Supplement. Colposcopy technologies and documentation

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Adjunctive technologies

A number of modern technologies based on spectroscopy and electrical impedance can be used in practice to increase the sensitivity, positive predictive value and specificity of colposcopy, including LuViva, DySIS and ZedScan.[1] Of these, only ZedScan is registered with the Therapeutic Goods Administration and is undergoing evaluation in Australia. These are not commonly used in Australia.

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Modalities of treatment not commonly used in Australia

CryotherapyThe use of extreme cold in surgery. Used in treatment of cervix with specially designed cryoprobe, but use limited to low resource countries

This is not recommended in resource-rich countries, where alternative treatment modalities exist, as the rate of clearance of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). (CIN3) is poor and the persistence or recurrence of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). (CIN2/3) is higher than with other techniques. When used for the treatment of a symptomatic inflamed ectropion or persistent low-grade disease, a double-freeze technique is preferred, and has lower rates of residual disease compared with a single-freeze technique.[2][3] It is rarely, if ever, used in Australia.

Thermal Coagulation (Semm or ‘Cold’ coagulation)

The thermal coagulator is a self-contained electrically powered device which works with a probe at 60–130 degrees Centigrade (it was known as ‘cold’ because it works at lower temperature than diathermy). The probe, which comes with half a dozen different profiles, goes through a self-sterilising cycle before being applied directly to cervix in 20-second applications that can be multiply repeated to cover 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.. Studies have confirmed its efficacy in benign, low and high-grade abnormalities.[4][5] There is currently a resurgence of interest in using this modality in Europe, and in future it may be promoted in Australia.

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Documentation

High-quality patient management requires meticulous documentation of the woman’s medical record. The results of consultations, examinations and treatments must be recorded, preferably electronically to facilitate submission of colposcopy data to the NCSRNational Cancer Screening Register. It is useful to keep an annotated diagram of the cervix and vagina or take a digitally captured image. The minimum colposcopy data set should always be recorded.

Description of abnormalities should be in line with the 2011 IFCPCThe International Federation of Cervical Pathology and Colposcopy terminology (see 2011 International Federation for Cervical Pathology and Colposcopy (IFCPC) nomenclature). The following information should be included:

  • the adequacy of the examination
  • the absence (or presence) of evidence of invasive disease
  • the presence of a squamous and/or glandular pre-cancerous abnormality
  • the extent 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., ectocervically and endocervically and hence 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. Type; 1, 2, or 3. This should also clearly mention extension of abnormalities onto the vaginal fornices, if present.
  • the number of cervical quadrants involved in any abnormality
  • the overall colposcopic impression.

Colposcopic findings at the time of treatment should be recorded especially if there has been a change in appearance of the cervix.

In addition the following should be included:

  • the mode and technique of treatment
  • the depth of tissue destruction achieved in all ablative treatments
  • the type of excision: Types 1, 2 or 3
  • the size of loop/fixed profile wire used in all LEEPLoop electrical excision procedureLoop electrical excision procedure/LLETZLarge loop excision of the transformation zone and Fisher/Utah conisation procedures and the diathermy settings
  • the laser setting and length of time of application
  • any complication occurring during or immediately following the treatment.

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References

  1. Tan JH, Wrede CD. New technologies and advances in colposcopic assessment. Best Pract Res Clin Obstet Gynaecol 2011 Oct;25(5):667-77 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21664876.
  2. Mitchell MF, Tortolero-Luna G, Cook E, Whittaker L, Rhodes-Morris H, Silva E. A randomized clinical trial of cryotherapy, laser vaporization, and loop electrosurgical excision for treatment of squamous intraepithelial lesions of the cervix. Obstet Gynecol 1998 Nov;92(5):737-44 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9794661.
  3. Chirenje ZM, Rusakaniko S, Akino V, Mlingo M. A randomised clinical trial of loop electrosurgical excision procedure (LEEP) versus cryotherapy in the treatment of cervical intraepithelial neoplasia. J Obstet Gynaecol 2001 Nov;21(6):617-21 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12521783.
  4. Loobuyck HA, Duncan ID. Destruction of CIN 1 and 2 with the Semm cold coagulator: 13 years' experience with a see-and-treat policy. Br J Obstet Gynaecol 1993 May;100(5):465-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8518248.
  5. Gordon HK, Duncan ID. Effective destruction of cervical intraepithelial neoplasia (CIN) 3 at 100 degrees C using the Semm cold coagulator: 14 years experience. Br J Obstet Gynaecol 1991 Jan;98(1):14-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1998626.
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