Week 6- cervical-vulval pathology

Question 1

What is the normal structure of the ectocervix?

Answer 1

Surface layer is called exfoliating cells

Then superficial and intermediate cells

Then parabasal cells

Basal cells

Basement membrane.

Question 2

This is the normal structure of the endocervix.

Answer 2

Question 3

What is the transition zone?

Answer 3

The sqaumo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia.

Question 4

What does the position of the transition zone alter in?

Answer 4

Menarche

Pregnancy

Menopause

Question 5

This is the squamocolumnar junction

Answer 5

Question 6

What is cervical erosion?

Answer 6

Exposure of delicate endocervical epithelium on the ectocervix causes the acid environment of vagina to cause a physiological squamous metaplasia.

Formation of Nabothian follicles- these are small fluid filled cysts that occur in response to growth of the squamous epithelium over the columnar epithelium in the endocervix.

(Endocervix grows down into the ectocervix which is in the acidic environment of the vagina. This then causes squamous metaplasia)

Question 7

What inflammatory causes can cause change to the cervix?

Answer 7

Cervicitis

Cervical polyps.

Question 8

What is cervicitis?

What causes it?

Answer 8

Inflammation of the cervix. Often can be asymptomatic- however can lead to infertility due to silent fallopian tube damage.

Could be due to:

• follicular cervicitis- sub-epithelial reactive lymphoid follicles present in the cervix.
• Chlamydia
• Herpes

Question 9

What is a cervical polyp?

What symptoms may occur?

Is it malignant?

Answer 9

A localised inflammatory outgrowth
Can cause bleeding

No its benign and NOT pre-malignant.

Question 10

What neoplastic causes can cause pathology of the cervix?

Answer 10

Cervical intraepithelial neoplasia

Cervical cancer- this can be squamous carcinoma or adenocarcinoma.

Question 11

What percentage of cervical cancer has HPV as its driving cause?

Answer 11

75%

Question 12

What are some risk factors for cervical intraepithelial neoplasia and cervical cancer?

Answer 12

HPV infection- particularly types 16 and 18.

Vulnerability of squamo-columnar junction in early reproductive life-e.g. age at first intercourse, long term contraceptives, non-use of barrier contraception

Smoking

Immunosuppression

Question 13

Which HPV’s cause genital warts?

Describe the changes that occur to the epithelial layer.

Answer 13

HPV type 6 and 11.

Condyloma Acuminatum- means changes that occur to the epithelial membrane in HPV. It becomes thickened, papillomatous squamous epithelium with cytoplasmic vacuolation.

Question 14

Describe the epithelial changes in cervical intraepithelial neoplasia. Which HPV types are associated with these changes?

Answer 14

Infected epithelium remains flat, but may show koilocytosis (squamous epithelial cells undergo structural changes due to HPV), which can be detected in cervical smears.

HPV types 16 and 18.

Question 15

Describe what occurs with the viral DNA and cervical cancer?

Answer 15

Virus integrates with the host DNA.

Question 16

How long can it take from being infected with HPV to having CIN?

Answer 16

6 months to 3 years.

Question 17

How long does it take for a high grade CIN to change to an invasive cancer?

Answer 17

5-20 years.

Question 18

Which age group are most likely to be infected by HPV?

Answer 18

15-25 year olds.

Question 19

What increases the risk of disease?

Answer 19

Persistently acquiring the virus.

Most people do develop immunity.

Question 20

What is CIN?

Where does it occur?

How can you detect for this?

Answer 20

The pre-invasive stage of cervical carcinoma. Dysplasia (abnormal cells) of squamous cells occurs.

It occurs at the transformation zone

It isnt visible by the naked eye but can be detected for in cervical screening.

Question 21

NOTE- koilocytosis is the presence of koilocytes. These are squamous cells that have changed due to HPV infection.

Answer 21

Question 22

Describe the histology of CIN?

Answer 22

Delay in maturation/differentiation-immature basal cells occupy more of the epithelium

Nuclear abnormalities-hyperchromasia, increased nuclear:cytoplasmic ratio (nucleus got bigger), pleomorphism

Excess mitotic activity-situated above basal layers. Abnormal mitotic forms.

Question 23

How is CIN classified? Describe these classifications

Answer 23

CIN I-Basal 1/3rd of epithelium occupied by abnormal cells. Raised mitosis in lower 1/3. Surface cells quite mature but nuclei abnormal

CIN II-Abnormal cells extend to middle third. mitoses in middle 1/3. Abnormal mitotic figures.

