3 prof walter colposcopic

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1. ColposcopicNomenclature
22.
JahrestagungderArbeitsgem
einschaft
fürZervixpathologieund
KolposkopieAG CPC
walterprendiville
IFCPC

2. Evolution of terminology
Progress evolves from clear understanding of
existing research and experience and clarity of
terminology is fundamental to this
It is not possible to compare apples with oranges
or to understand precisely published evidence
where terminology is unclear
cone biopsy (UK) with cone biopsy (US),
Height
Depth
atypia

3. Practice variation in OB/GYN
C Section, 3
rd
stage of labour
Antenatal V/E
Hysteroscopy
Management of Endometrial Cancer
Colposcopy

4. Evolution of colposcopy
First colposcope:: Hamburg
Early colposcopicskills
image recognition,
diagnosis of HSIL,
recognition of microinvasion
Late colposcopicskills =
discriminating between normal and
abnormal
facilitating precise treatment

5. MODERN COLPOSCOPY
Objective and easily achieved
skills through structured training as
part of a QA service
Risk assessment using biomarkers
and patient characteristics
Modified treatment techniques

6. Variation in colposcopyand
treatment
Colposcopyis not a defined entity and performs
differently in different settings
Treatment is not a defined entity and produces
different results and complications in different
settings
Nomenclature varies in interpretation and we
therefore can not easily compare practice

7. Colposcopyis not a defined entity
and performs differently in
different settings
Colposcopyperformed by variably
trained colposcopistswho do not
adhere to strict quality assured
practice or self audit is completely
different to colposcopyin a region
where QA, adherence to best
evidence guidelines and CME are
the norm’

8. Why is there such a difference in
colposcopic reward
ALTS 11.5% CIN 2+ after a normal colposcopy
72.3% of CIN2+ found at original colposcopy
UK NHS study 5.3% CIN2+ after a normal colposcopy
94.6% of CIN2+ found at original colposcopy

9. Why is there such a difference in
colposcopic reward
In the UK NHS CSP colposcopysetting the risk of
missing high grade disease appears to be much lower
than in the equivalent US setting
Why is this?

10. Why is there such a difference in
colposcopic reward
In the UK there exists
A comprehensive training programme
Preceptor based
Strict number of cases under supervision
andsubsequently unsupervised
Ongoing assessment during training
Exit exam (OSCE)
30% failure rate

11. Why is there such a difference in
colposcopic reward
In the UK
Colposcopypractice
Devoted colposcopyclinics
All women referred with a suspected
abnormality
Rate of CIN relatively high
Not rewarded according to
procedures performed
Comprehensive audit of practice

12. Treatment is not a defined entity
and produces different results and
complications in different settings
The resection of a small type 1 TZ is easy and
associated with minimal morbidity
The resection of a large Type 3 TZ is difficult
and associated with significant short and
long term morbidity

13. 13
Preterm delivery (<37W): Excision vs no treatment ~heigth
Height < 10mm
Risk ratio
.1.2 .512 510
Risk ratio (95% CI)
Raio, 1997 0.52 ( 0.06, 4.83)
Sadler, 2004 0.99 ( 0.57, 1.72)
Samson, 2005 3.02 ( 1.65, 5.53)
Nohr, 2007 0.83 ( 0.21, 3.25)
Overall 1.32 ( 0.59, 2.95)
Risk ratio
.1.2 .512 510
Raio, 1997 4.64 ( 1.20, 17.88)
Sadler, 2004 1.64 ( 1.13, 2.37)
Samson, 2004 3.84 ( 1.66, 8.88)
Nohr, 2007 2.46 ( 1.45, 4.16)
Overall 2.39 ( 1.55, 3.69)
Height >= 10mm
Risk ratio (95% CI)

14. Risk of preterm labourafter LLETZ Does size matter,
A retrospective study
Khalid S, DimitriouE &PrendivilleW
BSCCP (poster) 2009

15. Excision dimensions and preterm labour
Khalid S, Dimitriou E & Prendiville W2009
1999 -2002
Obstetric &Colpo
databases
353 pregnancies in
women after LLETZ

16. Excision dimensions and preterm labour
Khalid S, Dimitriou E & Prendiville W2009
Increased risk of
preterm labourif
specimens larger
than 6 cubic cms
RR 3.17, 95%CI 1.56 -
6.38

17. Excision dimensions and preterm labour
Khalid S, Dimitriou E & Prendiville W2009
Increased risk of
preterm labourif
specimens thicker
than 12 mms
RR 3.05, 95%CI 1.37 -
7.08

