Burghardt's Colposcopy and Cervical Pathology: Textbook and Atlas

242 Pages·2015·46.73 MB·English

by  Frank Girardi

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’
Burghardt s Colposcopy and Cervical Pathology
Textbook and Atlas
4th Edition
Frank Girardi, MD
Department of Gynecology and Obstetrics
University of Graz
Graz, Austria
Olaf Reich, MD
Department of Gynecology and Obstetrics
University of Graz
Graz, Austria
Karl Tamussino, MD
Department of Gynecology and Obstetrics
University of Graz
Graz, Austria
Hellmuth Pickel, MD
Department of Gynecology and Obstetrics (formerly)
University of Graz
Graz, Austria
538 illustrations
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Girardi,Frank,author. ualdevelopment.Researchandclinicalexperiencearecontinuallyexpand-
Burghardt's colposcopy and cervical pathology : textbook and atlas / ingourknowledge,inparticularourknowledgeofpropertreatmentand
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Colposcopyandcervicalpathology madeeveryefforttoensurethatsuchreferencesareinaccordancewiththe
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[DNLM: 1. Cervix Uteri–pathology. 2. Cervix Uteri–pathology– drugsthatareeitherrarelyusedorhavebeennewlyreleasedonthemarket.
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Contents
PrefacetotheFourthEdition ................................................................................. ix
PrefacetotheFirstEdition.................................................................................... xi
PrefacebytheTranslatortotheFirstEdition ............................................................... xiii
1 HistoryofColposcopy ......................................................................................... 2
2 RoleofColposcopy............................................................................................. 6
2.1 RoutineColposcopy.............................. 6 2.4 ColposcopytoEvaluateAbnormalCytologic
FindingsduringPregnancy ....................... 6
2.2 ColposcopytoEvaluateanAbnormalPapSmear ... 6
2.5 ColposcopytoEvaluateLesionsbeforeTreatment.. 6
2.3 ColposcopytoEvaluatePatientsPositiveforHPV
orOtherBiomarkers ............................. 6 2.6 ColposcopyinScreen-and-TreatApproachesin
Resource-PoorSettings........................... 6
3 HumanPapillomavirusesandCervicalCancer .............................................................. 10
3.1 EtiologyofCervicalCancer ....................... 10 3.3.1 MorphogenesisofSquamousCellCarcinomain
MetaplasticEpithelium........................... 15
3.2 NaturalHistoryofCervicalCancer................. 10
3.3.2 MorphogenesisofSquamousCellCarcinomain
OriginalSquamousEpithelium.................... 16
3.2.1 Introduction..................................... 10
3.3.3 MorphogenesisofAdenocarcinoma............... 17
3.2.2 PhasesofHPVInfection .......................... 12
LatentPhase....................................... 13 3.4 HPVVaccines.................................... 17
Permissive(Productive)Phase.......................... 13
TransformingPhase.................................. 14
3.3 MorphogenesisofCervicalCancer ................ 14
4 HistologyandHistopathology................................................................................ 24
4.1 NormalFindings;ReactiveandBenignHPV–Related SquamousIntraepithelialLesions(SIL,CIN)................ 32
Changes......................................... 24
Atypicalimmaturesquamousmetaplasia(AIM) ............ 33
AdenocarcinomainSitu .............................. 34
4.1.1 NormalSquamousEpithelium.................... 24
4.2.5 BiomarkersinDiagnosisofCervicalPrecancer ..... 34
4.1.2 NormalColumnarEpitheliumandEctopy ......... 24
HPV-DNATesting ................................... 34
4.1.3 MetaplasticSquamousEpitheliumandthe
HPVE6/E7mRNATesting............................. 35
TransformationZone............................. 24
HPV-DNAGenotyping................................ 35
EctopyandtheLastGland............................. 24
TheL1CapsidProtein................................ 35
4.1.4 TheMechanismofMetaplasiaandTransformation. 27
p16INK4a........................................... 35
4.1.5 VasculatureoftheNormalCervix................. 27
OtherPotentialBiomarkers............................ 37
4.1.6 ReactiveChangesofSquamousandColumnar
