Introduction to Colposcopy

Indication for Colposcopy

Epithelial cell abnormalities detected by cervical cytology

Positive high risk HPV DNA in ASC-US triage

Suspicious cervical lesions

Vulvar or vaginal neoplasia

History of in-utero DES exposure

Sexual partner of patients with genital tract neoplasia

Oncogenic Human Papillomavirus in appropriate guideline algorithms

Unexplained vaginal bleeding

Post–coital bleeding

Positive screening test by Cervicography or Speculoscopy

Basic Satisfactory Requirements of

Colposcopic Exam

Adequate Visualization

Entire TZ Zone seen

Abnormal areas seen in entirety

Endocervical Canal free of Dysplasia

No Evidence of Invasive Cancer

Abnormal Areas Biopsied

ECC Completed (Non-Pregnant patients)

Colposcopy - Objectives

Determines the presence of invasive cancer

Localizes the squamocolumnar junction

Identifies the most severe disease for biopsy

Evaluates the extent of disease

Instrumentation Procedure Colposcope

Vaginal speculum

Endocervical speculum

Large & small swabs

Endocervical curette

Cervical biopsy forceps

Solutions: Normal saline Acetic Acid Monsel’s

Instrumentation

Collin’s bivalve specula of different sizes Vaginal side wall retractor

Endocervical speculum Cervical punch biopsy forceps with sharp cutting edges

A method of identifyingouter & inner borders of the transformation zone

Colposcopic Examination

Obtain Pap, cultures, KOH as Needed

Perform Cervical Colposcopic Exam

Use Green Filter, if needed

Mentally Map Cervical Landmarks and abnormal areas

Colposcopic magnification of 10X – 15X

Is Exam Satisfactory?

Look for Satisfactory Colposcopy:

360 degree view of the T-zone

Proximal and distal extent of cervical lesions seen

Gross lesions or Pathology

Tumors

Infections

Don’t forget to check for vaginal and vulvar lesions

Collection of Target Biopsy Select the most severe lesion

Sharp instruments

2-3 mm biopsy

Colposcopically assisted always!

Biopsy at the SCJ

Monsel's solution /cauterisation for hemostasis

Satisfactory Colposcopy exam

360 degrees of squamocolumnar junction visualized

Proximal and distal extent of cervical lesions identified

Cytology, colposcopic impression and histology correlate

SCJ

Multiple nabothian cysts in the mature squamous metaplastic epithelium occupying the ectocervix

Nabothian cyst with regularly branching tree like vessels

Normal vascular pattern

Definition

Vertical single loop intraepithelial capillaries

viewed end on in a demarcated area

Etiology

Normal vascular pattern

Abnormal modification of existing vascular

architecture

Arises from the normal original columnar

epithelial angioarchitecture

Punctation

Colposcopic Appearance

Red dots usually seen within an area of acetowhite epithelium

Variable with increasing severity of disease

Increasing caliber of dot from fine to coarse

Increasing intercapillary distance

Coarse punctation

Coarse punctation before & after application of acetic acid

Differential and Significance

May result from inflammation, repair, viral effects,

neoplasia or the variant of fetal metaplasia (congenital

t-zone)

May represent normal to neoplasia

Vessel caliber and intercapillary distance predict the

severity

Average intercapillary distance is 100 microns

Increases with progressive neoplasia

Mosaic Intra epithelial capillaries encompassing blocks or buds forming a mosaic,

tile or “chicken wire” pattern

May be normal or abnormal modification of existing vascular architecture

Red, tile-like grid usually viewed within acetowhite epithelium

Fine or coarse caliber

Variable intercapillary distance with increasing severity of neoplasia

Mosaic: Differential and Significance

May be seen in the normal variant of fetal metaplasia (congenital t-zone)

Represented in any level of neoplasia

May be observed in benign tissue (not aceto-white)

Caliber and intercapillary distance predict the severity of disease

Atypical Vessels Superficial blood vessels exhibiting bizarre

variation in caliber, course and branching

pattern

Develop in response to tumor angiogenesis

factor (TAF)

