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Colposcopic features of cervical adenocarcinoma in situ (AIS) and adenocarcinoma exist, and colposcopists can learn to recognize them. This ability will increase the colposcopic discovery rate for these lesions and can lead to appropriate management in early stages. An excisional biopsy with negative margins is required to differentiate between in situ and invasive disease. The general categories of revealing features are surface patterns and blood vessels. Surface patterns indicative of AIS and adenocarcinoma are (1) lesions overlying columnar epithelium not contiguous with the squamocolumnar border; (2) lesions with large "gland"/cleft openings; (3) papillary lesions; (4) lesion exhibiting epithelial budding; and (5) variegated red and white lesions. Blood vessels indicative of AIS or adenocarcinoma are (1) waste-thread-like vessels; (2) tendril-like vessels; (3) rootlike vessels; (4) character-writing-like vessels; and (5) single and multiple dotlike formations in tips of papillary excrescences. Some of these characteristics also are apparent when other disease processes are present, but an observant colposcopist can differentiate lesions using inclusionary and exclusionary criteria. [ABSTRACT FROM AUTHOR]

Objective: The Home Study Course is intended for the practicing colposcopist who is seeking to develop or enhance his or her colposcopy skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management, or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions., Accme Accreditation: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category 1 of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.

Advanced practice nurses are increasingly using colposcopy to investigate abnormal cervical cytology. Specific colposcopic features can lead the clinician to suspect squamous cancer. This article discusses vascular pattern study, examination evaluation, lesion grading, and correlating colposcopy with histology and cytology to aid in identifying squamous cancer.

Objective: The Home Study Course is intended for the practicing colposcopist who is seeking to develop or enhance his or her colposcopic skills. The goals of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management, or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions., Accme Accreditation: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category 1 of the Physicians' Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.

Cytohistologic correlation was performed by 3 observers on 100 atypical squamous cells of undetermined significance (ASCUS) cases from a colposcopy clinic. Our objectives were to: 1) subclassify ASCUS cases and determine their clinical significance; 2) assess the independent predictive value of different cytologic parameters for biopsy-proven dysplasia (BPD); and 3) calculate interobserver variability. The prevalence of BPD was 73% in the ASCUS favor dysplasia (AFD) group, and 27% in the ASCUS favor reactive (AFR) group (P 0.001). The sensitivity of cervical cytology (AFD) for detecting BPD was 88.5%. Using multiple logistic regression, only nuclear membrane irregularity was found to be independently predictive of BPD (P 0.0001). The interobserver agreement (kappa) was 0.41. Colposcopic smears were inferior to referring smears in detecting dysplasia, with 67% of patients having a referring diagnosis of dysplasia. In a colposcopy clinic population there is a high prevalence (73%) of BPD in the AFD group. Attention should be paid to nuclear membrane irregularity in the risk stratification of ASCUS cases. Diagn. Cytopathol. 1999;21:211-216., (Copyright 1999 Wiley-Liss, Inc.)

The colposcopic appearances of VIN III differ on the vulva and adjacent sites according to the anatomic sites. Lesions on the hairy skin appear more well defined than lesions on nonhairy areas. VIN III histologically can extend into underlying adnexal structures. Most frequently, it is the hair follicles in which it may extend deeply. This involvement is not identified by colposcopic methods. A variety of colposcopic mimics or "look-alike" lesions occur on the vulvar skin. Therefore the performance of a biopsy is required to establish the diagnosis.

The colposcope, basically binoculars on a stand, is used for the evaluation of the genital tract. Its optics, although complicated in theory, are easy to use in practice. Certain adjustments are necessary for stereoscopic viewing. Other adjustments adapt the optics for high viewing and either adapt the optics for high magnification study of disease features or low magnification for seeing the entire surgical field during treatment.

