What is Colposcopy
Simple and painless, colposcopy is the second-level screening test, carried out to ascertain the real significance of pre-cancerous lesions emerged from the Pap test and attributable to cervical cancer .
For the execution of colposcopy, gynecologists use an instrument with lenses of various magnifications, similar to binoculars, which is called colposcope ; in many cases, then, in addition to the colposcope, they also resort to the use of two specific solutions - acetic acid or Lugol's liquid - which, applied on the inner surface of the uterine cervix, allow a better visualization, through the aforementioned colposcope.
Types of cervical cancer
Typically, cervical cancer is either a carcinoma- like neoplasm (80% of cases) or an adenocarcinoma- like neoplasm (15% of cases).
Carcinomas are malignant tumors that originate from epithelial tissue cells; adenocarcinomas, on the other hand, are their subclass and, to be precise, they are malignant tumors that develop from epithelial cells of exocrine glandular organs or tissues with secretory properties.
KEY POINTS - WHAT YOU KNOW
- The Pap test does NOT have a diagnostic significance : it limits itself to suggesting the presence of a pre-cancerous lesion and does not in any way provide a precise diagnosis .
The aim of the Pap test, therefore, is to operate - among women at risk for cervical cancer - a first selection of the subjects who could eventually develop the disease; in other words, the Pap test serves to distinguish women who are certainly without abnormalities from those women with even a remote possibility of predisposition to cervical cancer.
It is important to point out that the positivity of a Pap test does not require any surgical intervention, but only requires a more in-depth study of the situation with more specific examinations.
- The diagnostic confirmation of a positive Pap smear about the presence of possible pre-cancerous or cancerous lesions is up to other tests, first of all colposcopy. As mentioned, colposcopy is the second-level screening test, performed to ascertain whether the pre-tumor lesion is present and to determine its site and gravity; but that's not all: the colposcopic test, in fact, also allows the targeted collection of a sample of suspected cervical tissue, to be subsequently subjected to specific laboratory microscopic analyzes (see cervical biopsy). These analyzes are essential to confirm or exclude the presence of the disease from a histological point of view.
- The histological diagnosis on the tissue sample, collected during colposcopy, makes it possible to classify the woman subjected to the screening procedures as affected or not from cervical cancer and to set, in case of illness, the most appropriate treatment.
Results
Colposcopy can provide negative results (negative colposcopy or normal colposcopy) or positive (positive colposcopy or abnormal colposcopy).
- When the results of colposcopy are negative it means that the appearance of the cervix is normal, or shows signs of inflammation or hormonal deficiencies.
In any case, nothing that the gynecologist has observed using a colposcope had cancerous, pre-cancerous lesions or other significant anomalies in this regard.
Possible therapeutic implications: if the cervix is normal, the specialist's only disposition to the patient is to repeat the Pap test after a certain period of time (it is the same specialist who decides when); if, on the other hand, there are signs of inflammation or hormonal deficiencies, an adequate drug therapy is planned, planned by the gynecologist based on what has been observed.
In reverse
- When the results of colposcopy are positive it means that the cervix has suspicious lesions, which could have a pre-cancerous or even cancerous nature.
This finding makes it necessary to carry out a small cervical biopsy (see point 2 of the “KEY POINTS - WHAT YOU KNOW” section) of the areas presenting the most significant damaging alterations, so as to establish their meaning and arrive at a precise diagnosis.
Possible therapeutic implications: based on the nature and characteristics of the suspicious lesions - these information that emerge from the cervical biopsy - the gynecologist decides which is the most appropriate treatment. In the case of pre-cancerous or cancerous lesions, the therapeutic choice falls within the so-called excisional methods (conization with scalpel, conization with laser, conization with diathermic handle and coning with radiofrequency needle) and the so-called destructive methods (diathermocoagulation, cryotherapy, thermocoagulation and laser vaporization).
Therefore, as generally happens in the medical field, a colposcopy with negative results indicates the absence of serious pathologies, while a colposcopy with positive results indicates the presence of pathological conditions that require a very specific therapy.
Curiosity: for how many women is colposcopy negative and for how many is positive?
According to some interesting Anglo-Saxon statistical studies, colposcopy is negative for 4 out of 10 women, while it is positive for the remaining 6.
Cervical biopsy
Cervical biopsy involves the removal of cervical tissue fragments from areas that, due to colposcopy, have appeared abnormal; this sampling is then followed by the microscopic analysis, in the laboratory, of the sample thus taken, by a medical pathologist.
Biopsy samples are taken using small forceps, generally without anesthesia and without causing pain to the patient.
After collection, the analysis is sent to the laboratory immediately.
In general, the results of cervical biopsy, post-colposcopy, are available to patients within a few weeks (maximum 6, but much depends on the urgency of having a definitive diagnosis).
RESULTS OF CERVICAL BIOPSY
Cervical biopsy performed on completion of a colposcopy may highlight:
- Absence of significant alterations ( negative cervical biopsy ): in disagreement with what is shown by previous tests (Pap test and colposcopy), it means that the cervix is healthy.
Therapeutic implications: the patient must continue to carry out the periodic screening tests required, so as to keep the situation under control.
- Presence of condyloma, or genital wart : this result means that a sexually transmissible infection of the cervix is underway, caused by the viral agent known as Human Papilloma Virus (the main risk factor for cervical cancer uterine).
Sometimes associated with mild dysplasia or CIN I (see below), the aforementioned infection spontaneously regresses in a very high percentage of cases, without causing damage or other consequences.
Therapeutic implications: based on specific factors, first of all the severity of the infection, the gynecologist can opt for periodic monitoring of the condition, through Pap tests and possibly another colposcopy (less severe cases), or for surgery minimally invasive (more serious cases), aimed at eliminating / removing the abnormal area displayed during colposcopy.
