Colposcopy case studies2

Colposcopy Case Studies
Hatim Al-Dabbagh
MBBS.FRCSC
Gynecologic Oncologist
Dhahran Health Center
Saudi Aramco
Dec 7-8/2011
Abdulmohsen Alkushi
MBBS.FRCPC
Gynecologic Pathologist
National Guard Hospital
Riyadh

INTRODUCTION
A.  The colposcopic exam serves to
(1)  Identify normal landmarks
(2)  Identify abnormal areas in relation to these landmarks
(3)  Facilitate directed biopsy of abnormal areas for
histologic diagnosis
(4)  Rule out invasive cancer

INTRODUCTION
A.  Pre-malignant and malignant cervical conditions
produce colposcopically identifiable epithelial
changes that generally occur within the
transformation zone

A.  SQUAMOUS METAPLASIA
–  Physiological replacement
of the columnar epithelium
with squamous epithelium
–  The region where this
occurs is known as the
TRANSFORMATION ZONE
–  IMPORTANT because almost
ALL cervical cancer occur in
this zone

INTRODUCTION
A.  The key ingredients of the exam are the
observation of the cervical epithelium
–  after application of normal saline
–  3-5% acetic acid
–  Lugol s iodine solution in successive steps

INDICATIONS
A.  Suspicious visible lesion or palpable lesion of the cervix, vagina,
vulva, perineum or perianal area
B.  Pap smear consistent with dysplasia or cancer
C.  Pap smear with evidence of HPV infection (High Risk types)
D.  History of intrauterine DES exposure
E.  Follow-up of previously treated patients or high-risk patients
F.  Evaluation of child abuse or rape cases

RELATIVE CONTRAINDICATIONS
A.  Active, inflammatory cervicitis
B.  Non-cooperative patient
C.  Postmenopausal patient who is not estrogen-
primed
D.  Heavy menses

Steps in the colposcopic exam
A.  Explain the procedure and obtain informed
consent
B.  Obtain a relevant medical history
C.  R/O pregnancy
D.  Perform bimanual exam if not already done
E.  Examine vulva
F.  Insert speculum

A.  Examine cervix using low power (inflammation,
infection, leukoplakia, punctation, mosaicism,
abnormal vessels)
B.  Obtain KOH/WP, cultures and/or pap, if needed
C.  Use green filter and normal saline

A.  Apply 5% acetic acid. Repeat Q 5 min.
B.  Scan entire cervix with white light. Start with
low power and move to higher magnification
to document abnormal vascular patterns

A.  Use endocervical speculum if needed to view entire
transformation zone
B.  The entire TZ, including SCJ, and borders of all
lesions must be visualized in order for colposcopy
to be satisfactory

A.  Apply Lugol s iodine solution to aid in
delineating potential biopsy site

A.  Perform endocervical
curettage, if indicated
–  Glandular lesion
–  Unsatisfactory colposcopy
–  Normal colpoposcopy of
ectocervix, yet abnormal
cytology
–  CONTRAINDICATED in
pregnancy or active cervicitis

A.  Mentally map abnormal areas
–  Mild acetowhite < Intensely acetowhite
–  No blood vessel pattern < Punctation < Mosaicism
–  Diffuse vague borders < Sharply demarcated borders
–  Follows normal contours of the cervix < humped up
–  Leukoplakia – usually a very good (condylomata) or very
bad sign
–  Atypical vessels – usually cancer
–  Normal iodine reaction (dark) < Iodine-negative epithelium
(yellow)

A.  Perform cervical biopsies, if
necessary
–  Biopsy posterior areas first
–  A depth of 3 mm is adequate
–  Biopsy area of the lesion with
worst features and closest to
SCJ, include the area with
atypical vessels

A.  Apply pressure and Monsel s paste to bleeding sites after
biopsy
B.  Remove speculum and inspect vaginal walls, vulva, perineum,
and perianal areas
C.  Allow patient to recover
D.  Document findings
E.  Discuss findings with patient and give post-procedure
instructions

Post-Procedure Instructions
A.  No douching, intercourse, or tampons until spotting
subsides
B.  Return for foul odor or discharge, pelvic pain,
profuse bleeding or fever
C.  Fevadol or ibuprofen may be used for cramping
D.  Otherwise, follow-up is usually 1-3 weeks to discuss
histology results and definitive therapy

Post-Procedure Instructions
A.  Encourage contraception once definitive therapy
completed
B.  Re-emphasize the relationship of cervical dysplasia
with STDs, smoking, and non-monogamous sexual
practices
C.  Stress patients life-long risks of HPV infection

Complications
A.  Bleeding
–  Reapply Monsel s solution
–  Cauterize the biopsy site
–  Inject 1-2 cc of 2% lidocaine with epinephrine into the
bleeding site
–  Rarely, a cervical stitch of 4-0 absorbable suture across a
deep biopsy site

Complications
A.  Infection is rare but typically occurs on the 3rd or 4th day after
biopsy
B.  Avoid biopsy with active cervicitis
C.  Pain can be minimized by caring and careful explanation of
procedure, a warm room, NSAIDs given the night before and
morning of procedure (Avoid Aspirin)
D.  Missing disease – lack of correlation between pap cytology and
subsequent histology

Normal Colposcopic Findings
A.  Original squamous epithelium
B.  Columnar epithelium
C.  Squamocolumnar junction
D.  Squamous metaplasia
E.  Transformation Zone

Normal Findings w/ 5% Acetic Acid

Normal findings with Lugol s solution

Abnormal Colposcopic Findings
A.  Atypical transformation zone with the following
features suggestive of dysplasia or neoplasia:
–  1. Punctation
–  2. Mosaicism
–  3. Leukoplakia
–  4. Acetowhite
–  5. Abnormal blood vessels

Abnormal Lugol s Iodine Uptake

Glandular Lesions
(AIS and Adenocarcinoma)

Case 1
A 24 years old woman has liquid based PAP smear as
demonstrated in figure. it shows :
A.  Negative for
intraepithelial
neoplasia and
malignancy
B.  ASC-US
C.  LGSIL
D.  HGSIL
Question 1

Answer 1
B. Correct: ASC-US
These cells abnormal but not
sufficient enough to be
diagnosed as SIL.
There is a slight increase in
the nuclear to
cytoplasmic ratio, with
slight variation in nuclear
size and shape.

