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COLPOSCOPE
SAMIR FOUAD ABDEL AZIZ
ASSIST.PROFESSOR
AL-AZHAR UNIVERSITY
TERMINOLOGY
• SQUAMOCOLUMNAR JUNCTION
• morphologically there are two types of SCJ
• The original SCJ is the border where the
original squamous epithelium meets the
outermost limit of the developing TZ. The
present SCJ is the innermost border where
the maturing squamous metaplasia meets
the columnar epithelium
Squamocolumnar junction
• Squamous epithelium to the left and
columnar epithelium to right.
Transformation Zone TZ
• It is the area of actively maturing epithelium
between the present SCJ and the original
squamous epithelium. It is composed of
intermingling of squamous and columnar
epithelium. Squamous metaplasia, islands
of columnar epithelium, gland openings and
nabothian cysts may be identified. The
precise location of TZ varies in relation to
exo- and endocervix
Transformation zone
• TZ with gland
opening,sq.metaplasia,columnar epithelium
Nabothian Cysts
• Are inclusions or entrapments of mucous
from secreting columnar villae under the
developing squamous epithelial surface
Squamous Metaplasia
• The normal physiologic process by which
columnar epithelium evolves into squamous
epithelium.The outermost border is the
original SCJ while the innermost border is
the present SCJ.Histologically, in the early
stages of this process, immature squamous
cells push up columnar cells.Columnar
epithelium later become degenerted and
replaced by mature squamous epithelium
Leukoplakia
• Refers to a white plaque visible without
magnification and without application of
acetic acid.
• It is usually elevated from
• surrounding surfaces with a
• sharp border and Lugol’s non• staining.Histologically..hyperkeratosis
Atrophy
• Atrophic changes result from low estrogen
levels characteristic of the menopausal
patient.The appearance is that of a typically
smooth and thin epithelium. This result in
blood vessels being more readily visible and
truma easily incurred.these changes are
reversible by estrogen.It can result in
changes that mimic high-grade
abnormalities.
Acetic Acid
• Acetic acid 3%-5% dissolves mucous and
accentuates atypical areas (white
epithelium,punctation,mosiac and atypical
vessels)by inducing intracellular
dehydration and coagulation of protein. This
effect peaks approximately 2 minutes after
application and fades within 5 minutes.
Therfore, repeated applications is rquired
Lugol’s Iodine
• Lugol’s solution is composed of Iodine and
potassium iodide in water. It stains the
glycogen in mature squamous epithelium a
dark brown color. Consequently, areas
devoid of glycogen such as immature
squamous epithelium, columnar epithelium,
erosion and neoplasia will be non-staining
• non-staining is called Schiller’s positive
Cervical Intraepithelial
Neoplasia
• The term cervical intraepithelial
neoplasia refers to a spectrum of
abnormalities of the surface
epithelium. The spectrum includes
changes in the TZ ranging from
CIN I(mild dysplasia) to CIS
(carcinoma in situ)
CIN Cytology
• Cytologic aberrations seen in CIN
include: hyperchromaticity,
abnormal chromatin distribution,
increased nuclear to cytoplasmic
ratio and nuclear pleomorphisim.
These abnormalities may be seen
in exofoliated cells in a Pap smear
CIN Histology
• CIN grading is based upon the
proportion of the surface
epithelium composed of
undifferentiated cells characteristic
of the basal layer. Increasing grade
is associated with a progressive
loss of epithelial maturation
CIN I
• Represents atypical cells with
increased nuclear to cytoplasmic
ratio and hyperchromatic nuclei
present in the lower 1/3 of the
epithelial layer from the basement
membrane
CIN I
• Cytology
CIN II
• Shows further progression of
nuclear abnormalities with greater
involvement of the epithelial
thickness. In CIN II, immature
basaloid cells occupy the lower 2/3
of the epithelium
CIN II
• Cytology
CIN III
• Represents almost total
involvement of the epithelium with
only one or two layers of mature
cells remaining at the surface.
