Colposcopy Case Studies
Hatim Al-Dabbagh
MBBS.FRCSC
Gynecologic Oncologist
Dhahran Health Center
Saudi Aramco
Dec 7-8/2011...
INTRODUCTION
A.  The colposcopic exam serves to
(1)  Identify normal landmarks
(2)  Identify abnormal areas in relation to...
INTRODUCTION
A.  Pre-malignant and malignant cervical conditions
produce colposcopically identifiable epithelial
changes t...
A.  SQUAMOUS METAPLASIA
–  Physiological replacement
of the columnar epithelium
with squamous epithelium
–  The region whe...
Transformation Zone
Normal Colposcopic Findings
INTRODUCTION
A.  The key ingredients of the exam are the
observation of the cervical epithelium
–  after application of no...
COLPOSCOPE
INDICATIONS
A.  Suspicious visible lesion or palpable lesion of the cervix, vagina,
vulva, perineum or perianal area
B.  P...
RELATIVE CONTRAINDICATIONS
A.  Active, inflammatory cervicitis
B.  Non-cooperative patient
C.  Postmenopausal patient who ...
Steps in the colposcopic exam
A.  Explain the procedure and obtain informed
consent
B.  Obtain a relevant medical history
...
Steps in the colposcopic exam
A.  Examine cervix using low power (inflammation,
infection, leukoplakia, punctation, mosaic...
Steps in the colposcopic exam
A.  Apply 5% acetic acid. Repeat Q 5 min.
B.  Scan entire cervix with white light. Start wit...
5% Acetic Acid Application
Steps in the colposcopic exam
A.  Use endocervical speculum if needed to view entire
transformation zone
B.  The entire TZ...
Steps in the colposcopic exam
A.  Apply Lugol s iodine solution to aid in
delineating potential biopsy site
Steps in the colposcopic exam
A.  Perform endocervical
curettage, if indicated
–  Glandular lesion
–  Unsatisfactory colpo...
Steps in the colposcopic exam
A.  Mentally map abnormal areas
–  Mild acetowhite < Intensely acetowhite
–  No blood vessel...
Steps in the colposcopic exam
A.  Perform cervical biopsies, if
necessary
–  Biopsy posterior areas first
–  A depth of 3 ...
Steps in the colposcopic exam
A.  Apply pressure and Monsel s paste to bleeding sites after
biopsy
B.  Remove speculum and...
Documentation
Documentation
Post-Procedure Instructions
A.  No douching, intercourse, or tampons until spotting
subsides
B.  Return for foul odor or d...
Post-Procedure Instructions
A.  Encourage contraception once definitive therapy
completed
B.  Re-emphasize the relationshi...
Complications
A.  Bleeding
–  Reapply Monsel s solution
–  Cauterize the biopsy site
–  Inject 1-2 cc of 2% lidocaine with...
Complications
A.  Infection is rare but typically occurs on the 3rd or 4th day after
biopsy
B.  Avoid biopsy with active c...
Colposcopic Findings
Normal Colposcopic Findings
A.  Original squamous epithelium
B.  Columnar epithelium
C.  Squamocolumnar junction
D.  Squam...
Squamocolumnar Junction
Normal Findings w/ 5% Acetic Acid
Normal findings with Lugol s solution
Ectropian
Polyps
Cervicitis
Condylomata
Nabothian Cysts
Postmenopausal Cervix
Abnormal Colposcopic Findings
A.  Atypical transformation zone with the following
features suggestive of dysplasia or neop...
Punctation and Mosaicism
Leukoplakia
Acetowhite Changes CIN 1
Acetowhite Changes CIN 1
Acetowhite Changes CIN 2
Acetowhite Changes CIN 3
Abnormal Lugol s Iodine Uptake
Comparison CIN1 vs CIN3
Atypical Vessels
Invasive Carcinoma
Invasive carcinoma
Glandular Lesions
(AIS and Adenocarcinoma)
Colposcopy Case Studies
Case 1
A 24 years old woman has liquid based PAP smear as
demonstrated in figure. it shows :
A.  Negative for
intraepithel...
Answer 1
B. Correct: ASC-US
These cells abnormal but not
sufficient enough to be
diagnosed as SIL.
There is a slight incre...
Her test results was positive for oncogenic HPV.
Your colposcopic impression is :
A.  Normal metaplasia
B.  Low grade
C.  ...
Answer 2
B. Correct: Low grade
An acetowhite lesion with irregular
margins, satellite lesion,
translucent acetowhite color...
How would you proceed?
A.  Repeat the PAP smear in 4 to 6 moths
B.  Suggest immediate LEEP
C.  Obtain a cervical biopsy
D....
Answer 3
C. Correct: Obtain a cervical biopsy
It is probably important to confirm
your colposcopic impression with
a cervi...
What is your diagnosis?
A.  Normal
B.  CIN 1
C.  CIN 3
D.  Cancer
Question 4
Answer 4
B. Correct: CIN1
Celluler atypia is seen in the
lower one third of the
epithelium.
A few koilocytes can be
seen i...
Select the best management:
A.  Observation with subsequent cytology
B.  Cryotherapy
C.  LEEP
D.  Disclose the nature of y...
Answer 5
D. Correct:
Disclose the nature of your findings to your patient and ask
her for her management preference
The pa...
A year later the patients returns to your care. You obtain a
PAP smear visualize the cervix using your colposcope.
Your im...
Answer 6
B. Correct: Cervical stenosis
One of the complications of
cryotherapy is cervical
stenosis. This risk is
increase...
The PAP smear is reported as unsatisfactory absence of TZ
component. The best management at this time would be to:
A.  Rep...
Answer 7
A. Correct: Repeat the PAP test
If the next PAP smear is
satisfactory then usual
screening is appropriate
However...
Case 2
A 43-year-old female presents with the vaginal
smear shown in Figure. The patient previously had a
vaginal hysterec...
The Correct Cytologic Diagnosis for this is:
A.  ASC-US
B.  LGSIL
C.  HGSIL
D.  AGC
Question 1
The Correct Cytologic Diagnosis for this is:
C. Correct : HGSIL
Note the high nuclear
cytoplasmic ratio in these
cells.
An...
Given a Cytologic Diagnosis of HGSIL, the
Preferred Management Option at This Time Is:
A.  Reflex HPV-DNA testing
B.  Repe...
Given a Cytologic Diagnosis of HGSIL, the
Preferred Management Option at This Time Is:
C. Colposcopy: Correct
q  HPV Test...
Colposcopy of This Patient Can Be Seen in
Figures
Which of the Following Best Describes the
Lesion Seen in These Figures?
Question 3
A.  Condylomatous features
with papilla...
Figures indicate the following finding:
Answer 3
B. Acetowhite lesion: Correct
The lesion seen in the colposcopy is flat a...
Considering This Finding (ie, Acetowhite Lesion With Mosaic Pattern
and Distinct Borders), the Next Appropriate Step Would...
The next appropriate step is:
A. Correct : Lugol's staining of the vagina
In order to determine if there are other
lesions...
The Result of Lugol's Staining Is Seen in Figure Highlighting the
Lesion Seen in the Left Vaginal Fornix. The Pathology Fr...
Based on the Pathology, the Correct Diagnosis Is:
Question 5
A.  Atrophy and cervicitis
B.  VAIN1
C.  VAIN3
D.  Invasive v...
Based on the Pathology, the Correct Diagnosis Is:
C. Correct : VAIN3
The pathology shown in Figure
demonstrates increased ...
Based on the Pathology, the Correct Diagnosis is:
D. Invasive vaginal carcinoma: Incorrect
There is no evidence of invasio...
For this patient, the correct management
option at this time is:
A.  Cryotherapy
B.  Laser vaporization
C.  Loop excision
...
The correct management options are:
B. Correct: Laser vaporization
Most clinicians would treat this lesion with laser
vapo...
The correct management options are:
C. Correct: Loop excision
Loop excision has been reported for vaginal lesions and, in ...
The correct management options are:
A. Cryotherapy: Incorrect
Cryotherapy is not the preferred method as it is
difficult t...
Case -3
q  A 30-year-old patient presents for her first Pap
smear in 3 years.
q  She is asymptomatic with normal menses....
The correct cytologic diagnosis for
this slide is:
A.  ASC-US
B.  ASC-H
C.  LGSIL
D.  HGSIL
E.  AGC
Question 1
The correct cytologic diagnosis for
this slide is:
B. Correct : ASC-H
The 2001 Bethesda System
added a new category of ASC...
Given a Cytologic Diagnosis of ASC-H, the
Preferred Management Option at This Time Is:
A.  Reflex HPV-DNA testing
B.  Repe...
Given a Cytologic Diagnosis of ASC-H, the
Preferred Management Option at This Time Is:
C. Colposcopy: Correct
A.  The diag...
Which of the Following Findings Regarding the
Colposcopic Examination Are True?
A.  Satisfactory examination
B.  Atypical ...
Which of the Following Findings Regarding the
Colposcopic Examination Are True?
B. Atypical vessels: Correct
The area seen...
These Findings (i.e., Atypical Vessels and
Acetowhite Areas) Are Best Described As:
A. Invasive cancer
B. Metaplasia and c...
These Findings (i.e., Atypical Vessels and
Acetowhite Areas) Are Best Described As:
A. Invasive Cancer: Correct
The presen...
