chapter 7. Colposcopic terminology: the 2011 IFCPC nomenclature

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1 hpter 7. Colposopi terminology: the 2011 IFCPC nomenlture CHAPTER 1 CHAPTER 1 In ny rnh of siene, progress evolves from ler understnding of previous reserh nd experiene. Clrity of terminology nd prtie is fundmentl to understnding oth pulished reserh nd reports of experiene in similr nd in different linil irumstnes. Otherwise, it is very diffiult to urtely ompre existing prtie or to evlute new evidene. The ltest IFCPC nomenlture (Bornstein et l., 2012) ttempts to ring greter lrity to terminology in dignosti nd therpeuti olposopy prtie. Individul terms re listed in Annex 3. Sreening progrmmes for ervil prener hve redued the inidene of ervil ner, espeilly in those ountries with properly orgnized, qulity-ssured ll-ndrell systems. Of ourse, it is not the sreening itself tht redues the risk of ervil ner, ut rther the susequent tretment of sreen-positive women who re found to e t signifint risk of developing ner. Most sreen-positive women re t very low risk of progression to ner. These women my e ressured nd followed up ppropritely. Colposopi ssessment of the grde of normlity, nd therefore the risk of progression, is ruil to the proess of mnging sreen-positive women. So lso is ssessment of other TZ hrteristis, for exmple the TZ site nd size, nd the visiility of the entire TZ. Most importntly, when properly undertken, olposopy will redue the risk of oth overtretment nd undertretment. For those women who re t reltively high risk of progression to ner nd who do need to e treted, preise exision of the TZ is ssoited with the lowest risk of pregnny-relted moridity (Khlid et l., 2011; Cropino et l., 2013) nd the highest hne of hieving suessful erdition of ll prenerous epithelium (Ghem-Mghmi et l., 2007; Mnhnd et l., 2008). 7.1 Terms tht hve een omitted from the 2011 IFCPC nomenlture To most olposopists in the United Kingdom, one iopsy mens exision of signifint portion of the endoervil nl, nd the term would e reserved for those ervies where the lesion is thought to e out of olposopi view in the endoervil nl, either wholly or in prt. However, to mny olposopists in the USA nd Europe, one iopsy Chpter 7. Colposopi terminology: the 2011 IFCPC nomenlture 51

2 or oniztion mens exision of ny type of TZ, no mtter how muh of the endoervil nl hs een exised. Also, dimensionl terms like height nd depth re used lmost interhngely in different pulitions, nd this n led to invlid omprison of tretment methods. For these resons, the 2011 IFCPC nomenlture omits the terms one iopsy nd oniztion (see TZ exision types 1, 2, nd 3 in Tle 7.1) s well s depth nd height. 7.2 Generl ssessment A generl nd initil ssessment of the ervix will llow the olposopist to determine whether exmintion of the ervil epithelium is dequte or whether it is ompromised y inflmmtion, leeding, trophy, sr tissue, or suepithelil firoti hnge. Mking n ssessment of whether the TZ is fully visile nd where it is situted will llow determintion of the TZ type. 7.3 Trnsformtion zone type After it is estlished tht the exmintion is dequte, the TZ type nd size should e determined (Figs ). A fully visile nd etoervil TZ is type 1 TZ. A TZ tht is prtilly or ompletely endoervil ut is fully visile is type 2 TZ. A TZ tht is prtilly or ompletely endoervil ut is not fully visile is type 3 TZ. Fig Type 1 trnsformtion zone (TZ). () Illustrtion. ( d) Exmples of type 1 TZs. In eh, the entire TZ is visile on the etoervix. Trnsformtion Zone Clssifition Type 1 Is ompletely etoervil Is fully visile My e smll or lrge d Fig Type 2 trnsformtion zone (TZ). () Illustrtion; the upper limit of the TZ is in the endoervil nl ut is visile elow the upper limit of visiility, here represented y the horizontl line. (, ) A lrge type 2 TZ; two imges of the sme ervix. The upper limit of the TZ is esily seen on the posterior lip ut is visile in the nl only with the id of otton sw. In this young womn, the undnt nd ler muus of n uninfeted nd well-estrogenized ervix llows esy mnipultion nd visuliztion of the lower endoervil nl nd the upper limit of the TZ. Type 2 Hs endoervil omponent Is fully visile My hve etoervil omponent, whih Trnsformtion Zone Clssifition my e smll or lrge 52

