1. SAMIR FOUAD ABDEL AZIZ ASSIST.PROFESSOR AL-AZHAR UNIVERSITY
COLPOSCOPE
SAMIR FOUAD ABDEL AZIZ
ASSIST.PROFESSOR
AL-AZHAR UNIVERSITY

2. TERMINOLOGY SQUAMOCOLUMNAR JUNCTION
morphologically there are two types of SCJ
The original SCJ is the border where the original squamous epithelium meets the outermost limit of the developing TZ. The present SCJ is the innermost border where the maturing squamous metaplasia meets the columnar epithelium

3. Squamocolumnar junction
Squamous epithelium to the left and columnar epithelium to right.

4. Transformation Zone TZ
It is the area of actively maturing epithelium between the present SCJ and the original squamous epithelium. It is composed of intermingling of squamous and columnar epithelium. Squamous metaplasia, islands of columnar epithelium, gland openings and nabothian cysts may be identified. The precise location of TZ varies in relation to exo- and endocervix

5. Transformation zone
TZ with gland opening,sq.metaplasia,columnar epithelium

6. Nabothian Cysts
Are inclusions or entrapments of mucous from secreting columnar villae under the developing squamous epithelial surface

7. Squamous Metaplasia
The normal physiologic process by which columnar epithelium evolves into squamous epithelium.The outermost border is the original SCJ while the innermost border is the present SCJ.Histologically, in the early stages of this process, immature squamous cells push up columnar cells.Columnar epithelium later become degenerted and replaced by mature squamous epithelium

8. Leukoplakia
Refers to a white plaque visible without magnification and without application of acetic acid.
It is usually elevated from
surrounding surfaces with a
sharp border and Lugol’s non-
staining.Histologically..hyperkeratosis

9. Atrophy
Atrophic changes result from low estrogen levels characteristic of the menopausal patient.The appearance is that of a typically smooth and thin epithelium. This result in blood vessels being more readily visible and truma easily incurred.these changes are reversible by estrogen.It can result in changes that mimic high-grade abnormalities.

10. Acetic Acid
Acetic acid 3%-5% dissolves mucous and accentuates atypical areas (white epithelium,punctation,mosiac and atypical vessels)by inducing intracellular dehydration and coagulation of protein. This effect peaks approximately 2 minutes after application and fades within 5 minutes. Therfore, repeated applications is rquired

11. Lugol’s Iodine
Lugol’s solution is composed of Iodine and potassium iodide in water. It stains the glycogen in mature squamous epithelium a dark brown color. Consequently, areas devoid of glycogen such as immature squamous epithelium, columnar epithelium, erosion and neoplasia will be non-staining
non-staining is called Schiller’s positive

12. Cervical Intraepithelial Neoplasia
The term cervical intraepithelial neoplasia refers to a spectrum of abnormalities of the surface epithelium. The spectrum includes changes in the TZ ranging from CIN I(mild dysplasia) to CIS (carcinoma in situ)

13. CIN Cytology
Cytologic aberrations seen in CIN include: hyperchromaticity, abnormal chromatin distribution, increased nuclear to cytoplasmic ratio and nuclear pleomorphisim. These abnormalities may be seen in exofoliated cells in a Pap smear

14. CIN Histology
CIN grading is based upon the proportion of the surface epithelium composed of undifferentiated cells characteristic of the basal layer. Increasing grade is associated with a progressive loss of epithelial maturation

15. CIN I
Represents atypical cells with increased nuclear to cytoplasmic ratio and hyperchromatic nuclei present in the lower 1/3 of the epithelial layer from the basement membrane

16. CIN I
Cytology

17. CIN II
Shows further progression of nuclear abnormalities with greater involvement of the epithelial thickness. In CIN II, immature basaloid cells occupy the lower 2/3 of the epithelium

18. CIN II
Cytology

19. CIN III
Represents almost total involvement of the epithelium with only one or two layers of mature cells remaining at the surface. When the entire epithelium is involved, the term carcinoma in situ (CIS) is applied.

20. CIN III
Cytology Histology

21. Invasive Cervical Cancer
With all levels of CIN the basement membrane of the epithelium remains intact. Once the membrane is violated, invasive cancer is diagnosed

22. Pap Test
The Pap test was introduced as a cervical screening test in 1943 by George Papanicolaou for whom it is named. It is a way to examine cells collected from the cervix and vagina. This test can show the presence of infection, inflammation, abnormal cells, or cancer.

