The Papanicolaou (Pap) smear is a commonly employed screening test for dysplasia and cancer of the uterine cervix. Colposcopy is thediagnostic test to evaluate patients with an abnormal cervical cytologic smear or an abnormal-appearing cervix. The main goal of colposcopy is to highlight the areas of greatest abnormality in high-grade cervical intraepithelial neoplasia (CIN) or vaginal intraepithelial neoplasia (VAIN) for biopsy. It entails the use of a field microscope to examine the cervix after application of acetic acid (and possibly Lugol's iodine) to temporarily stain the cervix. The cervix and vagina are examined under magnification, and all abnormal areas are identified. The transformation zone (TZ) is the area of the cervix extending from the original (prepubertal) squamocolumnar junction (SCJ) to the current SCJ. This and other benign colposcopic findings are listed in Table 37-1. An atypical TZ is defined as one with findings suggesting cervical dysplasia or neoplasia.
TABLE 37-1. BENIGN COLPOSCOPIC FINDINGS
Leukoplakia is typically an elevated, white plaque on the cervical or vaginal mucosa seen before the application of acetic acid. It results from a thick keratin layer that obscures the underlying epithelium. It may represent exophytic human papilloma virus (HPV) disease or may signal severe dysplasia or cancer. Although it may be associated with benign findings, it generally warrants a biopsy.
Acetowhite lesions describe transient, white-appearing areas of epithelium after the application of acetic acid. Acetowhite changes correlate with areas of higher nuclear density in the tissue. Because both benign and dysplastic lesions may turn acetowhite, several features must be examined to estimate the severity. Assess the lesion's margins, including the sharpness of the margin and the angularity of the contour of the margin. The margins of high-grade CIN are straighter and sharper compared with the vague, feathery, geographic borders of CIN 1 or HPV disease. When high-grade CIN coexists in the same lesion with a lower-grade lesion, the higher-grade lesion often manifests with a sharply defined internal margin or border (i.e., border-within-a-border pattern).
With increasing levels of CIN, desmosomes (i.e., intracellular bridges) that attach the epithelium to the basement membrane are often lost, producing an edge that easily peels. This loss of tissue integrity should raise the suspicion of high-grade dysplasia. The extreme expression of this effect is the ulceration that sometimes forms with invasive disease. High-grade CIN lesions are usually adjacent to the SCJ. Higher-grade lesions often appear dull and less white than most low-grade lesions, which are usually snowy white with a shiny surface. Invasive lesions may lose the acetowhite effect altogether. Nodular elevations and ulceration may indicate high-grade disease or invasive cancer.
Increases in local factors such as tumor angiogenesis factor or vascular endothelial growth factor cause growth of abnormal surface vasculature, producing punctation, mosaic, and frankly abnormal vessels. However, most high-grade lesions do not develop any abnormal vessels. Punctation is a stippled appearance of small capillaries seen end-on, often found within the acetowhite area, appearing as fine to coarse, red dots. Coarse punctation represents increased caliber vessels that are spaced at irregular intervals and is more highly associated with increasing levels of dysplasia.
Figure. No caption available.
The mosaic pattern is an abnormal pattern of small blood vessels suggesting a confluence of “tiles” or a “chicken-wire pattern” with reddish borders. It represents capillaries that grow on or near the surface of the lesion that form partitions between blocks of proliferating epithelium. It develops in a manner very similar to punctation and is often found in the same lesions. A coarse mosaic pattern is more highly associated with increasing levels of dysplasia.
Figure. No caption available.
Abnormal blood vessels are atypical, irregular surface vessels that have lost their normal arborization or branching pattern. They represent an exaggeration of the abnormalities of punctation and mosaic, and increasing severity of the lesion. They are indicative of CIN3 or invasive cancer. These vessels are usually nonbranching, appear with abrupt courses and patterns, and often appear as commas, corkscrews, coarse parallel vessels, or spaghetti.
Lugol's iodine staining (i.e., Schiller's test) may be used when further clarification of potential biopsy sites is necessary. It need not be used in all cases, but the sharp outlining afforded by Lugol's iodine can be dramatic and very helpful. It darkly stains epithelium containing glycogen, such as normal mature squamous epithelium. Lugol's solution is often very helpful on the vagina and proximal vulva (i.e., nonkeratinized skin). It can be used to examine the entire vagina and cervix for glycogen-deficient areas, which correlate with HPV or dysplasia in nonglandular mucosa. High-grade lesions uniformly reject iodine due to the absence of glycogen and produce a beige to mustard yellow effect.
