Colposcopy

Question 1

What must be available to the colposcopist before examination?

Answer 1

Screening sample results.

Question 2

Should cervical screening be repeated at first colposcopy after referral for cytological abnormality or hrHPV positive/cytology negative?

Answer 2

A: No.

Question 3

Q: When should a repeat cytology sample be taken if the initial sample is inadequate?

Answer 3

A: No less than 3 months after the first sample.

Question 4

Q: What data must be recorded at colposcopic examination?

Answer 4

A: Indication for referral,
hrHPV result & cytology grade,
presence/absence of cervix,
adequacy of exam,
vaginal/endocervical extension,
lesion features,
lesion grade impression,
transformation zone type,
biopsy sites.

Question 5

Q: In what proportion of cases is excision recommended for invasive disease?

Answer 5

A: >95%.

Question 6

Q: When is excision recommended for invasive disease?

Answer 6

A:
- When most of the ectocervix is replaced with high grade abnormality.
- When low grade colposcopic change is associated with high grade dyskaryosis (severe) or worse.
- When a lesion extends into the endocervical canal, sufficient cervical tissue should be excised to remove the entire endocervical lesion.
- Where cytology is suggestive of invasive disease or of ?glandular neoplasia.

Question 7

Q: Are punch biopsies considered reliably informative in suspected invasive or glandular disease?

Answer 7

A: No, they are not considered to be reliably informative.

Question 8

Q: What small risk must colposcopists be aware of when managing suspected invasive or glandular disease?

Answer 8

A: The risk of inappropriate or inadvertent destruction of invasive or glandular lesions.

Question 9

Q: In what setting are invasive or glandular lesions most often encountered?

Answer 9

A: In association with high grade cytological or colposcopic change (CIN3).

Question 10

Q: What must always be recorded if excision is delayed (e.g., due to pregnancy)?

Answer 10

A: Reasons for not performing a biopsy.

Question 11

What is a type 1 transformation zone

Answer 11

Completely ectocervical, fully visible; small or large

Question 12

What is a type 2 transformation zone

Answer 12

Has an endocervical component which is fully visible, may have an ectocervical component which may be small or large

Question 13

What is a type 3 transformation zone

Answer 13

Has an endocervical component which is not fully visible; may have an ectocervical component which may be small or large.

Question 14

Q: When should a colposcopically directed punch biopsy be carried out (unless excisional treatment is planned)?

Answer 14

A:
- When the cytology is high grade.
- Always when a recognisably atypical transformation zone is present.

Question 15

Q: Do hrHPV positive and negative cytology, or low grade cytological abnormality (low grade dyskaryosis or less) with a low grade or negative colposcopic examination, necessarily require colposcopic biopsy?

Answer 15

A: No, biopsy is not required

Question 16

Q: What proportion of the biopsies taken (directed and excisional) should be suitable for histological interpretation?

Answer 16

A: ≥90% of the biopsy should be suitable for interpretation.

Question 17

Q: If a colposcopically directed biopsy is reported as inadequate for histological interpretation, when should it be repeated?

Answer 17

A: It should be repeated if there is a residual lesion on colposcopy.

Question 18

Treatment can be ablative or excisional.
Ablative techniques are only suitable when:

Answer 18

• When the entire transformation zone is visualised.
• When there is no evidence of any glandular abnormality, including either ?glandular neoplasia or borderline changes in endocervical cells, on cytology.
• When there is no suspicion of any invasive disease.
• When there is no major discrepancy between cytology and histology.
• When there is no history of post-coital or intermenstrual bleeding.
• When there is no gland crypt involvement on punch biopsy.
• When there is no history of previous treatment.

Question 19

Q: In what age group should ablative treatment only be considered in exceptional circumstances?

Answer 19

A: Individuals over 50 years of age.

Question 20

Q: What must women have within the 3 months prior to having ablative treatment? and why.

Answer 20

A: An established histological diagnosis.
To ensure cytology and histology can be correlated in advance to inform the decision on whether ablative treatment is suitable.

Question 21

Q: When should cryocautery be used and what technique must be applied?

Answer 21

A: It should only be used for low grade CIN, and a double freeze-thaw-freeze technique must be used.

Question 22

Q: In how many cases should excision specimens be removed as a single sample? and why.

Answer 22

A: in at least 80% of cases.
A: Because it increases difficulties in histopathological assessment, and if microinvasive disease is present, it may be impossible to allocate a sub-stage or define completeness of excision.

