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  1. 1. Benha Univesity Hospital, EGYPT Colposcopy Aboubakr Elnashar
  2. 2. Aboubakr Elnashar
  3. 3. Aboubakr Elnashar
  4. 4. Cervical intraepithelial neoplasia (CIN): It includes Dysplasia & CIS CIN 1 =Mild D. CIN 2=moderate D. CIN 3=Severe D or CIS. Low grade CIN=CIN 1 or HPV. High grade CIN=CIN 2 or 3 Aboubakr Elnashar
  5. 5. CINI CINII CINIIIAboubakr Elnashar
  6. 6. HPV Microinvasion Aboubakr Elnashar
  7. 7. Squamous intraepithelial lesion (SIL): includes HPV & CIN. Low grade SIL =CIN 1 or HPV. High grade SIL= CIN 2 or 3 Aboubakr Elnashar
  8. 8. Aboubakr Elnashar
  9. 9. History Hinselmanin (1925) Aboubakr Elnashar
  10. 10. Historic events related to colposcopy 1925: Invention of colposcope (Hinselman) 1928: Schiller test 1938: Acetic acid test (Hinselman) 1939: Green filter (Kratz) 1940: Pap test 1942: First photographs of cervix (Treite) 1960: Cryosurgery 1980: Laser surgery 1988: Computer-aided colposcope 1989: LLETZ (Prendiville & Cullimore) 1991: Pap Net 2000: Telecolposcopy (Harper et al)Aboubakr Elnashar
  11. 11. Instrument low power stereoscopic microscope. Its fundamental parts are 3: 1. An optical system that offers magnification between 6 & 40. The focal length is between 20 & 30 cm. 2. An axial illumination system (tungsten or halogen lamp) 3. A mounting device that permits easy movements of the apparatus. Aboubakr Elnashar
  12. 12. It is fitted with 3: 1.Green filter for easier observation of the vessels 2.Camera for photography 3.Monocular teaching arm. Aboubakr Elnashar
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  16. 16. Equipments needed 1.Examination table. 2.Instruments: a.Self-retaining vaginal speculum b. Endocervical speculum c. Dressing forceps d. Equipments for biopsy: punch biopsy forceps, endocervical curette, Iris hooks, single toothed tenaculum, solutions to stop the bleeding, formalin e. Equipments for cytology: spatula, fixatives Aboubakr Elnashar
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  18. 18. 3. Solutions: a. Saline b. Acetic acid (3-5%) c. Lugol, s iodine solution 4. Cotton swabs or dry gauze. 5.Documentation facilities: special form cervicogram Aboubakr Elnashar
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  20. 20. Modern colposcopes New optical lenses, fiberoptic light sources & Videocameras, digital computer Enhancement Manipulation according to physician,s preference. Telecolposcopy (Harper et al,2000) Aboubakr Elnashar
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  22. 22. Indications of colposcopy 1. Part of any gynecologic examination 2. 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 warts 9. Evaluation of sexual assault victims. Aboubakr Elnashar
  23. 23. •Screening colposcopy More sensitive & more cost effective than cytological screening. When access to cytopathology is difficult (Cecchini et al,1997). •Portable colposcopy in rural areas is cost effective & highly acceptable (Martin et al,1998). Aboubakr Elnashar
  24. 24. 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 Aboubakr Elnashar
  25. 25. Steps 1.Inspection of unprepared cervix 2.Inspection of the cervix after application of saline 3.Inspection with green filter 4.Inspection after application of acetic acid 5.Inspection after application of Lugol s iodine Aboubakr Elnashar
  26. 26. .± Exposure of the lower cervical canal (endocervical speculum) .± Biopsy: from that part with greatest degree of abnormality 1. Punch. False negative rate up to 54% (Buxton et al,1991) Multiple biopsies Excisional techniques are superior to destructive techniques 2. Loop excision 3.Endocervical curette: ECB has replaced ECC 4. Cone. Aboubakr Elnashar