3 Fig Type 3 trnsformtion zone (TZ). () Illustrtion; the upper limit of the TZ extends eyond the upper limit of visiility, here represented y the horizontl line. (, ) Exmples of type 3 TZs. In eh, the upper limit of the TZ nnot e seen, euse it extends into the nl ove the field of view. Type 3 Hs endoervil omponent Is not fully visile My hve etoervil omponent, whih Trnsformtion Zone Clssifition my e smll or lrge The visiility nd preise lotion of the TZ influene oth whether olposopy is dequte nd the method of tretment. 7.4 Exision type A fully visile etoervil nd smll TZ is oth esy to ssess nd simple to tret, either y destrution or y simple exision. In ontrst, lrge type 3 TZ will not e possile to ssess ompletely, nd tretment will e ssoited with greter diffiulty, higher risk of moridity (Khlid et l., 2011), nd n inresed risk of filure to erdite the disese (Ghem-Mghmi et l., 2007). The TZ exision types re illustrted in Fig Tle 7.1 lists the exisionl tretments nd when they re indited. The first two exision types, types 1 nd 2, re illustrted in Figs. 7.5 nd 7.6. They relte extly to the TZ types 1 nd 2. A type 3 exision, in ontrst, my e used in severl irumstnes not ditted purely y TZ type. For exmple, exision of glndulr lesion will usully wrrnt type 3 exision. Also, some liniins my wish to perform type 3 exision in the presene of miroinvsive disese in womn who hs ompleted her fmily or in ptient who hs previously een treted. Fig Exision types. () Type 1 exision. The dotted green line resets ompletely etoervil or type 1 trnsformtion zone (TZ). In this se, whih is the most ommon in women of reprodutive ge, the LLETZ/LEEP proedure need not enroh on the endoervil nl nd need not e greter thn 8 mm thik throughout the resetion. A smll type 1 TZ my lso e treted y destrution of the TZ. () Type 2 exision. The dotted green line resets type 2 TZ, whih, lthough it hs n endoervil omponent, is still ompletely visile with the olposope. In this se, the mount of exised endoervil epithelium my e tilored ording to how fr up the nl the TZ extends. () Type 3 exision. The dotted green line resets longer nd lrger mount of tissue. In this se, the upper limit of visiility does not reh the upper limit of the TZ, nd the exision hs to reset signifint proportion of endoervil epithelium. Type 1 Exision Type 2 Exision Type 3 Exision Upper limit of visiility Trnsformtion zone Exision line Upper limit of visiility Trnsformtion zone Exision line Upper limit of visiility Trnsformtion zone Exision line Chpter 7. Colposopi terminology: the 2011 IFCPC nomenlture 53

4 Tle 7.1. Clssifition of exisionl tretment Chrteristi Exision type Type 1 exision Type 2 exision Type 3 exision Trnsformtion zone type Type 1 Type 2 Type 3 Condition Any grde of squmous CIN Serious onsidertion should e given to exising CIN3 disese Any grde of squmous CIN Glndulr disese in women younger thn 36 yers Suspeted miroinvsion Any grde of squmous CIN Glndulr disese in women older thn 36 yers Suspeted miroinvsion Previous tretment Previous tretment LLETZ/LEEP SWETZ Lser exision Cold-knife one iopsy/ylindril exision LLETZ/LEEP SWETZ Cold-knife one iopsy/ylindril exision Other irumstnes Tehniques inluded in this tegory of exision LLETZ/LEEP Lser exision Alterntive tretment hoies Trnsformtion zone ltion or destrution CIN, ervil intrepithelil neoplsi; LEEP, loop eletrosurgil exision proedure; LLETZ, lrge loop exision of the trnsformtion zone; SWETZ, stright wire exision of the trnsformtion zone. Fig Type 1 exision with LLETZ/ LEEP. Fig Type 2 exision with LLETZ/ LEEP. 54 Fig (, ) Type 3 exision using lrge loop (LLETZ/LEEP). (, d) Type 3 exision using stright wire (SWETZ). d

