Colposcopy - University of Kentuckyobgyn.med.uky.edu/sites/default/files/Colposcopy.pdf · Colposcopy Cervical Pathology 3rd Ed. 1998 History Colposcopy was pioneered in Germany by
Post on 27-Aug-2018
221 Views
Preview:
Transcript
Colposcopy
Colposcopy
►
►
Chris DeSimone, M.D.
Chris DeSimone, M.D.
►
►
Gynecologic Oncology
Gynecologic Oncology
►
►
Images from
Images from
Colposcopy Cervical Pathology
Colposcopy Cervical Pathology
, 3
, 3
rd
rd
Ed., 1998
Ed., 1998
Colposcopy Cervical Pathology 3rd Ed. 1998
History
History
►
►
Colposcopy was pioneered in Germany by Dr.
Colposcopy was pioneered in Germany by Dr.
Hinselmann
Hinselmann
during the 1920’s
during the 1920’s
►
►
He sought to prove that microscopic examination
He sought to prove that microscopic examination
of the cervix would detect cervical cancer earlier
of the cervix would detect cervical cancer earlier
than 4 cm
than 4 cm
►
►
His work identified several atypical appearances
His work identified several atypical appearances
which are still used today:
which are still used today:
Luekoplakia
Luekoplakia
Punctation
Punctation
Felderung
Felderung
(mosaicism)
(mosaicism)
History
History
►
►
Through the 30’s and 40’s breakthroughs were
Through the 30’s and 40’s breakthroughs were
made regarding which appearances were more
made regarding which appearances were more
likely to progress to invasive carcinoma;
likely to progress to invasive carcinoma;
HOWEVER,
HOWEVER,
►
►
These findings were difficult to interpret since they
These findings were difficult to interpret since they
were not correlated with histology
were not correlated with histology
►
►
One researcher would claim his patients with X
One researcher would claim his patients with X
findings never had carcinoma while another
findings never had carcinoma while another
emphatically believed it did
emphatically believed it did
►
►
World wide colposcopy was underutilized as a
World wide colposcopy was underutilized as a
diagnostic tool secondary to these discrepancies
diagnostic tool secondary to these discrepancies
Papanicolaou, Traut: Diagnosis of uterine
cancer by the vaginal smear, 1943
History
History
►
►
Papanicolaou and
Papanicolaou and
Traut
Traut
revolutionized
revolutionized
screening of cervical cancer with cytology
screening of cervical cancer with cytology
►
►
It was easy to collect and provided a more
It was easy to collect and provided a more
objective findings than colposcopy
objective findings than colposcopy
►
►
Pap testing was rapidly accepted in North
Pap testing was rapidly accepted in North
America and Western Europe as the
America and Western Europe as the
screening test of choice
screening test of choice
►
►
Its acceptance in Germany was poor
Its acceptance in Germany was poor
Navratil: Dysplasia, CIS and microinvasive
carcinoma of the cervix uteri: Colposcopy, 1964.
History
History
►
►
During the 60’s colposcopy made a resurgence
During the 60’s colposcopy made a resurgence
►
►
New studies showed that detection of carcinoma
New studies showed that detection of carcinoma
-
-
in
in
-
-
situ (CIS) or invasive carcinoma were better
situ (CIS) or invasive carcinoma were better
detected by combining cytology with colposcopic
detected by combining cytology with colposcopic
directed biopsies
directed biopsies
Total 838 cases
Total 838 cases
Colposcopy 663 (79%)
Colposcopy 663 (79%)
Cytology 729 (87%)
Cytology 729 (87%)
Combination 828 (99%)
Combination 828 (99%)
History
History
►
►
Today colposcopy has been accepted as a
Today colposcopy has been accepted as a
diagnostic tool in evaluating abnormal pap
diagnostic tool in evaluating abnormal pap
tests
tests
►
►
Colposcopy elegantly identifies the location
Colposcopy elegantly identifies the location
of abnormal lesions allowing the practitioner
of abnormal lesions allowing the practitioner
to obtain histologic samples
to obtain histologic samples
►
►
Its utility as a screening test is likely
Its utility as a screening test is likely
finished in westernized nations
finished in westernized nations
Overview
Overview
►
►
Cytologic indications for colposcopy
Cytologic indications for colposcopy
