Colposcopy terminology

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2011 International Federation for Cervical Pathology and ColposcopyThe examination of the cervix and vagina with a magnifying instrument called a colposcope, to check for abnormalities. (IFCPCThe International Federation of Cervical Pathology and Colposcopy) nomenclature

The terminology surrounding the clinical reporting of colposcopic examinations has continued to evolve, reflecting the improved understanding of cervical oncogenesis and the normal and abnormal appearances of the cervix. It is timely to review the current terminology used in Australia and align it to internationally accepted standards.

In Australia, the current commonly used nomenclature is the terminology recommended by the International Federation for Cervical Pathology and ColposcopyThe examination of the cervix and vagina with a magnifying instrument called a colposcope, to check for abnormalities. (IFCPCThe International Federation of Cervical Pathology and Colposcopy) in 2002.[1] In 2008, IFCPCThe International Federation of Cervical Pathology and Colposcopy formed a nomenclature committee to review the previous IFCPCThe International Federation of Cervical Pathology and Colposcopy terminologies (1975, 1990 and 2002) and publications that critically analysed each colposcopic sign, aiming to create an evidence-based terminology. The committee, chaired by Jacob Bornstein, was composed of 13 colposcopists from different countries and one pathologist from Australia. After an exhaustive and transparent process the final terminology was reviewed and approved by all committee members, the IFCPCThe International Federation of Cervical Pathology and Colposcopy board and the IFCPCThe International Federation of Cervical Pathology and Colposcopy general assembly held at the World Congress in Rio de Janiero in July 2011.[2]

As the representative body of the national societies for colposcopy and cervical pathology, the IFCPCThe International Federation of Cervical Pathology and Colposcopy recommended that the 2011 terminology replace all other terminologies and be implemented without delay for diagnosis, treatment and research. It is recommended that the 2011 IFCPCThe International Federation of Cervical Pathology and Colposcopy terminology[2][3] (see the following section) should be used in Australia and replace other terminology.


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REC7.1:New colposcopy terminology
The new terminology adopted by the IFCPCThe International Federation of Cervical Pathology and Colposcopy in 2011 should be incorporated into Australian practice.

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Summary of IFCPCThe International Federation of Cervical Pathology and Colposcopy colposcopic terminology of the cervix[2][3]

General assessment

The colposcopist should assess and record the following:

  • adequate/inadequate: records whether the cervix has been visualised or not and includes the reason if inadequate (e.g. vaginal stenosis, cervix obscured by inflammation, bleeding, scarring)
  • squamocolumnar junctionThis is the junction where the ectocervical squamous epithelium and the endocervical columnar epithelium meet, and may be located on the visible ectocervix or may be within the endocervical canal. visibility: this refers to the internal margin of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. that is either completely visible, partially visible, or not visible
  • TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. should be classified as Types 1,2,3 according to the visibility of all or part of the upper limit of the squamocolumnar junctionThis is the junction where the ectocervical squamous epithelium and the endocervical columnar epithelium meet, and may be located on the visible ectocervix or may be within the endocervical canal.:
  • Type I – the whole TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. including all the upper limit is ectocervical
  • Type 2 – the upper limit of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. is partly or wholly visible in the canal and is completely visible around 360 degrees
  • Type 3 – part or the entire upper limit of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. cannot be seen in the canal. In Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal the outer limit may be visible on the ectocervix, in the canal or also not visible (Figure 7.1).

Figure 7.1. Description of transformation zone (TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone.) categories

Description of transformation zone (TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone.) categories

Normal colposcopic findings

The colposcopist should assess the following:

  • Identify the outer limit of the original squamocolumnar junctionThis is the junction where the ectocervical squamous epithelium and the endocervical columnar epithelium meet, and may be located on the visible ectocervix or may be within the endocervical canal..
  • Identify the columnar epithelium, and upper limit of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone..
  • Look for and note the following normal findings: ectopy, metaplastic squamous epitheliumIn the cervix and the vagina this is actually a stratified squamous epithelium, that consists of layers of cells arranged in layers on a basement membrane. (mature or immature), nabothian cystsThis is a mucus filled cyst on the surface of the cervix and is a normal finding, crypt (gland) openings, deciduosis in pregnancy or atrophy.

