2. The vagina is a fibromuscular tube with
anterior and posterior walls
Histology of the Vagina
Stratified squamous epithelium – this
layer provides protection and is
lubricated by cervical mucus (the vagina
itself does not contain any glands).
Elastic lamina propria – a dense
connective tissue layer which projects
papillae into the overlying epithelium.
The larger veins are located here.
Fibromuscular layer – comprising two
layers of smooth muscle; an inner
circular and an outer longitudinal layer.
Adventitia – a fibrous layer, which
provides additional strength to the
vagina whilst also binding it to
surrounding structures.
The vagina disorders:
3. Vaginal cancer
Cancer of the vagina is rare and is only 2% of all gynecological cancers .
• 80-90% are metastatic:- from
• Cervix or endometrium are more common.
• Vulva, ovaries, recto-sigmoid, bladder, renal cell carcinoma, melanoma,
and breast cancer are less common
• Mean age of patients with primary vaginal cancer is 60-65 years.
• Site :-
Upper third of the vagina (51%)
Lower third 30%.
Middle third 19%.
Risk factors of Vaginal Cancer
•Infection with human papillomavirus (HPV) type 16
•Infection with human immunodeficiency virus (HIV) type 1
•Previous history of cervical cancer
•Smoking
•Prenatal exposure to Diethylstilbestrol
4. VAIN (vaginal intraepithelial neoplasia)
• Cytologic atypia- (Pleomorphisim, irregular nuclear contours and
chromatin clumping), Abnormal maturation ,Without invasion of basement
membrane
• 10-30% progress to Vaginal Ca
Vaginal Cancer precursors
Types of VAIN :- VAIN 1
Susperficial koilocytosis and mild squamous atypia confined
to the lower third of the epithelium
VAIN 2
Moderate squamous atypia confined to the lower two-thirds of
the epithelium or marked atypia confined to the lower third of
the epithelium. Koilocytes may be seen
VAIN 3
– Severe cytologic atypia, are seen throughout the full thickness
of the squamous epithelium
– usually occurs in upper third of vagina and is multifocal and
diffuse in half the cases.
– 1/3 of patients have a hx/o CIN
5. Signs and symptoms:-
• Most vaginal cancers do not cause signs or symptoms early on.
• Vaginal discharge or abnormal bleeding. Unusually heavy flow of blood.
• Blood in the stool or urine. Feeling constipated.
• Frequent or urgent need to urinate.
• Pain during sexual intercourse.
• Lump or growth in the vagina that can be felt.
• Enlarged pelvic lymph nodes can sometimes be palpated.
6. Types of vaginal cancer :-
1- Squamous-cell carcinoma
Arises from the squamous cells (epithelium). It is the commonest type.
2- Adenocarcinoma
Arises from the glandular (secretory) cells in the lining of the vagina. More likely to
spread to the lungs and lymph nodes.
3- Clear cell adenocarcinoma
Occurs in a small percentage of women (termed "DES-Daughters") that were exposed
to the drug diethylstilbestrol (DES) in utero in Approximately one in 1,000 (0.1%).
4- Vaginal germ cell tumors
(primarily teratoma and endodermal sinus tumor)
Are rare., They are found most often in infants and children.
5- Sarcoma botryoides, a rhabdomyosarcoma
This is an uncommon, highly malignant vaginal tumor in infants and children
consisting of embryonal rhabdomyoblasts , The tumors are polypoid, bulky masses
composed of grapelike clusters (hence the alternative name, sarcoma botryoides) that
can protrude from the vagina. Tumors tend to invade locally and cause death by
penetration into the peritoneal cavity, or by obstructing the urinary tract.
6- Vaginal melanoma
7. FIGO Staging system
Stage 0:- Carcinoma in situ
Stage I:- Invasive carcinoma
confined to the vagina.
Stage IA Tumour < 2 cm wide &
< 1 mm depth of invasion.
Stage IB Tumour > 2cm wide &
> 1 mm depth of invasion.
Stage II:- Tumour invades
para-vaginal tissues but not to
the pelvic wall.
Stage III:- Extension to the
pelvic wall.
Stage IVA
Extension beyond the true pelvis or
invasion of bladder/rectum.
