Describe the two epithelia found in the cervix.
What separates them?
Stratified (non-keratinizing) squamous and simple columnar.
Separated by the squamocolumnar junction in the transformation zone (in turn within the cervical os)
Besides squamous epithelium, what other cell types may be found in the cervix?
How does the stroma compare to that of the uterus?
Endocervical glands (this will comprise a subset of cervical cancers), leukocytes, vessels, muscles blahblah.
More fibrous, with fewer muscle fibers.
What can be found on a pap smear?
Primarily used to find cervical squamous dysplasia (not great for finding adenoid dysplasia) but can also identify infectious elements.
Describe the structure of an endocervical polyp.
What are its complications?
A mass of glandular or squamous tissue protruding through the cervix.
It may bleed. That's it--no malignant potential.
What is the single greatest risk factor for cervical (and vaginal, and vulvar) neoplasia?
What behaviors increase this risk?
Persistent infection with high-risk HPV (16, 18, 31, 33).
Sexual exposure at a young age, promiscuity in general.
How common are HPV infections?
Where, specifically, does it infect?
Almost ubiquitous, 75-80% acquire it before age 50, about half of reproductive-age women (large spike in incidence in 20s-30s)
Infects the basal layer of the epithelium (stratum basale?)
HPV-related cervical (and vaginal, and vulvar) dysplasia is graded based on the thickness of epithelial involvement. Name 4 of these stages and distinguish between them.
How do they exchange with one another?
CIN I (involves less than the basal 1/3; "LSIL"), CIN II (less than 2/3), CIN III (almost all), CIS (full-thickness).
They may progress or regress. Note that more advanced dysplasia is less likely to regress.
What are the hallmarks seen on pap smear of HPV infection?
Name some immunostains that can ID HPV.
Koilocytes (in low-risk or in Condyloma acuminatum), increased N:C ratio, smaller cells, more atypia and mitoses.
HPV DNA, Ki-67, p16INK4.
Cervical cancer usually involves squamous epithelium, but may involve glandular tissue (adenocarcinoma).
How common is this?
What is the main risk factor?
What challenges does this present?
Only comprises about 15-20% of cervical cancers.
Still HPV infection!
Pap smears are of reduced sensitivity since adenoid tissue is not shed as readily.
What is the rarest subtype of cervical carcinoma?
How are they all treated?
Small cell carcinoma.
Who should receive a pap smear? How often?
What should be done upon a positive pap result?
Anyone between 21 and 65 (except those with hysterectomies). Every 3-5 years.
Follow up with colposcopy and biopsy.
Describe the structure of an HPV vaccine.
Describe the two vaccine preparations.
What should women receive following their vaccines?
Recombinant L1 protein (capsid) with aluminum adjuvant.
Gardasil (quadrivalent) protects from 6/11/16/18, Cervarix (bivalent) protects from 16/18.
Continued pap smears! Not every serotype is covered.
What serovars of HPV are "high-risk"?
What makes them high risk?
16, 18, 31, 33.
These express the genes E6 and E7, which respectively inhibit p53 and Rb (important tumor-suppressors). They are also more likely to integrate into the host cell genome and persist.
What are Bartholin's glands? Where are they located?
What epithelium lines the vestibule?
Vestibular glands which produce mucus. Located at "4 and 8 o'clock".
Non-keratinizing stratified squamous.
The external vulva is essentially skin. Therefore, any skin condition can manifest there.
Name 3 besides squamous cell carcinoma.
Basal cell carcinoma
Contact dermatitis (and probably a thousand other dermatites)
Between lichen sclerosus and lichen simplex chronicus, which:
1. Is a secondary process?
2. Features thinning of the epidermis?
3. Appears with leukoplakia?
4. Feels like leather?
5. Occurs mainly in the premenarchal or post-menopausal?
6. Can develop into squamous cell carcinoma?
1. Lichen simplex chronicus
2. Lichen sclerosus
4. Lichen simplex chronicus
5. Lichen sclerosus
6. Lichen sclerosus
Both vulvar and vaginal dysplasia can result from infection with high-risk HPV serovars. Describe their classifications.
What are the long-term consequences?
Follows the same grading based on epithelial depth of involvement as in cervical dysplasia (CIN).
Abbreviated VIN, VAIN.
Both can progress to cancer or fully regress.
Describe the appearance of cells in extramammary paget's disease.
Red, scaly plaques with epidermal malignancy (usually no underlying mesenchymal cancer). Large and pale cells.
Mucin, cytokeratin (CK7)
Unlike in cervical cancer, adenocarcinomas of the vagina arise from a teratogen exposure.
What is the teratogen, and what is the condition (and cancer) called?
DES exposure in utero causes vaginal adenosis which predisposes for clear cell carcinoma!
A 4-year old boy presents to your clinic with a soft, polypoid mass on his penis. Histology reveals "primitive cells".
What is the diagnosis?
This is embryonal rhabdomyosarcoma (sarcoma botryoides). Note it can occur in either the vagina of young girls or the penis of young boys!