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Prevention
is
Better thanCure
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Cervical CANCER
Raising Awareness & Prevention
Cervical CancerCervical Cancer --A major health problem & Social BurdenA major health problem & Social Burden
The commonest cancer in women in developing countries
Diagnosed in advanced stage
Cancer ofCervix is curable if detected in early stage
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Development of Cancer CervixDevelopment of Cancer Cervix
Normal Cervix
Pre Cancerous lesions ( CIN I,CIN - II )
Carcinoma in situ ( CIN-III)
Invasive Cancer
--------------------------------------------
Stage I Stage II Stage III Stage IV
Normal Cervix
Pre Cancerous lesions ( CIN I,CIN - II )
Carcinoma in situ ( CIN-III)
Invasive Cancer
--------------------------------------------
Stage I Stage II Stage III Stage IV
10 -15
years
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Screening for Cervical CancerScreening for Cervical Cancer
Paps Smear
Visual inspection ofCervix
- after application ofacetic acid (VIA)
- after application of Schillers iodine (VILI)
HPVDNA testing
Paps Smear
Visual inspection ofCervix
- after application ofacetic acid (VIA)
- after application of Schillers iodine (VILI)
HPVDNA testing
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What is a ColposcopeWhat is a Colposcope
Colposcope is a microscope designed to allowexamination of the cervix with magnificationranging between six- to - 40 fold
It is kept approx. 30cm away from the vagina & alight source is thrown in it & in return it showsreal, true magnified picture of cervix
Invented by Hinselmann, a German scientist, in1925
Colposcope is a microscope designed to allowexamination of the cervix with magnificationranging between six- to - 40 fold
It is kept approx. 30cm away from the vagina & alight source is thrown in it & in return it showsreal, true magnified picture of cervix
Invented by Hinselmann, a German scientist, in1925
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Colposcope
(Greek word)
Colposcope
(Greek word)_____________________
Kolpos Skope
Hollow Examine
_____________________
Kolpos Skope
Hollow Examine
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The man who thinks thatcytologyisbetter thancolposcopy,
or
thatcolposcopyis better thancytology,
is a fool who knows nothing of either-Hinselmann
The man who thinks thatcytologyisbetter thancolposcopy,
or
thatcolposcopyis better thancytology,
is a fool who knows nothing of either-Hinselmann
The Primary goal of Cervical Screening is to prevent
Cervical Cancer
The Primary goal of Cervical Screening is to prevent
Cervical Cancer
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COLPOSCOPY
The Colposcope is a magnifying instrument
Its lights are only on THE OUTSIDE
No anesthesia is required
Colposcopy is an outpatient procedure
Helps in identifying the abnormal or diseased area
It helps in taking biopsy
Colposcopy is not a Surgery
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Type of ColposcopeType of Colposcope
ManualColposcope
Main objective lensMagnification changer
Binocular lens
Filter: required for the
study of vasculararchitecture
Light source
ManualColposcope
Main objective lensMagnification changer
Binocular lens
Filter: required for the
study of vasculararchitecture
Light source
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0
20
40
60
80
100
1st
Qtr
3rd
Qtr
East
West
North
Eye piece
Object
ive
lens
Knob for
magnification
Light
source
Knob for
tilting
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Video-Colposcope
It utilizes video camera
Electronic green filter
Motorized zoom magnification
Fine focus control combinedin one unit
Omission of eye piece
Along with high resolution
monitor & optional
image management system Full screen image display
With live recording
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DigitalVideo- Colposcope
DigitalVideo-colposcopy:Includes computer withimage software
Images can be captured andstored digitally for
Documentation
Teaching purpose
Comparison of lesion duringfollow up
Statistical analysis and
Printing report
Software data for
confirmation of diagnosis
DigitalVideo Colposcopes are the
latest generation
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Why Do A Colposcopy ?Why Do A Colposcopy ?