Question 23

Q: What is the goal of excisional treatment?

Answer 23

A: To remove all the abnormal epithelium in accordance with the type of transformation zone.

Question 24

Q: For treating ectocervical lesions (Type I cervical transformation zone), what depth of tissue should be removed?

Answer 24

A: More than 7 mm in ≥95% of cases, though the aim should be <10 mm in individuals of reproductive age.

Question 25

Q: For a Type II cervical transformation zone, what depth of tissue should excisional techniques remove?

Answer 25

A: 10 to 15 mm in ≥95% of cases, depending on the position of the squamocolumnar junction within the endocervical canal.

Question 26

Q: For a Type III cervical transformation zone, what depth of tissue should excisional techniques remove?

Answer 26

A: 15 to 25 mm in ≥95% of cases, depending on the position of the squamocolumnar junction within the endocervical canal.

Question 27

What is the standard that should be met after a biopsy which is diagnostic of high grade CIN ?

Answer 27

>90% of women should be offered definitive treatment within 4 weeks of the colposcopy. 100% should be offered by 8 weeks with the exception of those who are pregnant.

Question 28

Q: High grade CIN extending to the deep lateral or endocervical margins of excision (or uncertain margin status) results in what, and does it justify routine repeat excision?

Answer 28

A: It results in a higher incidence of recurrence but does not justify routine repeat excision if: There is no evidence of glandular abnormality. There is no evidence of invasive disease. The individual is under 50 years of age.

Question 29

In which women must repeat excision be performed to try to obtain clear margins?

Answer 29

A: All women over the age of 50 who have CIN3 at the deep lateral or endocervical margins, and in whom satisfactory screening samples and colposcopy cannot be guaranteed

Question 30

Q: Do women under the age of 50 with HG CIN (CIN2+) on LLETZ or loop specimens at the deep lateral and/or endocervical canal margin need to have extra levels or the end blocks turned?

Answer 30

A: No, they do not

Question 31

Q: Should women over the age of 50 with potential deep lateral and/or endocervical canal margin involvement by HG CIN (CIN2+) have levels and/or end blocks turned?

Answer 31

A: Yes, to allow a definitive statement about the adequacy of excision of HG CIN at these margins.

Question 32

Q: Do women of any age with evidence of a glandular abnormality or invasive disease require extra work (levels and/or end blocks) if necessary?

Answer 32

A: Yes, to allow for a definitive comment on the adequacy of excision at these margins

Question 33

Q: How should CIN1 be managed when confirmed on biopsy or colposcopic impression (no biopsy) in women referred with low grade cytology, or hrHPV positive/cytology negative referrals?

Answer 33

A: Recall in 12 months.

Question 34

Q: How should CIN2 or CIN3 be managed?

Answer 34

A: Provide treatment and recall in 6 months.

Question 35

Q: How should CGIN be managed?

Answer 35

A: Provide treatment.

Question 36

Q: How should women who have been adequately treated (complete excision margins) for CGIN or stratified mucin producing intraepithelial lesions (SMILE) be followed up?

Answer 36

A: Recall in 6 months.

Question 37

Q: How can microinvasive squamous cancer FIGO stage Ia1 be managed?

Answer 37

A: By local excisional techniques if: The endocervical and deep lateral excision margins are free of both CIN and invasive disease (re-excision is not required when only the ectocervical margin is involved with CIN). The gynaecological cancer centre pathologist and multidisciplinary team (MDT) have reviewed the histology.

Question 38

Q: If the invasive lesion is excised but CIN extends only to the deep lateral and endocervical excision margin, what should be done?

Answer 38

A: A repeat excision should be performed to confirm complete excision of the CIN and to exclude further invasive disease.

Question 39

Q: How should samples be reported if they show cytological features suggestive of cervical glandular intraepithelial neoplasia (CGIN) or endocervical adenocarcinoma

Answer 39

A: Report as ?glandular neoplasia of endocervical type.

Question 40

Q: How should patients with ?glandular neoplasia of endocervical type be managed?

Answer 40

A: Refer to colposcopy. At least 93% should be seen within 2 weeks of referral

Question 41

Q: How should patients with ?glandular neoplasia (non-cervical) be managed?

Answer 41

A: Refer to gynaecology. At least 93% should be seen within 2 weeks of referral.