►
►
Cytologic correlation with histology
Cytologic correlation with histology
►
►
Tools, Techniques and stains of colposcopy
Tools, Techniques and stains of colposcopy
►
►
Normal colposcopic anatomy
Normal colposcopic anatomy
►
►
Abnormal colposcopic anatomy
Abnormal colposcopic anatomy
►
►
Unusual colposcopic anatomy
Unusual colposcopic anatomy
►
►
Treatment of abnormal histology
Treatment of abnormal histology
Indications for Colposcopy
Indications for Colposcopy
►
►
Abnormal pap tests suggestive of cervical
Abnormal pap tests suggestive of cervical
dysplasia
dysplasia
►
►
Types are classified according to Bethesda
Types are classified according to Bethesda
2001 nomenclature
2001 nomenclature
►
►
Best to delineate which pap tests correlate
Best to delineate which pap tests correlate
with mild dysplasia and those which are
with mild dysplasia and those which are
more severe
more severe
2001 Bethesda Nomenclature
2001 Bethesda Nomenclature
►
►
Mild dysplasia
Mild dysplasia
HPV
HPV
effect (Human
effect (Human
Papilloma Virus)
Papilloma Virus)
ASC
ASC
-
-
US
US
(Atypical
(Atypical
Squamous Cells of
Squamous Cells of
Unknown Significance)
Unknown Significance)
LSIL
LSIL
(Low Grade
(Low Grade
Squamous
Squamous
Intraepithelial Lesion)
Intraepithelial Lesion)
►
►
Severe dysplasia
Severe dysplasia
ASC
ASC
-
-
H
H
(Cannot rule
(Cannot rule
out HGSIL)
out HGSIL)
HSIL
HSIL
(High Grade
(High Grade
Squamous
Squamous
Intraepithelial Lesion)
Intraepithelial Lesion)
CIS
CIS
(Squamous
(Squamous
Carcinoma In
Carcinoma In
-
-
Situ)
Situ)
2001 Bethesda Nomenclature
2001 Bethesda Nomenclature
►
►
Glandular abnormalities
Glandular abnormalities
►
►
Should be handled with utmost caution
Should be handled with utmost caution
AGC
AGC
(Atypical Glandular Cells of Unknown
(Atypical Glandular Cells of Unknown
Significance)
Significance)
AIS
AIS
(Adenocarcinoma In
(Adenocarcinoma In
-
-
Situ)
Situ)
►
►
Biopsy medial to the transformation zone
Biopsy medial to the transformation zone
Frequency of Abnormal Pap Tests
Frequency of Abnormal Pap Tests
►
►
Estimated 50
Estimated 50
million pap
million pap
tests are
tests are
performed
performed
each year
each year
►
►
5% are
5% are
abnormal
abnormal
►
►
2
2
-
-
3 Million
3 Million
ASCUS
ASCUS
►
►
1 Million LSIL
1 Million LSIL
►
►
600,000 HSIL
600,000 HSIL
ASCUS
LGSIL
HGSIL
Cancer
Histologic Nomenclature
Histologic Nomenclature
►
►
CIN (Cervical Intraepithelial Neoplasia)
CIN (Cervical Intraepithelial Neoplasia)
CIN 1 corresponds to mild dysplasia
CIN 1 corresponds to mild dysplasia
CIN 2 corresponds to moderate dysplasia
CIN 2 corresponds to moderate dysplasia
CIN 3 corresponds to severe dysplasia
CIN 3 corresponds to severe dysplasia
CIS and CIN 3 are the same entity
CIS and CIN 3 are the same entity
Overview
Overview
►
►
Cytologic indications for colposcopy
Cytologic indications for colposcopy
►
►
Cytologic correlation with histology
Cytologic correlation with histology
►
►
Tools, Techniques and stains of colposcopy
Tools, Techniques and stains of colposcopy
►
►
Normal colposcopic anatomy
Normal colposcopic anatomy
►
►
Abnormal colposcopic anatomy
Abnormal colposcopic anatomy
►
►
Unusual colposcopic anatomy
Unusual colposcopic anatomy
►
►
Treatment of abnormal histology
Treatment of abnormal histology
Histologic correlation
Histologic correlation
►
►
As a colposcopist, histology is more
As a colposcopist, histology is more
important than cytology
important than cytology
►
►
The cytology is important for two reasons:
The cytology is important for two reasons:
1) indication to perform colposcopy
1) indication to perform colposcopy
2) gives the colposcopist a “hint” of the
2) gives the colposcopist a “hint” of the
histology
histology
►
►
Histology is important for determining
Histology is important for determining
patient treatment
patient treatment
►
►
Cytology does not equal histology
Cytology does not equal histology
Morin et al. J Reprod Med, 2001
Histologic correlation
Histologic correlation
►
►
ASC
ASC
-
-
US
US
Most common type of abnormal pap
Most common type of abnormal pap
Is it a premalignant change?
Is it a premalignant change?
