Cervical Pathology Case Studies

1
Cervical PathologyCase Studies

• Charles Dunton, MDCourse Director
• Professor of Obstetrics and GynecologyJefferson
  Medical College
• Director, Division of Gynecologic OncologyAlbert
  Einstein Medical Center

2
Initial Presentation
Figure 1

• A 43-year-old female presents with the vaginal
  smear shown in Figure 1. The patient previously
  had a vaginal hysterectomy for a CIN 2 lesion.

3
The Correct Cytologic Diagnosis for This Is
Differential Diagnosis

• A. ASC-NOS
• B. LSIL
• C. HSIL
• D. AGC

Figure 1
4
Your Diagnosis
Differential Diagnosis
Answer 1

• C. HSIL Correct
• A diagnosis of HSIL is correct. Note the high
  nuclear cytoplasmic ratio in these cells.
  ASC-US smears demonstrate only mild nuclear
  enlargement, and the cells seen here have a high
  nuclear-cytoplasmic ratio. This nuclear
  enlargement and lack of cytoplasm also precludes
  a diagnosis of LSIL. A diagnosis of AGUS is
  incorrect because evidence of glandular
  abnormality is not seen here.

Figure 1
5
Your Diagnosis
Differential Diagnosis
Answer 1 continued

• A. ASC-NOS Incorrect
• Atypical Squamous Cells Not Otherwise
  Specified (ASC-NOS) typically have normal
  amounts of cytoplasm and nuclei that are less
  than 4 times the normal size. Note the lack of
  cytoplasm in some of these cells as well as an
  increased nuclear content.

Figure 1
6
Your Diagnosis
Differential Diagnosis
Answer 1 continued

• B. LSIL Incorrect
• LSIL, or low-grade squamous intraepithelial
  lesions, will not demonstrate decreased
  cytoplasm. There are no perinuclear halos,
  which would also be present with LSIL.
• D. AGC Incorrect
• Atypical Glandular Cells are often arranged in a
  rosette pattern and show central cell polarity in
  clusters and sheets.

Figure 1
7
Given a Cytologic Diagnosis of HSIL, the
Preferred Management Option at This Time Is
Management

• A. Reflex HPV-DNA testing
• B. Repeat cytology in 3-6 months
• C. Colposcopy
• D. Vaginal 5-Fluorouracil cream

8
Given a Cytologic Diagnosis of HSIL, the
Preferred Management Option at This Time Is
Management
Answer 2

• C. Colposcopy Correct
• The diagnosis of HSIL requires colposcopy to
  detect high-grade lesions. Reflex HPV-DNA
  testing, although appropriate for triage of
  ASC-US cytology, does not have a role in the
  management of HSIL. Observation and repeat
  cytologic surveillance is also not appropriate
  for HSIL. Treatment with 5-FU cream should not be
  initiated until a definitive diagnosis is made.

9
Given a Cytologic Diagnosis of HSIL, the
Preferred Management Option at This Time Is
Management
Answer 2 continued

• A. Reflex HPV-DNA testing Incorrect
• HPV-DNA testing is indicated only for triage with
  ASC cytology.
• B. Repeat cytology in 3-6 months Incorrect
• This strategy is inappropriate for HSIL. Repeat
  cytology may be a false negative.

10
Given a Cytologic Diagnosis of HSIL, the
Preferred Management Option at This Time Is
Management
Answer 2 continued

• D. Vaginal 5-Fluorouracil cream Incorrect
• Cytology is not diagnostic. Treatment should not
  be started until a biopsy diagnosis is obtained.