5 Fig The top-ht resetion. () A first pss of the loop resets the etoervil TZ nd prt of the endoervil TZ. () A seond pss with smller loop resets further prt of the endoervil TZ. Fig. 7.7 depits two different wys of performing type 3 exision: the first with LLETZ/LEEP using longer loop, nd the seond using stright wire exision of the TZ (SWETZ), s desried y Cmrgo et l. (2015). Finlly, Fig. 7.8 illustrtes the topht tehnique for removing type 2 or type 3 TZ. The top-ht exisionl tehnique hs little to reommend it, euse it ompromises histologil interprettion. 7.5 The exised speimen The size of the exised TZ speimen is proportionl to the risk of susequent pregnny-relted omplitions, so urte dimensionl terms re importnt. Some terms hve onsensus greement, nd others, like depth, do not. In the 2011 IFCPC nomenlture, the terms depth nd height hve een ndoned. Length nd thikness of n opened speimen re universlly understood nd re inluded in the 2011 IFCPC nomenlture. When multiple exision speimens re otined, s is the se with the top-ht tehnique, eh speimen should e mesured seprtely. Fig. 7.9 depits the dimensions of the opened speimen (thikness, length, nd irumferene) just efore pinning onto ork ord nd immersion in formlin. 7.6 Colposopi terminology of ervil epithelium Norml olposopi findings Norml epithelil vritions tht my e reognized t olposopi exmintion of the ervix inlude originl squmous epithelium, nothin folliles (lso known s nothin ysts), metplsti squmous epithelium, rypt or glnd openings, nd deidul hnges ssoited with pregnny Anorml olposopi findings Where squmous lesion is present, it will e either proximl or distl to the originl SCJ. In other words, it my e inside or outside the TZ. The lesion my e smll or lrge nd over from one to four qudrnts of the TZ. The size of the lesion nd the proportion of the TZ tht it overs pper to e importnt preditors of lesion grde, nd this is inluded s one of the indies of severity in the Swede sore (see Annex 4). Minor-grde hnges inlude fine vsulr ptterns (i.e. mosiism or punttion), fint white epithelil uptke fter the pplition of 3% or 5% eti id, irregulr or geogrphil orders, nd stellite lesions. Mjor-grde hnges inlude shrp lesion orders, inner orders (within the TZ), the ridge sign, dense nd/or rpid uptke of eti id, orse vsulr ptterns (mosi or puntte), nd uffed rypt or glnd openings. Non-speifi norml findings inlude leukoplki (kertosis or Fig An opened LLETZ/LEEP speimen fter removl, with the dimensions used to determine thikness, length, nd irumferene. Chpter 7. Colposopi terminology: the 2011 IFCPC nomenlture 55

