ColposcopicNomenclature
22. JahrestagungderArbeitsgemeinschaftfurZervixpathologie und Kolposkopie AG CPC
walterprendiville
IFCPC
Evolution of terminology Progress evolves from clear understanding of
existing research and experience and clarity of terminology is fundamental to this
It is not possible to compare apples with oranges or to understand precisely published evidence where terminology is unclear
cone biopsy (UK) with cone biopsy (US),
Height
Depth
atypia
Practice variation in OB/GYN
C Section, 3rd stage of labour
Antenatal V/E
Hysteroscopy
Management of Endometrial Cancer
Colposcopy
Evolution of colposcopy
First colposcope :: Hamburg
Early colposcopic skills image recognition, diagnosis of HSIL, recognition of microinvasion
Late colposcopic skills = discriminating between normal and
abnormal
facilitating precise treatment
MODERN COLPOSCOPY
Objective and easily achieved
skills through structured training as
part of a QA service
Risk assessment using biomarkers
and patient characteristics
Modified treatment techniques
Variation in colposcopy and
treatment
Colposcopy is not a defined entity and performs differently in different settings
Treatment is not a defined entity and produces different results and complications in different settings
Nomenclature varies in interpretation and we therefore can not easily compare practice
Colposcopy is not a defined entity
and performs differently in
different settings
Colposcopy performed by variably trained colposcopists who do not adhere to strict quality assured practice or self audit is completely different to colposcopy in a region where QA, adherence to best evidence guidelines and CME are the norm’
Why is there such a difference in
colposcopic reward
ALTS 11.5% CIN 2+ after a normal colposcopy
72.3% of CIN2+ found at original colposcopy
UK NHS study 5.3% CIN2+ after a normal colposcopy94.6% of CIN2+ found at original colposcopy
Why is there such a difference in
colposcopic reward
In the UK NHS CSP colposcopy setting the risk ofmissing high grade disease appears to be much lowerthan in the equivalent US setting
Why is this?
Why is there such a difference in
colposcopic reward
In the UK there existsA comprehensive training programmePreceptor basedStrict number of cases under supervision
and subsequently unsupervised Ongoing assessment during trainingExit exam (OSCE)30% failure rate
Why is there such a difference in
colposcopic reward
In the UKColposcopy practice
Devoted colposcopy clinicsAll women referred with a suspected abnormalityRate of CIN relatively highNot rewarded according to
procedures performedComprehensive audit of practice
Treatment is not a defined entity
and produces different results and
complications in different settings
The resection of a small type 1 TZ is easy and associated with minimal morbidity
The resection of a large Type 3 TZ is difficult and associated with significant short and long term morbidity
13
Preterm delivery (<37W): Excision vs no treatment ~heigth
Height < 10mm
Risk ratio
.1 .2 .5 1 2 5 10
Risk ratio (95% CI)
Raio, 1997 0.52 ( 0.06, 4.83)
Sadler, 2004 0.99 ( 0.57, 1.72)
Samson, 2005 3.02 ( 1.65, 5.53)
Nohr, 2007 0.83 ( 0.21, 3.25)
Overall 1.32 ( 0.59, 2.95)
Risk ratio
.1 .2 .5 1 2 5 10
Raio, 1997 4.64 ( 1.20, 17.88)
Sadler, 2004 1.64 ( 1.13, 2.37)
Samson, 2004 3.84 ( 1.66, 8.88)
Nohr, 2007 2.46 ( 1.45, 4.16)
Overall 2.39 ( 1.55, 3.69)
Height >= 10mm
Risk ratio (95% CI)
Risk of preterm labourafter LLETZ Does size matter,
A retrospective study
Khalid S, Dimitriou E &Prendiville W
BSCCP (poster) 2009
Excision dimensions and preterm labourKhalid S, Dimitriou E & Prendiville W2009