When the entire epithelium is
involved, the term carcinoma in
situ (CIS) is applied.
CIN III
• Cytology
•
•
Histology
Invasive Cervical Cancer
• With all levels of CIN the basement
membrane of the epithelium remains intact.
Once the membrane is violated, invasive
cancer is diagnosed
Pap Test
• The Pap test was introduced as a
cervical screening test in 1943 by
George Papanicolaou for whom it is
named. It is a way to examine cells
collected from the cervix and vagina.
This test can show the presence of
infection, inflammation, abnormal
cells, or cancer.
How is a Pap test done?
• A Pap test is simple, quick, painless.While
a woman lies on an examination table, the
clinician inserts a speculum into her vagina
to open it. To do the test, a sample of cells is
taken from in and around the cervix with a
wooden scraper and placed on a glass slide
and rinsed in liquid fixative and sent to a
laboratory for examination.
WHO Should Have Pap test
• Women who are or have been sexually
active should have Pap tests and physical
examination regularly every 3 years. There
is no known upper age at which Pap tests
cease to be effective.Women who have had
hysterectomy for treatment of a
precancerous or cancerous condition should
have the end of the vaginal canal sampled
for abnormal changes.
When Should Pap Test be done?
• A woman should have this test when she is
not menstruating; the best time is between
10 and 20 days after the first day of the
menstrual period. For about 2 days before a
Pap test, she should avoid douching, or
using vaginal medicines or spermicidal
foams, creams or jellies. These may wash
away or hide abnormal cells.
What do abnormal test results
mean?
• A physician may simply describe Pap test
result as abnormal. Cells on the surface of
the cervix sometimes appear abnormal but
are not cancerous. It is important to
remember that abnormal conditions do not
always become cancerous, and some
conditions are more of a threat than others.
• There are several terms to describe
abnormal results
Terms to describe abnormal
results
• Dysplasia is a term used to describe
abnormal cells.It is not cancer, although it
may develop into very early cancer.
Cervical cells undergo a series of changes in
their appearance. The cells look abnormal
under the microscope but do not invade
nearby healthy tissues.It is classified into
mild, moderate and sever depending on how
abnormal the cells appear.
Terms to describe abnormal
results
• Squamous Intraepithelial Lesion (SIL)
• An intraepithelial lesion means that the
abnormal cells are present only in the
surface layers of the cells. SIL may be
described as low-grade(early changes in
size, shape and number of cells) or highgrade(a large number of precancerous cells
the look very different from normal cells)
Terms used to describe abnormal
results
• Cervical Intraepithelial Neoplasia CIN
• Another term widely used to describe
abnormalities of surface epithelium. The
term CIN along with a number (1 to 3),
describes how much of the cervix contains
abnormal cells.Carcinoma in situ(CIS)
describes a preinvasive cancer that involves
only the surface cells.
How do these terms compare?
• Mild dysplasia may be also classified as
low-grade SIL or CIN I
• Moderate dysplasia may also be classified
as high-grade SIL or CIN II
• Severe dysplasia may also be classified as
high-grade SIL or CIN III
• Carcinoma in situ may also be classified as
high-grade SIL or CIN III
False positive and False negative
Test
• A false positive Pap test occurs when a
specimen is called abnormal but the cells
are actually normal.
• A False negative Pap test occurs when a
specimen is called normal but the woman
has a lesion. It is at least 20%. This means
that biopsy is imperative for visible lesions.
Methods to Improve Accuracy of
Pap smear
• 1.Perform a Pap smear when the patient is
in the proliferative phase.
• 2.The patient should avoid intercourse or
intravaginal products/douches for 24-48
hours before examination
• 3.Use no lubricant prior to the test
• 4.Have cytobrush, spatula, slide and other
supplies on hand before exam.
