Colposcopy

TodayTodayProf. Aboubakr ElnasharProf. Aboubakr Elnashar

Benha University Hospital. EGYPT

E-mail: elnashar@hotmail.com

Colposcopy

TodayTodayProf. Aboubakr ElnasharProf. Aboubakr Elnashar

Benha University Hospital. EGYPT

E-mail: elnashar@hotmail.com

•The colposcope was The colposcope was first developedfirst developed in in 1925 & is well established in 1925 & is well established in gynecologic practice for defining & gynecologic practice for defining & delineating cytologically detected delineating cytologically detected lesions mainly of the cervix but also the lesions mainly of the cervix but also the vagina & vulva.vagina & vulva.

•Colpscopy is now gradually spreading Colpscopy is now gradually spreading allover the world & postgraduate allover the world & postgraduate training training coursescourses is now being given in many is now being given in many centers.centers.

Historic events related to colposcopyHistoric events related to colposcopy1925:1925: Invention of colposcope Invention of colposcope(Hinselman) (Hinselman)

1928:1928: Schiller test Schiller test

1938:1938: Acetic acid test Acetic acid test (Hinselman) (Hinselman)

1939:1939: Green filter Green filter (Kratz)(Kratz)

1940:1940: Pap test Pap test

1942:1942: First photographs of cervix First photographs of cervix (Treite)(Treite)

1960:1960: Cryosurgery Cryosurgery

1980:1980: Laser surgery Laser surgery

1988:1988: Computer-aided colposcope Computer-aided colposcope

1989:1989: LLETZ LLETZ (Prendiville & Cullimore)(Prendiville & Cullimore)1991: Pap Net2000: Telecolposcopy ( Harper et al)

Technologic advancesTechnologic advances

• New optical lenses, fiberoptic light cables & New optical lenses, fiberoptic light cables & videocameras with digital computer videocameras with digital computer enhancement,enhancement, all played a part in advances all played a part in advances of colposcopy.of colposcopy.

•Computer technologyComputer technology has made it possible has made it possible to capture images directly onto a computer & to capture images directly onto a computer & these images allow enhancement & these images allow enhancement & manipulation according to physicianmanipulation according to physician ,,s s preference.preference.

Colposcope Video camera(CCD)

Optical interface

Video monitorVideo digitizer board

PrinterPersonal computerMass storage

Digital imaging colposcopy

(CCD=charge couple device)

Telecolposcopy ( Harper et al,2000)

*Telecolposcopic system incorporating a custom software package. *All images were received without distortion in color, size, or orientation. *Telecolposcopy is technically feasible, can be implemented in an office system with limited technical support & is preferred by women who have to travel many miles to receive referral health care.

Current indications of colposcopy1. Part of any gynecologic examination2. Primary screening for cervical cancer.3. Clinically suspicious cervix.4. Abnormal Pap smear.5. Evaluation & treatment of CIN.6. Follow up after conservative therapy of CIN.7. Postcoital bleeding.8. Patients with external vulval warts9. Evaluation of sexual assault victims.10. Patients with history of DES exposure

Uses

•Screening colposcopy is a feasible procedure & more sensitive & more cost effective than cytological screening. When access to cytopathology is difficult, screening colposcopy is an alternative (Cecchini et al,1997).

•Portable colposcopy in rural areas is cost effective & highly acceptable (Martin et al,1998).

•The colposcopy improved detection of genital trauma in adult female sexual assault victims as compared with gross visual examination alone (Lenahan,1998).

Recent recommendations of FIGO for management of abnormal smear( Benedet,2000)

Persistent inflam., persistent ASCUS, LSIL, HSIL, AGCUS,Invasive

Colposcopy±biopsy

Normal or LSIL HGSIL Invasive

6 mo smear x 2 LEEP Appropriate TT

Normal Persistent

Annual screening

Steps• Lugols’iodine test: beneficial test..• ECB has replaced ECC: easier to use, malleable & less expensive.

Its specificity 92%, sensitivity 90% & positive predictive value 88% ( Martin et al, 1995).• Punch biopsy: False negative rate up to 54% ( Buxton et al,1991)

Multiple biopsies

Excisional techniques are superior to destructive techniques

Diagnostic criteria1. Vascular pattern. 2. Inercapillary distance 3. Contour. 4. Color 5. Clarity of demarcation 6. Appearance of gland opening. 7. Negativity after iodine test

8. Whiteness after acetic acid: Density of whiteness, time needed to appear & disappear, demarcation. Changes >35 yr are thinner & less demarcated., punch biopsy (Zahm et al, 1998).