From a Biopsy at 6 O Clock
Based on This Pathology,Your Initial Diagnosis Is:
A.  CIN3
B.  AIS
C.  Squamous cell carcinoma...
From a Biopsy at 6 O Clock
Based on This Pathology,Your Initial Diagnosis Is:
C. Squamous cell carcinoma
Invasion 1 mm: Co...
For this Patient, the Correct Management
Option at This Time Is:
A.  Simple hysterectomy for "microinvasion
B.  Radical hy...
The Correct Management Option Is:
C. Correct: Cold knife conization
A.  The diagnosis of microinvasion cannot be made on a...
Case 4
A 28 years old woman has G2,P2 PAP smear as
demonstrated in figure. it shows
A.  AGC
B.  HGSIL
C.  Koilocytotic cha...
B. Correct: HGSIL
Each cell shows gross
nuclear enlargement
without corresponding
enlargement of the cell
body.
There is a...
Figures of the cervix after the application of 5% acetic acid.
This colposcopic appearence is suspect for:
A.  Glandular d...
C. Correct: Mixed disease
Each cell shows gross
nuclear enlargement without
corresponding enlargement
of the cell body. Th...
The next step in the investigation is:
A.  Colposcopic biopsies from the
most abnormal appearing areas
B.  Cervical coniza...
A. Correct: Colposcopic
biopsies from the most
abnormal appearing areas
Answer 3
Considering the two histological appearances
together, histologic diagnosis consistent with:
A.  HGSIL and AIS
B.  Immatur...
A. Correct: HGSIL and AIS
Answer 4
The next step in the investigation is:
A.  Hysterectomy
B.  Cervical conization/ clindirical
excision
C.  Follow-up with c...
B. Correct: Cervical conization/
clindirical excision
Answer 3
Considering the two histological appearances
together, histologic diagnosis consistent with:
A.  Mixed disease (HGSIL and ...
A. Correct: Mixed disease
(HGSIL and AIS)
Answer 4
Case-5
The patient is a 30-year-old,
G3,P3 woman who four years earlier had a Pap
smear that was interpreted as a LSIL.
A ...
The slide at the right demonstrates the findings at
colposcopy after the application of 5% acetic acid.
What colposcopic f...
B. Correct:
There is an area of dense white
epithelium on the posterior lip
of the cervix.
There also appears to be a
lesi...
Using a cotton-tipped applicator, the anterior lip of the
cervix is raised and the slides at the right reveal the
followin...
B. Correct:
There is a lesion on the anterior aspect
of the distal canal with dense white
epithelium and coarse punctation...
After reviewing the 3 prior colpophotographs, these
findings are most consistent with what type of lesion?
A.  Immature
me...
C. Correct: The dense white epithelium, coarse
mosaic and punctation pattern is all consistent
with a high-grade lesion.
A...
The slide at the right is a view of the biopsy specimen
taken from the most abnormal area. These findings are
consistent w...
C. Correct: High
grade CIN
There are immature
cells extending the
full depth of the
epithelium, along
with cellular
crowdi...
Case 6
This is a 35 year-old woman whose
Pap smear showed a low grade
squamous intraepithelial lesion.
She presents for co...
The colpophotographs represent views of the
cervix. The findings are:
A.  Transformation zone fully visualized
acetowhite ...
D. Correct:
Transformation zone not fully
visualized
Colposcopic findings showed a
mosaic pattern on the posterior
lip of ...
The biopsy site, which will reveal the most information
regarding diagnosis, is at
A.  1 o’clock
B.  10 o’clock
C.  5 o’cl...
C. Correct: 5 o’clock
This is an area of coarse mosaic
that is most likely a high-grade
lesion
Answer 2
Histology of the area biopsied is present on the slides
shown on the right. They reveal:
A.  HGSIL
B.  LGSIL
C.  Metaplasi...
A. Correct:
Biopsies were taken at 8 o’clock and 5
o’clock. At 8 o’clock, the biopsy
shows severely inflamed tissue with
i...
The next step in management is:
A.  Follow with cytology and
colposcopy in 3 months
B.  Radical hysterectomy or
radiation ...
C. Correct:
Large complex lesions of the cervix when
associated with changes that are
characteristic of high-grade disease...
The final histologic specimen shown on the slides on the
right revealed:
A.  Clear cell
adenocarcinoma
B.  Giant cell gran...
C. Correct:
In a setting of condyloma and dysplasia,
there is a small (about 1-3 mm) area of
invasive squamous cell carcin...
Case 7
This is a 16 year old P 0,G0 whose Pap smear shows a
LGSIL with HPV.
She is referred to you for colposcopic evaluat...
The colposcopic pattern in the slides at the
right is characterized by:
A.  High grade acetowhitening with
sharply defined...
A. Correct:
The epithelium is very dense with a dull
off-white color, consistent with high
grade CIN.
In contrast, low gra...
Biopsies should be performed at:
A.  3, 6, 9, and 12 o’clock with an ECC
B.  2 and 10 o’clock
C.  No biopsy required since...
B. Correct: 2 and 10 o’clock
Biopsies should be taken from
both areas of acetowhite
epithelium
Answer 2
The histology from the worst biopsy site and demonstrates
low and high power views of the tissue which shows:
A.  Normal, ...
B. Correct:
The nuclei seen occupying the
lower portion of the epithelium
are regular without
hyperchromasia or clumped
ch...
Based upon the information on cytology, colposcopy, and
biopsy, this patient should have:
A.  Excision of the
transformati...
C. Correct:
Young sexually active women will
frequently demonstrate mild
cytologic abnormalities related to
HPV infection ...
Case 8
This is a 32-year-old, G0, P0, who had a Pap smear
showing LSIL
The colposcopic examination is:
A.  Satisfactory
B.  Unsatisfactory
Question 1
Answer 1
The SCJ is not completely
visible.
The lesion on the posterior lip
extends into the
endocervical canal.
When the ...
This slide shows a colposcopy of the anterior lip of the
cervix. This colpophotograph is most consistent with:
A.  Squamou...
Answer 2
C. Correct:
The lesion on the
anterior lip is well
circumscribed with
a sharp, angular
border. A mosaic
pattern i...
A colposcopically directed biopsy of the anterior lip was
performed which showed:
A.  Koilocytosis
B.  CIN 2 with
koilocyt...
Answer 3
D. Correct:
The biopsy is consistent with
CIN 3 and extensive
endocervical glandular
involvement.
Because the les...
The cone biopsy (LLETZ) was performed. The slide at the right is a
microscopic section of the cone biopsy. It reveals:
A. ...
Answer 4
D. Correct:
The cone biopsy (LLETZ)
revealed CIN 3 with
extensive glandular
involvement.
These results were consi...
How would you manage this patient?
A.  The colposcopy and cytology should be repeated in 3
to 6 months.
B.  Another cone b...
Answer 5
A. Correct:
Even though the cone margins are positive, the excisional
procedure does not need to be repeated at t...
Case -9
This is a 35-year-old woman referred to
you from another physician.
Her Pap smear showed HSIL .
There is acetowhite epithelium from approximately 12 to 1
o’clock and at 3 o’clock. Where should the biopsy be
taken?
A.  ...
Answer 1
C. Correct:
The colposcopic
evaluation
demonstrates two
areas of acetowhite
epithelium.
It is not possible with
c...
This represents the colposcopically directed biopsy of the
3 o’clock area. The diagnosis is:
A.  Normal squamous
epitheliu...
Answer 2
B. Correct: Koilocytosis
The lower third of the
epithelium shows cells
with a high
nuclear:cytoplasmic
ratio and
...
This represents the colposcopically directed biopsy of the
12 o’clock area. The diagnosis is:
A.  Normal squamous
epitheli...
Answer 3
C. Correct: CIN 2-3
The epithelium
displays cells with
various
morphologic
shapes, dense
chromatin, and the
absen...
Case 10
The colposcopic examination is:
A.  Cervical condyloma
B.  Cervical and vaginal
condyloma
C.  Vaginal condyloma and
cervic...
Answer 1
B. Correct: Cervical and
vaginal condyloma
The best management at this time would be to:
The best management at this
time would be to:
A.  Apply TCA
B.  Collect a sp...
Answer 2
D. Correct:
It may be appropriate to
confirm your confirm
colposcopic impression
with histologic sampling.
Cervic...
A cervical biopsy was taken from the lesion . The cervical
biopsy is diagnostic of:
A.  Cervical condyloma
B.  Cervical ca...
Answer 3
A. Correct:
A classic cervical wart is seen
histologically
Optimal recommendation to the patient would be to:
A.  Follow-up with cytology
and colposcopy
B.  Treat the cervical disea...
Answer 4
D. Correct: Treat all the
condylomas
Case -11
q A 24-year-old G0,P0 presents for her first pap smear in
3 years.
q There is no previous history of abnormal s...
Your diagnosis is:
A. ASC-US
B. ASC-H
C. LGSIL
D. HGSIL
E. AGC
Question 1
Your diagnosis is:
A. Correct: ASC-US
Note the normal cells present with
small nuclei and abundant
cytoplasm.
The more eos...
Given the diagnosis of ASC-US,
preferred management is to:
A.  Colposcopy
B.  HPV-DNA reflex testing
C.  Repeat cytology i...
Given the diagnosis of ASC-US,
preferred management is to:
A: Colposcopy is an acceptable option.
