1. Colposcopy Today Prof. Aboubakr Elnashar Benha University Hospital. EGYPT E-mail: elnashar@hotmail.com Colposcopy Today Prof. Aboubakr Elnashar Benha University Hospital. EGYPT E-mail: elnashar@hotmail.com

2. The colposcope was first developed in 1925 & is well established in gynecologic practice for defining & delineating cytologically detected lesions mainly of the cervix but also the vagina & vulva. The colposcope was first developed in 1925 & is well established in gynecologic practice for defining & delineating cytologically detected lesions mainly of the cervix but also the vagina & vulva. Colpscopy is now gradually spreading allover the world & postgraduate training courses is now being given in many centers. Colpscopy is now gradually spreading allover the world & postgraduate training courses is now being given in many centers.

3. Historic events related to colposcopy Historic events related to colposcopy 1925: Invention of colposcope (Hinselman) 1928: Schiller test 1938: Acetic acid test (Hinselman) 1939: Green filter (Kratz) 1940: Pap test 1942: First photographs of cervix (Treite) 1960: Cryosurgery 1980: Laser surgery 1988: Computer-aided colposcope 1989: LLETZ (Prendiville & Cullimore) 1991: Pap Net 2000: Telecolposcopy ( Harper et al)

4. Technologic advances New optical lenses, fiberoptic light cables & videocameras with digital computer enhancement, all played a part in advances of colposcopy. New optical lenses, fiberoptic light cables & videocameras with digital computer enhancement, all played a part in advances of colposcopy. Computer technology has made it possible to capture images directly onto a computer & these images allow enhancement & manipulation according to physician, s preference. Computer technology has made it possible to capture images directly onto a computer & these images allow enhancement & manipulation according to physician, s preference.

5. Colposcope Video camera (CCD) Optical interface Video monitor Video digitizer board Printer Personal computer Mass storage Digital imaging colposcopy (CCD=charge couple device)

6. Telecolposcopy ( Harper et al,2000) *Telecolposcopic system incorporating a custom software package. *All images were received without distortion in color, size, or orientation. *Telecolposcopy is technically feasible, can be implemented in an office system with limited technical support & is preferred by women who have to travel many miles to receive referral health care.

7. Current indications of colposcopy 1. Part of any gynecologic examination 2. Primary screening for cervical cancer. 3. Clinically suspicious cervix. 4. Abnormal Pap smear. 5. Evaluation & treatment of CIN. 6. Follow up after conservative therapy of CIN. 7. Postcoital bleeding. 8. Patients with external vulval warts 9. Evaluation of sexual assault victims. 10. Patients with history of DES exposure

8. Uses Screening colposcopy is a feasible procedure & more sensitive & more cost effective than cytological screening. When access to cytopathology is difficult, screening colposcopy is an alternative (Cecchini et al,1997). Portable colposcopy in rural areas is cost effective & highly acceptable (Martin et al,1998). The colposcopy improved detection of genital trauma in adult female sexual assault victims as compared with gross visual examination alone (Lenahan,1998).

9. Recent recommendations of FIGO for management of abnormal smear ( Benedet,2000) Persistent inflam., persistent ASCUS, LSIL, HSIL, AGCUS,Invasive Colposcopy±biopsy Normal or LSIL HGSIL Invasive 6 mo smear x 2 LEEP Appropriate TT Normal Persistent Annual screening

10. Steps Lugols’iodine test: beneficial test.. ECB has replaced ECC: easier to use, malleable & less expensive. Its specificity 92%, sensitivity 90% & positive predictive value 88% ( Martin et al, 1995). Punch biopsy: False negative rate up to 54% ( Buxton et al,1991) Multiple biopsies Excisional techniques are superior to destructive techniques

11. Diagnostic criteria 1. Vascular pattern. 2. Inercapillary distance 3. Contour. 4. Color 5. Clarity of demarcation 6. Appearance of gland opening. 7. Negativity after iodine test 8. Whiteness after acetic acid: Density of whiteness, time needed to appear & disappear, demarcation. Changes >35 yr are thinner & less demarcated., punch biopsy (Zahm et al, 1998). 9. Surface extent of the lesion: more important prognostic indicator for invasion than histological grading ( Tidbury et al,1992)