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Colposcopy of This Patient Can Be Seen in
Figures 2 and 3. Figure 2 Shows a Lesion at the
Apex of the Vagina Within the Left Fornix After
Acetic Acid. Figure 3 Shows the Same Lesion Under
a Green Filter.
Diagnostic Study
Figure 2 Image without filter
Figure 3 Image with filter
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Which of the Following Best Describes the Lesion
Seen in These Figures?
Diagnostic Study
A. Condylomatous features with papillary areas B.
Acetowhite lesion C. Atypical vessels,
ulceration D. Atrophic changes only
Figure 2 Image without filter
Figure 3 Image with filter
13
Figures 2 and 3 Indicate the Following Finding
Diagnostic Study
Answer 3
B. Acetowhite lesion Correct The lesion seen in
the colposcopy is flat and has well demarcated
margins. Under green filter, the vascular changes
represent relatively coarse mosaic patterns. No
ulceration is seen. The lesion does not
demonstrate typical condylomatous changes, such
as micropapillary projections and shiny white
epithelium. Atrophy typically shows pale
epithelium and indistinct vessel patterns.
Figure 2 Image without filter
Figure 3 Image with filter
14
Figures 2 and 3 Indicate the Following Finding
Diagnostic Study
Answer 3 continued
A. Condylomatous features with papillary areas
Incorrect Note that this lesion is relatively
flat. C. Atypical vessels, ulceration
Incorrect This lesion is flat and there are no
vascular patterns present.
Figure 2 Image without filter
Figure 3 Image with filter
15
Figures 2 and 3 Indicate the Following Finding
Diagnostic Study
Answer 3 continued
D. Atrophic changes only Incorrect There is
lesion visible with defined margins. Atrophy will
affect the vagina in a diffuse pattern.
Figure 2 Image without filter
Figure 3 Image with filter
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Considering This Finding (ie, Acetowhite Lesion
With Mosaic Pattern and Distinct Borders), the
Next Appropriate Step Would Be
Diagnostic Study
A. Lugol's staining of the vagina B.
Colposcopically-directed biopsy C. Laser
ablation D. Cryotherapy
Figure 2 Image without filter
Figure 3 Image with filter
17
The Next Appropriate Step Is
Diagnostic Study
Answer 4
A. Lugol's staining of the vagina Correct In
order to determine if there are other lesions in
the vagina, Lugol's iodine should be applied.
This will help to highlight the lesion and
eventually direct therapy. Biopsy will eventually
be necessary for diagnosis, but Lugol's staining
prior to this may be helpful. Lugol's staining is
very important in vaginal colposcopy as the
multiple folds and rugae of the vagina make a
colposcopic exam more difficult. The use of
Lugol's can also highlight areas where lesions
can be missed. Treatment such as laser ablation
or cryotherapy should not be initiated until a
diagnosis is made.
Figure 2 Image without filter
Figure 3 Image with filter
18
The Next Appropriate Step Is
Diagnostic Study
Answer 4 continued
B. Colposcopically-directed biopsy
Incorrect Correct, but Lugol's staining prior to
biopsy can highlight other areas of neoplasia. It
would be appropriate to use Lugol's priorto
biopsy. C. Laser ablation Incorrect Treatment
should not be undertaken prior to biopsy
diagnosis. D. Cryotherapy Incorrect Treatment
should not be undertaken priorto biopsy
diagnosis.
Figure 2 Image without filter
Figure 3 Image with filter
19
The Result of Lugol's Staining Is Seen in Figure
4, Highlighting the Lesion Seen in the Left
Vaginal Fornix. The Pathology From a Biopsy of
This Lesion Is Seen in Figure 5.
Final Diagnosis
Figure 4 Lugol's staining
Figure 5 Pathology
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Based on the Pathology, the Correct Diagnosis Is
Final Diagnosis
A. Atrophy and cervicitis B. VAIN 1 C. VAIN 3 D.
Invasive vaginal carcinoma
Figure 4 Lugol's staining
Figure 5 Pathology
21
Based on the Pathology, the Correct Diagnosis Is
Final Diagnosis
Answer 5
C. VAIN 3 Correct The pathology shown in Figure
5 demonstrates increased nuclear changes,
consistent with VAIN 3. The pathology also shows
full-thickness changes in the epithelium and an
intact basement membrane. Note that the vessels
below the epithelium represent the mosaic
patterns seen colposcopically. Mitotic activity
is also seen in VAIN 3, but it is not present in
this slide.
Figure 4 Lugol's staining
Figure 5 Pathology
22
Based on the Pathology, the Correct Diagnosis Is
Final Diagnosis
Answer 5 continued
A. Atrophy and cervicitis Incorrect Note the
nuclear changes in the epithelium. B. VAIN 1
Incorrect The nuclear changes are more than of
the surface epithelium which is not consistent
with VAIN 1.
Figure 4 Lugol's staining
Figure 5 Pathology
23
Based on the Pathology, the Correct Diagnosis is
Final Diagnosis
Answer 5 continued
D. Invasive vaginal carcinoma Incorrect There is
no evidence of invasion through the basement
membrane.
Figure 4 Lugol's staining
Figure 5 Pathology
24
For This Patient, the Correct Management Option
at This Time Is
Treatment