Methods to Improve Accuracy of
Pap smear(cont.)
• 5.Rotate the Ayers spatula through a 360degree arc over the SCJ and avoid excessive
pressure
• 6.Collect the endocervical specimen using
cytobrush or saline-moistened cotton swab
and apply it to the same slide
• 7.Rapidly apply fixative to the slide, if spry
used hold it 10 inches from the slide
Colposcope
• The colposcope is a binocular, lowmagnification (7x to 30x) microscope with
light source which is used to visualize the
cervix, vagina and vulva.The goal in the
evaluation of the lesions is to exclude the
possibility of malignancy.Satisfactory
colposcpies are those in which the lesion
and the SCJ can be seen in entirety
Examination view
Methods of Colposcopic
Examination
• Classical or Extended Colposcopy
• The cervix and vagina are first examined at
magnification of 7x or 10x following which
excess mucus is removed from the cervix
• Acetic acid 3% to 5% is applied by cotton
swab.Abnormal epithelium appear as thick
white (acteo-white)
• Schiller iodine test may be applied
The Saline Technique
• This depends entirely on the visualization of
various vessel patterns .
• After exposing the cervix saline is used to
remove mucous and then a green filter and
high magnification is used..in this way the
red capillaries appear darked and stand out
more clearly
Diagnostic criteria for
Colposcopy
• In its simplest form colposcopy is the
recognition of aceto-white epithelium but
benign conditions can produce aceto-white
epithelium so the colposcopist must be
aware of the other features which suggest
underlying abnormalities.
Colposcopic Diagnosis (cont.)
•
•
•
•
Features which suggest abnormality are:
1.The subepithelial vascular pattern
2.Intercapillary distance
3.Color tone differences at the junction of
normal and abnormal epithelium
• 4Surface pattern
• 5.Sharp line of demarcation bet.different
types of epithelium
Aceto-white epithelium
• Acetic acid causes some swelling of
epithelium particularly columnar epithelium
and abnormal epithelium
Vascular abnormality
• Atypical vessels :this vascular growth
is not symmetric and is often
associated with
• progressively smaller
• blood vessels
Vascular Abnormality
• Mosaic
• A vascular change of interconnecting
vessels resulting in cobble-stone or
honey-comb surface.
• This is usually seen with
• CIN and mandates biopsy
Vascular Abnormality
• Punctation
• It is a zone of red dots representing stromal
papillae and blood vessel loops reaching to
the surface epithelium.
• When this pattern is identified
• biopsy is indicated .
Biopsy Forceps
• Used for punch biopsy from abnormal area
Endocervical speculum
• Endocervical speculum allow visualization
of the inner bored of a lesion
Human Papilloma Virus and
Cervical neoplasia
• HPV is a circular, double-stranded DNA
virus that has a surrounding polyhedral
capsid..Included in the viral DNA are 2
oncogenes(E-6,E-7) and a protein that
suppresses expression of the oncogenes
• (E-2). There appear to be 3 variants of HPV
infection.Episomal/nonreplicating,
Episomal/replicating and integrated
Episomal/nonreplicating
• After infecting the host, the virus may exist
as an inactive extrachromosomal particle
(episomal)that is detectable only by DNA
testing. This type of infection
(sublinical,DNA only) is extremely
common, occurring in up to 50% of
sexually active young women.
Episomal/replicating
• The viral DNA is transcribed, and viral
particles are assembled. This type of
infection results in a clinically detectable
lesion (abnormal Pap smear, genital warts)
the infected cell is called koilocyte
• (empty cell)because of its
• perinuclear vacuolization
Integrated
• The viral DNA transforms host
DNA.Cofactors,high-risk HPV types and
comutagens appear to be necessary for this
to occur. The circular DNA episome breaks
into linear strand prior to integration into
host. E-2 normally control cellproliferation• inducing E-6andE-7.In absence of E-2,cell
growth is out of control and neoplasia
Prevalence of HPV
• Of more than 70 types of HPV, more than
35 are associated with anogenital disease
and 20 or more are associated with cancer.
