12 th sep - aogs - colposcopy

8/7/2019 12 Th Sep - AOGS - Colposcopy

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Prevention

is

Better thanCure


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Cervical CANCER

Raising Awareness & Prevention

Cervical CancerCervical Cancer --A major health problem & Social BurdenA major health problem & Social Burden

The commonest cancer in women in developing countries

Diagnosed in advanced stage

Cancer ofCervix is curable if detected in early stage


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Development of Cancer CervixDevelopment of Cancer Cervix

Normal Cervix

Pre Cancerous lesions ( CIN I,CIN - II )

Carcinoma in situ ( CIN-III)

Invasive Cancer

--------------------------------------------

Stage I Stage II Stage III Stage IV

Normal Cervix

Pre Cancerous lesions ( CIN I,CIN - II )

Carcinoma in situ ( CIN-III)

Invasive Cancer

--------------------------------------------

Stage I Stage II Stage III Stage IV

10 -15

years


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Screening for Cervical CancerScreening for Cervical Cancer

Paps Smear

Visual inspection ofCervix

- after application ofacetic acid (VIA)

- after application of Schillers iodine (VILI)

HPVDNA testing

Paps Smear

Visual inspection ofCervix

- after application ofacetic acid (VIA)

- after application of Schillers iodine (VILI)

HPVDNA testing


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What is a ColposcopeWhat is a Colposcope

Colposcope is a microscope designed to allowexamination of the cervix with magnificationranging between six- to - 40 fold

It is kept approx. 30cm away from the vagina & alight source is thrown in it & in return it showsreal, true magnified picture of cervix

Invented by Hinselmann, a German scientist, in1925

Colposcope is a microscope designed to allowexamination of the cervix with magnificationranging between six- to - 40 fold

It is kept approx. 30cm away from the vagina & alight source is thrown in it & in return it showsreal, true magnified picture of cervix

Invented by Hinselmann, a German scientist, in1925


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Colposcope

(Greek word)

Colposcope

(Greek word)_____________________

Kolpos Skope

Hollow Examine

_____________________

Kolpos Skope

Hollow Examine


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The man who thinks thatcytologyisbetter thancolposcopy,

or

thatcolposcopyis better thancytology,

is a fool who knows nothing of either-Hinselmann

The man who thinks thatcytologyisbetter thancolposcopy,

or

thatcolposcopyis better thancytology,

is a fool who knows nothing of either-Hinselmann

The Primary goal of Cervical Screening is to prevent

Cervical Cancer

The Primary goal of Cervical Screening is to prevent

Cervical Cancer


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COLPOSCOPY

The Colposcope is a magnifying instrument

Its lights are only on THE OUTSIDE

No anesthesia is required

Colposcopy is an outpatient procedure

Helps in identifying the abnormal or diseased area

It helps in taking biopsy

Colposcopy is not a Surgery


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Type of ColposcopeType of Colposcope

ManualColposcope

Main objective lensMagnification changer

Binocular lens

Filter: required for the

study of vasculararchitecture

Light source

ManualColposcope

Main objective lensMagnification changer

Binocular lens

Filter: required for the

study of vasculararchitecture

Light source


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0

20

40

60

80

100

1st

Qtr

3rd

Qtr

East

West

North

Eye piece

Object

ive

lens

Knob for

magnification

Light

source

Knob for

tilting


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Video-Colposcope

It utilizes video camera

Electronic green filter

Motorized zoom magnification

Fine focus control combinedin one unit

Omission of eye piece

Along with high resolution

monitor & optional

image management system Full screen image display

With live recording


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DigitalVideo- Colposcope

DigitalVideo-colposcopy:Includes computer withimage software

Images can be captured andstored digitally for

Documentation

Teaching purpose

Comparison of lesion duringfollow up

Statistical analysis and

Printing report

Software data for

confirmation of diagnosis

DigitalVideo Colposcopes are the

latest generation


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Why Do A Colposcopy ?Why Do A Colposcopy ?

Colposcope :Low power binocular microscope,

Modified with the specific purpose

To study of surface epithelium, stroma

& vascular pattern of the cervix

Diagnostic toolIdentification ofabnormalities in CERVIX

Location of the lesion

Aid in selection of biopsy siteSignificant role- Evaluation & treatment ofCIN, HPV, Erosion

Selection oftreatment ofCIN

Abnormal paps smearin pregnancy

Extension oflesion in vagina

Colposcope :Low power binocular microscope,

Modified with the specific purpose

To study of surface epithelium, stroma

& vascular pattern of the cervix

Diagnostic toolIdentification ofabnormalities in CERVIX

Location of the lesion

Aid in selection of biopsy siteSignificant role- Evaluation & treatment ofCIN, HPV, Erosion

Selection oftreatment ofCIN

Abnormal paps smearin pregnancy

Extension oflesion in vagina


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IndicationsIndications

HSIL /LSIL /PersistentLSIL / borderline nuclear changes

ASC-U (HPVTest - High Risk Positive)

