TEN COMMANDS TO BE A COLPOSCOPIST

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TEN COMMANDS TO BE A COLPOSCOPIST

• By
• Prof. Mohammad A. Emam Director Of Early Cancer
  Detection Unit OB GYN Dept.
• Mansoura Faculty Of Medicine - EGYPT

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What is a Colposcope?

• Colposcope
• Stereoscopic, Binocular
• Microscope with 3 specifications
• low magnification (10 40)
• Focal length (20 25 CM)
• Width of visual field gt 25 MM.
• - NB Colpomicroscope (150 200)

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TEN COMMANDS TO BE A COLPOSCOPIST

• Gynecologist should be aware of
• 1. Value
• 2. Instruments.
• 3. Different terminology (Anatomical
  histological Pathological Cytological and
  Colposcopic)
• 4. Indications.
• 5. Steps for colposcopy
• 6. Diagnostic Criteria. 7. Interpretation.
• 8. Pitfalls. 9.
  Training.
• 10. Treatment.

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Value of Colposcopy

• 1. Fill the gap bet. N/E Cytopathology.
• 2. Early detection for precancerous lesions of
  lower genital tract (CIN, VAIN, VIN).
• 3. Decrease diagnostic conization and
  hysterectomy.
• 4. Complementary for cytology or VIA (Each one
  cover the disadvantages of the other).
• CYTOLOGY DISCOVERS THE CRIME COLPOSCOPY LOCATES
  THE CULPRIT.

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Instrument
1.Colposcope

• Optical system ( 7.5 40 ).
• Illumination system ( Dim or Bright ).
• Stand (Easy movement).
• Accessories ( Gray filter Camera Electronic
  flash ).

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Instrument cont
2.Auxillary

• Set for cytology.
• Set for Biopsy.
• Speculae ( non polished or plastic ) Kogans.
• Chemicals( Lugols Iodine - Acetic acid 3 -
  Monsols sol .saline)
• Cotton Buds-singleys forceps iris hook

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Instrument cont..
III-extra auxillary

• Eye piece.
• Video printer.
• Computer graphic.

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TERMINOLOGY
Anatomical Terminology

• 1. Ectocervix ( vaginal surface of CX.).
• 2. Endocervix ( cervical canal).
• 3. Eversion (Dynamic process) may be true
  (erosion) or false (ectropion).

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TERMINOLOGY cont..
Pathological terminology

• Metalplasia.
• Dysplasia (BET SQU. Epith CIS.) (Dediff.
  disarrangement).
• CIN (I, II, III).
• Micro invasive (lt 5mm no vascualr and lymphatic
  extension).
• Invasive carcinoma
• Hyper keratoses ( leukoplakia)
• Parakeratosis.

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HISTOLOGICAL TERMINOLOGY

• Epith. Covering
• Original epithelia . Squamous.
• .
  Columnar
• Metaplastic epithelia (Neonatal Period puberty
  pregnancy).
• Squamo Columnar J. (primary Secondary)
• Underlying Stroma.

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Cytological Terminology

• positive smear.
• negative smear.
• doubtful Smear.
•  
• ( N/C Anisocytosis Hyperchromsia-Clumping).

Smear comment
Dyskaryotic cell
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Colposcopic Terminology

• Many classifications

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Transformation zone TZ

• Definition
• The area between the original squamocolumnar
  junction caudally (which is now squamo
  _Metaplastic junction) to the current (secondary)
  squamo Metaplastic columnar junction cranially
  (where islands of physiological Metaplastic
  Epithelium is identified)

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Transformation zone TZ cont....
T Z can be altered by

• Age
• Pregnancy
• Oestrogen
• Menopause

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Indications
I) Diagnostic

• Abnormal pap, smear.VIAM
• Any suspicious lesion (CX Vagina vulva).
• In utero exposure to diethyl stilbestrol (or)
  related drugs.
• Infertility (?) cervical factor.
• Sexual assault victims.
• Cryocautery.
• Diathermy (loop).
• Laser.