• A. Cryotherapy
• B. Laser vaporization
• C. Loop excision
• D. 5-Fluorouracil cream

25
The Correct Management Options Are
Treatment
Answer 6

• B. Laser vaporization Correct
• Most clinicians would treat this lesion with
  laser vaporization, which is the preferred
  technique and allows for adequate treatment to a
  depth of 1-2 mm and destruction of the entire
  lesion. If there is any concern that an invasive
  component is present, excision of the lesion
  should be performed.

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The Correct Management Options Are
Treatment
Answer 6 continued

• C. Loop excision Correct
• Loop excision has been reported for vaginal
  lesions and, in the hands of experienced
  operators, it may be possible to use loop
  excision, but laser vaporization may be more
  precise in controlling the depth of treatment.
• D. 5-Fluorouracil cream Correct
• 5-FU cream has been used for resistant cases, but
  there is an increased incidence of ulcerations
  with this technique.

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The Correct Management Options Are
Treatment
Answer 6 continued

• A. Cryotherapy Incorrect
• Cryotherapy is not the preferred method as it is
  difficult to control the depth of treatment.

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Summary

• Women treated for CIN with hysterectomy remain at
  risk for VAIN. Cytologic surveillance should
  continue for these patients. In women treated
  with hysterectomy for benign reasons and no
  history of CIN, cytologic screening may be
  omitted. The colposcopic criteria for a diagnosis
  of VAIN are the same as for CIN. Vaginal lesions
  may be more difficult to diagnosis due to the
  larger area to be evaluated colposcopically.
  Lugol's iodine is helpful in detection of these
  lesions. While most VAIN lesions are located in
  the upper third of the vagina, clinicians should
  inspect the entire vagina for abnormalities.
  After excluding an invasive lesion, treatment
  consists of excision or destruction of the
  noninvasive lesions.

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• Cardosi RJ. Bomalaski JJ. Hoffman MS. Diagnosis
  and management of vulvar and vaginal
  intraepithelial neoplasia. Review 65 refs
  Obstetrics Gynecology Clinics of North America.
  28(4)685-702, 2001 Dec.
• Wharton JT. Tortolero-Luna G. Linares AC. Malpica
  A. Baker VV. Cook E. Johnson E. Follen Mitchell
  M. Vaginal intraepithelial neoplasia and vaginal
  cancer. Review 32 refs Obstetrics
  Gynecology Clinics of North America.
  23(2)325-45, 1996 Jun.
• Dodge JA. Eltabbakh GH. Mount SL. Walker RP.
  Morgan A. Clinical features and risk of
  recurrence among patients with vaginal
  intraepithelial neoplasia. Gynecologic Oncology.
  83(2)363-9, 2001 Nov.
• Campagnutta E. Parin A. De Piero G. Giorda G.
  Gallo A. Scarabelli C. Treatment of vaginal
  intraepithelial neoplasia (VAIN) with the carbon
  dioxide laser. Clinical Experimental
  Obstetrics Gynecology. 26(2)127-30, 1999.
• Fanning J. Manahan KJ. McLean SA. Loop
  electrosurgical excision procedure for partial
  upper vaginectomy.comment. American Journal of
  Obstetrics Gynecology. 181(6)1382-5, 1999 Dec.
• Pearce KF. Haefner HK. Sarwar SF. Nolan TE.
  Cytopathological findings on vaginal Papanicolaou
  smears after hysterectomy for benign gynecologic
  disease.comment. New England Journal of
  Medicine. 335(21)1559-62, 1996 Nov 21.