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Figure8.6 Histologyofimmaturesquamousmetaplasia(chroniccervicitis).
UpperLimitofSquamousMetaplasia
The new squamocolumnar junction is an unstable boundary. Serial colposcopic
assessmentsofthecervixfrequentlyshowthenewsquamocolumnarjunctiontohavemoved
cephalad. Careful colposcopic assessment of columnar villi immediately above the new
squamocolumnarjunctionrevealsopaque,opalescenttipsandearlyvillousfusion(Fig.8.5).
Histologic study of colposcopically directed biopsy specimens reveals reserve cell
hyperplasiaandearlyimmaturesquamousmetaplasiaoccurringinepithelium,whichappears
colposcopicallycolumnar.Thisearlyimmaturesquamousmetaplasiacanextendasfaras
10mmabovethenewsquamocolumnarjunction.
Theimmature metaplasticepithelium cephalad tothe new squamocolumnarjunction isnot
includedinthemoderndefinitionoftheTZbutrepresentstheepitheliumatgreatestriskfor
future neoplastic transformation. During dynamic phases of metaplasia, occurring
particularlywithpubertyandinearlyadolescence,theimmaturemetaplasticcellsare
activelyphagocytic(106).
IFCPCColposcopicTerminologyoftheCervix,Vagina,and
Vulva
TheInternationalFederationforColposcopyandCervicalPathology(IFCPC)released
thelatestcolposcopicnomenclatureforcervicalandvulvardiseasein2011(Table8.3),
attempting to bring greater clarity to terminology in colposcopic practice (121,122). The
most recent nomenclature has introduced a classification of TZ distribution, which shapes
treatmentofCINlesions.Italsoincludesvulvarandvaginalterminologyforthefirsttime.
The formalization of a classification of the cervical TZ according to its distribution and
locationofthenewsquamocolumnarjunctionisofclinicalvalue(123).Atype1TZisfully
visiblewiththenewSCJontheectocervix(Fig.8.7A).Atype2TZispartiallyortotally
endocervical, but the new squamocolumnar junction is fully visible, usually in the distal
millimeters of the endocervical canal (Fig. 8.7B). A type 3 TZ is partially or completely
endocervical with the new squamocolumnar junction not fully visible as a result of its
extensionintotheendocervicalcanalorthetightnessofthecanal(Fig.8.7C).
ThelocationoftheTZ,andwhetherthenewSCJcanbeseeninitsentirety,influencesthe
diagnostic completion of the colposcopic examination and the method of treatment (Table
8.4).Inthecurrentnomenclature,threeTZexcisiontypeshavebeenintroduced(Fig.8.8A–
C). A fully visible small, ectocervical TZ is easy to assess and simple to treat by
destruction orsimple excision. Alarge type 3 TZ is not possible to completely assess
colposcopically. Treatment is more difficult and the risks of long-term morbidity and
treatmentfailureareincreased.
The current nomenclature emphasizes the importance of the colposcopic findings of an
internalmargin(Fig.8.9)(124,125)andtheraised,rolledmargindescribedasa“ridge-sign”
(124,126)(Fig.8.10).Eachisanintegralcomponentoftheassessmentofthelesionmargin
inthediscriminationofhigh-gradediseasewithintheReidColposcopicIndex(124)andthey
arehighlysensitivecolposcopicpredictorsofHSIL.
SystematicApproachtoColposcopy
Fromthe beginning of organized cervical cancer screeningprograms,colposcopy has
played a pivotal role in decreasing the incidence and mortality from cervical cancer
(127). Colposcopy was initially developed to detect early invasive cancer. Despite the
success of colposcopy in helping to decrease cervical cancer incidence, the sensitivity,
accuracy,andreproducibilityofcolposcopyarelimited(128).
The sensitivity of colposcopy for detecting prevalent precancerous lesions has been
reported to be as low as 50%, particularly for women with borderline cytologic
abnormalities that are associated with small, early lesions (129). Colposcopic findings
associated with severe precancerous lesions, dense acetowhitening and coarse vascular
changes,maynotbepresent(130).Traditionalcolposcopicteachinghasfocussedontheuse
ofgradingcriteriatoidentifytheworstlesion(s)forbiopsy.