Epithelium ...................................... 28 4.3 InvasiveCervicalCancer.......................... 38
4.1.7 HPV–InfectedSquamousEpithelium .............. 29
4.1.8 CondylomatousLesions .......................... 29 4.3.1 MicroinvasiveCarcinoma......................... 38
EarlyStromalInvasion................................ 38
4.2 PremalignantCervicalLesions .................... 31
4.3.2 FrankInvasiveCervicalCancer.................... 41
SquamousCellCarcinoma............................. 42
4.2.1 HistologicTerminology .......................... 31
AdenocarcinomaoftheCervix ......................... 44
SquamousIntraepithelialLesions ....................... 31
OtherEpithelialTumors............................... 46
4.2.2 ABriefHistoryoftheTerminologyofCervical
PrecursorLesions................................ 31 4.4 HistologyofColposcopicFindings................. 46
4.2.3 GlandularIntraepithelialLesions(Adenocarcinoma
inSitu).......................................... 32 4.4.1 MicroscopicVersusColposcopicMorphology...... 46
4.2.4 HistologyofPremalignantCervicalLesions........ 32 4.4.2 TopographyandExtensionofSIL(CIN) ............ 46
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Contents
LocationofDysplasticEpitheliumwithRespecttothe AcetowhiteEpithelium(Thin,Dense).................... 53
TransformationZone:theLastGland .................... 46 InnerBorderSignandRidgeSign....................... 53
SuperficialSpreadofSIL(CIN).......................... 46 ErosionandUlcer................................... 53
RoleoftheEpitheliuminColposcopicMorphology.......... 48 CondylomatousLesions .............................. 53
4.4.3 ColposcopicAppearanceoftheSurface............ 49 4.4.4 MicroinvasiveSquamousCellCarcinoma.......... 56
SharpEpithelialBorders.............................. 50 4.4.5 AdenocarcinomainsituandMicroinvasive
SizeandExtentofDysplasticEpithelialFields .............. 50 Adenocarcinoma ................................ 56
Leukoplakia(Keratosis)............................... 50 4.4.6 GrosslyInvasiveCarcinoma ...................... 56
MosaicandPunctation(Fine,Coarse).................... 50
5 TheColposcopeandtheColposcopicExamination......................................................... 62
5.1 ColposcopicInstruments......................... 62 5.2.2 Chrobak’sProbe................................. 63
5.1.1 Specula......................................... 62 5.3 TheColposcopicExamination..................... 63
5.1.2 Forceps ......................................... 63
5.1.3 Containers...................................... 63 5.3.1 ApplicationofAceticAcid........................ 64
5.3.2 Schiller(lodine)Test............................. 65
5.2 BiopsyInstruments.............................. 63
5.2.1 Tenacula........................................ 63
6 TeachingColposcopy.......................................................................................... 72
6.1 UnderstandingColposcopicFindings.............. 72
7 ColposcopicTerminology..................................................................................... 74
8 ColposcopicMorphology...................................................................................... 78
8.1 NormalColposcopicAppearances................. 78 8.3.4 InflammatoryChanges........................... 114
8.3.5 Polyps .......................................... 117
8.1.1 OriginalSquamousEpithelium ................... 78 8.3.6 PostconizationChanges.......................... 120
8.1.2 AtrophicSquamousEpithelium................... 78 8.3.7 ChangesResultingfromProlapse................. 125
8.1.3 Ectopy(ColumnarEpithelium) ................... 80 8.3.8 Endometriosis,Fistulas,AnatomicAnomalies...... 125
8.1.4 TransformationZone............................. 84
8.4 AssessmentofColposcopicFindings .............. 125
8.2 AbnormalColposcopicFindings................... 90
8.4.1 BenignMetaplasticEpitheliumandSquamous
8.2.1 AcetowhiteEpithelium........................... 90 IntraepithelialNeoplasia......................... 127
8.2.2 AtypicalTransformationZone.................... 94
8.2.3 Mosaic.......................................... 94 8.5 CriteriaforDifferentialDiagnosis................. 128
FineMosaic ....................................... 94
CoarseMosaic ..................................... 96 8.5.1 SharpBorders................................... 128
