Colposcopy: Comprehensive Textbook and Atlas

Description

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. 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