Topic review :

Essential Colposcopic Knowledge

Nitisa Tapanwong, MD
Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
 Indications
Contents
Technique

Abnormal findings

Interpretation and report

Expedited treatment

New technologies in colposcopy

 1
Indications
HPV and Oncogenesis

H Stark, HPV Vaccination: Prevention of Cervical Cancer in Serbia and in Europe, Acta Facultatis Medicae Naissensis, March 2018
HPV and Oncogenesis

K Hoppe-Seyler, The HPV E6/E7 Oncogenes:Key factors for viral carcinogenesis and therapeutic targets, Trends in microbiology, vol26, Feb,2018
Cervical cancer screening : Cytology

Normal cytology Atypical cells of undetermined

significance(ASC-US)

Squamous cell carcinoma

Low grade squamous High grade squamous

intraepithelial lesion (LSIL) intraepithelial lesion (HSIL)
ASCCP 2019
HPV 16 positive HSIL Immediate CIN3+ risk =60 %
HPV positive HSIL Immediate CIN3+ risk = 49-64%

HPV negative HSIL Immediate CIN3+ risk =25 %

HPV positive ASC-H Immediate CIN3+ risk =26 %
HPV positive AGC Immediate CIN3+ risk =26 %

HPV positive LSIL Immediate CIN3+ risk =4.3%

HPV positive ASC-US Immediate CIN3+ risk =4.5%

HPV positive NILM occurring at 2 Immediate CIN3+ risk =4 %

consecutive annual visits
HPV16 positive NILM Immediate CIN3+ risk =4.3%

HPV18 positive NILM Immediate CIN3+ risk =3 %

 2
Colposcopic
Technique
Equipment : Colposcope

The focal length of colposcope = 30 cm

Atlas of colposcopy; Principles and practice, WHO

Equipment

• 3-5% acetic acid

• Diluted Lugol’s iodine solution
• Monsel’s solution
(ferric subsulfate)
Technique
 Acetic acid

• Hyperosmotic environment that causes

transient contraction of the cytoplasm
• Higher nucleoprotein than normal cells
• Opaque and white
• Appearance within 10-30 sec
• The effect disappears after 30-60 sec
Lugol’s iodine solution
• Stains glycogen brown
• The intensity is proportional to the
quantity of glycogen
• Disappear after 10-15 minutes
• No effect on the glandular mucosa
which contains no glycogen

Lugol’s negative = Schiller’s test positive

 Acetic acid Vs Lugol’s solution
Huchko MJ,2015 :Randomized trial compared VIA vs VILI in HIV

• No significant difference in the diagnostic performance of VIA and VILI for the detection of CIN2+.
• Test positive rate 26.2% for VIA vs 30.6% for VILI (p = 0.22)
• The rate of detection of CIN2+ was 7.7% in the VIA arm and 11.5% in the VILI arm (p = 0.10).

Huchko MJ, and et al. A randomized trial comparing the diagnostic accuracy of VIA to VILI for cervical cancer screening in
HIV-infected women. PLoS One. 2015 Apr
Green filter
Enhances visualization of blood vessels
Complications

• Rarely
• Complications from biopsies
• Heavy bleeding
• Infection
• Pelvic pain
 Patient Information

Pre- During procedure Post-

- Avoid scheduling during period If biopsy May experience

- No SI 1-2 days
- No tampons usage 1-2 days
- No vaginal medications for 2
days before
- Mild discomfort - Vaginal pain 1-2 days
- If vaginal or vulva can - Light bleeding from vagina
cause pain a few days
- A dark discharge from vagina
Advice No SI 2 weeks
 Colposcopy in pregnancy
Management using the same Clinical Action Threshold

Low grade High grade Suspected

(CIN 2/3) invasive

f/u 6 week Cervical

postpartum conization

Colposcopy every Deferring Unacceptable :

12-24 weeks colposcopy to ECC, EB,
(Preferred) postpartum Expedited treatment
(Acceptable)
2019 ASCCP Risk-based Management Consensus Guidelines
 Sensitivity & Specificity
• Depend on the skill and experience of the colposcopist
• A moderate correlation between colposcopic evaluation and
histological diagnosis
• The number of biopsies taken can influence the sensitivity
of colposcopy.
Learning curve of colposcopic training

• Y. Kongthip,2019 :
• Gynecologic oncology fellows at KCMH
• The learning curve showed a plateau after 50 cases at
around 70% accuracy rate
• Overall accuracy rate of fellows after completion of training
was comparable to the attending staff

Y. Khongthip, T. Manchana, S. Oranratanaphan, R. Lertkhachonsuke. Learning curve in colposcopic

training among gynecologic oncology fellows. European Journal of Gynaecological Oncology, 2019
Cervical biopsy
 Number of cervical biopsy

