Colposcopy.Pdf

CCololppooscoscoppyy

► Chris DeSimone, M.D. ► Gynecologic Oncology ► Images from Colposcopy Cervical Pathology, 3rd Ed., 1998 HistoHistorryy

► ColColpposcopyoscopy wwasas ppiioneeredoneered inin GGeermrmaanyny bbyy DrDr.. HinselmannHinselmann dduriurinngg tthhee 19201920’s’s ► HeHe sousougghtht ttoo prprooveve ththaatt micmicrroscopicoscopic eexaminxaminaationtion ofof thethe cervixcervix wouwoulldd detectdetect cervicalcervical ccancanceerr eeararlliierer tthhaann 44 ccmm ► HisHis workwork identidentiifiefiedd severalseveral atatyypicalpical appeappeararanancceses whwhicichh araree stistillll usedused ttooddaay:y: . Luekoplakia . Punctation . Felderung (mosaicism)

Colposcopy Cervical Pathology 3rd Ed. 1998 HistoHistorryy

► ThrThrooughugh thethe 3030’s’s aanndd 4040’s’s brbreaeaktkthrhrouougghshs wwereere mamaddee regregaarrddinging whwhicichh aapppepeararancanceess wweerere moremore liklikelelyy toto prprogogressress toto invinvaasivesive ccaarcinomrcinomaa;; HHOOWEWEVVERER,, ► TheThessee ffiinndingsdings wweerere didifffficiculultt toto inteinterrpretpret sincesince theythey werweree notnot corcorrrelatedelated wwithith histologhistologyy ► OneOne resreseaearcrchherer wwouldould claclaiimm hhiiss ppatatientsients wwithith XX ffindindiingsngs nevernever hahadd ccaarcinomarcinoma whwhililee aannothotheerr emphemphaatiticcallyally belibelieevedved itit diddid ► WorldWorld wiwidede colposcopycolposcopy waswas uunnderderuutitillizizeedd asas aa diadiaggnosticnostic tooltool sseeconcondadaryry ttoo tthheseese discrepadiscrepannciescies HistoHistorryy

►►PapaniPapanicocolaoulaou aanndd TraTrauutt rrevevoolutionlutioniizezedd scrscreeeeninningg ofof cecerrvvicicaall cancecancerr wwitithh cytocytollogogyy ►►IItt wwaass easyeasy ttoo ccoolllelectct aanndd prprovideovidedd aa moremore obobjejecctitivvee findinfindingsgs tthahann cocollpoposscocoppyy ►►PapPap tetestingsting wwaass rarapidlpidlyy acceacceptpteded iinn NNororthth AAmmeriericcaa andand WWestesteernrn EEururoopepe asas tthhee scrscreeeeninningg tteestst ooff cchohoicicee ►►IItsts acaccceeptptanceance inin GermGermaannyy wawass ppoooror Papanicolaou, Traut: Diagnosis of uterine cancer by the vaginal smear, 1943 HistoHistorryy

► DuringDuring tthehe 6060’s’s ccolposcopyolposcopy mmaadede aa reressuurrgencegence ► NeNeww ststuudiesdies shshoowedwed tthhatat detectiondetection ofof ccaarcinomrcinomaa-- iinn--sisittuu (C(CIISS)) oorr ininvvasiasivvee cacarrcincinoomama werweree betbettterer detecteddetected byby combcombiiningning cytologycytology wwithith colcolpposcopicoscopic directeddirected biopsiesbiopsies . Total 838 cases . Colposcopy 663 (79%) . Cytology 729 (87%) . Combination 828 (99%)

Navratil: Dysplasia, CIS and microinvasive carcinoma of the cervix uteri: Colposcopy, 1964. HistoHistorryy

►►TodTodayay ccoollpoposcoscoppyy hashas bebeeenn acceacceptpteded asas aa ddiaiagngnosostticic ttooooll inin eevavalluauatintingg ababnnormalormal ppapap teteststss ►►CCololpoposscocoppyy elelegaegantlntlyy iidentifidentifieses tthehe llocaocatitionon ofof aabbnnoormrmaall leslesiiononss allalloowwiningg ththee practpractitiitioonenerr ttoo obobtataiinn hhiiststololooggiicc sasammplpleses ►►IItsts utilityutility asas aa scrscreeeeninningg tteestst iiss lilikkelelyy finfinishisheded iinn westewesternrniizedzed nanatitiononss OOvververvieieww

►►CyCyttologicologic indicatindicatiioonsns foforr colpcolpososcocoppyy ►►CyCyttoollogogicic correlacorrelatiotionn wwitithh hhiissttololooggyy ►►ToolTools,s, TTecechniquhniqueses aanndd stastaininss ooff cocollpoposscocoppyy ►►NoNorrmalmal cocolplposcooscoppiicc ananaattoommyy ►►AbnAbnormalormal ccoollpoposcoscoppicic ananaattoommyy ►►UUnunusuasuall cocollpoposscocopipicc anatanatomomyy ►►TrTreeatmeatmenntt ofof aabbnnoormrmaall hihistostollogogyy IInndidiccatioationnss fforor CCololppooscoscoppyy

