High grade / CIN2 / CIN3

 Age: 41

 HPV status: Positive

After normal saline: The cervix is congested. The SCJ is visible at the
external os.

After normal saline with green filter: No abnormal vessels seen.

(Green arrow: Fine mosaics)

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
After acetic acid: A large thin acetowhite lesion with a flocculated
margin covers almost the entire cervix. There is a dense acetowhite
lesion at the 6 o’clock region with a smooth, sharp margin.
The lesion within a lesion has resulted in the inner border sign. (Blue line:
SCJ. Green line: Inner border sign. Yellow arrow: Dense acetowhite area.
Blue arrow: Thin acetowhite area. Green arrow: Normal crypt)

After acetic acid with green filter: Fine mosaics are seen all over the
thin acetowhite lesion. No vessels are seen on the dense acetowhite area.
(Green arrow: Fine mosaics)

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
After acetic acid: The posterior extent of the lesion is seen.

Colposcopy report (2011 IFCPC nomenclature):

General assessment
Adequate
 Adequacy:
Completely visible
 Squamocolumnar junction visibility:
Type 1
 Transformation zone:
Normal colposcopic findings
Mature
 Original squamous epithelium:
Ectopy absent
 Columnar epithelium:
----
 Metaplastic squamous epithelium:
Not applicable
 Deciduosis in pregnancy:
Abnormal colposcopic findings
General principles
Position and size
Inside the T-zone
 Location of the lesion:
All around
 Location of the lesion by clock position:
4
 No. of quadrants:
> 75%
 % of cervix:
Grade 1 (minor)
Thin acetowhite epithelium Fine mosaic

Grade 2 (major)
Dense acetowhite epithelium Sharp border

Inner border sign

Non-specific

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
 ----

Suspicious for invasion

----

Miscellaneous finding
----

Swede score:

Swede score 0 1 2

Aceto uptake Nil or transparent Thin, milky Distinct, stearin

Sharp but irregular, Sharp and even, difference in

Margins Nil or diffuse
jagged, satellites level

Vessels Fine, regular Absent Coarse or atypical vessels

5-15 mm or 2 >15 mm, 3-4 quadrants, or

Lesion size < 5 mm
quadrants endocervically undefined

Faintly or patchy
Iodine uptake Brown Distinctly yellow
yellow

Final Swede score: Not possible (Iodine uptake missing)

Case Summary

Provisional Type 1 transformation zone with high-grade squamous intraepithelial lesion (HSIL)
diagnosis: and congenital transformation zone.

Management: LLETZ (type 1 excision).

Histopathology: HSIL-CIN3; LSIL-CIN1 in the anterior lip.

A lesion within a lesion gives rise to the inner border sign, and the inner lesion is
invariably high-grade. The larger lesion had features of the congenital transformation
Comment:
zone (large thin acetowhite area, oval-shaped lesion extending to the vaginal fornices,
and fine mosaic). The histopathology turned out to be CIN1.

Case link

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Inflammation and cervicitis / Inflammation

 Age: 52

 HPV status: Negative

Speculum examination: Case diagnosed earlier as cervical tuberculosis

looks normal after 6 months of antituberculosis therapy.

After normal saline: The cervix looks pale.

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
After normal saline with green filter: Normal branching blood vessels.

After acetic acid: No acetowhite area.

Examination with endocervical speculum: The SCJ is visualized inside

the canal.

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Colposcopy report (2011 IFCPC nomenclature):
General assessment
Adequate
 Adequacy:
Completely visible
 Squamocolumnar junction visibility:
Type 2
 Transformation zone:
Normal colposcopic findings
Mature
 Original squamous epithelium:
----
 Columnar epithelium:
----
 Metaplastic squamous epithelium:
Not applicable
 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
----

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Swede score:

Swede score 0 1 2

Aceto uptake Nil or transparent Thin, milky Distinct, stearin

Sharp but irregular, Sharp and even, difference in

Margins Nil or diffuse
jagged, satellites level

Vessels Fine, regular Absent Coarse or atypical vessels

5-15 mm or 2 >15 mm, 3-4 quadrants, or

Lesion size < 5 mm
quadrants endocervically undefined

Faintly or patchy
Iodine uptake Brown Distinctly yellow
yellow

Final Swede score: Not possible (Iodine uptake missing)

Case Summary

Provisional
Tuberculosis ulcer of cervix healed.
diagnosis:

Management: Routine screening after 5 years.