• Colposcopy with guided biopsy detects approximately two thirds

of CIN 3+.
• The sensitivity of the procedure does not differ significantly by
type of medical training
• The sensitivity was significantly greater when biopsy ≥ 2 (P<.01)

GageJC, the ALTS Group. Number of cervical biopsies and sensitivity of colposcopy. Obstet Gynecol,2006
 Random cervical biopsy
• Pretorius RG,2004 :
• If cytology is high grade, random biopsies should be considered.
• The diagnosis of ≥ CIN II
• Colposcopically directed biopsy in 57.1%
• Random biopsy in 37.4%
• ECC in 5.5% of women.
• The yield of ≥ CIN II for random biopsy when cytology was high grade (17.6%)
exceeded that when cytology was low grade (2.8%).

PretoriusRG, et al. Colposcopically directed biopsy, random cervical biopsy, and endocervical curettage
in the diagnosis of cervical intraepithelial neoplasia II or worse. Am J Obstet Gynecol2004
 Random cervical biopsy
• NamK,2010 :
• The detection of CIN 2+ can be increased by additional random
biopsies after satisfactory colposcopy.
• 12.7% were diagnosed using random biopsies
• correlated with high-grade cytology and lesion size (p <.001)
• LEEP can detect lesions not detected by punch biopsy.
• 15.3% cases was upgraded 1 or more grades

NamK, ChungS, et al. Random biopsy after colposcopy-directed biopsy improves the diagnosis of cervical
intraepithelial neoplasia grade 2 or worse. J Low Genit Tract Dis2010
 Cervical biopsy
• Phainpiset R, 2020 : Thai women
• No biopsy in the lowest-risk group
• Multiple targeted biopsies in the intermediate-risk and highest-risk
groups
• CIN 2+ pathology 11.2% in the intermediate-risk
• CIN 2+ pathology 61.9% in highest-risk
• High grade colposcopic impression was the strongest independent predictor

Lowest-risk (all) Highest-risk (2/3)

• ASC-US or LSIL • HSIL
• Negative HPV16/18 • HPV16/18
• Normal colposcopic impression • High-grade colposcopic impression
Phianpiset R,et al. ASCCP Risk-Based Colposcopy Recommendations Applied in Thai Women With ASC-US
or LSIL Cytology. Obstet Gynecol. 2020 Sep
 ASCCP 2019 : Cervical biopsy

• Biopsies all discrete acetowhite areas, usually 2-4 biopsies

• Not recommended random biopsies in lowest risk
• Less than HSIL
• No HPV 16/18
• Completely normal colposcopic impression
Endocervical sampling
 Endocervical sampling

• To the diagnosis of 5-15% of patients with lesions ≥ HSIL/CIN 2

• Should be performed when the colposcopic lesion shows an
endocervical component
• Endocervical brushing Vs endocervical curettage
• High sensitivity in ECB
• High specificity in ECC

AEPCC 2018, Colposcopy guidelines standards of quality

 Endocervical brushing Vs Curettage
• Maksem JA, 2006 :
• ECB may be superior to ECC
• Fewer proportion of positive outcomes CIN 2+ with biopsy
and ECC than with biopsy and ECB
• 9.2% vs. 16.8% for LSIL
• 63.7% vs. 72.2% for HSIL
• More negative outcomes in ECC than ECB
• 11.3% vs. 8.1% for LSIL
• 4.7% vs. 1.4% for HSIL

Maksem JA. Endocervical curetting vs. endocervical brushing as case finding methods.
Diagn Cytopathol. 2006 May;34(5):313-6.
Endocervical brushing Vs Curettage
• Goksedef BP,2013 (RCT)
• ECB was proved to be as accurate with
respect to diagnostic yield as ECC but
less painful
• ECB had a statistically significantly
higher percentage of specimens with
no stroma (44 %) than ECC group (24 %)
(p = 0.003)

Goksedef BP, et al. Diagnostic accuracy of two endocervical sampling method: RCT. Arch Gynecol Obstet. 2013 Jan
 3
Abnormal findings
Transformation zone
Normal colposcopic exam
Abnormal findings
Acetowhite changes

Margins/border

Punctation

Mosaic

Suspicious for invasive cancer

Leukoplakia
Thin acetowhite lesion
Dense acetowhite lesion
Inner border sign
Ridge sign
Cuffed gland opening
Punctation
Punctation
Fine vs Coarse Punctation
Mosaic
Mosaic
Fine vs Coarse Mosaic
 Suspicious for invasive cancer

• Large, complex acetowhite lesions obliterating the os

• Irregular and exophytic contour
• Raised and rolled out margins
• Peeled-off epithelium and contact bleeding
• Atypical blood vessels
Atypical vascular pattern
Atypical vascular pattern
• Characteristic of invasive cervical cancer and include
looped vessels, branching vessels, and reticular vessels
Atypical vascular pattern

Berek & Hacker’s gynecologic oncology, 6th ed.

