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Atlas of colposcopy – principles and practice

Abnormal colposcopic findings – Grade 2 (major) changes

  

The grade 2 or major changes indicate the presence of high-grade lesions and may include any of the following features.

  • Dense acetowhite epithelium: A distinct dense and opaque white area after application of acetic acid is suggestive of HSIL (CIN2 or CIN 3). The colour is typically “oyster white” or greyish white. The dense, thick acetowhite area is also known as stearin (fat in its solid form) in the Swede scoring system.





  • Rapid appearance of acetowhitening: It is important for the colposcopist to note real-time changes while applying acetic acid to the cervix. If the white patch appears within a few seconds of application of acetic acid and persists for a long time, the acetowhite patch is most likely due to CIN2/CIN3 or invasive cancer. In contrast, a white patch that appears slowly and disappears rapidly is usually due to a non-neoplastic condition or low-grade lesion.




  • Cuffed crypt (gland) opening: A normal crypt opening appears as a black dot surrounded by a thin acetowhite rim in the transformation zone. If the crypt opening is large and the acetowhite rim is dense white and is raised from the surface (like a doughnut), it is called a cuffed crypt opening. Such a cuffed crypt opening is usually located in the dense acetowhite area but may also be isolated. A cuffed crypt opening indicates extension of the neoplasia inside the crypt, which occurs in high-grade lesions only.








  • Coarse mosaic: In coarse mosaic patterns, the blood vessels are prominent, irregular in calibre, and unevenly spaced. The blood vessels may not be traced completely and are lost in places (“broken” or “open” mosaics). Coarse mosaic is a hallmark of high-grade or invasive lesions. Coarse mosaic patterns are more clearly visible after the effect of the acetic acid wears off.


























  
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