Presented in the BSCCP Annual Meeting 2009

1. Colposcopy - Abnormal
Appearance
Ayman Ewies
Consultant Gynaecologist
The Ipswich Hospital
24th April 2009

2. Terminology of Precancerous Lesions

3. 3
Cytological Terminology
 It was proposed by “the British Society for Clinical
Cytology” in 1987 to be used for smear reporting.
 The appearances of the cells are classified into:
1. Mild dyskariosis.
2. Moderate dyskariosis.
3. Severe dyskariosis.
4. Borderline nuclear abnormalities.
5. Severe dyskariosis ?invasive disease.
6. ?Glandular neoplasia (where the dyskariosis appear to be in
glandular cells).
 The various abnormalities can co-exist but management is
dictated by the worst diagnosis.

4. 4
Cytological Terminology
 Dyskariosis: disproportionate nuclear enlargement
in the cell in comparison with the amount of
cytoplasm.
 Dyskariotic cells:
• Have abnormal chromatin content & distribution.
• ± Have abnormal nuclear shape.

5. Normal Cells
Contain plentiful cytoplasm and regular nucleus

6. Mild Dyskariosis
= Low Grade Changes
Mildly increased nuclear / cytoplasm ratio
Mild Dyskariosis
& koilocytosis
N

7. Moderate or Severe Dyskariosis
= High Grade Changes
Considerably increased nuclear / cytoplasm ratio

8. Koilocytosis
 Perinuclear vacuolation.
 Associated with HPV infection.
 May occur in association with all grades of cytological
abnormality.
NN

9. 9
Histological Terminology
 The histological classification reflects the depth of
epithelial involvement.
 2 classifications are used universally:
1. WHO classification.
2. CIN classification (Richart, 1967).

10. Histological Terminology
Richart (1967) WHO
CIN 1 Mild dysplasia
Abnormal cells occupy basal 1/3
of the epithelium
CIN 2 Moderate dysplasia
Abnormal cells occupy 1/3 - 2/3
of epithelium
CIN 3 Severe dysplasia
Abnormal cells occupy > 2/3 of
epithelium

11. Histological Terminology
CIN is graded on the proportion of epithelium containing abnormal cells

12. 12
Histological Terminology
 A modified Richart classification was proposed by him in
1990:
1. Low grade lesions (CIN1 / HPV): unknown or low progressive
potential.
2. High grade lesions (CIN2 / 3): likely to be true cancer precursors.
 Irrespective of the terminology used there is a debate as to
whether CIN is a continuum.

13. 13
Risk of CIN Progression
 The mean time for progression of CIN to invasive cancer is
15-20 years (although it can be swift).
 Many CIN lesions will regress overtime.
 Determinants of disease regression or progression:
1. Age (women >30 years  higher risk of progression).
2. The grade of CIN
3. Size of the lesion.
4. HPV infection.
5. Smoking.

14. 14
Risk of CIN Progression
 CIN1 1/3 disappears spontaneously
1/3 persists
1/3 progress to CIN3 or invasive cancer
 CIN 2 & 3 lesions have definite progressive potentials (at
least 40%).

15. Colposcopic Assessment

16. 16
Colposcopic Parameters
1. Leukoplakia
2. Aceto-white epithelium
3. Vascular changes:
1. Mosaicism
2. Punctations
3. Atypical vessels
4. Iodine negativity

17. 17
Colposcopic Parameters
Leukoplakia
 It is visible without application of acetic acid, even with
naked eye.
 It appears as a white area of thickened epithelium:
– Patchy,
– Covers large area of the cervix, or
– Extends into the vagina
 Main significance: may obscure visualization of the TZ.
 Biopsy should always be taken.

18. Colposcopic Parameters
Leukoplakia

19. 19
Colposcopic Parameters
Aceto-white epithelium
 Application of 3-5% acetic acid  areas of high nuclear
density appear white.
 It is not diagnostic for CIN.
 Other conditions that display aceto-whitness are:
1. HPV related changes.
2. Columnar epithelium.
3. Immature squamous metaplasia
4. Healing or regenerating epithelium.
5. Congenital TZ.
6. Inflammation.
7. Invasive SCC.
8. ACIS or adenocarcinoma.

20. 20
Colposcopic Parameters
Aceto-white epithelium
 How to diagnose significant lesions?
1. More intense (denser) A/W change.
2. Well demarcated margins.
3. Sustained A/W change i.e. the epithelium holds the A/W change
longer.
4. Faster A/W change.
5. Large lesion (> 1cm2): not as good predictor as the others.
 Dense A/W change within columnar epithelium may
indicate glandular disease.

21. Colposcopic Parameters
Aceto-white epithelium - CIN 1
The border between the atypical area and normal squamous epithelium is fairly indistinct

22. Colposcopic Parameters
Aceto-white epithelium - CIN 2

23. Colposcopic Parameters
Aceto-white epithelium - CIN 3

24. Colposcopic Parameters
Aceto-white epithelium – CIN 3
Well demarcated aceto-white epithelium

25. Colposcopic Parameters
Aceto-white epithelium – CIN 3
Well demarcated aceto-white epithelium

26. Colposcopic Parameters
Aceto-white epithelium – CIN 3
An acetowhite lesion with a well-defined margin & punctation

27. Colposcopic Parameters
Aceto-white epithelium – CIN 3

28. Colposcopic Parameters
Aceto-white epithelium – CIN 3

29. Colposcopic Parameters
Aceto-white epithelium – SCC

30. 30
Colposcopic Parameters
Mosaicism
 A focal colposcopic appearance in which the new vessel
formation appears as a rectangular pattern like a mosaic.
 It is sometimes called “crazy-paving” pattern when the
capillaries are seen parallel to the surface.
 Combination of mosaic and punctation patterns often
intermingle.

