Colposcopy2 1

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Colposcopy2 1

  1. 1. Colposcopy
  2. 2. • Examination of cervix, vagina , vulva with a binocular microscope. PRINCIPLE • Pre-malignant and malignant cervical conditions produce colposcopically identifiable epithelial changes that generally occur within the transformation zone
  3. 3. • Focal distance usually between 250 – 300mm. • Low magnifications of 5x give birds eye view , and are best for localizing an area of interest. • For detailed exam usually 15x used, best for angioarchitecture. • Magnifications higher than 20x cause loss of orientarion.
  4. 4. Goals of Colposcopy  To detect abnormal epithelium,  To identify the area of epithelium with the highest degree of disease  To direct biopsies to that area 4
  5. 5. ANATOMY & HISTOLOGY RELEVANT TO COLPOSCOPIC ASSESSMENT
  6. 6. ECTOCERVIX – squamos epi stratified, non-keratinizing, glycogen-containing squamous epithelium. It is opaque, has multiple (15-20) layers of cells and is pale pink in colour
  7. 7. ECTOCERVIX – squamos epi  The intermediate and superficial layer cells contain abundant glycogen in their cytoplasm.  As cells mature they move upwards, increasing in size & radually losing their nuclear content. Immature cells & Neoplastic cells – • lack of normal glycogenation • High nuclear content
  8. 8. ENDOCERVIX • lined by the columnar epithelium (sometimes referred to as glandular epithelium). • composed of a single layer of tall cells with dark-staining nuclei close to the basement Membrane. • thin single cell layer allows the coloration of the underlying vasculature in the stroma to be seen more easily • The columnar epithelium forms several crypts into the substance of the cervical stroma.
  9. 9. COLPOSCOPIC APPEARANCE OF ENDOCERVIX / NS • Dark red colour due to easily visible stromal bv. • Grape like due to villi n crypts
  10. 10. ENDOCERVIX Glycogenation and mitoses are absent in the columnar epithelium. Nucleus is very small w.r.to cytoplasmic content
  11. 11. SCJ The ECTOcervix is covered by both stratified nonkeratinizing squamous and ENDOcervix columnar epithelium. These two types of epithelium meet at the squamocolumnar junction =. 2 TYPES  ORIGINAL / NATIVE.  NEW
  12. 12. Formation of NEW SCJ • SQUAMOUS METAPLASIA • Physiological replacement of the columnar epithelium with squamous epithelium • Metaplasia is most active during peripubertal and pregnancy years; the reserve cells also being most vulnerable in them
  13. 13. Transformation Zone • This is the most mitotically active area. • Cells most prone to oncogenic stimuli. • IMPORTANT because almost most cervical cancer occur in this zone
  14. 14. Transformation Zone
  15. 15. COLPOSCOPY & HISTOLOGY OF TZ • As reserve cell hyperplasia progresses to several layer thickness, columnar epithelium is pushed off and replaced, with flattening of columnar villi. When the crypts of columnar epithelium are blocked by the growing sq epi, nabothian cysts are formed. The outer extent being the limit of met epi n hence the outer limit of TZ ,ie, OLD SCJ.
  16. 16. Transformation Zone Identify new SCJ Identify old SCJ
  17. 17. Normal Colposcopic Findings
  18. 18. COLPOSCOPIC & NEOPLASTIC SIGNIFICANCE OF TZ • The older metaplastic epi will move outwards towards old SCJ, and will finally become indistinguishable from original sq epi in thickness & glycogenation. • The metaplastic epi closest to the new SCJ is the newest sq epi on the cervix. • Most cervical neoplasia occur in TZ • Within the TZ, More severe disease tends to be more cephalad where met epi most immature.
  19. 19. • For a colposcopic examination to be deemed ‘satisfactory’, the TZ must be viewed entirely, all the way upto col epi and 360⁰ around.