Colposcopy is most useful in evaluating squamous lesions of the lower genital tract. Its usefulness in evaluating glandular abnormalities of the uterine cervix now are limited. There are abnormal features in invasive adenocarcinoma of the cervix that allow the colposcopist to make that diagnosis with directed punch biopsies. The biopsy specimens should be large enough to allow the pathologist to make the diagnosis of invasion. At the present time, the colposcopic features of adenocarcinoma in situ are not well recognized. It must be stressed that where adenocarcinoma in situ is suspected colposcopically or by cytology, the definitive diagnostic procedure remains cone biopsy.

In order to determine the distribution of human papillomavirus (HPV) types and to compare in situ hybridization (ISH) with Southern blot hybridization (SBH), paired colposcopically directed cervical biopsies and cervical-vaginal lavages were obtained from 92 women referred for abnormal Pap smears. The lavages and one of the biopsies were snap-frozen and subsequently tested by SBH for HPV DNA. The other biopsy was formalin-fixed and paraffin-embedded for conventional light microscopy and for ISH using two commercially available kits from Digene Diagnostics Inc.: ViraType In Situ containing probe mixtures to HPVs 6 and 11, 16 and 18, and 31, 33, and 35; and Omniprobe containing a single probe mixture to 14 different anogenital HPVs. In addition to the aforementioned types Omniprobe contains probes for types 42, 43, 44, 45, 51, 52, and 56. HPV DNA was detected by SBH in 27% of specimens showing no specific pathological change and in 92% of cases of cervical intraepithelial neoplasia (CIN). The HPVs by SBH in CIN were type 16 in 25%, types 31 or 35 in 23%, types 52 or 56 in 17%, uncharacterized types in 13%, mixed types in 8%, and type 18 in 6%. None of the specimens was positive for the low-risk HPV types 6, 11, 42, 43, or 44. The proportion of cases of CIN containing HPV 16 increased as the grade of CIN increased. Otherwise there were no striking differences detected in the HPV types in the different grades of CIN. ISH using ViraType In Situ was positive in only 50% of cases of CIN that were HPV positive by SBH.(ABSTRACT TRUNCATED AT 250 WORDS)

Lower genital tract neoplasia appears associated with certain types of the human papilloma virus. Surgical approaches using lasers and electricity are available to treat the clinical diseases and in turn provide good cosmetic and functional anatomy. The surgical method employed depends upon the anatomical and histological distribution of disease regardless of its site. Of the three areas (cervix, vagina and vulva), cervical intraepithelial neoplasia is the least difficult to cure. Vulvar intraepithelial neoplasia is the most difficult since recurrences can occur at any time and in some patients for many years.

As part of the Quality Assurance Program, all surgical pathology reports of cervical colposcopic biopsies, cone biopsies, and hysterectomy specimens of 772 consecutive patients were correlated with cytology results for a period of 1 yr. The abnormality in cytology or histology ranged from HPV effect to invasive carcinoma. Cytohistological correlation within one grade of severity was obtained in 662 (86%) cases. On formal review of the remaining 110 (14%) cases, sampling error occurred in 75 cytology smears and in 21 colposcopic biopsies. Screening and interpretation error occurred in 10 smears and four biopsies. In this study the sensitivity of cervical cytology in detecting epithelial abnormalities was 90%, with a positive predictive value of 99.7%. The false-negative rate of cytology was 11% and the false-positive rate 0.26%. The majority (90%) of false negatives were due to sampling error; the rest were due to laboratory error. The sensitivity of colposcopic biopsy was 97% with a positive predictive value of 99.4%. The false-negative rate of biopsy was 2.7% and the false-positive rate 0.5%. Endocervical cells were seen in 48% (370) of smears and absent in 52% (402). However, in both instances the detection rate of squamous abnormality was 90%. Also 43% (33) of smears that showed endocervical cells failed to contain the abnormal cells. Endocervical curettage or cone biopsy in 16 of these 33 cases clearly showed a small CIN-III lesion high in the endocervical canal. We believe that the value of endocervical cells as an indicator of adequacy is questionable.(ABSTRACT TRUNCATED AT 250 WORDS)