Her test results was positive for oncogenic HPV.
Your colposcopic impression is :
A.  Normal metaplasia
B.  Low grade
C.  High grade
D.  Cancer
Question 2

Answer 2
B. Correct: Low grade
An acetowhite lesion with irregular
margins, satellite lesion,
translucent acetowhite color and
fine caliber punctation can be
seen.

How would you proceed?
A.  Repeat the PAP smear in 4 to 6 moths
B.  Suggest immediate LEEP
C.  Obtain a cervical biopsy
D.  Refer her to a gyn oncologist
Question 3

Answer 3
C. Correct: Obtain a cervical biopsy
It is probably important to confirm
your colposcopic impression with
a cervical biopsy.

What is your diagnosis?
A.  Normal
B.  CIN 1
C.  CIN 3
D.  Cancer
Question 4

Answer 4
B. Correct: CIN1
Celluler atypia is seen in the
lower one third of the
epithelium.
A few koilocytes can be
seen in the intermediate
superficial cell layers

Select the best management:
A.  Observation with subsequent cytology
B.  Cryotherapy
C.  LEEP
D.  Disclose the nature of your findings to your patient and
ask her for her management preference
Question 5

Answer 5
D. Correct:
Disclose the nature of your findings to your patient and ask
her for her management preference
The patient decided to have cryotherapy

A year later the patients returns to your care. You obtain a
PAP smear visualize the cervix using your colposcope.
Your impression is:
A.  Normal cervix
B.  Cervical stenosis
C.  CIN1
D.  CIN3
Question 6
A
Question 6

Answer 6
B. Correct: Cervical stenosis
One of the complications of
cryotherapy is cervical
stenosis. This risk is
increased for estrogen
deficient woman.

The PAP smear is reported as unsatisfactory absence of TZ
component. The best management at this time would be to:
A.  Repeat the PAP smear
B.  Dilate the endocervical os
C.  LEEP
D.  HPV DNA test
Question 7

Answer 7
A. Correct: Repeat the PAP test
If the next PAP smear is
satisfactory then usual
screening is appropriate
However, if her PAP smears
continue to be interpreted as
unsatisfactory, then access to
the TZ should be assured.

Case 2
A 43-year-old female presents with the vaginal
smear shown in Figure. The patient previously had a
vaginal hysterectomy for a CIN2 lesion.

The Correct Cytologic Diagnosis for this is:
A.  ASC-US
B.  LGSIL
C.  HGSIL
D.  AGC
Question 1

The Correct Cytologic Diagnosis for this is:
C. Correct : HGSIL
Note the high nuclear
cytoplasmic ratio in these
cells.
Answer 1

Given a Cytologic Diagnosis of HGSIL, the
Preferred Management Option at This Time Is:
A.  Reflex HPV-DNA testing
B.  Repeat cytology in 3-6 months
C.  Colposcopy
D.  Vaginal 5-Fluorouracil cream
Question 2

Given a Cytologic Diagnosis of HGSIL, the
C. Colposcopy: Correct
q  HPV Testing, although appropriate for triage of
ASC-US cytology, does not have a role in the
management of HGSIL.
q  Observation and repeat cytologic surveillance is
also not appropriate for HGSIL.
q  Treatment with 5-FU cream should not be
initiated until a definitive diagnosis is made.
Answer 2

Colposcopy of This Patient Can Be Seen in
Figures

Which of the Following Best Describes the
Lesion Seen in These Figures?
Question 3
A.  Condylomatous features
with papillary areas
B.  Acetowhite lesion
C.  Atypical vessels, ulceration
D.  Atrophic changes only

Figures indicate the following finding:
Answer 3
B. Acetowhite lesion: Correct
The lesion seen in the colposcopy is flat and
has well demarcated margins.
Under green filter, the vascular changes
represent relatively coarse mosaic patterns.

Considering This Finding (ie, Acetowhite Lesion With Mosaic Pattern
and Distinct Borders), the Next Appropriate Step Would Be:
Question 4
A.  Lugol's staining of the
vagina
B.  Colposcopically-directed
biopsy
C.  Laser ablation
D.  Cryotherapy

The next appropriate step is:
A. Correct : Lugol's staining of the vagina
In order to determine if there are other
lesions in the vagina, Lugol's iodine
should be applied. The use of Lugol's can
also highlight areas where lesions can be
missed.
Treatment such as laser ablation or
cryotherapy should not be initiated until a
diagnosis is made.
Answer 4

The Result of Lugol's Staining Is Seen in Figure Highlighting the
Lesion Seen in the Left Vaginal Fornix. The Pathology From a
Biopsy of This Lesion Is Seen in Figure.

Based on the Pathology, the Correct Diagnosis Is:
Question 5
A.  Atrophy and cervicitis
B.  VAIN1
C.  VAIN3
D.  Invasive vaginal carcinoma

Based on the Pathology, the Correct Diagnosis Is:
C. Correct : VAIN3
The pathology shown in Figure
demonstrates increased nuclear changes,
consistent with VAIN3.
The pathology also shows full-thickness
changes in the epithelium and an intact
basement membrane.
Mitotic activity is also seen in VAIN3.
Answer 5

Based on the Pathology, the Correct Diagnosis is:
D. Invasive vaginal carcinoma: Incorrect
There is no evidence of invasion
through the basement membrane.
Answer 5
Cont.