  20. 20. • There is a gradient of maturity in TZ . • The most mature metaplasia at periphery is acetic acid & iodine neg (like original sq epi) • Immature metaplasia is frosty acetowhite with some of the underying bv seen through at times resembling fine punctuation of Lg lesion. • The vessls overling nabothian cysts cabn be large & alarming, but will have a benign arborizing nature
  21. 21. THE COLPOSCOPIC PROCEDURE
  22. 22. INDICATIONS FOR COLPOSCOPY • • • • • • • • Abnormal Pap smear, with no gross lesion on cervix Women with PCB, metrorrhagia Persistence of inflammatory cels despite adequate treatment Grossly abnormal / unhealthy cx or vagina Women with positive high risk HPV DNA test, even if Pap neg. Trearment of women with CIN Monitoring of women treated for CIN Preop evaluation of women diagnosed with Stage Ia or b cervcal cs on cl ex & bx – to rule out vag involvement • Evaluation of women with anogenital condylomas
  23. 23. WHEN TO PERFORM COLPOSCOPY Ideally colp ex should be done under optimal hormOnal conditions, but no pt should be denied the test bcos she is not in the right phase nor bcos she has not received estrogen prior. Menstrual cycle : day8 – day 12 as cervical mucus abundant & clear, and ext os open. Postmenopausal women should ideally receive estrogen for 7 days, n colpo performed on last day of estr. Not after stopping as mucosa reverts rapidly. Colpo under adequate estr reduces chances of unsatisfactory colpo, need for ECC.
  24. 24. STEPS • • • • • • • • • Explain procedure & consent Insert speculum n visualise Apply normal saline Apply 3 – 5 % acetic acid Apply Lugol’s iodine Perform cervical biopsy from abnormal area Perform ECC , if indicated Inspect vagina, vulva, perineal areas. Bimanual & rectal examination
  25. 25. APPLYING NORMAL SALINE
  26. 26. APPLY NS HOW Swab off mucus with saline soaked swab Thoroughly moist cervix & vagina with NS GOAL To remove mucus to conduct a preliminary inspection for surface abnormalities (e.g., leukoplakia, condylomata) to identify the distal and proximal borders of the TRANSFORMATION ZONE the best way to examine THE VASCULATURE
  27. 27. NORMAL Colposcopic Findings AFTER APPLICATION OF NORMAL SALINE
  28. 28. Columnar epi = dark red grape like / villous Squamos epi = pink Metaplastic squamos = paler than original NEW SCJ based on colour difference – 360 deg Native / OLD SCJ – imaginary line through most distal crypts. Occasionally subtle color difference The entire TZ, including new SCJ, and borders of all lesions must be visualized 360oin order for colposcopy to be satisfactory
  29. 29. Viewing the TZ in difficult cases • Using a dry cotton swab, put pressure backwards on post lip to permit examn of post part of cervical canal. Similarly, ant. But lat lips not always seen. • Use endocervical speculum if needed to view entire transformation zone
  30. 30. UNSATISFACTORY COLPOSCOPY
  31. 31. VASCULATURE • NORMAL SALINE • GREEN / BLUE FILTER • 15X MAGNIFICATION – Mature sq vasc – Metaplastc sq – columnar
  32. 32. Normal vasculature - Squamos
  33. 33. Normal vasculature - Squamos • Two types of capillaries are colposcopically apparent in the native or original squamous epithelium: reticular (network) or hairpin-shaped capillaries • Usually appears as dots with only a slight, if any, appearance of a loop at each. Inflammation of the cervix (e.g., trichomoniasis) often causes hairpin vessels to form staghorn-like shapes, so that the vessels become more prominent and the loop appearance is more apparent • Often no vascular pattern is seen on the original squamous epithelium .
  34. 34. Normal vasculature – Metaplastic Squamos 3patterns •a tree branching •commonly seen overlying nabothian cysts •when healing has taken place after therapy for CIN the vessels are long and run parallel to one another
  35. 35. Normal vasculature - Columnar Terminal networks confined to the stromal core of each grape-like villus, which projects up to the epithelial surface. With the colposcope, the rounded tips of the individual villi are the main features seen and the top of the vessel network in each villus appears as a dot. Large, deep branching vessels may be seen in some cases.