9. Surface extent of the lesion: more important prognostic indicator for invasion than histological grading ( Tidbury et al,1992)

International Federation of Cervical Pathology & Colposcopy(1991)

Normal: Original squamous epithelium

Columnar epithelium

Normal transformation zone

Abnormal: Acetowhite epithelium Punctation

Mosaicism Leukoplakia

Iodine negative Atypical vessels

Suspect invasive cancer:Unsatisfactory:SCJ not visible, severe inflam or atrophy, invisible cervix

Miscellaneous:Nonacetowhite micropapillary surface,

exophytic condyloma, inflammation, atrophy, ulcer

Niekerk (1998) Low grade High grade•Acetowhite epithelium: shiny or snow dull, oyster white color

white,semitransparent•Surface: flat irregular contour, microexophytic•Demarcation: diffuse, irregular, sharp, straight line,

flocculated, feathered,

internal demarcation absent internal demarcation present•Vessels: fine, regular shape, uniform coarse, dilated, increased ICD,

caliber, normal arborization, spaghetti bizarre, commas, corkscrews

changing calibers sharp bends•Iodine: uniform mahogany brown mustard yellow, yellow or iodine -ve

Update of colposcopy of genital HPVMeisels et al (1982): Florid, spiked, flat, condylomatous . . vaginitis.

Flat condyloma & mild dysplasia represent the same biologic phenomenon, namely, productive HPV infection (Reid,1993).

The expression of viral activity may be clinical or subclinical when it is recognizable only on colposcopy.

Exophytic & flat condylomata are not homologous diseases. Exophytic is usually caused by cutaneotropic viruses (6,11). Flat are more likely to contain medium(31,33) or high risk(16,18) HPV types.

Micropapillary condyloma should not be confused with micropapillomatous labialis.

Colposcopy of the vulva*Steps:1. Examination after smearing with a water soluble lubricant.2. Prolonged acetic acid test3. Toludine blue test: little clinical value.* The junction between the glycogen bearing vaginal epithelium & keratin producing vulval epithelium: high risk for intraepithelial neoplasia.*Abnormalities: diffuse acetowhite, localized acetowhite, leukoplakia, micropapillae, papules.

Update on colposcopy in pregnancyDifficult. & reserved for the most experienced colposcopist.Reassurance of the patient.ECC is contrindicated & one directed biopsy.Large speculum is usually neededSponge forceps to remove the mucous & acetic acid as a mucolyticUnsatisfactory colposcopy: repeat after 8 wThe aim is to exclude cancer CIN: follow up & definitive treatment 1-2 mo postpartum.

Pitfalls in practice of colposcopyA. In the technique

1. Failure to use a diagnostic protocol2. Deviation from a diagnostic protocol.3. Failure to visualize TZ.

B. In diagnosis1. Misinterpretation of exagerated patterns of pregnancy, previously treated cervix, carvical cancer.2. Failure to select appropriate biopsy sites, enough biopsies, sufficient volume of tissue.3. Failure to accurately record colposcopic findings

C. In management1. Miscommunication with the pathologist.2. Failure to correlate cytology, colposcopy & histopathology.3.Destructive therapy without biopsy, for invasive or glandular lesions.

D. In the colposcopist1. Inadequate training. 2. Inadequate experience. 3. Inadequate understanding of the disease. 4. Failure to keep up with scientific developments 5. Failure to maintain skills. 6. Failure to seek consultation.

Diploma of colposcopy•No one should be allowed to practice colposcopy without having proper training or without a diploma in colposcopy( Jordan,1995).

•It would be a legal document that would safeguard the public & raise the status of the colposcopist.

Future research in colposcopyFuture research in colposcopy( Hilgarth,1998)( Hilgarth,1998)

1. Computerized colposcopic documentation & consecutive analysis of colposcopic findings.

2. Clinical significance & biologic behavior of minor lesions visible with colposcopy in the presence of different HPV types.

3. Clinical significance & relation to HPV infection of minor lesions beyond the TZ.

4. Vulvar lesions in vulvodynia related to HPV infection.

Future of colposcopy (Niekerk,1998)

1. There are going increasing costs of medical care & the demand for better quality control will intensify.

2. Technical advances will revolutionize this area & digital imaging, the storage of up to 4.500 images on an optical disk & rapid teletransmission of images will become practical..

The use of these new technologies for better & more cost effective patient care is the

challenge we will have to meet in the 21st century.

Benha University Hospital. EGYPT

E-mail: elnashar@hotmail.com