►►AbnAbnormalormal ppapap ttestsests susugggegestivstivee ofof cceervirvicalcal ddyyspsplalassiaia ►►TyTyppeses aarere claclasssisiffiieded acacccorordindingg ttoo BBeeththesesddaa 22000011 nnomomeenncclalattururee ►►BeBestst toto ddelielineateneate whwhiichch pappap tteestssts correlcorrelatatee wwithith mimilldd ddyysplsplasiasiaa andand ththoseose wwhihichch areare moremore sesevvereree 20012001 BBethetheessddaa NNoomenmenclclaattureure

► MildMild dysdyspplasilasiaa ► SevereSevere ddysplasiysplasiaa . HPV effect (Human . ASC-H (Cannot rule Papilloma Virus) out HGSIL) . ASC-US (Atypical . HSIL (High Grade Squamous Cells of Squamous Unknown Significance) Intraepithelial Lesion) . LSIL (Low Grade . CIS (Squamous Squamous Carcinoma In-Situ) Intraepithelial Lesion) 20012001 BBethetheessddaa NNoomenmenclclaattureure

►►GlaGlandulndularar aabbnnoormrmaalitlitiieess ►►SShhoulouldd bebe hahandndlleded wwitithh ututmostmost cacautioutionn .. AGAGCC (Atypica(Atypicall GlandulGlandulaarr CCeelllsls ofof UUnknnknoownwn SigniSignifficance)icance) .. AAIISS (Adenoc(Adenocaarcinomarcinoma IInn--SiSittu)u) ►►BBiiopopsysy memeddialial ttoo tthehe ttranranssfoforrmatmatiionon zzononee FrFreeqquueennccyy ofof AbAbnnoorrmmaall PPaapp TTeeststss

► Estimated 50 million pap tests are performed

each year ASCUS ► 5% are LGSIL abnormal HGSIL abnormal Cancer ► 2-3 Million ASCUS ► 1 Million LSIL ► 600,000 HSIL HistoHistollogicogic NNoomenmenclclaattureure

►►CCIINN (C(Ceerrvviiccalal InIntraetraepitpithhelielialal NeNeoploplasiasiaa)) .. CICINN 11 ccoorrreresspoponndsds ttoo mmiilldd dydyssplasiplasiaa .. CICINN 22 ccoorrreresspoponndsds ttoo modemoderaratete dysplasidysplasiaa .. CICINN 33 ccoorrreresspoponndsds ttoo severesevere dysdyspplasilasiaa .. CICISS aanndd CICINN 33 aarree thethe ssaameme entityentity HistHistopaopatholtholooggyy OOvververvieieww

►►CyCyttoollogogicic indindicaicationtionss ffoorr cocollpoposscocoppyy ►►CyCyttologicologic cocorrrelatrelatiionon withwith histologyhistology ►►ToolTools,s, TTecechniquhniqueses aanndd stastaininss ooff cocollpoposscocoppyy ►►NoNorrmalmal cocolplposcooscoppiicc ananaattoommyy ►►AbnAbnormalormal ccoollpoposcoscoppicic ananaattoommyy ►►UUnunusuasuall cocollpoposscocopipicc anatanatomomyy ►►TrTreeatmeatmenntt ofof aabbnnoormrmaall hihistostollogogyy HistoHistollogicogic ccororrreelatilatioonn

►►AsAs aa cocollpoposscocopipisstt,, hhiistostollogogyy isis moremore iimpmportortanantt tthahann ccytoytollogogyy ►►TheThe ccytoytollogogyy isis iimpmportortanantt fforor ttwowo reareassoonns:s: .. 1)1) indicationindication toto perfoperforrmm ccoolposcopylposcopy .. 2)2) ggiivesves tthehe colposcopistcolposcopist aa “hin“hintt”” ofof thethe histologyhistology ►►HiHistostollogogyy isis iimpmportortanantt fforor ddeettermerminininingg papatitieenntt treatmtreatmenentt ►►CyCyttoollogogyy dodoeses nnoott eqequauall hhisistotollogogyy HistoHistollogicogic ccororrreelatilatioonn

►►ASCASC--UUSS .. MosMostt cocommmonmon tytyppee ofof aabbnnoormarmall papapp .. IsIs itit aa prpremalignemalignaantnt chchanange?ge? .. No!No! RoughlyRoughly 770%0% ofof AASSCC--USUS ppaapsps aarere rreelatelatedd toto vvaaginitis,ginitis, aattrroophphy,y, ggraranulnulaationtion tisstissuue,e, chronicchronic cervicicervicittis,is, etcetc .. OnlOnlyy 3030%% araree dyspldysplaasticstic iinn nanaturturee ► 90% are CIN 1 ►5-10% are CIN 2-3 Morin et al. J Reprod Med, 2001 HistoHistollogicogic ccororrreelatilatioonn