B: HPV-DNA reflex testin...
What Are the Colposcopic Findings?
A.  Faint acetowhite,
geographic borders, fine
mosaic patterns
B.  Acetowhite lesion, w...
What Are the Colposcopic Findings?
B. Correct: Acetowhite lesion, well defined
margins, coarse mosaic and punctation:
Thes...
What is your colposcopic impression?
A.  Squamous Metaplasia
B.  CIN1, HPV
C.  CIN2, CIN3
D.  Invasive Squamous
cell cance...
What is your colposcopic impression?
C. Correct : CIN2, CIN3
The colposcopic findings here
are suggestive of a high grade
...
The most appropriate area for biopsy is:
A.  3 o'clock
B.  6 o'clock
C.  9 o'clock
D.  12 o'clock
Question 3C
The most appropriate area for biopsy is:
D. 12 o'clock: Correct
It would be most appropriate
to biopsy the lesion near
the...
Your diagnosis is:
A.  Squamous Metaplasia
B.  CIN1
C.  CIN3
D.  Invasive Squamous
Cell Cancer
Question 4
Your diagnosis is:
C. Correct : CIN3
Note the full thickness change
in the squamous epithelium
and lack of invasion of the...
Management Options for This Patient Include:
A. Observation
B. Loop excision
C. Cryotherapy
D. Cold-Knife Conization
Quest...
Management Options for This Patient Include:
B. Correct : Loop excision
Observation is not appropriate for high-grade dysp...
Management Options for This Patient Include:
D. Correct: Cold-Knife Conization
Cold knife conization would be appropriate;...
Case -12
q  A 26-year-old woman presents with a history of a
previously abnormal Pap smear at age 18.
q  The patient did...
The correct cytologic diagnosis for this is:
A.  ASC-H
B.  ASC-US
C.  LGSIL
D.  HGSIL
E.  AGC
Question 1
The correct cytologic diagnosis for this is:
E. Correct: AGC
• According to the ASCCP Guidelines, the term atypical
glandu...
Given AGC diagnosis,
the preferred management option is:
A.  Reflex HPV-DNA testing
B.  Repeat cytology
C.  Colposcopy and...
Given AGC diagnosis,
the preferred management option is:
C. Correct : Colposcopy and endocervical evaluation
AGC have been...
Given AGC diagnosis,
the preferred management option is:
• The total number of abnormal Pap smears with
glandular lesions ...
Colposcopy of this patient can be seen. The
following statements are true:
Question 3
A.  There is a wide transformation
z...
Colposcopy of this patient can be seen. The
following statements are true:
Answer 3
A. Correct: There is a wide transforma...
Colposcopy of this patient can be seen. The
following statements are true:
B.  Correct: There are acetowhite lesions
prese...
A biopsy is taken from one of the areas
of atypical vessels, the correct histologic diagnosis is:
Question 4
A.  High grad...
A biopsy is taken from one of the areas
of atypical vessels, the correct histologic diagnosis is:
Answer 4
C. Correct: Ade...
The correct treatment for this patient includes
which of the following:
A.  Cryotherapy
B.  Laser vaporization
C.  Cold kn...
The correct treatment for this patient includes
which of the following:
C. Correct: Cold knife conization
The preferred me...
The correct treatment for this patient includes
which of the following:
• In patients who have completed their childbearin...
Case 13
This 27-year-old patient had a series of Pap
smears several months apart, each of which
showed ASC-US.
Her most re...
This is the colposcopic appearance of her cervix after the
application of 5% acetic acid. The lesion is most consistent
wi...
B. Correct: LGSIL
This acetowhite area has
characteristics of a low-
grade lesion.
The borders are feathery.
Acetowhitenes...
Colposcopic view of the cervix reveals an acetowhite area
on the posterior lip of the cervix adjacent to the
squamocolumna...
D. Correct:
This lesion exhibits
dense acetowhiteness
and is directly adjacent to
the squamocolumnar
junction.
It is impor...
Colposcopically directed biopsies were performed and
this slide is representative of those biopsies. It shows:
A.  Squamou...
A. Correct:
The inflammatory cells in the
epithelium are indicative of
cervicitis.
The term chronic cervicitis
implies tha...
LLETZ was performed because of the discrepancy between the high-
grade cytology and the negative biopsy. The histology rep...
B. Correct: High Grade CIN
The LLETZ specimen
revealed CIN3 with
superficial endocervical
extension.
The full thickness of...
Case 14
Based of the colpophotograph her examination is:
A.  Unsatisfactory
B.  Satisfactory
Question 1
Answer 1
A. Correct: Unsatisfactory
The entire SCJ can not be completely
identified
The lesion appears to extend within th...
Your colposcopic impression is:
A.  Normal
B.  Low grade
C.  High grade
D.  Cancer
Question 2
Answer 2
C. Correct: High grade
An acetowhite lesion with a regular margin
can be seen. The color is an opaque
white. Bloo...
Your management at this time would be to:
A.  Repeat PAP smear in 6 and 12 months
B.  Collect a cervical biopsy
C.  Collec...
Answer 3
C. Correct: Collect a cervical biopsy and ECC
Given an unsatisfactory colposcopic
examination, a HGSIL PAP smear ...
The cervical biopy is seen in figure. What is your
diagnosis?
A.  Normal
B.  CIN 1
C.  CIN 2
D.  CIN 3
Question 4
Answer 4
C. Correct: CIN 2
Cellular atypia is seen
in the lower two
thirds of the
epithelium
The ECC is seen in figure. What is your diagnosis?
A.  Insufficient material
B.  Normal
C.  Positive, CIN
D.  Positive, su...
Answer 5
C. Correct: Positive, CIN
There is no evidence of
malignant epithelium
What management is appropriate at this time ?
A.  Hysterectomy
B.  Cryotherapy
C.  Cold conization
D.  LEEP
Question 6
Answer 6
C. Correct: Cold conization is required
based on the unsatisfactory colposcopic
examination and a positive ECC.
C...
Case 15
This is a 60-year-old ,
Para 8, whose last menstrual period was 12
years prior to this visit.
A routine Pap smear ...
This image shows:
A.  Diffuse white (pale) epithelium
B.  A focal area of acetowhite
epithelium that is incompletely
visua...
Answer 1
A. Correct:
The cervix of this 60-year-old
female appears pale. The pale
color may reflect an atrophic
epithelium...
Which of the following colposcopic features are present?
A.  Nabothian cysts
B.  Focal area of acetowhite
epithelium
C.  P...
Answer 2
B. Correct:
There is a well-circumscribed,
gray-white lesion at 8 o’clock
that is seen in its entirety.
There is ...
On low power view of the cervix, the colposcopic
examination is:
A.  Satisfactory
B.  Unsatisfactory
C.  Cannot be certain...
Answer 3
C. Correct:
The transformation zone is not
completely visualized.
Nowhere can you see
grape-like structures of th...
A cervical biopsy was taken from the lesion noted in
question 2. The cervical biopsy is diagnostic of:
A.  Squamous epithe...
Answer 4
A. Correct: Squamous epithelium with no pathologic
findings
The transformation zone is not represented in this sp...
The endocervical curettage is most compatible with
diagnosis of:
A.  Normal columnar
epithelium
B.  Adenocarcinoma,
uncert...
Answer 5
C. Correct: Histology of the endocervical curettage revealed
a squamous intraepithelial neoplasia with no underly...