The most common HPV types detected in
cervical lesions are those classified as highrisk HPV types, including types,16,18,45,
and 56, found in 77% of HSIL(CIN II-III)
and in 84% of invasive cancer
Prevention and Screening
Cervical Cancer
• Cervical cancer is one of the most
common cancers, accounting for 6% of
all malignancies in women. There are
an estimated 16,000 new cases of
invasive cancer of the cervix and 5,000
deaths in the U.S each year
Prevention and Screening
Cervical Cancer
• Because a vast majority (greater than
90%) of these cases can and should be
detected early through the use of Pap
smear, the current death rate is far
higher than it should be and reflects
that ,even today, Pap smears are not
done on approximately one-third of
eligible women.
Prevention and Screening
Cervical Cancer
• Strong risk factors include: Early age at first
intercourse (16 years or younger), a history
of multiple sexual partners,a history of
genital HPV infection or other sexually
transmitted disease. Additional factors
include active or passive smoking, a current
or past risky sexual partner,
immunodeficiency or HIV positively,poor
nutrition.
Prevention and Screening
Cancer Cervix
• Abundant evidence suggests that regular
gynecologic examination and Pap tests for
all women beginning at the onset of sexual
activity, or by approximately age 18 years if
not sexually active, decreases cervical
cancer incidence and mortality.An upper
age limit at which such screening cease to
be effective is not known
Prevention and Screening
Cancer Cervix
• Evidence supports a sexual mode of
transmission of a carcinogen and HPV is
strongly implicated epidemiologically as the
main infectious etiologic agent. Barrier
methods of contraception lower the
incidence of cervical neoplasia,
presumptively secondary to lessened
exposure to HPV
Prevention and Screening
Cervical Cancer
• Exposure to cigarette smoke is associated
with increased risk
• this risk increases with longer duration and
intensity of smoking and is present with
exposure to environmental tobacco smoke
as well, being as high as three times that of
women who are nonsmokers and not
exposed to environmental smoking
Prevention and Screening
Cervical Cancer
• Increased intake of micronutrients and other
dietary factors such as carotenoids are
associated with decreased risk
• A considerable amount of experimental data
suggests that vitamin A and its derivatives
inhibit HPV-associated proliferation, several
trials using retinoids showed increased
regression of CIN2 .
Prevention and Screening
Cancer Cervix
• Education regarding risk factors for
cervical cancer may lead to behavioral
modification resulting in diminished
exposure
Impact of cervical cancer
screening on mortality
• Mortality from cervical cancer has
decreased in several large populations
following the introduction of well-run
screening programs. Data from several large
Scandinavian studies show sharp reduction
in incidence and mortality. Iceland reduced
mortality by 80% over 20 years, Finland
and Sweden reduced their mortality by 50%
and 34% respectively
Impact of cervical cancer
screening on mortality
• Reduction in incidence and mortality seem
to be proportional to the intensity of
screening efforts. The Scandinavian
countries with the highest rates of screening
activity reported greater reductions in
mortality than those countries with lower
rates of screening
Impact of screening for cervical
cancer on mortality
• Case-control studies have found that the
risk of developing invasive cancer is 3-10
times greater in women who have not been
screened. Risk also increases with longer
duration following the last normal Pap
smear, or similarly, with decreasing
frequency of screening.Screening every 3
years give 91% protection rate.
Management of Abnormal Pap
Test
•
Abnormal Pap Smear
suspicious of CIN/SIL
Biopsy
ECC
Repeat Pap test
No suspicon of
invasion
Cryotherapy
or
Laser therapy
Leep(ectocervix)
Suspicion of Invasion
Cone Biopsy
Cold-knife
laser cone
Leep(ecto-and endocervix
Management of Abnormal
Pap Smear
• Approximately 1-3% of Pap
smears will read as abnormal.