23. How is a Pap test done?
A Pap test is simple, quick, painless.While a woman lies on an examination table, the clinician inserts a speculum into her vagina to open it. To do the test, a sample of cells is taken from in and around the cervix with a wooden scraper and placed on a glass slide and rinsed in liquid fixative and sent to a laboratory for examination.

24. WHO Should Have Pap test
Women who are or have been sexually active should have Pap tests and physical examination regularly every 3 years. There is no known upper age at which Pap tests cease to be effective.Women who have had hysterectomy for treatment of a precancerous or cancerous condition should have the end of the vaginal canal sampled for abnormal changes.

25. When Should Pap Test be done?
A woman should have this test when she is not menstruating; the best time is between 10 and 20 days after the first day of the menstrual period. For about 2 days before a Pap test, she should avoid douching, or using vaginal medicines or spermicidal foams, creams or jellies. These may wash away or hide abnormal cells.

26. What do abnormal test results mean?
A physician may simply describe Pap test result as abnormal. Cells on the surface of the cervix sometimes appear abnormal but are not cancerous. It is important to remember that abnormal conditions do not always become cancerous, and some conditions are more of a threat than others.
There are several terms to describe abnormal results

27. Terms to describe abnormal results
Dysplasia is a term used to describe abnormal cells.It is not cancer, although it may develop into very early cancer. Cervical cells undergo a series of changes in their appearance. The cells look abnormal under the microscope but do not invade nearby healthy tissues.It is classified into mild, moderate and sever depending on how abnormal the cells appear.

28. Terms to describe abnormal results
Squamous Intraepithelial Lesion (SIL)
An intraepithelial lesion means that the abnormal cells are present only in the surface layers of the cells. SIL may be described as low-grade(early changes in size, shape and number of cells) or high-grade(a large number of precancerous cells the look very different from normal cells)

29. Terms used to describe abnormal results
Cervical Intraepithelial Neoplasia CIN
Another term widely used to describe abnormalities of surface epithelium. The term CIN along with a number (1 to 3), describes how much of the cervix contains abnormal cells.Carcinoma in situ(CIS) describes a preinvasive cancer that involves only the surface cells.

30. How do these terms compare?
Mild dysplasia may be also classified as low-grade SIL or CIN I
Moderate dysplasia may also be classified as high-grade SIL or CIN II
Severe dysplasia may also be classified as high-grade SIL or CIN III
Carcinoma in situ may also be classified as high-grade SIL or CIN III

31. False positive and False negative Test
A false positive Pap test occurs when a specimen is called abnormal but the cells are actually normal.
A False negative Pap test occurs when a specimen is called normal but the woman has a lesion. It is at least 20%. This means that biopsy is imperative for visible lesions.

32. Methods to Improve Accuracy of Pap smear
1.Perform a Pap smear when the patient is in the proliferative phase.
2.The patient should avoid intercourse or intravaginal products/douches for hours before examination
3.Use no lubricant prior to the test
4.Have cytobrush, spatula, slide and other supplies on hand before exam.

33. Methods to Improve Accuracy of Pap smear(cont.)
5.Rotate the Ayers spatula through a 360-degree arc over the SCJ and avoid excessive pressure
6.Collect the endocervical specimen using cytobrush or saline-moistened cotton swab and apply it to the same slide
7.Rapidly apply fixative to the slide, if spry used hold it 10 inches from the slide

34. Colposcope
The colposcope is a binocular, low-magnification (7x to 30x) microscope with light source which is used to visualize the cervix, vagina and vulva.The goal in the evaluation of the lesions is to exclude the possibility of malignancy.Satisfactory colposcpies are those in which the lesion and the SCJ can be seen in entirety

35. Examination view

36. Methods of Colposcopic Examination
Classical or Extended Colposcopy
The cervix and vagina are first examined at magnification of 7x or 10x following which excess mucus is removed from the cervix
Acetic acid 3% to 5% is applied by cotton swab.Abnormal epithelium appear as thick white (acteo-white)
Schiller iodine test may be applied

37. The Saline Technique
This depends entirely on the visualization of various vessel patterns .
After exposing the cervix saline is used to remove mucous and then a green filter and high magnification is used..in this way the red capillaries appear darked and stand out more clearly

38. Diagnostic criteria for Colposcopy
In its simplest form colposcopy is the recognition of aceto-white epithelium but benign conditions can produce aceto-white epithelium so the colposcopist must be aware of the other features which suggest underlying abnormalities.

