3 prof walter colposcopic

ColposcopicNomenclature

22. JahrestagungderArbeitsgemeinschaftfurZervixpathologie und Kolposkopie AG CPC

walterprendiville

IFCPC

Evolution of terminology Progress evolves from clear understanding of

existing research and experience and clarity of terminology is fundamental to this

It is not possible to compare apples with oranges or to understand precisely published evidence where terminology is unclear

cone biopsy (UK) with cone biopsy (US),

Height

Depth

atypia

Practice variation in OB/GYN

C Section, 3rd stage of labour

Antenatal V/E

Hysteroscopy

Management of Endometrial Cancer

Colposcopy

Evolution of colposcopy

First colposcope :: Hamburg

Early colposcopic skills image recognition, diagnosis of HSIL, recognition of microinvasion

Late colposcopic skills = discriminating between normal and

abnormal

facilitating precise treatment

MODERN COLPOSCOPY

Objective and easily achieved

skills through structured training as

part of a QA service

Risk assessment using biomarkers

and patient characteristics

Modified treatment techniques

Variation in colposcopy and

treatment

Colposcopy is not a defined entity and performs differently in different settings

Treatment is not a defined entity and produces different results and complications in different settings

Nomenclature varies in interpretation and we therefore can not easily compare practice

Colposcopy is not a defined entity

and performs differently in

different settings

Colposcopy performed by variably trained colposcopists who do not adhere to strict quality assured practice or self audit is completely different to colposcopy in a region where QA, adherence to best evidence guidelines and CME are the norm’

Why is there such a difference in

colposcopic reward

ALTS 11.5% CIN 2+ after a normal colposcopy

72.3% of CIN2+ found at original colposcopy

UK NHS study 5.3% CIN2+ after a normal colposcopy94.6% of CIN2+ found at original colposcopy

Why is there such a difference in

colposcopic reward

In the UK NHS CSP colposcopy setting the risk ofmissing high grade disease appears to be much lowerthan in the equivalent US setting

Why is this?

Why is there such a difference in

colposcopic reward

In the UK there existsA comprehensive training programmePreceptor basedStrict number of cases under supervision

and subsequently unsupervised Ongoing assessment during trainingExit exam (OSCE)30% failure rate

Why is there such a difference in

colposcopic reward

In the UKColposcopy practice

Devoted colposcopy clinicsAll women referred with a suspected abnormalityRate of CIN relatively highNot rewarded according to

procedures performedComprehensive audit of practice

Treatment is not a defined entity

and produces different results and

complications in different settings

The resection of a small type 1 TZ is easy and associated with minimal morbidity

The resection of a large Type 3 TZ is difficult and associated with significant short and long term morbidity

13

Preterm delivery (<37W): Excision vs no treatment ~heigth

Height < 10mm

Risk ratio

.1 .2 .5 1 2 5 10

Risk ratio (95% CI)

Raio, 1997 0.52 ( 0.06, 4.83)

Sadler, 2004 0.99 ( 0.57, 1.72)

Samson, 2005 3.02 ( 1.65, 5.53)

Nohr, 2007 0.83 ( 0.21, 3.25)

Overall 1.32 ( 0.59, 2.95)

Risk ratio

.1 .2 .5 1 2 5 10

Raio, 1997 4.64 ( 1.20, 17.88)

Sadler, 2004 1.64 ( 1.13, 2.37)

Samson, 2004 3.84 ( 1.66, 8.88)

Nohr, 2007 2.46 ( 1.45, 4.16)

Overall 2.39 ( 1.55, 3.69)

Height >= 10mm

Risk ratio (95% CI)

Risk of preterm labourafter LLETZ Does size matter,

A retrospective study

Khalid S, Dimitriou E &Prendiville W

BSCCP (poster) 2009

Excision dimensions and preterm labourKhalid S, Dimitriou E & Prendiville W2009

1999 - 2002

Obstetric &Colpodatabases

353 pregnancies in women after LLETZ

Excision dimensions and preterm labourKhalid S, Dimitriou E & Prendiville W2009

Increased risk of

preterm labour if specimens larger than 6 cubic cms

RR 3.17, 95%CI 1.56 -6.38

Excision dimensions and preterm labourKhalid S, Dimitriou E & Prendiville W2009

Increased risk of

preterm labour if specimens thicker than 12 mms

RR 3.05, 95%CI 1.37 -7.08

2011 IFCPC colposcopic terminology of the cervix(draft – May 2011)

SCJ visualization: complete/partial/noneAdequate/inadequate for the reason … (i.e.: cervix obscured by inflammation, bleeding, scar)

