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.