References
A.  American Society for Colposcopy and Cervical Pathology. www.asccp.org.
B.  Newkirk, G. The Colposcopic Exam...
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Colposcopy case studies2

  1. 1. Colposcopy Case Studies Hatim Al-Dabbagh MBBS.FRCSC Gynecologic Oncologist Dhahran Health Center Saudi Aramco Dec 7-8/2011 Abdulmohsen Alkushi MBBS.FRCPC Gynecologic Pathologist National Guard Hospital Riyadh
  2. 2. INTRODUCTION A.  The colposcopic exam serves to (1)  Identify normal landmarks (2)  Identify abnormal areas in relation to these landmarks (3)  Facilitate directed biopsy of abnormal areas for histologic diagnosis (4)  Rule out invasive cancer
  3. 3. INTRODUCTION A.  Pre-malignant and malignant cervical conditions produce colposcopically identifiable epithelial changes that generally occur within the transformation zone
  4. 4. A.  SQUAMOUS METAPLASIA –  Physiological replacement of the columnar epithelium with squamous epithelium –  The region where this occurs is known as the TRANSFORMATION ZONE –  IMPORTANT because almost ALL cervical cancer occur in this zone
  5. 5. Transformation Zone
  6. 6. Normal Colposcopic Findings
  7. 7. INTRODUCTION A.  The key ingredients of the exam are the observation of the cervical epithelium –  after application of normal saline –  3-5% acetic acid –  Lugol s iodine solution in successive steps
  8. 8. COLPOSCOPE
  9. 9. INDICATIONS A.  Suspicious visible lesion or palpable lesion of the cervix, vagina, vulva, perineum or perianal area B.  Pap smear consistent with dysplasia or cancer C.  Pap smear with evidence of HPV infection (High Risk types) D.  History of intrauterine DES exposure E.  Follow-up of previously treated patients or high-risk patients F.  Evaluation of child abuse or rape cases
  10. 10. RELATIVE CONTRAINDICATIONS A.  Active, inflammatory cervicitis B.  Non-cooperative patient C.  Postmenopausal patient who is not estrogen- primed D.  Heavy menses
  11. 11. Steps in the colposcopic exam A.  Explain the procedure and obtain informed consent B.  Obtain a relevant medical history C.  R/O pregnancy D.  Perform bimanual exam if not already done E.  Examine vulva F.  Insert speculum
  12. 12. Steps in the colposcopic exam A.  Examine cervix using low power (inflammation, infection, leukoplakia, punctation, mosaicism, abnormal vessels) B.  Obtain KOH/WP, cultures and/or pap, if needed C.  Use green filter and normal saline
  13. 13. Steps in the colposcopic exam A.  Apply 5% acetic acid. Repeat Q 5 min. B.  Scan entire cervix with white light. Start with low power and move to higher magnification to document abnormal vascular patterns
  14. 14. 5% Acetic Acid Application
  15. 15. Steps in the colposcopic exam A.  Use endocervical speculum if needed to view entire transformation zone B.  The entire TZ, including SCJ, and borders of all lesions must be visualized in order for colposcopy to be satisfactory
  16. 16. Steps in the colposcopic exam A.  Apply Lugol s iodine solution to aid in delineating potential biopsy site
  17. 17. Steps in the colposcopic exam A.  Perform endocervical curettage, if indicated –  Glandular lesion –  Unsatisfactory colposcopy –  Normal colpoposcopy of ectocervix, yet abnormal cytology –  CONTRAINDICATED in pregnancy or active cervicitis
  18. 18. Steps in the colposcopic exam A.  Mentally map abnormal areas –  Mild acetowhite < Intensely acetowhite –  No blood vessel pattern < Punctation < Mosaicism –  Diffuse vague borders < Sharply demarcated borders –  Follows normal contours of the cervix < humped up –  Leukoplakia – usually a very good (condylomata) or very bad sign –  Atypical vessels – usually cancer –  Normal iodine reaction (dark) < Iodine-negative epithelium (yellow)
  19. 19. Steps in the colposcopic exam A.  Perform cervical biopsies, if necessary –  Biopsy posterior areas first –  A depth of 3 mm is adequate –  Biopsy area of the lesion with worst features and closest to SCJ, include the area with atypical vessels
  20. 20. Steps in the colposcopic exam A.  Apply pressure and Monsel s paste to bleeding sites after biopsy B.  Remove speculum and inspect vaginal walls, vulva, perineum, and perianal areas C.  Allow patient to recover D.  Document findings E.  Discuss findings with patient and give post-procedure instructions
  21. 21. Documentation
  22. 22. Documentation
  23. 23. Post-Procedure Instructions A.  No douching, intercourse, or tampons until spotting subsides B.  Return for foul odor or discharge, pelvic pain, profuse bleeding or fever C.  Fevadol or ibuprofen may be used for cramping D.  Otherwise, follow-up is usually 1-3 weeks to discuss histology results and definitive therapy
  24. 24. Post-Procedure Instructions A.  Encourage contraception once definitive therapy completed B.  Re-emphasize the relationship of cervical dysplasia with STDs, smoking, and non-monogamous sexual practices C.  Stress patients life-long risks of HPV infection
  25. 25. Complications A.  Bleeding –  Reapply Monsel s solution –  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
  26. 26. Complications A.  Infection is rare but typically occurs on the 3rd or 4th day after biopsy B.  Avoid biopsy with active cervicitis C.  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) D.  Missing disease – lack of correlation between pap cytology and subsequent histology
  27. 27. Colposcopic Findings
  28. 28. Normal Colposcopic Findings A.  Original squamous epithelium B.  Columnar epithelium C.  Squamocolumnar junction D.  Squamous metaplasia E.  Transformation Zone
  29. 29. Squamocolumnar Junction
  30. 30. Normal Findings w/ 5% Acetic Acid
  31. 31. Normal findings with Lugol s solution
  32. 32. Ectropian
  33. 33. Polyps
  34. 34. Cervicitis
  35. 35. Condylomata
  36. 36. Nabothian Cysts
  37. 37. Postmenopausal Cervix
  38. 38. Abnormal Colposcopic Findings A.  Atypical transformation zone with the following features suggestive of dysplasia or neoplasia: –  1. Punctation –  2. Mosaicism –  3. Leukoplakia –  4. Acetowhite –  5. Abnormal blood vessels
  39. 39. Punctation and Mosaicism
  40. 40. Leukoplakia
  41. 41. Acetowhite Changes CIN 1
  42. 42. Acetowhite Changes CIN 1
  43. 43. Acetowhite Changes CIN 2
  44. 44. Acetowhite Changes CIN 3
  45. 45. Abnormal Lugol s Iodine Uptake
  46. 46. Comparison CIN1 vs CIN3
  47. 47. Atypical Vessels
  48. 48. Invasive Carcinoma
  49. 49. Invasive carcinoma
  50. 50. Glandular Lesions (AIS and Adenocarcinoma)
  51. 51. Colposcopy Case Studies
  52. 52. Case 1 A 24 years old woman has liquid based PAP smear as demonstrated in figure. it shows : A.  Negative for intraepithelial neoplasia and malignancy B.  ASC-US C.  LGSIL D.  HGSIL Question 1
  53. 53. Answer 1 B. Correct: ASC-US These cells abnormal but not sufficient enough to be diagnosed as SIL. There is a slight increase in the nuclear to cytoplasmic ratio, with slight variation in nuclear size and shape.
  54. 54. Her test results was positive for oncogenic HPV. Your colposcopic impression is : A.  Normal metaplasia B.  Low grade C.  High grade D.  Cancer Question 2
  55. 55. Answer 2 B. Correct: Low grade An acetowhite lesion with irregular margins, satellite lesion, translucent acetowhite color and fine caliber punctation can be seen.
  56. 56. How would you proceed? A.  Repeat the PAP smear in 4 to 6 moths B.  Suggest immediate LEEP C.  Obtain a cervical biopsy D.  Refer her to a gyn oncologist Question 3
  57. 57. Answer 3 C. Correct: Obtain a cervical biopsy It is probably important to confirm your colposcopic impression with a cervical biopsy.
  58. 58. What is your diagnosis? A.  Normal B.  CIN 1 C.  CIN 3 D.  Cancer Question 4
  59. 59. Answer 4 B. Correct: CIN1 Celluler atypia is seen in the lower one third of the epithelium. A few koilocytes can be seen in the intermediate superficial cell layers
  60. 60. Select the best management: A.  Observation with subsequent cytology B.  Cryotherapy C.  LEEP D.  Disclose the nature of your findings to your patient and ask her for her management preference Question 5
  61. 61. Answer 5 D. Correct: Disclose the nature of your findings to your patient and ask her for her management preference The patient decided to have cryotherapy
  62. 62. A year later the patients returns to your care. You obtain a PAP smear visualize the cervix using your colposcope. Your impression is: A.  Normal cervix B.  Cervical stenosis C.  CIN1 D.  CIN3 Question 6 A Question 6
  63. 63. Answer 6 B. Correct: Cervical stenosis One of the complications of cryotherapy is cervical stenosis. This risk is increased for estrogen deficient woman.
  64. 64. The PAP smear is reported as unsatisfactory absence of TZ component. The best management at this time would be to: A.  Repeat the PAP smear B.  Dilate the endocervical os C.  LEEP D.  HPV DNA test Question 7
  65. 65. Answer 7 A. Correct: Repeat the PAP test If the next PAP smear is satisfactory then usual screening is appropriate However, if her PAP smears continue to be interpreted as unsatisfactory, then access to the TZ should be assured.
  66. 66. Case 2 A 43-year-old female presents with the vaginal smear shown in Figure. The patient previously had a vaginal hysterectomy for a CIN2 lesion.
  67. 67. The Correct Cytologic Diagnosis for this is: A.  ASC-US B.  LGSIL C.  HGSIL D.  AGC Question 1
  68. 68. The Correct Cytologic Diagnosis for this is: C. Correct : HGSIL Note the high nuclear cytoplasmic ratio in these cells. Answer 1
  69. 69. Given a Cytologic Diagnosis of HGSIL, the Preferred Management Option at This Time Is: A.  Reflex HPV-DNA testing B.  Repeat cytology in 3-6 months C.  Colposcopy D.  Vaginal 5-Fluorouracil cream Question 2
  70. 70. Given a Cytologic Diagnosis of HGSIL, the Preferred Management Option at This Time Is: C. Colposcopy: Correct q  HPV Testing, although appropriate for triage of ASC-US cytology, does not have a role in the management of HGSIL. q  Observation and repeat cytologic surveillance is also not appropriate for HGSIL. q  Treatment with 5-FU cream should not be initiated until a definitive diagnosis is made. Answer 2
  71. 71. Colposcopy of This Patient Can Be Seen in Figures
  72. 72. Which of the Following Best Describes the Lesion Seen in These Figures? Question 3 A.  Condylomatous features with papillary areas B.  Acetowhite lesion C.  Atypical vessels, ulceration D.  Atrophic changes only
  73. 73. Figures indicate the following finding: Answer 3 B. Acetowhite lesion: Correct The lesion seen in the colposcopy is flat and has well demarcated margins. Under green filter, the vascular changes represent relatively coarse mosaic patterns.
