Colposcopy Commandments

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Transcript of Colposcopy Commandments

TEN COMMANDS TO BE TEN COMMANDS TO BE A COLPOSCOPIST A COLPOSCOPIST

ByBy

Prof. Mohammad A. Emam Prof. Mohammad A. Emam Director Of Early Cancer Detection Director Of Early Cancer Detection

Unit OB & GYN Dept.Unit OB & GYN Dept.

Mansoura Faculty Of Medicine - EGYPT Mansoura Faculty Of Medicine - EGYPT

What is a ColposcopeWhat is a Colposcope??

ColposcopeColposcopeStereoscopic, Binocular Microscope with 3

specifications: low magnification (10 – 40) * Focal length (20 – 25 CM) Width of visual field > 25 MM.- NB: Colpomicroscope (150 – - NB: Colpomicroscope (150 –

200)200)

TEN COMMANDS TO BE TEN COMMANDS TO BE A COLPOSCOPISTA 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 ColposcopyValue 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 Instrument

Optical system ( 7.5 – 40 ).Illumination system ( Dim

or Bright ).Stand (Easy movement).Accessories ( Gray filter –

Camera +Electronic flash ).

1.Colposcope:

InstrumentInstrument cont…cont…

Set for cytology.Set for Biopsy.Speculae ( non polished or plastic ) &

Kogan’s.Chemicals( Lugol’s Iodine - Acetic acid

3% - Monsol’s sol .saline)Cotton Buds-singley’s forceps – iris hook

2.Auxillary:

Instrument Instrument cont..cont..

Eye – piece.

Video – printer.

Computer graphic.

III-extra –auxillary:III-extra –auxillary:

TERMINOLOGYTERMINOLOGY

1. Ectocervix (= vaginal surface of CX.).

2. Endocervix (= cervical canal).

3. Eversion (Dynamic process) may be true (erosion) or false (ectropion).

Anatomical TerminologyAnatomical Terminology

TERMINOLOGY TERMINOLOGY cont…..cont…..

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.

Pathological terminology

HISTOLOGICAL TERMINOLOGYHISTOLOGICAL TERMINOLOGY

Epith. Covering: Original epithelia . Squamous.

. Columnar

Metaplastic epithelia (Neonatal Period –puberty – pregnancy).

Squamo – Columnar J. (primary – Secondary)

Underlying Stroma.

Cytological TerminologyCytological Terminology

*positive smear.*negative smear.*doubtful Smear. 

( N/C –Anisocytosis –Hyperchromsia-Clumping).

Smear comment

Dyskaryotic cell

Colposcopic TerminologyColposcopic Terminology

Many Many classificationsclassifications

Graz 1975Graz 1975Rome 1990Rome 1990I) Normal colposcopic findings

I) Normal

II) Abnormal colposcopic finding:

a) Atypical T.Z.:

b) Suspect Frank invasive carcinoma.

II) Abnormal colposcopic findings:

A) Within the transformation zone.

B) Outside the transformation zone e.g. ectocervix, vagina.

III) Unsatisfactory (indecisive) Colposcopic findings.

III) Colposcopically suspect invasive cancer.

IV) Miscellaneous colposcopic findings

IV) Unsatisfactory colposcopy

V) Miscellaneous: Non –acetowhite

Transformation zone “TZ”Transformation zone “TZ”

Definition: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 Transformation zone “TZ” “TZ” contcont..…....…..

Age

Pregnancy

Oestrogen

Menopause

T Z can be altered by

IndicationsIndications

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.

Cryocautery. Diathermy (loop). Laser.

I) Diagnostic:

II) Therapeutic:

Role of ColposcopeRole of Colposcope

Prove (or) disprove invasive cancer.Localization of the most ABN. Site

for biopsy.Evaluation of extent (need for

Conization).

1. During Diagnosis:1. During Diagnosis:

Localization of TZ

Role of ColposcopeRole of Colposcope cont..….cont..….

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.

2. During therapy:2. During therapy:

Steps for ColposcopySteps for Colposcopy

History ( VIA - pap smear – drugs – infections – sexual….. etc)

Counseling: explanation of the procedure to the patient (psychic element).

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

Steps for ColposcopySteps for Colposcopy cont..cont..

Exam.Inspection.

Bimanual exam, (?!).

Insertion of speculum (precautions).Cytology (spatula – cytobrush – CVE

– Cotton buds – or aspirator)Colposcopy.

SQ. COL. J. & endocervix & vascular.Green filter.Use (Kogan’s speculum – cotton bud –

singley’s forceps).

A) Direct (saline)

B) Amplified:

C) Endo C.C. OR ECB (easier)D) Colposcopic – Guided Punch biopsy.

Acetic Acid 3% (3 – 4 min).

Lugol’s iodine (?) (1 part I2 + 2KI + 97H20).

Steps for ColposcopySteps for Colposcopy cont..cont..

Diagnostic criteria of ColposcopyDiagnostic criteria of Colposcopy

Vascular pattern.

Intercapillary distance.

Contour (surface pattern).

Colour tone & opacity.

Borders (Dermarcation).

- Major (5)

Diagnostic criteria of Colposcopy Diagnostic criteria of Colposcopy cont..…cont..…

  Size (Extent).

Keratosis.

Aceto white areas.

Iodine uptake.

Cervical gland openings.

Minor (5)Minor (5)

InterpretationInterpretationColposcopic

CriteriaBenign AspectPre & Maling.

aspect

1. Vascular patternFine – RegularCoarse & ABN.

2. Intercap. DistanceWithin N. rangeLarge than N.

3. ContourSmoothIrregular elevations and valleys.

4. colour tone Reddish – GreyYellow – reddish yellow whitish – grey & Fatty – glazy

InterpretationInterpretation contcont……

Colposcopic CriteriaBenign AspectPre & Maling. aspect

5. Borders & MarginsDiffuseSharp

6. Extent- Localized

- peripheral + I2 positive strip intervening

- Widely spread.

- Within C. canal or directed towards it.

7. KeratosisFineCoarse & crusty

8. Acetowhite AreaSlight to moderateIntense

9. Iodine uptakeWell delineated – sharpWeak or serrated

10. Cervical gland openings

Rare – absent ± thin white rings

Present – thick white rings.

Pitfalls of ColposcopyPitfalls of Colposcopy1. 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 TreatmentLines 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 destructiveCriteria for local destructiveTherapy (LDT)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.

RecommendationsRecommendationsColposcopy 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.

RecommendationsRecommendationscont…cont…

Colposcopy, can not be done in a 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.

Colposcopy, can not be done in vacuum, rather it must be performed in combination with cytology ,VIA

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