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1 1090 GebFra Science Explanation and Use of the Rio 2011 Colposcopy Nomenclature of the IFCPC (International Federation for Cervical Pathology and Colposcopy) Comments on the general colposcopic assessment of the uterine cervix: adequate/inadequate; squamocolumnar junction; transformation zone Erluterung und Anwendung der kolposkopischen Nomenklatur der IFCPC (International Federation for Cervical Pathology and Colposcopy) Rio 2011 Zu den grundstzlichen Hinweisen fr die Kolposkopie der Cervix uteri adquat/inadquat; Plattenepithel-Zylinderepithelgrenze; Transformationszone Authors J. Quaas 2, O. Reich 1, V. Kppers 2 1 Affiliations Vorstand der Arbeitsgemeinschaft Kolposkopie (AGK) [Board of the Austrian Society of Colposcopy] 2 Vorstand der Arbeitsgemeinschaft fr Kolposkopie und Zervixpathologie (AGCPC) [Board of the German Society of Colposcopy and Cervical Pathology] Key words Abstract Zusammenfassung l " colposcopy ! ! l " cervix uteri In July 2012 the IFCPC adopted a revised termi- Im Juli 2012 wurde eine berarbeitete Nomenkla- l " nomenclature nology for colposcopic examinations of the uter- tur zur kolposkopischen Untersuchung der Cervix l " IFCPC Rio de Janeiro 2011 ine cervix. In 2012, the Boards of the Arbeitsge- uteri durch die IFCPC verabschiedet. 2012 erfolgte l " transformation zone l " adequate colposcopy meinschaft Kolposkopie (AGK Austrian Society eine durch die Vorstnde der Arbeitsgemein- l " inadequate colposcopy of Colposcopy), the Arbeitsgemeinschaft fr Kol- schaft Kolposkopie (AGK, sterreich), der Arbeits- poskopie und Zervixpathologie (AGKOL Swiss So- gemeinschaft fr Kolposkopie und Zervixpatho- Schlsselwrter ciety of Colposcopy and Cervical Pathology) and logie (AGKOL, Schweiz) und der Arbeitsgemein- l " Kolposkopie the Arbeitsgemeinschaft fr Kolposkopie und Zer- schaft fr Kolposkopie und Zervixpathologie l " Cervix uteri l " Nomenklatur vixpathologie (AGCPC German Society of Colpo- (AGCPC, Deutschland) anerkannte Darstellung l " IFCPC Rio de Janeiro 2011 scopy and Cervical Pathology) accepted the valid- mit Empfehlung zur Nutzung fr den deutsch- l " Transformationszone ity of the 2011 IFCPC nomenclature and recom- sprachigen Raum. Die Nomenklatur ist so auf- l " adquate Kolposkopie mended its use in general clinical practice across gebaut, dass der Untersucher nach einem be- l " inadquate Kolposkopie German-speaking countries. The revised nomen- stimmten Schema kolposkopische Kriterien beur- clature was devised so that examiners can evalu- teilen soll. Zu Beginn der kolposkopischen Unter- Deutschsprachige ate colposcopic criteria according to a specific suchung wird geprft, ob die Kolposkopie repr- Zusatzinformationen scheme. At the start of the examination, the ex- sentativ ist: 1. Ist die Untersuchung als adquat online abrufbar unter: aminer must assess whether the colposcopy is oder inadquat (mit Begrndung) einzuschtzen? representative or not. 1. Can the examination be 2. Wie sind die Einsehbarkeit der Plattenepithel- ejournals/toc/gebfra classed as adequate or inadequate (reasons must Zylinderepithelgrenze und der Typus der Trans- be given)? 2. How would you describe the visibil- formationszone zu bewerten? Im Folgenden wird Bibliography ity of the squamocolumnar junction and catego- auf einige Aspekte dieser grundstzlichen Vor- DOI rize the transformation zone? Below we discuss bemerkungen der Nomenklatur eingegangen, die 10.1055/s-0034-1383216 Geburtsh Frauenheilk 2014; 74: some aspects of this general assessment as out- sich im praktischen Gebrauch als klrungsbedrf- 10901092 Georg Thieme lined in the nomenclature which were found to tig erwiesen haben. Verlag KG Stuttgart New York require further clarification for general practice. ISSN 00165751 Correspondence Dr. Jens Quaas Sekretr der Arbeitsgemein- Introduction vixpathologie (AGCPC German Society of Colpo- schaft Zervixpathologie ! scopy and Cervical Pathology) accepted the valid- & Kolposkopie Grnthal 22 The current colposcopic nomenclature was pub- ity of the revised nomenclature and recom- 18437 Hansestadt Stralsund lished on July 1, 2012 in Obstetrics & Gynecology mended its use in general clinical practice across [email protected] [1]. German-speaking countries. In Frauenarzt 2012 [2] and Geburtshilfe & Frauen- It must be emphasized that one of the primary Priv.