The goal of colposcopy is to identify and biopsy the most abnormal appearing areas in abnormal lesions. This requires that the borders of all lesions be seen in entirety. Colposcopy is considered satisfactory if the entire TZ (including the entire SCJ) is examined and the extent of all lesions is seen. Directed biopsies of the most severe lesions are performed and lead to a tissue diagnosis of the disease present. If the entire SCJ or the limits of all lesions cannot be completely visualized (unsatisfactory examination), a diagnostic conization with a cold knife cone, laser cone, or loop electrosurgical excisional procedure (LEEP) cone is necessary. The uncooperative patient or patient with a severely flexed uterus with inadequate visualization
are common potential causes of unsatisfactory colposcopy. Lesions that are more likely to be missed or underread by colposcopic examination include endocervical lesions, extensive lesions that are difficult to sample, and necrotic lesions.
Carefully note the shape, position, and characteristics of all lesions to draw a picture of the lesions and biopsy sites after the procedure is completed. Do not let the finding of vessels divert you from carefully observing acetowhite and border changes, because the areas with vessel abnormalities may not be the most abnormal areas on the cervix. Classically, the parameters in Table 37-2 are used to grade severity, and the more “advanced” findings indicate more severe dysplasia.
TABLE 37-2. PARAMETERS USED TO GRADE SEVERITY OF CERVICAL DYSPLASIA
Leukoplakia is usually a very good sign (i.e., condylomata) or a very bad sign (i.e., high-grade CIN or squamous cell carcinoma). Abnormal vessels are always suspicious because they may indicate cancer. When multiple areas of dysplasia are present, the areas of highest-grade dysplasia are usually most proximal to the SCJ. With all other things being equal, the presence of vessel atypia in any lesion implies more severe dysplasia.
Large, high-grade lesions that cover three or four quadrants of the cervix should be carefully evaluated for the possibility of unsuspected invasive cancer. Although many lesions have vascular abnormalities, some invasive lesions are densely acetowhite and avascular. They may also manifest as ulcerative lesions. Lesions that extend more than 5 mm into the cervical os have an increased risk of higher-grade disease beyond the limits of the examination. This is why conization is recommended in cases of an unsatisfactory examination with high-grade disease.
Assure your patient that you will attempt to minimize pain, because this is often a consuming worry for patients. Although studies show that the sharpness of the instruments is the most important factor in the pain of a biopsy, many physicians apply topical 20% benzocaine (i.e., Hurricane solution) to decrease pain (perform preprocedure testing if necessary). This topical anesthetic is effective in 30 to 45 seconds. Know the pregnancy status of your patient. Ibuprofen (800 mg) may be administered 30 minutes to several hours before the procedure.
Place the patient in the dorsal lithotomy position. Insert a speculum, and position the colposcopy to observe the cervix. Gross focus is achieved by moving
the scope toward or away from the cervix. Fine focus is achieved by knobs, handles, or motorized foot pedals that finely move the head of the scope forward or backward.
When performing the procedure, apply solutions with a cotton ball held in a ring forceps or with a rectal swab. Gently apply copious amounts of vinegar quickly and without trauma. Biopsy posterior areas first to avoid blood dripping over future biopsy sites. The cervix can be manipulated with a cotton-tipped applicator or hook if necessary to provide an adequate angle for biopsy. It is not necessary to include normal margins with biopsy samples. If bleeding is profuse from a particular site and more biopsies are needed, apply a cotton-tipped applicator (without Monsel's solution) to the area, and proceed with the next biopsy. Beginning colposcopists often place samples from different biopsy sites in different bottles, subsequently correlating them with colposcopic impressions. Separate specimens can increase costs and generally are not necessary because the entire TZ is treated based on the worse biopsy result found.