Colposcope :Low power binocular microscope,
Modified with the specific purpose
To study of surface epithelium, stroma
& vascular pattern of the cervix
Diagnostic toolIdentification ofabnormalities in CERVIX
Location of the lesion
Aid in selection of biopsy siteSignificant role- Evaluation & treatment ofCIN, HPV, Erosion
Selection oftreatment ofCIN
Abnormal paps smearin pregnancy
Extension oflesion in vagina
Colposcope :Low power binocular microscope,
Modified with the specific purpose
To study of surface epithelium, stroma
& vascular pattern of the cervix
Diagnostic toolIdentification ofabnormalities in CERVIX
Location of the lesion
Aid in selection of biopsy siteSignificant role- Evaluation & treatment ofCIN, HPV, Erosion
Selection oftreatment ofCIN
Abnormal paps smearin pregnancy
Extension oflesion in vagina
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IndicationsIndications
HSIL /LSIL /PersistentLSIL / borderline nuclear changes
ASC-U (HPVTest - High Risk Positive)
ASC-H
Suggestion of invasive cancer
Persistent unsatisfactory smears
Presence ofglandular lesion
Excessive numbers of keratinized cells
Clinically suspicious looking cervix
Leucoplakia
Abnormal / unexplained intermenstrual bleeding
Postcoital bleeding
Unexplained, persistent vaginal discharge
HSIL /LSIL /PersistentLSIL / borderline nuclear changes
ASC-U (HPVTest - High Risk Positive)
ASC-H
Suggestion of invasive cancer
Persistent unsatisfactory smears
Presence ofglandular lesion
Excessive numbers of keratinized cells
Clinically suspicious looking cervix
Leucoplakia
Abnormal / unexplained intermenstrual bleeding
Postcoital bleeding
Unexplained, persistent vaginal discharge
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Materials required for performing Colposcopy
Examination table: Table allows the woman to be placed in
a modified lithotomy position
The womens feet may be placed either
in heel rests or legs may be supported inknee crutches
Table: For instruments
OptionalItems :
Computer for documentation purpose
Printer, Video Recorder, Appropriate
software for recording of
patient data
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CUSCOS speculums - different sizes - metal /plastic disposable
-inserted gently to widen the opening of the vagina
enables visualization of the cervix
-If lateral walls of the vaginal canal are
obstructing the view,a latex condom can be put on
speculum after cutting its tip
Sponge holding forceps / larger cotton-tipped swabsticks
Cotton or blood holding pads
Bottles : 1. normal saline2. 3-5% acetic acid &
3. Lugols Iodine
Monsels Solution : Local Haemostatic agent
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Acetic Acid: It is applied with a cotton
applicator (cotton balls held by
sponge forceps or small swabs)
Acetic acid dissolves & coagulates
the protein available on cervix in
order to make it more clear
Duration : 1-3 minutes
Acetonic effect: After application a
white layer appears
Acetic Acid
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GREEN FILTER
It is used to study the
vascular pattern of cervix
Actually, this absorbs the
red from the color &
enhance the image of blood
vessels which appear black
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Lugols Iodine Application :
This solution is also known asSchillers test
Reaction obtained when iodine solution is painted on cervix
Normal epithelium is glucogen rich - stains brown
Abnormal epithelium -contains little or no glycogen doesnt
take up the stain
Hence abnormal area can be easily marked
Help in selection of area -for biopsy
LugolsIodine
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SchillersIodine :SchillersIodine :
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TechniqueTechniqueOPD procedure
No Anesthesia required
Insertion of cuscos speculum
Inspection of unprepared cervix
Excess mucus is removed -saline soaked cotton wool swab
Colposcopy after application of 3-5%acetic acid
Examine ofCervix under green filter
Application of Schillers iodine
OPD procedure
No Anesthesia required
Insertion of cuscos speculum
Inspection of unprepared cervix
Excess mucus is removed -saline soaked cotton wool swab
Colposcopy after application of 3-5%acetic acid
Examine ofCervix under green filter
Application of Schillers iodine
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International Colposcopic Terminology
Normal colposcopic findings:
Original squamous epithelium
Columnar epithelium
Normal Transformation zone
Unsatisfactory colposcopy:
Squamocolumnar junction notvisible
Miscellaneous findings:
Micropapillary surface
Condyloma
Inflammation / Atrophy /Ulcer
Other
Abnormal ( within the TZ )
Acetowhite epithelium* Punctation*
Mosaic*
Leukoplakia*
Iodine negative
Atypical vessels Colposcopically suspect
invasive carcinoma
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Anatomy of the CervixAnatomy of the Cervix
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Cervical EpitheliumColposcopic AppearancesCervical EpitheliumColposcopic Appearances
OriginalSquamous epithelium
Original Columnarepithelium
Transformation zone
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Original Squamous EpitheliaOriginal Squamous Epithelia
Smooth, usually
featureless covering of
the cervix
Uniformpink colour
It joins the columnar
epithelium at the
original SCJ
Smooth, usually
featureless covering of
the cervix
Uniformpink colour
It joins the columnar
epithelium at the
original SCJ
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Original Columnar EpitheliaOriginal Columnar Epithelia
An areawith multiple
villi / grapelikeprojections
Characteristic reddish
colour
Each villus has one /more capillary loops
with a thin overlying
epithelium
An areawith multiple
villi / grapelikeprojections
Characteristic reddish
colour
Each villus has one /more capillary loops
with a thin overlying
epithelium
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Original Squamo-columnar JunctionOriginal Squamo-columnar Junction
Permanent pointof meetingbetween original squamous
and columnar epithelia
Outlines the lateral border ofthe TZ
It isfixed, but moves inrelation to the whole cervix
Permanent pointof meetingbetween original squamous
and columnar epithelia
