Becoming a colposcopist: Colposcope case studies

Becoming a colposcopist: Colposcope case studies Seon-Kyung Lee, M.D. Department of Obstetrics and Gynecology College of Medicine, Kyung Hee University

Value of Colposcopy Cytology is an effective screening method, and colposcopy with directed biopsy is the critical diagnostic step for women with cervical cytologic abnormalities Decrease diagnostic conization and hysterectomy. Limitation; It takes some time and experience to properly analyze what you see.

Role of colposcopist 1. Colposcopist must be able to locate the disease. 2. Colposcopically assess the severity of lesions. 3. Determine the most severe lesion to biopsy. 4. Correlate the colposcopic impression with the cytologic and histologic findings. 5. Then the colposcopist determines the appropriate management or treatment.

Practical knowledge Precisely localise TZ, Recognize normal and abnormal TZ, TZ with gland opening, sq.met aplasia, columnar epithelium Clinical skills Punch biopsy, LLETZ

Colposcopy: Work-up Explain to the patient. Inspect the vagina and cervix and apply 3-5% acetic acid. Position the colposcope and focus on the cervix with the desired magnification (7X-15X). Drawings the lesion topography and lesion grade(s) Biopsy samples should be obtained from all abnormal lesions. A cytobrush or ECC may be used to evaluate the endocervical pathology. Hemostatic agent can be applied to each biopsy site. Results should be reviewed to confirm.

Diagnostic accuracy of colposcopy Calculated based on the agreement of the colposcopic impression with the histologic interpretation within one histologic grade. Limitations; Colposcopy is highly sensitive in well-trained hands, but has low specificity, and, thus, is not a good screening tool.

Colposcopical scoring system Colposcopy is a subjective diagnostic method with high sensitivity and low specificity. Because of low specificity, the scoring system for colposcopic findings is important when deciding on the necessity of cervical biopsy, and it contributes to the decreasing of unnecessary biopsy.

Colposcopic accuracy The colposcopic accuracy index threshold of 80% appears to be a reasonable proficiency level and a useful goal for training programs. The colposcopist may overestimate minor benign cervical epithelial and vascular alterations that mimic low-grade premalignant disease features. The error is common when the colposcopist has knowledge of a preexisting minor cytologic smear abnormality.

Colpo. Appearance of Benign Lesions Keratosis, Erosions and Ulcers, Cervicitis, Atrophy, Nabothian cysts, Ectopy, Deciduosis, Endometriosis, Endocervical polyps. The difficulty lies in learning to distinguish lowgrade lesions from immature metaplasia which also exhibits aceto-whitening and fine vascular patterns. Due to the variability of the colposcopic appearance of low-grade lesions, the accuracy and reproducibility of diagnosis is less than that of higher grade lesions.

Colpo. Appearance of Benign Lesions nabothian cyst cervical polyp

Colpo. Appearance of Benign Lesions immature squamous metaplasia(pinkish white hue) crypt opening

Colpo. Appearance of Benign Lesions immature squamous metaplasia mild acetowhite lesion with fine mosaic and irregular margin

Colpo. Appearance of LSIL Flat with a smooth surface, except condylomas. Leukoplakia ; benign hyperkeratosis or low-grade HPV lesions. Variable aceto-whitening; faint Irregular, feathered or geographic outer borders. Partial iodine uptake Either featureless or have fine mosaicism or punctation.

Colpo. appearance of Low Grade Lesion mildly dense acetowhite lesion irregular geographical margin

Colpo. appearance of HPV infection Condylomas may arise within TZ or as skip lesions within the mature squamous epithelium. The papillary spike-like projections of acuminate warts and the regular projections(asperites) on surface of flat condylomas with colposcopic magnification. It also may be a bright aceto-white, which is characteristic of condyloma.

Colpo. appearance of HPV infection The bright aceto-white and the asperites on the surface

Colpo. appearance of HSIL Sharply demarcated lesion edges lesion within a lesion or border within a border More prompt and persistent aceto-white change Absence of vessels due to increased lesion density Coarse vascular patterns (punctation, mosaicism, or both), Umbilicated mosaic patterns suggests CIN 3 / carcinoma-in-situ.

Colpo. appearance of HSIL dense acetowhite lesion with sharp demarcated margins internal borders within lesion

Colpo. appearance of HSIL dense acetowhite lesion with rolled out margins coarse punctation and mosaic with umbilication

HSIL site and Topography The most severe disease is found at the most proximal (cephalad) extent of lesion. Size of lesions variable but tends to correlate with severity of disease and risk of occult invasion Size of lesion correlates with risk of treatment failure

Colpo. Findings of Adenocarcinoma in Situ The colposcopic findings are often subtle and nonspecific. The two primary findings are (1) a wide area of eversion and (2) ginger root like vessels. Approximately 40% of adenocarcinoma in situ (ACIS) will have an associated SIL. ASCCP guidelines for AGC require colposcopic evaluation and directed biopsies, ECC and D&C for women over 35 years of age.