It is debatable whether endocervical curettage (ECC) adds any useful information to a clearly adequate colposcopy, because of the high false-positive and false-negative rates. Patients in whom there is not a clear view of the canal or who have had previous treatment should have an ECC. The ECC can be performed before or after taking biopsies, with the decision based on whether bleeding will obscure subsequent biopsy sites. Following curettage, the ECC sample appears as a coagulum of mucus, blood, and small tissue fragments. Use ring forceps or a cytobrush to gently retrieve the sample. In addition to retreiving the ECC, a cytobrush can be used to evaluae the endocervical canal. A short drinking straw placed over a cytobrush can act as a sheath to protect the brush from contamination from ectocervical disease.
After a colposcopy, advise patients to avoid douching, intercourse, or tampons for 1 to 2 weeks (or until the return visit). Instruct patients to return if they experience a foul vaginal odor or discharge, pelvic pain, or fever. Tylenol, ibuprofen, or naproxen sodium may be used for cramps. The follow-up visit is usually in 1 to 3 weeks to discuss pathology results and plan treatment, if necessary. With the high regression rate of CIN 1, patients can be followed with serial Pap smears or colposcopy if adequate follow-up can be ensured. CIN 2 and 3 lesions are usually treated with cervical cryotherapy, LEEP, or laser vaporization. Be concerned if a significant discrepancy is found between the colposcopic impression, Pap smear cytology, and biopsy histology, especially if the biopsy reports are significantly less severe than the Pap cytology. A discrepancy of two grades should be considered significant and a contraindication to ablative therapy. If the discrepancy cannot be explained or corrected on a repeat colposcopy, conization is indicated.
Cervical conization (i.e., cold cone, laser, or LEEP cone) is indicated if the ECC sample reveals dysplasia, dysplasia visually extends into the cervical canal more than 3 or 4 mm, or the colposcopic results are unsatisfactory. There is a higher risk of poor outcomes if ablative therapies are used when disease is present in the endocervical canal. Positive ECC findings are sometimes a result of contamination with dysplastic lesions at the verge of the os, but this should not be assumed.
Prepare your patient, obtain informed consent (see Appendix J), and answer her questions. If a bimanual examination was not done with the Pap smear, perform it now. Examine the vulva for obvious condylomata or other lesions. Warm the speculum with water, and gently insert it. Consider using a vaginal side wall retractor, a Penrose drain, or latex glove thumb with obese, pregnant, or multiparous women with vaginal redundancy.
(1) Vaginal side wall retractor in a Graves speculum.
PITFALL: Repeating the Pap smear is usually unnecessary, and even a correctly performed Pap smear may irritate the cervix and cause bleeding.
Examine the cervix for inflammation or infection. Gently blot or wipe away any excess mucus using normal saline. Look for leukoplakia and abnormal vessels. Apply 5% acetic acid. Repeat the application every 2–5 minutes, as necessary. Examine the cervix starting with low power and using white light. Use higher magnification and the red-free (green) filter to carefully document any abnormal vascular patterns. Use a vinegar-soaked Q-tip to help manipulate the cervix and SCJ into view, as necessary.
(2) Use a vinegar-soaked Q-tip to help manipulate the cervix and SCJ into view, as necessary.
PITFALL: Calling the solution acetic acid may increase the patient's perception of burning; describing the solution as vinegar is preferable.
PITFALL: A tenaculum is almost never necessary to move the cervix and may cause cervix-obscuring bleeding.
Determine if the colposcopy is satisfactory. A Kogan endocervical speculum can greatly aid the examination of the distal endocervical canal. Mentally map and characterize abnormal areas, and note all margin features and vascular changes. Grade the severity of lesions. Then, if desired, the clinician may use Lugol's solution (i.e., Schiller's test) and apply benzocaine (i.e., Hurricaine solution) to the entire face of the cervix using a cotton ball.
(3) A Kogan endocervical speculum.
PITFALL: Unsatisfactory colposcopy with cytologic evidence of dysplasia usually requires cervical cone biopsy for further evaluation.
PITFALL: Make sure the patient is not allergic to iodine (shellfish) or benzocaine before using these solutions.
Perform an endocervical curettage if indicated. Use a Kevorkian curette (preferably without a basket), and scrape all walls of the canal, rotating the curette twice through 360 degrees of rotation. Place the curette into the canal until resistance is felt (Figure 4A), push it against the canal while pulling it out (stop short of the external os) (Figure 4B), and then push it back in with a slight (approximately 30 degree) twist to sample the next strip of canal with the next outward stroke (Figure 4C). After removing the curette, use ring forceps or a cytobrush to gently retrieve the sample.
