Cervical, vulval pathology 2

Question 1

How do invasive cervical carcinomas typically present and what do some rarely do making detection difficult?

Answer 1

As an unclerating mass protruding into the vagina

Note some carcinomas may grow inwards (rather than outwards to the vagina) resulting in a ‘barrel-shaped cervix’ adenocarcinomas are the most common type of carcinoma to potetially grow in this fashion, making it difficult to detect on cervical screening resulting in them potnetially being caught much later on

Question 2

What is the most common type of cervical carcinoma ?

Answer 2

Squamous

Question 3

Where do squamous cervical carcinomas arise ?

Answer 3

In the transformation zone developing from pre-exisiting CIN

Question 4

Recall the guidelines for cervical screening in scotland

Answer 4

All women who are registered with a GP are invited for cervical screening:

• aged 25 to 49 – every 3 years
• aged 50 to 64 – every 5 years
• over 65 – only women who haven’t been screened since age 50 or those who have recently had abnormal tests

Question 5

What are the symptoms of invasive cervical carcinomas

Answer 5

Usually no symptoms at microinvasive and early invasive stages (detected at screening):

• 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

Question 6

What is the different staging of squamous cervical carcinoma ? (FIGO staging for cervical cancers)

Answer 6

Stage 1 - tumours confined to the cervix

• Stage 1A1 - depth up to 3mm, width up to 7mm
• Stage 1A2 - depth up to 5mm, width up to 7mm
• Low risk of lymph node metastases
• Stage 1B – clinically visible or dimensions greater than 1A

Stage 2 - spread to adjacent organs (vagina, uterus, etc..)

Stage 3 - involvement of pelvic wall

Stage 4 - distant metastases or involvement of rectum or bladder.

Question 7

Describe the different areas squamous carcinoma can spread too

Answer 7

1. Local e.g. uterine body, vagina, bladder, ureters, rectum
2. Lymphatic (in early spread) e.g. pelvic, para-aortic nodes
3. Haematogenous (in late spread) e.g. liver, lungs, bone

Question 8

Appreciate that squamous carcinoma can be graded from:

Well-differentiated to poorly differentiated

What implications does this have on prognosis ?

Answer 8

Poorly differentiated carcinomas tend to have a more aggressive progression and ==> worse prognosis

Question 9

What is the precursor lesion for cervical adenocarcinomas ?

Answer 9

Cervical Glandular Intraepithelial Neoplasia (CGIN) - note this is not graded like CIN

Question 10

Where does Cervical Glandular Intraepithelial Neoplasia (CGIN) originate in the cervix ?

Answer 10

Endocervical epithelium ==> adenocarcinomas of the cervix typically arise from the endocarvical epithelium (columnar)

Question 11

Why is it more difficult to diagnose cervical adenocarcinomas comapred to squamous ?

Answer 11

Becuase they arise in endocervical epithelium which is not as easily swabbed during smear test

Question 12

What are the risk factors for endocervical andenocarcinoma ?

Answer 12

• Higher Socioeconmic Class
• Later onset of sexual activity
• Smoking
• HPV again, particularly HPV18.

Question 13

Which carries the worse prognosis - adenocarcinoma or squamous carcinoma of the cervix?

Answer 13

Adenocarcinoma as often caught later

Question 14

What type of cervical carcinoma is shown here ?

Answer 14

Squamous cell carcinoma of the cervix, its characterisitcs include:

• normal features of cancer but also better differentiated ones may have kertain perals seen (the swirlls of pink)
• Compared to adenocarcinoma, have more irregular cellular and nuclear shapes, more cytoplasmic density, more chromatin granularity, more hyperchromasia

Question 15

What type of cervical cancer is shown

Answer 15

Adenocarcinoma

Increased number of glands plus normal malignant features

Question 16

What is the main type of cancer affecting the vulva ?

Answer 16

Squamous cell carcinoma

Question 17

What is the precursor lesion for vulval carcinomas and how are they graded ?

Answer 17

• Vulvar intraepithelial neoplasia
• Has 3 grades just like CIN

Question 18

What are the two main groups of women in which Vulvar intraepithelial neoplasia can arise in ?

