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Colposcopy


Medical editor Ameli Tropé MD
Gynecologist

Oslo University Hospital
Norway

General

When discovering abnormal cervical cells the work-up should be performed by a gynecologist using a colposcope. In general, cell changes in the cervical mucosa are causing neither symptoms nor visible changes. At colposcopy magnification is used together with acetic acid wash and possibly application of a iodine solution and color filters to improve visualization of abnormal areas and perform biopsies targeted to these areas.

An important requirement for the use of colposcopy is that the area of transformation is located on the ectocervix, thereby accessible for examination. This is the case for most women of fertile age, but usually not in post-menopausal women. Colposcopy is therefore not always indicative for taking a biopsy. In addition, the method is of low-sensitivity (varying from 49% to 85%). Colposcopy should therefore be considered a tool for targeted biopsy taking, but not used as an independent diagnostic method.

If pap test is abnormal, histological samples should always be performed. ”Blind samples” must be taken if colposcopy is negative. ”Blind samples” increase the sensitivity for each biopsy taken, but it is necessary to know from where to take the samples. Colposcopy training improves sensitivity for discovering cervical neoplasia grade 2 or more (CIN2+).

Goal

The goal of colposcopy, biopsy and endocervical curretage is to:

  • identify the transformation zone (TZ).
  • identify or exclude CIN and determine the grade of CIN, identify and exclude abnormal glandular epithelium.
  • identify and exclude cancer, determine type of treatment.
  • in some cases, follow the progression or regression of CIN.

Indication

  • Work-up for abnormal cervical cells.
  • Persistent HPV-infection or symptoms such as contact bleeding.
  • Abnormal menstruation pattern or abnormal vaginal discharge.

Supplies

  • The colposcope should have adequate lighting, and should have between 6 and 24 × magnification in multiple levels.
  • 3-5% acetic acid.
  • Lugol’s solution (be aware of iodine allergy).
  • Swabs
  • Punch forceps
  • Cotton swabs
  • Biopsy forceps
  • Cervix curette
  • Local anesthetic: Citanest Dental Octapressin® or Xylocain-Adrenalin® 10 mg/ml + 5 microgram/ml with syringe.

 


Implementation

A woman who is informed of an abnormal result from a Pap test is usually quite anxious, and notions of fatal cancer are not uncommon. It is important that the information she is given before the examination quells her anxiety. Not only for the patient`s wellbeing, but also because an anxious patient is difficult to examine, and one of the main criteria for a colposcopy is that the patient is relaxed, allowing for adequate access.

Quickly inspect the vulva for condyloma or other lesions. Place the speculum into the vagina. If colposcopy of the cervix is normal, examine the vagina when the speculum is removed. Iodine is used to help visualize the abnormal cells. Cell changes are not always a result of changes on the vaginal portion of the cervix, but may be from VAIN.

Begin the colposcopy with white light and low magnification to obtain an overview of the cervix. Carefully remove mucous and blood with saline. Use green light to identify atypical blood vessels before coating with acetic acid.

Is the colposcopy adequate?

The whole transformation zone (TZ)  and entire border to all lesions must be examined (not disappear into the canal) in order for colposcopy to be deemed adequate.

Use for example a cotton swab to obtain the best overview of TZ and lesions. A cotton swab can also be used to push mucous into the cervical canal to obtain a better view. Is there inflammation or infection present? Active cervicitis may hide cell changes.

Identify the transition between cylinder and squamous-cell epithelia and type of TZ 

Under the influence of hormones, the cylinder epithelia unfold toward the ectocervix changing to a low pH, and mechanical damage stimulates cylinder epithelia on the cervix to change to squamous epithelia. The TZ is between the original and new transition between cylinder and squamous epithelia (squamo collumnar junction (SCJ)) . Before epithelium becomes mature squamous epithelia, metaplasia is observed. The new squamous epithelia cover old crypts where small crypt openings and clogged openings can be observed and these may create ovula Nabothi. It is usually difficult to identify the original SCJ, but the most lateral crypt openings or ovula Nabothi may indicate where it is located.

Depending on the age and endocrine status or status after treatment, the SCJ may have different locations in the cervical canal. It is customary to divide this TZ in types 1, 2 and 3 depending on where the transition is. In Norway, the TZ-type terminology is not used yet, but describing the localization of SCJ is important to explain the choice of treatment, and is useful for quality assurance of work-up and treatment.

Identify abnormal areas

The colposcopic diagnosis of cervical dysplasia is made by using five observations Swede/Strander score. (Reffering to the tab documentation).

  • Intensity (the hue) of acetowhite
  • Margins and surface contour of acetowhite areas
  • Vascular patterns
  • Size of the lesion
  • Color changes after brushing with iodine

Use plenty of 5% acetic acid. Observe with white light constantly while the acetic acid is working. Patience is required in this step, because the effect of acetic acid develops gradually over one minute. New acetic acid should be applied every 2.-3. minutes because the effect of the acetic acid disappears quickly. The higher the degree of dysplasia is, the faster it becomes acetowhite, and the thicker the change will become, and abnormal blood vessels are appearing slower. High-grade lesions are losing the acetowhite change more slowly.

