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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5186_Библиотеки_им_академика_М_И_Перельмана.pdf
Figure 8.8 A: Type 1 Excision resects a completely ectocervical or type 1
Transformation Zone. The large loop excision of the TZ (LLETZ) procedure need not
encroachtheendocervicalcanalnorbegreaterthan8mmthickthroughouttheresection.The
excisionmarginisdepictedbyadashedgreenline.(AdaptedfromSilvioTattiS,BornsteinJ,
Prendiville W. Colposcopy: a global perspective introduction of the new IFCPC colposcopy
terminology.ObstetGynecolClinNAm 2013;40(2):235–250.Copyright©2013Elsevier.With
permission.)B:AType2excisionresectsaType2TransformationZone(hasanendocervical
component but is fully visible). The excision margin is depicted by a dashed green line.
(AdaptedfromSilvioTatti S,Bornstein J, Prendiville W.Colposcopy:aglobalperspective
introduction of the New IFCPC colposcopy terminology. Obstet Gynecol Clin N Am
2013;40(2):235–250. Copyright © 2013 Elsevier. With permission.) C: A Type 3 excision
resects a Type 3 Transformation Zone. A longer and larger amount of tissue of tissue is
resected.Theexcisionmarginisdepictedbyadashedgreenline.(AdaptedfromSilvioTatti
S, Bornstein J, Prendiville W. Colposcopy: a global perspective introduction of the new
IFCPCcolposcopyterminology. Obstet Gynecol Clin N Am 2013;40(2):235–250.Copyright©
2013Elsevier.Withpermission.)
Figure 8.9 Colpophotograph of the cervix of a 25-year-old woman with low-grade
ectocervical SIL, and an internal margin with a high-grade central lesion revealing an
atypicalvesselatafocusofmicroinvasivecancer.
Figure 8.10 Colpophotograph of the cervix of a 33-year-old woman with a high-grade
SILshowinga“ridge”signorraised,rolled,peelingmarginatanareaofearlyinvasion.
Table8.5KeyDifferencesbetweenthe2017ASCCPand2011IFCPCTerminology
ASCCP IFCPC
Generalassessment:Cervix
visibility
Fully/notfullyvisible Adequate/inadequate
Generalassessment:SCJ
visibility
Fully/notfullyvisible Completely/partially/notvisible
Generalassessment:TZtype Notused Transformationzonetypes1,2,3
Abnormalcolposcopicfindings Low-gradefeatures Grade1(minor)
High-gradefeatures Grade2(major)
Excisiontype Notused Excisiontypes1,2,3
ReprintedwithpermissionfromKhanMJ,WernerCL,DarraghTM,etal.ASCCPColposcopyStandards:Role
ofColposcopy,Benefits,PotentialHarms,andTerminologyforColposcopicPractice.JLowGenitTractDis
2017;21(4):223–229.
Table8.6StandardizedASCCPTerminologyforColposcopicPractice
Category Features/Criteria Details
Generalassessment
Visualizationofthecervix
VisualizationoftheSCJ
Fullyvisualized/notfullyvisualized
Fullyvisualized/notfullyvisualized
Acetowhitechanges
Anydegreeofwhiteningafter
applicationof3–5%aceticacid
Yes/no
Normalcolposcopicfindings
Originalsquamousepithelium:
mature,atrophic
Columnarepithelium
Ectopy/ectropion
Metaplasticsquamousepithelium
Nabothiancysts
Crypt(gland)openings
Deciduosisinpregnancy
Submucosalbranchingvessels
Lesion(s)present(acetowhiteor
other)
Yes/No
Clockposition
Abnormalcolposcopicfindings
Locationofeachlesion AttheSCJ(yes/no)
Lesionvisualized(fully/notfully)
Satellitelesion
Sizeofeachlesion
Numberofcervicalquadrants
thelesioninvolves
Percentageofsurfaceareaof
TZoccupiedbylesion
Low-gradefeatures
Acetowhite
Thin/translucent
Rapidlyfading
Acetowhite
Finemosaic
Finepunctuation
Acetowhite
Irregular/geographicborder
Acetowhite
Condylomatous/raised/papillary
Flat
High-gradefeatures
Acetowhite
Thick/dense
Rapidlyappearing/slowlyfading
Cuffedcrypt(gland)openings
Variegatedredandwhite
Acetowhite
Coarsemosaic
Coarsepunctuation
Acetowhite
Sharpborder
Innerbordersign(Internal
margin)
Ridgesign
Peelingedges
Contour
Flat
Fusedpapillae
Suspiciousforinvasivecancer
Atypicalvessels
Irregularsurface
Exophyticlesion
Necrosis
Ulceration
Tumororgrossneoplasm
Maynotbeacetowhite
Other(nonspecific)
Leukoplakia
Erosion
Contactbleeding
Friabletissue
Lugolstaining
Notused
Stained
Partiallystained
Nonstained
Miscellaneousfindings
Polyp(ectocervicalor
endocervical)
Inflammation
Stenosis
CongenitalTZ
Congenitalanomaly
Posttreatmentconsequence
(scarring)
ColposcopicImpression
(highestgrade)
Normal/benign
Lowgrade
Highgrade
Cancer
SCJ,squamocolumnarjunction;TZ,transformationzone.