For this patient, the correct management
option at this time is:
A.  Cryotherapy
B.  Laser vaporization
C.  Loop excision
D.  5-Fluorouracil cream
Question 6

The correct management options are:
B. Correct: Laser vaporization
Most clinicians would treat this lesion with laser
vaporization, which is the preferred technique and
allows for adequate treatment to a depth of 1-2 mm and
destruction of the entire lesion.
If there is any concern that an invasive component is
present, excision of the lesion should be performed.
Answer 6

C. Correct: Loop excision
Loop excision has been reported for vaginal lesions and, in the
hands of experienced operators, it may be possible to use loop
excision, but laser vaporization may be more precise in
controlling the depth of treatment.
D. Correct: 5-Fluorouracil cream
5-FU cream has been used for resistant cases, but there is an
increased incidence of ulcerations with this technique.
Answer 6
Cont.

A. Cryotherapy: Incorrect
Cryotherapy is not the preferred method as it is
difficult to control the depth of treatment.
Answer 6
Cont.

Case -3
q  A 30-year-old patient presents for her first Pap
smear in 3 years.
q  She is asymptomatic with normal menses.
q  She is G4,P4.
q  A cigarette smoker.
q  Has no relevant history of treatment or other
abnormal cytology.

The correct cytologic diagnosis for
this slide is:
A.  ASC-US
B.  ASC-H
C.  LGSIL
D.  HGSIL
E.  AGC
Question 1

The correct cytologic diagnosis for
this slide is:
B. Correct : ASC-H
The 2001 Bethesda System
added a new category of ASC-H
This diagnosis should only
account for 5-10% of all ASC
cases,
It does have a high predictive
value for CIN2 and 3.
Answer 1

Given a Cytologic Diagnosis of ASC-H, the
B.  Repeat cytology
C.  Colposcopy
D.  Loop excision

Question 2

Given a Cytologic Diagnosis of ASC-H, the
C. Colposcopy: Correct
A.  The diagnosis of ASC-H requires colposcopy to detect
high-grade lesions.
B.  The risk of CIN2 and 3 associated with this diagnosis has
been reported to range from 24% to 94% in various
studies. The risk of invasion is 0.1-0.2%.
C.  Published reports do not suggest that intermediate triage
such as HPV DNA testing is useful
D.  Repeat cytological testing would be inappropriate.
E.  Loop excision is not indicated prior to colposcopic
diagnosis.
Answer 2

Which of the Following Findings Regarding the
Colposcopic Examination Are True?
A.  Satisfactory examination
B.  Atypical vessels
C.  Acetowhite areas
D.  Nodularity
Question 3

Which of the Following Findings Regarding the
Colposcopic Examination Are True?
B. Atypical vessels: Correct
The area seen in the colposcopy
appears flat. There are numerous
atypical vessels in a background of
acetowhite changes. The entire
squamo-columnar junction is not
visible.
C. Acetowhite areas: Correct
Answer 3

These Findings (i.e., Atypical Vessels and
Acetowhite Areas) Are Best Described As:
A. Invasive cancer
B. Metaplasia and cervicitis
C. High grade CIN
D. HPV changes
Question 4

These Findings (i.e., Atypical Vessels and
Acetowhite Areas) Are Best Described As:
A. Invasive Cancer: Correct
The presence of atypical vessels should
alert the clinician to the possibility of
invasive cancer.
Other warning signs of invasion include:
areas of necrosis, large lesions,
nodularity, ulceration, invasive cytology,
lesions extending to the canal and a
positive endocervical curettage.
Answer 4

From a Biopsy at 6 O Clock
Based on This Pathology,Your Initial Diagnosis Is:
A.  CIN3
B.  AIS
C.  Squamous cell carcinoma
–  Invasion 1 mm
D.  Squamous cell carcinoma
–  Invasion 5 mm
Question 5

C. Squamous cell carcinoma
Invasion 1 mm: Correct
The pathology shown in Figure
demonstrates full-thickness
dysplasia and invasion below
the basement membrane.
In this slide, the invasion is
minimal.
Answer 5
Answer 5

For this Patient, the Correct Management
Option at This Time Is:
A.  Simple hysterectomy for "microinvasion
B.  Radical hysterectomy for cervical cancer
C.  Cold knife conization
D.  Loop excision
Question 6

The Correct Management Option Is:
C. Correct: Cold knife conization
A.  The diagnosis of microinvasion cannot be made on a colposcopic
biopsy. In this case, it would appear that a significant invasion is
present.
B.  Excisional biopsy is necessary to discover the depth of invasion.
C.  Cold knife conization is preferred in order to most accurately
determine depth of invasion and margin status without thermal
artifact.
D.  Radical hysterectomy may be necessary, depending on results of
the cone biopsy.
Answer 6

Case 4
A 28 years old woman has G2,P2 PAP smear as
demonstrated in figure. it shows
A.  AGC
B.  HGSIL
C.  Koilocytotic changes/
CIN1
D.  Immature metaplastic
squamous cells
Question 1

B. Correct: HGSIL
Each cell shows gross
nuclear enlargement
without corresponding
enlargement of the cell
body.
There is an irregular
nuclear outline coupled
with irregular chromatin
distribution
Answer 1

Figures of the cervix after the application of 5% acetic acid.
This colposcopic appearence is suspect for:
A.  Glandular disease
(AIS/ Adeno ca)
B.  Metaplasia
C.  Mixed disease (squamous
and glandular)
D.  Condyloma
Question 2

C. Correct: Mixed disease
Each cell shows gross
nuclear enlargement without
corresponding enlargement
of the cell body. There is an
irregular nuclear outline
coupled with irregular
chromatin distribution
Answer 2

The next step in the investigation is:
A.  Colposcopic biopsies from the
most abnormal appearing areas
B.  Cervical conization/ clindirical
excision
C.  Repeat the PAP smear
D.  Hysterectomy
Question 3

