Colposcopy Acetic acid test

Colposcopy
Acetic acid test (3-5% acetic acid)
Schiller test (Lugol’s solution)

Squamous epithelium
Columnar epithelium
Squamo-columnar junction
Metaplasia
Transformation Zone

Squamous epithelium
Collumnar epithelium

Squamo-collumnar
junction- SCJ

Metaplasia
a physiological and benign process
whereby the columnar epithelium is gradually
replaced by squamous epithelium
Transformation zone
the area where metaplasia takes place

The result of normal metaplasia is
a normal Transformation zone

Immature metaplastic cells are
susceptible
to the development of
atypical cellular changes

The process of transformation from
normal cells to atypical cells
occurs under the influence
of Human papillomavirus (HPV) and cofactors

If atypical metaplasia takes place
an abnormal
Transformation zone develops

N
O
R
M
A
L
M
E
T
A
P
L
A
S
I
A
A
T
Y
P
I
C
A
L

In colposcopy, it is essential to asses
whether Transformation zone is
normal or abnormal

International Federation for Cervical Pathology
and Colposcopy (IFCPC)
Colposcopic Classification
I Normal colposcopic findings
II Abnormal colposcopic findings
III Colposcopic findings suggestive of invasive cancer
IN Unsatisfactory colposcopy
V Miscellaneous findings

Components of a normal Transformation zone
Islands of columnar epithelium
Cleft openings Nabothian cysts

The abnormal Transformation zone is manifested
as a wide spectrum of
epithelial and vascular findings

Abnormal transformation zone is
presented by
abnormal (atypical) colposcopic findings

Abnormal colposcopic findings
Leukoplakia
Acetowhite epithelium
Punctation
Mosaic
Iodine negativity
Atypical vessels

Leukoplakia
or white plaque
is visible grossly as a white often raised
area that is not necessarily confined to TZ

Leukoplakia
HPV infection
Keratinizing CIN
Keratinizing cancer
Chronic trauma
Radiotherapy Immature metaplasia

Acetowhite epitehlium
Appears grossly normal
but turns white after application
of 3% to 5% acetic acid

Acetowhite epithelium
HPV infection
Immature squamous metaplasia
Regenerative or reparative changes Congenital Transformation zone
Inflammation
CIN
Adenocarcinoma
Invasive squamous carcinoma

Any cells with an enlarged nucleus
such as metaplatic cells or
cells traumatized by infection or friction,
may exibit
varying degrees of acetowhiteness

Punctation
a focal colposcopic pattern in which cappilaries
appear in stippled pattern.
Mozaik
a focal colposcopic appearance in which the
new vessel formation appears as a rectangular
pattern like mosaic

Punctation
colposcopic finding reflecting
the capillaries in the stromal papillae
that are seen end-on and
penetrate the epithelium

Mosaic
colposcopic finding reflecting
the islands of squamous epithelium,
encircled by blood
vessels in a basket-like arrangement

Punctation and Mosaic
Inflammation
Rapidly growing metaplastic epithelium
CIN
Invasive squamous cancer
Recurrence of cervical cancer

If the punctation or mosaic
is not located
in a field of acetowhite epithelium,
it is unlikely to be associated with CIN

Iodine negativity
Immature metaplasia
Cervical intraepithelial neoplasia
Low estrogen status (atrophy)

Atypical vessels
Irregular vessels with an
abrupt and
interrupted course
Appearing as commas,
corkscrw capillaries or
spaghetti-like forms

Atypical vessels
are the hallmark of invasion,
but can be associated with other conditions such as
Inflammation
Postirradiation effect
Rapidly growing metaplastic epitheluim
Normal epithelium
Systemic diseases

Development of abnormal
colposcopic features may be the
result of:
Immature physiologic metaplasia
Papilloma virus infection
Developing CIN

Colposcopic index (score)
a grading system used to evaluate the severity
of the colposocpic findings

A number of scoring systems
have been introduced:
Coppleson & Pixley Burghardt
Rubin & Barbo
Reid

Grading of colposcopical findings
Vascular pattern
Intercapillary distance
Color tone and opacity
Surface pattern
Borders with normal tissue

Colour
Severe abnormalities become whiter
than minor lesions
They tend to become white more quickly
Retain their whiteness longer than
the mild lesions

Borders
A clear zone of demarcation exists between
the native squamous epithelium and
high grade CIN lesion.
Mild changes usually have a less distinct outline

Surface pattern
More uneven and elevated contours are,
the higher grade the lesion is.

Intercapillary distance
Increases as the lesion becomes more severe.
The larger vessels and further apart they lie,
the more severe is the lesion

Ideally, colposcopic scoring should allow
categorizing the colposcopic pattern as:
Normal
Insignificant Clinically significant

Colposcopic features suggestive of
metaplastic changes
A smooth surface with fine, uniform-caliber vessels
Mild acetowhite change
Negative or partial positivity with Lugol’s iodine

As the metaplastic cells transform into
mature squamous cells,
the coloration is indistinquisable from
the mature ectocervix

Colposcopic features suggestive of
low grade disease
(minor changes)
A smooth surface with an irregular outer border
Slight acetowhite change
slow to appear and
quick to dissapear
Mild, often speckled iodine partial posivitity
Fine punctation and fine regular mosaic

The subtle differences between the features of
squamous metaplasia and those of low-grade
intraepithelial lesions
make both the colposcopic and histologic diagnosis
of these conditions difficult

It is easier to determine that a cervix is
either normal or very abnormal,
than it is to distinguish between
minor degrees of change

Misinterpretation of trivial changes
as atypical findings can lead
to mismanagement and
overtreatment of the patient

Colposcopic features suggestive of
high- grade disease
(major changes)
A generally smooth surface with sharp outer border
Dense acetowhite change, may be oyster white
appears early
slow to resolve
Iodine negativity
Coarse punctation and wide irregular mosaic of
different size

Signs of microinvasion
Yellow discoloration
Ulceration
Thickened areas
Nodularity
Abnormal vascularity Rapid increase in size

There is a direct relationship
between the size of a lesion and
the likelihood of invasion

Early stromal invasion
is more common when
there are different types of epithelia
(complex colposcopic changes)

Microinvasion should be suspected
when relatively flat lesions
display focal collections of
atypical vessels

Colposcopic features suggestive of
invasive cancer
Irregular surface, erosion or ulceration
Dense acetowhite change
Wide irregular punctation and mosaic
Atypical vessels

In most cases
biopsy is mandatory to establish
the correct diagnosis