Atlas of Colposcopy: Principles and Practice / Activity 6

Case

High grade / CIN2 / CIN3
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Age: 34
HPV status: Positive

Speculum examination

After normal saline

After normal saline with green filter

After acetic acid

After acetic acid

After acetic acid with higher magnification

After acetic acid

After Lugol’s iodine

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

General assessment
Adequacy:

Squamocolumnar junction visibility:

Transformation zone:

Normal colposcopic findings
Original squamous epithelium:

Columnar epithelium:

Metaplastic squamous epithelium:

Deciduosis in pregnancy:

Abnormal colposcopic findings
General principles
Position and size

Location of the lesion:

Location of the lesion by clock position:
No. of quadrants:

% of cervix:

Grade 1 (minor)

Grade 2 (major)

Non-specific

Suspicious for invasion

Miscellaneous finding

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: 9

Case Summary
Provisional diagnosis: Type 1 transformation zone; high-grade squamous intraepithelial lesion (HSIL) in pregnancy.
Management: Multiple punch biopsies obtained from the posterior lip and also from the extension of the lesion to the vaginal wall.
Histopathology: HSIL-CIN3.
Comment: The posterior lip had a large high-grade lesion that extended to the vagina. Biopsies were obtained to exclude invasive cancer. The anterior lip had a thin acetowhite area with indistinct margin that suggests metaplastic changes. The patient had LLETZ 2 months after normal delivery. The lesion was less extensive at that time. Sometimes apparently high-grade lesions in pregnancy may resolve completely after delivery. A repeat colposcopy 2–3 months after delivery is essential before making any decision about treatment.

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

Provisional diagnosis:	Type 1 transformation zone; high-grade squamous intraepithelial lesion (HSIL) in pregnancy.
Management:	Multiple punch biopsies obtained from the posterior lip and also from the extension of the lesion to the vaginal wall.
Histopathology:	HSIL-CIN3.
Comment:	The posterior lip had a large high-grade lesion that extended to the vagina. Biopsies were obtained to exclude invasive cancer. The anterior lip had a thin acetowhite area with indistinct margin that suggests metaplastic changes. The patient had LLETZ 2 months after normal delivery. The lesion was less extensive at that time. Sometimes apparently high-grade lesions in pregnancy may resolve completely after delivery. A repeat colposcopy 2–3 months after delivery is essential before making any decision about treatment.