A. Correct: Colposcopic
biopsies from the most
abnormal appearing areas
Answer 3

Considering the two histological appearances
together, histologic diagnosis consistent with:
A.  HGSIL and AIS
B.  Immature squamous
metaplasia and
microglandular hyperplasia
C.  AIS and LGSIL
D.  Reactive endocervical
changes and HGSIL
Question 4

A. Correct: HGSIL and AIS
Answer 4

The next step in the investigation is:
A.  Hysterectomy
B.  Cervical conization/ clindirical
excision
C.  Follow-up with cytology and
colposcopy
D.  Repeat the biopsies in 4
months
Question 5

B. Correct: Cervical conization/
clindirical excision
Answer 3

Considering the two histological appearances
together, histologic diagnosis consistent with:
A.  Mixed disease (HGSIL and AIS)
B.  AIS and Immature squamous
metaplasia
C.  Condyloma and HGSIL
D.  Adenocarcinoma and HGSIL
Question 4

A. Correct: Mixed disease
(HGSIL and AIS)
Answer 4

Case-5
The patient is a 30-year-old,
G3,P3 woman who four years earlier had a Pap
smear that was interpreted as a LSIL.
A colposcopic evaluation found no visible
lesion.
A repeat smear the following year was read as
ASC-US and she had no follow-up until a
recent routine exam Pap smear was
reported as a HGSIL.

The slide at the right demonstrates the findings at
colposcopy after the application of 5% acetic acid.
What colposcopic features are present?
A.  Mild acetowhite epithelium on the
posterior lip of the cervix
B.  Dense acetowhite epithelium on the
posterior lip of the cervix
C.  Satisfactory exam
D.  Coarse punctation
Question 1

B. Correct:
There is an area of dense white
epithelium on the posterior lip
of the cervix.
There also appears to be a
lesion in the canal at 12 o’clock
and the squamocolumnar
junction can not be seen fully
anteriorly.
The current findings are
suggestive of high grade CIN.
Answer 1

Using a cotton-tipped applicator, the anterior lip of the
cervix is raised and the slides at the right reveal the
following colposcopic findings at a low and higher power:
A.  A faint well defined low-
grade acetowhite
epithelium at the
squamocolumnar
junction
B.  A well defined high grade
acetowhite lesion in the
canal with atypical
vessels
C.  Leukoplakia
D.  Fine punctation
Question 2

B. Correct:
There is a lesion on the anterior aspect
of the distal canal with dense white
epithelium and coarse punctation.
A mosaic pattern is also seen in the
lesion at 6 o’clock. Some of the vessels
within the punctation pattern are linear
and therefore qualify as atypical
vessels.
This case demonstrates both the
technique and the benefits of looking
into the endocervical canal.
Answer 2

After reviewing the 3 prior colpophotographs, these
findings are most consistent with what type of lesion?
A.  Immature
metaplasia
B.  Low grade CIN
C.  High grade CIN
D.  Frankly invasive
cancer
Question 3

C. Correct: The dense white epithelium, coarse
mosaic and punctation pattern is all consistent
with a high-grade lesion.
Answer 3
Atypical vessels may be
seen in CIN3,
microinvasion, frankly
invasive cancer, and
adenocarcinoma as well as
inflammatory conditions,
and following radiotherapy.

The slide at the right is a view of the biopsy specimen
taken from the most abnormal area. These findings are
consistent with:
A.  Immature
metaplasia
B.  Low grade CIN
C.  High grade CIN
D.  Frankly
invasive
cancer
Question 4

C. Correct: High
grade CIN
There are immature
cells extending the
full depth of the
epithelium, along
with cellular
crowding and loss
of polarity.
Answer 4

Case 6
This is a 35 year-old woman whose
Pap smear showed a low grade
squamous intraepithelial lesion.
She presents for colposcopic
evaluation.

The colpophotographs represent views of the
cervix. The findings are:
A.  Transformation zone fully visualized
acetowhite change with a warty pattern
B.  Transformation zone NOT fully
visualized acetowhite change with a
warty pattern
C.  Transformation zone fully visualized
large complex pattern with coarse
mosaic and punctation
D.  Transformation zone NOT fully
visualized
Question 1

D. Correct:
Transformation zone not fully
visualized
Colposcopic findings showed a
mosaic pattern on the posterior
lip of the cervix.
A close-up of the mosaic pattern at
4 o’clock shows the irregularity
of the pattern that suggests this
is a high-grade lesion.
Answer 1

The biopsy site, which will reveal the most information
regarding diagnosis, is at
A.  1 o’clock
B.  10 o’clock
C.  5 o’clock
D.  12 o’clock
Question 2

C. Correct: 5 o’clock
This is an area of coarse mosaic
that is most likely a high-grade
lesion
Answer 2

Histology of the area biopsied is present on the slides
shown on the right. They reveal:
A.  HGSIL
B.  LGSIL
C.  Metaplasia
D.  Cancer
Question 3

A. Correct:
Biopsies were taken at 8 o’clock and 5
o’clock. At 8 o’clock, the biopsy
shows severely inflamed tissue with
immature metaplasia and foci of
koilocytosis with binucleation.
At 5 o’clock, there are also areas with
increased mitotic activity and
epithelial crowding consistent with
CIN2.
Answer 3

The next step in management is:
A.  Follow with cytology and
colposcopy in 3 months
B.  Radical hysterectomy or
radiation therapy
C.  Conization of cervix
D.  Laser ablation
Question 4

C. Correct:
Large complex lesions of the cervix when
associated with changes that are
characteristic of high-grade disease, such as
patterns of coarse mosaic and punctation, are
the most difficult to sample adequately by
directed biopsy.
The risk of missing small foci of early invasion can
be significant in the best of hands. These
lesions are best evaluated by diagnostic
conization.
The transformation zone is not fully visualized so
that this patient has a further indication for the
performance of conization.
Answer 3

The final histologic specimen shown on the slides on the
right revealed:
A.  Clear cell
adenocarcinoma
B.  Giant cell granuloma -
typical of tuberculosis
C.  HSIL with microinvasion
D.  LSIL
Question 5

C. Correct:
In a setting of condyloma and dysplasia,
there is a small (about 1-3 mm) area of
invasive squamous cell carcinoma.
The lesion is microinvasive, extending
downward about 1.25 mm. On the
surface, the epithelium is thinned and
dysplastic.
With the successful and complete removal of
a microinvasive lesion (Stage 1A1), the
cone may be acceptable as therapy in
circumstance where preservation of the
uterus is desirable.
Answer 5

Case 7
This is a 16 year old P 0,G0 whose Pap smear shows a
LGSIL with HPV.
She is referred to you for colposcopic evaluation.