-Doz. Dr. med. Volkmar heilkunde 2013 [8], the Boards of the Arbeitsge- aims of the new IFCPC nomenclature was to cre- Kppers, Facharzt fr Frauen- heilkunde und Geburtshilfe meinschaft Kolposkopie (AGK Austrian Society ate a closer association between terminology and Zytologisches Labor of Colposcopy), the Arbeitsgemeinschaft fr Kol- therapeutic procedures. Examples for this include Dysplasie-Sprechstunde poskopie und Zervixpathologie (AGKOL Swiss So- the introduction of a grading to describe the visi- Knigsallee 64 40212 Dsseldorf ciety of Colposcopy and Cervical Pathology) and bility of the squamocolumnar junction and the [email protected] the Arbeitsgemeinschaft fr Kolposkopie und Zer- types of excision outlined in the Addendum. Quaas J et al. Explanation and Use Geburtsh Frauenheilk 2014; 74: 10901092

2 Statement 1091 Fig. 1 Inadequate Fig. 2 Adequate con- conditions for colpo- ditions for colposcopic scopic assessment, assessment, transfor- inflammation. mation zone type 1. In the authors opinion, this is a welcome step as it simplifies in- be performed after treatment (l " Fig. 1). Shifting the questions dividualized planning and implementation of treatment. See also whether an assessment is doable and whether the colposcopic various publications on this point (e.g. Khn 2011 [7], Reich & examination is valid to the beginning of the nomenclature em- Fritsch 2014 [9]). Overall, the new colposcopy nomenclature em- phasizes the significance of these criteria. phasizes the significance of colposcopic investigations more than It is important to emphasize that even if the border between the preceding version did. squamous and columnar epithelium is not entirely visible (trans- It is particularly gratifying that two recent publications from Ger- formation zone type 3), it may still be possible to carry out an many (Scheungraber et al. [3, 4]) were also incorporated in the adequate colposcopic examination, and this is usually the case revised nomenclature. (l" Fig. 4). Adequate colposcopic examination thus refers to the It should be noted that the distinction between lesions located general condition under which a colposcopic examination is car- inside and those located outside the transformation zone de- ried out. Assessment of the type of transformation zone is virtu- scribed in the nomenclature (an important distinction in clinical ally only possible in adequate conditions (l " Fig. 2). practice) as well as the significance of superficial expansion of abnormal colposcopic findings in the uterine cervix were scien- tifically confirmed by publications from German-speaking coun- Border between Squamous and Columnar Epithelium tries [5, 6]. and Transformation Zone Some aspects, which were found to require further clarification ! for general practice, are discussed below. Basically, assessment of the transformation zone and classifica- tion into the respective transformation zones type 1, 2 or 3 is done after the application of acetic acid. Adequate or Inadequate The transformation zone in its native state is usually gray to red. ! After cleaning with a dry swab, colposcopic observation will usu- The colposcopy nomenclature for the uterine cervix and the vagi- ally show a network of regular branching vessels (an indication na begins with a basic but fundamentally important distinction: that the vessels are unremarkable), openings of the cervical Is the colposcopic examination adequate (doable) or inad- glands, and the nabothian glands. With the exception of the ves- equate (not doable); if it is inadequate, the reason why it is un- sels, all of these structures are more clearly visible after the appli- feasible must be stated. These terms have replaced the former cation of acetic acid. The border between squamous and colum- terminology satisfactory/unsatisfactory colposcopy. This nar epithelium is a sharp, often demarcated border between the change aimed to emphasize that in cases where colposcopy was grape-like columnar epithelium and the metaplastic squamous inadequate, e.g. due to inflammation, a control examination must epithelium and is more or less visible on colposcopy. Fig. 3 a and b Adequate conditions for colpo- scopic assessment, transformation zone type 2. Quaas J et al. Explanation and Use Geburtsh Frauenheilk 2014; 74: 10901092