ReprintedwithpermissionfromKhanMJ,WernerCL,DarraghTM,etal.ASCCPColposcopyStandards:Role
ofColposcopy,Benefits,PotentialHarms,andTerminologyforColposcopicPractice.JLowGenitTractDis
2017;21(4):223–229.
Risk-BasedColposcopicPractice
Womenreferredforcolposcopybecauseofabnormalcervicalcancerscreeningresultshavea
widerange of underlying risk ofcervicalprecancer (150). The risk can be estimated from
screening and triage tests (e.g., cytology and HPV with HPV 16/18 genotyping), and the
colposcopic impression. Risk markers can be combined to stratify the population and to
guidehowmanybiopsiesshouldbetaken.Manystudieshaveshownthattakingasingle
biopsy targeting the worst appearing lesion may miss up to one-third of prevalent
precancers and that taking multiple targeted biopsies substantially improves disease
detection,whereasadditionalnontargetedbiopsies(randombiopsies)providefewadditional
benefits.
Table8.7RecommendationsforMinimumandComprehensiveColposcopyPractice
ComprehensiveColposcopic
Practice MinimumColposcopicPractice
PrecolposcopicEvaluation Evaluateatleastthefollowing:
Indicationsforcolposcopy
Pasthistoryofcervicalcytology,
colposcopy,treatment
Evaluateanddocumentatleastthe
following:
Indicationsforcolposcopy
Pregnancystatus
Parity
Contraception
Pregnancystatus
Menopausalstatus
Hysterectomystatus
Smokinghistory
HIVstatus
HPVvaccinationstatus
Menopausalstatus
Hysterectomystatus
Obtaininformedconsent Obtaininformedconsent
Examination Examinevulvaandvaginagrossly Examinevulvaandvaginagrossly
Examinethecervixwithmultiple
magnificationsafterapplicationof
3–5%aceticacid
Examinethecervixwith
magnificationafterapplicationof3–
5%aceticacid
Examinecervixwithbothwhitelight
andared-free(blueorgreen)filter
Examineuppervaginawith
magnification
Documentation Documentfindingsusingadiagram
orphotograph,annotatedifpossible
Findingsshouldbeimportedinto
electronicmedicalrecord
Documentfindingsatleastintext
format
Documentcervixvisibility(fully/not
fullyvisualized)
DocumentSCJvisibility(fully/not
fullyvisualized),andwhether
cervicalmanipulationisneeded,to
completelyvisualizetheSCJ,e.g.,
usinganapplicatorstickor
endocervicalspeculum
DocumentSCJvisibility(fully/not
fullyvisualized)
Documentcolposcopicfindings
Acetowhiteningpresent(yes/no)
Lesion(s)present(yes/no)
Iflesion(s)present,document
extentoflesion(s)visualized
(fully/notfully),lesionsizeand
location,description(color,
contour,border,vascular
changes)
Documentcolposcopicfindings
Acetowhiteningpresent(yes/no)
Lesion(s)present(yes/no)
Documentacolposcopicimpression
(benignnormal/lowgrade/high
grade/cancer)
Documentacolposcopicimpression
(benignnormal/lowgrade/high
grade/cancer)
Biopsy Ifbiopsiesareindicated,take
biopsiesattheSCJanddocument
theirlocation
Ifbiopsiesareindicated,take
biopsiesattheSCJ
Documentwhetherendocervical
samplingperformedandmethod:
curettagevsbrushorboth
Documentwhetherendocervical
samplingperformed
Postprocedure Documenthowpatientwillbe
notifiedofresultsandmanagement
plan
Makearrangementstonotifypatient
ofresults
HIV,humanimmunodeficiencyvirus;HPV,humanpapillomavirus;SCJ,squamocolumnarjunction.