►►LLSISILL .. CoCommmon,mon, 11 mmilillliionon ppaappss diadiaggnosnoseedd eeaachch yeayearr .. MosMostt errerrooneoneouuslysly mamannageagedd papapp testestt.. WWhhy?y? ►Pap repeated frequently ►HPV testing .. 330%0% ofof LLSILSIL ppaappss hhararborbor CICINN 22 andand CICINN 33 onon colcolpposcopicoscopic ddirectedirected biopsiesbiopsies .. ColColpposcopyoscopy nneedseeds toto bebe donedone fifirstrst aandnd forforeemostmost toto aasscertaincertain hhistoistollogicogic diadiaggnosisnosis HistoHistollogicogic ccororrreelatilatioonn

►►ASCASC--HH .. 2828--440%0% ofof thesethese ppaapp testtestss areare CICINN 22--33 onon histologihistologicc biopsbiopsyy .. AAcccordicordinngly,gly, HPVHPV testingtesting isis positivepositive 7070--886%6% .. ColColpposcopicoscopic eexaminxaminaationtion wwiillll revealreveal aa wwiiddee rrananggee ofof ffindindiingngss ►►HHSISILL && CICISS .. ExpExpeectct wwoorrrisomerisome colcolpposcopicoscopic abnabnorormalimalittiesies

wwithith thethessee pShperaamappn. Am tete J Clissn tsPathtsol 2001 CCololppooscopicscopic CCororrreelatilatioonn

► MildMild dysdyspplasilasiaa ► SevereSevere ddysplasiysplasiaa . Acetowhite changes . Dull, pearly grey . Bright white epithelium . Clear demarcation . Faint to difficult to between normal and interpret demarcation abnormal epithelium between abnormal and normal epithelium . Fine punctations normal epithelium . Coarse punctations . Mosaicism . Abnormal vessels OOvververvieieww

►►CyCyttoollogogicic indindicaicationtionss ffoorr cocollpoposscocoppyy ►►CyCyttoollogogicic correlacorrelatiotionn wwitithh hhiissttololooggyy ►►ToToools,ls, TTeecchnhniiqqueuess aandnd staistainnss ofof colpcolpososcocoppyy ►►NoNorrmalmal cocolplposcooscoppiicc ananaattoommyy ►►AbnAbnormalormal ccoollpoposcoscoppicic ananaattoommyy ►►UUnunusuasuall cocollpoposscocopipicc anatanatomomyy ►►TrTreeatmeatmenntt ofof aabbnnoormrmaall hihistostollogogyy TTooololss,, TTeecchhnniiqquueses && SSttaaininss

►►CCololpoposscocoppee .. SteSterreoscopiceoscopic binoculabinocularr mmicicrosrosccopeope .. MMagagninificficatioationn fromfrom 88×× toto 4400×× .. GeGennerallyerally ppaanonoraramimicc viviewew atat 1010×× mostmost useuseffulul .. AA greengreen fifilterlter ►Used to highlight vascular patterns ►Demarcate color differences between normal and abnormal tissue CCololppooscoscoppee TTooololss,, TTeecchhnniiqquueses && SSttaaininss

►►IInnststrurummeennttss .. KevorkiKevorkianan--YoYouungenge biopsybiopsy forceforceppss .. EnEnddocervicaocervicall cucurretteette .. EnEnddocervicaocervicall brbruusshh .. CCytytoologylogy bbrruusshh .. SilvSilveerr NiNitrtrateate stickstick .. MoMonnsesell’s’s solutionsolution InInsstrtruumentsments Curette

Kevorkian Cytology Broom InInsstrtruumentsments

Endocervical Brush Lugol’s

Monsel’s Silver Nitrate Stick TTooololss,, TTeecchhnniiqquueses && SSttaaininss

►►SStataiinsns .. 3%3% AceAcetiticc AciAcidd .. WoWorrksks aass aa ddesicesicccaanntt .. TheThe cecelllluularlar cytoplasmcytoplasm isis reducedreduced enhenhaancingncing aa prproominmineentnt nnuclucleeuuss .. TheThe nucleusnucleus isis enlenlaargrgeedd seconsecondadaryry ttoo HHPPVV replrepliicationcation .. ThisThis nuclearnuclear enlargenlargeementment isis seenseen asas aacetowhicetowhittee chachanngesges AAccetetiicc AcAcidid TTooololss,, TTeecchhnniiqquueses && SSttaaininss