  74. 74. Considering This Finding (ie, Acetowhite Lesion With Mosaic Pattern and Distinct Borders), the Next Appropriate Step Would Be: Question 4 A.  Lugol's staining of the vagina B.  Colposcopically-directed biopsy C.  Laser ablation D.  Cryotherapy
  75. 75. The next appropriate step is: A. Correct : Lugol's staining of the vagina In order to determine if there are other lesions in the vagina, Lugol's iodine should be applied. The use of Lugol's can also highlight areas where lesions can be missed. Treatment such as laser ablation or cryotherapy should not be initiated until a diagnosis is made. Answer 4
  76. 76. The Result of Lugol's Staining Is Seen in Figure Highlighting the Lesion Seen in the Left Vaginal Fornix. The Pathology From a Biopsy of This Lesion Is Seen in Figure.
  77. 77. Based on the Pathology, the Correct Diagnosis Is: Question 5 A.  Atrophy and cervicitis B.  VAIN1 C.  VAIN3 D.  Invasive vaginal carcinoma
  78. 78. Based on the Pathology, the Correct Diagnosis Is: C. Correct : VAIN3 The pathology shown in Figure demonstrates increased nuclear changes, consistent with VAIN3. The pathology also shows full-thickness changes in the epithelium and an intact basement membrane. Mitotic activity is also seen in VAIN3. Answer 5
  79. 79. Based on the Pathology, the Correct Diagnosis is: D. Invasive vaginal carcinoma: Incorrect There is no evidence of invasion through the basement membrane. Answer 5 Cont.
  80. 80. For this patient, the correct management option at this time is: A.  Cryotherapy B.  Laser vaporization C.  Loop excision D.  5-Fluorouracil cream Question 6
  81. 81. The correct management options are: B. Correct: Laser vaporization Most clinicians would treat this lesion with laser vaporization, which is the preferred technique and allows for adequate treatment to a depth of 1-2 mm and destruction of the entire lesion. If there is any concern that an invasive component is present, excision of the lesion should be performed. Answer 6
  82. 82. The correct management options are: C. Correct: Loop excision Loop excision has been reported for vaginal lesions and, in the hands of experienced operators, it may be possible to use loop excision, but laser vaporization may be more precise in controlling the depth of treatment. D. Correct: 5-Fluorouracil cream 5-FU cream has been used for resistant cases, but there is an increased incidence of ulcerations with this technique. Answer 6 Cont.
  83. 83. The correct management options are: A. Cryotherapy: Incorrect Cryotherapy is not the preferred method as it is difficult to control the depth of treatment. Answer 6 Cont.
  84. 84. Case -3 q  A 30-year-old patient presents for her first Pap smear in 3 years. q  She is asymptomatic with normal menses. q  She is G4,P4. q  A cigarette smoker. q  Has no relevant history of treatment or other abnormal cytology.
  85. 85. The correct cytologic diagnosis for this slide is: A.  ASC-US B.  ASC-H C.  LGSIL D.  HGSIL E.  AGC Question 1
  86. 86. The correct cytologic diagnosis for this slide is: B. Correct : ASC-H The 2001 Bethesda System added a new category of ASC-H This diagnosis should only account for 5-10% of all ASC cases, It does have a high predictive value for CIN2 and 3. Answer 1
  87. 87. Given a Cytologic Diagnosis of ASC-H, the Preferred Management Option at This Time Is: A.  Reflex HPV-DNA testing B.  Repeat cytology C.  Colposcopy D.  Loop excision   Question 2
  88. 88. Given a Cytologic Diagnosis of ASC-H, the Preferred Management Option at This Time Is: C. Colposcopy: Correct A.  The diagnosis of ASC-H requires colposcopy to detect high-grade lesions. B.  The risk of CIN2 and 3 associated with this diagnosis has been reported to range from 24% to 94% in various studies. The risk of invasion is 0.1-0.2%. C.  Published reports do not suggest that intermediate triage such as HPV DNA testing is useful D.  Repeat cytological testing would be inappropriate. E.  Loop excision is not indicated prior to colposcopic diagnosis. Answer 2
  89. 89. Which of the Following Findings Regarding the Colposcopic Examination Are True? A.  Satisfactory examination B.  Atypical vessels C.  Acetowhite areas D.  Nodularity Question 3
  90. 90. Which of the Following Findings Regarding the Colposcopic Examination Are True? B. Atypical vessels: Correct The area seen in the colposcopy appears flat. There are numerous atypical vessels in a background of acetowhite changes. The entire squamo-columnar junction is not visible. C. Acetowhite areas: Correct Answer 3
  91. 91. These Findings (i.e., Atypical Vessels and Acetowhite Areas) Are Best Described As: A. Invasive cancer B. Metaplasia and cervicitis C. High grade CIN D. HPV changes Question 4
  92. 92. These Findings (i.e., Atypical Vessels and Acetowhite Areas) Are Best Described As: A. Invasive Cancer: Correct The presence of atypical vessels should alert the clinician to the possibility of invasive cancer. Other warning signs of invasion include: areas of necrosis, large lesions, nodularity, ulceration, invasive cytology, lesions extending to the canal and a positive endocervical curettage. Answer 4
  93. 93. From a Biopsy at 6 O Clock Based on This Pathology,Your Initial Diagnosis Is: A.  CIN3 B.  AIS C.  Squamous cell carcinoma –  Invasion 1 mm D.  Squamous cell carcinoma –  Invasion 5 mm Question 5
  94. 94. From a Biopsy at 6 O Clock Based on This Pathology,Your Initial Diagnosis Is: C. Squamous cell carcinoma Invasion 1 mm: Correct The pathology shown in Figure demonstrates full-thickness dysplasia and invasion below the basement membrane. In this slide, the invasion is minimal. Answer 5 From a Biopsy at 6 O Clock Based on This Pathology,Your Initial Diagnosis Is: Answer 5
  95. 95. For this Patient, the Correct Management Option at This Time Is: A.  Simple hysterectomy for "microinvasion B.  Radical hysterectomy for cervical cancer C.  Cold knife conization D.  Loop excision Question 6
  96. 96. The Correct Management Option Is: C. Correct: Cold knife conization A.  The diagnosis of microinvasion cannot be made on a colposcopic biopsy. In this case, it would appear that a significant invasion is present. B.  Excisional biopsy is necessary to discover the depth of invasion. C.  Cold knife conization is preferred in order to most accurately determine depth of invasion and margin status without thermal artifact. D.  Radical hysterectomy may be necessary, depending on results of the cone biopsy. Answer 6
  97. 97. Case 4 A 28 years old woman has G2,P2 PAP smear as demonstrated in figure. it shows A.  AGC B.  HGSIL C.  Koilocytotic changes/ CIN1 D.  Immature metaplastic squamous cells Question 1
  98. 98. B. Correct: HGSIL Each cell shows gross nuclear enlargement without corresponding enlargement of the cell body. There is an irregular nuclear outline coupled with irregular chromatin distribution Answer 1
  99. 99. Figures of the cervix after the application of 5% acetic acid. This colposcopic appearence is suspect for: A.  Glandular disease (AIS/ Adeno ca) B.  Metaplasia C.  Mixed disease (squamous and glandular) D.  Condyloma Question 2
  100. 100. C. Correct: Mixed disease Each cell shows gross nuclear enlargement without corresponding enlargement of the cell body. There is an irregular nuclear outline coupled with irregular chromatin distribution Answer 2
  101. 101. The next step in the investigation is: A.  Colposcopic biopsies from the most abnormal appearing areas B.  Cervical conization/ clindirical excision C.  Repeat the PAP smear D.  Hysterectomy Question 3
  102. 102. A. Correct: Colposcopic biopsies from the most abnormal appearing areas Answer 3
  103. 103. Considering the two histological appearances together, histologic diagnosis consistent with: A.  HGSIL and AIS B.  Immature squamous metaplasia and microglandular hyperplasia C.  AIS and LGSIL D.  Reactive endocervical changes and HGSIL Question 4
  104. 104. A. Correct: HGSIL and AIS Answer 4
  105. 105. The next step in the investigation is: A.  Hysterectomy B.  Cervical conization/ clindirical excision C.  Follow-up with cytology and colposcopy D.  Repeat the biopsies in 4 months Question 5
  106. 106. B. Correct: Cervical conization/ clindirical excision Answer 3
  107. 107. Considering the two histological appearances together, histologic diagnosis consistent with: A.  Mixed disease (HGSIL and AIS) B.  AIS and Immature squamous metaplasia C.  Condyloma and HGSIL D.  Adenocarcinoma and HGSIL Question 4
  108. 108. A. Correct: Mixed disease (HGSIL and AIS) Answer 4
  109. 109. Case-5 The patient is a 30-year-old, G3,P3 woman who four years earlier had a Pap smear that was interpreted as a LSIL. A colposcopic evaluation found no visible lesion. A repeat smear the following year was read as ASC-US and she had no follow-up until a recent routine exam Pap smear was reported as a HGSIL.