  36. 36. ECTOCERVIX – squamos epi After menopause, the cells do not mature beyond the parabasal layer. Consequently, the epithelium becomes thin and atrophic. On visual examination, it appears pale, with subepithelial petechial haemorrhagic spots, as it is easily prone to trauma
  37. 37. NORMAL VASCULATURE – ECTO & ENDOCX
  38. 38. NORMAL VASCULATURE
  39. 39. APPLYING ACETIC ACID
  40. 40. APPLY ACETIC ACID HOW Swab liberally with AA soaked swab for 45sec to 1 mte.. Donot rub as it abrades the epi 3 – 5%. 5% preferred for all except PMW (3%). 5% causes burning in some esply if inflamed. 3% takes longer to elicit response. Action transient n disappears in 1 – 3mts, so reapply ACTION coagulates and cleares the mucus. Dehydrates the cell  It causes a reversible coagulation or precipitation of the nuclear proteins and cytokeratins.
  41. 41. NORMAL Colposcopic Findings AFTER ACETIC ACID APPLICATION
  42. 42. FOLLOWING APPLICATION OF ACETIC ACID
  43. 43. COLUMNAR EPITHELIUM -AA
  44. 44. Normal TZ findings - AA Nabothian follicle Immature sq metaplasi Mature sq metaplasi The new SCJ appears like a white step due to adjoining immature metaplastic epi
  45. 45. FINDINGS OF TZ FOLL AA • Grossly, the metaplastic islands appear as glassy islands over col epi and translucent tongues from original sq. epi • Acetowhitening around gland openings.
  46. 46. AWA • immature squamous metaplasia • congenital transformation zone • in healing and regenerating epithelium (associated with inflammation) • leukoplakia (hyperkeratosis) • condyloma.
  47. 47. LUGOL’S IODINE • Role debatabe. • Some say it adds little to the colposcopic evaluation. • Some argue that it helps in doubtful situations, esply in assessment of grade2 lesions. They say that a large number of grade 2 lesions are of mature metaplasia: when theses stain dark brown, there is no suspicion of abn , and biopsy avoided. • It may also pick up LGL which may be too subtle on AA • Lugol’s iodine solution to aid in delineating potential biopsy site
  48. 48. BASIS OF SCHILLER’S TEST Iodine is glycophilic and hence the application of iodine solution results in uptake of iodine in glycogencontaining epithelium. original and newly formed mature squamous metaplastic epithelium is glycogenated = I positive mahogony brown CIN and invasive cancer contain little or no glycogen = i neg mustard to golden yellow Columnar epithelium doesnot contain glycogen I neg Immature squamous metaplastic epithelium usually lacks glycogen or, occasionally, may be partially glycogenated = partial uptake +/_
  49. 49. NORMAL Colposcopic Findings FOLLOWING APPLICATION OF LUGOLS IODINE
  50. 50. Col epi – I neg yellow Squamos native & mature met – I positive mahogony / dark brown Immature metaplasia – Ineg / partial uptake if partially glycogenated Endocervical polyps – I neg as covered by col epi / immature met epi After application of Lugol’s iodine solution, the endocervical polyp and the immature squamous metaplasia surrounding the os partially take up iodine
  51. 51. COLPOSCOPIC FINDINGS IN CIN Colposcopy has a reported sensitivity ranging from 87% to 99% to diagnose cervical neoplasia, but its specificity is lower, between 23% and 87%
  52. 52. COLPOSCOPIC FINDINGS IN CIN AFTER APLICATION OF NORMAL SALINE
  53. 53. ABNORMAL VASCULATURE Normal vessels of of columnar epithelium become compressed during the normal metaplastic process and are not incorporated within the newly formed squamous epithelium. In HPV infection and arypia, capillary system may be trapped (incorporated) into the diseased dysplastic epithelium through several elongated stromal papillae and a thin layer of epithelium may remain on top of these vessels.
