Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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Colposcopic assessment of cervical intraepithelial neoplasia b a FIGURE 7.2a: Fine punctation (a) and coarse mosaic (b) seen after application of normal saline Mosaic Punctation Stromal capillary Rete pegs FIGURE 7.2b: Schematic diagram to show the rete pegs and the stromal capillaries which on end-on view appear as punctations acetowhite area. The abnormalities of interest are punctation, mosaics and atypical vessels. Capillaries: The afferent and efferent capillaries within the villi (Figure 6.4) of columnar epithelium become compressed during the normal metaplastic process and are not incorporated within the newly formed squamous epithelium. Instead, they form a fine network below the basement membrane. When CIN develops as a result of HPV infection and atypical metaplasia, the afferent and efferent capillary system may be trapped (incorporated) into the diseased dysplastic epithelium through several elongated stromal papillae (Figures 2.3 and 2.4), and a thin layer of epithelium may remain on top of these vessels. This FIGURE 7.3: Coarse punctation before and after application of acetic acid forms the basis of the punctate and mosaic blood vessel patterns (Figures 7.1, 7.2 and 7.3). The terminating vessels in the stromal papillae underlying the thin epithelium appear as black points in a stippling pattern in an end-on view under the colposcope, making what are called punctate areas (Figures 7.1, 7.2 and 7.3). The inter-connecting blood vessels in the stromal papillae surrounding the rete pegs of the epithelium, running parallel to the surface, are observed colposcopically as cobbled areas of mosaic pattern (Figures 7.1 and 7.2). In mosaic areas, the epithelium 57
Chapter 7 appears as individual small, large, round, polygonal, regular or irregular blocks. Punctation and mosaic areas may be classified as either fine or coarse. Coarse changes tend to be associated with more severe degrees of abnormality. When both punctation and mosaic patterns are found to coexist, the same evaluation criteria for colposcopic prediction of disease are used as when they exist separately. Vessels exhibiting punctation and mosaics are usually more strikingly obvious than the normal stromal vessels because these vessels penetrate into the epithelium and are thus closer to the surface. When acetic acid is applied, these abnormal vascular patterns seen to be confined to the acetowhite areas. Fine punctation refers to looped capillaries - viewed end-on - that appear to be of fine calibre and located close to one another, producing a delicate stippling effect (Figures 7.1 and 7.2a). Fine mosaics are a network of fine-calibre blood vessels that appear in close proximity to one another, as a mosaic pattern, when viewed with the colposcope (Figure 7.1). These two vascular appearances may occur together and may be found in low-grade (CIN 1) lesions. The patterns do not necessarily appear throughout the whole lesion. Coarse punctation (Figure 7.3) and coarse mosaics (Figures 7.1 and 7.2) are formed by vessels having larger calibre and larger intercapillary distances, in contrast to the corresponding fine changes. Coarse punctation and mosaicism tend to occur in more severe neoplastic lesions such as CIN 2, CIN 3 lesions and early preclinical invasive cancer. Sometimes, the two patterns are superimposed in an area so that the capillary loops occur in the centre of each mosaic ‘tile’. This appearance is called umbilication (Figure 7.1). Leukoplakia (hyperkeratosis) Leukoplakia or hyperkeratosis (Figure 7.4) is a white, well-demarcated area on the cervix that may be apparent to the unaided eye, before the application of acetic acid. The white colour is due to the presence of keratin and is an important observation. Usually leukoplakia is idiopathic, but it may also be caused by chronic foreign body irritation, HPV infection or squamous neoplasia. No matter where the area of leukoplakia is located on the cervix, it should be biopsied to rule out high-grade CIN or malignancy. It is not usually possible to colposcopically evaluate the vasculature beneath such an area. FIGURE 7.4: Hyperkeratosis (leukoplakia) (a) FIGURE 7.5: The geographic satellite lesions (a) far away from the squamocolumnar junction suggestive of condyloma Condylomata a An exophytic lesion on the cervix usually represents and exhibits the characteristic features of a condyloma (Figures 7.5- 7.8). Condylomata are multiple, exophytic lesions, that are infrequently found on the cervix, but more commonly in the vagina or on the vulva. Depending on their size, they may be obvious to the naked eye. They present as soft pink or white vascular growths with multiple, fine, finger-like projections on the surface, before the application of acetic acid. Under the colposcope, condylomata have a typical appearance, with a vascular papilliferous or frond-like surface, each element of which contains a central a a