8.2.4 Punctation...................................... 96 8.5.2 ResponsetoAceticAcid(WhiteEpithelium)....... 128
FinePunctation .................................... 97 8.5.3 SurfaceContour................................. 129
CoarsePunctation .................................. 98 8.5.4 CuffedGlandOpenings .......................... 129
8.2.5 Leukoplakia(Keratosis) .......................... 98 8.5.5 BloodVessels.................................... 129
8.2.6 Erosion,Ulcer ................................... 101 8.5.6 NonsuspiciousVascularPattern .................. 131
8.2.7 SignsofEarlyInvasiveCarcinoma................. 104 8.5.7 SuspiciousVascularPattern ...................... 131
8.2.8 InvasiveCarcinoma.............................. 107 8.5.8 AtypicalVessels ................................. 131
8.2.9 AdenocarcinomainSituandMicroinvasive 8.5.9 SurfaceArea(Size)............................... 131
Adenocarcinoma ................................ 110
8.6 CombinationsofAbnormalities................... 131
8.3 MiscellaneousColposcopicFindings............... 110
8.6.1 IodineUptake................................... 135
8.3.1 NonsuspiciousIodine-YellowArea................ 110 8.6.2 Keratinization................................... 135
8.3.2 CongenitalTransformationZone.................. 110 8.6.3 WeighingDifferentialDiagnostic
8.3.3 CondylomatousLesions.......................... 112 Criteria ......................................... 137
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Contents
9 ColposcopyinPregnancy...................................................................................... 140
9.1 EffectsofPregnancyonColposcopicFindings...... 141 9.3 SuspiciousChanges .............................. 143
9.1.1 AceticAcidTest.................................. 141 9.4 ThePuerperium.................................. 143
9.1.2 Schiller(lodine)Test............................. 141
9.5 BiopsyduringPregnancy......................... 145
9.2 BenignChangesinPregnancy..................... 141
10 Colposcopic–HistologicCorrelation.......................................................................... 154
10.1 TheTopographyofAbnormalColposcopic
Findings......................................... 159
11 TherapeuticImplicationsofAbnormalColposcopicFindings.............................................. 164
11.1 ManagementofBenignColposcopicFindings...... 164 11.2.3 ExcisionalModalities:LoopExcisionand
Conization....................................... 166
11.1.1 Ectopy .......................................... 164 CompleteExcision................................... 166
11.1.2 NormalTransformationZone..................... 164 IncompleteExcision ................................. 166
11.1.3 MetaplasticEpitheliumwithLeukoplakia, RepeatConization................................... 167
Punctation,orMosaic............................ 164 11.2.4 PrimaryHysterectomy........................... 167
11.1.4 CondylomatousLesions .......................... 164 11.2.5 PrimaryMedicalTreatmentofSIL................. 167
11.2 TreatmentofPremalignantCervicalLesions ....... 164 11.3 TreatmentofMicroinvasiveCarcinoma............ 167
11.2.1 DiagnosticPrerequisites.......................... 164 11.4 Follow-upafterTreatment........................ 168
11.2.2 AblativeTreatmentofSquamousIntraepithelial
Neoplasia(SIL)................................... 165
12 CervicalConization:TechniquesandHistologicProcessingoftheSpecimen............................ 172
12.1 DiagnosticConization............................ 172 12.3.4 LaserConeBiopsy................................ 173
12.3.5 ComparisonofLoopExcision,Cold-Knife
12.2 TherapeuticConization........................... 172
Conization,andLaserConeBiopsy................ 174
12.3 TechniqueofConization.......................... 172
12.4 ConizationDuringPregnancy..................... 175
12.3.1 LoopDiathermyExcision......................... 172 12.5 HistopathologicProcessingoftheCone ........... 175
12.3.2 Cold-KnifeConization............................ 172
12.3.3 ComplicationsofConization...................... 173
13 ColposcopyoftheVulva....................................................................................... 182
13.1 HistologyoftheVulva............................ 182 13.3.2 HPV-IndependentCarcinogenesis................. 190
