Key words
colposcopy - cervix uteri - nomenclature - IFCPC Rio de Janeiro 2011 - transformation zone - adequate colposcopy - inadequate colposcopy
Schlüsselwörter
Kolposkopie - Cervix uteri - Nomenklatur - IFCPC Rio de Janeiro 2011 - Transformationszone - adäquate Kolposkopie - inadäquate Kolposkopie
Introduction
The current colposcopic nomenclature was published on July 1, 2012 in Obstetrics & Gynecology [1].
In Frauenarzt 2012 [2] and Geburtshilfe & Frauenheilkunde 2013 [8], the Boards of the Arbeitsgemeinschaft Kolposkopie (AGK – Austrian Society of Colposcopy), the Arbeitsgemeinschaft für Kolposkopie und Zervixpathologie (AGKOL – Swiss Society of Colposcopy and Cervical Pathology) and the Arbeitsgemeinschaft für Kolposkopie und Zervixpathologie (AGCPC – German Society of Colposcopy and Cervical Pathology) accepted the validity of the revised nomenclature and recommended its use in general clinical practice across German-speaking countries.
It must be emphasized that one of the primary aims of the new IFCPC nomenclature was to create a closer association between terminology and therapeutic procedures. Examples for this include the introduction of a grading to describe the visibility of the squamocolumnar junction and the types of excision outlined in the Addendum.
In the authorsʼ opinion, this is a welcome step as it simplifies individualized planning and implementation of treatment. See also various publications on this point (e.g. Kühn 2011 [7], Reich & Fritsch 2014 [9]). Overall, the new colposcopy nomenclature emphasizes the significance of colposcopic investigations more than the preceding version did.
It is particularly gratifying that two recent publications from Germany (Scheungraber et al. [3], [4]) were also incorporated in the revised nomenclature.
It should be noted that the distinction between lesions located inside and those located outside the transformation zone described in the nomenclature (an important distinction in clinical practice) as well as the significance of superficial expansion of abnormal colposcopic findings in the uterine cervix were scientifically confirmed by publications from German-speaking countries [5], [6].
Some aspects, which were found to require further clarification for general practice, are discussed below.
Border between Squamous and Columnar Epithelium and Transformation Zone
Basically, assessment of the transformation zone and classification into the respective transformation zones type 1, 2 or 3 is done after the application of acetic acid.
The transformation zone in its native state is usually gray to red. After cleaning with a dry swab, colposcopic observation will usually show a network of regular branching vessels (an indication that the vessels are unremarkable), openings of the cervical glands, and the nabothian glands. With the exception of the vessels, all of these structures are more clearly visible after the application of acetic acid. The border between squamous and columnar epithelium is a sharp, often demarcated border between the grape-like columnar epithelium and the metaplastic squamous epithelium and is more or less visible on colposcopy.
Localizing the border between squamous and columnar epithelium is the prerequisite for classifying the transformation zone as type 1, 2 or 3.
The two terms (border between squamous and columnar epithelium, transformation zone) describe two different but overlapping aspects. The border between squamous and columnar epithelium constitutes the “inner” margin of the transformation 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) ([Fig. 2]). Transformation zones type 2 and 3 always have an endocervical portion, meaning that the border between squamous and columnar epithelium extends into the cervical canal. If the border is completely visible, it is referred to as a type 2 transformation zone. Visualization of the border can be done with or without additional instruments (endospeculum) ([Fig. 3] a and b). The transformation zone is only classified as type 3 if the border between squamous and columnar epithelium is not completely visible (even with the help of additional instruments) ([Fig. 4]). If this is the case, colposcopy can only provide information about the visible part of the transformation zone; however, if the conditions for colposcopic examination are otherwise optimal, this examination must still be classified as adequate.
As mentioned above, one of the aims of the nomenclature commission of the IFCPC was to improve the planning of potentially necessary therapeutic options. Evaluation of these two aspects makes this easier, for example, when planning the targeted excision of the lesion (type of excision).
Three different types of excision are mentioned in the addendum to the nomenclature, which also included for the first time the dimensions of excision specimens. The excision types link the different transformation types to clinical practice; the aim is to replace the continued use of a wide range of excision terms by descriptions of the types of excision performed and not the methods used for excision.