(4) Perform an endocervical curettage if indicated.
PITFALL: Do not do an ECC on pregnant patients.
A cytobrush can be used to retrieve ECC sample or, alternately, a brush can be used to sample the endocervical canal. A short drinking straw may be placed over a cervical Pap smear brush (i.e., pipe-cleaner—type brush) to act as a sheath to protect the brush from contamination by the ectocervix while the device is being introduced or withdrawn. Place the brush inside the straw, and place the straw against the os (Figure 5A). Advance the brush into the cervical canal, spin it around five times (Figure 5B), withdraw the brush back into the straw (Figure 5C), and remove the straw and brush from the vagina (Figure 5D).
(5) A short drinking straw may be placed over a cervical Pap smear brush to act as a sheath to protect the brush from contamination by the ectocervix while the device is being introduced or withdrawn.
Align the forceps radially from the os so that the fixed jaw of the forceps is placed on the most posterior part of the site (Figure 6A). Note that the fixed position is away from the os (above) and within the os (below). The jaws should be centered over the area to be biopsied (Figure 6B). Biopsies should be approximately 3 mm deep and should include all areas with vessel atypism. Apply pressure and Monsel's solution, if needed, to bleeding sites.
(6) Perform a cervical biopsy.
PITFALL: Do not apply Monsel's solution until all biopsies are completed.
PITFALL: Swab out the excess Monsel's solution and blood debris, which appears as a coffegrounds-like black substance that eventually will pass and may cause alarm (and late-night phone calls).
Gently remove the speculum, and view the vaginal wall collapse around the receding blades of the speculum. Inspect for any abnormal areas on the vagina or vulva. Carefully draw and label a picture of lesions and biopsy sites. Correlate the pictures with the submitted samples, if placed in different containers. Note whether the colposcopy was satisfactory.
(7) After the speculum has been removed, check for any abnormal areas on the vagina or vulva, and carefully draw and label a picture of lesions and biopsy sites.
PITFALL: Fainting and light-headedness are not uncommon. Have the patient rest supine for at least several minutes and then sit up slowly.
No 2002 fee is listed for new colposcopy codes introduced in 2003.
INSTRUMENT AND MATERIALS ORDERING
A 20% solution of benzocaine (i.e., Hurricane solution) can be obtained at Beutlich Pharmaceuticals LP, 1541 Shields Drive, Waukegan IL, 60085 (phone: 847-473-1100 or 800-238-8542; http://www.beutlich.com/products.htm). Colposcopes and supplies may be obtained from Circon/Cryomedics, Racine WI (phone: 888-524-7266 or 414-639-7205; http://www.acmicorp.com/acmi/user/); CooperSurgical, Shelton, CT (phone: 800-645-3760 or 203-929-6321; http://www.coopersurgical.com); DFV, 1990 NE 163rd Street, Suite 107, North Miami Beach, FL 33162 (phone: 800-933-0009; http://www.dfv.com.br); Gyne-tech Instruments, Burbank, CA (phone: 800-496-3832 or 818-842-0933); Leisegang Medical, Inc., Boca Raton, FL (phone: 800-448-4450 or 561-994-0202; http://www.leisegang.com) Olympus America, Inc., Melville, NY (phone: 800-548-555 or 631-844-5000; http://www.olympusamerica.com); Techman International Corp., Charlton, MA (phone: 508-248-3211; http://www.techmaninc.com); Wallach Surgical Devices, Inc., Orange, CT (phone: 203-799-2000 or 800-243-2463;http://www.wallachsurgical.com); and Welch Allen, Skaneateles Falls, NY (phone: 800-535-6663 or 315-685-4100;http://www.welchallyn.com).
Acetic acid (3% to 5%) and normal saline can be obtained from a supermarket (i.e., white vinegar) or from a medical supply source. Monsel's solution (i.e., ferric subsulfate) performs best when it has a thick, toothpaste-like consistency. It can be bought this way or produced by allowing the stock solution to sit exposed to the air in a small open container. This allows evaporation and thickening of the agent, a process that can be enhanced by placing the open container in a warm place, such as on top of a refrigerator. The resulting paste texture can be maintained by keeping the paste in a closed container and by adding small amounts of Monsel's solution whenever the paste becomes excessively thick. Appendix B lists standard gynecologic instruments.
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