This comprehensive textbook and atlas provides detailed guidance on the performance and interpretation of colposcopy, with a particular focus on the diagnosis of precancerous cervical, vulvar, and vaginal lesions. The book not only describes the role of colposcopy in state of the art cervical cancer screening and triage but also covers the prevention, diagnosis, and management of cervical cancer in low-resource settings, where the vast majority of cases occur worldwide. The indications for colposcopy are clearly identified, and its use is described in a variety of specific circumstances, including during pregnancy, following surgical interventions and radiation treatment, and in the immunocompromised patient. The book will be of value for gynecologists and gynecologic oncologists, general practitioners, and family practice doctors; furthermore, physician assistants, nurses, and midwives will find it very useful for training and as a source of reference, regardless of whether they are working within an established screening program based on cytopathology and/or HPV testing or within a low-resource environment applying visual inspection as the primary screening strategy.
Author(s): Ralph J. Lellé, Volkmar Küppers
Publisher: Springer
Year: 2023
Language: English
Pages: 476
City: Cham
Preface
Acknowledgements
Contents
Abbreviations
1: Introduction
1.1 The Origin of Colposcopy
1.2 Acetic Acid Test
1.3 Schiller’s Iodine Test
References
2: Normal Anatomy of the Cervix
2.1 General Principles of Cervical Anatomy
2.2 Colposcopic Appearance of the Normal Cervix
References
3: Abnormal Findings of the Cervix
3.1 Introduction
3.1.1 Leukoplakia
3.1.2 Acetowhite Epithelium
3.1.3 Punctation and Mosaic
3.1.4 Abnormal Vessels
3.1.5 True Erosion Versus Ulceration
3.1.6 Atrophy
3.1.7 Inflammation
3.2 Intraepithelial Neoplasia
3.2.1 Low-Grade Dysplasia
3.2.1.1 Pathogenesis
3.2.1.2 Colposcopic Appearance
3.2.2 High-Grade Dysplasia
3.2.2.1 Pathogenesis
3.2.2.2 Colposcopic Appearance
3.3 Carcinoma of the Cervix
3.3.1 Epidemiology and Clinical Presentation
3.3.2 Colposcopic Appearance
3.4 Special Considerations on Cervical Adenocarcinoma and Adenocarcinoma In Situ (AIS)
References
4: International Nomenclature of Colposcopy
4.1 Cervix
4.2 Vagina
4.3 Vulva
References
5: Indications for Colposcopy
5.1 General Objectives
5.2 Triage of Abnormal Cytological Findings
5.3 Colposcopy as Triage of a Positive HPV Test Result
5.4 Other Indications
5.5 Contraindications
5.6 Summary of Colposcopy Indications of the Cervix
References
6: The Significance of Cytology, Biopsy, and HPV Testing
6.1 Cytology
6.1.1 Cytological Morphology
6.1.2 Cytological Nomenclature
6.1.3 Cytology as a Screening Tool
6.1.4 Liquid-Based Cytology
6.1.4.1 Principle of LBC
6.1.4.2 LBC Procedures
6.1.4.2.1 ThinPrep® (Hologic)
6.1.4.2.2 SurePath® (Becton Dickinson)
6.1.4.3 Morphological Features of Liquid-Based Cytology
6.1.4.4 Comparison of Conventional Cytology, ThinPrep®, and SurePath®
6.1.4.5 Computer-Aided Cytological Evaluation
6.1.5 Adjunctive Cytological Tests
6.1.5.1 DNA Ploidy Analysis
6.1.5.2 HPV L1 Capsid Protein Detection
6.1.5.3 p16/Ki67 Dual Stain (CINtecPlus®)
6.2 Biopsy
6.2.1 Histological Morphology
6.2.1.1 p16 (p16INK4a Protein) Immunohistochemistry
6.2.1.2 Reliability of Colposcopically Guided Biopsy Sampling
6.3 HPV Test
6.3.1 HPV Assays Suitable for Clinical Use
6.3.1.1 Hybrid Capture II Test (HC2)
6.3.1.2 Other HPV Assays
6.3.2 Clinical Application of HPV Testing
