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  1. 1. Introduction to Colposcopy
  2. 2. Indication for Colposcopy <ul><li>Epithelial cell abnormalities detected by cervical cytology </li></ul><ul><li>Positive high risk HPV DNA in ASC-US triage </li></ul><ul><li>Suspicious cervical lesions </li></ul><ul><li>Vulvar or vaginal neoplasia </li></ul><ul><li>History of in-utero DES exposure </li></ul><ul><li>Sexual partner of patients with genital tract neoplasia </li></ul><ul><li>Oncogenic Human Papillomavirus in appropriate guideline algorithms </li></ul><ul><li>Unexplained vaginal bleeding </li></ul><ul><li>Post–coital bleeding </li></ul><ul><li>Positive screening test by Cervicography or Speculoscopy </li></ul>
  3. 3. Basic Satisfactory Requirements of Colposcopic Exam <ul><li>Adequate Visualization </li></ul><ul><li>Entire TZ Zone seen </li></ul><ul><li>Abnormal areas seen in entirety </li></ul><ul><li>Endocervical Canal free of Dysplasia </li></ul><ul><li>No Evidence of Invasive Cancer </li></ul><ul><li>Abnormal Areas Biopsied </li></ul><ul><li>ECC Completed (Non-Pregnant patients) </li></ul>
  4. 4. Colposcopy - Objectives <ul><li>Determines the presence of invasive cancer </li></ul><ul><li>Localizes the squamocolumnar junction </li></ul><ul><li>Identifies the most severe disease for biopsy </li></ul><ul><li>Evaluates the extent of disease </li></ul>
  5. 5. Instrumentation Procedure <ul><li>Colposcope </li></ul><ul><li>Vaginal speculum </li></ul><ul><li>Endocervical speculum </li></ul><ul><li>Large & small swabs </li></ul><ul><li>Endocervical curette </li></ul><ul><li>Cervical biopsy forceps </li></ul><ul><li>Solutions: </li></ul><ul><ul><li>Normal saline </li></ul></ul><ul><ul><li>Acetic Acid </li></ul></ul><ul><ul><li>Monsel’s </li></ul></ul>
  6. 6. Instrumentation
  7. 7. Collin’s bivalve specula of different sizes Vaginal side wall retractor Endocervical speculum Cervical punch biopsy forceps with sharp cutting edges
  8. 8. A method of identifying outer & inner borders of the transformation zone
  9. 9. Colposcopic Examination <ul><li>Obtain Pap, cultures, KOH as Needed </li></ul><ul><li>Perform Cervical Colposcopic Exam </li></ul><ul><li>Use Green Filter, if needed </li></ul><ul><li>Mentally Map Cervical Landmarks and abnormal areas </li></ul><ul><ul><li>Colposcopic magnification of 10X – 15X </li></ul></ul><ul><li>Is Exam Satisfactory? </li></ul>
  10. 10. Look for <ul><li>Satisfactory Colposcopy: </li></ul><ul><ul><li>360 degree view of the T-zone </li></ul></ul><ul><ul><li>Proximal and distal extent of cervical lesions seen </li></ul></ul><ul><li>Gross lesions or Pathology </li></ul><ul><ul><li>Tumors </li></ul></ul><ul><ul><li>Infections </li></ul></ul><ul><li>Don’t forget to check for vaginal and vulvar lesions </li></ul>
  11. 11. Collection of Target Biopsy <ul><li>Select the most severe lesion </li></ul><ul><li>Sharp instruments </li></ul><ul><li>2-3 mm biopsy </li></ul><ul><li>Colposcopically assisted always! </li></ul><ul><li>Biopsy at the SCJ </li></ul><ul><li>Monsel's solution /cauterisation for hemostasis </li></ul>
  12. 12. Satisfactory Colposcopy exam <ul><li>360 degrees of squamocolumnar junction visualized </li></ul><ul><li>Proximal and distal extent of cervical lesions identified </li></ul><ul><li>Cytology, colposcopic impression and histology correlate </li></ul>
  13. 14. SCJ
  14. 15. Multiple nabothian cysts in the mature squamous metaplastic epithelium occupying the ectocervix Nabothian cyst with regularly branching tree like vessels
  15. 16. Normal vascular pattern
  16. 17. Definition <ul><li>Vertical single loop intraepithelial capillaries viewed end on in a demarcated area </li></ul><ul><li>Etiology </li></ul><ul><li>Normal vascular pattern </li></ul><ul><li>Abnormal modification of existing vascular architecture </li></ul><ul><li>Arises from the normal original columnar epithelial angioarchitecture </li></ul>Punctation
  17. 18. Colposcopic Appearance <ul><li>Red dots usually seen within an area of acetowhite epithelium </li></ul><ul><li>Variable with increasing severity of disease </li></ul><ul><li>Increasing caliber of dot from fine to coarse </li></ul><ul><li>Increasing intercapillary distance </li></ul>
  18. 19. Coarse punctation Coarse punctation before & after application of acetic acid
  19. 20. Differential and Significance <ul><li>May result from inflammation, repair, viral effects, neoplasia or the variant of fetal metaplasia (congenital t-zone) </li></ul><ul><li>May represent normal to neoplasia </li></ul><ul><li>Vessel caliber and intercapillary distance predict the severity </li></ul><ul><li>Average intercapillary distance is 100 microns </li></ul><ul><li>Increases with progressive neoplasia </li></ul>
  20. 21. Mosaic <ul><li>Intra epithelial capillaries encompassing blocks or buds forming a mosaic, tile or “chicken wire” pattern </li></ul><ul><li>May be normal or abnormal modification of existing vascular architecture </li></ul><ul><li>Red, tile-like grid usually viewed within acetowhite epithelium </li></ul><ul><li>Fine or coarse caliber </li></ul><ul><li>Variable intercapillary distance with increasing severity of neoplasia </li></ul>