No! Roughly 70% of ASC
No! Roughly 70% of ASC
-
-
US paps are related to
US paps are related to
vaginitis, atrophy, granulation tissue, chronic
vaginitis, atrophy, granulation tissue, chronic
cervicitis, etc
cervicitis, etc
Only 30% are dysplastic in nature
Only 30% are dysplastic in nature
►
►
90% are CIN 1
90% are CIN 1
►
►
5
5
-
-
10% are CIN 2
10% are CIN 2
-
-
3
3
Histologic correlation
Histologic correlation
►
►
LSIL
LSIL
Common, 1 million paps diagnosed each year
Common, 1 million paps diagnosed each year
Most erroneously managed pap test. Why?
Most erroneously managed pap test. Why?
►
►
Pap repeated frequently
Pap repeated frequently
►
►
HPV testing
HPV testing
30% of LSIL paps harbor CIN 2 and CIN 3 on
30% of LSIL paps harbor CIN 2 and CIN 3 on
colposcopic directed biopsies
colposcopic directed biopsies
Colposcopy needs to be done first and foremost
Colposcopy needs to be done first and foremost
to ascertain histologic diagnosis
to ascertain histologic diagnosis
Sherman. Am J Clin Pathol 2001
Histologic correlation
Histologic correlation
►
►
ASC
ASC
-
-
H
H
28
28
-
-
40% of these pap tests are CIN 2
40% of these pap tests are CIN 2
-
-
3 on
3 on
histologic biopsy
histologic biopsy
Accordingly, HPV testing is positive 70
Accordingly, HPV testing is positive 70
-
-
86%
86%
Colposcopic examination will reveal a wide
Colposcopic examination will reveal a wide
range of findings
range of findings
►
►
HSIL & CIS
HSIL & CIS
Expect worrisome colposcopic abnormalities
Expect worrisome colposcopic abnormalities
with these pap tests
with these pap tests
Colposcopic Correlation
Colposcopic Correlation
►
►
Mild dysplasia
Mild dysplasia
Acetowhite changes
Acetowhite changes
Bright white
Bright white
Clear demarcation
Clear demarcation
between normal and
between normal and
abnormal epithelium
abnormal epithelium
Fine punctations
Fine punctations
►
►
Severe dysplasia
Severe dysplasia
Dull, pearly grey
Dull, pearly grey
epithelium
epithelium
Faint to difficult to
Faint to difficult to
interpret demarcation
interpret demarcation
between abnormal and
between abnormal and
normal epithelium
normal epithelium
Coarse punctations
Coarse punctations
Mosaicism
Mosaicism
Abnormal vessels
Abnormal vessels
Overview
Overview
►
►
Cytologic indications for colposcopy
Cytologic indications for colposcopy
►
►
Cytologic correlation with histology
Cytologic correlation with histology
►
►
Tools, Techniques and stains of
Tools, Techniques and stains of
colposcopy
colposcopy
►
►
Normal colposcopic anatomy
Normal colposcopic anatomy
►
►
Abnormal colposcopic anatomy
Abnormal colposcopic anatomy
►
►
Unusual colposcopic anatomy
Unusual colposcopic anatomy
►
►
Treatment of abnormal histology
Treatment of abnormal histology
Tools, Techniques & Stains
Tools, Techniques & Stains
►
►
Colposcope
Colposcope
Stereoscopic binocular microscope
Stereoscopic binocular microscope
Magnification from 8
Magnification from 8
×
×
to 40
to 40
×
×
Generally panoramic view at 10
Generally panoramic view at 10
×
×
most useful
most useful
A green filter
A green filter
►
►
Used to highlight vascular patterns
Used to highlight vascular patterns
►
►
Demarcate color differences between normal and
Demarcate color differences between normal and
abnormal tissue
abnormal tissue
Tools, Techniques & Stains
Tools, Techniques & Stains
►
►
Instruments
Instruments
Kevorkian
Kevorkian
-
-
Younge biopsy forceps
Younge biopsy forceps
Endocervical curette
Endocervical curette
Endocervical brush
Endocervical brush
Cytology brush
Cytology brush
Silver Nitrate stick
Silver Nitrate stick
Monsel’s solution
Monsel’s solution
Tools, Techniques & Stains
Tools, Techniques & Stains
►
►
Stains
Stains
3% Acetic Acid
3% Acetic Acid
Works as a desiccant
Works as a desiccant
The cellular cytoplasm is reduced enhancing a
The cellular cytoplasm is reduced enhancing a
prominent nucleus
prominent nucleus
The nucleus is enlarged secondary to HPV
The nucleus is enlarged secondary to HPV
replication
replication
This nuclear enlargement is seen as acetowhite
This nuclear enlargement is seen as acetowhite