6.3.2.1 HPV Triage of ASC-US and LSIL
6.3.2.2 HPV Test for Post-Treatment Follow-Up (“Test of Cure”)
6.3.2.3 Primary HPV Screening
References
7: Colposcopic Examination
7.1 History Taking
7.2 Colposcopes
7.3 Handling of the Colposcope and Speculum
7.4 Cytological Smear
7.5 Tissue Sampling
7.5.1 Biopsy
7.5.2 Endocervical Curettage
7.6 Documentation
7.7 Practical Colposcopic Examination Step by Step
References
8: Operative Colposcopy
8.1 Risks for Future Pregnancies
8.2 Surgical Procedures
8.2.1 Cold-Knife Conization
8.2.2 Monopolar Loop Resection (LEEP)
8.2.3 Cryosurgery
8.2.4 CO2 Laser Vaporization
8.3 Assessment of Complete Removal of Cervical Dysplasia
8.3.1 Squamous Dysplasia
8.3.2 Adenocarcinoma In Situ (AIS)
References
9: Colposcopy of the Surgically Treated Cervix
9.1 State of Preservation of the Cervix
9.2 Visibility of the Transformation Zone
9.3 Stenosis of the Cervical Canal
9.4 Colposcopic Diagnosis of Persistent or Recurrent Cervical Dysplasia
References
10: Colposcopy During Pregnancy
10.1 Pregnancy-Related Changes of the Cervix
10.2 Management of Cervical Dysplasia During Pregnancy
10.3 Conization (LEEP) During Pregnancy
10.4 Management of HSIL After Delivery
References
11: Colposcopy of Radiation-Induced Changes
12: Colposcopy of the Vagina
12.1 Condylomata Acuminata
12.2 Adenoma
12.3 Vaginal Intraepithelial Neoplasia (VAIN)
12.3.1 Pathogenesis of VAIN
12.3.2 VAIN with Existing Cervix with or without Simultaneous CIN
12.3.3 VAIN Following Hysterectomy
12.3.4 VAIN and Immunosuppression
12.3.5 Colposcopic Appearance of VAIN
12.3.6 Treatment Options for VAIN
12.3.6.1 Wait and See
12.3.6.2 Partial or Total Colpectomy and Laser-Skinning Colpectomy
12.3.6.3 Cryosurgery
12.3.6.4 CO2 Laser Vaporization
12.3.6.5 Topical and Systemic Drug Treatment
12.3.6.6 Radiation Therapy
12.4 Vaginal Carcinoma
12.5 Vaginal Metastases
References
13: Colposcopy of the Vulva
13.1 Anatomy of the Vulva
13.2 Altered Self-Perception of the Vulva
13.3 Diagnosis of Vulvar Diseases
13.4 Nomenclature of Vulvar Diseases
13.5 Nonneoplastic Epithelial Changes of the Vulva
13.5.1 Lichen Sclerosus
13.5.2 Lichen Ruber Planus
13.6 Neoplastic Epithelial Changes of the Vulva
13.6.1 Condylomata Acuminata
13.6.2 Vulvar Intraepithelial Neoplasia (VIN)/HSIL of the Vulva
13.6.3 Paget’s Disease
13.6.4 Carcinoma of the Vulva
13.6.5 Malignant Melanoma
13.6.6 Follow-Up
References
14: The Immunocompromised Patient
14.1 The Relationship Between HIV and HPV
14.2 Management of the Immunocompromised Patient
References
15: HPV Vaccination
15.1 Structure of the HP Virus
15.2 Development of Prophylactic Vaccination
15.3 Indications for HPV Vaccination
15.3.1 HPV Vaccination for Children and Adolescents
15.3.2 HPV Vaccination for Men
15.3.3 Catch-Up HPV Vaccination
15.3.4 HPV Vaccination Following Treatment for Cervical Dysplasia
15.4 Efficacy of HPV Vaccination
15.4.1 Real-Life Effectiveness of HPV Vaccines
15.4.2 HPV Vaccination Efficacy in Glandular Lesions
15.4.3 Prophylaxis of Condylomata Acuminata through Gardasil®
15.4.4 Statistic Modeling of HPV Vaccination Impact
15.5 Adverse Reactions of HPV Vaccination and the Risk of Serotype Replacement
15.6 Impact of HPV Vaccination on Secondary Screening
References
16: Psychological Considerations of Screening and Triage
16.1 Psychological Effects of Screening for Cervical Cancer
16.2 Strategies to Reduce Psychological Distress
References
17: Cervical Cancer Prevention, Diagnosis, and Management Within a Low-Resource Environment