Outlines the lateral border ofthe TZ
It isfixed, but moves inrelation to the whole cervix
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T
ransformation zoneT
ransformation zone The area lying between the original squamo-columnar
junction and the colposcopic new squamo-columnar
junction
Zone in which transformation will occur during fetal
life, adolescence and pregnancy
Characterized by presence ofmetaplastic epithelium
This is the area where transformation to CINoccurs
which may lead to invasive cancer
The area lying between the original squamo-columnar
junction and the colposcopic new squamo-columnar
junction
Zone in which transformation will occur during fetal
life, adolescence and pregnancy
Characterized by presence ofmetaplastic epithelium
This is the area where transformation to CINoccurs
which may lead to invasive cancer
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Transformation ZoneTransformation Zone
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SquamousMetaplasiaSquamousMetaplasia
Conversion ofColumnar epithelium to SquamousepitheliumConversion ofColumnar epithelium to Squamousepithelium
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Periods of development late fetal life, menarche, first
pregnancy
Early /Immature stage villi opaque at tips pale
Mature difficult to distinguish between metaplastic and
original squamous epithelia
Gland openings Patent preexisting clefts
(lateral margin of TZ)
Nabothian follicles occluded clefts
SquamousMetaplasiaSquamousMetaplasia
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Tissue basis for ColposcopyTissue basis for Colposcopy
The colposcopic appearances of the cervix are asummation of various factors
These include:-1.The architecture of the epithelium and possiblevariations in its thickness & formation
2.The composition of the underlying stroma
3.The surface configuration of the tissue of the
cervix
The colposcopic appearances of the cervix are asummation of various factors
These include:-1.The architecture of the epithelium and possiblevariations in its thickness & formation
2.The composition of the underlying stroma
3.The surface configuration of the tissue of the
cervix
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Surface configurationSurface configuration
Smooth / papillary
Vascular patterns
- Punctations
- Mosaics
Leukoplakia (white patches on surface), due to thick
keratin which may overlie normal / abnormal
epithelium
Irregular surface
Smooth / papillary
Vascular patterns
- Punctations
- Mosaics
Leukoplakia (white patches on surface), due to thick
keratin which may overlie normal / abnormal
epithelium
Irregular surface
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Miscellaneous findings :-
Colposcopic appearance
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Cervical Ectopy / EctropionCervical Ectopy / Ectropion
Menarche, pregnancy and oral contraceptives
SCJ situated outside external os
Surface columnar epithelium displaced outward
Gives an exophytic appearance
Only colposcopy can differentiate between a perfectlybenign effect and malignant changes
Menarche, pregnancy and oral contraceptives
SCJ situated outside external os
Surface columnar epithelium displaced outward
Gives an exophytic appearance
Only colposcopy can differentiate between a perfectlybenign effect and malignant changes
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Trichomonas vaginalis---strawberry appearance
Schillers iodine test--- leopard skin appearance
Trichomonas vaginalis---strawberry appearance
Schillers iodine test--- leopard skin appearance
Inflammatory LesionsInflammatory Lesions
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Lesions can be single/multiple
Flat plaque ofacetowhite epithelium -mosaics & punctations
With increasing keratinization surface appear heaped upresembling the surface of cerebral cortex
May even occur outside the T.Z.
FINALDIAGNOSIS BYHPE
Lesions can be single/multiple
Flat plaque ofacetowhite epithelium -mosaics & punctations
With increasing keratinization surface appear heaped upresembling the surface of cerebral cortex
May even occur outside the T.Z.
FINALDIAGNOSIS BYHPE
Human PapillomaVirusInfectionHuman PapillomaVirusInfection
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Cervical epithelium MenopauseCervical epithelium Menopause
TZtends to retract
Squamous epithelium becomes atrophic
Glycogenation is lost Subepithelial capillaries much more readily
traumatized
TZtends to retract
Squamous epithelium becomes atrophic
Glycogenation is lost Subepithelial capillaries much more readily
traumatized
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Abnormal epithelium extending high into theendocervix
Entire T.Z. not seen
Abnormal epithelium extending high into theendocervix
Entire T.Z. not seen
Unsatisfactory ColposcopyUnsatisfactory Colposcopy
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Selection of biopsySelection of biopsy
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Four basic Colposcopic diagnosis
1. Normal& satisfactory / Unsatisfactory2. Low-grade disease (HPV / CIN-1)
3. High-grade disease (CIN-2 or 3)
4. Invasive cancer
Four basic Colposcopic diagnosis
1. Normal& satisfactory / Unsatisfactory2. Low-grade disease (HPV / CIN-1)
3. High-grade disease (CIN-2 or 3)
4. Invasive cancer
DiagnosisDiagnosis
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Colposcopy is a important aid in diagnosis
Pap's smear & Colposcopy are complementary
Requires specialized training, skill & knowledge
Colposcopist should be aware ofall the terminology
Colposcopy is totally subjective
FINALDIAGNOSIS BYHISTO-PATHOLOGY
Management depends on the histo-pathology reports
Colposcopy is a important aid in diagnosis
Pap's smear & Colposcopy are complementary
Requires specialized training, skill & knowledge
Colposcopist should be aware ofall the terminology
Colposcopy is totally subjective
FINALDIAGNOSIS BYHISTO-PATHOLOGY
Management depends on the histo-pathology reports
To ConcludeTo Conclude
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CYTOLOGYIDENTIFIESTHECRIME
WHILE
COLPOSCOPELOCATESTHECULPRIT
CYTOLOGYIDENTIFIESTHECRIME
WHILE
COLPOSCOPELOCATESTHECULPRIT
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