ReprintedwithpermissionfromKhanMJ,WernerCL,DarraghTM,etal.ASCCPColposcopyStandards:Role
ofColposcopy,Benefits,PotentialHarms,andTerminologyforColposcopicPractice.JLowGenitTractDis
2017;21(4):216–222.
1. Adaptingcolposcopicpracticetopreviousriskandcolposcopicimpression
Recommendation:Colposcopicpracticemaybemodifiedbasedontherisklevel(which
canbeviewedastheprobabilityoffindingprecancer/canceratthetimeoftheprocedure),
basedonreasonforreferralandcolposcopicimpression.
2. Numberandtypeofbiopsiestakenatcolposcopy
Recommendation:Multiplebiopsiestargetingallareas withacetowhitening,metaplasia,
orhigher abnormalitiesare recommended.Usually,atleast twoand uptofourtargeted
biopsiesfromdistinctacetowhitelesionsshouldbetaken.
3. Biopsypracticeinwomenwithlowriskofprecancer
Recommendation: Nontargeted biopsies are not recommended for women referred to
colposcopy at the lowest end of risk, that is, those with less than HSIL cytology, no
evidence for HPV 16/18, and a completely normal colposcopic impression (i.e., no
acetowhitening,metaplasia,orothervisibleabnormality).
4. Biopsypracticeinwomenwithveryhighriskofprecancer
Recommendation: In nonpregnant women 25 years and older with very high risk of
precancer(atleasttwoofthefollowing:HSILcytology,HPV16and/orHPV18positive,
high-gradecolposcopicimpression)eitherimmediateexcisionaltreatmentwithoutbiopsy
confirmation,orcolposcopywithmultipletargetedbiopsiesisacceptable.
Endocervical sampling should be conducted according to the 2012 ASCCP Management
Guidelines(85).Ifbiopsiesaretakenanddonotshowprecancer,managementaccordingto
the2012ASCCPManagementGuidelinesisrecommended(85).
ColposcopicProceduresandAdjuncts(151)
The ASCCP Colposcopy Standards Committee developed recommendations on how
colposcopy should be performed in routine practice and on the use of adjuncts to aid
colposcopy. An extensive literature review did not reveal quality evidence for or against
individual elements of the colposcopic examination, and no high-quality randomized
controlledtrialsorobservationalstudiescomparingcolposcopyalonewithcolposcopyusing
anadjunctwerefound.
1. Colposcopicproceduresforminimallyacceptableandcomprehensivepractice
Recommendation:Minimallyacceptableandcomprehensivecolposcopicproceduresare
summarized in Table 8.7. Five major areas of colposcopic procedures were covered,
including the following: (1) precolposcopic evaluation, (2) examination, (3)
documentation,(4)biopsysampling,and(5)postcolposcopicprocedures.
2. Evaluationofcolposcopicadjuncts
Recommendation:Currentevidenceisinsufficienttorecommendfororagainsttheuseof
anyadjunctincolposcopicpractice.
IndicationsforColposcopy
Colposcopyismostfrequentlyperformedinresponsetoanabnormalcervicalscreening
test. Abnormal findings on high-risk HPV-DNA testing and/or cytology can both be
indicationsforcolposcopy.Ifthecervixisclinicallyabnormalorsuspiciouson naked-eye
examination, colposcopy is indicated. Abnormal and unexplained intermenstrual or
postcoital bleeding and unexplained, persistent vaginal discharge may be assessed by
colposcopytoexcludeaneoplasticcause.Otherindicationsincludeapersonalhistoryofin
uterodiethylstilbestrol(DES)exposure(rareinmodernpractice),vulvarorvaginalneoplasia
orcondylomataacuminata,and possibly,in some settings, sexual partners of patientswith
genitaltractneoplasiaorcondylomataacuminata.
