Atlas of Colposcopy: Principles and Practice / Activity 6

Case

High grade / CIN2 / CIN3
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Age: 60
HPV status: Positive

Speculum examination

After normal saline

After acetic acid

After acetic acid with green filter

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: Not possible (Iodine uptake missing)

Case Summary
Provisional diagnosis: Type 3 transformation zone; high-grade squamous intraepithelial lesion (HSIL) of the cervix extending to the vagina.
Management: LLETZ (type 3 excision) with laser ablation of the residual vaginal lesion.
Histopathology: HSIL-CIN3.
Comment: CIN3 lesions may extend to the vagina, especially in elderly women. In such cases, LLETZ is crucial to exclude invasive focus, especially inside the endocervical canal. Hysterectomy with removal of adequate vaginal cuff may be performed after excluding invasive cancer by LLETZ.

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 3 transformation zone; high-grade squamous intraepithelial lesion (HSIL) of the cervix extending to the vagina.
Management:	LLETZ (type 3 excision) with laser ablation of the residual vaginal lesion.
Histopathology:	HSIL-CIN3.
Comment:	CIN3 lesions may extend to the vagina, especially in elderly women. In such cases, LLETZ is crucial to exclude invasive focus, especially inside the endocervical canal. Hysterectomy with removal of adequate vaginal cuff may be performed after excluding invasive cancer by LLETZ.