3 1092 GebFra Science Localizing the border between squamous and columnar epitheli- Fig. 4 Adequate con- um is the prerequisite for classifying the transformation zone as ditions for colposcopic type 1, 2 or 3. assessment, transfor- The two terms (border between squamous and columnar epithe- mation zone type 3; lium, transformation zone) describe two different but overlap- only limited assessment ping aspects. The border between squamous and columnar epi- of the transformation thelium constitutes the inner margin of the transformation zone is possible. zone. It can be completely visible, partially visible or even not visible. If a transformation zone 1 or 2 is present, the border between squamous and columnar epithelium will be entirely visible. A transformation zone is classified as type 1 when it is entirely ectocervical (without any endocervical portion) (l " Fig. 2). Trans- formation zones type 2 and 3 always have an endocervical por- References tion, meaning that the border between squamous and columnar 1 Bornstein J, Bentley J, Bsze P et al. 2011 colposcopic terminology of the epithelium extends into the cervical canal. If the border is com- International Federation for Cervical Pathology and Colposcopy. Obstet Gynecol 2012; 120: 166172 pletely visible, it is referred to as a type 2 transformation zone. 2 Girardi F, Frey Tirri B, Kppers V et al. Neue kolposkopische IFCPC-No- Visualization of the border can be done with or without addition- menklatur der Cervix uteri (Rio de Janeiro 2011). Frauenarzt 2012; 53: al instruments (endospeculum) (l " Fig. 3 a and b). The transfor- 10641065 mation zone is only classified as type 3 if the border between 3 Scheungraber C, Glutig K, Fechtel B et al. Inner bordera specific and sig- nificant colposcopic sign for moderate or severe dysplasia (cervical in- squamous and columnar epithelium is not completely visible traepithelial neoplasia 2 or 3). J Low Genit Tract Dis 2009; 13: 14 (even with the help of additional instruments) (l " Fig. 4). If this 4 Scheungraber C, Koenig U, Fechtel B et al. The colposcopic feature ridge is the case, colposcopy can only provide information about the sign is associated with the presence of cervical intraepithelial neopla- visible part of the transformation zone; however, if the condi- sia 2/3 and human papillomavirus 16 in young women. J Low Genit tions for colposcopic examination are otherwise optimal, this ex- Tract Dis 2009; 13: 1316 5 Girardi F, Reich O, Tamussino K. Burghardts Colposcopy and cervical amination must still be classified as adequate. Pathology. 4th ed. Stuttgart: Thieme; 2014 As mentioned above, one of the aims of the nomenclature com- 6 Fritsch H, Hoermann R, Bitsche M et al. Development of epithelial and mission of the IFCPC was to improve the planning of potentially mesenchymal regionalization of the human fetal utero-vaginal an- necessary therapeutic options. Evaluation of these two aspects lagen. J Anat 2013; 222: 462472 makes this easier, for example, when planning the targeted exci- 7 Khn W. Kolposkopie zur Frherkennung des Zervixkarzinoms. Patho- loge 2011; 32: 497504 sion of the lesion (type of excision). 8 Quaas J, Reich O, Frey Tirri B et al. Explanation and use of the colpos- Three different types of excision are mentioned in the addendum copy terminology of the IFCPC (International Federation for Cervical to the nomenclature, which also included for the first time the Pathology and Colposcopy) Rio 2011. Geburtsh Frauenheilk 2013; 73: dimensions of excision specimens. The excision types link the dif- 904907 9 Reich O, Fritsch H. The developmental origin of cervical and vaginal ep- ferent transformation types to clinical practice; the aim is to re- ithelium and their clinical consequences: a systematic review. J Low place the continued use of a wide range of excision terms by Genit Tract Dis 2014; 18: 358360 descriptions of the types of excision performed and not the methods used for excision. Quaas J et al. Explanation and Use Geburtsh Frauenheilk 2014; 74: 10901092

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