changes
changes
Tools, Techniques & Stains
Tools, Techniques & Stains
►
►
Stains
Stains
Lugol’s iodine solution (Schiller test)
Lugol’s iodine solution (Schiller test)
Works by staining glycogen
Works by staining glycogen
Dysplastic tissue has an increased metabolic
Dysplastic tissue has an increased metabolic
rate thereby lowering cellular glycogen
rate thereby lowering cellular glycogen
Normal tissue stains black/brown while
Normal tissue stains black/brown while
dysplastic tissue appears highlighted or yellow
dysplastic tissue appears highlighted or yellow
Useful stain for hard to see lesions
Useful stain for hard to see lesions
Tools, Techniques & Stains
Tools, Techniques & Stains
►
►
Technique
Technique
Orient colposcope so that a panoramic view is
Orient colposcope so that a panoramic view is
obtained
obtained
Start with normal light and 10× magnification
Start with normal light and 10× magnification
Entire cervix should be visualized
Entire cervix should be visualized
Apply generous amount of acetic acid while
Apply generous amount of acetic acid while
cleaning off obscuring mucous or discharge
cleaning off obscuring mucous or discharge
You can never apply too much acetic acid
You can never apply too much acetic acid
Tools, Techniques & Stains
Tools, Techniques & Stains
►
►
Evaluate the squamocolumnar junction
Evaluate the squamocolumnar junction
(SCJ) or transformation zone (TZ)
(SCJ) or transformation zone (TZ)
Dysplasia originates from this boundary and
Dysplasia originates from this boundary and
spreads lateral to this junction
spreads lateral to this junction
Medial to this border are columnar
Medial to this border are columnar
cells/glandular cells
cells/glandular cells
A large volume of glandular cells are called
A large volume of glandular cells are called
ectropion
ectropion
Young women and pregnant women generally
Young women and pregnant women generally
have ectropion
have ectropion
Colposcopy
Colposcopy
Ectropion or
Ectropion or
glandular cells
glandular cells
Endocervical Os
Endocervical Os
Squamous
Squamous
Epithelium
Epithelium
3% Acetic acid applied to cervix
3% Acetic acid applied to cervix
Cervix viewed under magnification and green light
Cervix viewed under magnification and green light
Entire transformation zone must be visualized
Entire transformation zone must be visualized
Dysplastic epithelium will be
Dysplastic epithelium will be
“acetowhite” due to higher
“acetowhite” due to higher
Nuclear/cytoplasmic ratio
Nuclear/cytoplasmic ratio
Squamocolumnar
Junction
Tools, Techniques & Stains
Tools, Techniques & Stains
►
►
Evaluate areas of acetowhite changes
Evaluate areas of acetowhite changes
Are they small or larges patches?
Are they small or larges patches?
Does it have a sharp or indistinct border?
Does it have a sharp or indistinct border?
Is it a bright white or a dull, pearly grey?
Is it a bright white or a dull, pearly grey?
►
►
Evaluate areas of punctation
Evaluate areas of punctation
Are the punctations small or large caliber?
Are the punctations small or large caliber?
Are the punctations sparse or numerous?
Are the punctations sparse or numerous?
►
►
Evaluate areas of mosaicism
Evaluate areas of mosaicism
►
►
Evaluate areas of abnormal blood vessels
Evaluate areas of abnormal blood vessels
Are the blood vessels uniform or sporadic?
Are the blood vessels uniform or sporadic?
Are the vessels large caliber or small caliber?
Are the vessels large caliber or small caliber?
Adequacy of Colposcopy
Adequacy of Colposcopy
►
►
Must evaluate the entirety of the lesion
Must evaluate the entirety of the lesion
Can you follow the entire lesion?
Can you follow the entire lesion?
Does it go past the SCJ and into the endocervix?
Does it go past the SCJ and into the endocervix?
Does it move into the vagina?
Does it move into the vagina?
►
►
Must evaluate the entirety of the SCJ
Must evaluate the entirety of the SCJ
Is it obscured by prior treatments?
Is it obscured by prior treatments?
Does it recede into the endocervix?
Does it recede into the endocervix?