ASC-H

Suggestion of invasive cancer

Persistent unsatisfactory smears

Presence ofglandular lesion

Excessive numbers of keratinized cells

Clinically suspicious looking cervix

Leucoplakia

Abnormal / unexplained intermenstrual bleeding

Postcoital bleeding

Unexplained, persistent vaginal discharge

HSIL /LSIL /PersistentLSIL / borderline nuclear changes

ASC-U (HPVTest - High Risk Positive)

ASC-H

Suggestion of invasive cancer

Persistent unsatisfactory smears

Presence ofglandular lesion

Excessive numbers of keratinized cells

Clinically suspicious looking cervix

Leucoplakia

Abnormal / unexplained intermenstrual bleeding

Postcoital bleeding

Unexplained, persistent vaginal discharge


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Materials required for performing Colposcopy

Examination table: Table allows the woman to be placed in

a modified lithotomy position

The womens feet may be placed either

in heel rests or legs may be supported inknee crutches

Table: For instruments

OptionalItems :

Computer for documentation purpose

Printer, Video Recorder, Appropriate

software for recording of

patient data


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CUSCOS speculums - different sizes - metal /plastic disposable

-inserted gently to widen the opening of the vagina

enables visualization of the cervix

-If lateral walls of the vaginal canal are

obstructing the view,a latex condom can be put on

speculum after cutting its tip

Sponge holding forceps / larger cotton-tipped swabsticks

Cotton or blood holding pads

Bottles : 1. normal saline2. 3-5% acetic acid &

3. Lugols Iodine

Monsels Solution : Local Haemostatic agent


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Acetic Acid: It is applied with a cotton

applicator (cotton balls held by

sponge forceps or small swabs)

Acetic acid dissolves & coagulates

the protein available on cervix in

order to make it more clear

Duration : 1-3 minutes

Acetonic effect: After application a

white layer appears

Acetic Acid


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GREEN FILTER

It is used to study the

vascular pattern of cervix

Actually, this absorbs the

red from the color &

enhance the image of blood

vessels which appear black


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Lugols Iodine Application :

This solution is also known asSchillers test

Reaction obtained when iodine solution is painted on cervix

Normal epithelium is glucogen rich - stains brown

Abnormal epithelium -contains little or no glycogen doesnt

take up the stain

Hence abnormal area can be easily marked

Help in selection of area -for biopsy

LugolsIodine


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SchillersIodine :SchillersIodine :


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TechniqueTechniqueOPD procedure

No Anesthesia required

Insertion of cuscos speculum

Inspection of unprepared cervix

Excess mucus is removed -saline soaked cotton wool swab

Colposcopy after application of 3-5%acetic acid

Examine ofCervix under green filter

Application of Schillers iodine

OPD procedure

No Anesthesia required

Insertion of cuscos speculum

Inspection of unprepared cervix

Excess mucus is removed -saline soaked cotton wool swab

Colposcopy after application of 3-5%acetic acid

Examine ofCervix under green filter

Application of Schillers iodine


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International Colposcopic Terminology

Normal colposcopic findings:

Original squamous epithelium

Columnar epithelium

Normal Transformation zone

Unsatisfactory colposcopy:

Squamocolumnar junction notvisible

Miscellaneous findings:

Micropapillary surface

Condyloma

Inflammation / Atrophy /Ulcer

Other

Abnormal ( within the TZ )

Acetowhite epithelium* Punctation*

Mosaic*

Leukoplakia*

Iodine negative

Atypical vessels Colposcopically suspect

invasive carcinoma


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Anatomy of the CervixAnatomy of the Cervix


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Cervical EpitheliumColposcopic AppearancesCervical EpitheliumColposcopic Appearances

OriginalSquamous epithelium

Original Columnarepithelium

Transformation zone


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Original Squamous EpitheliaOriginal Squamous Epithelia

Smooth, usually

featureless covering of

the cervix

Uniformpink colour

It joins the columnar

epithelium at the

original SCJ

Smooth, usually

featureless covering of

the cervix

Uniformpink colour

It joins the columnar

epithelium at the

original SCJ


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Original Columnar EpitheliaOriginal Columnar Epithelia

An areawith multiple

villi / grapelikeprojections

Characteristic reddish

colour

Each villus has one /more capillary loops

with a thin overlying

epithelium

An areawith multiple

villi / grapelikeprojections

Characteristic reddish

colour

Each villus has one /more capillary loops

with a thin overlying

epithelium


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Original Squamo-columnar JunctionOriginal Squamo-columnar Junction

Permanent pointof meetingbetween original squamous

and columnar epithelia

Outlines the lateral border ofthe TZ

It isfixed, but moves inrelation to the whole cervix

Permanent pointof meetingbetween original squamous

and columnar epithelia

Outlines the lateral border ofthe TZ

It isfixed, but moves inrelation to the whole cervix


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T

ransformation zoneT

ransformation zone The area lying between the original squamo-columnar

junction and the colposcopic new squamo-columnar

junction

Zone in which transformation will occur during fetal

life, adolescence and pregnancy

Characterized by presence ofmetaplastic epithelium

This is the area where transformation to CINoccurs

which may lead to invasive cancer

The area lying between the original squamo-columnar

junction and the colposcopic new squamo-columnar

junction

Zone in which transformation will occur during fetal

life, adolescence and pregnancy

Characterized by presence ofmetaplastic epithelium

This is the area where transformation to CINoccurs

which may lead to invasive cancer


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Transformation ZoneTransformation Zone