18. 2011 IFCPC colposcopic terminology of the cervix(draft –May 2011)
SCJ visualization: complete/partial/none
Adequate/inadequate for the reason … (i.e.: cervix
obscured by inflammation, bleeding, scar)
Basic definitions
Deciduosis in
pregnancy,
Atrophic epithelium,
Nabothian cyst,
Gland(crypt)
openings
Original squamous epithelium,
Columnar epithelium
including ectopy,
Transformation zone types 1,2,3
Normal colposcopic
findings
Inside or outside the T-zone,
Numberof cervical quadrantsthe lesioncovers,
Size of the lesion in percentage of cervix,
Lugol’s staining(Schiller’s test): stained/non-stained
General
principles
Abnormal
colposcopic
findings
Fine mosaic,
Fine punctation
Fine aceto-white epitheliumGrade 1
(Minor)
Rapid appearance of
acetowhitening,
Cuffed gland(crypt)
openings
Sharp border,
Exophytic
lesion,
Inner border
sign,
Ridge sign
Dense aceto-
white
epithelium,
Coarse mosaic,
Coarse
punctuation,
Leukoplakia
Grade 2
(Major)
Atypical vessels, fragile vessels, Irregular surface,
Necrosis, Ulceration(necrotic), tumor/gross neoplasm
Suspicious for invasion
Stenosis,
Congenital anomaly,
Post treatment
consequence
Endometriosis,
Condyloma,
Polyp
(Ectocervical/
endocervical)
Erosion
(traumatic)
Inflammation
Miscellaneous finding

19. Nomenclature committee 2011
Jim Bentley -Canada
Jacob Bornstein –Israel (Chairman of the
Committee)
Peter Bosze–Hungary
Frank Girardi–Austria
Hope Haefner-USA
Michael Menton–Germany
MyriamPerrota–Argentina
Walter Prendiville–Ireland
Peter Russell -Australia
Mario Sideri–Italy

20. The new IFCPC nomenclature for cervix,
(vagina and vulva)
WWW.IFCPC.ORG
Bornstein et al
Amer J Obstet Gynecol
Vol 120 No 1 July 2012

21. 2011 committee considerations
Establish an evidence base
KeratosisvLeukoplakia
Inside/outside TZ
Size of lesion
Inner border and ridge signs
Treatment types

24. Abnormal vessel
Coarse punctation

27. Colposcopic features suggestive of
highgradedisease (major change)
A generally smooth surface with an sharp outer border.
Dense acetowhite change, that appears early and is slow to resolve; it may
appear oyster white.
Iodine negativity, a yellow appearance in a previously densely white
epithelium.
Coarse punctation and wide irregular mosaics of differing size.
Dense acetowhite change within columnar epithelium may indicate
glandular disease.

28. New S C Junction
Columnar
Original
squamous epithelium
Crypt openings

32. Dr SC Quek
Polyps

35. Size of cervical lesions
Kierkegaard 1995: lesion size has independent
predictive value
Ferris 2005: Size of cervical lesions correlates directly with
the severity of disease.
Hopmanet al. 1995 reported an inter-observer
agreement rate of 68% when evaluating colposcopic
photographs for lesion size.
Hammes2007: Lesions >50% of cervix had higher
probability for high-grade lesion / carcinoma (OR, 3.45).
Prof Jacob Bornstein

38. New colposcopic sign-Ridge sign
An opaque acetowhite ridge
at the squamocolumnar junction
Prof Jacob Bornstein
Scheungraber C, Koenig U, Fechtel B, Kuehne-Heid R, Duerst M, Schneider A. The colposcopic feature ridge sign is associated withthe
presence of cervical intraepithelial neoplasia 2/3 and human papillomavirus 16 in young women. J Low Genit Tract Dis. 2009;13(1):13-
16.

39. A New Scoring System
Strander et al 2005
Designed to evaluate a scoring system for high
grade lesions
297 examinations of women referred for
colposcopy, Department of Obstetrics and
Gynecology, Göteborg, Sweden
First Scoring system to incorporate lesion sizeas a
variable
Subsequently validated at the Royal Free

40. Aceto-white
colour
Iodine stainingVascular Pattern
Peripheral Margins

41. 0 1 2 Score
ACETO UPTAKE Zero or transparentShady, Milky
(not transparent
not opaque)
Distinct, opaque
white
MARGINS/
SURFACE
Diffuse Sharp but
irregular, jagged,
“geographical”
Satellites
Sharp and even,
difference in
surface level incl
“cuffing”
VESSELS Fine, regular Absent Coarse or atypical
LESION SIZE <5mm 5-15mm or 2
quadrants
>15mm or 3-4
quadrants or
endocervically
undefined
IODINE STAINING Brown Faintly or patchy
yellow
Distinct yellow
Total score
10