Rag sign: Peeled off
 Glandular lesions

• White color of villous structures after application of acetic acid

• Patchy red and white areas in ectropion
• Single, isolated, densely acetowhite and elevated lesion
• Large and irregular gland openings -> cuffed gland openings
• Atypical vessels : Root-like and hairpin vessels
• Copious mucus production
• Hemorrhage and necrosis on surface
• Barrel shape cervix
Milky white abnormal papillae
Atypical vessels Barrel shape cervix

Patchy red and white lesions

Photo: 1.),3) Richard Lieberman,MD
2) Apgar, Brotzman, Spitzer.
 4
Interpretation
&
Report
IFCPC 2011 Nomenclature
• General assessment
• Adequate/Inadequate
• Transformation zone type 1,2,3
• Normal colposcopic finding
• Original squamous epithelium : mature, atrophic
• Columnar epithelium : ectopy
• Metaplastic squamous epithelium : Nabothian cyst , crypt openings
• Deciduosis in pregnancy
• Abnormal colposcopic finding
• Suspicious invasion
Abnormal General Principles Location of the lesion :Inside or outside the T-zone, Location of
Colposcopic the lesion by clock position
findings Size of the lesion : number of cervical quadrants the lesion
covers, size of the lesion in percentage of cervix
Grade 1 (Minor) Thin aceto-white epithelium Fine mosaic,
Irregular, geographic border Fine punctuation
Grade 2 (Major) Dense aceto-white epithelium , Coarse mosaic,
Rapid appearance of Coarse punctation
acetowhitening, Sharp border,
Cuffed crypt (gland) opening Inner border sign,
Ridge sign
Non specific Leukoplakia(keratosis hyperkeratosis), Erosion
Lugol’s staining (Schiller’s test) : stained/non-stained
Suspicious for Atypical vessels
invasion Additional signs : Fragile vessels, Irregular surface, Exophytic lesion, Necrosis,
Ulceration(necrosis), Tumor/gross neoplasm
Miscellaneous findings Congenital transformation zone, Stenosis,
Condyloma, Congenital anomaly,
Polyp Post treatment consequence,
(Ectocervical/endocervical) Endomethtfioma
Inflammation
ASCCP 2017 :
Colposcopic terminology
• General assessment : Fully visualized /Not fully
• Acetowhite changes
• Normal colposcopic findings
• Abnormal colposcopic findings
• Miscellaneous findings
• Polyp, inflammation, stenosis, posttreatment consequence
• Colposcopic impression :
• Normal/Low grade/High grade/Cancer
 Abnormal Details
Features/Criteria
Lesion Yes/No
Location of each Clock position
lesion At the SCJ(yes/no)
Lesion visualized (fully/not fully)
Satellite lesion
Size of each lesion Quadrants, percentage of surface
Low-grade
High-grade
Suspicious for Atypical vessels, Irregular surface, Exophytic
invasive Necrosis, Ulceration, Tumor or gross neoplasm
Nonspecific Leukoplakia, Erosion, Contact bleeding, Friable
Lugol staining Not used/stained/partially/nonstained
 Key differences:
ASCCP 2017 vs IFCPC 2011
General assessment : Cervix
General assessment : SCJ
General assessment : TZ
Abnormal findings
Excision type
ASCCP IFCPC
Fully/not fully visible Adequate/inadequate
Fully/not fully visible Completely/partially/not
visible
Not used TZ type 1,2,3
Low-grade features Grade 1 (minor)
High-grade features Grade 2 (major)
Not used Excision type 1,2,3
Colposcopic index
 Reid’s colposcopic index
Colposcopy sign Score 0 Score 1 Score 2
Margin -Condylomatous or Regular lesion with Rolled, peeling edges, sharp
micropapillary contour smooth indistinct margins
-Flocculated or feathered, borders
jagged, satellite lesion
-Acetowhite beyond SCJ
Color Shiny, snow white, faint Intermediate shade Dull, oyster grey
whitening (shiny but grey white)
Vessels Uniform, fine punctuation Absence of surface Definite, coarse punctuation or
or mosaic vessels mosaic individual vessels dilated
Iodine staining Any lesion staining Partial iodine uptake Mustard yellow staining
Mahagany brown (mottled pattern)
Score Colposcopic findings
0-2 Likely to be CIN 1
3-5 Likely to be CIN 1-2
6-8 Likely to be CIN 2-3
 Swede score
Colposcopy sign Score 0 Score 1 Score 2
Aceto uptake Zero or transparent Shady, milky Distinct, opaque white
(not opaque)
Margin/Surface Diffuse Sharp but irregular, Sharp and even, difference
jagged, geographical in surface level, cuffing
satellites
Vessels Fine, regular Absent Coarse or atypical
Lesion size < 5 mm 5-15 mm or 2 quadrants >15 mm or 3-4 quadrants/
endocervically undefined
Iodine staining Brown Faintly or patchy yellow Distinct yellow