II) Therapeutic
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Role of Colposcope
1. During Diagnosis
Localization of TZ

• Prove (or) disprove invasive cancer.
• Localization of the most ABN. Site for biopsy.
• Evaluation of extent (need for Conization).

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Role of Colposcope cont...
2. During therapy

• Suitability of the lesion for local destruction.
• Indications for conization
• No Colposcopic lesions (ve pap. Smear).
• Too extensive lesion.
• ECC Atypia.
• Micro invasion by Colposcopy Biopsy.
• Extensive CIN III but fertility is needed.

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Steps for Colposcopy

• History ( VIA - pap smear drugs infections
  sexual.. etc)
• Counseling explanation of the procedure to the
  patient (psychic element).
• Timing (8 12 day of the cycle).
• Position Examination table.

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Steps for Colposcopy cont..

• Exam.
• Inspection.
• Bimanual exam, (?!).
• Insertion of speculum (precautions).
• Cytology (spatula cytobrush CVE Cotton buds
  or aspirator)
• Colposcopy.

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Steps for Colposcopy cont..
A) Direct (saline)

• SQ. COL. J. endocervix vascular.
• Green filter.
• Use (Kogans speculum cotton bud singleys
  forceps).

B) Amplified

• Acetic Acid 3 (3 4 min).
• Lugols iodine (?) (1 part I2 2KI 97H20).

C) Endo C.C. OR ECB (easier)
D) Colposcopic Guided Punch biopsy.
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Diagnostic criteria of Colposcopy
- Major (5)

• Vascular pattern.
• Intercapillary distance.
• Contour (surface pattern).
• Colour tone opacity.
• Borders (Dermarcation).

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Diagnostic criteria of Colposcopy cont..
Minor (5)

•  
• Size (Extent).
• Keratosis.
• Aceto white areas.
• Iodine uptake.
• Cervical gland openings.

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Interpretation
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Interpretation cont
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Pitfalls of Colposcopy

• 1. False squamo- columnar j.(finger speculum
  smear ).
• 2. High squamo columnar J. in canal (gt 5mm up).
• 3. Previously treated cervix by cryo, or laser.
• 4. Adenocarcinoma in situ (difficult) -?
  hysterocolpomicroscope.
• 5. Subjective method (cervicography digital
  color imaging Colposcopy (DCIC) are objective
  methods.

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Lines of Treatment

• 1. No treatment.
• 2. Follow up.
• 3. Local destructive therapy (Electro
  coagulation diathermy cryocautery cold
  coagulation laser , photodynamic).
• 4. Cone biopsy.
• 5. Hysterectomy.

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Criteria for local destructiveTherapy (LDT)

• 1. Satisfactory Colposcopy.
• 2. Expert colposcopist.
• 3. No suspicious of invasion (Cytology
  Colposcopy Histopathology).
• 4. ECC or ECB is negative.
• 5. Done by the expert colposcopist.
• 6. Good follow up.

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Recommendations

• Colposcopy is not a difficult procedure, but
  without good training, maximum benefits are not
  realized and serious mistakes can be made.
• In modern practice, Colposcopy has become an
  integral part of the gynecologic examination.

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Recommendationscont

• Colposcopy, can not be done in a vacuum, rather
  it must be performed in combination with cytology
  ,VIA and tissue sampling.
• Cervicography , digital colour imaging Colposcopy
  (DCIC) computer aided colposcopy are objective
  rather than subjective methods.

• Colposcopy, can not be done in vacuum, rather it
  must be performed in combination with cytology
  ,VIA
• Cervicography , digital colour imaging Colposcopy
  (DCIC) computer aided colposcopy are objective
  rather than subjective methods.

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Thank you
Prof. MOHAMMAD EMAM
OB GYN, Mansoura Faculty of Medicine Mansoura
Integrated Fertility Center (MIFC) EGYPT Telfax
0020502319922 0020502312299 Email.
mae335_at_hotmail.com