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  28. 28. .To stop bleeding after biopsy: compression with gauze, ferric sulphate (Monsel s) soln., silver nitrate, Albothyl concentrate, vaginal gauze pack, stitches .Documentation: 1. Colposcopy record form 2. Longhand drawing 3. Colpophotography 4. Video-camera Aboubakr Elnashar
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  30. 30. Colposcopy evaluates changes in the: terminal vascular network surface epithelium after application of acetic acid. Colposcopy is based on evaluation of the transformation zone (T.Z). Colposcopy: Cervix Vulva Vagina. Aboubakr Elnashar
  31. 31. Diagnostic criteria .Vascular pattern: 1.Normal & benign: branched, hairpin & network. It is tree like branching 2.Preinvasive & invasive: Mosaic, punctation & atypical vessels Matue-Aragones classification: I.Normal fine capillary network II.Increased as in vaginitis III. Dilated as in ATZ G1 IV. Irregular as in ATZ G2 &3 V. Atypical as in invasive cancer. Aboubakr Elnashar
  32. 32. .Inter-capillary distance (ICD): Increased in preinvasive & invasive lesions. Decreased in inflammatory lesions Measured by comparing with that of adjacent normal epithelium or colpophtograph. Aboubakr Elnashar
  33. 33. .Contour: 1.Smooth (original sq. epi.) 2. Grape like (col. Epi. & ectopy) 3. Slightly elevated (preinvasive lesions) 4. Nodular, polypoidal or ulcerated (invasive lesions) . Aboubakr Elnashar
  34. 34. .Color: Contrast is more important. CIS is darker than dysplasia & much darker than normal epi. Invasive cancer is whitish with glazed gelatinous appearance. Aboubakr Elnashar
  35. 35. .Clarity of demarcation: 1.Sharp: CIN 3 2. Diffuse: CIN 1 & inflammatory lesions . Aboubakr Elnashar
  36. 36. .Whiteness after acetic acid: .Density of whiteness .Time needed for whiteness to appear & disappear .Sharpness of demarcation .Presence of punctation or mosaic Aboubakr Elnashar
  37. 37. .Negativity of Iodine test: beneficial test. .Appearance of gland opening. .Surface extent of the lesion: The larger the colposcopic lesion, the more likely it is to be high grade large CIN 3 lesions are more likely to have areas of micro-invasion than small lesions. The size of the lesion being considered to be a more important prognostic indicator for invasion than histological grading Aboubakr Elnashar
  38. 38. Advantages 1.Can be applied at each gynecologic examination 2.Immediate & exact diagnosis 3.Determine the site & the extent of the lesion 4.The method is not very expensive. 5.The method can be learned by every physician through self-study or continuing education. Aboubakr Elnashar
  39. 39. 6.Differentiate between inflammatory atypia & neoplasia, between invasive & non-invasive lesions. 7.HPV are best detected by colposcopy. 8.Helps to avoid unnecessary smear, biopsy, conization, hystrectomy 9.Cytologic smears may be obtained under colposcopic direction 10.Good for follow-up. Aboubakr Elnashar
  40. 40. Disadvantages Inadequate for detection of endocervical lesions. Aboubakr Elnashar
  41. 41. 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 Aboubakr Elnashar
  42. 42. Normal Aboubakr Elnashar
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  48. 48. Abnormal Aboubakr Elnashar
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  57. 57. Suspect invasive cancer Aboubakr Elnashar
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  60. 60. Unsatisfactory Aboubakr Elnashar
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  62. 62. Miscellaneous Aboubakr Elnashar
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  67. 67. Colposcopy of the vulva *Steps: 1.Examination after smearing with a water soluble lubricant. 2. Prolonged acetic acid test 3.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. Aboubakr Elnashar
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  70. 70. Thank You Aboubakr Elnashar Aboubakr Elnashar