Basic definitions

Deciduosis in pregnancy,Atrophic epithelium,Nabothian cyst,Gland (crypt)openings

Original squamous epithelium,Columnar epithelium

including ectopy,Transformation zone types 1,2,3

Normal colposcopic findings

Inside or outside the T-zone,Numberof cervical quadrantsthe l esioncovers ,Size of the lesion in percentage of cervix,Lugol’s staining (Schiller’s test): stained/non-stained

General principles

Abnormal colposcopic findings

Fine mosaic,Fine punctation

Fine aceto-white epitheliumGrade 1(Minor)

Rapid appearance of acetowhitening,

Cuffed gland (crypt)openings

Sharp border,Exophytic lesion,Inner border sign,Ridge sign

Dense aceto-white epithelium,Coarse mosaic,Coarse punctuation,Leukoplakia

Grade 2(Major)

Atypical vessels, fragile vessels, Irregular surface, Necrosis, Ulceration (necrotic), tumor/gross neoplasm

Suspicious for invasion

Stenosis,Congenital anomaly,

Post treatmentconsequence

Endometriosis,Condyloma,Polyp (Ectocervical/endocervical)

Erosion(traumatic)

Inflammation

Miscellaneous finding

Nomenclature committee 2011

Jim Bentley - Canada

Jacob Bornstein – Israel (Chairman of the Committee)

Peter Bosze – Hungary

Frank Girardi – Austria

Hope Haefner - USA

Michael Menton – Germany

MyriamPerrota – Argentina

Walter Prendiville – Ireland

Peter Russell - Australia

Mario Sideri – Italy

The new IFCPC nomenclature for cervix,

(vagina and vulva)WWW.IFCPC.ORG

Bornstein et al

Amer J Obstet Gynecol

Vol 120 No 1 July 2012

2011 committee considerations

Establish an evidence base

KeratosisvLeukoplakia

Inside/outside TZ

Size of lesion

Inner border and ridge signs

Treatment types

Abnormal vessel

Coarse punctation

Colposcopic features suggestive of

highgrade disease (major change)

A generally smooth surface with an sharp outer border.

Dense acetowhite change, that appears early and is slow to resolve; it may appear oyster white.

Iodine negativity, a yellow appearance in a previously densely white epithelium.

Coarse punctation and wide irregular mosaics of differing size.

Dense acetowhite change within columnar epithelium may indicate glandular disease.

New S C Junction

Columnar

Original

squamous epithelium

Crypt openings

Dr SC Quek

Polyps

Size of cervical lesions

Kierkegaard 1995: lesion size has independent predictive value

Ferris 2005: Size of cervical lesions correlates directly with the severity of disease.

Hopman et al. 1995 reported an inter-observer agreement rate of 68% when evaluating colposcopicphotographs for lesion size.

Hammes 2007: Lesions >50% of cervix had higher probability for high-grade lesion / carcinoma (OR, 3.45).

Prof Jacob Bornstein

New colposcopic sign- Ridge signAn opaque acetowhite ridge

at the squamocolumnar junction

Prof Jacob Bornstein

Scheungraber C, Koenig U, Fechtel B, Kuehne-Heid R, Duerst M, Schneider A. The colposcopic feature ridge sign is associated with the presence of cervical intraepithelial neoplasia 2/3 and human papillomavirus 16 in young women. J Low Genit Tract Dis. 2009;13(1):13-16.

A New Scoring System

Strander et al 2005

Designed to evaluate a scoring system for high grade lesions

297 examinations of women referred for colposcopy, Department of Obstetrics and Gynecology, Göteborg, Sweden

First Scoring system to incorporate lesion size as a variable

Subsequently validated at the Royal Free

Aceto-white

colour

Iodine stainingVascular Pattern

Peripheral Margins

0 1 2 Score

ACETO UPTAKE Zero or transparent Shady, Milky

(not transparent

not opaque)

Distinct, opaque

white

MARGINS/

SURFACE

Diffuse Sharp but

irregular, jagged,

“geographical”

Satellites

Sharp and even,

difference in

surface level incl

“cuffing”

VESSELS Fine, regular Absent Coarse or atypical

LESION SIZE <5mm 5-15mm or 2

quadrants

>15mm or 3-4

quadrants or

endocervically

undefined

IODINE STAINING Brown Faintly or patchy

yellow

Distinct yellow

Total score 10

The transformation zone

A Type 1 transformation zone is completely ectocervical and fully visible, and may be small or large