13.2 DiagnosticMethodsforEvaluatingVulvarLesions.. 183 13.4 PreinvasiveIntraepithelialLesions................. 191
13.2.1 HistoryandSymptoms........................... 183 13.4.1 SquamousIntraepithelialLesions(SIL)and
13.2.2 Inspection....................................... 183 Differentiated-typeVulvarIntraepithelial
13.2.3 Palpation........................................ 183 Neoplasia(dVIN)................................. 191
13.2.4 ToluidineBlueTest(CollinsTest).................. 183 HistologicTerminologyandClassification................. 192
13.2.5 ColposcopyoftheVulva.......................... 184 HistologyofSILanddVIN ............................. 193
13.2.6 HistologicCorrelatesofColposcopicFindings...... 186 ManagementofSILanddVIN.......................... 195
13.2.7 Biopsy .......................................... 188 SurgicalTherapyofSIL ............................... 195
13.2.8 ExfoliativeCytology.............................. 188 MedicalTherapyofSIL ............................... 196
13.2.9 HPVTesting..................................... 189 TherapeuticVaccination.............................. 197
TherapyofdVIN .................................... 197
13.3 VulvarCarcinogenesis............................ 189
13.4.2 PagetDisease.................................... 197
Diagnosis ......................................... 197
13.3.1 HPV–DependentCarcinogenesis.................. 189
Treatment......................................... 198
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Contents
13.4.3 IntraepithelialVulvarMelanocyticLesionsand 13.5.2 LichenSclerosus................................. 200
MalignantMelanoma............................ 199 13.5.3 LichenPlanus ................................... 202
13.5.4 Psoriasis ........................................ 204
13.5 Non-Neoplastic.................................. 200 13.5.5 LichenSimplex.................................. 204
13.5.6 VulvarEczema .................................. 205
13.5.1 EpithelialDisordersoftheVulva.................. 200
14 ColposcopyoftheVagina..................................................................................... 208
14.1 Histology ....................................... 208 14.5 HistologicTerminologyandClassification......... 211
14.2 VaginalCarcinogenesis........................... 208 14.6 HistomorphologyofVaginalSIL .................. 211
14.3 SquamousIntraepithelialLesions(SIL;formerly 14.7 ManagementofSIL.............................. 211
knownasVaginalIntraepithelialNeoplasia
orVAIN) ........................................ 208
14.7.1 LSILoftheVagina................................ 211
14.7.2 HSILoftheVagina............................... 211
14.4 DiagnosticMethodsforSIL....................... 208
14.7.3 SurgicalTherapy................................. 212
14.7.4 MedicalTherapy................................. 212
14.4.1 History ......................................... 208
14.7.5 OtherTreatmentModalities...................... 212
14.4.2 ColposcopyoftheVagina......................... 208
14.4.3 Cytology........................................ 210
14.8 VaginalMelanoma............................... 212
14.4.4 Biopsy.......................................... 210
14.4.5 Biomarkers...................................... 210
15 ColposcopyofthePerianalRegion........................................................................... 216
15.1 AnatomyandHistology.......................... 216 15.4.3 Biopsy.......................................... 218
15.4.4 Biomarkers...................................... 218
15.2 AnalCarcinogenesis ............................. 216
15.5 HistologicTerminologyandClassification......... 218
15.3 AnalIntraepithelialNeoplasia .................... 216
15.6 ManagementofAIN ............................. 218
15.4 DiagnosticMethodsforAIN...................... 217
15.6.1 SurgicalTherapy................................. 218
15.4.1 ColposcopyoftheAnus(Anoscopy)............... 217
15.6.2 MedicalTherapy................................. 220
15.4.2 Cytology........................................ 218
Index............................................................................................................ 221
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