  110. 110. The slide at the right demonstrates the findings at colposcopy after the application of 5% acetic acid. What colposcopic features are present? A.  Mild acetowhite epithelium on the posterior lip of the cervix B.  Dense acetowhite epithelium on the posterior lip of the cervix C.  Satisfactory exam D.  Coarse punctation Question 1
  111. 111. B. Correct: There is an area of dense white epithelium on the posterior lip of the cervix. There also appears to be a lesion in the canal at 12 o’clock and the squamocolumnar junction can not be seen fully anteriorly. The current findings are suggestive of high grade CIN. Answer 1
  112. 112. Using a cotton-tipped applicator, the anterior lip of the cervix is raised and the slides at the right reveal the following colposcopic findings at a low and higher power: A.  A faint well defined low- grade acetowhite epithelium at the squamocolumnar junction B.  A well defined high grade acetowhite lesion in the canal with atypical vessels C.  Leukoplakia D.  Fine punctation Question 2
  113. 113. B. Correct: There is a lesion on the anterior aspect of the distal canal with dense white epithelium and coarse punctation. A mosaic pattern is also seen in the lesion at 6 o’clock. Some of the vessels within the punctation pattern are linear and therefore qualify as atypical vessels. This case demonstrates both the technique and the benefits of looking into the endocervical canal. Answer 2
  114. 114. After reviewing the 3 prior colpophotographs, these findings are most consistent with what type of lesion? A.  Immature metaplasia B.  Low grade CIN C.  High grade CIN D.  Frankly invasive cancer Question 3
  115. 115. C. Correct: The dense white epithelium, coarse mosaic and punctation pattern is all consistent with a high-grade lesion. Answer 3 Atypical vessels may be seen in CIN3, microinvasion, frankly invasive cancer, and adenocarcinoma as well as inflammatory conditions, and following radiotherapy.
  116. 116. The slide at the right is a view of the biopsy specimen taken from the most abnormal area. These findings are consistent with: A.  Immature metaplasia B.  Low grade CIN C.  High grade CIN D.  Frankly invasive cancer Question 4
  117. 117. C. Correct: High grade CIN There are immature cells extending the full depth of the epithelium, along with cellular crowding and loss of polarity. Answer 4
  118. 118. Case 6 This is a 35 year-old woman whose Pap smear showed a low grade squamous intraepithelial lesion. She presents for colposcopic evaluation.
  119. 119. The colpophotographs represent views of the cervix. The findings are: A.  Transformation zone fully visualized acetowhite change with a warty pattern B.  Transformation zone NOT fully visualized acetowhite change with a warty pattern C.  Transformation zone fully visualized large complex pattern with coarse mosaic and punctation D.  Transformation zone NOT fully visualized Question 1
  120. 120. D. Correct: Transformation zone not fully visualized Colposcopic findings showed a mosaic pattern on the posterior lip of the cervix. A close-up of the mosaic pattern at 4 o’clock shows the irregularity of the pattern that suggests this is a high-grade lesion. Answer 1
  121. 121. The biopsy site, which will reveal the most information regarding diagnosis, is at A.  1 o’clock B.  10 o’clock C.  5 o’clock D.  12 o’clock Question 2
  122. 122. C. Correct: 5 o’clock This is an area of coarse mosaic that is most likely a high-grade lesion Answer 2
  123. 123. Histology of the area biopsied is present on the slides shown on the right. They reveal: A.  HGSIL B.  LGSIL C.  Metaplasia D.  Cancer Question 3
  124. 124. A. Correct: Biopsies were taken at 8 o’clock and 5 o’clock. At 8 o’clock, the biopsy shows severely inflamed tissue with immature metaplasia and foci of koilocytosis with binucleation. At 5 o’clock, there are also areas with increased mitotic activity and epithelial crowding consistent with CIN2. Answer 3
  125. 125. The next step in management is: A.  Follow with cytology and colposcopy in 3 months B.  Radical hysterectomy or radiation therapy C.  Conization of cervix D.  Laser ablation Question 4
  126. 126. C. Correct: Large complex lesions of the cervix when associated with changes that are characteristic of high-grade disease, such as patterns of coarse mosaic and punctation, are the most difficult to sample adequately by directed biopsy. The risk of missing small foci of early invasion can be significant in the best of hands. These lesions are best evaluated by diagnostic conization. The transformation zone is not fully visualized so that this patient has a further indication for the performance of conization. Answer 3
  127. 127. The final histologic specimen shown on the slides on the right revealed: A.  Clear cell adenocarcinoma B.  Giant cell granuloma - typical of tuberculosis C.  HSIL with microinvasion D.  LSIL Question 5
  128. 128. C. Correct: In a setting of condyloma and dysplasia, there is a small (about 1-3 mm) area of invasive squamous cell carcinoma. The lesion is microinvasive, extending downward about 1.25 mm. On the surface, the epithelium is thinned and dysplastic. With the successful and complete removal of a microinvasive lesion (Stage 1A1), the cone may be acceptable as therapy in circumstance where preservation of the uterus is desirable. Answer 5
  129. 129. Case 7 This is a 16 year old P 0,G0 whose Pap smear shows a LGSIL with HPV. She is referred to you for colposcopic evaluation.
  130. 130. The colposcopic pattern in the slides at the right is characterized by: A.  High grade acetowhitening with sharply defined, raised borders B.  Low grade acetowhitening, no clear border, no vascular change C.  Acetowhitening with focal areas, geographic borders, a large dilated T-zone vessel, and small satellites D.  Large area of glandular epithelium surrounded by minimally acetowhitened squamous epithelium with large areas that are non-iodine stained Question 1
  131. 131. A. Correct: The epithelium is very dense with a dull off-white color, consistent with high grade CIN. In contrast, low grade CIN will have mild white epithelium and irregular borders. It is not clear whether the blood seen on lower slide is a dilated atypical vessel or more likely just a small amount of traumatic bleeding since it is not seen on slide top slide. Answer 1
  132. 132. Biopsies should be performed at: A.  3, 6, 9, and 12 o’clock with an ECC B.  2 and 10 o’clock C.  No biopsy required since lesion is benign D.  5, 6, 7, and 8 o’clock Question 2
  133. 133. B. Correct: 2 and 10 o’clock Biopsies should be taken from both areas of acetowhite epithelium Answer 2
  134. 134. The histology from the worst biopsy site and demonstrates low and high power views of the tissue which shows: A.  Normal, mature squamous epithelium B.  Squamous metaplasia with epithelial hyperplasia, parakeratosis, and inflammation C.  Microinvasive squamous cell carcinoma D.  Adenocarcinoma-in-situ Question 3
  135. 135. B. Correct: The nuclei seen occupying the lower portion of the epithelium are regular without hyperchromasia or clumped chromatin, consistent with normal squamous cells. Answer 3
  136. 136. Based upon the information on cytology, colposcopy, and biopsy, this patient should have: A.  Excision of the transformation zone B.  Antiviral therapy with interferon C.  Re-evaluation in six months with cytology and/ or colposcopy D.  Simple hysterectomy Question 4
  137. 137. C. Correct: Young sexually active women will frequently demonstrate mild cytologic abnormalities related to HPV infection of the cervical epithelium. In the subsequent time after infection and in the presence of reactive and reparative changes within the cervical transformation zone of these young women, we may see both typical and atypical tissue responses, i.e. metaplasia along with parakeratosis, epithelial hyperplasia, and inflammation. Answer 4
  138. 138. Case 8 This is a 32-year-old, G0, P0, who had a Pap smear showing LSIL
  139. 139. The colposcopic examination is: A.  Satisfactory B.  Unsatisfactory Question 1
  140. 140. Answer 1 The SCJ is not completely visible. The lesion on the posterior lip extends into the endocervical canal. When the lesion is located partially or completely in the endocervical canal, its upper limit may not be visualized colposcopically and excisional therapy is necessary to rule out invasion. B. Correct: The colposcopy is unsatisfactory
  141. 141. This slide shows a colposcopy of the anterior lip of the cervix. This colpophotograph is most consistent with: A.  Squamous metaplasia B.  Low-grade lesion C.  High-grade lesion D.  Invasive cervical cancer Question 2
  142. 142. Answer 2 C. Correct: The lesion on the anterior lip is well circumscribed with a sharp, angular border. A mosaic pattern is present focally at the peripheral margin of the lesion.
  143. 143. A colposcopically directed biopsy of the anterior lip was performed which showed: A.  Koilocytosis B.  CIN 2 with koilocytosis C.  CIN 3 D.  CIN 3 with extensive endocervical glandular involvement Question 3
  144. 144. Answer 3 D. Correct: The biopsy is consistent with CIN 3 and extensive endocervical glandular involvement. Because the lesion is not completely visualized, an ablative procedure would not be appropriate. An unsatisfactory colposcopy, glandular involvement in a high-grade intraepithelial neoplasia is an indication for an excisional procedure.
  145. 145. The cone biopsy (LLETZ) was performed. The slide at the right is a microscopic section of the cone biopsy. It reveals: A.  Koilocytosis only B.  CIN 2 with koilocytosis C.  Invasive cancer D.  CIN 3 Question 4
  146. 146. Answer 4 D. Correct: The cone biopsy (LLETZ) revealed CIN 3 with extensive glandular involvement. These results were consistent with the cervical biopsy. However, the cone specimens demonstrated extensive involvement of the endocervical margins.