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Abnormal colposcopic findings (after application of acetic acid)

Aceto-white changes:

  • Minor (Grade 1)
  • thin aceto-white epithelium; irregular geographic border
  • fine mosaic, fine punctation
  • Major (Grade 2)
  • dense aceto-white epithelium, rapid appearance of aceto-whitening, cuffed crypt (gland) openings
  • coarse mosaic, coarse punctation, sharp border, inner border sign, ridge sign

Suspicious for invasion

Atypical vessels

  • additional signs (suspicious for invasion): fragile vessels, irregular surface, exophytic lesion, necrosis, ulceration (necrotic), tumour/gross neoplasm suspicious for invasion

Lugol’s staining (Schiller’s test) if performed:

  • stained/non-stained

Location of the lesion:

  • Is this inside or outside the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone.?
  • location of the lesion by clock position

Size of the lesion:

  • number of cervical quadrants the lesion covers
  • size of the lesion (as percentage of cervix)

Miscellaneous findings

  • StenosisA narrowing of a cylindrical canal. (partial or complete), congenital anomalyA structural or functional abnormality (anomaly) that occur during intrauterine life and can be identified prenatally, at birth or later in life., post treatment consequences, endometriosis, congenital TZCongenital transformation zoneDuring early embryonic life, the cuboidal epithelium of the vaginal tube is replaced by the squamous epithelium, which begins at the caudal end of the dorsal urogenital sinus. This process is completed well before birth and the entire length of vagina and the ectocervix is meant to be covered by squamous epithelium. This process proceeds very rapidly along the lateral walls, and later in the anterior and posterior vaginal walls. If the epithelialization proceeds normally, the original squamocolumnar junction will be located at the external os at birth. On the other hand, if this process is arrested for some reason or incomplete, the original squamocolumnar junction will be located distal to the external os or may rarely be located on the vaginal walls, particularly involving the anterior and posterior fornices. The cuboidal epithelium remaining here will undergo squamous metaplasia. This late conversion to squamous epithelium in the anterior and posterior vaginal walls, as well as the ectocervix, results in the formation of the congenital transformation zone. Thus, it is a variant of intrauterine squamous metaplasia, in which differentiation of the squamous epithelium is not fully completed due to an interference with normal maturation. Excessive maturation is seen on the surface (as evidenced by keratinization) with delayed, incomplete maturation in deeper layers. Clinically, it may be seen as an extensive whitish-grey, hyperkeratotic area extending from the anterior and posterior lips of the cervix to the vaginal fornices. Gradual maturation of the epithelium may occur over several years. This type of transformation zone is seen in less than 5 % of women and is a variant of the normal transformation zone., condyloma, polyp (ectocervical/endocervical) inflammationA polyp is a small protrusion of tissue that looks like a ball on the end of a slim stalk, and can be visible on the cervix, usually arising from the endocervical or endometrial tissue of uterus. Polyps are usually not neoplastic but can unusually be neoplastic or cancerous..

Excision treatment types

This includes stratification and measurement of treatment excision specimens (Australian modification of IFCPCThe International Federation of Cervical Pathology and Colposcopy excision nomenclature).

Excision treatment by whatever mode defined by the length of cervical tissue excised as:

  • Type 1 < 10 mm
  • Type 2 > 10 mm and < 15 mm
  • Type 3 > 15 mm

(See Treatment.)

NB: This stratification is modified from that of the IFCPCThe International Federation of Cervical Pathology and Colposcopy (2012) because, traditionally in Australia, excision specimens are measured using two diameters (anterior to posterior; 12 to 6 o’clock, and side to side; 3 to 9 o’clock) and length (external os to endocervical margin).

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References

  1. Walker P, Dexeus S, De Palo G, Barrasso R, Campion M, Girardi F, et al. International terminology of colposcopy: an updated report from the International Federation for Cervical Pathology and Colposcopy. Obstet Gynecol 2003 Jan;101(1):175-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12517664.
  2. 2.02.12.2 Bornstein J, Bentley J, Bösze P, Girardi F, Haefner H, Menton M, et al. 2011 colposcopic terminology of the International Federation for Cervical Pathology and Colposcopy. Obstet Gynecol 2012 Jul;120(1):166-72 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22914406.
  3. 3.03.1 Quaas J, Reich O, Küppers V. Explanation and Use of the Rio 2011 Colposcopy Nomenclature of the IFCPC (International Federation for Cervical Pathology and Colposcopy): Comments on the general colposcopic assessment of the uterine cervix: adequate/inadequate; squamocolumnar junction; transformation zone. Geburtshilfe Frauenheilkd 2014 Dec;74(12):1090-1092 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25568464.
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