This percentage may approach
7-10% in high-risk groups such
as a sexually transmitted
disease clinic.
Management of abnormal
Pap Smear (cont.)
• The standard evaluation of an abnormal
Pap smear is colposcopy and biopsies.
Endocervical curettage at the time of
colposcopy allows evaluation of cells from
the endocervicl canal.
• Biopsy should confirm the Pap smear
abnormality and then appropriate
treatment can be applied
Management of Abnormal
Pap Smear(cont.)
• If there is discrepancy between
the Pap smear and the biopsy,
then a larger biopsy such as
leep or cold conization biopsy
may be needed
Ablative Therapy
• These techniques remove up to 8
mm in tissue depth and up to 30
mm in diameter, including the
transformation zone.
• When applied correctly have
excellent success rate (90-95%).
Cryotherapy
• Cryotherapy is freezing the cervix to
destroy the abnormal cells.
• It has minimal discomfort, moderate
cervical distortion, and minimal expense.
• The technique involves the use of a gas
with a boiling point in the cryptogenic
range to freeze the cervix for 3 to 6
minutes
Cryotherapy (cont.)
• Tissue destruction occurs to a depth
of 8 mm when an ice ball extending 5
mm beyond the lesion is created.
• The disadvantage is the remainder of
the lesion cannot be examined by
pathologist to absoultly sure a worse
lesion was not present
LASER Ablative
Therapy
• This involves the use of carbon dioxide
laser to evaporate tissue.
• The laser can be precisely controlled and
is used in conjunction with a colposcope
or operating microscope to destroy tissue
to a depth of 8 mm.
• This technique provides no specimen for
pathologic diagnosis
Before the use of
ablative therapy
• 1 No Evidence of invasive cancer
on Pap smear, cervical biopsy or
colposcopy.
• 2 No evidence of an adenomatous
lesion (adenocarcinoma in situ or
adenocarcinoma)
Before ablative
therapy
• 3 satisfactory colposcopy i.e
complete visualization of the
lesion and TZ.
• 4 Endocervical curettage
negative for CIN
Before Ablative
therapy
• 6 No discrepancy between Pap
smear and biopsy
• 7 Patients is complaint with
follow-up
Cone Biopsy
• The most commonly used cone biopsy
include:
• Cold-knife cone
• Laser excisional cone
• Loop Electrosurgical Excision
Procedure (LEEP) cone
Cold-Knife Cone
• It is simply removal of a cone of tissue
with a scalpel.
• Usually performed under anaecthesia
• It delivers a perfect specimen for
patological examination
Laser Excisional Cone
• This was advocated during a period of
higher laser use
• It delivers a specimen with artifact but
allows the surgeon increased control
because it is used with microscope.
LEEP Cone
• Performed using two loops, one 20mm
by 8mm for the ectocervix. And one 10
by 10 mm for the endocervical canal.
• Performed under anaesthesia in the
clinic and rquires less than 5 minutes
of operating time.
• Cones are not as deep as cold-knife
Indications for Cone Biopsy
• 1.Evidence of invasive cancer on Pap
smear, cervical biopsy or colposcopy
• 2. Evidence of adenomatous lesion
(adenocarcinoma in situ or
adenocarcinoma)
• 3.Colposcopy unsatisfactory(incomplete
visualization of the lesion or SCJ)
Indications for Cone biopsy
(cont.)
• 4.Endocervical curettage positive for
CIN/SIL
• 5.Grade of CIN/SIL on Pap smear worse
(by two grades) than that on biopsy
specimen
• 6.Patient is not complaint with follow-up
Hysterectomy
• Hysterectomy is not a conservative mode
of therapy for preinvasive lesions.
• Its increased expense and potential
morbidity make other approaches much
more desirable.
• It is indicated when patient is not
complaint with follow-up and has
completed her family