Answer 18

• Most common group is post-menopasual women greater risk of progression to invasive squamous cell carcinomas
• 2nd group is young women who it is often multifocal, recurrent or persistent causing treatment problems and typically develop basloid or warty carcinoma (squamous)

Question 19

What are vulval carcinomas often associated with ?

Answer 19

HPV infection

Question 20

If Vulvar intraepithelial neoplasia is detected what is there also going on ?

Answer 20

Cervical and vaginal neoplasia (CIN & VaIN).

Question 21

Describe the typical presentation of vulval squamous cell carcinoma and someone with it

Answer 21

Usually elderly women but may present in someone considerably younger

Presents with vulval itching, irritation or pain. Women may also notice a lump, bleeding or discharge.

Question 22

How is vulval carcinoma diagnosed ?

Answer 22

Biopsy of the lesion

Question 23

What is the likely place in which an invasive carcinoma (squamous) of the vulva can spread too ?

Answer 23

The inguinal lymph nodes

Question 24

What is the treatment of vulvar squamous cell carcinoma ?

Answer 24

• Lesions less than 2 cm in diameter and confined to the vulva or perineum, with stromal invasion less than or equal to 1.0 mm (FIGO stage Ia) can be managed by wide local excision only, without groin node dissection.
• Dissection of the groin nodes (unilateral or bilateral) should be performed when the depth of invasion is greater than 1 mm (FIGO stage Ib or worse) or the maximum diameter of the tumour is greater than 2 cm.
• Advanced vulval carcinoma - Wide, radical, local excision with a minimum of 15 mm diseasefree margin may be used but some tumours will require a radical vulvectomy + inguinal lymphadenectomy

Question 25

What is pagets disease of the vulva and describe its presentation?

Answer 25

A rare, slow-growing, usually noninvasive intraepithelial (in the epidermis) adenocarcinoma Presents as a erythematous plaque with typical white scaling + irritation, itching, and burning.

Question 26

What are the other diseases to simply be aware of which can affect the vulva ?

Answer 26

Infections: * Candida (Particularly diabetics) * Vulvar warts (HPV 6 & 11) * Bartholin’s gland abscess (blockage of gland duct) Non Neoplastic Epithelial disorders: * Lichen Sclerosis * Other dermatoses * Lichen planus * Psoriasis

Question 27

What is the take home message about vaginal carcinomas ?

Answer 27

* Primary tumours are very rare here and the most common type of prmiary tumour is squamous carcinomas * Before diagnosis of a primary tumour of the vagina can be made the possibility of extension of either a vulval or cervical carcinoma into the vagina must be excluded as this is the most common. * VaIN :Vaginal intraepithelial neoplasia is the precursor lesion and often associated with ongoing cervical and vulva lesions so check these areas

Question 28

What is the treatment for vulval carcinoma ?

Answer 28

radical vulvectomy and inguinal lymphadenectomy.

Question 29

Define what lichen sclerosus is and where is commonly affects

Answer 29

* It is an inflammatory condition which usually affects the genitalia and is more common in elderly females. * Lichen sclerosus leads to atrophy of the epidermis with white plaques forming

Question 30

Describe the appearance of vulval lichen sclerosus

Answer 30

* Ivory or porcleain-white, shiny lesions * Commonly associated with areas of purpura

Question 31

What are the signs/symptoms of vulval lichen sclerosus

Answer 31

* **Pruritus vulva (itch) is the main symptom - worse at night, may disturb sleep** * Painful vulva * Genital or anal bleeding * Constipation * Dysparenuria and sexual dysfunction * Dysuria Symptoms are generally due to tightening around the area

Question 32

What are the potential complications of vulval lichen sclerosus ?

Answer 32

1. Scarring of vulval skin 2. Small risk of development into squamous cell carcinoma

Question 33

How is vulval lichen sclerosus diagnosed ?

Answer 33

* 1st line = clinical diagnosis from appearance * 2nd line = skin biopsy for histopathology to exlcude cancer biopsy done if there if there is suspicion of cancer - new or exisiting skin lesions that are not responsive to steroid treatment

Question 34

What is the management of vulval lichen sclerosus ?

Answer 34

1st line = steroid ointments (clobetasol proprionate) + emoillients & avoid skin irritants