It is important to examine a lot of women with normal Pap tests to know how a normal cervix looks like. Metaplasia becomes thin acetowhite and may be difficult to distinguish from low-grade CIN.

Low-grade CIN is often seen as thin, smooth acetowhite lesions with well-demarcated, but irregular, geographical, blurred or satellites or sharp edges.

High-grade CIN is associated with thick, dense, matte, opaque or gray-white acetowhite areas with clearly defined, regular margins, often with elevated edge. Acetowhite changes may be associated with coats of white paint. The higher CIN grade the more layers of paint. The surface contours of the acetowhite areas associated with high-grade CIN lesions are tending to be irregular and nodular. The visualization of one or more borders within an acetowhite lesion or acetowhite lesion with varying color intensity and thick rings around the crypts, is associated with high-grade lesions.  

Vascular patterns as punctuation and mosaics are significant if these are seen confined to acetowhite areas. Vascular pattern, such as fine punctuation and/or fine mosaics in acetowhite areas, are most often associated with low-grade CIN. Thick acetowhite without fine punctuation and mosaics often have more severe CIN than if fine punctuation and mosaics are observed. Coarse punctuation and/or coarse mosaics with big spaces in acetowhite areas tend to occur in high-grade lesions. Atypical blood vessels are often a bit "messy", "bizarre", thick and tree trunk-like. One should react if vessels looking like thick commas or corkscrews are observed. .Atrophic cervix squamous often has thin branch-like vessels.

Adenocarcinoma in situ is difficult to identify and are often not identified with colposcopy alone. Colposcopy findings that can be observed  for adenocarcinoma in situ:
  • Raised lesion with an irregular acetowhite surface on cylindrical epithelium, but not connected to SCJ. It looks like patchy coalesced  villi that may look like immature squamous metaplasia.
  • Big glandel crypts producing a lot of mucus, in the area with other colposcopic abnormalities.
  • Papillary lesions next to areas with coalesced villi that look more like metaplasia.
  • Edematous epithelial excrescence.
  • Areas with mixed red and white after application of acetic acid, but with a ulcerated surface.
  • The blood vessels are often similar to parasitic plants in connection to one or more punctuations.

Use of iodine

Iodine, also called Lugol's or Schiller's iodine solution, is taken up in mature epithelium with glycogen. The mature squamous epithelium is being stained mahogany brown. The dysplastic epithelium is not stained and are therefore marked yellow. Iodine often visualizes scattered lesions localized a little further out on the cervix, these may easily be overlooked with acetic acid alone. Everything colored yellow with iodine is not dysplasia, this is important to be aware of so no more tissue than necessary is being removed.

In vagina there is a big benefit using iodine, but it is important to first examine with acetic acid. One can quickly see yellow spots with VAIN, which are easily overlooked with acetic acid. For hysterectomy due to repeated cell changes after several conisations, colposcopy with iodine is smart to use to ensure free margins vaginally. Five percent of the population has original SCJ all the way to the upper part of the vagina.

To identify cell changes iodine cannot be used alone because immature epithelium does not turn brown. Inflammation creates a lighter yellow-stained area. Columnar epithelium is usually being stained with orange spots by iodine. Iodine is not relevant in women with low estrogen levels in vaginal epithelium, as in breastfeeding or after menopause, when the epithelium contains little or no glycogen.

Where should the biopsies be taken?

The HPV infection usually starts in SCJ. Premalignant lesions in squamous epithelium occur in metaplastic squamous epithelium and extending in a distal direction. Premalignant lesions in columnar epithelium occur in columnar epithelium and extending in a proximal direction. It is important to take biopsies in areas where the most severe changes in lesions are observed, but most often the highest level of VIN is located in a lesion closest to SCJ. If the colposcopy is normal, biopsies should be taken in SCJ to get a representative sample. It is important to prioritize sharp biopsy forceps for adequate assessment of cervical dysplasia. Colposcopy has low sensitivity. The sensitivity increases significantly by three to four biopsies.

For unsatisfactory colposcopic conditions (total SCJ not visible and/or upper limitation of the lesion is not visible), prior treatment of cervical dysplasia and abnormal gland epithelial changes, a endocervical curettage must be performed.


Follow-up Care

Follow-up care after cervical biopsies and cervical abrasion, which are taken as part of the work-up for abnormal cell biopsies, depend on the test result and testing background. 

Normal histology

Evaluate whether the test was representative, the basis for the test taking, and probability for which uncertain/confirmed cell changes have gone into spontaneous remission. 

Have a low threshold to re-test the patient with a new biopsy. In addition:  

  • If following high-grade dysplasia, new cytological and HPV testing are recommended based on clinical indication within 6 months.
  • If following high grade dysplasia during pregnancy (normal colposcopy and representative normal biopsy postpartum if the choice has been made not to konsiere?), it is recommended to do new cytological testing in addition to HPV testing based on clinical indication within 6 months.

CIN 1

  • Cytology and HPV-test based on clinical indication in 6 months. 