6 hyperkertosis) nd erosion. Fetures tht might rise the suspiion of invsive disese inlude typil vessels, frgile vessels, n irregulr epithelil surfe, exophyti lesions, nerosis, ulertion, tumour formtion, or gross neoplsm. Misellneous findings inluded in this lssifition re the ongenitl or originl TZ, ondylom, polyps, inflmmtion, stenosis, ongenitl nomly, post-tretment epithelil hnges, nd endometriosis. Some of these terms re open to sujetive interprettion. For exmple, it is diffiult to define in words the differene etween irregulr or geogrphil mrgins nd stright ones. However, mrgin sttus hs een found to e importnt in prediting high-grde normlity (Hmmes et l., 2007; Reid nd Slzi, 1985). 7.7 Individul terms in the IFCPC nomenlture Colposopi exmintion egins with generl ssessment of the ervix, nd most olposopists will im to determine the level of reliility of the exmintion t this stge. The populr terms stisftory olposopy nd unstisftory olposopy hve een disrded, euse they hve the onnottion of n exmintion tht needs to e repeted. The olposopi exmintion is now ssessed y three vriles: dequy, visiility of the SCJ, nd TZ type (Annex 3). The first vrile is whether the exmintion is dequte, nd if not why not. The reson should e doumented; for exmple, the ervix my e osured y inflmmtion, leeding, or srring. The seond vrile is visiility of the SCJ, whih n e desried s ompletely visile, prtilly visile, or not visile. The reson tht the visiility nd site of the SCJ re so importnt is tht this influenes oth the ility to perform omplete exmintion nd, when tretment is indited, the extent nd type of exision. The terms dequy nd SCJ visiility re not mutully exlusive; the SCJ my e prtilly visile euse portion of its inner mrgin is loted high in the endoervil nl, wheres the exmintion is still dequte euse the ervix is not osured y lood or inflmmtion. The third prmeter is the TZ type. It overlps to some degree, ut not ompletely, with the visiility of the SCJ. The TZ nd the SCJ re not the sme thing; the SCJ is the inner mrgin of the TZ. Both type 1 nd type 2 TZs re ompletely visile, nd the differene etween the two is importnt, minly for plnning tretment. The TZ type defines oth the site nd the visiility of the SCJ. Loliztion of the lesion inside or outside the TZ is importnt. This is euse lesion inside the TZ, s opposed to one outside (Fig. 7.10), hs een shown to e n independent preditor of high-grde lesion or rinom (Hmmes et l., 2007). Lesion size (Figs nd 7.12) hs lso een shown to e n independent preditor of high-grde disese (Kierkegrd et l., 1995; Shw et l., 2003). The size my e quntified s (i) the numer of ervil qudrnts the lesion overs or (ii) the size of the lesion s perentge of the ervix. Two reltively new olposopi imge terms re inluded in the grde 2 (mjor) lesions of the 2011 IFCPC nomenlture: the inner order sign nd the ridge sign. Pulished work hs vlidted their worth s mrkers of high-grde CIN (Sheungrer et l., 2009, 2009). A shrp order round lesion hs lso een reported s eing ssoited with more severe lesion. The term leukoplki is inluded in the tegory of non-speifi norml findings. This is euse it hs een reported to hve 25% independent preditive vlue of Fig Stellite lesions. In this norml ervix, there re two smll stellite lesions outside the trnsformtion zone. Fig A smll lesion oupying only one qudrnt of the trnsformtion zone, with severl stellite lesions t the 12 o lok position. Fig A lrge lesion oupying more thn three qudrnts of lrge trnsformtion zone. 56

7 ontining high-grde or invsive neoplsi (Hmmes et l., 2007). In truth, leukoplki my over innoent or pthologil epithelium, nd olposopi exmintion nnot relily determine whih. The uptke of Lugol s iodine is prt of the non-speifi findings euse severl pulitions hve suggested reltively poor reliility of the test (Ruio nd Thomssen, 1976). Cervil polyps re pled in the tegory of misellneous findings. They my, of ourse, e etoervil or endoervil in origin. Key points The 2011 IFCPC nomenlture is the glol referene stndrd for ervil olposopi exmintion findings. Trnsformtion zone type nd size s well s trnsformtion zone exision type hve een inluded in the ltest nomenlture. Using the IFCPC lssifition llows vlid omprison etween reserhers pulishing reserh or reports of experiene. Chpter 7. Colposopi terminology: the 2011 IFCPC nomenlture 57