CIN III-Abnormal cells occupy full thickness of epithelium. Mitoses, often abnormal in upper 1/3.

Question 24

This shows CIN I. The abnormal cells (there seems to be lots compressed into one small space) at the bottom.

Answer 24

This is CIN II. The compressed cells have moved up to the middle third.

Question 25

This shows CIN III. The compressed cells have taken over the whole epithelium.

Question 26

What makes up the majority of malignant cervical tumours?

Answer 26

Invasive squamous carcinoma. (2nd commenest female cancer worldwide).

Question 27

What does invasive squamous carcinoma develop from?

Answer 27

Pre-exisiting CIN- therefore should be detectable and preventable through screening.

Question 28

Describe the staging in invasive carcinoma?

Answer 28

Stage 1 A1- depth up to 3mm, width up to 7mm Stage 1 A2- depth up to 5mm, width up to 7mm Stage 1B-confined to the cervix Stage 2-spread to adjacent organs e.g. uterus, vagina Stage 3-involvement of pelvic wall Stage 4-distant metastases or involvement or rectum or bladder.

Question 29

This shows stage 1A

Answer 29

Question 30

What are the symptoms with 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 Haematuria/ urinary infections Ureteric obstruction/renal failure

Question 31

Where is invasive squamous carcinoma likely to invade locally?

Answer 31

Likely to invade the uterine body, vagina, bladder, ureters and rectum.

Question 32

Where (lymphatics wise) is squamous cell carcinoma likely to spread?

Answer 32

Early to pelvic and para-aortic nodes

Question 33

Where (in the blood) is invasive squamous cell carcinoma likely to spread?

Answer 33

Spreads late to liver, lungs and bone.

Question 34

How do you grade squamous cell carcinoma?

Answer 34

Well differentiated Moderately differentiated Poorly differentiated Undifferentiated/anaplastic.

Question 35

What is cervical glandular intraepithelial neoplasia?

Answer 35

CGIN is the pre-invasive phase of endocervical carcinoma. They originate from the cervical epithelium and are therefore difficult to diagnose on smear (hard to get too).

Question 36

Which has a worse prognosis- squamous carcinoma or adenosquamous?

Answer 36

Adenosquamous has the worse prognosis.

Question 37

Who gets adenocarcinoma?

Answer 37

Higher socio-economic classes. Later onset of sexual activity Smoking HPV-particularly 18.

Question 38

What are some other HPV driven diseases?

Answer 38

Vulvar intraepithelial neoplasia Vaginal intraepithelial neoplasia Anal intraepithelial neoplasia.

Question 39

What is VIN associated with?

Answer 39

Pagets disease (not the same as pagets disease of the bone- just has the same name).

Question 40

What is vulval intraepithelial neoplasia?

Answer 40

Variable behaviour- graded three ways. Has a bimodal variation- affects: - young women-often multifocal, recurrent or persistent causing treatment problems. - older women- greater risk of progression to invasive squamous carcinoma There is often synchronous cervical and vaginal neoplasia.

Question 41

Describe vulvar invasive squamous carcinoma? What is the most important prognostic factor?

Answer 41

USually elderly women, ulcer or exophytic rash. Can arise from normal epithelium or VIN. Mostly well differnetiated Spread to the inguinal lymph nodes.

Question 42

How is vulvar invasive squamous carcinoma treated?

Answer 42

Surgical treatment- radical vulvectomy and inguinal lymphadenopathy.

Question 43

What is vulvar pagets disease?

Answer 43

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

Question 44

Question 45

What is colposcopy?

Answer 45

Examination of the cervix by a colposcope. A speculum is inserted, and the transformation zone of the cervix is painted with 5% acetic acid (or lugols iodine). This is preferentially taken up by neoplastic cells. Aceto-white areas show abnormal cells allowing a punch biopsy to be taken.

Question 46

What does a cervical smear identify?

Answer 46

It collects cells for microscopy to show dyskariosis (abnormalities which reflect CIN).

Question 47

If a women has a smear and has borderline abnormalities, what is the management?

Answer 47

Tested for HPV. If positive reffered for colposcopy.

Question 48

If a women has a smear and has moderate-severe abnormalities, what is the management?

Answer 48

Colposcopy regardless of HPV status.

Question 49

What is the english cervical screening criteria?

Answer 49

Sexually active women aged 25-64 3 yearly for women 25-50, 5 yearly until 65