12. International Federation of Cervical Pathology & Colposcopy(1991) Normal: Original squamous epithelium Columnar epithelium Normal transformation zone Abnormal: Acetowhite epithelium Punctation Mosaicism Leukoplakia Iodine negative Atypical vessels Suspect invasive cancer: Unsatisfactory: SCJ not visible, severe inflam or atrophy, invisible cervix Miscellaneous:Nonacetowhite micropapillary surface, exophytic condyloma, inflammation, atrophy, ulcer

13. Niekerk (1998) Low grade High grade Acetowhite epithelium: shiny or snow dull, oyster white color white,semitransparent Surface: flat irregular contour, microexophytic Demarcation: diffuse, irregular, sharp, straight line, flocculated, feathered, internal demarcation absent internal demarcation present Vessels: fine, regular shape, uniform coarse, dilated, increased ICD, caliber, normal arborization, spaghetti bizarre, commas, corkscrews changing calibers sharp bends Iodine: uniform mahogany brown mustard yellow, yellow or iodine -ve

14. Update of colposcopy of genital HPV Meisels et al (1982): Florid, spiked, flat, condylomatous.. vaginitis. Flat condyloma & mild dysplasia represent the same biologic phenomenon, namely, productive HPV infection (Reid,1993). The expression of viral activity may be clinical or subclinical when it is recognizable only on colposcopy. Exophytic & flat condylomata are not homologous diseases. Exophytic is usually caused by cutaneotropic viruses (6,11). Flat are more likely to contain medium(31,33) or high risk(16,18) HPV types. Micropapillary condyloma should not be confused with micropapillomatous labialis.

15. Colposcopy of the vulva *Steps: 1. Examination after smearing with a water soluble lubricant. 2. Prolonged acetic acid test 3. Toludine blue test: little clinical value. * The junction between the glycogen bearing vaginal epithelium & keratin producing vulval epithelium: high risk for intraepithelial neoplasia. *Abnormalities: diffuse acetowhite, localized acetowhite, leukoplakia, micropapillae, papules.

16. Update on colposcopy in pregnancy Difficult. & reserved for the most experienced colposcopist. Reassurance of the patient. ECC is contrindicated & one directed biopsy. Large speculum is usually needed Sponge forceps to remove the mucous & acetic acid as a mucolytic Unsatisfactory colposcopy: repeat after 8 w The aim is to exclude cancer CIN: follow up & definitive treatment 1-2 mo postpartum.

17. Pitfalls in practice of colposcopy A. In the technique 1. Failure to use a diagnostic protocol 2. Deviation from a diagnostic protocol. 3. Failure to visualize TZ. B. In diagnosis 1. Misinterpretation of exagerated patterns of pregnancy, previously treated cervix, carvical cancer. 2. Failure to select appropriate biopsy sites, enough biopsies, sufficient volume of tissue. 3. Failure to accurately record colposcopic findings

18. C. In management 1. Miscommunication with the pathologist. 2. Failure to correlate cytology, colposcopy & histopathology. 3.Destructive therapy without biopsy, for invasive or glandular lesions. D. In the colposcopist 1. Inadequate training. 2. Inadequate experience. 3. Inadequate understanding of the disease. 4. Failure to keep up with scientific developments 5. Failure to maintain skills. 6. Failure to seek consultation.

19. Diploma of colposcopy No one should be allowed to practice colposcopy without having proper training or without a diploma in colposcopy ( Jordan,1995). It would be a legal document that would safeguard the public & raise the status of the colposcopist.

20. Future research in colposcopy ( Hilgarth,1998) 1. Computerized colposcopic documentation & consecutive analysis of colposcopic findings. 2. Clinical significance & biologic behavior of minor lesions visible with colposcopy in the presence of different HPV types. 3. Clinical significance & relation to HPV infection of minor lesions beyond the TZ. 4. Vulvar lesions in vulvodynia related to HPV infection.

21. Future of colposcopy (Niekerk,1998) 1. There are going increasing costs of medical care & the demand for better quality control will intensify. 2. Technical advances will revolutionize this area & digital imaging, the storage of up to 4.500 images on an optical disk & rapid teletransmission of images will become practical.. The use of these new technologies for better & more cost effective patient care is the challenge we will have to meet in the 21st century.

22. Benha University Hospital. EGYPT E-mail: elnashar@hotmail.com