1999 - 2002
Obstetric &Colpodatabases
353 pregnancies in women after LLETZ
Excision dimensions and preterm labourKhalid S, Dimitriou E & Prendiville W2009
Increased risk of
preterm labour if specimens larger than 6 cubic cms
RR 3.17, 95%CI 1.56 -6.38
Excision dimensions and preterm labourKhalid S, Dimitriou E & Prendiville W2009
Increased risk of
preterm labour if specimens thicker than 12 mms
RR 3.05, 95%CI 1.37 -7.08
2011 IFCPC colposcopic terminology of the cervix(draft – May 2011)
SCJ visualization: complete/partial/noneAdequate/inadequate for the reason … (i.e.: cervix obscured by inflammation, bleeding, scar)
Basic definitions
Deciduosis in pregnancy,Atrophic epithelium,Nabothian cyst,Gland (crypt)openings
Original squamous epithelium,Columnar epithelium
including ectopy,Transformation zone types 1,2,3
Normal colposcopic findings
Inside or outside the T-zone,Numberof cervical quadrantsthe l esioncovers ,Size of the lesion in percentage of cervix,Lugol’s staining (Schiller’s test): stained/non-stained
General principles
Abnormal colposcopic findings
Fine mosaic,Fine punctation
Fine aceto-white epitheliumGrade 1(Minor)
Rapid appearance of acetowhitening,
Cuffed gland (crypt)openings
Sharp border,Exophytic lesion,Inner border sign,Ridge sign
Dense aceto-white epithelium,Coarse mosaic,Coarse punctuation,Leukoplakia
Grade 2(Major)
Atypical vessels, fragile vessels, Irregular surface, Necrosis, Ulceration (necrotic), tumor/gross neoplasm
Suspicious for invasion
Stenosis,Congenital anomaly,
Post treatmentconsequence
Endometriosis,Condyloma,Polyp (Ectocervical/endocervical)
Erosion(traumatic)
Inflammation
Miscellaneous finding
Nomenclature committee 2011
Jim Bentley - Canada
Jacob Bornstein – Israel (Chairman of the Committee)
Peter Bosze – Hungary
Frank Girardi – Austria
Hope Haefner - USA
Michael Menton – Germany
MyriamPerrota – Argentina
Walter Prendiville – Ireland
Peter Russell - Australia
Mario Sideri – Italy
The new IFCPC nomenclature for cervix,
(vagina and vulva)WWW.IFCPC.ORG
Bornstein et al
Amer J Obstet Gynecol
Vol 120 No 1 July 2012
2011 committee considerations
Establish an evidence base
KeratosisvLeukoplakia
Inside/outside TZ
Size of lesion
Inner border and ridge signs
Treatment types
Abnormal vessel
Coarse punctation
Colposcopic features suggestive of
highgrade disease (major change)
A generally smooth surface with an sharp outer border.
Dense acetowhite change, that appears early and is slow to resolve; it may appear oyster white.
Iodine negativity, a yellow appearance in a previously densely white epithelium.
Coarse punctation and wide irregular mosaics of differing size.
Dense acetowhite change within columnar epithelium may indicate glandular disease.
New S C Junction
Columnar
Original
squamous epithelium
Crypt openings
Dr SC Quek
Polyps
Size of cervical lesions
Kierkegaard 1995: lesion size has independent predictive value
Ferris 2005: Size of cervical lesions correlates directly with the severity of disease.
Hopman et al. 1995 reported an inter-observer agreement rate of 68% when evaluating colposcopicphotographs for lesion size.
Hammes 2007: Lesions >50% of cervix had higher probability for high-grade lesion / carcinoma (OR, 3.45).
Prof Jacob Bornstein
New colposcopic sign- Ridge signAn opaque acetowhite ridge
at the squamocolumnar junction
Prof Jacob Bornstein
Scheungraber C, Koenig U, Fechtel B, Kuehne-Heid R, Duerst M, Schneider A. The colposcopic feature ridge sign is associated with the presence of cervical intraepithelial neoplasia 2/3 and human papillomavirus 16 in young women. J Low Genit Tract Dis. 2009;13(1):13-16.