►►SStataiinsns .. LugoLugoll’s’s iioodinedine solutionsolution (Schi(Schilllerler test)test) .. WoWorrksks bbyy sstatainingining glyglyccogeogenn .. DysDyspplasticlastic titisssuesue hhaass anan iinncrecreaasedsed metabolicmetabolic rrateate thetherrebyeby loweringlowering cceelllulullaarr glycogenglycogen .. NoNorrmalmal tisstissuuee ststaainsins black/brblack/broownwn whwhililee dysdyspplasticlastic titisssuesue aapppepeaarsrs highlightedhighlighted oror yelyelllowow .. UseUseffulul stainstain fforor hahardrd ttoo seesee lelessionsions LLuugolsgols SSoolulutitioonn TTooololss,, TTeecchhnniiqquueses && SSttaaininss

►►TTeechniqchniqueue .. OriOrieentnt colposcopecolposcope soso tthhatat aa papanonoraramimicc viviewew isis obobttainedained .. SSttaartrt wwithith nonorrmalmal llightight aanndd 110×0× mamaggninificficatioationn .. EntiEntirree cervixcervix shouldshould bebe visualizedvisualized .. AppAppllyy genergeneroousus aamountmount ofof aceticacetic aaccidid wwhilehile cleaningcleaning ooffff obscuriobscurinngg mucomucouuss oror dischdischaarrggee .. YouYou cancan nevernever apapplyply tootoo muchmuch aacceticetic acidacid TTooololss,, TTeecchhnniiqquueses && SSttaaininss

►►EEvvalaluauattee ththee squamocsquamocoolluummnnarar jjuunnctictionon ((SCSCJ)J) oorr trtraansnsfoformrmaationtion zzononee (T(TZ)Z) .. DysDyspplasilasiaa originatoriginateess fromfrom thisthis bounboundadaryry aanndd sprspreeaaddss latlatereralal toto thisthis junctionjunction .. MedialMedial toto thisthis bobordrderer araree cocollumumnanarr cecellllss/gl/glaandulndulaarr cellscells .. AA lalarrgege volumevolume ofof glaglannduldulaarr celcelllss aarree calcallleded ectropionectropion .. YoungYoung wwomenomen anandd pprregnegnaantnt wwomenomen genegenerarallylly hhaaveve ectropionectropion CCololppooscoscoppyy 3% Acetic acid applied to cervix Cervix viewed under magnification and green light Entire transformation zone must be visualized Squamocolumnar Junction Ectropion or glandular cells

Squamous Epithelium

Endocervical Os Dysplastic epithelium will be “acetowhite” due to higher Nuclear/cytoplasmic ratio SqSquamuamooccoluolummnarnar JJuunnctctiioonn

SCJ TTooololss,, TTeecchhnniiqquueses && SSttaaininss

► EEvvalualuaatete arareeasas ofof acetowhacetowhiitete chachanngesges . Are they small or larges patches? . Does it have a sharp or indistinct border? . Is it a bright white or a dull, pearly grey? ► EEvvalualuaatete arareeasas ofof pupunnctationctation . Are the punctations small or large caliber? . Are the punctations sparse or numerous? ► EEvvalualuaatete arareeasas ofof mosaicimosaicissmm ► EEvvalualuaatete arareeasas ofof ababnnorormmalal bloodblood vesvessselsels . Are the blood vessels uniform or sporadic? . Are the vessels large caliber or small caliber? AAddeeqquacyuacy ofof CCololppooscoscoppyy

► Must evaluate the entirety of the lesion . Can you follow the entire lesion? . Does it go past the SCJ and into the endocervix? . Does it move into the vagina? ► Must evaluate the entirety of the SCJ . Is it obscured by prior treatments? . Does it recede into the endocervix? ► Proper evaluation of both the lesion and the SCJ is an adequate colposcopy ► Failure of either criteria is an inadequate colposcopy and leads to changes in treatment NOT diagnosis of histopathology BBiioopsiespsies

►►BeBestst toto oobbttainain bbiiopopsysy ooff wwoorstrst arareeaa ►►TTryry ttoo iincncoorporporrateate SCSCJJ iiff aatt allall poposssisiblblee ►►MuMultipltiplele bbiiopopsiessies araree rereccoommmemennddeedd bubutt shshoulouldd bebe kkeepptt wwithiithinn reareassoonn (2(2--33)) ►►EndEndocerocervvicicaall ccuurerettttageage ((ECECC)C) sshhooululdd ggeneneraleralllyy bbee iincncluluddeedd aass paparrtt ooff eaeacchh cocolplposcooscoppyy ►►HaHavinvingg tthehe papatitieenntt cocougughh ddururiningg bbiiopopsysy iiss ggoooodd didistracstractiotionn TToo ECECCC oorr notnot toto EECCCC

