausal women causing pain and bleeding?
- atrophy of the vulva
60
candida shows what on cytology?
- hyphae and spores
61
what does a viral wart/condyloma acuninatum show on cytology?
- papillomatous architecture (also characteristic of VIN)
- koilocytes
62
what does lichen sclerosus et atrophicus show on microscopy?
- epidermis
- glassy subepithelial hyalinised band
63
name some kind of vaginal pathologies in the vagina?
- benign - polyps, cysts
- VaIN - vaginal intraepithelial neoplasia. may also have cervical and vulval lesions
- squamous carcinoma: less common than cervical and vulval counterparts. disease of the elderly, primary tumours are rare
- melanoma: rare, may appear as a polyp
