Becoming a colposcopist: Colposcope case studies

Seon-Kyung Lee, M.D.

Department of Obstetrics and Gynecology College of Medicine, Kyung Hee

University

Value of Colposcopy

• Cytology is an effective screening method, and

colposcopy with directed biopsy is the critical

diagnostic step for women with cervical cytologic

abnormalities

• Decrease diagnostic conization and hysterectomy.

• Limitation;

It takes some time and experience to properly

analyze what you see.

Role of colposcopist

1. Colposcopist must be able to locate the disease.

2. Colposcopically assess the severity of lesions.

3. Determine the most severe lesion to biopsy.

4. Correlate the colposcopic impression with the cytologic and histologic findings.

5. Then the colposcopist determines the appropriate management or treatment.

Practical knowledge

• Precisely localise TZ,

• Recognize normal and

abnormal TZ,

• TZ with gland opening, sq.met

aplasia, columnar epithelium

• Clinical skills – Punch biopsy,

LLETZ

Colposcopy: Work-up

• Explain to the patient.

• Inspect the vagina and cervix and apply 3-5% acetic acid.

• Position the colposcope and focus on the cervix with the desired magnification (7X-15X).

• Drawings the lesion topography and lesion grade(s)

• Biopsy samples should be obtained from all abnormal lesions.

• A cytobrush or ECC may be used to evaluate the endocervical pathology.

• Hemostatic agent can be applied to each biopsy site.

• Results should be reviewed to confirm.

Diagnostic accuracy of colposcopy

• Calculated based on the agreement of the

colposcopic impression with the histologic

interpretation within one histologic grade.

• Limitations;

Colposcopy is highly sensitive in well-trained hands,

but has low specificity, and, thus, is not a good

screening tool.

Colposcopical scoring system

• Colposcopy is a subjective diagnostic method with high sensitivity and low specificity.

• Because of low specificity, the scoring system for colposcopic findings is important when deciding on the necessity of cervical biopsy, and it contributes to the decreasing of unnecessary biopsy.

Colposcopic accuracy

• The colposcopic accuracy index threshold of 80%

appears to be a reasonable proficiency level and a

useful goal for training programs.

• The colposcopist may overestimate minor benign

cervical epithelial and vascular alterations that

mimic low-grade premalignant disease features. The

error is common when the colposcopist has

knowledge of a preexisting minor cytologic smear

abnormality.

Colpo. Appearance of Benign Lesions

• Keratosis, Erosions and Ulcers, Cervicitis, Atrophy, Nabothian cysts, Ectopy, Deciduosis, Endometriosis, Endocervical polyps.

• The difficulty lies in learning to distinguish low-grade lesions from immature metaplasia which also exhibits aceto-whitening and fine vascular patterns.

• Due to the variability of the colposcopic appearance of low-grade lesions, the accuracy and reproducibility of diagnosis is less than that of higher grade lesions.

Colpo. Appearance of Benign Lesions

nabothian cyst cervical polyp

Colpo. Appearance of Benign Lesions

immature squamous metaplasia(pinkish white hue)

crypt opening

Colpo. Appearance of Benign Lesions

immature squamous metaplasia

mild acetowhite lesion with fine mosaic and irregular margin

Colpo. Appearance of LSIL

• Flat with a smooth surface, except condylomas.

• Leukoplakia

; benign hyperkeratosis or low-grade HPV lesions.

• Variable aceto-whitening; faint

• Irregular, “feathered” or “geographic” outer borders.

• Partial iodine uptake

• Either featureless or have fine mosaicism or

punctation.

Colpo. appearance of Low Grade Lesion

mildly dense acetowhite lesion

irregular geographical margin

Colpo. appearance of HPV infection

• Condylomas may arise within TZ or as skip lesions

within the mature squamous epithelium.

• The papillary spike-like projections of acuminate

warts and the regular projections(asperites) on

surface of flat condylomas with colposcopic

magnification.

• It also may be a bright aceto-white, which is

characteristic of condyloma.

Colpo. appearance of HPV infection

The bright aceto-white and the asperites on the surface

Colpo. appearance of HSIL

• Sharply demarcated lesion edges

• “lesion within a lesion” or “border within a border”

• More prompt and persistent aceto-white change

• Absence of vessels due to increased lesion density

• “Coarse” vascular patterns (punctation, mosaicism,

or both) ,“Umbilicated” mosaic patterns suggests

CIN 3 / carcinoma-in-situ.