The colposcopic pattern in the slides at the
right is characterized by:
A.  High grade acetowhitening with
sharply defined, raised borders
B.  Low grade acetowhitening, no clear
border, no vascular change
C.  Acetowhitening with focal areas,
geographic borders, a large dilated
T-zone vessel, and small satellites
D.  Large area of glandular epithelium
surrounded by minimally
acetowhitened squamous epithelium
with large areas that are non-iodine
stained
Question 1

A. Correct:
The epithelium is very dense with a dull
off-white color, consistent with high
grade CIN.
In contrast, low grade CIN will have mild
white epithelium and irregular
borders.
It is not clear whether the blood seen on
lower slide is a dilated atypical
vessel or more likely just a small
amount of traumatic bleeding since it
is not seen on slide top slide.
Answer 1

Biopsies should be performed at:
A.  3, 6, 9, and 12 o’clock with an ECC
B.  2 and 10 o’clock
C.  No biopsy required since lesion is
benign
D.  5, 6, 7, and 8 o’clock
Question 2

B. Correct: 2 and 10 o’clock
Biopsies should be taken from
both areas of acetowhite
epithelium
Answer 2

The histology from the worst biopsy site and demonstrates
low and high power views of the tissue which shows:
A.  Normal, mature squamous
epithelium
B.  Squamous metaplasia with
epithelial hyperplasia,
parakeratosis, and
inflammation
C.  Microinvasive squamous cell
carcinoma
D.  Adenocarcinoma-in-situ
Question 3

B. Correct:
The nuclei seen occupying the
lower portion of the epithelium
are regular without
hyperchromasia or clumped
chromatin, consistent with
normal squamous cells.
Answer 3

Based upon the information on cytology, colposcopy, and
biopsy, this patient should have:
A.  Excision of the
transformation zone
B.  Antiviral therapy with
interferon
C.  Re-evaluation in six
months with cytology and/
or colposcopy
D.  Simple hysterectomy
Question 4

C. Correct:
Young sexually active women will
frequently demonstrate mild
cytologic abnormalities related to
HPV infection of the cervical
epithelium.
In the subsequent time after infection
and in the presence of reactive and
reparative changes within the
cervical transformation zone of
these young women, we may see
both typical and atypical tissue
responses, i.e. metaplasia along
with parakeratosis, epithelial
hyperplasia, and inflammation.
Answer 4

Case 8
This is a 32-year-old, G0, P0, who had a Pap smear
showing LSIL

The colposcopic examination is:
A.  Satisfactory
B.  Unsatisfactory
Question 1

Answer 1
The SCJ is not completely
visible.
The lesion on the posterior lip
extends into the
endocervical canal.
When the lesion is located
partially or completely in
the endocervical canal, its
upper limit may not be
visualized colposcopically
and excisional therapy is
necessary to rule out
invasion.
B. Correct: The colposcopy is unsatisfactory

This slide shows a colposcopy of the anterior lip of the
cervix. This colpophotograph is most consistent with:
A.  Squamous
metaplasia
B.  Low-grade lesion
C.  High-grade lesion
D.  Invasive cervical
cancer
Question 2

Answer 2
C. Correct:
The lesion on the
anterior lip is well
circumscribed with
a sharp, angular
border. A mosaic
pattern is present
focally at the
peripheral margin
of the lesion.

A colposcopically directed biopsy of the anterior lip was
performed which showed:
A.  Koilocytosis
B.  CIN 2 with
koilocytosis
C.  CIN 3
D.  CIN 3 with
extensive
endocervical
glandular
involvement
Question 3

Answer 3
D. Correct:
The biopsy is consistent with
CIN 3 and extensive
endocervical glandular
involvement.
Because the lesion is not
completely visualized, an
ablative procedure would
not be appropriate.
An unsatisfactory colposcopy,
glandular involvement in a
high-grade intraepithelial
neoplasia is an indication
for an excisional procedure.

The cone biopsy (LLETZ) was performed. The slide at the right is a
microscopic section of the cone biopsy. It reveals:
A.  Koilocytosis only
B.  CIN 2 with
koilocytosis
C.  Invasive cancer
D.  CIN 3
Question 4

Answer 4
D. Correct:
The cone biopsy (LLETZ)
revealed CIN 3 with
extensive glandular
involvement.
These results were consistent
with the cervical biopsy.
However, the cone
specimens demonstrated
extensive involvement of
the endocervical margins.

How would you manage this patient?
A.  The colposcopy and cytology should be repeated in 3
to 6 months.
B.  Another cone biopsy should be performed
immediately
C.  Simple hysterectomy
D.  Radical hysterectomy and pelvic lymphadenectomy
Question 5

Answer 5
A. Correct:
Even though the cone margins are positive, the excisional
procedure does not need to be repeated at this time. Patients
with positive margins often have no residual disease on repeat
surgical specimens.
The cure rate for patients with positive margins on a cone biopsy
without further treatment is approximately 70%.
In cases of CIN when the dysplasia extends to the endocervical
border of the excision, expectant management, including
intensive cytologic surveillance, may be employed rather than
repeat excision.

Case -9
This is a 35-year-old woman referred to
you from another physician.
Her Pap smear showed HSIL .