  54. 54. Abnormal vasculature in CIN • Terminal vessels in the papillae viewed end – on = punctuation • Interconnecting vessels running parallel to surface = mosaic • Both when seen = umbilication
  55. 55. SIGNIFICANT ONLY WHEN SEEN IN ACETO WHITE AREAS
  56. 56. MOSAIC
  57. 57. COLPOSCOPIC FINDINGS IN CIN FOLLOWING APPLICATION OF ACETIC ACID
  58. 58. AA CHANGES GRADIENT With low-grade CIN, the acetic acid must penetrate into the lower onethird of the epithelium (where most of the abnormal cells with high nuclear density are located). Hence, the appearance of the whiteness is delayed and less intense . Areas of high-grade CIN and invasive cancer turn densely white and opaque immediately after application of acetic acid, due to their higher Concentration of abnormal nuclear protein and the presence of large numbers of dysplastic cells in the superficial layers of the epithelium.
  59. 59. AA CHANGES GRADIENT The grade of lesion correlates with intensity of whiteness, surface shine, rapidity of appearance and duration of whiteness. LOW-GRADE LESIONS less dense, less extensive and less complex acetowhite areas close to or abutting the squamocolumnar junction with well demarcated, but irregular, feathery or digitating margins satellite acetowhite lesions detached (far away) from the squamocolumnar junction geographical patterns (resembling geographical regions).
  60. 60. Acetowhite Changes CIN 1
  61. 61. High Grade Lesions       dense, opaque, grey white acetowhite areas coarse punctation and/or mosaic regular and well demarcated borders Raised / rolled edge; extensive and often involve both lips and may occasionally harbour atypical vessels
  62. 62. HGL
  63. 63. HGL A dense acetowhite, opaque, complex, circumorificial CIN 3 lesion
  64. 64. HIGH GRADE LESION ctd  Visualization of one or more borders within an acetowhite lesion (‘lesion within lesion’) or a lesion with differing colour intensity.  The crypt openings may have thick, dense and wide acetowhite rims called cuffed crypt openings . These are whiter and wider than the mild, line-like acetowhite rings that are sometimes seen around normal crypt openings.
  65. 65. COLPOSCOPIC FINDINGS IN CIN FOLLOWING APPLICATION OF LUGOL’S IODINE
  66. 66. COLPOSCOPIC GRADING SYSTEM
  67. 67. COLPOSCOPIC FINDINGS IN MICRO EARLY INVASIVE CANCER
  68. 68. FEATURES S/O INVASIVE CA • lesions with irregular and exophytic surface contour, strikingly thick chalky white lesions with raised and rolled out margins, • Strikingly excessive atypical vessels, bleeding on touch or the presence of symptoms such as vaginal bleeding • Large high-grade lesions, involving more than three quadrants of the cervix • the presence of a wide abnormal transformation zone (greater than 40 mm ), • Complex acetowhite lesions involving both lips of the cervix, • lesions obliterating the os, •
  69. 69. ATYPICAL BV’s – sign of invasive cancer One of the earliest colposcopic signs of possible invasion is blood vessels breaking out from the mosaic formations and producing irregular longitudinal vessels. . As the neoplastic process closely approaches the stage of invasive cancer, the blood vessels can take on increasingly irregular, bizarre patterns , as a result of horizontal pressure of the expanding neoplastic epithelium on the vascular spaces, . Appearance of atypical vessels usually indicates the first signs of invasion
  70. 70. ATYPICAL BV’s • Progressively Increasing calibre despite branching • Tapering foll by widening • Bizarre • cockscrew • Sudden angulation • comma
  71. 71. ATYPICAL BV - CA
  72. 72. Invasive carcinoma
  73. 73. INNER BORDER
  74. 74. Inv ca- cotton wool AWA
  75. 75. RAISED IRREG SURFACE
  76. 76. RAISED IRREG SURF CTD
  77. 77. INVASIVE CANCER
  78. 78. Coarse mosaic – inv ca
  79. 79. COLPOSCOPY IN GLANDULAR NEOPLASIA
  80. 80. COLPOSCOPY IN GLANDULAR NEOPLASIA • There are no obvious colposcopic features that allow definite diagnosis of adenocarcinoma in situ (AIS) and adenocarcinoma. • Most cervical AIS or early adenocarcinomas are discovered incidentally after biopsy for squamous intraepithelial neoplasia • SUSPICIOUS     Dense acetowhite area in col epi More acetowhite nature of some villous tips compared to others Abnormal vessels in col ep esply root and writing like Multiple cuffed crypt openings in dense AWA
  81. 81. Glandular Lesions (AIS and Adenocarcinoma)
  82. 82. BIOPSY – THE GOAL • The main objective of colposcopist is to distinguish between lesions that are “insignificant” not requiring biopsy and those that are “suspicious” requiring biopsy.