Colpo. Findings of Adenocarcinoma in Situ Pap; ASC-H, HPV(HC); - Biopsy: AIS endocervix CIS exocervix Pap ; HSIL, HPV; 18+ Biopsy; adenocarcinoma, eversion and root like vessels.

Colpo. appearance of Invasive cancer The surface is irregular but the borders tend to be sharply defined. In some cases, subtle ulceration can be the only feature present. exophytic mass ulcerative lesion; 12-3 oclock

Vaginal colposcopy Indicated when cytology suggests disease in: 1) patients with a normal cervix 2) in patients in whom the cervix is absent The entire surface area of the vagina is examined, including that behind the blades of the speculum. In post hysterectomy patients, the lateral invagination of the vaginal vault must be carefully evaluated. Areas of VaIN are typically discrete with slightly elevated borders and are pinkish or white in color.

Colpo. appearance of VaIN Pap; HSIL post-tah state, Pap; mod.dysplasia

Colposcopy in pregnant women Cervix must be handled atraumatically in order to avoid bleeding of the congested, hyperaemic tissues. The degree of acetowhitening and the confusing angioarchitecture, with coarse punctation and mosaicism, may give the impression that the lesion is severer than it is.

Colposcopy During Pregnancy Increased vascularity produces a cyanotic, bluish hue. progressive eversion of the scj onto the ectocervix makes colposcopy satisfactory more often.

CASE STUDY 23 year old Pap ; benign cellular change Colpo.index; 0-2, SPI Bx ; 10 o clock, chonic cervicitis HPV(HC); negative

CASE STUDY 53 year old Pap ; LSIL Colpo.index; 3-5, r/o HSIL Bx ; 10 o'clock CIS HPV(HC); positive

CASE STUDY 38 year old Pap ; AGUS Colpo.index; 0-2, r/o endocervical lesion Bx ; 5 o'clock cervicitis HPV(HC); negative Dx Tx conization

CASE STUDIES from ASCCP

CASE STUDY from ASCCP A 25-year-old G2 P1011, her first Pap test showed ASC-US. She was then lost to follow-up until this current examination. Question The cytology shows: a. negative for intraepithelial lesion or malignancy. b. ASC-US. c. LSIL d. HSIL

The patient was evaluated with colposcopy. Question 1 Colposcopic findings include: a. atypical vessels, corkscrew vessels. b. coarse mosaic pattern with punctation and sharp borders. c. microglandular hyperplasia. d. cervical ectopy. e. condyloma. Question 2 The most likely colposcopic impression is: a. metaplasia, cervicitis. b. CIN 1. c. CIN 3. d. microinvasive cancer.

CASE STUDY from ASCCP A 26 year-old woman, G4 P2012, was seen for her first prenatal visit at 9 weeks gestation. A Pap test at that time was read as HSIL. Her previous Pap test results, performed 3 years ago, was read as normal. Question The next step in the management of this patient is: a. To repeat Pap test in 3 months. b. reflex testing for high-risk human papillomavirus. c. immediate colposcopy. d. colposcopy post partum.

The patient underwent a colposcopy at 13 weeks' gestation. Question 1 What colposcopic features are present in Figures? a. fine punctation. b. coarse mosaic pattern with punctation. c. leukoplakia. d. atypical blood vessels. Question 2 The colposcopic impression is: a. CIN 1. b. CIN 2. c. CIN 3. d. microinvasive cancer. e. Either (b) or (c).

The patient was seen again at 28 weeks with no change in the colposcopic impression. She delivered at term and was seen back in the clinic at 6 weeks postdelivery. At that time, a Pap test and colposcopy were done. Question The colposcopic impression is: a. CIN 1. b. CIN 2. c. CIN 3. d. normal.

CASE STUDY from ASCCP A 26 year old G1 P1001 presented for evaluation of a LSIL Pap test. In this clinic, women found to have ASCUS x 2 or LSIL Paps were invited to enroll in an IRB approved study conducted through the local University. Women with biopsy-proven CIN1 or less were followed with surveillance Paps and Cervicography every 4-6 months and annual colposcopy. In this case, HPV DNA is positive for High Risk (HR) types.

The cervigram and findings of her repeat cytology Question 1 Her initial cervigram was interpreted as: a. negative; normal cervix; squamous metaplasia b. positive; compatible with low grade lesion c. positive; probable normal variant d. positive; compatible with high grade lesion Question 2 The cytology shows: a. negative for intraepithelial lesion or malignancy b. atypical squamous cells of undetermined significance c. LSIL; parakeratosis d. high grade squamous intraepithelial lesion

14 months after initial enrollment, the image of her cervix is shown (Figure ). HPV DNA is positive for HR types. Question 1 Colposcopic findings seen include: a. atypical vessels, corkscrew vessels, condyloma b. dense acetowhite epithelium; absent vessels; straight border c. mosaic d. cervical ectopy Question 2 The next step in her management would be: a. re-appoint for study follow-up in 4-6 months b. repeat colposcopy and biopsy c. LLETZ c. cryosurgery

CASE STUDY from ASCCP 20 year old Female G0 with a history of LSIL presented to another colposcopist. Question This colposcopic image is most consistent with: a. satisfactory colposcopy, three low-grade acetowhite lesions seen. b. unsatisfactory colposcopy, no evidence of any abnormalities. c. unsatisfactory colposcopy, endocervical lesion seen. d. satisfactory colposcopy, one abnormal lesion seen at 5- to 7-o'clock. e. None of the above.