Histopathology: Normal.

Tuberculosis of the cervix is rare and accounts for 0.1–0.6% of all cases of
tuberculosis. Treatment with a four-drug regime for 6 months is highly effective. The
Comment:
cervix has been reported to regain normal appearance with 4 weeks of starting
treatment. [Click here to see the colposcopy images before anti-TB treatment ].

Case link

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
High grade / CIN2 / CIN3

 Age: 52

 HPV status: Positive

Speculum examination: The cervix and the vagina are atrophied, with
thin discharge.

After normal saline: Atrophic cervix with shallow fornices. The SCJ is
not visible.

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
After acetic acid: A dense acetowhite area with a sharp, smooth margin
is seen on the posterior lip. The lesion extends inside the canal. (Blue
line: Dense acetowhite area)

Examination with endocervical speculum: The SCJ could not be seen

with the endocervical speculum.

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Colposcopy report (2011 IFCPC nomenclature):
General assessment
Adequate
 Adequacy:
Not visible
 Squamocolumnar junction visibility:
Type 3
 Transformation zone:
Normal colposcopic findings
Atrophic
 Original squamous epithelium:
Ectopy absent
 Columnar epithelium:
----
 Metaplastic squamous epithelium:
Not applicable
 Deciduosis in pregnancy:
Abnormal colposcopic findings
General principles
Position and size
Inside the T-zone
 Location of the lesion:
04 o?clock 05 o?clock
 Location of the lesion by clock position:
06 o?clock 07 o?clock

2
 No. of quadrants:
25-50%
 % of cervix:
Grade 1 (minor)
----

Grade 2 (major)
Dense acetowhite epithelium Sharp border

Non-specific
----

Suspicious for invasion

----

Miscellaneous finding
----

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Swede score:

Swede score 0 1 2

Aceto uptake Nil or transparent Thin, milky Distinct, stearin

Sharp but irregular, Sharp and even, difference in

Margins Nil or diffuse
jagged, satellites level

Vessels Fine, regular Absent Coarse or atypical vessels

5-15 mm or 2 >15 mm, 3-4 quadrants, or

Lesion size < 5 mm
quadrants endocervically undefined

Faintly or patchy
Iodine uptake Brown Distinctly yellow
yellow

Final Swede score: Not possible (Iodine uptake missing)

Case Summary

Provisional
Type 3 transformation zone; high-grade squamous intraepithelial lesion (HSIL).
diagnosis:

Management: LLETZ (type 3 excision).

Histopathology: HSIL-CIN2.

Obtaining a punch biopsy in such a case is quite difficult and unreliable. LLETZ
Comment: based on colposcopy findings (“see and treat”) is both diagnostic and therapeutic in
this case.

Case link

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Early and advanced cancers / Squamous cell cancer

 Age: 50

 HPV status: Positive

After normal saline: Atrophic cervix, pale in colour. (Green arrow:

Atrophy)

After normal saline with green filter: A few blood vessels seen inside
the canal do not have normal branching patterns. (Blue arrow: Atypical
vessels)

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
After acetic acid: A dense acetowhite area is seen in the anterior lip.
The acetowhite lesion extends inside the canal like a ridge. An eroded
area is seen at the 8 o’clock position. (Yellow arrow: Dense acetowhite
area. Green arrow: Erosion. Blue arrow: Sharp margin)

Visualization of the SCJ: On opening the canal, a denser acetowhite

area that bleeds on contact is seen. The SCJ is not visible. (Yellow arrow:
Dense acetowhite area, growth inside the canal)

