Colposcopy

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Colposcopy Today Prof. Aboubakr Elnashar Benha
University Hospital. EGYPT E-mail
elnashar_at_hotmail.com
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• The colposcope was first developed in 1925 is
  well established in gynecologic practice for
  defining delineating cytologically detected
  lesions mainly of the cervix but also the vagina
  vulva.
• Colpscopy is now gradually spreading allover the
  world postgraduate training courses is now
  being given in many centers.

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Historic events related to
colposcopy 1925 Invention of colposcope(Hinselman
) 1928 Schiller test 1938 Acetic acid test
(Hinselman) 1939 Green filter (Kratz) 1940 Pap
test 1942 First photographs of cervix
(Treite) 1960 Cryosurgery 1980 Laser
surgery 1988 Computer-aided colposcope 1989
LLETZ (Prendiville Cullimore) 1991 Pap
Net 2000 Telecolposcopy ( Harper et al)
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• Technologic advances
• New optical lenses, fiberoptic light cables
  videocameras with digital computer enhancement,
  all played a part in advances of colposcopy.
• Computer technology has made it possible to
  capture images directly onto a computer these
  images allow enhancement manipulation according
  to physician,s preference.

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Digital imaging colposcopy (CCDcharge couple
device)
Colposcope
Video camera (CCD)
Optical interface
Video monitor
Video digitizer board
Mass storage
Printer
Personal computer
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Telecolposcopy ( Harper et al,2000) Telecolposcop
ic system incorporating a custom software
package.
All images were received without
distortion in color, size, or orientation.
Telecolposcopy
is technically feasible,
can be implemented in an office
system with limited technical support is
preferred by women who have to travel many miles
to receive referral health care.
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Current indications of colposcopy 1. Part of any
gynecologic examination 2. Primary screening for
cervical cancer. 3. Clinically suspicious
cervix. 4. Abnormal Pap smear. 5. Evaluation
treatment of CIN. 6. Follow up after conservative
therapy of CIN. 7. Postcoital bleeding. 8.
Patients with external vulval warts 9. Evaluation
of sexual assault victims. 10. Patients with
history of DES exposure
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• Uses
• Screening colposcopy is a feasible procedure
  more sensitive more cost effective than
  cytological screening. When access to
  cytopathology is difficult, screening colposcopy
  is an alternative (Cecchini et al,1997).
• Portable colposcopy in rural areas is cost
  effective highly acceptable (Martin et
  al,1998).
• The colposcopy improved detection of genital
  trauma in adult female sexual assault victims as
  compared with gross visual examination alone
  (Lenahan,1998).

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Recent recommendations of FIGO for management of
abnormal smear( Benedet,2000) Persistent
inflam., persistent ASCUS, LSIL, HSIL,
AGCUS,Invasive Colposcopybiopsy Normal or
LSIL HGSIL
Invasive 6 mo smear x 2
LEEP
Appropriate TT Normal
Persistent Annual screening
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• Steps
• Lugolsiodine test beneficial test..
• ECB has replaced ECC easier to use, malleable
  less expensive.
• Its specificity 92, sensitivity 90 positive
  predictive value 88 ( Martin et al, 1995).
• Punch biopsy False negative rate up to 54 (
  Buxton et al,1991)
• Multiple biopsies
• Excisional techniques are superior to destructive
  techniques

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Diagnostic criteria 1. Vascular pattern.
2. Inercapillary distance
3. Contour. 4.
Color
5. Clarity of demarcation
6.
Appearance of gland opening.
7. Negativity after iodine
test 8. Whiteness after acetic acid
Density of whiteness, time
needed to appear disappear, demarcation.
Changes
gt35 yr are thinner less demarcated., punch
biopsy (Zahm et al, 1998). 9. Surface extent of
the lesion more important prognostic indicator
for invasion than histological grading ( Tidbury
et al,1992)
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International Federation of Cervical Pathology
Colposcopy(1991) Normal Original squamous
epithelium Columnar epithelium
Normal transformation zone Abnormal
Acetowhite epithelium
Punctation Mosaicism
Leukoplakia
Iodine negative
Atypical vessels Suspect invasive
cancer UnsatisfactorySCJ not visible, severe
inflam or atrophy, invisible cervix Miscellaneous
Nonacetowhite micropapillary surface,
exophytic condyloma, inflammation,
atrophy, ulcer
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• Niekerk (1998)
• Low grade
  High grade
• Acetowhite epithelium shiny or snow dull,
  oyster white color
• white,semitransparent
• Surface flat
  irregular contour, microexophytic
• Demarcation diffuse, irregular,
  sharp, straight line,
• flocculated, feathered,
• internal demarcation absent
  internal demarcation present
• Vessels fine, regular shape, uniform
  coarse, dilated, increased ICD,
• caliber, normal arborization, spaghetti
  bizarre, commas, corkscrews
• changing calibers
  sharp bends
• Iodine uniform mahogany brown mustard
  yellow, yellow or iodine -ve