►
►
Proper evaluation of both the lesion and the SCJ is an
Proper evaluation of both the lesion and the SCJ is an
adequate colposcopy
adequate colposcopy
►
►
Failure of either criteria is an inadequate colposcopy and
Failure of either criteria is an inadequate colposcopy and
leads to changes in treatment NOT diagnosis of
leads to changes in treatment NOT diagnosis of
histopathology
histopathology
Biopsies
Biopsies
►
►
Best to obtain biopsy of worst area
Best to obtain biopsy of worst area
►
►
Try to incorporate SCJ if at all possible
Try to incorporate SCJ if at all possible
►
►
Multiple biopsies are recommended but
Multiple biopsies are recommended but
should be kept within reason (2
should be kept within reason (2
-
-
3)
3)
►
►
Endocervical curettage (ECC) should
Endocervical curettage (ECC) should
generally be included as part of each
generally be included as part of each
colposcopy
colposcopy
►
►
Having the patient cough during biopsy is
Having the patient cough during biopsy is
good distraction
good distraction
Williams. Obstet Gynecol, 2000
To ECC or not to ECC
To ECC or not to ECC
►
►
Never wrong to perform
Never wrong to perform
►
►
However, ECC can be avoided if entire lesion is
However, ECC can be avoided if entire lesion is
visible on ectocervix
visible on ectocervix
►
►
This position is strengthened since squamous
This position is strengthened since squamous
dysplasia is continuous; it does not skip
dysplasia is continuous; it does not skip
►
►
Others proclaim it evaluates occult endocervical
Others proclaim it evaluates occult endocervical
dysplasia
dysplasia
►
►
Ultimate decision lies with wisdom and expertise
Ultimate decision lies with wisdom and expertise
of practitioner
of practitioner
Tate. Obstet Gynecol, 1997
ECC
ECC
►
►
Most uncomfortable portion of colposcopic
Most uncomfortable portion of colposcopic
directed biopsies
directed biopsies
►
►
Good to have patient take NSAID 30 min before
Good to have patient take NSAID 30 min before
colposcopy
colposcopy
►
►
Apply curette at four cardinal directions
Apply curette at four cardinal directions
►
►
Swirl curette in fixative then take endocervical
Swirl curette in fixative then take endocervical
brush to collect rest of sample
brush to collect rest of sample
►
►
Prospective randomized trial showing better
Prospective randomized trial showing better
results with curette and brush than either alone
results with curette and brush than either alone
Overview
Overview
►
►
Cytologic indications for colposcopy
Cytologic indications for colposcopy
►
►
Cytologic correlation with histology
Cytologic correlation with histology
►
►
Tools, Techniques and stains of colposcopy
Tools, Techniques and stains of colposcopy
►
►
Normal colposcopic anatomy
Normal colposcopic anatomy
►
►
Abnormal colposcopic anatomy
Abnormal colposcopic anatomy
►
►
Unusual colposcopic anatomy
Unusual colposcopic anatomy
►
►
Treatment of abnormal histology
Treatment of abnormal histology
Overview
Overview
►
►
Cytologic indications for colposcopy
Cytologic indications for colposcopy
►
►
Cytologic correlation with histology
Cytologic correlation with histology
►
►
Tools, Techniques and stains of colposcopy
Tools, Techniques and stains of colposcopy
►
►
Normal colposcopic anatomy
Normal colposcopic anatomy
►
►
Abnormal colposcopic anatomy
Abnormal colposcopic anatomy
►
►
Unusual colposcopic anatomy
Unusual colposcopic anatomy
►
►
Treatment of abnormal histology
Treatment of abnormal histology
Abnormal Colposcopic Anatomy
Abnormal Colposcopic Anatomy
►
►
Acetowhite epithelium or changes
Acetowhite epithelium or changes
►
►
Punctations
Punctations
►
►
Mosaicism
Mosaicism
►
►
Abnormal Vessels
Abnormal Vessels
►
►
Invasive carcinoma
Invasive carcinoma
Abnormal Colposcopic Anatomy
Abnormal Colposcopic Anatomy
►
►
Acetowhite changes
Acetowhite changes
Mildest changes of cervical dysplasia
Mildest changes of cervical dysplasia
Caused by desiccation of cytoplasm from acetic
Caused by desiccation of cytoplasm from acetic
acid leading to increased nuclear /cytoplasmic
acid leading to increased nuclear /cytoplasmic
ratio
ratio
Other areas of abnormal change can be found
Other areas of abnormal change can be found
within acetowhite lesions
within acetowhite lesions
Often times very clear area of demarcation from
Often times very clear area of demarcation from
normal to abnormal
normal to abnormal
Punctations
Punctations
►
►
Punctations are vessels that run
Punctations are vessels that run
perpendicular to the portio of the cervix
perpendicular to the portio of the cervix
►
►
They are end on end to the colposcopist
They are end on end to the colposcopist
►
►
The green filter removes red light thus
The green filter removes red light thus
vessels are darkened
vessels are darkened
►
►
Punctation can be small vessels (fine
Punctation can be small vessels (fine
punctation) or large vessels (coarse
punctation) or large vessels (coarse
punctation)
punctation)
Mosaicism
Mosaicism
►
►
A mosaic is a large image pieced together
A mosaic is a large image pieced together
by smaller usually colorful tiles
by smaller usually colorful tiles
►
►
In colposcopy it is essentially the same