► NeNevverer wwrorongng toto performperform ► HoHowweveeverr,, ECECCC cacann bebe avoidedavoided ifif enenttireire lleesionsion isis visibvisibllee onon ectocervixectocervix ► ThisThis positionposition iiss sstrtrengengtthenheneedd sincesince sqsquauamousmous dysdyspplasilasiaa isis ccontinuontinuoous;us; iitt ddooeses notnot sskkipip ► OthersOthers prproclaoclaiimm itit evaluevaluaatestes occultoccult endendoocervicalcervical dysdyspplasilasiaa ► UltUltiimamattee decidecissionion lilieess wwithith wiwisdsdoomm andand expeexperrtisetise ofof practitpractitiioneonerr Williams. Obstet Gynecol, 2000 EECCCC

► MosMostt uncomuncomfforortatableble portiportioonn ofof colcolpposcopicoscopic directeddirected biopsiesbiopsies ► GoGooodd toto hhaaveve patpatiientent ttakeake NSAIDNSAID 3030 miminn beforebefore colcolpposcoposcopyy ► AppAppllyy cucurretteette atat fourfour cacardinalrdinal ddirectirectiiononss ► SwirSwirll cucurretteette inin fifixxativativee thenthen ttaakeke endoendoccervicalervical bbrruusshh toto cocolllleectct restrest ofof sasammpleple ► ProProsspectpectiiveve rraannddoomizmizeedd trialtrial sshhoowwinging betterbetter resuresulltsts wwiithth curecurettttee aanndd bbrrushush tthhaann eithereither aalloneone Tate. Obstet Gynecol, 1997 OOvververvieieww

►►CyCyttoollogogicic indindicaicationtionss ffoorr cocollpoposscocoppyy ►►CyCyttoollogogicic correlacorrelatiotionn wwitithh hhiissttololooggyy ►►ToolTools,s, TTecechniquhniqueses aanndd stastaininss ooff cocollpoposscocoppyy ►►NormalNormal colpcolpososcocoppicic anatoanatommyy ►►AbnAbnormalormal ccoollpoposcoscoppicic ananaattoommyy ►►UUnunusuasuall cocollpoposscocopipicc anatanatomomyy ►►TrTreeatmeatmenntt ofof aabbnnoormrmaall hihistostollogogyy NNoorrmmalal CCololppooscoscoppyy NNoorrmmalal HistoHistollooggyy NNoorrmmalal CCololppooscoscoppyy//EctrEctroopionpion NNoorrmmalal CCololppooscoscoppyy NNoorrmmalal CCololppooscoscoppyy NNoorrmmalal CCololppooscoscoppyy CClloosese--uupp ofof SSCCJJ OOvververvieieww

►►CyCyttoollogogicic indindicaicationtionss ffoorr cocollpoposscocoppyy ►►CyCyttoollogogicic correlacorrelatiotionn wwitithh hhiissttololooggyy ►►ToolTools,s, TTecechniquhniqueses aanndd stastaininss ooff cocollpoposscocoppyy ►►NoNorrmalmal cocolplposcooscoppiicc ananaattoommyy ►►AbnoAbnorrmalmal colpcolpososcocoppicic anatoanatommyy ►►UUnunusuasuall cocollpoposscocopipicc anatanatomomyy ►►TrTreeatmeatmenntt ofof aabbnnoormrmaall hihistostollogogyy AAbbnnoorrmmalal CCololppooscopicscopic AAnatnatoomymy

►►AcAcetetoowhiwhittee eepitpithhelieliumum oror chachanngesges ►►PPununctactatiotionsns ►►MosaicismMosaicism ►►AbnAbnormalormal VVesessselsels ►►InInvvasiasivvee ccaarcircinnomaoma AAbbnnoorrmmalal CCololppooscopicscopic AAnatnatoomymy

►►AcAcetetoowhiwhittee chachannggeess .. MilMilddestest chchanangesges ofof cecervicrvicaall dysplasidysplasiaa .. CaCauusseded byby desiccationdesiccation ofof ccyytopltoplaasmsm ffromrom aceticacetic acidacid leadingleading ttoo ininccrereasaseded nuclnucleeaarr /cytoplasmic/cytoplasmic rratioatio .. OtherOther aarreeasas ofof ababnnorormmalal chachanngege cancan bebe ffouounndd wwithithiinn aaccetoetowwhitehite llesionesionss .. OOftfteenn timestimes ververyy clecleaarr aarreeaa ofof demdemaarcrcaationtion fromfrom nonorrmalmal toto aabnbnorormalmal NNoorrmmalal versversuuss AbAbnnoorrmmaall

SCJ PostPost AAccetetiicc AcAcidid AAccetowetowhhiteite cchanhanggeses AAccetowetowhhiteite cchanhanggeses AAccetowetowhhiteite cchanhanggeses

Mosaicism Line of demarcation LLiinnee ofof ddemaremarccatioationn AAccetowetowhhiteite cchanhanggeses

Punctations FFaaiintnt AAccetowetowhhiteite LLeesisioonn FFoouunndd PunctatioPunctationnss

