7.1. Terms that have been omitted from the 2011 IFCPC nomenclature

To most colposcopists in the United Kingdom, “cone biopsy” means excision of a significant portion of the endocervical canal, and the term would be reserved for those cervices where the lesion is thought to be out of colposcopic view in the endocervical canal, either wholly or in part. However, to many colposcopists in the USA and Europe, “cone biopsy” or “conization” means excision of any type of TZ, no matter how much of the endocervical canal has been excised. Also, dimensional terms like “height” and “depth” are used almost interchangeably in different publications, and this can lead to invalid comparison of treatment methods. For these reasons, the 2011 IFCPC nomenclature omits the terms “cone biopsy” and “conization” (see TZ excision types 1, 2, and 3 in Table 7.1) as well as “depth” and “height”.

Table 7.1

Classification of excisional treatment.

7.2. General assessment

A general and initial assessment of the cervix will allow the colposcopist to determine whether examination of the cervical epithelium is adequate or whether it is compromised by inflammation, bleeding, atrophy, scar tissue, or subepithelial fibrotic change. Assessing whether the TZ is fully visible and where it is situated will allow determination of the TZ type.

7.3. Transformation zone type

After it is established that the examination is adequate, the TZ type and size should be determined (Figs. 7.1–7.3). A fully visible and ectocervical TZ is a type 1 TZ. A TZ that is partially or completely endocervical but is fully visible is a type 2 TZ. A TZ that is partially or completely endocervical but is not fully visible is a type 3 TZ. The visibility and precise location of the TZ influence both whether colposcopy is satisfactory and the method of treatment.

Fig. 7.1

Type 1 transformation zone (TZ). (a) Illustration. (b–d) Examples of type 1 TZs. In each, the entire TZ is visible on the ectocervix.

Fig. 7.3

Type 3 transformation zone (TZ). (a) Illustration; the upper limit of the TZ extends beyond the upper limit of visibility, here represented by the horizontal line. (b, c) Examples of type 3 TZs. In each, the upper (more...)

7.4. Excision type

A fully visible ectocervical and small TZ is both easy to assess and simple to treat, either by destruction or by simple excision. In contrast, a large type 3 TZ will not be possible to assess completely, and treatment will be associated with greater difficulty, a higher risk of morbidity (Khalid et al., 2011), and an increased risk of failure to eradicate the disease (Ghaem-Maghami et al., 2007). The TZ excision types are illustrated in Fig. 7.4. Table 7.1 lists the excisional treatments and when they are indicated.

Fig. 7.4

Excision types. (a) Type 1 excision. The dotted green line resects a completely ectocervical or type 1 transformation zone (TZ). In this case, which is the most common in women of reproductive age, the LLETZ/LEEP procedure need (more...)

The first two excision types, types 1 and 2, are illustrated in Figs. 7.5 and 7.6. They relate exactly to the TZ types 1 and 2. A type 3 excision, in contrast, may be used in several circumstances not dictated purely by TZ type. For example, excision of a glandular lesion will usually warrant a type 3 excision. Also, some clinicians may wish to perform a type 3 excision in the presence of microinvasive disease in a woman who has completed her family or in a patient who has previously been treated. Fig. 7.7 depicts two different ways of performing a type 3 excision: the first with LLETZ/LEEP using a longer loop, and the second using a straight wire excision of the TZ (SWETZ), as described by Camargo et al. (2015). Finally, Fig. 7.8 illustrates the “top-hat” technique for removing a type 2 or type 3 TZ. The top-hat excisional technique has little to recommend it, because it compromises histological interpretation.

Fig. 7.5

Type 1 excision with LLETZ/LEEP.

Fig. 7.6

Type 2 excision with LLETZ/LEEP.

Fig. 7.7

(a, b) Type 3 excision using a large loop (LLETZ/LEEP). (c, d) Type 3 excision using a straight wire (SWETZ).

Fig. 7.8

The “top-hat” resection. (a) A first pass of the loop resects the ectocervical TZ and a part of the endocervical TZ. (b) A second pass with a smaller loop resects a further part of the endocervical TZ.