Inrecentyears,theaccuracyofcolposcopyandcolposcopicallydirectedbiopsyfordetection
of high-grade lesions has been widely studied (131–138). Stoler and colleagues (134)
compared the results of colposcopically directed biopsy with subsequent cervical
excision(definitivetherapy)among737womenintheplaceboarmofthequadrivalentHPV
vaccine randomized controlled trials. The authors concluded that “colposcopy functioned
wellwhen alloweda one-degree differencebetween the biopsy and the surgical histologic
interpretations,asdoneinclinicalpractice”;whenCIN2wasgroupedtogetherwithCIN3
and adenocarcinoma in situ (AIS) as the diagnosis of high-grade disease, the overall
agreementwas92%.
Ithasbeensuggestedthattheaccuracyofcolposcopicdiagnosiscouldbeimprovedby
taking more than one biopsy at colposcopy (137,138), potentially including random
biopsies from normal tissue and possible return to the precolposcopy era of four-quadrant
cervical biopsies. Random four-quadrant biopsies have high sensitivity for detecting CIN
grade 2 or higher (CIN 2+) (138–142). This suggestion needs to be balanced against the
inevitableincreaseinpatientdiscomfort,psychologicaltrauma andcost. Thistechniqueis
notusualpracticeandisnotacceptabletomostwomen.
Current changes in primary and secondary cervical cancer prevention exacerbate the
limitations of colposcopic accuracy and reproducibility (143). Although HPV vaccination
rates remain below the Healthy People 2020 goal of 80% in the United States, HPV 16
prevalencehasdecreasedamongyoungwomen(144).HPV16lesionstendtobethemost
visiblecolposcopiclesions.ColposcopyforwomenwiththenonvaccineHPVtypesismore
difficult(141,145).
Secondary prevention of cervical cancer in the United States now includes three
different screening modalities: cytology, cytology-HPV co-testing, and primary HPV
screening (146). Primary HPV screening leads to even more challenging colposcopy.
LesionsassociatedwithpersistentHPVinfectionswithoutcytologicabnormalitiesarelikely
tobe smallandharder todetect,particularly intheolder agegroups.Amoreconservative
screening and management approach for younger women has reduced colposcopy and
treatmentinthisgroup(147).
Table8.32011IFCPCTerminologyoftheCervix
2011IFCPCColposcopicTerminologyoftheCervix
Generalassessment
Adequate/inadequateforthereason(i.e.,cervixobscuredbyinflammation,
bleeding,scar)
Squamocolumnarjunctionvisibility:Completelyvisible,partiallyvisible,not
visible
Transformationzonetypes1,2,3
Normalcolposcopic
findings
Originalsquamousepithelium
Mature
Atrophic
Columnarepithelium
Ectopy
Metaplasticsquamousepithelium
Nabothiancysts
Crypt(gland)openings
Deciduosisinpregnancy
Abnormalcolposcopic
findings
Generalprinciples Locationofthelesion:InsideoroutsidetheT-zone,
Locationofthelesionbyclockposition
Sizeofthelesion:Numberofcervicalquadrantsthe
lesioncovers,
Sizeofthelesioninpercentageofcervix.
Grade1(Minor) Thinacetowhiteepithelium
Irregular,geographic
border
Finemosaic,
Finepunctation
Grade2(Major) Denseacetowhite
epithelium,
Rapidappearanceof
acetowhitening,
Cuffedcrypt(gland)
openings
Coarsemosaic,Coarse
punctuation,Sharp
border,Innerborder
sign,Ridgesign
Nonspecific Leukoplakia(keratosis,hyperkeratosis),
ErosionLugolstaining(Schillertest):
Stained/nonstained
Suspiciousforinvasion Atypicalvessels
Additionalsigns:Fragilevessels,irregularsurface,
exophyticlesion,necrosis,ulceration(necrotic),
tumor/grossneoplasm
Miscellaneousfinding Congenitaltransformation
zone
Condyloma
Polyp
(ectocervical/endocervical)
Inflammation
Stenosis
Congenitalanomaly
Post-treatment
consequence
Endometriosis
2011IFCPCColposcopicTerminologyoftheCervix—Addendum
Excisiontreatmenttypes Excisiontypes1,2,3
Excisionspecimendimensions Length—thedistancefromthedistal/externalmargin
totheproximal/internalmargin
Thickness—thedistancefromthestromalmarginto
thesurfaceoftheexcisedspecimen
Circumference(Optional)—theperimeterofthe
excisedspecimen
2011IFCPCNomenclatureAcceptedinRioWorldCongress,July5,2011.
ReprintedwithpermissionfromBornsteinJ,BentleyJ,BoszeP,etal.The2011ColposcopicTerminologyof
theInternationalFederationforCervicalPathologyandColposcopy.ObstetGynecol2012;120(1):166–172.
