Comprehensive Colposcopy Skills

Comprehensive Colposcopy Skills
Barbara S. Apgar, MD, MS
Candice Tedeschi, RNC, NP
Disclosures
 Barbara Apgar, MD, MS
 Elsevier: Book co-editor. Apgar B, Brotzman G, Spitzer M.
Colposcopy Text and Atlas. 2002, 2008.
 Co-author. Brotzman G, Spitzer M, Apgar B. Colposcopic Image
Library CD. 2004. SABK, Inc.
 Candice Tedeschi, RNC, NP
 Nothing to disclose
 Thanks to Dr. Mark Spitzer and Dr. Alan Waxman for
sharing some their slides
Objectives
 At the conclusion of this lecture, one should be
able to:
 Discuss the evidence that has changed our
approach to colposcopic practice
 Discuss tips to improve colposcopy skills
 Describe the identification of colposcopic lesions
 Identify colposcopic features that direct the
biopsy
Colposcopy:
The Old Approach
• If it’s white, take a bite
• If you don’t know what it is, take a biopsy
• Take lots of biopsies
Colposcopy:
The More Modern Approach
You can’t biopsy everything so
you need to identify the worst
area using colposcopic criteria
and “grading”
Is this applicable in 2016?
Multiple Biopsies
 408 women from ALTS with satisfactory colposcopy and <CIN 3 on
biopsy were diagnosed with CIN 3+ over the 2 years.
 In 69.9%, the initial colposcopy was "true-positive" (CIN 2+)
 The sensitivity of colposcopy did not vary by type of colposcopist
but was significantly greater when two or more biopsies were
taken instead of one (P<.01).
 In order, taking multiple biopsies: nurse practitioners > general
gynecologists > gynecologic oncology fellows > gynecologic
oncologists (P<.01).
 Conclusion: The sensitivity of colposcopy does not differ significantly
by type of medical training, but is greater when two or more biopsies
are taken.
Gage J et al. Obstet Gynecol 2006;108(2):264-72
Number of biopsies taken that lead to ultimate
diagnosis of CIN 3+
 2675 women in ALTS with adequate colposcopy
on enrollment
Success in diagnosing CIN 2 or worse over the
course of the study
 68.3% (142 / 208) when one biopsy taken
 81.8% (108 /132) when two biopsies taken
 83.3% (35 / 42) when three or more biopsies taken
Gage J et.al. Obstet Gynecol 2006;108:264-72
Inter-observer Agreement on
Biopsy Placement
Jeronimo J; Gage JC; Waxman A ; Apgar B; Brotzman G; Carter S; Gold MA; Krumholz
B; Mitchell K; O’Connor D; Papa D; Rubin M; Spitzer M; Tedeschi C; Waage R.
 Review of 100 images.
 3 evaluators per image.
 300 pairs of evaluators.
 Allowed to select multiple areas for biopsy.
 For the selection of the first choice of biopsy
placement, 55.7% of pairs of evaluators marked
overlapping areas.
 Overlapping increased to 97% when the evaluators
added an additional area for biopsy.
Argument Pro: Endocervical
curettage should be performed
with every colposcopy.
8497 women in Shanxi provence China
364 with CIN 2,3, or cancer and satisfactory
colposcopy
The diagnosis of CIN 2,3 was made on ECC
alone in 20 (5.5%)
Authors recommend routine ECC with all
colposcopy exams
Pretorius et al Am J Obstet Gynecol 2004;191:430-434
Argument Con: Endocervical
curettage is of limited value.
Large Canadian Study
 N= 13,115 colposcopies
 ECC alone diagnosed CIN 2+ in 1.01%
 99 ECCs needed to find one additional CIN 2+
 Utility greatest in women 46 years of age and older
referred for high-grade cytology

Gage et al Am J Obstet Gynecol 2010;203(5):481
Does a positive ECC reliably localize
disease to the endocervical canal?
in 210 women with satisfactory colposcopy all positive
ECCs (9.5%) disrupted an ectocervical lesion
69% of Women with CIN 2+ diagnosed on ECC alone
actually had ectocervical lesions on excision.
12.5% had high grade endocervical lesions
ECC missed 45% of endocervical lesions later found on
conization
Spirtos N, Obstet Gyncol. Nov 198770(5):729-33
Moniak CW. J. Reprod Med 2000;45(4):285-92
So when should we do ECC?
Maximize the chance of finding disease.
ASC-US or worse cytology and no lesion seen
on colposcopy
HSIL on cytology and excision not planned
Unsatisfactory colposcopy and excision not
planned
AGC / AIS on Pap
If follow-up not likely
Failure to do an ECC in a
Previously Treated Patient
 The colposcopic principle that there is no such
thing as a skip lesion is only valid in a patient
who has not been previously treated
 Once the transformation zone is disrupted by cervical
therapy, islands of metaplastic or lesional tissue may be
left behind the newly formed SCJ.
 The colposcopy appears adequate and yet there may be
disease in the endocervical canal.
 Conclusion: Whenever there is an abnormal Pap test
in a previously treated patient, ECC should be done.
Few tips to help
make your
colposcopic exam
easier
Getting an Adequate Colposcopy

Do not use a cotton-tipped
applicator to manipulate or
pry open the cervix at the
external os
 This traumatizes the cervix
and may cause bleeding or
detach dysplastic epithelium
 A cotton-tipped applicator
should be inserted into the
vaginal fornix and pushed
inward to cause the cervix to
deviate anteriorly or
posteriorly. This allows
easier visualization of the
SCJ
Taking a Biopsy
 We know our patients and which ones may be
challenged by the colposcopy, biopsy, ECC.
 Most patients will manage without anesthesia.
 Closing the jaws of the biopsy forceps quickly and
suddenly startles the patient and she will perceive it
as painful
 Close a sharp biopsy forceps very gradually.
 Ask the patient to take a deep breath and cough
when the biopsy is taken.
Taking a Biopsy
 Small biopsies are all you need; they hurt and
bleed less.
 It may be easier to take a small biopsy by using a
portion of a regular Tischler than by filling the jaws
of a mini Tischler.
 Small biopsy forceps will often slip off the intended
biopsy site
Misdirected biopsy, no biopsy at all or (even
worse) damaging or “stripping” the epithelium
making it un-interpretable.
Colposcopy at a Crossroads
Jeronimo, Schiffman. AJOG 2006
• “Historical success of the conventional
approach based on cytology, colposcopy and
histology in reducing cervical cancer incidence
is undeniable.”
• Optimizing the accuracy of colposcopy and
biopsy is now one of the leading concerns in
the cervical cancer screening process.
Important colposcopic considerations
• Avoid using a single colposcopic sign to
formulate a colposcopic impression.
–Differentiating the normal from abnormal
TZ requires more flexibility in biopsy.
• Consider all the colposcopic findings.
Colposcopic findings are neither site nor
location specific >>> look everywhere!
26 year old with HSIL
1. Normal.
2. Low grade.
3. High grade.
4. Cancer.
25 year old with ASC-H.
1. Normal
2. Low-grade.
3. High-grade.
4. Cancer.
42 year old G5 P5 with LSIL
1. Normal.
2. Low grade.
3. High grade.
4. Cancer.
The Last Word
 Grading when done systematically can help direct
biopsies to the lesions most likely to be of higher
grade
 However
 Even in the hands of expert colposcopists, grading is
not a substitute for biopsies
 The only proven technique available to increase the
sensitivity of colposcopy is taking additional biopsies