A Type 2 transformation zone has an endocervical component, is fully visible, and may have an ectocervical component that may be small or large

A Type 3 transformation zone has an endocervical component that is not fully visible and may have an ectocervical component that may be small or large

Type 1

• Completely ectocervical

• Fully visible

• small or large

Transformation Zone

Classification

SBX1739_3Histology CIN1

Cytology LSIL,CIN 1;Atyp

endocerv,

neopl

Carcinogenic

HPV

16, 58, 66

Age 28

Category Mario Walter

SCJ visibility Fully Visible Fully Visible

TZ type Type 1 - Small Type 1 - Small

TZ pattern Abnormal Grade 1 Abnormal Grade 2

Image quality Good Good

Jim Usha

Partially Visible Partially Visible

Type 2 - Large Type 1 - Large

Abnormal Grade 2 Normal

Good Limited

SBX1759_3Histology CIN3

Cytology LSIL,CIN 1;Atyp

endocerv,

neopl

Carcinogenic

HPV

16, 51

Age 25

Category Mario Walter

SCJ visibility Partially Visible Fully Visible

TZ type Type 2 - Small Type 1 - Small

TZ pattern Abnormal Grade 2 Abnormal Grade 1

Image quality Good Limited

Jim Usha

Fully Visible Fully Visible

Type 1 - Small Type 1 - Small

Abnormal Grade 1 Normal

Good Good

Type 2

• has endocervicalcomponent

• Fully visible

• may have ectocervial

component which may be small or large

Transformation Zone

Classification

SBX1842_1Histology CIN3

Cytology HSIL,CIN

3;Adeno, NOS

Carcinogenic

HPV

16, 18

Age 30

Category Mario Walter

SCJ visibility Partially Visible Partially Visible

TZ type Type 3 - Small Type 2 - Small

TZ pattern Abnormal Grade 2 Suspicious for invasion

Image quality Limited Limited

Jim Usha

Fully Visible Fully Visible

Type 2 - Small Type 1 - Small

Abnormal Grade 2 Abnormal Grade 2

Good Limited

Transformation Zone

Classification

Type 3

• has endocervicalcomponent

• is not fully visible

• may have ectocervial

component which may be small or large

SBX1216_2Histology CIN3

Cytology HSIL,CIN 2;Adeno in situ (AIS)

Carcinogenic HPV 31

Age 21

Category Mario Walter

SCJ visibility Not Visible Partially Visible

TZ type Type 3 - Small Type 2 - Small

TZ pattern Abnormal Grade 1 Abnormal Grade 2

Image quality Good Good

Jim Usha

Not Visible Fully Visible

Type 3 - Small Type 1 - Large

Abnormal Grade 2 Abnormal Grade 1

Good Good

SBX1774_1Histology CIN3

Cytology HSIL,CIN

3;Adeno, NOS

Carcinogenic

HPV

16

Age 47

Category Mario Walter

SCJ visibility Not Visible Partially Visible

TZ type Type 3 - Small Type 2 - Small

TZ pattern Abnormal Grade 2 Suspicious for invasion

Image quality Good Good

Jim Usha

Not Visible Not Visible

Type 3 - Small Type 3 - Large

Suspicious for invasion Suspicious for invasion

Good Good

SBX1928_1Histology CIN3

Cytology HSIL,CIN

3;Adeno, NOS

Carcinogenic

HPV

16, 39

Age 30

Category Mario Walter

SCJ visibility Not Visible Not Visible

TZ type Type 3 - Small Type 3 - Small

TZ pattern Abnormal Grade 2 Abnormal Grade 2

Image quality Good Good

Jim Usha

Partially Visible Fully Visible

Type 3 - Small Type 1 - Small

Abnormal Grade 1 Abnormal Grade 1

Good Good

The BSCCP invites

you to the

15th World

Congress

On behalf of

IFCPC

In London

26-30th May 2014

www.IFCPC2014.

com

www.IFCPC2014.com

Bemvindo a Londres al 26de30 de Mayo 2014

Queen Elizabeth II conference centre

Westminster Hall for the plenary sessions

Up to 2160 delegates2070 m2 exhibition space

¡NosvemosemLondres ! 2014

St James’s Park – 5 minutes walk from venue

Shopping...................

Covent Garden, London

National Institute of Medical Research- The biology of HPV and molecular markers

Wolfson Institute of Preventive of Medicine- Screening across the world

St Thomas’s Hospital – Improving Cytology

Institute of Women’s Health

Imperial College

Post Congress Seminars

See you in London