Questionnaire data from 376 undergraduates (mean age=19.3 years) were used to test a model describing interrelationships among deidealization, relatedness, autonomy, and insecurity in late adolescents' relationships with their parents. As expected, deidealization predicted greater autonomy and less relatedness (i.e., more disengagement), greater disengagement predicted greater insecurity, and greater insecurity predicted less autonomy. However, disengagement from parents proved to be a "double-edged sword" in that it was linked not only to insecurity, but also to feelings of greater separateness and self-directedness in relation, to parents. Additional analyses identified significant associations between the adolescent/parent relationship variables and the adolescents' psychological health and ego identity status.

Twenty-nine patients with grade 3 vulvar intraepithelial neoplasia were treated with the carbon dioxide laser while they were under anesthesia. Superficial lesions in nonhairy areas were vaporized to less than 1 mm, but lesions extending onto hairy areas were vaporized to 3 mm to destroy disease in skin appendages. Eighty-three percent of lesions involved nonhairy areas alone. Seventy-two percent of cases were cured by one laser application, 25% by two, and one case by three. Two patients had permanent hair loss after healing. The laser is an appropriate modality for lesions in nonhairy areas but scalpel excision is probably better for vulvar intraepithelial neoplasia in hairy areas.

Four hundred twenty-nine consecutive cases of cervical intraepithelial neoplasia were managed by one of three techniques of carbon dioxide laser surgery: dome-shaped vaporization of ectocervical lesions, cylinder-shaped excision of endocervical disease, or a combination of the two in the case of ectocervical disease that extended into the lower cervical canal. Ninety-two patients (21.5%) had grade 1, 137 (31.9%) had grade 2, and 200 (46.6%) had grade 3 cervical intraepithelial neoplasia. The success rates subsequent to one surgical intervention were 97.8% for grade 1, 94.9% for grade 2, and 94.5% for grade 3 of the disease. Success for the entire patient population was 95.3% after the first treatment. A second treatment was required in 20 cases: 18 laser procedures and two hysterectomies. The overall success of laser surgery (one or two procedures) approached 100%. Complications were negligible. These findings suggest that these techniques are very effective in eliminating cervical intraepithelial neoplasia of all degrees when a planned approach is followed.

To study the effect of a topical antibiotic spray in reducing postoperative morbidity when used during surgery, a randomized, double-blind study was done on 150 women who had a vaginal hysterectomy with or without colporrhaphy. The spray contained neomycin sulfate, polymyxin B sulfate and zinc bacitracin and was used in 75 patients; a placebo spray was used in the other 75 patients. The antibiotic spray significantly (P < 0.01) decreased the frequency of pelvic infections postoperatively--14.7% in the antibiotic group compared with 37.3% in the placebo group.

The colposcope is a low-powered microscope with built-in illumination which can be used for a close examination of the cervix and vagina, enlarging the area 10-20 times. With this instrument, cervical areas of dysplasia, carcinoma in situ and early invasive cancer are usually visible. As a result the colposcope can be used to direct the actual site for cervical biopsy with great accuracy. The colposcope is also useful in visualizing the vaginal vault to study the possibility of neoplastic changes both before and after surgical treatment for carcinoma of the cervix.

Carcinoma of the vulva often presents as a large ulcerating or fungating tumor with considerable destruction of the vulva and surrounding tissues. The area usually is very painful and foul smelling. Most such tumors are of the squamous-cell variety. Despite the degree of histologic differentiation, the lymph nodes are involved in more than 50% of the cases. The best therapeutic results are obtained with radical vulvectomy and groin node dissection "en bloc." Occasionally treatment should be modified in the geriatric patient because of associated medical problems. Various techniques are discussed. Since the disease is rare, best results are achieved by referral to a specialized treatment center.