  147. 147. How would you manage this patient? A.  The colposcopy and cytology should be repeated in 3 to 6 months. B.  Another cone biopsy should be performed immediately C.  Simple hysterectomy D.  Radical hysterectomy and pelvic lymphadenectomy Question 5
  148. 148. Answer 5 A. Correct: Even though the cone margins are positive, the excisional procedure does not need to be repeated at this time. Patients with positive margins often have no residual disease on repeat surgical specimens. The cure rate for patients with positive margins on a cone biopsy without further treatment is approximately 70%. In cases of CIN when the dysplasia extends to the endocervical border of the excision, expectant management, including intensive cytologic surveillance, may be employed rather than repeat excision.
  149. 149. Case -9 This is a 35-year-old woman referred to you from another physician. Her Pap smear showed HSIL .
  150. 150. There is acetowhite epithelium from approximately 12 to 1 o’clock and at 3 o’clock. Where should the biopsy be taken? A.  12 to 1 o’clock B.  3 o’clock C.  Both areas should be biopsied D.  Do not need to be biopsied. Question 1
  151. 151. Answer 1 C. Correct: The colposcopic evaluation demonstrates two areas of acetowhite epithelium. It is not possible with certainty, to determine which acetowhite area represents the most severe histology. Both of these lesions should be biopsied.
  152. 152. This represents the colposcopically directed biopsy of the 3 o’clock area. The diagnosis is: A.  Normal squamous epithelium B.  Koilocytosis C.  CIN 3 D.  Invasive cervical cancer Question 2
  153. 153. Answer 2 B. Correct: Koilocytosis The lower third of the epithelium shows cells with a high nuclear:cytoplasmic ratio and hyperchromatic nuclei. The intermediate and upper layers of the epithelium demonstrate koilocytosis. The presence of perinuclear halos and nuclear atypia characterize the koilocytes
  154. 154. This represents the colposcopically directed biopsy of the 12 o’clock area. The diagnosis is: A.  Normal squamous epithelium B.  Koilocytosis C.  CIN 2-3 D.  Invasive cervical cancer Question 3
  155. 155. Answer 3 C. Correct: CIN 2-3 The epithelium displays cells with various morphologic shapes, dense chromatin, and the absence of koilocytotic changes. The nuclei are enlarged in relation to the amount of cytoplasm.
  156. 156. Case 10
  157. 157. The colposcopic examination is: A.  Cervical condyloma B.  Cervical and vaginal condyloma C.  Vaginal condyloma and cervical cancer D.  Microglandular hyperplasia and vaginal cancer Question 1
  158. 158. Answer 1 B. Correct: Cervical and vaginal condyloma
  159. 159. The best management at this time would be to: The best management at this time would be to: A.  Apply TCA B.  Collect a specimen for HPV- DNA Testing C.  Freeze the warts D.  Collect cervical histologic specimen(s) Question 2
  160. 160. Answer 2 D. Correct: It may be appropriate to confirm your confirm colposcopic impression with histologic sampling. Cervical cryotherapy is contrindicated without previous biopsy. HPV DNA testing has no utility once condyloma are histologically confirmed.
  161. 161. A cervical biopsy was taken from the lesion . The cervical biopsy is diagnostic of: A.  Cervical condyloma B.  Cervical cancer C.  Cervical polip D.  Cervical desidua Question 3
  162. 162. Answer 3 A. Correct: A classic cervical wart is seen histologically
  163. 163. Optimal recommendation to the patient would be to: A.  Follow-up with cytology and colposcopy B.  Treat the cervical disease only C.  Treat the vulvar disease only D.  Treat all the condylomas Question 4
  164. 164. Answer 4 D. Correct: Treat all the condylomas
  165. 165. Case -11 q A 24-year-old G0,P0 presents for her first pap smear in 3 years. q There is no previous history of abnormal smears. q She has smoked in the past but stopped one year ago. q She has no history of STDs. q She is using oral contraceptives.
  166. 166. Your diagnosis is: A. ASC-US B. ASC-H C. LGSIL D. HGSIL E. AGC Question 1
  167. 167. Your diagnosis is: A. Correct: ASC-US Note the normal cells present with small nuclei and abundant cytoplasm. The more eosinophilic cell to the right of the screen has a slightly enlarged nucleus, approximately 2 to 3 times the size of normal nuclei. There is, however, abundant cytoplasm. Answer 1
  168. 168. Given the diagnosis of ASC-US, preferred management is to: A.  Colposcopy B.  HPV-DNA reflex testing C.  Repeat cytology in 4-6 months D.  Cryotherapy Question 2
  169. 169. Given the diagnosis of ASC-US, preferred management is to: A: Colposcopy is an acceptable option. B: HPV-DNA reflex testing. C: Repeat Cytology in 4 to 6 months is also an acceptable option. Answer 2
  170. 170. What Are the Colposcopic Findings? A.  Faint acetowhite, geographic borders, fine mosaic patterns B.  Acetowhite lesion, well defined margins, coarse mosaic and punctation C.  Dense acetowhite, atypical vessels D.  Satellite lesions Question 3A What Are the Colposcopic Findings? Question 3A
  171. 171. What Are the Colposcopic Findings? B. Correct: Acetowhite lesion, well defined margins, coarse mosaic and punctation: These colposcopic photographs show a lesion at 12 o'clock with a well-defined margin. There is, of course, punctation and mosaic patterns and acetowhite lesion. There are no atypical vessels present. Satellite lesions are not seen. Answer 3A
  172. 172. What is your colposcopic impression? A.  Squamous Metaplasia B.  CIN1, HPV C.  CIN2, CIN3 D.  Invasive Squamous cell cancer Question 3B
  173. 173. What is your colposcopic impression? C. Correct : CIN2, CIN3 The colposcopic findings here are suggestive of a high grade CIN, CIN2-3. There is no evidence that this is an invasive lesion Answer 3B
  174. 174. The most appropriate area for biopsy is: A.  3 o'clock B.  6 o'clock C.  9 o'clock D.  12 o'clock Question 3C
  175. 175. The most appropriate area for biopsy is: D. 12 o'clock: Correct It would be most appropriate to biopsy the lesion near the transformation zone at 12 o'clock. Answer 3C
  176. 176. Your diagnosis is: A.  Squamous Metaplasia B.  CIN1 C.  CIN3 D.  Invasive Squamous Cell Cancer Question 4
  177. 177. Your diagnosis is: C. Correct : CIN3 Note the full thickness change in the squamous epithelium and lack of invasion of the basement membrane. These findings are consistent with a CIN3 lesion. Answer 4
  178. 178. Management Options for This Patient Include: A. Observation B. Loop excision C. Cryotherapy D. Cold-Knife Conization Question 5
  179. 179. Management Options for This Patient Include: B. Correct : Loop excision Observation is not appropriate for high-grade dysplasia. This is a true cancer precursor and requires treatment. Loop excision would be the author's preferred treatment plan, though cryotherapy and cold knife conization have their advantages and disadvantages. You can prefer a loop excision for treatment of this high- grade lesion with satisfactory colposcopy. Answer 5
  180. 180. Management Options for This Patient Include: D. Correct: Cold-Knife Conization Cold knife conization would be appropriate; however, this generally requires more anesthesia than a Loop excision does. Cryotherapy is certainly appropriate. However, given a satisfactory colposcopy, an endocervical curettage would need to be performed prior to performing cryotherapy. Answer 5 Cont.
  181. 181. Case -12 q  A 26-year-old woman presents with a history of a previously abnormal Pap smear at age 18. q  The patient did not follow-up at that time and has not had a Pap smear since then. q  The patient used to smoke a pack of cigarettes per day, but has not smoked for the past year. q  She has noted no abnormalities and presented for this Pap smear because of a yeast infection. q  She has no abnormal bleeding or intermenstrual bleeding
  182. 182. The correct cytologic diagnosis for this is: A.  ASC-H B.  ASC-US C.  LGSIL D.  HGSIL E.  AGC Question 1
  183. 183. The correct cytologic diagnosis for this is: E. Correct: AGC • According to the ASCCP Guidelines, the term atypical glandular cells of undetermined significance (AGC-US or AGUS) has been replaced with the term atypical glandular cells (AGC) • The cytopathologist should attempt to determine whether these are endocervical endometrial cells, adenocarcinoma in situ, or frank adenocarcinoma of endocervical, endometrial, extrauterine or not otherwise specified. Answer 1
  184. 184. Given AGC diagnosis, the preferred management option is: A.  Reflex HPV-DNA testing B.  Repeat cytology C.  Colposcopy and endocervical evaluation D.  Loop excision Question 2
  185. 185. Given AGC diagnosis, the preferred management option is: C. Correct : Colposcopy and endocervical evaluation AGC have been associated with a greater risk for cervical neoplasia than other categories (ASC or LSIL) AGC –  % 9-54 CIN –  % 8 Adenocarcinoma insitu –  % 9 Invasive carcinoma Answer 2
  186. 186. Given AGC diagnosis, the preferred management option is: • The total number of abnormal Pap smears with glandular lesions is generally < 1%. • Colposcopy and endocervical evaluation would not unduly stress busy clinical services. Therefore, the recommendation has been made that all of these patients be properly evaluated. Answer 2 Cont.