  83. 83. BIOPSY – THE GOAL • Mentally map abnormal areas. • Remember that colposcopic observation's main goal is to highlight areas for biopsy. • Use the following parameters to grade severity of lesions: – – – – – – Mild acetowhite epithelium < Intensely acetowhite Diffuse vague borders < Sharply demarcated borders Follows normal contours of the cervix < "humped up" No blood vessel pattern < Punctation < Mosaic Atypical vessels - usually cancer Normal iodine reaction (dark) < Iodine-negative epithelium (yellow) – Leukoplakia - usually a very good (condylomata) or a very bad sign
  84. 84. BIOPSY - WHEN • All areas of keratoses even smear neg. Prolapse pts may be exempted esply if smear neg n lesion outside TZ. • All colposcopically abnormal lesions • All unusual lesions difficult to interpret at colpo. • Any doubt (overtreatment better)
  85. 85. BIOPSY - WHERE • Homogenous Abnormal area – closest to new SCJ • Heterogenous – most suspicious looking area • Always include the area with vessel atypism • In case of doubt n large lesion, multiple biopsies • Biopsy of posterior lesion first • In the endo cervix only if os wide open and lesion in lower part of cervical canal with its upper limit seen. ( in all other cases, ECC)
  86. 86. BIOPSY - TECHNIQUE Atleast 3mm depth
  87. 87. BIOPSY- TECHNIQUE • When biopsy site at margin of the ext os, the fixed part of forceps introduced into cervical canal, whilst the mobile part remains on ectocervix. • After each bite, cervix is swabbed with AA soaked swab to confirm bx has been taken from correct site. • Ideally, when multiple biopsies, place in separately labelled containers, n write corresponding nos on colposcopic diagram to be sent to pathologist.
  88. 88. BIOPSY WHEN TO AVOID • AWA in TZ extending into cervical canal , and upper extent n new SCJ not visible. BX of lower part of lesion will be of no value unless nature of upper part determined • Also may unnecessarily cause confusion after a cone / HE due to reepithelialization as changes mimicking inv.
  89. 89. ECC – Glandular lesion (irrespective of findings of colposcopy ) – Unsatisfactory colposcopy (whether or not a cervical lesion identified on colposcopy) – Normal colpoposcopy of ectocervix, yet abnormal cytology – CONTRAINDICATED in pregnancy or active cervicitis
  90. 90. • Before ECC is performed, the posterior fornix must be dry to avoid the loss of curetted tissue in the acetic acid solution which accumulated during its application on the cervix. • In order to avoid the potential confusion of inadvertently sampling a visible lesion on the ectocervix or including residual tissue from an ectocervical biopsy in the neighbourhood of the external os in the endocervical curette specimen, ECC may be performed under colposcopic control, before obtaining a cervical biopsy. • The yield of an ECC is very low in inexperienced hands, as it is frequently associated with inadequate tissue sampling. Thus, in such situations, a negative ECC should not be taken as unequivocal evidence of the absence of neoplasia in the endocervical canal.
  91. 91. Examination of the Vagina • Very imp, esply in women with abnormal pap but no cervical abn on colpo • Cervix mobilized with swab, to visualise fornices. • Lat walls swabbed with acetic acid • Speculum progressively withdrawn open to examine ant & post walls.