39. Colposcopic Diagnosis (cont.)
Features which suggest abnormality are:
1.The subepithelial vascular pattern
2.Intercapillary distance
3.Color tone differences at the junction of normal and abnormal epithelium
4Surface pattern
5.Sharp line of demarcation bet.different types of epithelium

40. Aceto-white epithelium
Acetic acid causes some swelling of epithelium particularly columnar epithelium and abnormal epithelium

41. Vascular abnormality
Atypical vessels :this vascular growth is not symmetric and is often associated with
progressively smaller
blood vessels

42. Vascular Abnormality Mosaic
A vascular change of interconnecting vessels resulting in cobble-stone or honey-comb surface.
This is usually seen with
CIN and mandates biopsy

43. Vascular Abnormality Punctation
It is a zone of red dots representing stromal papillae and blood vessel loops reaching to the surface epithelium.
When this pattern is identified
biopsy is indicated .

44. Biopsy Forceps
Used for punch biopsy from abnormal area

45. Endocervical speculum
Endocervical speculum allow visualization of the inner bored of a lesion

46. Human Papilloma Virus and Cervical neoplasia
HPV is a circular, double-stranded DNA virus that has a surrounding polyhedral capsid..Included in the viral DNA are 2 oncogenes(E-6,E-7) and a protein that suppresses expression of the oncogenes
(E-2). There appear to be 3 variants of HPV infection.Episomal/nonreplicating, Episomal/replicating and integrated

47. Episomal/nonreplicating
After infecting the host, the virus may exist as an inactive extrachromosomal particle (episomal)that is detectable only by DNA testing. This type of infection (sublinical,DNA only) is extremely common, occurring in up to 50% of sexually active young women.

48. Episomal/replicating
The viral DNA is transcribed, and viral particles are assembled. This type of infection results in a clinically detectable lesion (abnormal Pap smear, genital warts) the infected cell is called koilocyte
(empty cell)because of its
perinuclear vacuolization

49. Integrated
The viral DNA transforms host DNA.Cofactors,high-risk HPV types and comutagens appear to be necessary for this to occur. The circular DNA episome breaks into linear strand prior to integration into host. E-2 normally control cell-proliferation-
inducing E-6andE-7.In absence of E-2,cell growth is out of control and neoplasia result.

50. Prevalence of HPV
Of more than 70 types of HPV, more than 35 are associated with anogenital disease and 20 or more are associated with cancer. The most common HPV types detected in cervical lesions are those classified as high-risk HPV types, including types,16,18,45, and 56, found in 77% of HSIL(CIN II-III) and in 84% of invasive cancer

51. Prevention and Screening Cervical Cancer
Cervical cancer is one of the most common cancers, accounting for 6% of all malignancies in women. There are an estimated 16,000 new cases of invasive cancer of the cervix and 5,000 deaths in the U.S each year

52. Prevention and Screening Cervical Cancer
Because a vast majority (greater than 90%) of these cases can and should be detected early through the use of Pap smear, the current death rate is far higher than it should be and reflects that ,even today, Pap smears are not done on approximately one-third of eligible women.

53. Prevention and Screening Cervical Cancer
Strong risk factors include: Early age at first intercourse (16 years or younger), a history of multiple sexual partners,a history of genital HPV infection or other sexually transmitted disease. Additional factors include active or passive smoking, a current or past risky sexual partner, immunodeficiency or HIV positively,poor nutrition.

54. Prevention and Screening Cancer Cervix
Abundant evidence suggests that regular gynecologic examination and Pap tests for all women beginning at the onset of sexual activity, or by approximately age 18 years if not sexually active, decreases cervical cancer incidence and mortality.An upper age limit at which such screening cease to be effective is not known

55. Prevention and Screening Cancer Cervix
Evidence supports a sexual mode of transmission of a carcinogen and HPV is strongly implicated epidemiologically as the main infectious etiologic agent. Barrier methods of contraception lower the incidence of cervical neoplasia, presumptively secondary to lessened exposure to HPV

56. Prevention and Screening Cervical Cancer
Exposure to cigarette smoke is associated with increased risk
this risk increases with longer duration and intensity of smoking and is present with exposure to environmental tobacco smoke as well, being as high as three times that of women who are nonsmokers and not exposed to environmental smoking

57. Prevention and Screening Cervical Cancer
Increased intake of micronutrients and other dietary factors such as carotenoids are associated with decreased risk
A considerable amount of experimental data suggests that vitamin A and its derivatives inhibit HPV-associated proliferation, several trials using retinoids showed increased regression of CIN2 .