Colpo. appearance of HSIL

dense acetowhite lesion with sharp demarcated margins

internal borders within lesion

Colpo. appearance of HSIL

dense acetowhite lesion with

rolled out margins

coarse punctation and mosaic

with umbilication

HSIL site and Topography

• The most severe disease is found at the most

proximal (cephalad) extent of lesion.

• Size of lesions variable but tends to correlate with

severity of disease and risk of occult invasion

• Size of lesion correlates with risk of treatment failure

Colpo. Findings of Adenocarcinoma in Situ

• The colposcopic findings are often subtle and nonspecific.

The two primary findings are

(1) a wide area of eversion and

(2) ginger root–like vessels.

• Approximately 40% of adenocarcinoma in situ (ACIS) will have an associated SIL.

• ASCCP guidelines for AGC require colposcopic evaluation and directed biopsies, ECC and D&C for women over 35 years of age.

Colpo. Findings of Adenocarcinoma in Situ

Pap; ASC-H, HPV(HC); -

Biopsy: AIS endocervix

CIS exocervix

Pap ; HSIL, HPV; 18+

Biopsy; adenocarcinoma,

eversion and root–like vessels.

Colpo. appearance of Invasive cancer

The surface is irregular but the borders tend to be sharply defined.

In some cases, subtle ulceration can be the only feature present.

ulcerative lesion; 12-3 ‘oclockexophytic mass

Vaginal colposcopy

• Indicated when cytology suggests disease in:

1) patients with a normal cervix

2) in patients in whom the cervix is absent

• The entire surface area of the vagina is examined, including

that behind the blades of the speculum.

• In post hysterectomy patients, the lateral invagination of the

vaginal vault must be carefully evaluated.

• Areas of VaIN are typically discrete with slightly elevated

borders and are pinkish or white in color.

Colpo. appearance of VaIN

Pap; HSIL post-TAH state, Pap; mod.dysplasia

Colposcopy in pregnant women

• Cervix must be handled atraumatically in order to

avoid bleeding of the congested, hyperaemic tissues.

• The degree of acetowhitening and the confusing

angioarchitecture, with coarse punctation and

mosaicism, may give the impression that the lesion

is severer than it is.

Colposcopy During Pregnancy

progressive eversion of the scj onto the

ectocervix makes colposcopy

satisfactory more often.

Increased vascularity produces a

cyanotic, bluish hue.

CASE STUDY

23 year old

Pap ; benign cellular

change

Colpo.index; 0-2, SPI

Bx ; 10 o’clock, chonic

cervicitis

HPV(HC); negative

CASE STUDY

53 year old

Pap ; LSIL

Colpo.index; 3-5, r/o HSIL

Bx ; 10 o'clock

CIS

HPV(HC); positive

CASE STUDY

38 year old

Pap ; AGUS

Colpo.index; 0-2, r/o

endocervical lesion

Bx ; 5 o'clock

cervicitis

HPV(HC); negative

Dx Tx conization

CASE STUDIES from ASCCP

CASE STUDY from ASCCP

A 25-year-old G2 P1011, her first Pap test showed ASC-US. She was then lost to follow-up until this current examination.

Question

The cytology shows:

a. negative for intraepithelial lesion or malignancy.

b. ASC-US.

c. LSIL

d. HSIL

CASE STUDY from ASCCP

A 25-year-old G2 P1011, her first Pap test showed ASC-US. She was then lost to follow-up until this current examination.

Question

The cytology shows:

a. negative for intraepithelial lesion or malignancy.

b. ASC-US.

c. LSIL

d. HSIL

The patient was evaluated with colposcopy.

Question 1

Colposcopic findings include:

a. atypical vessels, corkscrew vessels.

b. coarse mosaic pattern with

punctation and sharp borders.

c. microglandular hyperplasia.

d. cervical ectopy.

e. condyloma.

Question 2

The most likely colposcopic

impression is:

a. metaplasia, cervicitis.

b. CIN 1.

c. CIN 3.

d. microinvasive cancer.

