Key words
colposcopy - cervix uteri - nomenclature - IFCPC Rio de Janeiro 2011
Schlüsselwörter
Kolposkopie - Cervix uteri - Nomenklatur - IFCPC Rio de Janeiro 2011
Introduction
The new and thus currently valid coloscopic nomenclature was published on 1 July 2012
in the journal “Obstetrics & Gynecology” [1]. This had
been preceded by the appointment of a nomenclature committee in 2008 on the occasion
of the world congress in Oakland, New Zealand.
After extensive literature searches, several meetings and detailed discussions in
the
website of IFCPC, the new version of the nomenclature was accepted at the world
congress in Rio de Janeiro in July 2011.
The new nomenclature 2011 consists of 3 parts:
-
Nomenclature concerning the cervix uteri ([Tab. 1]) including an appendix on the definition of types of excision
([Table 2]).
-
Nomenclature for the vagina.
-
Nomenclature for the vulva which was formulated in cooperation with the
International Society for the Study of Vulvovaginal Diseases (ISSVD). These
were published in a second publication.
Table 1 Colposcopic nomenclature of cervix uteri
(IFCPC 2011), after [9].
|
IFCPC 2011
|
Rio de Janeiro
|
Colposcopic nomenclature for cervix uteri
|
|
General:
|
|
adequate/inadequate: reason:
(e.g., inflammation,
bleeding, scars)
columnar – squamous epithelium – border
(CSB): completely/partially/not visible
transformation
zone (type 1, 2, 3)
|
|
Normal finding
|
|
original squamous epithelium:
columnar epithelium
metaplastic squamous epithelium
deciduosis in pregnancy
|
|
Abnormal finding
|
general:
|
localisation of the lesion:
inside or outside the
epithelium, given according to clock face
size
of the lesion:
number of affected
quadrants
percent of the cervix
|
|
|
grade 1 (minor change)
|
delicate acetic-white epithelium, delicate mosaic, delicate
puncturing
|
|
|
grade 2 (major change)
|
intensive acetic-white epithelium
coarse mosaic, coarse
puncturing
prominent excretory ducts of
glands
sharp borders
inner border sign, ridge
sign
rapid acetic acid reaction
|
|
|
not specific
|
leukoplakia (keratosis, hyperkeratosis), erosion
Lugolʼs
reaction (Schiller test)
|
|
Suspected invasion
|
|
atypical vessels
additional findings: vessels that
bleed on contact, irregular surfaces, exophytic lesion,
necrosis, ulcer, tumour
|
|
Miscellaneous findings
|
|
congenital transformation zones (CTZ), congenital anomalies,
condylomas (papillomas), endometriosis, polyps (ectocervical,
endocervical)
inflammation, stenosis, postoperative
changes (scarred portio, vaginal stump)
|
Table 2 Addendum to colposcopic nomenclature for cervix uteri
(IFCPC 2011), after [9].
|
IFCPC 2011
|
Colposcopic nomenclature
|
Cervix uteri addendum
|
|
Excision types
|
type 1 – flat
type 2 – medium
type 3 – steep
|
|
|
Dimensions of conisation specimens
|
height (length):
distance from cervical to vaginal
resection border (see Fig.
below)
width:
distance from stromal
resection border to epithelial surface
circumference
(optional):
perimeter of the opened cone
specimen
|
|
|
|
red: height (length) of the conisation specimen,
blue: thickness of the cone
|
The aim of the following explanations is to create a relationship between the new
nomenclature and the daily routine of colposcopic examinations.
At the same time, the authors want to point out that a common foundation for the use
of the now internationally valid colposcopic nomenclature of cervix uteri in the
German-speaking countries has been published [9].The
boards of AGK, AGCPC and AGKOL have thus recognised the validity of the colposcopic
nomenclature 2011 and recommend their members to use them in their daily
routine.
We appeal to all interested colleagues to send their comments and ideas to their
management boards. These will then be introduced at the next meeting of the
nomenclature commission of the IFCPC.
It should be emphasised that the aim of the nomenclature commission is to develop
an
evidence-based terminology. It is also apparent that the commitment of the IFCPC was
to promote a closer relationship to therapeutic procedures. Examples of this are the
introduction of a grading for the visibility of the columnar-squamous epithelium
boundary and the types of excision mentioned in the appendix ([Table 2]). In the authorsʼ opinion this step is to be welcomed as it
leads to a clearer position with regard to individualised therapy planning and
performance. See also the corresponding German-language groundwork (e.g., Kühn 2011
[7], Kühn et al. 2012 [8]).
Overall, the new colposcopic nomenclature more clearly emphasises the significance
of colposcopic examinations than did the preceding version.
Especially gratifying is the fact that two current publications from Germany-speaking
countries (Scheungraber et al. [3], [4]) have been duly incorporated in the revision of the nomenclature.