In colposcopy it is essentially the same
-
-
a
a
larger lesion made of small heaped
larger lesion made of small heaped
epithelial islands and tiny vessels
epithelial islands and tiny vessels
►
►
These islands look like a cobblestone road
These islands look like a cobblestone road
►
►
Islands are separated by vessels running
Islands are separated by vessels running
parallel to the portio or colposcopist
parallel to the portio or colposcopist
Abnormal Vessels
Abnormal Vessels
►
►
In the natural progression of dysplasia to
In the natural progression of dysplasia to
invasive cervical cancer, many genetic and
invasive cervical cancer, many genetic and
pathologic changes occur
pathologic changes occur
►
►
One important change is angiogenesis
One important change is angiogenesis
►
►
The evolving carcinoma needs oxygen and
The evolving carcinoma needs oxygen and
nutrients to grow at an exponential rate
nutrients to grow at an exponential rate
►
►
In order to achieve maximal growth, new
In order to achieve maximal growth, new
blood vessels are synthesized
blood vessels are synthesized
Abnormal Vessels
Abnormal Vessels
►
►
The newly created vessels are perfect for
The newly created vessels are perfect for
pooling blood
pooling blood
►
►
They have low flow, little
They have low flow, little
pulsativity
pulsativity
and
and
poor resistance
poor resistance
►
►
The above factors are caused by multiple
The above factors are caused by multiple
tributaries arising from any one vessel
tributaries arising from any one vessel
►
►
End result is like a delta from a river, lots of
End result is like a delta from a river, lots of
nutrients are brought in but blood is slow to
nutrients are brought in but blood is slow to
return
return
Invasive Cancer
Invasive Cancer
►
►
Conglomeration of all colposcopic finding:
Conglomeration of all colposcopic finding:
acetowhite, punctations, mosaicism, and vessels
acetowhite, punctations, mosaicism, and vessels
►
►
Necrotic tissue results in anaerobic odors
Necrotic tissue results in anaerobic odors
►
►
Think ahead when performing biopsies: Monsel's,
Think ahead when performing biopsies: Monsel's,
packing and even suture might be necessary to
packing and even suture might be necessary to
control hemorrhage
control hemorrhage
►
►
Shoot for a good tissue collection, often time not
Shoot for a good tissue collection, often time not
enough tissue is obtained for pathologist to
enough tissue is obtained for pathologist to
document invasion!!!
document invasion!!!
Overview
Overview
►
►
Cytologic indications for colposcopy
Cytologic indications for colposcopy
►
►
Cytologic correlation with histology
Cytologic correlation with histology
►
►
Tools, Techniques and stains of colposcopy
Tools, Techniques and stains of colposcopy
►
►
Normal colposcopic anatomy
Normal colposcopic anatomy
►
►
Abnormal colposcopic anatomy
Abnormal colposcopic anatomy
►
►
Unusual colposcopic anatomy
Unusual colposcopic anatomy
►
►
Treatment of abnormal histology
Treatment of abnormal histology
Overview
Overview
►
►
Cytologic indications for colposcopy
Cytologic indications for colposcopy
►
►
Cytologic correlation with histology
Cytologic correlation with histology
►
►
Tools, Techniques and stains of colposcopy
Tools, Techniques and stains of colposcopy
►
►
Normal colposcopic anatomy
Normal colposcopic anatomy
►
►
Abnormal colposcopic anatomy
Abnormal colposcopic anatomy
►
►
Unusual colposcopic anatomy
Unusual colposcopic anatomy
►
►
Treatment of abnormal histology
Treatment of abnormal histology
Treatment Modalities
Treatment Modalities
►
►
Cryosugery
Cryosugery
►
►
Loop Electricosurgical Excision Procedure
Loop Electricosurgical Excision Procedure
(LEEP)
(LEEP)
►
►
Laser Ablation
Laser Ablation
►
►
Cold Knife Conization
Cold Knife Conization
►
►
Hysterectomy
Hysterectomy
Cryosurgery
Cryosurgery
►
►
Inexpensive, easy to perform, tolerated well by
Inexpensive, easy to perform, tolerated well by
patients
patients
►
►
Cells are destroyed by (cold) thermal damage
Cells are destroyed by (cold) thermal damage
►
►
3 minute freeze/ 1 minute thaw/ 3 minute freeze
3 minute freeze/ 1 minute thaw/ 3 minute freeze
well documented technique
well documented technique
►
►
Does cause 2
Does cause 2
-
-
3 weeks of malodorous discharge
3 weeks of malodorous discharge
►
►
Does hinder repeat colposcopy (SCJ often
Does hinder repeat colposcopy (SCJ often
obscured)
obscured)
LEEP
LEEP
►
►
Procedure of choice for most OB/
Procedure of choice for most OB/
GYN’s
GYN’s
►
►
Easy to perform, well tolerated and provides
Easy to perform, well tolerated and provides
specimen for pathologic evaluation
specimen for pathologic evaluation
(Margins)
(Margins)
►
►
Good rule to keep specimens less than 4 cm
Good rule to keep specimens less than 4 cm
wide and 2 cm tall
wide and 2 cm tall
►
►
Concern that multiple excisions or one large
Concern that multiple excisions or one large
excision will increase rate of preterm
excision will increase rate of preterm
labor/incompetent cervix
labor/incompetent cervix
Preterm Delivery and LEEP
Preterm Delivery and LEEP
►
►
Kyrgiou
Kyrgiou
et al. Lancet 2006; 367: 489
et al. Lancet 2006; 367: 489
-
-
98.