The American Society for Colposcopy and Cervical Pathology (ASCCP) has recently
produced Evidence-Based Recommendations for Colposcopy Practice for Cervical Cancer
Preventionin the United States (148). Therecommendationswere developed by an expert
workinggroupappointedbytheASCCP’sBoardofDirectors.Theyidentifiedthefollowing
importantfactorsthatmaycontributetothe limitationsof colposcopyin theUnited States:
(1)thelackof standardized terminology,(2) the lack of recommendations for colposcopic
practiceandprocedures,and(3)thelackofqualityassurancemeasures(149–151).
TheASCCPTerminologyforColposcopicPractice(149)
Thegoalofthe newrecommendationswastosimplifyandclarifyreportingofcolposcopic
findings and to enhance standardized documentation of colposcopic appearances. An
importantobjectivewastohavethemwidelyadoptedbyU.S.colposcopistsintheirdiverse
workenvironments.The2011IFCPCterminology(121,122)wasused asa basisforthe
creation of the ASCCP terminology to allow as much consistency with international
terminologyaspossible.RatherthandirectlyadoptingthefullIFCPCterminology,itinstead
wasadaptedasnecessarytofitcolposcopicpracticeintheUnitedStateswithanadditional
emphasis on the facilitation of simple and clear provider-to-provider communication. Key
Differences between the 2017 ASCCP and 2011 IFCPC Terminology are summarized in
Table8.5.
1. Standardizedterminologyforcolposcopicpractice
Recommendation:ThenewASCCPcolposcopicterminologyissummarizedinTable8.6.
Thesix major areasincludethe following: (1)generalassessment,(2) evaluation for
presenceof any acetowhite lesions,(3)description of normal colposcopic findings,
(4) description of abnormal colposcopic findings, (5) description of
other/miscellaneousfindings,and(6)reportingofthecolposcopicimpression,defined
asthehighest-gradeimpressionofanyvisiblelesiononthecervix.
2. Reportingofcomprehensiveandminimalcolposcopiccriteria
Recommendation: A comprehensive colposcopic examination should include a
description of the visibility of the cervix and squamocolumnar junction, presence of
acetowhitening, presence and visualization of a lesion, color/contours/borders/vascular
changes of lesions, the location and size(s) of lesion(s), other features, and the
colposcopicimpression.Adiagramormarkedimageannotatingthefindingsshouldalso
beincluded.Minimumcriteriaforreportingfindingsatcolposcopicexaminationshould
include the following: squamocolumnar junction visibility (fully/not fully),
acetowhitening(yes/no),lesion(s)present(acetowhiteorother)(yes/no),andcolposcopic
impression (normal/benign, low-grade, high-grade, cancer). Recommendations for
minimumandcomprehensivecolposcopypracticearesummarizedinTable8.7.
Figure 8.7 A: The Transformation Zone Classification—Type 1 TZ. B: The
Transformation Zone Classification—Type 2 TZ. C: The Transformation Zone
Classification—Type3TZ.
Table8.42011IFCPCClassificationofTypesofExcisionalProceduresforCervicalDiseaseBasedon
TypeofTransformationZone
ExcisionType Type1Excision Type2Excision Type3Excision
TransformationZone
type
Type1 Type2 Type3
Condition Anygradeofsquamous
CIN,serious
considerationshould
begiventoexcising
CIN3disease
Anygradeofsquamous
CIN
Glandulardiseasein
women<36yrs
Suspectedmicroinvasion
Anygradeofsquamous
CIN
Glandulardiseasein
women>36yrs
Suspectedmicroinvasion
Othercircumstances Previoustreatment Previoustreatment
Techniquesincludedin
thiscategoryof
excision
LLETZ/LEEP
Laserexcision
LLETZ/LEEP
SWETZ
Laserexcision
Coldknifecone
biopsy/cylindrical
excision
LLETZ/LEEP
SWETZ
Coldknifecone
biopsy/cylindrical
excision
Alternativetreatment
choices
Type1ablation
LLETZ,largeloopexcisionofthetransformationzone;LEEP,loopelectrosurgicalexcisionprocedure;SWETZ,
straightwireexcisionofthetransformationzone.
ReprintedfromSilvioTattiS,BornsteinJ,PrendivilleW.Colposcopy:aglobalperspectiveintroductionofthe
newFCPCcolposcopyterminology.ObstetGynecolClinNAm2013;40:235–250.Copyright©2013Elsevier.
Withpermission.