►►PPununctactatiotionsns areare vvesselsessels tthathat rruunn peperrppendendiicucularlar ttoo ththee pporortitioo ofof tthhee cecerrvivixx ►►TheTheyy areare eenndd oonn eendnd toto tthehe cocollpoposcoscoppisistt ►►TheThe greengreen filfilteterr remremovoveses rreded lighlightt ththuuss vvesselsessels areare dardarkenkeneded ►►PPununctactatiotionn cancan bebe smalsmalll vvesselsessels ((finfinee punpunctactatiotion)n) oror llargearge vveesselsssels ((ccoaroarssee punpunctactatiotion)n) PunctatioPunctationnss

Coarse Punctations

Coarse Punctations PunctatioPunctationnss

Fine Punctations PunctatioPunctationnss

Bright Acetowhite lesion with coarse punctations MosaMosaiciciissmm

►►AA mosaicmosaic isis aa llaargerge imageimage ppieiecceded ttoogetgetheherr bbyy ssmalmalllerer uusuasuallllyy cocololorfurfull titilesles ►►IInn ccoollpoposcoscoppyy iitt isis esessseentintialalllyy tthehe sasammee-- aa larlarggerer llesiesioonn mmadeade ofof ssmalmalll hheeapedaped eepitpithhelielialal islaislandndss andand tintinyy vvesessselsels ►►TheThesese islaislanndsds lloookok liklikee aa ccoobbbblleeststononee roadroad ►►IslIslanandsds areare seseppaarratedated bbyy vvesessselsels rrunninunningg parallparallelel toto tthehe poportirtioo oorr cocollpoposscocopipistst MosaMosaiciciissmm Large lesion Islands composed of multiple islands and intervening small vessels MiMicroscopiccroscopic MosaMosaiciciissmm MosaMosaiciciissmm MosaMosaiciciissmm Area of mosaicism with large punctations consistent Punctations with CIN 3 AAbbnnoorrmmalal VessVesseellss

►►IInn tthehe nanatturaurall prproogressigressionon ofof ddyyspsplalassiaia ttoo ininvvaassiivvee cecerrvvicicaall cancecancerr,, mmaannyy ggeneneetticic anandd papaththoologlogicic chachannggeess occuroccur ►►OnOnee iimmpoportrtantant chachannggee isis aangngiiooggenenesisesis ►►TheThe eevvolvinolvingg carcicarcinnomaoma nneeedseds ooxxyyggenen andand nunuttrriiententss ttoo grgrooww atat anan eexpoxponnententiaiall raterate ►►IInn oorderrder toto achachieieveve maximamaximall grgroowwthth,, nneeww bblloooodd vveesselsssels aarree ssynthynthesiesizzeded AAbbnnoorrmmalal VessVesseellss

►►TheThe nneewwllyy crecreaatteedd vvesselsessels areare peperfrfectect forfor ppoolinoolingg bblloooodd ►►TheTheyy hahavvee llowow flfloow,w, littllittlee pupulsalsativitivittyy aanndd ppoooorr rreesissisttanceance ►►TheThe ababovovee facfacttorsors areare causedcaused bbyy mmultipultipllee ttribuributariestaries arisiarisinngg ffromrom ananyy oonnee vveesselssel ►►EndEnd reressulultt iiss lliikkee aa ddelteltaa ffrromom aa rriivveer,r, lloottss ofof nunuttrriiententss aarree brbroouughghtt iinn bubutt blblooodod isis ssllowow ttoo reretuturnrn EExxaammplpleess ofof NNoorrmmaall VVessesselelss AAbbnnoorrmmalal VessVesseellss NNoorrmmalal versversuuss AbAbnnoorrmmaall AAbbnnoorrmmalal VessVesseellss AAbbnnoorrmmalal VessVesseellss IInnvasvasivivee CanCanccerer

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Polyp

Polyp PoPollyyppss NNaabbooththiianan CCyyststss Normal Vessels NNaabbooththiianan CCyyststss Prominent vessels of normal caliber surrounding multiple Nabothian cysts ConConddyylloommaass Heaped vaginal/ cervical condyloma in a gravid female OOvververvieieww

►►CCryryososuugegerryy ►►LoLooopp EEllectectriricosurcosurgigicalcal EExcxciisisionon ProceProceddureure (L(LEEEP)EP) ►►LLasaserer AAbblalatiotionn ►►CCololdd KniKniffee CCononizizationation ►►HHyysstertereecctomtomyy CryosurgCryosurgeeryry