Question 1

Colposcopic findings include:

a. atypical vessels, corkscrew vessels.

b. coarse mosaic pattern with

punctation and sharp borders.

c. microglandular hyperplasia.

d. cervical ectopy.

e. condyloma.

Question 2

The most likely colposcopic

impression is:

a. metaplasia, cervicitis.

b. CIN 1.

c. CIN 3.

d. microinvasive cancer.

The patient was evaluated with colposcopy.

CASE STUDY from ASCCP

A 26 year-old woman, G4 P2012, was seen for her first

prenatal visit at 9 weeks gestation. A Pap test at that

time was read as HSIL. Her previous Pap test results,

performed 3 years ago, was read as normal.

Question

The next step in the management of this patient is:

a. To repeat Pap test in 3 months.

b. reflex testing for high-risk human papillomavirus.

c. immediate colposcopy.

d. colposcopy post partum.

A 26 year-old woman, G4 P2012, was seen for her first

prenatal visit at 9 weeks gestation. A Pap test at that

time was read as HSIL. Her previous Pap test results,

performed 3 years ago, was read as normal.

Question

The next step in the management of this patient is:

a. To repeat Pap test in 3 months.

b. reflex testing for high-risk human papillomavirus.

c. immediate colposcopy.

d. colposcopy post partum.

CASE STUDY from ASCCP

The patient underwent a colposcopy at 13 weeks' gestation.

Question 1

What colposcopic features are

present in Figures?

a. fine punctation.

b. coarse mosaic pattern with

punctation.

c. leukoplakia.

d. atypical blood vessels.

Question 2

The colposcopic impression is:

a. CIN 1.

b. CIN 2.

c. CIN 3.

d. microinvasive cancer.

e. Either (b) or (c).

Question 1

What colposcopic features are

present in Figures?

a. fine punctation.

b. coarse mosaic pattern with

punctation.

c. leukoplakia.

d. atypical blood vessels.

Question 2

The colposcopic impression is:

a. CIN 1.

b. CIN 2.

c. CIN 3.

d. microinvasive cancer.

e. Either (b) or (c).

The patient underwent a colposcopy at 13 weeks' gestation.

The patient was seen again at 28 weeks with no change in the colposcopic impression.

She delivered at term and was seen back

in the clinic at 6 weeks postdelivery. At

that time, a Pap test and colposcopy

were done.

Question

The colposcopic impression is:

a. CIN 1.

b. CIN 2.

c. CIN 3.

d. normal.

She delivered at term and was seen back

in the clinic at 6 weeks postdelivery. At

that time, a Pap test and colposcopy

were done.

Question

The colposcopic impression is:

a. CIN 1.

b. CIN 2.

c. CIN 3.

d. normal.

The patient was seen again at 28 weeks with no change in the colposcopic impression.

CASE STUDY from ASCCP

A 26 year old G1 P1001 presented for evaluation of a LSIL

Pap test. In this clinic, women found to have ASCUS x 2

or LSIL Paps were invited to enroll in an IRB approved

study conducted through the local University.

Women with biopsy-proven CIN1 or less were followed with

surveillance Paps and Cervicography™ every 4-6 months

and annual colposcopy. In this case, HPV DNA is positive

for High Risk (HR) types.

The cervigram and findings of her repeat cytology

Question 1Her initial cervigram was interpreted as:

a. negative; normal cervix; squamous metaplasia

b. positive; compatible with low grade lesion

c. positive; probable normal variant

d. positive; compatible with high grade lesion

Question 2The cytology shows:

a. negative for intraepithelial lesion or

malignancy

b. atypical squamous cells of undetermined

significance

c. LSIL; parakeratosis

d. high grade squamous intraepithelial lesion

Question 1Her initial cervigram was interpreted as:

a. negative; normal cervix; squamous metaplasia

b. positive; compatible with low grade lesion

c. positive; probable normal variant

d. positive; compatible with high grade lesion

Question 2The cytology shows:

a. negative for intraepithelial lesion or

malignancy

b. atypical squamous cells of undetermined

significance

c. LSIL; parakeratosis

d. high grade squamous intraepithelial lesion

The cervigram and findings of her repeat cytology

14 months after initial enrollment, the image of her cervix is shown (Figure ). HPV DNA is positive for HR types.