It should also be mentioned that the practically important differentiation between
the localisation of lesions inside and outside of the transformation zones has been
explicitly described in the nomenclature and also that the significance of the
surface expansion of dysplasia in cervix uteri has been scientifically confirmed by
publications from German-speaking countries [10], [11].
In the following paragraphs those aspects are mentioned that have changed in
comparison to the previously valid terminology (Barcelona 2002 [6]) or, respectively have been included for the first time.
Nomenclature of Cervix Uteri
Some basic preliminary remarks of fundamental importance need to be made about the
colposcopic nomenclature for cervix uteri and the vagina. Is the colposcopic
examination “adequate” or “inadequate with reasons”? This replaces the term
“satisfactory/unsatisfactory colposcopy”. This change should emphasise that in the
case of an inadaquate coposcopy due to, e.g., inflammation, a control examination
has to be performed after therapy. Moving the evaluability and general significance
of a colposcopic examination to the beginning of the nomenclature emphasises the
relative values.
This applies especially to the visualisation of the columnar-squamous epithelium
border and thus the classification of the transformation zones into types 1–3. The
two classifications certainly overlap but represent two differerent aspects. The
columnar-squamous epithelium border is the “inner” border for the transformation
zone (mature columnar epithelium border) and can, accordingly, be “completely”,
“partially” or even “not visible”. In the transformation zones 1 and 2 the
columnar-squamous epithelium border is completely visible. As mentioned above it was
the intention of the IFCPC nomenclature committee to make the planning of possibly
necessary therapeutic options better. Evaluation of the above two aspects does make
this better, e.g., for the targeted excision of abnormal areas (excision type).
For normal findings, an extension has also been made: atrophic squamous epithelium,
changes in pregnancy (deciduosis) and metaplasia. It should be noted critically that
making the diagnosis of metaplasia actually necessitates a prior histological
clarification in order to prove the existence of the metaplasia and exclude other
functional findings, e.g., hyperplastic or polypous ectopy.
In abnormal colposcopic findings, the localisation of the lesion – inside or outside
the transformation zone – has been re-included in the nomenclature and supplemented
with the terms “inner border” (border within the acetic-white epithelium) and “ridge
sign” [3], [4].
The size of the lesion has been incorporated in the nomenclature whereby the
dimensions of the lesion are to be given as number of afflicted quadrants or,
respectively, as percentage of the cervix.
The grading into “minor” and “major changes” that was already defined in the Rome
1991 nomenclature [5] has been retained. “Minor changes”
can also be described as grade 1 changes ([Fig. 1]) and
“major changes” as grade 2 changes ([Figs. 2] to [5]).
Fig. 1 Regular acetic-white mosaic on cytological PAP II, histological
sign of cervicitis.
Fig. 2 Opaque acetic-white epithelium on the anterior lip of the cervical
os at 12 oʼclock with coarse mosaic (major change), transformation zone 1.
Fig. 3 Pronounced acetic-white epithelium with “inner border” at 1 oʼclock
ectocervical in histologically confirmed CIN 2.
Fig. 4 Pronounced acetic-white epithelium on the anterior lip of the
cervical os with typical “ridge sign” (major change) in histologically confirmed
CIN 3, transformation zone 1.
Fig. 5 Acetic-white elevated mound of excretory ducts of the cervical
gland on the posterior lip of the cervical os (major change) in histologically
confirmed CIN 3.
Newly taken into consideration is the interpretation of the dynamics of the acetic
acid reaction in cervix uteri. It is pointed out that a rapid and intensive,
positive acetic acid reaction must be classified as “major changes”. It should be
noted that the slow development of a positive acetic acid reaction, which in
individual cases may require a reaction time of up to 3 minutes, belongs to the
“major changes” when the other “major change” criteria are applicable.
As already mentioned in the introduction, the committee could not agree to classify
the term leukoplakia into the groups of minor or, respectively, major changes.
Leukoplakia, erosion and Lugolʼs reaction (Schiller test) are classified as “non
specific”. In particular, the classification of Lugolʼs reaction as an unspecific
examination method emphasises the necessity of the preoperative application of an
acetic acid text. Lugolʼs reaction alone is not a suitable measure for the
preoperative planning of the excision line.
An extension is found in cases of suspected invasion in that atypical vessels are
now
merely defined as invasion characteristics in contrast to previous neomclature
suggestions. So far atypical vessels were assigned to the “major change” lesions.
In
addition, further clinical aspects have been incorporated such as, for example,
vessels that bleed upon contact.
Under the so-called miscellaneous findings we now find the “congenital transformation
zone, CTZ” and postoperative changes such as “scarred portio” (after conisation) or
“vaginal stump”. An exact description of the term CTZ is still lacking and will be
subject of further discussion in the IFCPC nomenclature commission.
Addendum: Excision Types and Conisation Specimens
Three different excision types and also the dimensions of conisation specimens have
been added as an addendum ([Table 2]). The excision types
represent a practical relationship to the types of transformation zones and are
intended to replace the further use of widely differing excision terms by
descriptions of the excisions performed and not the methods themselves.