A New Scoring System
Strander et al 2005
Designed to evaluate a scoring system for high grade lesions
297 examinations of women referred for colposcopy, Department of Obstetrics and Gynecology, Göteborg, Sweden
First Scoring system to incorporate lesion size as a variable
Subsequently validated at the Royal Free
Aceto-white
colour
Iodine stainingVascular Pattern
Peripheral Margins
0 1 2 Score
ACETO UPTAKE Zero or transparent Shady, Milky
(not transparent
not opaque)
Distinct, opaque
white
MARGINS/
SURFACE
Diffuse Sharp but
irregular, jagged,
“geographical”
Satellites
Sharp and even,
difference in
surface level incl
“cuffing”
VESSELS Fine, regular Absent Coarse or atypical
LESION SIZE <5mm 5-15mm or 2
quadrants
>15mm or 3-4
quadrants or
endocervically
undefined
IODINE STAINING Brown Faintly or patchy
yellow
Distinct yellow
Total score 10
The transformation zone
A Type 1 transformation zone is completely ectocervical and fully visible, and may be small or large
A Type 2 transformation zone has an endocervical component, is fully visible, and may have an ectocervical component that may be small or large
A Type 3 transformation zone has an endocervical component that is not fully visible and may have an ectocervical component that may be small or large
Type 1
• Completely ectocervical
• Fully visible
• small or large
Transformation Zone
Classification
SBX1739_3Histology CIN1
Cytology LSIL,CIN 1;Atyp
endocerv,
neopl
Carcinogenic
HPV
16, 58, 66
Age 28
Category Mario Walter
SCJ visibility Fully Visible Fully Visible
TZ type Type 1 - Small Type 1 - Small
TZ pattern Abnormal Grade 1 Abnormal Grade 2
Image quality Good Good
Jim Usha
Partially Visible Partially Visible
Type 2 - Large Type 1 - Large
Abnormal Grade 2 Normal
Good Limited
SBX1759_3Histology CIN3
Cytology LSIL,CIN 1;Atyp
endocerv,
neopl
Carcinogenic
HPV
16, 51
Age 25
Category Mario Walter
SCJ visibility Partially Visible Fully Visible
TZ type Type 2 - Small Type 1 - Small
TZ pattern Abnormal Grade 2 Abnormal Grade 1
Image quality Good Limited
Jim Usha
Fully Visible Fully Visible
Type 1 - Small Type 1 - Small
Abnormal Grade 1 Normal
Good Good
Type 2
• has endocervicalcomponent
• Fully visible
• may have ectocervial
component which may be small or large
Transformation Zone
Classification
SBX1842_1Histology CIN3
Cytology HSIL,CIN
3;Adeno, NOS
Carcinogenic
HPV
16, 18
Age 30
Category Mario Walter
SCJ visibility Partially Visible Partially Visible
TZ type Type 3 - Small Type 2 - Small
TZ pattern Abnormal Grade 2 Suspicious for invasion
Image quality Limited Limited
Jim Usha
Fully Visible Fully Visible
Type 2 - Small Type 1 - Small
Abnormal Grade 2 Abnormal Grade 2
Good Limited
Transformation Zone
Classification
Type 3
• has endocervicalcomponent
• is not fully visible
• may have ectocervial
component which may be small or large
SBX1216_2Histology CIN3
Cytology HSIL,CIN 2;Adeno in situ (AIS)
Carcinogenic HPV 31
Age 21
Category Mario Walter
SCJ visibility Not Visible Partially Visible
TZ type Type 3 - Small Type 2 - Small
TZ pattern Abnormal Grade 1 Abnormal Grade 2
Image quality Good Good
Jim Usha
Not Visible Fully Visible
Type 3 - Small Type 1 - Large
Abnormal Grade 2 Abnormal Grade 1
Good Good
SBX1774_1Histology CIN3
Cytology HSIL,CIN
3;Adeno, NOS
Carcinogenic
HPV
16
Age 47
Category Mario Walter
SCJ visibility Not Visible Partially Visible
TZ type Type 3 - Small Type 2 - Small
TZ pattern Abnormal Grade 2 Suspicious for invasion
Image quality Good Good
Jim Usha
Not Visible Not Visible
Type 3 - Small Type 3 - Large
Suspicious for invasion Suspicious for invasion
Good Good
SBX1928_1Histology CIN3
Cytology HSIL,CIN
3;Adeno, NOS
Carcinogenic
HPV
16, 39
Age 30
Category Mario Walter
SCJ visibility Not Visible Not Visible
TZ type Type 3 - Small Type 3 - Small
TZ pattern Abnormal Grade 2 Abnormal Grade 2
Image quality Good Good
Jim Usha
Partially Visible Fully Visible
Type 3 - Small Type 1 - Small
Abnormal Grade 1 Abnormal Grade 1
Good Good
The BSCCP invites
you to the
15th World
Congress
On behalf of
IFCPC
In London
26-30th May 2014
www.IFCPC2014.
com
www.IFCPC2014.com
Bemvindo a Londres al 26de30 de Mayo 2014
Queen Elizabeth II conference centre
Westminster Hall for the plenary sessions
Up to 2160 delegates2070 m2 exhibition space
¡NosvemosemLondres ! 2014
St James’s Park – 5 minutes walk from venue
Shopping...................
Covent Garden, London
National Institute of Medical Research- The biology of HPV and molecular markers
Wolfson Institute of Preventive of Medicine- Screening across the world
St Thomas’s Hospital – Improving Cytology
Institute of Women’s Health
Imperial College
Post Congress Seminars
See you in London