Disease onset in 747 routinely screened women who developed cervical intraepithelial neoplasia was analyzed. Average age at diagnosis was 30 years; the range was 16 to 71 years. In 19% diagnosis was made after age 35, and in 1% after age 60. Grouping cases by age at beginning of coitus produced significant differences (p less than 0.001) in cumulative proportions of patients with the diagnosis made at any age. In 11% of patients initiating intercourse between ages 15 and 17 diagnosis was made after age 35; the figure was 19% for the 18 to 19 age group and 36% for the 20+ group. Screening by chronologic age is effective for women initiating intercourse early. Screening by years of exposure to intercourse produced a uniform distribution regardless of age at beginning of coitus. In 75% the diagnosis was made within the first 15 years of intercourse, in 88% by year 20; and in 97% by year 30. In 70% the diagnosis was made between 6 and 20 years. Cytologic surveillance should be concentrated during the sixth through twentieth years when most cases develop.

During vaginal hysterectomy with or without colporrhaphy a topical aerosol spray containing neomycin sulfate, polymyxin B sulfate and zinc bacitracin was used in 50 patients to decrease the change of postoperative pelvic infection; a placebo spray was used in another 50 patients. All patients were treated preoperatively with povidone iodine and postoperatively with nitrofurantoin and an antibacterial irrigating solution for the bladder if catheter drainage was necessary. The frequency of postoperative pelvic infection was 16% in the group sprayed with the antibiotic combination and 34% in the group sprayed with the placebo, a significant difference (P less than 0.05).

In 1917 Einstein theorized tha through an atomic process a unique kind of electromagnetic radiation could be produced by stimulated emission. When such radiation is in the optical or infrared spectrum it is termed laser (light amplification by stimulated emission of radiation) light. A laser, a high-intensity light source, emits a nearly parallel electromagnetic beam of energy at a given wavelength that can be captured by a lens and concentrated in the focal spot. The wavelength determines how the laser will be used. The carbon dioxide laser is now successfully employed for some surgical procedures in gynecology, otorhinolaryngology, neurosurgery, and plastic and general surgery. The CO2 laser beam is directed through the viewing system of an operating microscope or through a hand-held laser component. Its basic action in tissue is thermal vaporization; it causes minimal damage to adjacent tissues. Surgeons require special training in the basic methods and techniques of laser surgery, as well as in the safety standards that must be observed.

The Walton Report on cervical cancer screening programs recently recommended a new program for screening for cervical cancer based on chronologic age, calling for 3- and 5-year intervals between examinations. It recommended that such examinations be discontinued after 60 years of age. In a group of 232 routinely examined women (aged 18 to 47 years) in whom cervical intraepithelial neoplasia developed the timing of onset of the disease and the implications for screening were studied. The average age at the time of diagnosis was 30 years; in 20% of the patients the diagnosis had been made after age 35. The screening program recommended in the Walton Report would have been effective in diagnosing most cases (80%) in this sample by age 35 and all by age 60. However, when the patients were grouped according to age at the time of first intercourse, the diagnosis had been made after age 35 in only 13% of those who started having intercourse at age 15 to 17 years, 20% of those who started at age 18 to 19 years and 33% of those who started at age 20 years of later. When the times of diagnosis were expressed by number of years of intercourse the distributions became uniform in the same three groups; in 72% of all the patients the diagnosis had been made within the first 15 years of intercourse, in 88% it had been made within 20 years and in 100% it had been made by 30 years. These data suggest that a program based on number of years of intercourse may be more uniform and more efficient than one based on chronologic age, and that cytologic examinations should be concentrated during the time when most cases develop -- 6 to 20 years after the time of first intercourse.

