19.) Instruments And Technique Of Coloscopy

Question 1

What is colposcopy, and when is it typically indicated?

Answer 1

Colposcopy is a procedure to examine the cervix under magnification, allowing detailed inspection of abnormal areas. It’s commonly indicated for:
- Abnormal Pap smear results (e.g., atypical cells or high-grade lesions).
- Unexplained post-coital bleeding (which may signal cervical pathology).
- Abnormal vaginal discharge (e.g., persistent brown discharge) which can indicate precancerous or cancerous changes.

Question 2

How are Pap smear results categorized, and what follow-up is recommended based on these categories?

Answer 2

• Group 1 & 2: Normal cytology; no further action needed.
  
  • Group 3: Atypical cells, requiring a follow-up in 2 weeks with anti-inflammatory treatment. If abnormalities persist, colposcopy is recommended.
  • Group 4 & 5: High-grade abnormalities; immediate colposcopy and biopsy are advised to assess for potential malignancy.

Question 3

What are the primary tools used in colposcopy, and what is their function?

Answer 3

• Speculum: Opens the vaginal canal to visualize the cervix.
  
  • Colposcope: A microscope-like device that magnifies cervical tissues for detailed inspection.
  • Acetic acid or Lugol’s iodine: Applied to highlight abnormal cells, turning atypical areas white (aceto-white) or brown with Lugol’s iodine.
  • Biopsy forceps: Used to obtain tissue samples from suspicious areas for histopathological examination.
  • Formalin: Preserves biopsy samples for transport to histology labs.

Question 4

Describe the role of acetic acid and Lugol’s iodine in colposcopy.

Answer 4

Acetic acid and Lugol’s iodine are used to identify abnormal areas:
- Acetic acid: Causes proteins in abnormal cells to coagulate, turning them white (aceto-white areas) and indicating high nuclear density often associated with dysplasia.
- Lugol’s iodine: Stains normal cells (rich in glycogen) brown, while dysplastic or cancerous cells, which lack glycogen, remain unstained or pale. This contrast helps to locate lesions.

Question 5

What types of lesions might be visible during colposcopy, and what do they indicate?

Answer 5

• Leukoplakia: White patches on the cervix, often a sign of keratinized areas or dysplasia.
  
  • Erythroplakia: Red patches indicating vascular changes, often associated with inflammation or early malignancy.
  • Atypical blood vessels: Abnormal vascular patterns can signal advanced dysplasia or invasive carcinoma.
  • Erosions and papillary growths: Signs of HPV-related lesions, often requiring biopsy for definitive diagnosis.

Question 6

Explain the technique for performing a biopsy during colposcopy.

Answer 6

Once an abnormal area is identified, a pinch biopsy is taken:
- Use biopsy forceps to remove a small tissue sample from the abnormal area.
- Apply a hemostatic agent to control any bleeding.
- Place the sample in 10% formalin for preservation.
- The biopsy is then sent to histology to evaluate the presence and extent of atypical or malignant cells.

Question 7

How are cervical intraepithelial neoplasia (CIN) grades defined based on dysplasia, and what treatments are recommended?

Answer 7

• CIN I (Mild dysplasia): Atypical cells cover the lower 1/3 of the epithelium. Often managed with close observation or laser coagulation.
  
  • CIN II (Moderate dysplasia): Atypical cells cover up to 1/2 of the epithelial layer. Treatment options include laser coagulation or conization if persistent.
  • CIN III (Severe dysplasia/Carcinoma in situ): Atypical cells occupy more than 2/3 of the epithelium, though the basal membrane remains intact. Conization or amputation of the affected cervical area is recommended.

Question 8

What is conization, and when is it indicated in colposcopy findings?

Answer 8

Conization is the excision of a cone-shaped portion of the cervix, which includes the transformation zone where most cervical cancers develop. It is indicated for:
- High-grade dysplasia (CIN II and CIN III).
- Suspected carcinoma in situ (precancerous cells across most of the cervical layer).
- Conization allows both treatment and diagnosis, as the excised tissue is sent to histology to confirm margins are free of atypical cells.

Question 9

What are the treatment options if atypical cells are present at the surgical margins after conization?

Answer 9

If atypical cells are detected at the margins:
- Hysterectomy (removal of the uterus) may be recommended, especially in cases of invasive carcinoma.
- Options include laparoscopic total hysterectomy (LHT), with or without removal of the adnexa (ovaries and fallopian tubes).
- Radical hysterectomy with lymph node removal (lymphadenectomy) is considered for advanced cases.

Question 10

Why is the transformation zone important in colposcopy, and what role does HPV play in cervical dysplasia?

Answer 10

The transformation zone is where the single-layered columnar epithelium of the endocervix meets the multilayered squamous epithelium of the ectocervix. This area is highly susceptible to HPV infection, which can cause:
- DNA replication errors during cell division.
- Formation of atypical (dysplastic) cells, which may progress to cervical intraepithelial neoplasia (CIN) and, potentially, cervical cancer if untreated.