42. The transformation zone
A Type 1 transformation zone is completely
ectocervicaland fully visible, and may be small
or large
AType 2transformation zone has an
endocervicalcomponent, is fully visible, and
may have an ectocervicalcomponent that may
be small or large
A Type 3 transformation zone has an
endocervicalcomponent that is not fully visible
and may have an ectocervicalcomponent that
may be small or large

43. Type 1
•Completely
ectocervical
•Fully visible
•small or large
Transformation Zone
Classification

44. SBX1739_3
Histology CIN1
Cytology LSIL,CIN 1;Atyp
endocerv,
neopl
Carcinogenic
HPV
16, 58, 66
Age 28
Category Mario Walter
SCJ visibilityFully Visible Fully Visible
TZ type Type 1 -Small Type 1 -Small
TZ patternAbnormal Grade 1Abnormal Grade 2
Image qualityGood Good
Jim Usha
Partially Visible Partially Visible
Type 2 -Large Type 1 -Large
Abnormal Grade 2 Normal
Good Limited

45. SBX1759_3
Histology CIN3
Cytology LSIL,CIN 1;Atyp
endocerv,
neopl
Carcinogenic
HPV
16, 51
Age 25
Category Mario Walter
SCJ visibilityPartially VisibleFully Visible
TZ type Type 2 -Small Type 1 -Small
TZ patternAbnormal Grade 2Abnormal Grade 1
Image qualityGood Limited
Jim Usha
Fully Visible Fully Visible
Type 1 -Small Type 1 -Small
Abnormal Grade 1 Normal
Good Good

46. Type 2
•has
endocervical
component
•Fully visible
•may have
ectocervial
component
which may be
small or large
Transformation Zone
Classification

48. SBX1842_1
Histology CIN3
Cytology HSIL,CIN
3;Adeno, NOS
Carcinogenic
HPV
16, 18
Age 30
Category Mario Walter
SCJ visibilityPartially VisiblePartially Visible
TZ type Type 3 -Small Type 2 -Small
TZ patternAbnormal Grade 2Suspicious for invasion
Image qualityLimited Limited
Jim Usha
Fully Visible Fully Visible
Type 2 -Small Type 1 -Small
Abnormal Grade 2 Abnormal Grade 2
Good Limited

49. Transformation Zone
Classification
Type 3
•has endocervical
component
•is notfully visible
•may have
ectocervial
component which
may be small or
large

51. SBX1216_2
Histology CIN3
Cytology HSIL,CIN 2;Adeno
in situ (AIS)
Carcinogenic HPV31
Age 21
Category Mario Walter
SCJ visibilityNot Visible Partially Visible
TZ type Type 3 -Small Type 2 -Small
TZ patternAbnormal Grade 1Abnormal Grade 2
Image qualityGood Good
Jim Usha
Not Visible Fully Visible
Type 3 -Small Type 1 -Large
Abnormal Grade 2 Abnormal Grade 1
Good Good

52. SBX1774_1
Histology CIN3
Cytology HSIL,CIN
3;Adeno, NOS
Carcinogenic
HPV
16
Age 47
Category Mario Walter
SCJ visibilityNot Visible Partially Visible
TZ type Type 3 -Small Type 2 -Small
TZ patternAbnormal Grade 2Suspicious for invasion
Image qualityGood Good
Jim Usha
Not Visible Not Visible
Type 3 -Small Type 3 -Large
Suspicious for invasionSuspicious for invasion
Good Good

53. SBX1928_1
Histology CIN3
Cytology HSIL,CIN
3;Adeno, NOS
Carcinogenic
HPV
16, 39
Age 30
Category Mario Walter
SCJ visibilityNot Visible Not Visible
TZ type Type 3 -Small Type 3 -Small
TZ patternAbnormal Grade 2Abnormal Grade 2
Image qualityGood Good
Jim Usha
Partially Visible Fully Visible
Type 3 -Small Type 1 -Small
Abnormal Grade 1 Abnormal Grade 1
Good Good

58. The BSCCP invites
you to the
15
th
World
Congress
On behalf of
IFCPC
In London
26-30
th
May 2014
www.IFCPC2014.
com

59. www.IFCPC2014.com
Bemvindoa Londresal 26de30 de Mayo 2014
Queen Elizabeth II conference centre

60. Westminster Hall for the plenary sessions
Up to 2160 delegates
2070 m
2
exhibition space

61. ¡NosvemosemLondres !2014
St James’s Park –5 minutes walk from venue

62. Shopping...................
Covent Garden, London

63. National Institute of Medical Research-The biology of HPV and molecular markers
WolfsonInstitute of Preventive of Medicine-Screening across the world
St Thomas’s Hospital –Improving Cytology
Institute of Women’s Health
Imperial College
Post Congress Seminars

64. See you in London