In this report we describe the use of the carbon dioxide laser for the outpatient management of cervical intraepithelial neoplasia (CIN). A comparison of treatment effectiveness for different grades of CIN is also included. Two hundred fifty-six cases were evaluated by colposcopy, cytology, and histopathology, treated by at least 5 to 6 mm of laser vaporization, and followed up for an average of 10.7 months. Follow-up examinations included cytology, colposcopy, and directed biopsy if a suspicious lesion was discovered. During the follow-up, 18 cases of persistent CIN were identified (7.0%). Most of these were successfully managed with repeat laser treatment. Overall success of laser surgery for CIN, one or two applications, was 97.6%. Few complications were encountered. Laser surgery appears to offer acceptable treatment effectiveness, early identification of persistent disease, and easy retreatment when required.

The colposcope is a stereoscopic microscope mounted on a tripod and is capable of magnifying the cervix ten to 45 times. Differential diagnosis of a diseased cervix is easily obtained through using the colposcope. A diagnosis of epidermization, ectopy, atypical epithelial changes and their extent can be established immediately. Use of colposcopy should diminish the use of tissue biopsy for benign cervical lesions and will modify the treatment of cervical dysplasia and carcinoma in situ by preserving the uterus in many cases.

This report describes the procedures and results of two techniques, which were developed by the senior author (V.C.W.), for eliminating cervical intraepithelial neoplasia involving, to some degree, the endocervical canal. These are excision by carbon dioxide laser of a tall cylinder of tissue for pure endocervical lesions and shallow excision of a similar specimen followed by peripheral vaporization. In 364 consecutive referred cases one of these two procedures was performed. A total of 15.9% of patients required attention for bleeding; most cases were managed in the clinic. Near-normal tissue mass and a squamocolumnar junction at the os were observed during 3 to 60 months of follow-up. In 95.9% of cases, over half of which were grade 3 cervical intraepithelial neoplasia, normal cytologic and colposcopic findings were demonstrated after one laser procedure. A repeat laser procedure was used to eliminate persistent disease identified at 3 or 6 months. Five hysterectomies were performed. These procedures appear to be therapeutically effective, appear to preserve organ function, and allow regeneration of cervical mass.

This study comprises 336 consecutive patients of whom 283 were candidates for conservative therapy involving either cryosurgery or the carbon dioxide laser for the management of cervical intraepithelial neoplasia (CIN). A total of 152 patients were treated first in the series with cryosurgery followed by 131 patients in the laser group. Distribution of disease classification within CIN groups was similar. The overall persistent disease after one treatment was higher in the cryo group (14.5 per cent) as compared to the laser group (3.1 per cent). Of particular significance is the high percentage of failures in the cryo treated group (25.0 per cent) with CIN III disease as compared to the CIN III laser treated group (7.7 per cent). The high persistent disease rate observed in the CIN III lesions treated by cryosurgery suggests that this modality be employed with caution in this disease classification.

Genital warts are believed to be caused by human papilloma viruses and to be sexually transmitted. The viruses are classified by DNA types, which appear to cause different types of disease. The choice of treatment, and usually its success rate, vary according to the type of disease and its location.

Cervical dysplasia appears to be a precursor of frank invasive cancer; the same epidemiological factors probably apply in cervical intraepithelial neoplasia. This article describes the tissue at risk and how it can be evaluated, treated and followed up using the colposcope.

Carcinoma in situ is not always cured (even though it could be) because of errors in morphological diagnosis and inadequate operative techniques. In the past we have been conditioned to accept the tissue biopsy diagnosis in preference to the cytological diagnosis. In many cases positive exfoliative cytology has not been explained by tissue biopsy, mainly because the technique of tissue sampling has been inadequate. Insufficient operative techniques have failed to remove sufficient vaginal vault adjacent to the cervix. Failure to recognize that these early lesions may spread to the vaginal vault has resulted in a recurrence to the vaginal apex, either as a carcinoma in situ or an early invasive carcinoma. Because of the multicentricity of carcinoma in situ, cancerization of the entire female genital tract may occur. It is therefore mandatory that all patients be followed up with cytology after any method of management.