98.
►
►
Meta
Meta
-
-
analysis of 27 studies
analysis of 27 studies
►
►
Studies chosen had to have a control group
Studies chosen had to have a control group
►
►
Evaluation of CKC, LEEP and laser for:
Evaluation of CKC, LEEP and laser for:
preterm delivery (<37 weeks gestation)
preterm delivery (<37 weeks gestation)
Low birth weight (<2500 g)
Low birth weight (<2500 g)
Cesarean delivery
Cesarean delivery
Preterm Delivery and LEEP
Preterm Delivery and LEEP
►
►
CKC
CKC
Preterm delivery
Preterm delivery
-
-
RR 2.59 (95% CI 1.80
RR 2.59 (95% CI 1.80
-
-
3.72)
3.72)
Low birth weight
Low birth weight
-
-
RR 2.53 (95% CI 1.19
RR 2.53 (95% CI 1.19
-
-
5.36)
5.36)
Cesarean section
Cesarean section
-
-
RR 3.17 (95% CI 1.07
RR 3.17 (95% CI 1.07
-
-
9.40)
9.40)
►
►
LEEP
LEEP
Preterm delivery
Preterm delivery
-
-
RR 1.70 (95% CI 1.24
RR 1.70 (95% CI 1.24
-
-
2.35)
2.35)
Low birth weight
Low birth weight
-
-
RR 1.82 (95% CI 1.09
RR 1.82 (95% CI 1.09
-
-
3.06)
3.06)
Cesarean section
Cesarean section
-
-
RR 2.69 (95% CI 1.62
RR 2.69 (95% CI 1.62
-
-
4.46)
4.46)
►
►
Laser
Laser
NS for Preterm delivery
NS for Preterm delivery
-
-
RR 1.71 (95% CI 0.93
RR 1.71 (95% CI 0.93
-
-
3.14)
3.14)
Preterm Delivery and LEEP
Preterm Delivery and LEEP
►
►
Summary
Summary
►
►
CKC patients are 2.5 times more likely to
CKC patients are 2.5 times more likely to
have a preterm delivery, low birth weight
have a preterm delivery, low birth weight
infant and/or cesarean section
infant and/or cesarean section
►
►
LEEP 1.5 times more likely
LEEP 1.5 times more likely
►
►
Incidence of preterm delivery is 2
Incidence of preterm delivery is 2
-
-
3%
3%
CKC ~ 7.5% (1 in 15 women)
CKC ~ 7.5% (1 in 15 women)
LEEP ~ 4.5% (1 in 20 women)
LEEP ~ 4.5% (1 in 20 women)
Dietrich, Obstet Gynecol 2002
Margins and LEEP
Margins and LEEP
►
►
Margin status helpful in predicting
Margin status helpful in predicting
recurrence of cervical dysplasia
recurrence of cervical dysplasia
►
►
Negative margins ~15%
Negative margins ~15%
►
►
Positive margins ~ 30
Positive margins ~ 30
-
-
60%
60%
►
►
Re
Re
-
-
excision not needed. Follow patient with
excision not needed. Follow patient with
serial pap tests and treat accordingly if
serial pap tests and treat accordingly if
patient recurs
patient recurs
Laser
Laser
►
►
CO2 laser works by vaporizing cervical cells
CO2 laser works by vaporizing cervical cells
►
►
Very precise method; only need 5
Very precise method; only need 5
-
-
7 mm of
7 mm of
vaporization for treatment
vaporization for treatment
►
►
Heals great, spares cervical excisions
Heals great, spares cervical excisions
►
►
COST major problem
COST major problem
►
►
No pathology specimen
No pathology specimen
Cold Knife Conization (CKC)
Cold Knife Conization (CKC)
►
►
Used to be the treatment of choice before
Used to be the treatment of choice before
LEEP
LEEP
►
►
Surgically excises dysplasia with
Surgically excises dysplasia with
scalpel/scissors
scalpel/scissors
►
►
Large cost to patient from physician,
Large cost to patient from physician,
anesthesia, and hospital charges
anesthesia, and hospital charges
►
►
Incompetent cervix an issue
Incompetent cervix an issue
►
►
Indications to perform are few
Indications to perform are few
Hysterectomy
Hysterectomy
►
►
The final treatment for cervical dysplasia
The final treatment for cervical dysplasia
►
►