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Colposcopy report (2011 IFCPC nomenclature):
General assessment
Adequate
 Adequacy:
Not visible
 Squamocolumnar junction visibility:
Type 3
 Transformation zone:
Normal colposcopic findings
----
 Original squamous epithelium:
----
 Columnar epithelium:
----
 Metaplastic squamous epithelium:
Not applicable
 Deciduosis in pregnancy:
Abnormal colposcopic findings
General principles
Position and size
Inside the T-zone
 Location of the lesion:
Endocervical
 Location of the lesion by clock position:
----
 No. of quadrants:
----
 % of cervix:
Grade 1 (minor)
----

Grade 2 (major)
Dense acetowhite epithelium Sharp border

Non-specific
Erosion

Suspicious for invasion

Atypical vessels Tumour, gross neoplasm

Miscellaneous finding
----

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Swede score:

Swede score 0 1 2

Aceto uptake Nil or transparent Thin, milky Distinct, stearin

Sharp but irregular, Sharp and even, difference in

Margins Nil or diffuse
jagged, satellites level

Vessels Fine, regular Absent Coarse or atypical vessels

5-15 mm or 2 >15 mm, 3-4 quadrants, or

Lesion size < 5 mm
quadrants endocervically undefined

Faintly or patchy
Iodine uptake Brown Distinctly yellow
yellow

Final Swede score: Not possible (Iodine uptake missing)

Case Summary

Provisional Type 3 transformation zone; suspicion of invasive cancer likely to be squamous in

diagnosis: nature.

Management: Punch biopsy and endocervical curettage.

Histopathology: Invasive squamous cell carcinoma.

This case highlights the importance of endocervical assessment if the

Comment: squamocolumnar junction is not fully visualized. The ectocervical lesion appeared as
HSIL, and the cancer was confined to the canal.

Case link

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Early and advanced cancers / Adenocarcinoma

 Age: 54

 HPV status: Positive

Speculum examination: The cervix is covered with copious mucoid

discharge. (Green arrow: Large amount of mucoid discharge)

After normal saline: There is a red patch at the centre of the cervix
with an irregular surface. (Green arrow: Columnar epithelium)

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
After acetic acid: There is a dense acetowhite area on the columnar
epithelium with an irregular surface and an elevated margin; “grated
coconut appearance”. (Yellow arrow: Dense acetowhite area on columnar
epithelium. Green arrow: Sharp border. Blue arrow: Irregular surface)

After acetic acid with green filter: Abnormal vessels are seen. (Green
arrow: Atypical and fragile vessels)

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Colposcopy report (2011 IFCPC nomenclature):
General assessment
Adequate
 Adequacy:
Not visible
 Squamocolumnar junction visibility:
Type 3
 Transformation zone:
Normal colposcopic findings
Mature
 Original squamous epithelium:
----
 Columnar epithelium:
----
 Metaplastic squamous epithelium:
Not applicable
 Deciduosis in pregnancy:
Abnormal colposcopic findings
General principles
Position and size
Inside the T-zone
 Location of the lesion:
All around
 Location of the lesion by clock position:
4
 No. of quadrants:
> 75%
 % of cervix:
Grade 1 (minor)
----

Grade 2 (major)
Dense acetowhite epithelium Sharp border

Non-specific
----

Suspicious for invasion

Atypical vessels Fragile vessels Irregular surface

Miscellaneous finding
----

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php
Swede score:

Swede score 0 1 2

Aceto uptake Nil or transparent Thin, milky Distinct, stearin

Sharp but irregular, Sharp and even, difference in

Margins Nil or diffuse
jagged, satellites level

Vessels Fine, regular Absent Coarse or atypical vessels

5-15 mm or 2 >15 mm, 3-4 quadrants, or

Lesion size < 5 mm
quadrants endocervically undefined

Faintly or patchy
Iodine uptake Brown Distinctly yellow
yellow

Final Swede score: Not possible (Iodine uptake missing)

Case Summary

Provisional
Type 3 transformation zone; suspicion of adenocarcinoma.
diagnosis:

Management: Multiple punch biopsies.

Histopathology: Adenocarcinoma.

Dense acetowhite patches over columnar epithelium is known as “grated coconut

Comment:
appearance” and is characteristic of a glandular lesion.

Case link

Extracted from the Atlas of Colposcopy - Principles and Practice, IARC Screening Group:
http://screening.iarc.fr/atlascolpo.php