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

What is a Colposcope?
Colposcope
Stereoscopic, Binocular Microscope with 3 specifications: low magnification (10 40) * Focal length (20 25 CM) Width of visual field > 25 MM. - NB: Colpomicroscope (150 200)

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.

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.

Instrument
1.Colposcope:
Optical system ( 7.5 40 ). Illumination system ( Dim or Bright ). Stand (Easy movement). Accessories ( Gray filter Camera +Electronic flash ).

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

Instrument cont..
III-extra auxillary:
Eye piece. Video printer. Computer graphic.

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

TERMINOLOGY cont..
Pathological terminology

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

HISTOLOGICAL TERMINOLOGY
Epith.

Covering:
. Squamous. . Columnar

Original epithelia

Metaplastic epithelia (Neonatal Period puberty

pregnancy).

Squamo Columnar J. (primary Secondary)

Underlying

Stroma.

Cytological Terminology
Smear comment
*positive smear. *negative smear. *doubtful Smear.

Dyskaryotic cell
( N/C Anisocytosis HyperchromsiaClumping).

Colposcopic Terminology

Many classifications

Graz 1975
I) Normal colposcopic findings I) Normal

Rome 1990

II) Abnormal colposcopic finding: a) Atypical T.Z.: b) Suspect Frank invasive carcinoma.
III) Unsatisfactory (indecisive) Colposcopic findings. IV) Miscellaneous colposcopic findings

II) Abnormal colposcopic findings: A) Within the transformation zone. B) Outside the transformation zone e.g. ectocervix, vagina.
III) Colposcopically suspect invasive cancer. IV) Unsatisfactory colposcopy

V) Miscellaneous: Non acetowhite

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)

Transformation zone TZ cont....

T Z can be altered by Age Pregnancy Oestrogen Menopause

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.

II) Therapeutic:

Cryocautery. Diathermy (loop). Laser.

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).

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.

Steps for Colposcopy

History ( VIA - pap smear drugs

infections sexual.. etc)

Counseling:

explanation of the procedure to the patient (psychic

element).

(8 12 day of the cycle). Position & Examination table.

Timing

Steps for Colposcopy cont..

Exam.
Inspection. Bimanual exam, (?!). Insertion of speculum (precautions).

Cytology (spatula cytobrush CVE Cotton buds or aspirator) Colposcopy.

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.

Diagnostic criteria of Colposcopy

- Major (5)
Vascular pattern.

Intercapillary distance.
Contour (surface pattern).

Colour tone & opacity.

Borders (Dermarcation).

Diagnostic criteria of Colposcopy cont.. Minor (5)

Size

(Extent). white areas.

Keratosis.
Aceto

Iodine

uptake.
gland openings.

Cervical

Interpretation
Colposcopic Benign Aspect Pre & Maling. Criteria aspect 1. Vascular pattern Fine Regular Coarse & ABN. 2. Intercap. Distance Within N. range Large than N. 3. Contour Smooth Irregular elevations and valleys.

4. colour tone

Reddish Grey Yellow reddish yellow whitish grey & Fatty glazy

Interpretation
Colposcopic Criteria Benign Aspect

cont
Pre & Maling. aspect

5. Borders & Margins

6. Extent

Diffuse
- Localized - peripheral + I2 positive strip intervening Fine

Sharp
- Widely spread. - Within C. canal or directed towards it. Coarse & crusty

7. Keratosis

8. Acetowhite Area
9. Iodine uptake 10. Cervical gland openings

Slight to moderate
Well delineated sharp

Intense
Weak or serrated

Rare absent thin white Present thick rings white rings.

Pitfalls of Colposcopy
1. False squamo- columnar j.(finger speculum smear ). 2. High squamo columnar J. in canal (> 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.

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.

Criteria for local destructive Therapy (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.

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.

Recommendations
cont

Colposcopy, can not be done in

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.

OB& GYN, Mansoura Faculty of Medicine

Mansoura Integrated Fertility Center (MIFC) EGYPT

Telfax 0020502319922 & 0020502312299 Email. mae335@hotmail.com