Stage IVB
Pelvic or inguinal
lymphadenopathy
or distant metastases.
8. Cervix is The elongated lower part of the uterus that communicates above with the uterine
cavity at the internal os and below with the vagina at the external os.
Measuring 2.5-3.0 cm.
Divided by the vaginal attachment into
– supravaginal portion above
– vaginal portion (portio-vaginalis) below.
The cervix disorders:
• Endocervix: Lined by simple columnar epithelium with compound glands or crypts that are
liable to chronic infection. It secretes alkaline cervical mucus.
• Muscle layer: Outer longitudinal and inner circular muscles.(2 layers only)
• Ectocervix: Formed of stratified squamous epithelium covering the outer portion of the
cervix. The junction between squamous and columnar epithelium at the external os is
either abrupt or it may form a transitional zone 1-3 mm known as the transformation zone.
Squamocolumnar Junction
9. Sequamous metaplasia :-
is the change of the endocervical columnar
epithelial to sequamous epithelial due to
high vaginal acidity . It is a premalignant
lesion
may be seen in the context of benign lesions (e.g., atypical
polypoid adenomyoma), chronic irritation, or cancer (e.g.,
endometrioid endometrial carcinoma), as well as
pleomorphic adenoma.
10. CERVICAL INTRAEPITHELIAL NEOPLASIA
Nearly all invasive cervical squamous cell carcinomas arise from
precursor epithelial changes referred to as CIN
Premalignant and Malignant
Cervical Neoplasms
Pathogenesis • High oncogenic risk HPV types are the most
important factor in cervical oncogenesis’
HPV 16 (60% of cervical cancer)
HPV 18 (10% of cervical cancer)
• Risk factors
• HPV
• Early marriage
• Multiple sexual
pattern
• Male pattern &
deviation
• Smoking
• Immune deficiency
• Most HPV infections are asymptomatic and
do not cause any tissue changes;
• 50% are cleared within 8 months & in 90%
cleared within 2 years.
• Persistent infection (as with high-risk types
or immunocompromise) increases the risk
of developing malignancy.
11. Diagnosis :
• Pap smear cytology :- Papanicolaou test is a method of cervical
screening used to detect potentially precancerous and cancerous
processes in the cervix or colon (in both men and women).
• Abnormal findings are often followed up by more sensitive diagnostic
procedures or interventions to prevent progression to cervical cancer.
• A procedure in which a small brush or spatula is used to gently remove
cells from the cervix so they can be checked under a microscope for
cervical cancer or cell changes that may lead to cervical cancer.
Clinically :- often asymptomatic but occasionally with contact
bleeding
Close-up of SCJ
12. Colposcopic examination & biopsy.
Colposcopy
is a medical diagnostic procedure to visually examine the cervix as
well as the vagina and vulva using a colposcope which provides a
magnified and illuminated view of the areas, allowing the
colposcopist to visually distinguish normal from abnormal appearing
tissue, such as damaged or abnormal changes in the tissue , and
take directed biopsies for further pathological examination if
needed
13. Post Acetic Acid Acetowhite changes
Punctations Mosaicism
Gross:
14. CIN
- Grades:
*CIN-I (mild dysplasia) - mild changes -only in the lower 1/3
*CIN-II (moderate dysplasia) - moderate change - in the lower 2/3
*CIN-III (severe dysplasia-CIS) - severe changes - full thickness
15. Cervical Intraepithelial Neoplasia
Classified as :-
Low - grade or High - grade squamous intraepithelial lesions (LSIL
and HSIL, respectively).
More than 80% of LSIL and 100% of HSIL lesions are associated with
high-risk HPV;
HPV 16 is the most common type associated with both.
• In LSIL, the atypia is confined to the
basal third of the epithelium.
• 60% of LSIL spontaneously regress
within 2 years,
• 30% persist over that period;
• only 10% progress to HSIL,
• LSIL does not proceed directly to
invasive carcinoma.
• It is therefore not treated like a
premalignant lesion.
HSIL exhibit moderate to severe
dysplasia and extends to two thirds
(or more) of the epithelial thickness.
• Also includes carcinoma in
situ.
• 30% of HSIL will regress over 2
years,
• 60% will persist,
• 10% will progress to carcinoma
within a 2- to 10-year period.