Result in chaotic, rapidly proliferating vessels

attempting to nourish rapidly in neoplastic

tissue

Lack systematic, uniform branching

Atypicalvessels pattern ِ

ASSOCIATED WITH CANCER UNTIL PROVEN OTHERWISE

May be observed in areas of immature metaplasia

Colposcopically directed biopsy is mandatory

Atypical Vessels:

Differential and Significance

Post Menopausal Cervix:Epithelium is pale, brittle, lacks lusture,shows sub-epithelial petichiae, SCJ not

visualized

The entire new SCJ is visiblecolposcopic examination is satisfactory.the TZ is fully visualized. The metaplastic squamous epithelium is pinkish-white compared to the pink original squamous epithelium

Squamous metaplasia

Earliest colposcopic changes in immature squamous metaplasia (after 5% AA) in which tips of columnar villi stain white & adjacent villi start fusing together

Prominent white line corresponds to the new SCJ & tongues of immature Squamous metaplasia a) with crypt

openings at 4-8 o’clock positions b) after application of AA

Immature squamous metaplastic epithelium (narrow arrow)on the polyp with intervening areas of columnar epithelium

a) after application of AA

The endocervical polyp &the immature squamous metaplasia surrounding the os partially take up

iodine.

Leukoplakia

Usually benign

May obscure an underlying

neoplasia

Therefore, all patches

observed before application of

acetic acid must be biopsied

Hyperkeratosis ( Leukoplakia)

Geographic satellite lesion

condyloma low-grade lesion

Thin acetowhite lesion with geographic margins in the upper lip. Histology indicated CIN 1

Moderately dense acetowhite lesions with irregular margins in

the anterior & posterior lips ( CIN 1)

circumorificial acetowhite CIN 1lesion with irregular margin & fine mosaics

Moderately dense acetowhite lesions with well defined margins & coarse punctations in the anterior lip & in 3 o’clock position (CIN 2 lesion

Dense well defined acetowhite area with regular margins &

coarse mosaic ( CIN 2 lesion )

A dense acetowhite lesion with varying colour intensity &

coarse mosaics (a) in a CIN 2 lesion

Acetowhite lesions with coarse punctation (a) & mosaics (b) in a CIN 2 lesion

A circumoral dense opaque acetowhite area withcoarse mosaics ( CIN 3 lesion)

A dense acetowhite lesion with regular margin & coarse,

irregular punctation in a CIN 3 lesion.

ModifiedReid

Score

Early invasive cancer: note the raised irregular mosaics with umbilication (a), breaking mosaics (b), surface irregularity & the atypical vessels after the application of 5% AA

Preclinical invasive Carcinoma

AtypicalVesselspattern ِ

Note the irregular surface contour with mountains & valleys appearance with atypical blood vessels in the dense acetowhite area

Invasive cervical cancer

A dense acetowhite lesion in the endocervical canal visible after stretching the os with a long dissection forceps (adenocarcinoma in situ)

Glandular lesions

Adenocarcinoma in situ: The tips of some of the columnar villi turn densely white compared to the surrounding columnar villi after the application of acetic

acid (arrow). The nabothian cysts turn white after the application of AA

the greyish white dense acetowhite lesion withcharacter writning-like atypical blood vessels(a)

The elongated, dense acetowhite lesion withirregular surface in the columnar epithelium

with atypical blood vessels (a)

Adenocarcinoma:

Reddish “angry-looking”, inflamed columnar epithelium with loss of the

villous structure & with inflammatory exudate (before application of 5% AA)

Inflammatory lesions of the

Uterine Cervix

Chronic cervicitis: This cervix is extensively inflammed with a reddish

appearance &bleeding on touch, there are ill-

defined, patchy acetowhite areasscattered all over the cervix after the

application of AA

TV after Acetic acid

T.V. After Lugol’s

Multiple red spots (a) suggestive of Trichomonas vaginalis colpitis ( strawberry appearance), after application of 5% AA

Trichomonas vaginalis colpitis after application of Lugol’s iodine

(leopard-skin appearance)

Lines of treatment

No treatment

Follow up

LEEP

Cryotherapy

Laser

Cone biopsy

Hysterectomy