► InInexexpenpenssive,ive, easeasyy toto perform,perform, tolertoleraatedted wwelelll byby patipatieentntss ► CellsCells areare desdesttroyroyeedd bbyy (co(colld)d) tthhermalermal ddaamamaggee ► 33 miminutnutee frefreeeze/ze/ 11 miminutnutee ththaaw/w/ 33 miminnuteute ffreereezzee wwelelll docdocuumentedmented ttechniqueechnique ► DoesDoes ccaauseuse 22 --33 weweeeksks ofof malodomalodorrousous dischdischaarrggee ► DoesDoes hinderhinder rrepeepeaatt cocollposcopyposcopy ((SSCJCJ oftofteenn obscureobscuredd)) LLEEEPEP

►►ProceProcedudurere ofof cchohoicicee forfor mostmost OOB/B/GYGYN’N’ss ►►EasyEasy toto perfoperforrm,m, wewellll ttololeratederated aanndd prprovideovidess spspeecicimmenen fforor ppatathohollogogicic eevvalualuatatioionn (M(Maargrginins)s) ►►GoGooodd rruulele ttoo kkeeepep spespecicimensmens llessess tthanhan 44 cmcm wwididee aanndd 22 cmcm ttallall ►►CCononcercernn tthathat multipmultiplele eexcixcisiosionsns oror oonene llargearge exexcicisisionon wiwillll iincreancreassee rraatete ooff pprreettermerm lalabobor/r/inincompcompeteteenntt cercervivixx PPrreteretermm DDelieliveryvery anandd LLEEEPEP

►►KyrgKyrgiiouou etet aall.. LancetLancet 22000606;; 367367:: 448989--998.8. ►►MeMettaa--aananallyysissis ofof 2277 sstudtudiieess ►►StudStudieiess chchoosensen hahadd toto hhavavee aa coconnttrolrol grgrououpp ►►EEvvalaluauatiotionn ofof CKC,CKC, LLEEEEPP aanndd llaseaserr fofor:r: .. preprettermerm delidelivveryery ((<<3377 weweeeksks ggestestatation)ion) .. LLooww birtbirthh wweieightght ((<<25025000 g)g) .. CeCesasarereanan deldeliiververyy PPrreteretermm DDelieliveryvery anandd LLEEEPEP

► CCKCKC . Preterm delivery- RR 2.59 (95% CI 1.80-3.72) . Low birth weight- RR 2.53 (95% CI 1.19-5.36) . Cesarean section- RR 3.17 (95% CI 1.07-9.40) ► LEEPLEEP . Preterm delivery- RR 1.70 (95% CI 1.24-2.35) . Low birth weight- RR 1.82 (95% CI 1.09-3.06) . Cesarean section- RR 2.69 (95% CI 1.62-4.46) ► LaseLaserr . NS for Preterm delivery- RR 1.71 (95% CI 0.93-3.14) PPrreteretermm DDelieliveryvery anandd LLEEEPEP

►►SumSummmararyy

►►CKCCKC papattiiententss aarree 2.2.55 ttiimesmes moremore llikelikelyy toto hhavavee aa prpretetermerm ddeliveliveeryry,, loloww bbiirrtthh weweighightt ininfafanntt aanndd//oror cesacesarreanean sesecctiontion ►►LLEEEEPP 1.1.55 ttiimesmes moremore llikelikelyy ►►IInnciciddenencece ofof pprreettermerm dedelilivveerryy isis 22--3%3% .. CCKKCC ~~ 77..5%5% (1(1 inin 1155 wowommen)en) .. LEEPLEEP ~~ 44.5%.5% (1(1 inin 2200 wowommen)en) MaMarrginsgins andand LLEEEEPP

►►MMarargiginn stastattusus hheelpfulpfull inin prepreddiictinctingg recrecuurrerrenncece ofof cceerrvviiccalal ddyysplsplasiasiaa ►►NeNeggatatiivvee margmargiinsns ~1~155%% ►►PosPositivitivee mamarrgiginsns ~~ 3030--660%0% ►►ReRe--exexcicisisionon nnotot nneeedededed.. FoFollloloww patpatienientt wwithith serialserial ppapap ttestsests andand treattreat acacccorordinglydingly ifif papatitieenntt recrecuursrs

Dietrich, Obstet Gynecol 2002 LaserLaser

►►CCO2O2 lalasserer worksworks bbyy vvaapoporirizzinging cecerrvvicicaall ccelellsls ►►VeVerryy pprreciecissee memeththood;d; oonnllyy nneeeded 55--77 mmmm ofof vvapapororizizatatioionn foforr treatmetreatmenntt ►►HealsHeals ggrreaeat,t, spspaaresres cercervvicalical exexcicisisiononss ►►CCOSOSTT mmajoajorr prproboblleemm ►►NoNo papaththoologlogyy sspepecicimenmen CCololdd KKninifefe CoConiznizatioationn (CKC)(CKC)