31. 31
Colposcopic Parameters
Mosaicism
 There are 2 degrees:
1. Fine:
– Small.
– Fine calibre vessels surrounding small areas of regular size &
shape.
– Low grade lesion or metaplasia is more likely.
2. Coarse:
– Wide.
– Coarser, more hyperaemic, more superficial vessels
surrounding irregular fields, with wider intercapillary distance.
– High grade lesion is more likely.

32. Colposcopic Parameters
Mosaicism - CIN 3

33. Colposcopic Parameters
Mosaicism - CIN 3

34. Colposcopic Parameters
Mosaicism - CIN 3

35. Colposcopic Parameters
Mosaicism - CIN 3

36. Colposcopic Parameters
Mosaicism - SCC

37. Colposcopic Parameters
Mosaicism - SCC

38. Colposcopic Parameters
Mosaicism - SCC

39. Colposcopic Parameters
Mosaicism - SCC

40. 40
Colposcopic Parameters
Punctation
 A focal colposcopic pattern in which capillaries appear in a stippled
pattern.
 Basic unit of this structure is the single, looped capillary within the
stromal papilla, seen end-on as a dot and coursing obliquely or
perpendicularly towards the surface of the epithelium.
 2 degrees:
1. Fine punctation:
– Capillaries of narrow calibre, closely spaced, forming regular patterns.
– Low grade lesion or metaplasia is more likely.
2. Coarse punctation:
– Capillaries of increased calibre, irregularly spaced, forming irregular patterns
even coiled (corkscrew) vessels.
– High grade lesion is more likely.

41. Colposcopic Parameters
Punctation

42. 42
Colposcopic Parameters
Atypical Vessels
 The blood vessels pattern appears not as the finely
branching capillaries of a normal epithelium, but rather as:
“irregular vessels with an abrupt and interrupted
course appearing as
-Commas
-Corkscrew
-Spaghetti-like”
 Invasive lesions have new vessels demonstrating gross
variation in caliber, branching and arrangement.
– The inter-capillary distance is much greater than found in normal
epithelium.

43. Colposcopic Parameters
Atypical Vessels - SCC

44. Colposcopic Parameters
Atypical Vessels - SCC

45. 45
Colposcopic Parameters
SCC

46. 46
Colposcopic Parameters
Application of Lugol’s Iodine (Schiller’s test)
 Mature squamous epithelium  Mahogany brown (-ve
Schiller’s test).
 Failure to take up iodine stain (+ve Schiller’s test):
1. Squamous metaplasia
2. Low oestrogen state (atrophy)
3. Columnar epithelium
4. CIN
 This test is useful for the beginner in delineating any
abnormalities.

47. 47
Colposcopic Parameters
Application of Lugol’s Iodine (Schiller’s test)
CIN 3: The atypical area fails to stain “Schiller’s test positive”

48. Colposcopic features of low grade V high grade CIN
Low grade CIN High grade CIN
Smooth surface with irregular outer
border
Smooth surface with sharp outer
border
Slight aceto-white change; slow to
appear and quick to disappear
Dense aceto-white change; appears
early and is slow to resolve
Mild, often speckled iodine partial
positivity
Iodine negativity
Fine punctation and mosaicism Coarse punctation and mosaicism
Dense aceto-white change within
columnar epithelium may indicate
glandular disease

49. 49
Colposcopic features suggestive of invasive cancer
 Irregular surface, rolled edges, ulceration or raised lesion.
 Dense aceto-white change.
 Wide irregular punctation and mosaicism.
 Atypical vessels.
 N.B.: Invasive disease may present as an overt exophytic
fragile mass.

50. Colposcopic Parameters
SCC
Stage 1B1

51. 51
HPV and CIN Differential Diagnosis
1. CIN lesions tend to be confined to the TZ, whereas benign
HPV lesions may also exist in the native squamous
epithelium.
2. HPV lesions can be apparent prior to acetic acid
application.
3. CIN lesions may show characteristic features such as
punctations and mosaicism.
4. CIN lesions are sharply demarcated from the normal
epithelium (HPV lesions are indistinct or fuzzy)
5. CIN lesions almost always do not stain with iodine.

52. Unsatisfactory Colposcopy

53. 53
Unsatisfactory Colposcopy
 TZ / SCJ cannot be visualized in its entirety.
 Trauma.
 Inflammation.
 Atrophy.
“Consider it even if only CIN 1 is suspected or
diagnosed with punch since occult high grade CIN
might be present”

54. Unsatisfactory Colposcopy
CIN 1
SCJ is not entirely seen

55. Flow Chart for Managment

56. Colposcopy Flow Chart for Management
Abnormal findings
Unsatisfactory Colposcopy
?Malignancy
?Malignant cells on CytologyRepeat Cytology
F/U ± Diagnostic LLETZ
Abnormal Cytology
Colposcopy
Normal findings
Satisfactory Colposcopy
If still abnormal Diagnostic LLETZ or Cone
Abnormal Findings
Satisfactory Colposcopy
Punch Biopsy V See & Treat
SCCHPV
Observe by Cytology ± Colposcopy
CIN 1 CIN 2-3
LLETZ Surgery V Adjuvant

57. Practicing Colposcopy Is Enjoyable!