Question 1 During colposcopy, the preferred course of action would be: a. no biopsies necessary. b. to biopsy the lesion at 5- to 7-o'clock position. c. to perform ECC only. d. to perform multiple biopsies of lesions noted that appear abnormal. e. immediate LEEP at the time of colposcopy. Question 2 The preferred course of management would be: a. LEEP b. cryotherapy. c. return colposcopy evaluation within 6 months. d. vaginal antibiotic therapy, e. conization with ECC

CASE STUDY from ASCCP A 19-year-old, G0, presents for evaluation after a Pap test showing a LSIL. This was her first abnormal Pap test and her previous Pap test 1 year earlier was normal. Her coitarche at age 16 years, and 12 total lifetime sexual partners. The patient returned 1 year later for a repeat Pap test. This time the Pap was reported as HSIL.

The patient underwent a colposcopic examination with a biopsy. Question 1 The colposcopic appearance of the cervix was most consistent with: a. squamous metaplasia b. CIN 1 c. CIN 2,3 d. adenocarcinoma in situ (AIS) e. squamous carcinoma Question 2 The histological diagnosis is consistent with: a. squamous metaplasia b. mild dysplasia (CIN 1) c. moderate dysplasia (CIN 2) d. severe dysplasia (CIN 3) e. squamous carcinoma

CASE STUDY from ASCCP A 27-year-old, G5 P3013, presents to the clinic for prenatal care at 20 weeks. The patient has a history of abnormal Pap tests dating back 7 years. Colposcopic exams and biopsies have shown low-grade squamous intraepithelial lesion (LSIL). Her last Pap test 2 years ago was normal. The patient s current Pap test was read as HSIL.

Question 1 The findings on colposcopy are consistent with: a. CIN 1 b. CIN 2,3 c. invasive cancer d. metaplasia Question 2 The next step in the management of this patient is: a. repeat cytology and colposcopy in 8 weeks b.repeat cytology and colposcopy in 12 Weeks c. cold-knife conization d. repeat cytology and colposcopy 6 weeks postpartum e. either (b) or (d)

Question 1 The findings on colposcopy are consistent with: a. CIN 1 b. CIN 2,3 c. invasive cancer d. metaplasia Question 2 The next step in the management of this patient is: a. repeat cytology and colposcopy in 8 weeks b. repeat cytology and colposcopy in 12 weeks c. cold-knife conization d. repeat cytology and colposcopy 6 weeks postpartum e. either (b) or (d)

CASE STUDY from ASCCP A 22-year-old presents with HPV positive ASC-US Papanicoloau smear. She has no previous history of abnormal Pap smears and has been screened in the past. She does not smoke. Question Appropriate management options for this patient include: a. repeat HPV testing in 12 months b. Pap at 6 and 12 months c. colposcopy d. HPV DNA specific typing

Consensus guidelines for the management of women with abnormal cervical cancer screening tests ASC-H, LGSIL, HGSIL, squamous cell cancer: colposcopic evaluation and biopsy of abnormal sites is recommended. ASC-US: Repeat cytologic evaluation at 6 and 12 months Reflex testing for the presence of high-risk HPV serotypes. If either of these strategies results in abnormal findings, colposcopy is indicated. AGC: colposcopic, endocervical and endometrial evaluation, and sampling in addition to HPV testing. AIS, adenocarcinoma: excisional procedures

Question 1 The best answer which fits this colposcopic picture is: a. satisfactory colposcopy with high grade lesion b. unsatisfactory colposcopy with no lesion seen c. satisfactory colposcopy no lesion seen d. satisfactory colposcopy with low grade lesion seen Question 2 Which management option is NOT appropriate in this patient: a. ECC b. repeat Pap and HPV in 6-12 months c. HPV DNA testing for high risk virus at 12 months d. loop excision

Thank you!

이선경 연자약력 ; 경희대학교의과대학의학과졸업 1979.2 미국 Vanderbilt university medical center special fellowships in gynecologic oncology 1991.11 --- 1992 10 경희대학교동서신의학병원산부인과과장경희대학교의과대학산부인과주임교수 학회활동 : 대한부인종양 - 콜포스코피학회 ; 이사, 학술위원회위원대한부인종양연구회연구위원회위원대한산부인과학회 ; 이사, 학술위원회위원, 논문심사위원한국자궁경부확대촬영연구회판독위원, 회장미국질확대경 - 자궁경부병리학회정회원세계부인암학회정회원