There is acetowhite epithelium from approximately 12 to 1
o’clock and at 3 o’clock. Where should the biopsy be
taken?
A.  12 to 1 o’clock
B.  3 o’clock
C.  Both areas should be
biopsied
D.  Do not need to be
biopsied.
Question 1

Answer 1
C. Correct:
The colposcopic
evaluation
demonstrates two
areas of acetowhite
epithelium.
It is not possible with
certainty, to determine
which acetowhite area
represents the most
severe histology.
Both of these lesions
should be biopsied.

This represents the colposcopically directed biopsy of the
3 o’clock area. The diagnosis is:
A.  Normal squamous
epithelium
B.  Koilocytosis
C.  CIN 3
cancer
Question 2

Answer 2
B. Correct: Koilocytosis
The lower third of the
epithelium shows cells
with a high
nuclear:cytoplasmic
ratio and
hyperchromatic nuclei.
The intermediate and
upper layers of the
epithelium
demonstrate
koilocytosis.
The presence of
perinuclear halos and
nuclear atypia
characterize the
koilocytes

This represents the colposcopically directed biopsy of the
12 o’clock area. The diagnosis is:
A.  Normal squamous
epithelium
B.  Koilocytosis
C.  CIN 2-3
cancer
Question 3

Answer 3
C. Correct: CIN 2-3
The epithelium
displays cells with
various
morphologic
shapes, dense
chromatin, and the
absence of
koilocytotic
changes.
The nuclei are
enlarged in
relation to the
amount of
cytoplasm.

The colposcopic examination is:
A.  Cervical condyloma
B.  Cervical and vaginal
condyloma
C.  Vaginal condyloma and
cervical cancer
D.  Microglandular
hyperplasia and vaginal
cancer
Question 1

Answer 1
B. Correct: Cervical and
vaginal condyloma

The best management at this time would be to:
The best management at this
time would be to:
A.  Apply TCA
B.  Collect a specimen for HPV-
DNA Testing
C.  Freeze the warts
D.  Collect cervical histologic
specimen(s)
Question 2

Answer 2
D. Correct:
It may be appropriate to
confirm your confirm
colposcopic impression
with histologic sampling.
Cervical cryotherapy is
contrindicated without
previous biopsy.
HPV DNA testing has no
utility once condyloma
are histologically
confirmed.

A cervical biopsy was taken from the lesion . The cervical
biopsy is diagnostic of:
A.  Cervical condyloma
B.  Cervical cancer
C.  Cervical polip
D.  Cervical desidua
Question 3

Answer 3
A. Correct:
A classic cervical wart is seen
histologically

Optimal recommendation to the patient would be to:
A.  Follow-up with cytology
and colposcopy
B.  Treat the cervical disease
only
C.  Treat the vulvar disease
only
D.  Treat all the condylomas
Question 4

Answer 4
D. Correct: Treat all the
condylomas

Case -11
q A 24-year-old G0,P0 presents for her first pap smear in
3 years.
q There is no previous history of abnormal smears.
q She has smoked in the past but stopped one year ago.
q She has no history of STDs.
q She is using oral contraceptives.

Your diagnosis is:
A. ASC-US
B. ASC-H
C. LGSIL
D. HGSIL
E. AGC
Question 1

Your diagnosis is:
A. Correct: ASC-US
Note the normal cells present with
small nuclei and abundant
cytoplasm.
The more eosinophilic cell to the
right of the screen has a slightly
enlarged nucleus, approximately
2 to 3 times the size of normal
nuclei. There is, however,
abundant cytoplasm.
Answer 1

Given the diagnosis of ASC-US,
preferred management is to:
A.  Colposcopy
B.  HPV-DNA reflex testing
C.  Repeat cytology in 4-6 months
D.  Cryotherapy
Question 2

Given the diagnosis of ASC-US,
preferred management is to:
A: Colposcopy is an acceptable option.
B: HPV-DNA reflex testing.
C: Repeat Cytology in 4 to 6 months is also an acceptable
option.
Answer 2

What Are the Colposcopic Findings?
A.  Faint acetowhite,
geographic borders, fine
mosaic patterns
B.  Acetowhite lesion, well
defined margins, coarse
mosaic and punctation
C.  Dense acetowhite,
atypical vessels
D.  Satellite lesions
Question 3A
Question 3A

B. Correct: Acetowhite lesion, well defined
margins, coarse mosaic and punctation:
These colposcopic photographs show a
lesion at 12 o'clock with a well-defined
margin.
There is, of course, punctation and mosaic
patterns and acetowhite lesion.
There are no atypical vessels present.
Satellite lesions are not seen.
Answer 3A

What is your colposcopic impression?
A.  Squamous Metaplasia
B.  CIN1, HPV
C.  CIN2, CIN3
D.  Invasive Squamous
cell cancer
Question 3B

What is your colposcopic impression?
C. Correct : CIN2, CIN3
The colposcopic findings here
are suggestive of a high grade
CIN, CIN2-3.
There is no evidence that this
is an invasive lesion
Answer 3B

The most appropriate area for biopsy is:
A.  3 o'clock
B.  6 o'clock
C.  9 o'clock
D.  12 o'clock
Question 3C

The most appropriate area for biopsy is:
D. 12 o'clock: Correct
It would be most appropriate
to biopsy the lesion near
the transformation zone at
12 o'clock.
Answer 3C

Your diagnosis is:
A.  Squamous Metaplasia
B.  CIN1
C.  CIN3
D.  Invasive Squamous
Cell Cancer
Question 4

Your diagnosis is:
C. Correct : CIN3
Note the full thickness change
in the squamous epithelium
and lack of invasion of the
basement membrane.
These findings are consistent
with a CIN3 lesion.
Answer 4

Management Options for This Patient Include:
A. Observation
B. Loop excision
C. Cryotherapy
D. Cold-Knife Conization
Question 5

B. Correct : Loop excision
Observation is not appropriate for high-grade dysplasia.
This is a true cancer precursor and requires treatment.
Loop excision would be the author's preferred treatment
plan, though cryotherapy and cold knife conization have
their advantages and disadvantages.
You can prefer a loop excision for treatment of this high-
grade lesion with satisfactory colposcopy.
Answer 5

D. Correct: Cold-Knife Conization
Cold knife conization would be appropriate;
however, this generally requires more
anesthesia than a Loop excision does.
Cryotherapy is certainly appropriate. However,
given a satisfactory colposcopy, an
endocervical curettage would need to be
performed prior to performing cryotherapy.
Answer 5
Cont.