  21. 22. Mosaic: Differential and Significance <ul><li>May be seen in the normal variant of fetal metaplasia (congenital t-zone) </li></ul><ul><li>Represented in any level of neoplasia </li></ul><ul><li>May be observed in benign tissue (not aceto-white) </li></ul><ul><li>Caliber and intercapillary distance predict the severity of disease </li></ul>
  22. 23. Atypical Vessels <ul><li>Superficial blood vessels exhibiting bizarre variation in caliber, course and branching pattern </li></ul><ul><li>Develop in response to tumor angiogenesis factor (TAF) </li></ul><ul><li>Result in chaotic, rapidly proliferating vessels attempting to nourish rapidly in neoplastic tissue </li></ul><ul><li>Lack systematic, uniform branching </li></ul>Atypical vessels pattern ِ
  23. 24. <ul><li>ASSOCIATED WITH CANCER UNTIL PROVEN OTHERWISE </li></ul><ul><li>May be observed in areas of immature metaplasia </li></ul><ul><li>Colposcopically directed biopsy is mandatory </li></ul>Atypical Vessels: Differential and Significance
  24. 25. Post Menopausal Cervix: Epithelium is pale, brittle, lacks lusture, shows sub-epithelial petichiae, SCJ not visualized The entire new SCJ is visible colposcopic examination is satisfactory. the TZ is fully visualized. The metaplastic squamous epithelium is pinkish-white compared to the pink original squamous epithelium
  25. 26. Squamous metaplasia Earliest colposcopic changes in immature squamous metaplasia (after 5% AA) in which tips of columnar villi stain white & adjacent villi start fusing together Prominent white line corresponds to the new SCJ & tongues of immature Squamous metaplasia a) with crypt openings at 4-8 o’clock positions b) after application of AA
  26. 27. Immature squamous metaplastic epithelium (narrow arrow) on the polyp with intervening areas of columnar epithelium a) after application of AA The endocervical polyp & the immature squamous metaplasia surrounding the os partially take up iodine.
  27. 28. Leukoplakia <ul><li>Usually benign </li></ul><ul><li>May obscure an underlying neoplasia </li></ul><ul><li>Therefore, all patches observed before application of acetic acid must be biopsied </li></ul>Hyperkeratosis ( Leukoplakia)
  28. 29. Geographic satellite lesion condyloma low-grade lesion
  29. 30. Thin acetowhite lesion with geographic margins in the upper lip. Histology indicated CIN 1 Moderately dense acetowhite lesions with irregular margins in the anterior & posterior lips ( CIN 1)
  30. 31. circumorificial acetowhite CIN 1 lesion with irregular margin & fine mosaics
  31. 32. Moderately dense acetowhite lesions with well defined margins & coarse punctations in the anterior lip & in 3 o’clock position (CIN 2 lesion Dense well defined acetowhite area with regular margins & coarse mosaic ( CIN 2 lesion )
  32. 33. A dense acetowhite lesion with varying colour intensity & coarse mosaics (a) in a CIN 2 lesion Acetowhite lesions with coarse punctation (a) & mosaics (b) in a CIN 2 lesion
  33. 34. A circumoral dense opaque acetowhite area with coarse mosaics ( CIN 3 lesion) A dense acetowhite lesion with regular margin & coarse, irregular punctation in a CIN 3 lesion.
  34. 35. Modified Reid Score
  35. 37. Early invasive cancer: note the raised irregular mosaics with umbilication (a), breaking mosaics (b), surface irregularity & the atypical vessels after the application of 5% AA Preclinical invasive Carcinoma
  36. 38. Atypical Vessels pattern ِ Note the irregular surface contour with mountains & valleys appearance with atypical blood vessels in the dense acetowhite area Invasive cervical cancer
  37. 39. A dense acetowhite lesion in the endocervical canal visible after stretching the os with a long dissection forceps (adenocarcinoma in situ) Glandular lesions
  38. 40. Adenocarcinoma in situ: The tips of some of the columnar villi turn densely white compared to the surrounding columnar villi after the application of acetic acid (arrow). The nabothian cysts turn white after the application of AA
  39. 41. the greyish white dense acetowhite lesion with character writning-like atypical blood vessels(a) The elongated, dense acetowhite lesion with irregular surface in the columnar epithelium with atypical blood vessels (a) Adenocarcinoma:
  40. 42. Reddish “angry-looking”, inflamed columnar epithelium with loss of the villous structure & with inflammatory exudate (before application of 5% AA) Inflammatory lesions of the Uterine Cervix Chronic cervicitis: This cervix is extensively inflammed with a reddish appearance & bleeding on touch, there are ill-defined, patchy acetowhite areas scattered all over the cervix after the application of AA
  41. 43. TV after Acetic acid T.V. After Lugol’s Multiple red spots (a) suggestive of Trichomonas vaginalis colpitis ( strawberry appearance), after application of 5% AA Trichomonas vaginalis colpitis after application of Lugol’s iodine (leopard-skin appearance)
  42. 44. Lines of treatment <ul><li>No treatment </li></ul><ul><li>Follow up </li></ul><ul><li>LEEP </li></ul><ul><li>Cryotherapy </li></ul><ul><li>Laser </li></ul><ul><li>Cone biopsy </li></ul><ul><li>Hysterectomy </li></ul>