CIN2+

  • Treatment (usually)  

Work-up if persisting discrepancy between cytology, colposcopy and histology:

  • Diagnostic conization should be considered. 
  • It may be appropriate to perform a more extensive colposcopy of the entire vagina followed by application of Lugol's solution. 
  • Request a re-evaluation of results for cytology, histology, and HPV testing. 


Documentation

Colposcopic findings can be classified according to "International Federation for Cervical Pathology and Colposcopy" (IFCPC).

2011 IFCPC Colposcopic terminology
General assessment
  • Adequate/inadequate PGA (for example bleeding, scars,inflammation)
  • Squamocolumnar junction visibility: Completely visible, partially visible, not visible
  • Transformation zone(TZ) types 1,2,3
Normal colposcopic findings

Original squamous epithelium:

  • Mature
  • Atrophic

Cylindrical epithelium

  • Ectopy

Metaplastic squamous epithelium

  • Nabothian cysts
  • Crypt (gland) openings
  • Deciduosis in pregnancy

Abnormal colposkopic findings
General principles

Location of the lesion: Inside or outside the T-zone. Location of the lesion by clock position

Size of the lesion:Number of cervical quadrants the lesion covers. Size of the lesion in percentage of cervix.


Grade 1 (Minor)

Thin aceto-white epithelium, irregular, geographic border

Fine mosaic, fine punctuation


Grade 2 (Major)

Dense aceto-white epithelium, rapid apperance of acetowhitening, Cuffed crypt (gland) openings

Coarse mosaic, coarse punctuation, sharp border, inner border sign, ridge sign?


Non specific
Leukoplacia, erosion, iodine/Lugol´s staining (brown/yellow)
Suspicious for invasion

Atypical vessel. Additional signs: Fragile vessles, irregular surface, exophytic lesion, necrosis, ulceration (necrotic tumor)
Miscellaneous finding

Congenital transformation zone, condyloma, polyp, (ectocervical/endocervical), inflammation Stenosis, congenital anomaly, post treatment consequence, endometriosis

Strander/Swede colposcopic score

  • Five variables equivalent to 1-5 above has a value of 0,1 or 2
  • At full deflection, the maximum is 10 point
  • 1-4 points speak against CIN2+, while 8-10 points indicates for CIN2+ 

Strander/Swede colposcopic score is a newer and international approved scoring system, easy to use and helpful to systematize colposcopic findings and knowing where to take biopsies.

It is important to try out this scoringsystem in practice.

Score 0 1 2
Uptake of asetic acid
0 or tranpsarent
Shady, milky
Stearin-like
Margins
0 eller diffuse
Sharp, but irregular, jagged. Satelittes
Sharp end even, difference in surface level
Vessels
Fine, regular
Absent
Coarse or atypical vessels
Size < 5mm
5-15 mm or 2 quadrants
> 15 mm or spanning, 3-4 quadrants or endocervically undefined
Iodine absorbtion
Brown Faintly or patchy yellow
Distinct yellow

Documentation is important

In order to document the choice of treatment, to track changes and not least to learn from colposcopy findings, it is important that the findings are documentet by photographs or drawings. If the observation of what is interpreted as a high-grade lesion is certain, multiple cutting or using specific markers for immunostaining may be performed

References

  1. Ferris DG, Spitzer M, Werner C, Dickman ED, Shiver RL. Colposcopy quality control for clinical trials: the positive effects from brief, intensive educational intervention. J Low Genit Tract Dis. 2002;6(1):11-6.
  2. Underwood M, Arbyn M, Parry-Smith W, De Bellis-Ayres S, Todd R, Redman CW, et al. Accuracy of colposcopy-directed punch biopsies: a systematic review and meta-analysis. BJOG. 2012;119(11):1293-301.
  3. Leeson SC, Alibegashvili T, Arbyn M, Bergeron C, Carriero C, Mergui JL, et al. The future role for colposcopy in Europe. J Low Genit Tract Dis. 2014;18(1):70-8.
  4. Pretorius RG, Belinson JL, Burchette RJ, Hu S, Zhang X, Qiao YL. Regardless of skill, performing more biopsies increases the sensitivity of colposcopy. J Low Genit Tract Dis. 2011;15(3):180-8.
  5. Tatti S, Bornstein J, Prendiville W. Colposcopy: a global perspective: introduction of the new IFCPC colposcopy terminology. Obstet Gynecol Clin North Am. 2013;40(2):235-50.
  6. Sjoborg KD, Vistad I, Myhr SS, Svenningsen R, Herzog C, Kloster-Jensen A, et al. Pregnancy outcome after cervical cone excision: a case-control study. Acta Obstet Gynecol Scand. 2007;86(4):423-8.
  7. Albrechtsen S, Rasmussen S, Thoresen S, Irgens LM, Iversen OE. Pregnancy outcome in women before and after cervical conisation: population based cohort study. BMJ. 2008;337:a1343.
  8. Strander B, Andersson-Ellstrom A, Milsom I, Sparen P. Long term risk of invasive cancer after treatment for cervical intraepithelial neoplasia grade 3: population based cohort study. BMJ. 2007;335(7629):1077.

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