►►UsedUsed ttoo bebe tthehe treatmtreatmenentt ooff cchohoicicee bbefeforeore LLEEEEPP ►►SSuurgrgicaicallllyy eexcixcisseses dydysplsplasiasiaa wwitithh scascallppeell//scissorscissorss ►►LLarargege ccostost ttoo ppatatienientt fromfrom phyphysiciasiciann,, anesanestthheesia,sia, anandd hohospispitatall chargescharges ►►IInnccoommppeteteenntt cercervivixx aann issueissue ►►IndiIndicatcatioionsns ttoo pperferfoormrm areare fefeww HysterectHysterectoomymy

►►TheThe ffininalal ttrreaeattmemenntt fforor cecervirvicalcal ddyyspsplalassiaia ►►CCoomesmes wwitithh ssigniigniffiicancantt morbmorbidityidity// mortamortalitlityy anandd llengthengthyy rreeccovoveerryy (6(6 weeks)weeks) ►►CCoommpliplicatcatioionsns iinnclucluddee:: hheemorrhagmorrhagee,, ininffeecctiotionnss,, bobowwelel && blbladadddeerr ininjjuurriiees,s, MMII,, pulpulmmoonarynary eemmboboluluss,, ssttroke,roke, deadeatthh ►►1010--2200%% ofof ppatatiienentsts wwililll ccontinontinuuee toto hhavavee ababnnormalormal ppapap ttests:ests: vvagiaginalnal ddyysplasiasplasia EffEffiicacycacy ofof trtreeaattmentment

►►RandRandoomimizzeded concontrtroollleledd trtriialal bbetetwweeeenn crcryoyosursurggeery,ry, LEEPLEEP anandd lalasserer sshhowedowed nnoo stastatitisstticalical difdiffeferrenenccee inin eeffifficacaccyy ►►RecurrRecurreencnceess wwereere memeaasuresure frfroomm 66--3737 mmontonthhss ►►CCryryosuosurrgegerryy 1919%% ►►LLEEEEPP 13%13% ►►LLasaserer 13%13% Mitchell, Obstet Gynecol 1998. EffEffiicacycacy ofof trtreeaattmentment

► ReReicichh etet al.al. pperformederformed twtwoo retretrrospospeectivctivee ststuudiesdies onon coldcold knikniffee conconiizatizatioonn ► 44441717 wwoomenmen wwithith CINCIN 33 wwereere ttrereatateded wwithith CCKCKC aanndd ffoolllloowedwed forfor medmediianan 110077 monthsmonths ((negnegaativetive mamarrginsgins)) ► OnlOnlyy 1155 wowommenen devedevellopeopedd recurecurrrreencence (0.(0.335%)5%) ► 339900 wowommenen wwithith CICINN 33 wewerree trtreeateatedd wwithith CCKCKC anandd ffoolllloowedwed forfor aa mmeediandian ofof 1199 yyeeaarsrs ((positivepositive mamarrginsgins)) ► 8844 wwomenomen developeddeveloped recrecururrerenncece (2(22%)2%) Reich, Obstet Gynecol. 2001 and 2002 WhWhiicchh methomethodd ttoo cchhose?ose?

►►SSeevveraleral facfacttorsors toto coconnsisideder:r: agagee,, dedesisirere forfor fefertility,rtility, sizsizee ofof llesiesionon,, sisizeze ooff ththee cercervix,vix, sesevvereritityy ofof ddyyspsplalassiiaa,, aanndd prprioiorr tthhereraappieiess ►►GeGenneraleraliizazatiotionns:s: .. CCrryoyossuurrggeryery-- bestbest forfor youyounngg wwoomenmen wwithith ffeeww ffinainanncesces aanndd CICINN 11 oror 2.2. .. LEEPLEEP-- ththee majoritmajorityy ofof wowommenen wwithith CICINN 22 oror 3.3. WomenWomen wwithith endocervicaendocervicall leslesiionsons alsoalso suitedsuited forfor LEEPLEEP WhWhiicchh methomethodd ttoo cchhose?ose?

.. LaserLaser-- wwomenomen whowho hhaaveve hadhad multmultiipleple recrecururrerenncesces ofof CCIINN 22 oror 33 aanndd whowho wantwant toto rerettainain fertifertillity.ity. ExExaamplmplee:: aa 1199 yyeeaarr oldold GG0 whwhoo hhaass CICINN 3,3, pprriorior LLEEPEEP,, anandd aa ssmallmall cervixcervix.. .. CCKKCC-- glaglannduldulaarr ababnonorrmalimalittiesies ((AISAIS)) oror eeaarlyrly invinvaasivesive cancercancer .. HysHystterectomyerectomy-- wwomenomen ffinishedinished wwithith chilchilddbebeararinging aandnd wwhoho hhaveave perspersiistestenntt CICIN.N. OOftfteenn bestbest uuttiillizizeedd wwithith oottherher gyngyneecolcoloogicgic prproboblemlemss llikeike pelvpelviicc painpain oror aabbnnoormarmall uteuterrineine blebleeedingding UnkUnknnownsowns UnkUnknnownsowns