Question 1

Colposcopic findings seen include:

a. atypical vessels, corkscrew vessels,

condyloma

b. dense acetowhite epithelium; absent

vessels; straight border

c. mosaic

d. cervical ectopy

Question 2

The next step in her management would be:

a. re-appoint for study follow-up in 4-6 months

b. repeat colposcopy and biopsy

c. LLETZ

c. cryosurgery

14 months after initial enrollment, the image of her cervix is shown (Figure ). HPV DNA is positive for HR types.

Question 1

Colposcopic findings seen include:

a. atypical vessels, corkscrew vessels,

condyloma

b. dense acetowhite epithelium; absent

vessels; straight border

c. mosaic

d. cervical ectopy

Question 2

The next step in her management would be:

a. re-appoint for study follow-up in 4-6 months

b. repeat colposcopy and biopsy

c. LLETZ

c. cryosurgery

CASE STUDY from ASCCP

20 year old Female G0 with a history of LSIL presented to another colposcopist.

Question

This colposcopic image is most consistent with:

a. satisfactory colposcopy, three low-grade acetowhite lesions seen.

b. unsatisfactory colposcopy, no evidence of any abnormalities.

c. unsatisfactory colposcopy, endocervical lesion seen.

d. satisfactory colposcopy, one abnormal lesion seen at 5- to 7-o'clock.

e. None of the above.

CASE STUDY from ASCCP

20 year old Female G0 with a history of LSIL presented to another colposcopist.

Question

This colposcopic image is most consistent with:

a. satisfactory colposcopy, three low-grade acetowhite lesions seen.

b. unsatisfactory colposcopy, no evidence of any abnormalities.

c. unsatisfactory colposcopy, endocervical lesion seen.

d. satisfactory colposcopy, one abnormal lesion seen at 5- to 7-o'clock.

e. None of the above.

Question 1

During colposcopy, the preferred course of action would be:

a. no biopsies necessary.

b. to biopsy the lesion at 5- to 7-o'clock position.

c. to perform ECC only.

d. to perform multiple biopsies of lesions noted that appear abnormal.

e. immediate LEEP at the time of colposcopy.

Question 2

The preferred course of management would be:

a. LEEP

b. cryotherapy.

c. return colposcopy evaluation within 6 months.

d. vaginal antibiotic therapy,

e. conization with ECC

Question 1

During colposcopy, the preferred course of action would be:

a. no biopsies necessary.

b. to biopsy the lesion at 5- to 7-o'clock position.

c. to perform ECC only.

d. to perform multiple biopsies of lesions noted that appear abnormal.

e. immediate LEEP at the time of colposcopy.

Question 2

The preferred course of management would be:

a. LEEP

b. cryotherapy.

c. return colposcopy evaluation within 6 months.

d. vaginal antibiotic therapy,

e. conization with ECC

CASE STUDY from ASCCP

A 19-year-old, G0, presents for evaluation after a Pap test

showing a LSIL. This was her first abnormal Pap test

and her previous Pap test 1 year earlier was normal. Her

coitarche at age 16 years, and 12 total lifetime sexual

partners.

The patient returned 1 year later for a repeat Pap test. This

time the Pap was reported as HSIL.

The patient underwent a colposcopic examination with a biopsy.

Question 1

The colposcopic appearance of the cervix was

most consistent with:

a. squamous metaplasia

b. CIN 1

c. CIN 2,3

d. adenocarcinoma in situ (AIS)

e. squamous carcinoma

Question 2

The histological diagnosis is consistent with:

a. squamous metaplasia

b. mild dysplasia (CIN 1)

c. moderate dysplasia (CIN 2)

d. severe dysplasia (CIN 3)

e. squamous carcinoma

Question 1

The colposcopic appearance of the cervix was

most consistent with:

a. squamous metaplasia

b. CIN 1

c. CIN 2,3

d. adenocarcinoma in situ (AIS)

e. squamous carcinoma

Question 2

The histological diagnosis is consistent with:

a. squamous metaplasia

b. mild dysplasia (CIN 1)

c. moderate dysplasia (CIN 2)

d. severe dysplasia (CIN 3)

e. squamous carcinoma

The patient underwent a colposcopic examination with a biopsy.