Case -12
q  A 26-year-old woman presents with a history of a
previously abnormal Pap smear at age 18.
q  The patient did not follow-up at that time and has
not had a Pap smear since then.
q  The patient used to smoke a pack of cigarettes
per day, but has not smoked for the past year.
q  She has noted no abnormalities and presented
for this Pap smear because of a yeast infection.
q  She has no abnormal bleeding or intermenstrual
bleeding

The correct cytologic diagnosis for this is:
A.  ASC-H
B.  ASC-US
C.  LGSIL
D.  HGSIL
E.  AGC
Question 1

The correct cytologic diagnosis for this is:
E. Correct: AGC
• According to the ASCCP Guidelines, the term atypical
glandular cells of undetermined significance (AGC-US or
AGUS) has been replaced with the term atypical glandular
cells (AGC)
• The cytopathologist should attempt to determine whether
these are endocervical endometrial cells, adenocarcinoma in
situ, or frank adenocarcinoma of endocervical, endometrial,
extrauterine or not otherwise specified.
Answer 1

Given AGC diagnosis,
the preferred management option is:
B.  Repeat cytology
C.  Colposcopy and endocervical evaluation
D.  Loop excision
Question 2

C. Correct : Colposcopy and endocervical evaluation
AGC have been associated with a greater risk for cervical
neoplasia than other categories (ASC or LSIL)
AGC
–  % 9-54 CIN
–  % 8 Adenocarcinoma insitu
–  % 9 Invasive carcinoma
Answer 2

• The total number of abnormal Pap smears with
glandular lesions is generally < 1%.
• Colposcopy and endocervical evaluation would not
unduly stress busy clinical services. Therefore, the
recommendation has been made that all of these
patients be properly evaluated.
Answer 2
Cont.

Colposcopy of this patient can be seen. The
following statements are true:
Question 3
A.  There is a wide transformation
zone
B.  There are acetowhite lesions
present
C.  There are atypical vascular
patterns present
D.  The colposcopy is unsatisfactory

Answer 3
A. Correct: There is a wide transformation
zone

B.  Correct: There are acetowhite lesions
present:
  In these colposcopic photographs, at 12
o'clock there are acetowhite lesions
present.
C. Correct: There are atypical vascular
patterns present
Answer 3
Cont.

A biopsy is taken from one of the areas
of atypical vessels, the correct histologic diagnosis is:
Question 4
A.  High grade CIN
B.  Low grade CIN
C.  Adenocarcinoma in situ
D.  Invasive adenocarcinoma

A biopsy is taken from one of the areas
of atypical vessels, the correct histologic diagnosis is:
Answer 4
C. Correct: Adenocarcinoma in situ
This is a good example of
adenocarcinoma in situ.
Please note that the glands are quite
complex.
There is no invasion into the stroma
surrounding these glands.

The correct treatment for this patient includes
which of the following:
A.  Cryotherapy
B.  Laser vaporization
C.  Cold knife conization
D.  Loop excision procedure
Question 5

C. Correct: Cold knife conization
The preferred method of excisional of biopsy is cold
knife conization.
While Loop excision is sometimes performed, a higher
rate of recurrence of adenocarcinoma in situ has been
found in patients undergoing Loop electrosurgical
excision procedures as opposed to cold knife
conizations.
Answer 5

• In patients who have completed their childbearing after an
invasive lesion has been ruled out by cold knife conization,
standard therapy continues to be a simple hysterectomy
• In patients who wish to continue fertility, if the margins are
negative, close clinical follow-up is recommended. A change in
the recommendations for conservative follow-up includes four
consecutive normal Pap smears rather than three.
Answer 5
Cont.

Case 13
This 27-year-old patient had a series of Pap
smears several months apart, each of which
showed ASC-US.
Her most recent Pap smear showed a HSIL.

This is the colposcopic appearance of her cervix after the
application of 5% acetic acid. The lesion is most consistent
with:
A.  Squamous metaplasia
B.  LGSIL
C.  HGSIL
cancer
Question 1

B. Correct: LGSIL
This acetowhite area has
characteristics of a low-
grade lesion.
The borders are feathery.
Acetowhiteness is very
dense, a biopsy would
need to be performed in
order to grade the lesion.
Answer 1

Colposcopic view of the cervix reveals an acetowhite area
on the posterior lip of the cervix adjacent to the
squamocolumnar junction. It shows:
A.  Atypical vessel pattern
consistent with invasive
cancer.
B.  Nabothian cyst.
C.  A fine mosaic patterns
consistent with squamous
metaplasia or LGSIL.
D.  Dense acetowhite epithelium
with scattered coarse
punctation or gland
openings consistent with a
HGSIL.
Question 2

D. Correct:
This lesion exhibits
dense acetowhiteness
and is directly adjacent to
the squamocolumnar
junction.
It is important to biopsy
this lesion.
Answer 2

Colposcopically directed biopsies were performed and
this slide is representative of those biopsies. It shows:
A.  Squamous
metaplasia with
chronic cervicitis
B.  CIN1
C.  CIN3
D.  Invasive squamous
carcinoma
Question 3

A. Correct:
The inflammatory cells in the
epithelium are indicative of
cervicitis.
The term chronic cervicitis
implies that reserve cell
formation is occurring
beneath the layer of tall
mucus-secreting columnar
cells and does not imply that
an infection is present.
Answer 2