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Colposcopy and Treatment of Cervica
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INTERNATIONAL AGENCY FOR RESEARCH O
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Published by the International Agen
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Contents 11 Management that provide
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Acknowledgements The authors gratef
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Preface Health care providers have
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Chapter 1 An introduction to the an
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An introduction to the anatomy of t
Page 17 and 18: An introduction to the anatomy of t
Page 25 and 26: Chapter 2 An introduction to cervic
Page 27 and 28: An introduction to cervical intraep
Page 33 and 34: Chapter 3 An introduction to invasi
Page 35 and 36: An introduction to invasive cancer
Page 41 and 42: Chapter 4 Table 4.1: Indications fo
Page 43 and 44: Chapter 4 FIGURE 4.2: Colposcope wi
Page 45 and 46: Chapter 4 FIGURE 4.6: Endocervical
Page 47 and 48: Chapter 4 Table 4.2: Preneoplastic
Page 49 and 50: Chapter 5 between the two ocular le
Page 51 and 52: Chapter 5 Obtain specimens for labo
Page 53 and 54: Chapter 5 FIGURE 5.2: Biopsy techni
Page 55 and 56: Chapter 5 tissue tends to mimic inv
Page 57 and 58: Chapter 6 invasive carcinoma. Even
Page 59 and 60: Chapter 6 ages (Figures 1.7d, 1.7e,
Page 61 and 62: Chapter 6 FIGURE 6.7: The colour ch
Page 63 and 64: Chapter 6 Crypt openings Immature s
Page 65 and 66: Chapter 6 a FIGURE 6.17: An area of
Page 67: Chapter 7 The colposcopic diagnosis
Page 71 and 72: Chapter 7 acid stain is correlated
Page 73 and 74: Chapter 7 FIGURE 7.15: Moderately d
Page 75 and 76: Chapter 7 FIGURE 7.23: A dense acet
Page 77 and 78: Chapter 7 FIGURE 7.30: Mustard yell
Page 79 and 80: Chapter 7 We recommend that the stu
Page 81 and 82: Chapter 8 highlights this responsib
Page 83 and 84: Chapter 8 Appearance before applica
Page 85 and 86: Chapter 8 diagnosis of AIS and aden
Page 87 and 88: Chapter 8 a ↑ FIGURE 8.10: Adenoc
Page 89 and 90: Chapter 9 Inflammatory lesions of t
Page 91 and 92: Inflammatory lesions of the uterine
Page 93 and 94: Inflammatory lesions of the uterine
Page 95 and 96: Chapter 10 Table 10.1: Common sourc
Page 97 and 98: Chapter 10 Table 10.2 (cont.): A su
Page 99 and 100: Chapter 11 FIGURE 11.1: Flow chart
Page 101 and 102: Chapter 11 treatment policies for p
Page 103 and 104: Chapter 11 Vaginal delivery can be
Page 105 and 106: Chapter 12 involvement increases wi
Page 107 and 108: Chapter 12 Table 12.1: Eligibility
Page 109 and 110: Chapter 12 a b c d e f FIGURE 12.6:
Page 111 and 112: Chapter 12 during the follow-up in
Page 113 and 114: Chapter 13 (2) (1) FIGURE 13.2: Ele
Page 115 and 116: Chapter 13 (1) (2) (3) (4) (5) (8)
Page 117 and 118: Chapter 13 Once the specimen has be
Page 119 and 120:
Chapter 13 in the endocervical cana
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Chapter 14 Decontamination, cleanin
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Decontamination, cleaning, high-lev
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References Herrero, R. (1997) Preva
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Further reading Suggestions on furt
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Appendix Leukoplakia Condylom
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Appendix regardless of your pregnan
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Appendix Monsel’s paste Ingredien
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Appendix 5 The modified Reid colpos
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Index Acetowhitening . . . . . . .
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Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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