17.1 Introduction
17.2 Worldwide Cervical Cancer Statistics
17.3 Cervical Cancer Prevention
17.3.1 Barriers to Cervical Cancer Prevention
17.3.2 Primary Prevention: HPV Vaccination
17.3.3 Secondary Screening Strategies
17.3.3.1 Pap Test
17.3.3.2 Visual Inspection
17.3.3.2.1 Visual Inspection with Acetic Acid (VIA)
Rationale and Effectiveness of VIA
Practice of VIA
Target Population
VIA-Negative Patients
VIA-Positive Patients
Suspicious for Cancer
Squamocolumnar Junction Not Visible/Atrophy and Inflammation
17.3.3.2.2 Visual Inspection with Lugol’s Iodine (VILI)
Rationale and Effectiveness of VILI
Practice of VILI
17.3.3.2.3 Alternative Colposcopy Devices
17.3.3.3 HPV Test
17.3.3.4 HPV and HIV Infection
17.3.3.5 Reporting of Screening Results
17.3.4 Treatment of Preinvasive Disease
17.3.4.1 Cryotherapy
17.3.4.2 Loop Electrosurgical Excision Procedure (LEEP)
17.3.4.3 Hysterectomy
17.3.4.4 Vaginal and Vulvar Dysplasia
17.4 Cervical Carcinoma
17.4.1 Visual Cervical Cancer Diagnosis
17.4.2 Pitfalls of Cervical Cancer Diagnosis
17.4.3 Management of Patients with Invasive Cervical Carcinoma
17.4.3.1 Special Treatment Considerations (META Hospital, Mbeya, Tanzania)
17.4.3.1.1 Radiation Therapy
17.4.3.1.2 Pelvic Lymph Node Dissection
17.4.3.1.3 Neoadjuvant Chemotherapy
17.4.3.1.4 FIGO Staging
17.4.3.1.5 Preservation of the Ovaries and Bilateral Salpingectomy
17.4.3.2 Postoperative Bladder Dysfunction
17.4.3.3 Preservation of Fertility
17.4.3.4 Summary: Radical Surgery for Cervical Cancer
17.5 Conclusions and Outlook
17.6 Further Reading and Online Resources
References
18: Clinical Scenarios for Colposcopy Training
18.1 Cervical Dysplasia
18.1.1 Overtreatment of LSIL/CIN1
18.1.2 Cervix Before and After CO2 Laser Treatment for CIN2
18.1.3 Cervix Before and After LEEP for CIN2
18.1.4 Cervix Before and After LEEP for CIN2
18.1.5 Cervix Before and After LEEP for CIN3
18.1.6 Cervix Before and After LEEP for CIN3
18.1.7 Cervix Before and After LEEP for CIN3
18.1.8 Cervix Before and After LEEP for CIN3
18.1.9 Cervix Before and After LEEP and CO2 Laser Treatment for CIN3
18.1.10 Cervix Before and After LEEP and CO2 Laser Treatment for CIN3
18.1.11 Cervix Before and After LEEP and CO2 Laser Treatment for CIN3
18.1.12 Cervix Before and After LEEP and CO2 Laser Treatment for CIN3
18.1.13 Cervix Before and After LEEP and CO2 Laser Treatment for CIN3
18.1.14 CIN3 Presenting with Prominent Vessels
18.1.15 Diagnostic Surgery Revealing CIN3
18.1.16 CIN3 Look-Alike
18.1.17 Intracervical CIN3
18.1.18 CIN3 and HIV Infection
18.1.19 CIN3 and HIV Infection
18.1.20 Ruling Out Cervical Dysplasia Through Colposcopic Triage
18.1.21 Delayed Colposcopic Diagnosis of HSIL
18.1.22 Cervix After Three Surgical Interventions
18.2 Recurrent Cervical Dysplasia
18.2.1 HSIL Recurrence After Conization During Pregnancy
18.2.2 Suspected Recurrence After LEEP/CO2 Laser Treatment
18.2.3 Recurrence 16 Months After LEEP
18.2.4 Recurrence After Positive Endocervical Curettage
18.2.5 Large Recurrence 4 Months After Conization
18.2.6 Recurrence After Two Prior Conizations
18.2.7 Atrophy and Intracervical Recurrence
18.2.8 Cervical Stenosis After Two Conizations
18.3 Vaginal Intraepithelial Neoplasia
18.3.1 VAIN After Hysterectomy for HSIL/CIN3
18.3.2 VAIN3 and HSIL of the Vulva in a Liver Transplant Patient
18.3.3 VAIN3 Misdiagnosed as CIN3
18.4 Squamous Cell Carcinoma of the Cervix
18.4.1 Squamous Cell Carcinoma of the Cervix