LLETZ was performed because of the discrepancy between the high-
grade cytology and the negative biopsy. The histology represented is
consistent with:
A.  Low-grade CIN
B.  High-grade CIN
C.  Microinvasive
squamous cell
carcinoma
D.  Invasive squamous
cell carcinoma
Question 4

B. Correct: High Grade CIN
The LLETZ specimen
revealed CIN3 with
superficial endocervical
extension.
The full thickness of the
epithelium is dysplastic.
There are a few koilocytes
in the upper layer.
The margins were
uninvolved with dysplasia.
Answer 4

Case 14
Based of the colpophotograph her examination is:
A.  Unsatisfactory
B.  Satisfactory
Question 1

Answer 1
A. Correct: Unsatisfactory
The entire SCJ can not be completely
identified
The lesion appears to extend within the
endocervical canal beyond view

Your colposcopic impression is:
A.  Normal
B.  Low grade
C.  High grade
D.  Cancer
Question 2

Answer 2
C. Correct: High grade
An acetowhite lesion with a regular margin
can be seen. The color is an opaque
white. Blood vessels are not apparent

Your management at this time would be to:
A.  Repeat PAP smear in 6 and 12 months
B.  Collect a cervical biopsy
C.  Collect a cervical biopsy and ECC
D.  Obtain an ECC
Question 3

Answer 3
C. Correct: Collect a cervical biopsy and ECC
Given an unsatisfactory colposcopic
examination, a HGSIL PAP smear report
and a high grade lesion on the cervix, both
cervical biopy and ECC are indicated

The cervical biopy is seen in figure. What is your
diagnosis?
A.  Normal
B.  CIN 1
C.  CIN 2
D.  CIN 3
Question 4

Answer 4
C. Correct: CIN 2
Cellular atypia is seen
in the lower two
thirds of the
epithelium

The ECC is seen in figure. What is your diagnosis?
A.  Insufficient material
B.  Normal
C.  Positive, CIN
D.  Positive, suspicion
of cancer
Question 5

Answer 5
C. Correct: Positive, CIN
There is no evidence of
malignant epithelium

What management is appropriate at this time ?
A.  Hysterectomy
B.  Cryotherapy
C.  Cold conization
D.  LEEP
Question 6

Answer 6
C. Correct: Cold conization is required
based on the unsatisfactory colposcopic
examination and a positive ECC.
Cryotherapy is contrindicated prior to
excluding presence of invasive cancer by
conization

Case 15
This is a 60-year-old ,
Para 8, whose last menstrual period was 12
years prior to this visit.
A routine Pap smear performed one month ago
was read as HGSIL, but invasion could not
be ruled out.

This image shows:
A.  Diffuse white (pale) epithelium
B.  A focal area of acetowhite
epithelium that is incompletely
visualized
C.  A focal area of acetowhite
epithelium with coarse
punctation
D.  Atypical vessels in an area of
acetowhite epithelium
Question 1

Answer 1
A. Correct:
The cervix of this 60-year-old
female appears pale. The pale
color may reflect an atrophic
epithelium.
There is a focal area of
acetowhite epithelium at 8
o’clock which is completely
visualized.
There is no evidence of abnormal
or atypical vessels raising the
suspicion for intraepithelial
neoplasia or invasive disease.

Which of the following colposcopic features are present?
A.  Nabothian cysts
B.  Focal area of acetowhite
epithelium
C.  Punctation
D.  Mosaic
Question 2

Answer 2
B. Correct:
There is a well-circumscribed,
gray-white lesion at 8 o’clock
that is seen in its entirety.
There is no evidence of
abnormal or atypical vessels.
A biopsy of this lesion
should be performed.
Lesions, which are densely
acetowhite even in the
absence of vessel patterns,
can be CIN 2 or CIN 3.

On low power view of the cervix, the colposcopic
examination is:
A.  Satisfactory
B.  Unsatisfactory
C.  Cannot be certain
based on this
colpophotograph
Question 3

Answer 3
C. Correct:
The transformation zone is not
completely visualized.
Nowhere can you see
grape-like structures of the
columnar epithelium. In
fact, the view is distorted
and the examiner can
easily miss significant
disease. The colposcopist
must attempt to visualize
the entire SCJ at each
examination.

A cervical biopsy was taken from the lesion noted in
question 2. The cervical biopsy is diagnostic of:
A.  Squamous epithelium
with no pathologic
findings
B.  CIN 1 with koilocytosis
C.  CIN 3
D.  Invasive squamous cell
carcinoma
Question 4

Answer 4
A. Correct: Squamous epithelium with no pathologic
findings
The transformation zone is not represented in this specimen.
The histologic results do not correlate with the severity
of the cytology (HGSIL). An ECC must be performed to
rule out disease in the endocervical canal.

The endocervical curettage is most compatible with
diagnosis of:
A.  Normal columnar
epithelium
B.  Adenocarcinoma,
uncertain origin
C.  Detached fragments of
CIN 3
D.  Detached fragments of
CIN 1
Question 5

Answer 5
C. Correct: Histology of the endocervical curettage revealed
a squamous intraepithelial neoplasia with no underlying
stroma. Because of the absence of underlying stroma,
invasion cannot be ruled out. A cervical conization is
indicated to rule out the presence of invasive cancer.

References
A.  American Society for Colposcopy and Cervical Pathology. www.asccp.org.
B.  Newkirk, G. The Colposcopic Examination. Pfenninger & Fowler's Procedures
for Primary Care Physician: 616-630.
C.  Johnson, B. The Colposcopic Examination. American Family Physician. June
1996.
D.  AAFP Colposcopy Position Paper
E.  Colposcopy and Treatment of Cervical Intraepithelial Neoplasia:
A Beginner's Manual. http://screening.iarc.fr/colpo.php
F.  Educational material CD (100 challenging colposcopy cases)

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