CASE STUDY from ASCCP

A 27-year-old, G5 P3013, presents to the clinic for prenatal care at 20 weeks.

The patient has a history of abnormal Pap tests dating back 7 years. Colposcopic exams and biopsies have shown low-grade squamous intraepithelial lesion (LSIL). Her last Pap test 2 years ago was normal.

The patient’s current Pap test was read as HSIL.

Question 1

The findings on colposcopy are consistent with:

a. CIN 1

b. CIN 2,3

c. invasive cancer

d. metaplasia

Question 2

The next step in the management of this patient is:

a. repeat cytology and colposcopy in 8 weeks

b.repeat cytology and colposcopy in 12 Weeks

c. cold-knife conization

d. repeat cytology and colposcopy 6 weeks postpartum

e. either (b) or (d)

Question 1

The findings on colposcopy are consistent with:

a. CIN 1

b. CIN 2,3

c. invasive cancer

d. metaplasia

Question 2

The next step in the management of this patient is:

a. repeat cytology and colposcopy in 8 weeks

b. repeat cytology and colposcopy in 12 weeks

c. cold-knife conization

d. repeat cytology and colposcopy 6 weeks postpartum

e. either (b) or (d)

CASE STUDY from ASCCP

A 22-year-old presents with HPV positive ASC-US

Papanicoloau smear. She has no previous history of

abnormal Pap smears and has been screened in the

past. She does not smoke.

Question

Appropriate management options for this patient include:

a. repeat HPV testing in 12 months

b. Pap at 6 and 12 months

c. colposcopy

d. HPV DNA specific typing

CASE STUDY from ASCCP

A 22-year-old presents with HPV positive ASC-US

Papanicoloau smear. She has no previous history of

abnormal Pap smears and has been screened in the

past. She does not smoke.

Question

Appropriate management options for this patient include:

a. repeat HPV testing in 12 months

b. Pap at 6 and 12 months

c. colposcopy

d. HPV DNA specific typing

Consensus guidelines for the management of women with abnormal cervical cancer screening tests

ASC-H, LGSIL, HGSIL, squamous cell cancer:

colposcopic evaluation and biopsy of abnormal sites is

recommended.

• ASC-US:

Repeat cytologic evaluation at 6 and 12 months

“Reflex” testing for the presence of high-risk HPV serotypes.

If either of these strategies results in abnormal findings,

colposcopy is indicated.

• AGC:

colposcopic, endocervical and endometrial evaluation, and sampling in addition to HPV testing.

• AIS, adenocarcinoma: excisional procedures

Question 1

The best answer which fits this colposcopic

picture is:

a. satisfactory colposcopy with high grade lesion

b. unsatisfactory colposcopy with no lesion seen

c. satisfactory colposcopy no lesion seen

d. satisfactory colposcopy with low grade lesion

seen

Question 2

Which management option is NOT appropriate

in this patient:

a. ECC

b. repeat Pap and HPV in 6-12 months

c. HPV DNA testing for high risk virus at 12

months

d. loop excision

Question 1

The best answer which fits this colposcopic

picture is:

a. satisfactory colposcopy with high grade lesion

b. unsatisfactory colposcopy with no lesion seen

c. satisfactory colposcopy no lesion seen

d. satisfactory colposcopy with low grade lesion

seen

Question 2

Which management option is NOT appropriate

in this patient:

a. ECC

b. repeat Pap and HPV in 6-12 months

c. HPV DNA testing for high risk virus at 12

months

d. loop excision

Thank you !

이선경

• 연자약력;경희대학교 의과대학 의학과 졸업 1979.2

미국 Vanderbilt university medical center special fellowships in gynecologic oncology 1991.11 --- 1992 10

경희대학교 동서신의학병원 산부인과과장경희대학교 의과대학 산부인과 주임교수

• 학회활동: 대한부인종양-콜포스코피학회; 이사, 학술위원회 위원대한부인종양연구회 연구위원회 위원대한 산부인과학회; 이사, 학술위원회 위원, 논문심사위원

한국 자궁경부확대촬영 연구회 판독위원, 회장미국 질확대경-자궁경부병리학회 정회원세계 부인암학회 정회원