Comes with significant morbidity/ mortality
Comes with significant morbidity/ mortality
and lengthy recovery (6 weeks)
and lengthy recovery (6 weeks)
►
►
Complications include: hemorrhage,
Complications include: hemorrhage,
infections, bowel & bladder injuries, MI,
infections, bowel & bladder injuries, MI,
pulmonary embolus, stroke, death
pulmonary embolus, stroke, death
►
►
10
10
-
-
20% of patients will continue to have
20% of patients will continue to have
abnormal pap tests: vaginal dysplasia
abnormal pap tests: vaginal dysplasia
Mitchell, Obstet Gynecol 1998.
Efficacy of treatment
Efficacy of treatment
►
►
Randomized controlled trial between
Randomized controlled trial between
cryosurgery, LEEP and laser showed no
cryosurgery, LEEP and laser showed no
statistical difference in efficacy
statistical difference in efficacy
►
►
Recurrences were measure from 6
Recurrences were measure from 6
-
-
37
37
months
months
►
►
Cryosurgery 19%
Cryosurgery 19%
►
►
LEEP 13%
LEEP 13%
►
►
Laser 13%
Laser 13%
Reich, Obstet Gynecol. 2001 and 2002
Efficacy of treatment
Efficacy of treatment
►
►
Reich et al. performed two retrospective studies
Reich et al. performed two retrospective studies
on cold knife conization
on cold knife conization
►
►
4417 women with CIN 3 were treated with CKC
4417 women with CIN 3 were treated with CKC
and followed for median 107 months (negative
and followed for median 107 months (negative
margins)
margins)
►
►
Only 15 women developed recurrence (0.35%)
Only 15 women developed recurrence (0.35%)
►
►
390 women with CIN 3 were treated with CKC and
390 women with CIN 3 were treated with CKC and
followed for a median of 19 years (positive
followed for a median of 19 years (positive
margins)
margins)
►
►
84 women developed recurrence (22%)
84 women developed recurrence (22%)
Which method to chose?
Which method to chose?
►
►
Several factors to consider: age, desire for
Several factors to consider: age, desire for
fertility, size of lesion, size of the cervix,
fertility, size of lesion, size of the cervix,
severity of dysplasia, and prior therapies
severity of dysplasia, and prior therapies
►
►
Generalizations:
Generalizations:
Cryosurgery
Cryosurgery
-
-
best for young women with few
best for young women with few
finances and CIN 1 or 2.
finances and CIN 1 or 2.
LEEP
LEEP
-
-
the majority of women with CIN 2 or 3.
the majority of women with CIN 2 or 3.
Women with endocervical lesions also suited for
Women with endocervical lesions also suited for
LEEP
LEEP
Which method to chose?
Which method to chose?
Laser
Laser
-
-
women who have had multiple
women who have had multiple
recurrences of CIN 2 or 3 and who want to
recurrences of CIN 2 or 3 and who want to
retain fertility. Example: a 19 year old G
retain fertility. Example: a 19 year old G
0
0
who
who
has CIN 3, prior LEEP, and a small cervix.
has CIN 3, prior LEEP, and a small cervix.
CKC
CKC
-
-
glandular abnormalities (AIS) or early
glandular abnormalities (AIS) or early
invasive cancer
invasive cancer
Hysterectomy
Hysterectomy
-
-
women finished with
women finished with
childbearing and who have persistent CIN.
childbearing and who have persistent CIN.
Often best utilized with other gynecologic
Often best utilized with other gynecologic
problems like pelvic pain or abnormal uterine
problems like pelvic pain or abnormal uterine
bleeding
bleeding
top related