58. Prevention and Screening Cancer Cervix
Education regarding risk factors for cervical cancer may lead to behavioral modification resulting in diminished exposure

59. Impact of cervical cancer screening on mortality
Mortality from cervical cancer has decreased in several large populations following the introduction of well-run screening programs. Data from several large Scandinavian studies show sharp reduction in incidence and mortality. Iceland reduced mortality by 80% over 20 years, Finland and Sweden reduced their mortality by 50% and 34% respectively

60. Impact of cervical cancer screening on mortality
Reduction in incidence and mortality seem to be proportional to the intensity of screening efforts. The Scandinavian countries with the highest rates of screening activity reported greater reductions in mortality than those countries with lower rates of screening

61. Impact of screening for cervical cancer on mortality
Case-control studies have found that the risk of developing invasive cancer is 3-10 times greater in women who have not been screened. Risk also increases with longer duration following the last normal Pap smear, or similarly, with decreasing frequency of screening.Screening every 3 years give 91% protection rate.

62. Management of Abnormal Pap Test

63. Management of Abnormal Pap Smear
Approximately 1-3% of Pap smears will read as abnormal. This percentage may approach 7-10% in high-risk groups such as a sexually transmitted disease clinic.

64. Management of abnormal Pap Smear (cont.)
The standard evaluation of an abnormal Pap smear is colposcopy and biopsies. Endocervical curettage at the time of colposcopy allows evaluation of cells from the endocervicl canal.
Biopsy should confirm the Pap smear abnormality and then appropriate treatment can be applied

65. Management of Abnormal Pap Smear(cont.)
If there is discrepancy between the Pap smear and the biopsy, then a larger biopsy such as leep or cold conization biopsy may be needed

66. Ablative Therapy
These techniques remove up to 8 mm in tissue depth and up to 30 mm in diameter, including the transformation zone.
When applied correctly have excellent success rate (90-95%).

67. Cryotherapy
Cryotherapy is freezing the cervix to destroy the abnormal cells.
It has minimal discomfort, moderate cervical distortion, and minimal expense.
The technique involves the use of a gas with a boiling point in the cryptogenic range to freeze the cervix for 3 to 6 minutes

68. Cryotherapy (cont.)
Tissue destruction occurs to a depth of 8 mm when an ice ball extending 5 mm beyond the lesion is created.
The disadvantage is the remainder of the lesion cannot be examined by pathologist to absoultly sure a worse lesion was not present

69. LASER Ablative Therapy
This involves the use of carbon dioxide laser to evaporate tissue.
The laser can be precisely controlled and is used in conjunction with a colposcope or operating microscope to destroy tissue to a depth of 8 mm.
This technique provides no specimen for pathologic diagnosis

70. Before the use of ablative therapy
1 No Evidence of invasive cancer on Pap smear, cervical biopsy or colposcopy.
2 No evidence of an adenomatous lesion (adenocarcinoma in situ or adenocarcinoma)

71. Before ablative therapy
3 satisfactory colposcopy i.e complete visualization of the lesion and TZ.
4 Endocervical curettage negative for CIN

72. Before Ablative therapy
6 No discrepancy between Pap smear and biopsy
7 Patients is complaint with follow-up

73. Cone Biopsy The most commonly used cone biopsy include:
Cold-knife cone
Laser excisional cone
Loop Electrosurgical Excision Procedure (LEEP) cone

74. Cold-Knife Cone
It is simply removal of a cone of tissue with a scalpel.
Usually performed under anaecthesia
It delivers a perfect specimen for patological examination

75. Laser Excisional Cone
This was advocated during a period of higher laser use
It delivers a specimen with artifact but allows the surgeon increased control because it is used with microscope.

76. LEEP Cone
Performed using two loops, one 20mm by 8mm for the ectocervix. And one 10 by 10 mm for the endocervical canal.
Performed under anaesthesia in the clinic and rquires less than 5 minutes of operating time.
Cones are not as deep as cold-knife

77. Indications for Cone Biopsy
1.Evidence of invasive cancer on Pap smear, cervical biopsy or colposcopy
2. Evidence of adenomatous lesion (adenocarcinoma in situ or adenocarcinoma)
3.Colposcopy unsatisfactory(incomplete visualization of the lesion or SCJ)

78. Indications for Cone biopsy (cont.)
4.Endocervical curettage positive for CIN/SIL
5.Grade of CIN/SIL on Pap smear worse (by two grades) than that on biopsy specimen
6.Patient is not complaint with follow-up

79. Hysterectomy
Hysterectomy is not a conservative mode of therapy for preinvasive lesions.
Its increased expense and potential morbidity make other approaches much more desirable.
It is indicated when patient is not complaint with follow-up and has completed her family