7.5. The excised specimen

The size of the excised TZ specimen is proportional to the risk of subsequent pregnancy-related complications, so accurate dimensional terms are important. Some terms have consensus agreement, and others, like “depth”, do not. In the 2011 IFCPC nomenclature, the terms “depth” and “height” have been abandoned. “Length” and “thickness” of an opened specimen are universally understood and are included in the 2011 IFCPC nomenclature. When multiple excision specimens are obtained, as is the case with the top-hat technique, each specimen should be measured separately. Fig. 7.9 depicts the dimensions of the opened specimen (thickness, length, and circumference) just before pinning onto a cork board and immersion in formalin.

Fig. 7.9

An opened LLETZ/LEEP specimen after removal, with the dimensions used to determine thickness, length, and circumference.

7.6. Colposcopic terminology of cervical epithelium

7.7. Individual terms in the IFCPC nomenclature

Colposcopic examination begins with a general assessment of the cervix, and most colposcopists will aim to determine the level of reliability of the examination at this stage. The popular terms “satisfactory colposcopy” and “unsatisfactory colposcopy” have been discarded, because they have the connotation of an examination that needs to be repeated. The colposcopic examination is now assessed by three variables: adequacy, visibility of the SCJ, and TZ type (Annex 3).

The first variable is whether the examination is adequate, and if not why not. The reason should be documented; for example, the cervix may be obscured by inflammation, bleeding, or scarring. The second variable is visibility of the SCJ, which can be described as “completely visible”, “partially visible”, or “not visible”. The reason that the visibility and site of the SCJ are so important is that this influences both the ability to perform a satisfactory examination and, when treatment is indicated, the extent and type of excision. The terms “adequacy” and “SCJ visibility” are not mutually exclusive; the SCJ may be partially visible because a portion of its inner margin is located high in the endocervical canal, whereas the examination is still adequate because the cervix is not obscured by blood or inflammation. The third parameter is the TZ type. It overlaps to some degree, but not completely, with the visibility of the SCJ. The TZ and the SCJ are not the same thing; the SCJ is the inner margin of the TZ. Both type 1 and type 2 TZs are completely visible, and the difference between the two is important, mainly for planning treatment. The TZ type defines both the site and the visibility of the SCJ.

Localization of the lesion inside or outside the TZ is important. This is because a lesion inside the TZ, as opposed to one outside (Fig. 7.10), has been shown to be an independent predictor of a high-grade lesion or carcinoma (Hammes et al., 2007). Lesion size (Figs. 7.11 and 7.12) has also been shown to be an independent predictor of high-grade disease (Kierkegaard et al., 1995; Shaw et al., 2003). The size may be quantified as (i) the number of cervical quadrants the lesion covers or (ii) the size of the lesion as a percentage of the cervix.

Fig. 7.10

Satellite lesions. In this normal cervix, there are two small satellite lesions outside the transformation zone.

Fig. 7.11

A small lesion occupying only one quadrant of the transformation zone, with several satellite lesions at the 12 o’clock position.

Fig. 7.12

A large lesion occupying more than three quadrants of a large transformation zone.

Two relatively new colposcopic image terms are included in the grade 2 (major) lesions of the 2011 IFCPC nomenclature: the “inner border sign” and the “ridge sign”. Published work has validated their worth as markers of high-grade CIN (Scheungraber et al., 2009a, 2009b). A sharp border around a lesion has also been reported as being associated with a more severe lesion. The term “leukoplakia” is included in the category of non-specific abnormal findings. This is because it has been reported to have a 25% independent predictive value of containing high-grade or invasive neoplasia (Hammes et al., 2007). In truth, leukoplakia may cover innocent or pathological epithelium, and colposcopic examination cannot reliably determine which. The uptake of Lugol’s iodine is part of the non-specific findings because several publications have suggested relatively poor reliability of the test (Rubio and Thomassen, 1976). Cervical polyps are placed in the category of miscellaneous findings. They may, of course, be ectocervical or endocervical in origin.

Box

Key points.

Fig. 7.2

Type 2 transformation zone (TZ). (a) Illustration; the upper limit of the TZ is in the endocervical canal but is visible below the upper limit of visibility, here represented by the horizontal line. (b, c) A large type 2 (more...)