Score Colposcopic findings

0-4 Low grade/normal
CIN 1
5-6 High grade/non invasive cancer
CIN2+
7-10 High grade/suspected invasive cancer
CIN2+
 Swede vs Reid’s score
• Ranga R ,2017
• The correlation coefficient (R2) between RCI and Swede score was 0.919
• Swede score can be used flexibly depending on the setting
• Threshold 5 with high sensitivity for screening
• Threshold 8 with high specificity for screen and treat selection
• Swede score is an option for cancer prevention programs in low-
resource settings

Ranga R,A Comparison of the Strength of Association of Reid Colposcopic Index and Swede Score With
Cervical Histology. J Low Genit Tract Dis. 2017 Jan;21(1):55-58.
Swede vs Reid’s score

• There was a good association between RCI and Swede score with
the correlation coefficient was 0.986
• Both scoring systems had the good performance.
• Swede score is effective for practical use and applied in Thailand.
 Swede vs Reid’s score

RCI and Swede scores at a cutoff of 5 best sensitivity and specificity for high-grade lesion
RCI 7 equal as Swede score 9 High specificity(99.1%) Apply to see-and-treat strategy
 5
Expedited
treatment
ASCCP 2019
HPV 16 positive HSIL Immediate CIN3+ risk =60 %
HPV positive HSIL Immediate CIN3+ risk = 49-64%

HPV negative HSIL Immediate CIN3+ risk =25 %

HPV positive ASC-H Immediate CIN3+ risk =26 %
HPV positive AGC Immediate CIN3+ risk =26 %
 CIN Treatment
Ablative method Excisional method
• Cryotherapy • LEEP/LLETZ
• Laser ablation • Laser Conization (LC)
• Thermal ablation • Needle Excision of the
Transformation Zone (NETZ)
• Cold Knife Conization (CKC)
• Hysterectomy
 6
New Technologies
in
Colposcopy
 Mobile Colposcopy

Enhanced visual assessment (EVA) system

Mobile Colposcope versus
Standard Colposcope
• TM Lombardi , 2016 :
• Non-inferiority trial, compare EVA with standard colposcope
in San Diego, California and Tijuana, Mexico
• The data reveals equivalence between images.
• The EVA system can help more providers perform more
advanced cervical cancer screening and diagnosis to women
in low resource settings

TM Lombardi and et al. Image comparison of a mobile colposcope(EVA) versus a standard colposcope for directing cervical biopsies in
women with abnormal pap smears:A non-inferiority trial Journal of minimally invasive synecology. 2016 Nov
 AI-guided digital Colposcopy
• Could assist colposcopists to
improve diagnostic performance,
optimize clinical workflow
• In low-middle income countries

Xue, P., and et al. The challenges of colposcopy for cervical cancer screening in LMICs and solutions by artificial intelligence. BM
Xue, P., and et al. The challenges of colposcopy for cervical cancer screening in LMICs and solutions by artificial intelligence. BM
Quiz
Question 1

Nabothian cyst
 Question 2

Thin AWE with fine mosaic at 6-7, 11-1 o’clock

 Question 3

Dense AWE with sharp border, raised border

 Question 4

Erosion with atypical vessels at 8-9 o’clock

Take Home messages
 Colposcopic report
General assessment
Normal colposcopic findings
Abnormal colposcopic findings
Colposcopic impression : Normal / Low grade / High grade/ Cancer

• High grade lesion • Suspicious invasive cancer

• Dense AWE • Atypical vessels , Fragile vessels
• Rapid appearance • Irregular surface, Exophytic lesion
• Cuffed crypt (gland) opening • Necrosis, Ulceration(necrosis)
• Coarse mosaic/punctation • Tumor/gross neoplasm
• Sharp border
• Inner border sign
• Ridge sign
 Pitfalls
• Failure to identify significant disease
• Miss lesion in vagina behind the blades
• Vaginal atrophy
• 2-3 weeks vaginal estrogen in women with vaginal atrophy before
colposcopy to enhance the appearance of dysplastic epithelium
• Endocervical biopsy
• Selection of biopsy sites
Thank you