  92. 92. VAG EX
  93. 93. P/V/R f it is performed before colposcopy, only water should be used as a lubricant.
  94. 94. EX OF VUVLA, PERINEUM As the speculum is withdrawn, the vaginal walls and, subsequently, the vulvar, perineal, and perianal epithelium should be inspected. The surfaces are bathed with acetic acid and after one or two minutes the acetowhite areas are noted and evaluated. no general agreement on whether these areas should be routinely examined in this fashion
  95. 95. Complications • Bleeding – Saturate the end of a tampon with Monsel’s and insert to provide pressure and astringent action for persistent oozing – Cauterize the biopsy site – Inject 1-2 cc of 2% lidocaine with epinephrine into the bleeding site – Rarely, a cervical stitch of 4-0 absorbable suture across a deep biopsy site
  96. 96. Complications • Infection is rare but typically occurs on the 3rd or 4th day after biopsy • Avoid biopsy with active cervicitis • Pain can be minimized by caring and careful explanation of procedure, a warm room, NSAIDs given the night before and morning of procedure (Avoid Aspirin)
  97. 97. ERRORS IN COLPOSCOPY • Gr.2 AWA lesions interpreted as LGL/HGL by colposcopist may be reported by pathologist as met epi. • Microconvoluted and exophytic condyloma misinterpreted as inv. Ca • Acetowhite strands of immat met epi over col epi of endocx may be misinterpreted as AIS.( n vice versa) • When keratosis in the TZ is light, it may become dense white after AA n resemble HGL • Severe candidiasis may be misinterpreted as keratosis • Coarse punctuations and vascular patterns of inflammation may be misinterpreted as inv ca.
  98. 98. Met epi mimicking HSIL
  99. 99. MET EPI MIMICKING HGL
  100. 100. CONDYLOMA MIMICKING CANCER
  101. 101. CANDIDA MIMICKING KERATOSIS
  102. 102. INFLAMMATION MIMICKING CA
  103. 103. MISCALLENEOUS
  104. 104. Leukoplakia • Well demarcated white area before AA application. • Usually leukoplakia is idiopathic, but it may also be caused by chronic foreign body irritation, HPV infection or squamous neoplasia. • It is not usually possible to colposcopically evaluate the vasculature beneath such an area • No matter where the area of leukoplakia is located on the cervix, it should be biopsied to rule out high-grade CIN or malignancy.
  105. 105. Condylomata They present as soft pink or white vascular growths with multiple, fine, finger-like projections on the surface, before the application of acetic acid. Under the colposcope, condylomata have a typical appearance, with a vascular papilliferous or frond-like surface, It is always prudent to obtain a biopsy to confirm the diagnosis of any exophytic lesion and to rule out malignancy
  106. 106. CONDYLOMA
  107. 107. INFLAMMATION
  108. 108. Inflammation
  109. 109. Polyps
  110. 110. SUMMARY • The main goal of colposcopist is to identify the site to biopsy • Of value in colposcopic interpretation Response to AA Surface cintour & margins Puntuation, mosaicism &ICD Atypical bv Appearance of gland openings I uptake
  111. 111. SUMMARY • Mild flat AWA = immat met / LGL • Dense AWA = HGL • Dense AWA in col epi = glandular disease • I neg could be immat met , col epi, atrophy, inflammation, HPV , CIN, Ca • I partial pos = immat met / LSIL, HPV subclinical inf
  112. 112. SUMMARY • Fine mosaic = LSIL • Coarse mosaic = HGL • Atypical vessels ( parallel, abn calibre, comma , cockscrew, spaghetti ) = INV CA • S/O INV CA – – – – – Irregular surface contour ( mountain range) Denses AWA Wide , irregular coarse punctuation & mosaic Atypical vessels in sharply demarcated raised dense AWA. In flattish lesions microinv ca
  113. 113. SUMMARY • Metaplastic epi, hpv infection, inflammation, condyloma, keratosis can mimic neoplasia. • Can be differentiated by the experienced colposcopist; else better to biopsy
  114. 114. COLPOSCOPIC DIAGRAMS

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