Atlas of Colposcopy: Principles and Practice / Activity 6

Case

High grade / CIN2 / CIN3
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Age: 41

HPV status: Positive

After normal saline

After normal saline with green filter

After acetic acid

After acetic acid with green filter

After acetic acid

Colposcopy report (2011 IFCPC nomenclature):
/ Post-treatment consequence / Endometriosis

General assessment

Adequacy: ----AdequateInadequate

Squamocolumnar junction visibility: ----Completely visiblePartially visibleNot visible

Transformation zone: ----Type 1Type 2Type 3

Normal colposcopic findings

Original squamous epithelium: ----MatureAtrophic

Columnar epithelium: ----Ectopy absentEctopy present

Metaplastic squamous epithelium: ----Nabothian cystsCrypt (gland) openingsNabothian cysts and Crypt (gland) openings

Deciduosis in pregnancy: ----Not applicableNoYes

Abnormal colposcopic findings

General principles

Position and size

Location of the lesion: ----Inside the T-zoneOutside the T-zoneInside and outside the T-zoneOn polyp

Location of the lesion by clock position: ----01 o'clock02 o'clock03 o'clock04 o'clock05 o'clock06 o'clock07 o'clock08 o'clock09 o'clock10 o'clock11 o'clock12 o'clockAll aroundon polypInside canalEndocervical02-06 o'clock12-01 o'clock06-08 o'clock10-02 o'clock05-08 o'clock03-09 o'clock07-09 o'clock07-10 o'clock04-06 o'clock03-10 o'clock04-09 o'clock07-04 o'clock04-07 o'clock08-02 o'clock03-07 o'clock11-01 o?clock04-08 o?clock11-12 o'clock11-02 o?clock03-08 o'clock06 & 08 o'clock04-10 o'clock

No. of quadrants: ----1234On polypInside canal

% of cervix: ----< 25%25-50%50-75%> 75%Inside canalOn polyp

Grade 1 (minor)

----Thin acetowhite epitheliumIrregular borderGeographic borderFine mosaicFine punctation ----Thin acetowhite epitheliumIrregular borderGeographic borderFine mosaicFine punctation

Grade 2 (major)

----Dense acetowhite epitheliumDistinct marginAppearance of acetowhiteningCuffed crypt (gland) openingsCoarse mosaicCoarse punctationSharp borderInner border signRidge signRag sign ----Dense acetowhite epitheliumDistinct marginAppearance of acetowhiteningCuffed crypt (gland) openingsCoarse mosaicCoarse punctationSharp borderInner border signRidge signRag sign ----Dense acetowhite epitheliumDistinct marginAppearance of acetowhiteningCuffed crypt (gland) openingsCoarse mosaicCoarse punctationSharp borderInner border signRidge signRag sign

Non-specific

----LeukoplakiaErosionIodine (non-stained)Iodine (stained)

Suspicious for invasion

----Atypical vesselsFragile vesselsIrregular surfaceExophytic lesionsNecrosisUlceration (necrotic)Tumour, gross neoplasm

Miscellaneous finding

----Congenital transformation zoneCondylomaCondyloma (satellite)Polyp (ectocervical)InflammationInflammation (candidiasis)Inflammation (ulcer)StenosisCongenital anomalyPost treatment consequenceEndometriosisPolyp (endocervical)

Swede score:

Swede score	0	1	2
Aceto uptake	Nil or transparent	Thin, milky	Distinct, stearin
Margins	Nil or diffuse	Sharp but irregular, jagged, satellites	Sharp and even, difference in level
Vessels	Fine, regular	Absent	Coarse or atypical vessels
Lesion size	< 5 mm	5-15 mm or 2 quadrants	>15 mm, 3-4 quadrants, or endocervically undefined
Iodine uptake	Brown	Faintly or patchy yellow	Distinctly yellow

Final Swede score: Not possible (Iodine uptake missing)



Case Summary

Provisional diagnosis:	Type 1 transformation zone with high-grade squamous intraepithelial lesion (HSIL) and congenital transformation zone.
Management:	LLETZ (type 1 excision).
Histopathology:	HSIL-CIN3; LSIL-CIN1 in the anterior lip.
Comment:	A lesion within a lesion gives rise to the inner border sign, and the inner lesion is invariably high-grade. The larger lesion had features of the congenital transformation zone (large thin acetowhite area, oval-shaped lesion extending to the vaginal fornices, and fine mosaic). The histopathology turned out to be CIN1.