18.4.2 Squamous Cell Carcinoma of the Cervix
18.4.3 Squamous Cell Carcinoma of the Cervix
18.4.4 Hidden Cervical Carcinoma After Prior Conization
18.4.5 Microcarcinoma of the Cervix
18.4.6 Long-Term Outcome of Cervical Carcinoma Treated by Conization
18.5 Cervical Adenocarcinoma
18.5.1 Adenocarcinoma of the Cervix
18.5.2 Adenosquamous Carcinoma of the Cervix
18.5.3 Villoglandular Carcinoma of the Cervix
18.6 Pregnancy
18.6.1 CIN3 at Tenth Week of Gestation with Postpartum Diagnosis of Microcarcinoma
18.6.2 CIN3 at 14th Week of Gestation
18.6.3 CIN3 at 17th Week of Gestation with 40 Months Colposcopic Follow-Up
18.6.4 CIN3 at 29th Week of Gestation
18.6.5 Suspected Cervical Cancer at Eighth Week of Gestation
18.6.6 CIN3 Postpartum
18.6.7 Persistent CIN3 in Pregnancy and Postpartum
18.6.8 Regression of CIN3 After Miscarriage at 10 Weeks of Pregnancy
18.7 Vulva
18.7.1 Acetowhite Epithelium of the Vulva
18.7.2 Paget’s Disease
18.7.3 HSIL of the Vulva with Microcarcinoma Mimicking Condyloma Acuminata
18.7.4 HSIL of the Vulva with Microcarcinoma
18.7.5 HSIL of the Vulva Associated with Vulvar Cancer
18.7.6 Malignant Melanoma of the Vulva and Vagina
18.7.7 Vulvar Manifestation of Primary Syphilis
18.7.8 Condylomata Acuminata of the Vulva in the 33rd Week of Gestation
18.7.9 Lichen Planus with Complete Vulvar Synechia
18.7.10 Circumscribed HSIL of the Vulva
18.7.11 Subclitoral HSIL
18.7.12 Periurethral HSIL
18.7.13 Long-Term Follow-Up of Recurrent HSIL of the Vulva
18.7.14 Vulvar Carcinoma Associated with Lichen Sclerosus
18.7.15 Vulvar Carcinoma Associated with Lichen Sclerosus
18.7.16 Advanced Cancer of the Vulva
18.7.17 Midline Carcinoma of the Vulva in a 33-Year-Old Patient
18.7.18 Paget’s Disease of the Vulva
18.8 Miscellaneous Findings
18.8.1 Findings After Trachelectomy
18.8.2 Radiation-Induced Changes of the Vagina
18.8.3 Bicornuate and Bicollis Uterus
18.8.4 Colposcopic Triage of Irradiation-Induced Tissue Changes
18.8.5 Advanced Ovarian Carcinoma Misdiagnosed as CIN
18.9 Scenarios Within a Low-Resource Environment
18.9.1 Recurrent Squamous Cell Carcinoma of the Cervix 19 Months After Limited Radical Surgery
18.9.2 Advanced-Stage Carcinoma of the Vulva in a 29-Year-Old HIV-Positive Patient
18.9.3 Advanced but Operable Adenocarcinoma of the Cervix
18.9.4 FIGO Stage IB1 Squamous Cell Carcinoma of the Cervix
18.9.5 Fifteen Months of Treatment Delay in a Patient with Cancer of the Cervix
18.9.6 Hysterectomy for Suspected HSIL of the Cervix
18.9.7 HSIL of the Cervix and VIN in a 24-Year-Old HIV-Positive Patient
18.9.8 HSIL of the Cervix Not Eligible for Cryosurgery
18.9.9 FIGO Stage IIIB Squamous Cell Carcinoma of the Cervix
18.9.10 Operable FIGO Stage IIB Cancer of the Cervix
18.9.11 Large Cervical Condyloma in an HIV-Positive Patient
18.9.12 Choriocarcinoma Mimicking Carcinoma of the Cervix
18.9.13 Radical Hysterectomy and Pelvic Lymph Node Dissection for FIGO Stage IB2 Carcinoma of the Cervix
18.9.14 Large VIA-Positive Lesion Treated by Loop Resection
18.9.15 Recurrent CIN3 and Condylomata Acuminata of the Vulva in a 51-Year-Old HIV-Positive Patient
18.9.16 FIGO Stage IB1 Carcinoma of the Cervix Treated by Radical Hysterectomy and Bilateral Pelvic Lymph Node Dissection
18.9.17 Myoma in Statu Nascendi 1
18.9.18 Myoma in Statu Nascendi 2
18.9.19 VIA+/VILI+ Patient Treated by LEEP
18.9.20 Advanced Cervical Cancer with Urinary Fistula Formation
18.9.21 Cervical Carcinoma Without Ulceration or Exophytic Growth Pattern
References