Therearenoabsolutecontraindicationstocolposcopy.Theexaminationmaybedeferred
until after bleeding ceases for women who are menstruating. Acute cervicitis or
vulvovaginitisshould beevaluatedand treatedbeforecolposcopyis performed,unless
poor patient compliance is anticipated. The colposcopic procedure should be modified in
pregnancy, withaless liberal use of biopsy intheabsence of warning signs of high-grade
disease or cancer,and avoidance of endocervical curettage. Postmenopausal women who
arenot taking hormone replacement may benefit froma 3-week course of topical or
oralestrogenbeforecolposcopy.Patientsshouldavoiduseofallintravaginalproductsfor
24hoursbeforetheexamination.
InitialClinicalWorkup
Thepatientshouldbepreparedfortheexaminationby acomprehensive explanationof the
indication for colposcopy and a verbal description of the procedure in a culturally and
linguisticallyappropriate format.The primaryreason forreferral shouldbedocumented. A
completemedicalhistory,as wellas afull obstetricand gynecologichistoryincludingpast
sexually transmitted infections should be obtained. A history of any previous cervical
screening, detection of premalignant cervical disease or cervical treatment should be
determined. Ahistory of smoking or of endogenous or exogenous immune suppression is
relevant.HPVvaccinationstatusshouldbedetermined.
Aclinicalandspeculumexaminationofthecervix,vagina,vulva,andperianalareasshould
be performed before the colposcopic examination. Squamous neoplasia may be
multicentric(involvingmorethanonegenitaltractsite,thatis,cervix,vagina,orvulva)
or multifocal (involving several areas at one site). A bimanual pelvic and rectal
examination should be performed, usually on completion of the colposcopy, to exclude
clinicallyapparentcoexistentgynecologicorpelvicdisease.Uncommonly,abnormalcervical
smearsarecausedbymalignanciesoftheendocervix,uterinebody,adnexae,orbowel.
LocatingtheSourceofAbnormalCells
Colposcopyshouldbeperformedinthedorsallithotomypositionwithadrapecoveringthe
patient’s legs. The cervix should be visualized using a standard speculum, and examined
underlow-powermagnificationpriortoapplicationofsolutionstoexcludeclinicallyinvasive
diseaseandtonotethepresenceofinflammation,infection,oratrophy.
The colposcopic examination involves the application of three standard solutions to the
cervix:
1. Normalsalineshouldbeinitiallyappliedtoremoveobscuringmucusanddebris,to
moistenthecervix,andtoexaminethecervixunalteredbysubsequentsolutions.The
two abnormal colposcopic findings detected after application of normal saline are
hyperkeratosis(leukoplakia)andatypicalvessels.Hyperkeratosisisawhite,thickened
epithelial area of the cervix (or lower genital tract) that is clinically apparent before
application of acetic acid. Biopsy is indicated to exclude an underlying neoplastic
process.Atypicalvesselsarethecolposcopicallyapparentbizarrevascularabnormalities
thatoccur in associationwithinvasive cancer.Green-filterexaminationof the cervix
enhancestheangioarchitecture.
2. A 3–5% acetic acid solution is then liberally applied to the cervix using soaked
swabsoraspraytechnique.Theabnormalcolposcopicfindingsafterapplicationof
acetic acid are acetowhite epithelium and abnormal vascular patterns. Abnormal
vascular patterns, reflecting the underlying capillary distribution, are mosaicism and
punctation. Tissue swelling associated with the initial application of acetic acid
compresses subepithelial capillaries, rendering vascular patterns less distinct. As the
acetic acid reaction fades, mosaicism and punctation become vivid against the whiter
background.
3. Lugol iodine (one-quarterstrength)application to the cervix (if the patient is not
allergictoiodine)iscalledaSchiller’stest.Normalectocervicalandvaginalsquamous