  187. 187. Colposcopy of this patient can be seen. The following statements are true: Question 3 A.  There is a wide transformation zone B.  There are acetowhite lesions present C.  There are atypical vascular patterns present D.  The colposcopy is unsatisfactory
  188. 188. Colposcopy of this patient can be seen. The following statements are true: Answer 3 A. Correct: There is a wide transformation zone
  189. 189. Colposcopy of this patient can be seen. The following statements are true: B.  Correct: There are acetowhite lesions present:   In these colposcopic photographs, at 12 o'clock there are acetowhite lesions present. C. Correct: There are atypical vascular patterns present Answer 3 Cont.
  190. 190. A biopsy is taken from one of the areas of atypical vessels, the correct histologic diagnosis is: Question 4 A.  High grade CIN B.  Low grade CIN C.  Adenocarcinoma in situ D.  Invasive adenocarcinoma
  191. 191. A biopsy is taken from one of the areas of atypical vessels, the correct histologic diagnosis is: Answer 4 C. Correct: Adenocarcinoma in situ This is a good example of adenocarcinoma in situ. Please note that the glands are quite complex. There is no invasion into the stroma surrounding these glands.
  192. 192. The correct treatment for this patient includes which of the following: A.  Cryotherapy B.  Laser vaporization C.  Cold knife conization D.  Loop excision procedure Question 5
  193. 193. The correct treatment for this patient includes which of the following: C. Correct: Cold knife conization The preferred method of excisional of biopsy is cold knife conization. While Loop excision is sometimes performed, a higher rate of recurrence of adenocarcinoma in situ has been found in patients undergoing Loop electrosurgical excision procedures as opposed to cold knife conizations. Answer 5
  194. 194. The correct treatment for this patient includes which of the following: • In patients who have completed their childbearing after an invasive lesion has been ruled out by cold knife conization, standard therapy continues to be a simple hysterectomy • In patients who wish to continue fertility, if the margins are negative, close clinical follow-up is recommended. A change in the recommendations for conservative follow-up includes four consecutive normal Pap smears rather than three. Answer 5 Cont.
  195. 195. Case 13 This 27-year-old patient had a series of Pap smears several months apart, each of which showed ASC-US. Her most recent Pap smear showed a HSIL.
  196. 196. This is the colposcopic appearance of her cervix after the application of 5% acetic acid. The lesion is most consistent with: A.  Squamous metaplasia B.  LGSIL C.  HGSIL D.  Invasive cervical cancer Question 1
  197. 197. B. Correct: LGSIL This acetowhite area has characteristics of a low- grade lesion. The borders are feathery. Acetowhiteness is very dense, a biopsy would need to be performed in order to grade the lesion. Answer 1
  198. 198. Colposcopic view of the cervix reveals an acetowhite area on the posterior lip of the cervix adjacent to the squamocolumnar junction. It shows: A.  Atypical vessel pattern consistent with invasive cancer. B.  Nabothian cyst. C.  A fine mosaic patterns consistent with squamous metaplasia or LGSIL. D.  Dense acetowhite epithelium with scattered coarse punctation or gland openings consistent with a HGSIL. Question 2
  199. 199. D. Correct: This lesion exhibits dense acetowhiteness and is directly adjacent to the squamocolumnar junction. It is important to biopsy this lesion. Answer 2
  200. 200. Colposcopically directed biopsies were performed and this slide is representative of those biopsies. It shows: A.  Squamous metaplasia with chronic cervicitis B.  CIN1 C.  CIN3 D.  Invasive squamous carcinoma Question 3
  201. 201. A. Correct: The inflammatory cells in the epithelium are indicative of cervicitis. The term chronic cervicitis implies that reserve cell formation is occurring beneath the layer of tall mucus-secreting columnar cells and does not imply that an infection is present. Answer 2
  202. 202. LLETZ was performed because of the discrepancy between the high- grade cytology and the negative biopsy. The histology represented is consistent with: A.  Low-grade CIN B.  High-grade CIN C.  Microinvasive squamous cell carcinoma D.  Invasive squamous cell carcinoma Question 4
  203. 203. B. Correct: High Grade CIN The LLETZ specimen revealed CIN3 with superficial endocervical extension. The full thickness of the epithelium is dysplastic. There are a few koilocytes in the upper layer. The margins were uninvolved with dysplasia. Answer 4
  204. 204. Case 14 Based of the colpophotograph her examination is: A.  Unsatisfactory B.  Satisfactory Question 1
  205. 205. Answer 1 A. Correct: Unsatisfactory The entire SCJ can not be completely identified The lesion appears to extend within the endocervical canal beyond view
  206. 206. Your colposcopic impression is: A.  Normal B.  Low grade C.  High grade D.  Cancer Question 2
  207. 207. Answer 2 C. Correct: High grade An acetowhite lesion with a regular margin can be seen. The color is an opaque white. Blood vessels are not apparent
  208. 208. Your management at this time would be to: A.  Repeat PAP smear in 6 and 12 months B.  Collect a cervical biopsy C.  Collect a cervical biopsy and ECC D.  Obtain an ECC Question 3
  209. 209. Answer 3 C. Correct: Collect a cervical biopsy and ECC Given an unsatisfactory colposcopic examination, a HGSIL PAP smear report and a high grade lesion on the cervix, both cervical biopy and ECC are indicated
  210. 210. The cervical biopy is seen in figure. What is your diagnosis? A.  Normal B.  CIN 1 C.  CIN 2 D.  CIN 3 Question 4
  211. 211. Answer 4 C. Correct: CIN 2 Cellular atypia is seen in the lower two thirds of the epithelium
  212. 212. The ECC is seen in figure. What is your diagnosis? A.  Insufficient material B.  Normal C.  Positive, CIN D.  Positive, suspicion of cancer Question 5
  213. 213. Answer 5 C. Correct: Positive, CIN There is no evidence of malignant epithelium
  214. 214. What management is appropriate at this time ? A.  Hysterectomy B.  Cryotherapy C.  Cold conization D.  LEEP Question 6
  215. 215. Answer 6 C. Correct: Cold conization is required based on the unsatisfactory colposcopic examination and a positive ECC. Cryotherapy is contrindicated prior to excluding presence of invasive cancer by conization
  216. 216. Case 15 This is a 60-year-old , Para 8, whose last menstrual period was 12 years prior to this visit. A routine Pap smear performed one month ago was read as HGSIL, but invasion could not be ruled out.
  217. 217. This image shows: A.  Diffuse white (pale) epithelium B.  A focal area of acetowhite epithelium that is incompletely visualized C.  A focal area of acetowhite epithelium with coarse punctation D.  Atypical vessels in an area of acetowhite epithelium Question 1
  218. 218. Answer 1 A. Correct: The cervix of this 60-year-old female appears pale. The pale color may reflect an atrophic epithelium. There is a focal area of acetowhite epithelium at 8 o’clock which is completely visualized. There is no evidence of abnormal or atypical vessels raising the suspicion for intraepithelial neoplasia or invasive disease.
  219. 219. Which of the following colposcopic features are present? A.  Nabothian cysts B.  Focal area of acetowhite epithelium C.  Punctation D.  Mosaic Question 2
  220. 220. Answer 2 B. Correct: There is a well-circumscribed, gray-white lesion at 8 o’clock that is seen in its entirety. There is no evidence of abnormal or atypical vessels. A biopsy of this lesion should be performed. Lesions, which are densely acetowhite even in the absence of vessel patterns, can be CIN 2 or CIN 3.
  221. 221. On low power view of the cervix, the colposcopic examination is: A.  Satisfactory B.  Unsatisfactory C.  Cannot be certain based on this colpophotograph Question 3
  222. 222. Answer 3 C. Correct: The transformation zone is not completely visualized. Nowhere can you see grape-like structures of the columnar epithelium. In fact, the view is distorted and the examiner can easily miss significant disease. The colposcopist must attempt to visualize the entire SCJ at each examination.
  223. 223. A cervical biopsy was taken from the lesion noted in question 2. The cervical biopsy is diagnostic of: A.  Squamous epithelium with no pathologic findings B.  CIN 1 with koilocytosis C.  CIN 3 D.  Invasive squamous cell carcinoma Question 4
  224. 224. Answer 4 A. Correct: Squamous epithelium with no pathologic findings The transformation zone is not represented in this specimen. The histologic results do not correlate with the severity of the cytology (HGSIL). An ECC must be performed to rule out disease in the endocervical canal.
  225. 225. The endocervical curettage is most compatible with diagnosis of: A.  Normal columnar epithelium B.  Adenocarcinoma, uncertain origin C.  Detached fragments of CIN 3 D.  Detached fragments of CIN 1 Question 5
  226. 226. Answer 5 C. Correct: Histology of the endocervical curettage revealed a squamous intraepithelial neoplasia with no underlying stroma. Because of the absence of underlying stroma, invasion cannot be ruled out. A cervical conization is indicated to rule out the presence of invasive cancer.
  227. 227. References A.  American Society for Colposcopy and Cervical Pathology. www.asccp.org. B.  Newkirk, G. The Colposcopic Examination. Pfenninger & Fowler's Procedures for Primary Care Physician: 616-630. C.  Johnson, B. The Colposcopic Examination. American Family Physician. June 1996. D.  AAFP Colposcopy Position Paper E.  Colposcopy and Treatment of Cervical Intraepithelial Neoplasia: A Beginner's Manual. http://screening.iarc.fr/colpo.php F.  Educational material CD (100 challenging colposcopy cases)
  228. 228. Thank You For Listening

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