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Update of colposcopy of genital HPV Meisels et al
(1982) Florid, spiked, flat, condylomatous
. .
vaginitis. Flat condyloma mild dysplasia
represent the same biologic phenomenon, namely,
productive HPV infection (Reid,1993). The
expression of viral activity may be clinical or
subclinical when it is recognizable only on
colposcopy. Exophytic flat condylomata are not
homologous diseases. Exophytic is usually caused
by cutaneotropic viruses (6,11). Flat are more
likely to contain medium(31,33) or high
risk(16,18) HPV types. Micropapillary condyloma
should not be confused with micropapillomatous
labialis.
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Colposcopy of the vulva Steps 1. Examination
after smearing with a water soluble lubricant. 2.
Prolonged acetic acid test 3. Toludine blue test
little clinical value. The junction between the
glycogen bearing vaginal epithelium keratin
producing vulval epithelium high risk for
intraepithelial neoplasia. Abnormalities
diffuse acetowhite, localized acetowhite,
leukoplakia, micropapillae, papules.
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Update on colposcopy in pregnancy Difficult.
reserved for the most experienced
colposcopist. Reassurance of the patient. ECC is
contrindicated one directed biopsy. Large
speculum is usually needed Sponge forceps to
remove the mucous acetic acid as a
mucolytic Unsatisfactory colposcopy repeat after
8 w The aim is to exclude cancer CIN follow up
definitive treatment 1-2 mo postpartum.
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Pitfalls in practice of colposcopy A. In the
technique 1. Failure to use a diagnostic
protocol 2. Deviation from a diagnostic
protocol. 3. Failure to visualize TZ. B. In
diagnosis 1. Misinterpretation of exagerated
patterns of pregnancy, previously treated cervix,
carvical cancer. 2. Failure to select appropriate
biopsy sites, enough biopsies, sufficient volume
of tissue. 3. Failure to accurately record
colposcopic findings
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C. In management 1. Miscommunication with the
pathologist. 2. Failure to correlate cytology,
colposcopy histopathology. 3.Destructive
therapy without biopsy, for invasive or
glandular lesions. D. In the colposcopist 1.
Inadequate training.
2. Inadequate
experience.
3. Inadequate understanding of
the disease. 4. Failure to keep
up with scientific developments 5.
Failure to maintain skills.
6. Failure to seek
consultation.
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• Diploma of colposcopy
• No one should be allowed to practice colposcopy
  without having proper training or without a
  diploma in colposcopy( Jordan,1995).
• It would be a legal document that would safeguard
  the public raise the status of the
  colposcopist.

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Future research in colposcopy( Hilgarth,1998) 1.
Computerized colposcopic documentation
consecutive analysis of colposcopic findings. 2.
Clinical significance biologic behavior of
minor lesions visible with colposcopy in the
presence of different HPV types. 3. Clinical
significance relation to HPV infection of minor
lesions beyond the TZ. 4. Vulvar lesions in
vulvodynia related to HPV infection.
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Future of colposcopy (Niekerk,1998) 1. There are
going increasing costs of medical care the
demand for better quality control will
intensify. 2. Technical advances will
revolutionize this area digital imaging, the
storage of up to 4.500 images on an optical disk
rapid teletransmission of images will become
practical.. The use of these new technologies
for better more cost effective patient care is
the challenge we will have to meet in the 21st
century.
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Thank you
Prof Aboubakr Elnashar
Benha University Hospital. EGYPT E-mail
elnashar_at_hotmail.com