Cervical, vulval pathology

Question 1

Define the ectocervix and the endocervix

Answer 1

• Ectocervix = The lower part of the cervix, known as the vaginal portion of the cervix (orectocervix), bulges into the top of the vagina.
• Endocervix = or endocervical canal, is a tunnel through the cervix, from the external os into the uterus.

Question 2

What is the linning of the ectocervix and the endocervix ?

Answer 2

• The ectocervix is linned by stratified squamous epithelium
• The endocervix is linned by simple columnar epithelium

Question 3

Define what the transformation zone is

Answer 3

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

Question 4

Does the transformation zone stay in the same place and if not why?

Answer 4

It does not, it moves about throughout life due various factors:

• Menarche
• Pregnancy
• Menopause

Question 5

Define metaplasia

Answer 5

Transformation of one differentiated cell type to another differentiated cell type.

Question 6

What can cervical erosion/ectropion lead too and how does it occur ?

Answer 6

• It occurs due to exposure of delicate endocervical (endocervix) epithelium to acid environment of vagina because glandular cells (or columnar epithelium), are present on the ‘outside’ of the vaginal portion of the cervix.
• Leading to physiological squamous metaplasia
• Nabothian follicles (mucus-filled cysts on the surface of the cervix) - often form when squamous (statified) metaplasia occurs where columnar epithelium once was

Question 7

What is the presentation of cervical erosion/ectropion ?

Answer 7

There is a red ring around the cervical os because columnar epithelium has this appearance

It is prone to bleeding, excess mucus production and to infection

Question 8

What are the 2 main inflammatory cervical pathologies ?

Answer 8

Cervicitis and cervical polyps

Question 9

Define what cervicitis is and what are its causes

Answer 9

It is inflammation of the cervix whcih can lead to infertility due to simultaneous silent fallopian tube damage and can be caused by

Causes include:

• non-specific acute/chronic inflammation.
• Follicular cervicitis – sub epithelial reactive lymphoid follicles present in cervix.
• Chlamydia Trachomatis – sexually transmitted
• Herpes Simplex Viral Infection

Question 10

What are the signs/symptoms of cervicitis ?

Answer 10

Many women dont have symptoms and it may only be found on routine exammination

Possible symptoms include:

• Grayish or pale yellow vaginal discharge
• Abnormal vaginal bleeding, such as bleeding after sex or between periods
• Pain during sex
• Difficult, painful, or frequent urination
• Pelvic or abdominal pain or fever, in rare cases

Question 11

What is a cervical polyp ?

Answer 11

These are pendunculated benign tumours of the endocervical epithelium

Question 12

Describe the presentation of a cervical polyp

Answer 12

• Pedunculated (elognated sac of tissue)
• May cause increased mucus discharge and/or postcoital bleeding

Question 13

Define neoplasia

Answer 13

Neoplasia is the abnormal growth and proliferation of abnormal cells - these can be benign or malignant

Question 14

What are the 2 main neoplastic pathologies seen in the cervix?

Answer 14

1. Cervical intraepithelial neoplasia (CIN)
2. Cervical cancer

Question 15

What are the 2 main types of cervical cancer ?

Answer 15

• Adenocarcinoma
• Squamouscarcinoma

Question 16

What are the risk factors for developing CIN/Cervical carcinoma ?

Answer 16

Persistence of High Risk Human Papilloma Viruses, mostly types 16,18 (there are other types, these 2 account for roughly 75% of cases)

Vulnerability of SC Junction in early reproductive life:

1. age at first intercourse (earlier the higher risk)
2. long term use of oral contraceptives - once used for 5 years the risk increases
3. non-use of barrier contraception

Smoking: 3 x risk

Immunosuppression

Question 17

Describe the progression of infection with high risk HPV (16&18) if not cleared from the body

Answer 17

1. HPV infection ==> causing High grade CIN roughly 6 months - 3 years later
2. High Grade CIN ==> results in Invasive Cancer roughly 5 -20 years later

Note 90% of women who are infected with HPV there cells heal (i.e. not all with CIN progress to cervical cancer, increased grade of CIN makes progression more likely though)

Question 18

What is CIN ?

Answer 18

Pre-invasive stage of cervical cancer

It is defined as the replacement of the normal cervical mucosa by neoplastic cells, but there is still an intact basement membrane

Question 19

Where does CIN occur ?

Answer 19

Occurs at the transformation zone. - so this is talking about the cervical intraepithelial neoplasia (CIN) whcih can give rise to squamous carcinoma (slight difference convered later for pre-cursor for adenocarcinoma)

Question 20

How is CIN detected ?

Answer 20

Cervical screening as it is asymptomatic so wont be able to detect it anyother way

Question 21

What are the histological features of CIN?

Answer 21

Due to classic morphological features of malignancy:

Delay in maturation/differentiation:

• immature basal cells occupying more of epithelium

Nuclear abnormalities:

• hyperchromasia - more intensely staining nucleus than normal
• increased nucleocytoplasmic ratio
• pleomorphism - variation in size and shape of cells

Excess mitotic activity

• situated above basal layers
• abnormal mitotic forms

Question 22

Appreicate this pic of HPV infection causing mild dyskaryosis (CIN 1)

Dyskaryosis = An abnormality of nuclei seen in exfoliated cells, often cells from the uterine cervix, in which the cytoplasm remains unchanged but the nuclei exhibit hyperchromatism, irregularity or enlargement, or an increase in number.

Question 23

How is CIN graded ?

Answer 23

It is graded from 1 to 3 on the proportion of in thirds of the epithelium whcih is occupied by abnormal cells

CIN I - 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.

CIN II - Abnormal cells extend to middle 1/3.

• 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

What classification of CIN is shown ?

Answer 24

CIN 1

Compare to the normal ectocervix its easier to see this way

Question 25

What classification of CIN is shown ?

Answer 25

CIN 2

Question 26

What classification of CIN is shown ?

Answer 26

CIN 3 - not how the basement membrane is still intake hence grade 3 and not invasive carcinoma