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SquamousMetaplasiaSquamousMetaplasia

Conversion ofColumnar epithelium to SquamousepitheliumConversion ofColumnar epithelium to Squamousepithelium


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Periods of development late fetal life, menarche, first

pregnancy

Early /Immature stage villi opaque at tips pale

Mature difficult to distinguish between metaplastic and

original squamous epithelia

Gland openings Patent preexisting clefts

(lateral margin of TZ)

Nabothian follicles occluded clefts

SquamousMetaplasiaSquamousMetaplasia


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Tissue basis for ColposcopyTissue basis for Colposcopy

The colposcopic appearances of the cervix are asummation of various factors

These include:-1.The architecture of the epithelium and possiblevariations in its thickness & formation

2.The composition of the underlying stroma

3.The surface configuration of the tissue of the

cervix

The colposcopic appearances of the cervix are asummation of various factors

These include:-1.The architecture of the epithelium and possiblevariations in its thickness & formation

2.The composition of the underlying stroma

3.The surface configuration of the tissue of the

cervix


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Surface configurationSurface configuration

Smooth / papillary

Vascular patterns

- Punctations

- Mosaics

Leukoplakia (white patches on surface), due to thick

keratin which may overlie normal / abnormal

epithelium

Irregular surface

Smooth / papillary

Vascular patterns

- Punctations

- Mosaics

Leukoplakia (white patches on surface), due to thick

keratin which may overlie normal / abnormal

epithelium

Irregular surface


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Miscellaneous findings :-

Colposcopic appearance


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Cervical Ectopy / EctropionCervical Ectopy / Ectropion

Menarche, pregnancy and oral contraceptives

SCJ situated outside external os

Surface columnar epithelium displaced outward

Gives an exophytic appearance

Only colposcopy can differentiate between a perfectlybenign effect and malignant changes

Menarche, pregnancy and oral contraceptives

SCJ situated outside external os

Surface columnar epithelium displaced outward

Gives an exophytic appearance

Only colposcopy can differentiate between a perfectlybenign effect and malignant changes


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Trichomonas vaginalis---strawberry appearance

Schillers iodine test--- leopard skin appearance

Trichomonas vaginalis---strawberry appearance

Schillers iodine test--- leopard skin appearance

Inflammatory LesionsInflammatory Lesions


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Lesions can be single/multiple

Flat plaque ofacetowhite epithelium -mosaics & punctations

With increasing keratinization surface appear heaped upresembling the surface of cerebral cortex

May even occur outside the T.Z.

FINALDIAGNOSIS BYHPE

Lesions can be single/multiple

Flat plaque ofacetowhite epithelium -mosaics & punctations

With increasing keratinization surface appear heaped upresembling the surface of cerebral cortex

May even occur outside the T.Z.

FINALDIAGNOSIS BYHPE

Human PapillomaVirusInfectionHuman PapillomaVirusInfection


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Cervical epithelium MenopauseCervical epithelium Menopause

TZtends to retract

Squamous epithelium becomes atrophic

Glycogenation is lost Subepithelial capillaries much more readily

traumatized

TZtends to retract

Squamous epithelium becomes atrophic

Glycogenation is lost Subepithelial capillaries much more readily

traumatized


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Abnormal epithelium extending high into theendocervix

Entire T.Z. not seen

Abnormal epithelium extending high into theendocervix

Entire T.Z. not seen

Unsatisfactory ColposcopyUnsatisfactory Colposcopy


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Selection of biopsySelection of biopsy


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Four basic Colposcopic diagnosis

1. Normal& satisfactory / Unsatisfactory2. Low-grade disease (HPV / CIN-1)

3. High-grade disease (CIN-2 or 3)

4. Invasive cancer

Four basic Colposcopic diagnosis

1. Normal& satisfactory / Unsatisfactory2. Low-grade disease (HPV / CIN-1)

3. High-grade disease (CIN-2 or 3)

4. Invasive cancer

DiagnosisDiagnosis


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Colposcopy is a important aid in diagnosis

Pap's smear & Colposcopy are complementary

Requires specialized training, skill & knowledge

Colposcopist should be aware ofall the terminology

Colposcopy is totally subjective

FINALDIAGNOSIS BYHISTO-PATHOLOGY

Management depends on the histo-pathology reports

Colposcopy is a important aid in diagnosis

Pap's smear & Colposcopy are complementary

Requires specialized training, skill & knowledge

Colposcopist should be aware ofall the terminology

Colposcopy is totally subjective

FINALDIAGNOSIS BYHISTO-PATHOLOGY

Management depends on the histo-pathology reports

To ConcludeTo Conclude


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CYTOLOGYIDENTIFIESTHECRIME

WHILE

COLPOSCOPELOCATESTHECULPRIT

CYTOLOGYIDENTIFIESTHECRIME

WHILE

COLPOSCOPELOCATESTHECULPRIT


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12 th sep - aogs - colposcopy

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