- Presence of cervical dysplasia, or CIN ( Cervical Intra-epethelial Neoplasia, in English, and Intra-epithelial Neoplasia Cervical, in Italian): dysplasia is the medical-oncological term that indicates a variation in the tumor sense (pre-tumoral variation or pre- cancerous) of a tissue usually of epithelial type; this variation can include qualitative, morphological and sometimes also quantitative alterations of the cells constituting the aforementioned tissue.
Therefore, with cervical dysplasia or CIN, doctors mean the presence of variations in the tumor sense against the cells constituting the epithelial tissues of the uterus neck.
Cervical dysplasia represents the possible prelude to cancer of the cervix of the carcinoma type ( cervical carcinoma ).
As with any form of dysplasia, even for cervical dysplasia there are 3 levels (or degrees) of increasing severity, identified as mild (or CIN I), moderate (CIN II) and severe (CIN III):
- Mild dysplasia, or CIN I : the pre-cancerous alterations to this degree of cervical dysplasia concern only the lower third of the thickness of cells that covers the cervix; therefore, the number of epithelial cells involved is small.
In general, this degree of dysplasia remains unchanged over time (ie it hardly evolves into a tumor) or regresses spontaneously.
Therapeutic implications: in the face of these circumstances, gynecologists opt for conservative and waiting conduct, based on periodic monitoring of the situation through appropriate diagnostic tests; therefore, they tend to exclude therapeutic intervention.
- Moderate dysplasia, or CIN II : alterations to this degree of cervical dysplasia concern half the thickness of cells that lines the cervix; therefore, the number of epithelial cells involved is more than discrete.
Compared to mild dysplasia, moderate cervical dysplasia more frequently tends to persist or evolve into carcinoma
Therapeutic implications: these circumstances require a therapeutic intervention, aimed at removing the dysplastic lesion. In general, doctors perform this removal using an excisional method.
- Severe dysplasia, or " in situ " carcinoma or CIN III : alterations to this degree of cervical dysplasia involve the entire thickness of cells lining the cervix, excluding basement membrane; therefore, the number of epithelial cells involved is high.
This type of dysplasia has a high probability of persisting or evolving into carcinoma.
Therapeutic implications: severe cervical dysplasia absolutely needs a therapeutic intervention aimed at removing the dysplastic lesion. Normally, doctors perform this removal using an excisional method.
| In-depth table. Treatment of various degrees of cervical dysplasia. | |
| Degree of cervical dysplasia | Most indicated treatment |
CIN I | If the doctor considers it necessary to intervene (a very remote case), he almost always uses the aforementioned destructive methods (diathermocoagulation, cryotherapy, thermocoagulation and laser vaporization). These methods eliminate the abnormal area by exploiting heat or cold. Consequences: the use of these treatments involves the destruction of the abnormal tissue, which does not allow to perform a histological examination on this tissue. |
CIN II | In such circumstances, doctors tend to prefer the already mentioned excisional or ablative methods (conization with scalpel, conization with laser, conization with diathermic handle and coning with radiofrequency needle). These methods involve the removal of a small cone of tissue belonging to the cervix, through electric loops, lasers or scalpels. Consequences: the use of these therapeutic methods allows to perform a histological examination on what has been removed. |
CIN III | |
- Presence of adenocarcinoma " in situ " or CGIN ( Cervical Glandular Intra-epithelial Neoplasia, in English, and Intra-epithelial Glandular Neoplasia Cervical, in Italian): it is a pre-tumoral (or pre-cancerous) lesion, confined to the glandular epithelium of the cervix; over time, this type of anomaly can invade the endocervix cells and turn into a tumor of the cervical glandular cells, that is, a tumor of the uterine cervix adenocarcinoma ( cervical adenocarcinoma ).
Therapeutic implications: in the presence of an " in situ " adenocarcinoma, there is a need to remove the lesion with excisional (or ablative) procedures, which tend to be as conservative as possible in young patients desiring pregnancy. to preserve the possibility of having children.
- Presence of cervical adenocarcinoma : it is the tumor of the glandular cells of the cervix (due to the precision of the endocervix), to which reference was made earlier. It is the most serious and feared outcome of a cervical biopsy during colposcopy.
In cervical adenocarcinoma, the lesion is cancerous and resides not only in the epithelial glandular lining of the cervix, but also in the deeper cellular layers.
The more the cervical adenocarcinoma has crept in depth (infiltration process) and the higher the risk of metastasis.
Therapeutic implications: in the presence of a cervical adenocarcinoma, it is essential to remove the tumor by surgical intervention. When the tumor is in the early stages, this intervention generally consists of an excisional method (conization); when instead the tumor is at medium-advanced stages, the aforementioned intervention may consist in the partial removal or total removal of the diseased uterus (respectively, partial hysterectomy and total hysterectomy ). From what has just been stated, therefore, it is possible to deduce that the more serious the cervical adenocarcinoma and the more bloody the surgical operation must be for the removal of the tumor.
It is important to remind readers that ...
From the time of infection sustained by oncogenic HPV strains at the time of cervical cancer there is a latency period of several years, quantifiable in at least a decade (see figure).
Therefore, screening by Pap test and colposcopy allows the discovery of cervical tumors at the initial stages (micro-invasive) or even when they are still at the pre-cancerous stage.
All this offers the important possibility of performing simple, effective and not very aggressive treatments, which almost always allow the preservation of the uterus and its functions.
Figure: as shown in the image, any transformation into a tumor takes place over a very long period of time, measurable in years. Pap tests and colposcopy allow to act before such a transformation takes place.
