Colposcopic examination is mandatory for patients with suspected early invasive cancer based on cervical cytology and a grossly normal-appearing cervix. Colposcopic findings that suggest invasion are (i) abnormal blood vessels, (ii) irregular surface contour with loss of surface epithelium, and (iii) color tone change. Colposcopically directed biopsies may permit the diagnosis of frank invasion and thus avoid the need for diagnostic cone biopsy, allowing treatment to be administered without delay. If there is debate about the depth of invasion based on the cervical biopsies, and if the clinical stage may be upstaged to stage IA2 or IB1, the patient should undergo a conization. In the presence of a large cervical biopsy specimen showing invasion greater than 3 mm, or two biopsy specimens separated by 7 mm showing invasive cervical carcinoma, therapy should proceed without delay, and the patient could undergo radical surgery or radiation therapy.
Abnormal Blood Vessels Abnormal vessels may be looped, branched, or reticular. Abnormal looped vessels are the most common colposcopic finding and arise from the punctated and mosaic vessels present in cervical intraepithelial neoplasia (CIN). As the neoplastic growth process proceeds and the need for oxygen and nutrition increases, angiogenesis occurs as a result of tumor and local tissue production of vascular endothelial growth factor (VEGF),
Histologic Appearance of Invasion platelet-derived growth factor (PDGF), epidermal growth factor (EGF), and other cytokines, resulting in the proliferation of blood vessels and neovascularization. Punctate vessels push out over the surface of the epithelium in an erratic fashion, producing the looped, corkscrew, or J-shaped pattern of abnormal vessels characteristic of invasive disease. Abnormal blood vessels arise from the cervical stroma and are pushed to the surface as the underlying cancer invades. The normally branching cervical stromal vessels are best observed over nabothian cysts. In this area, the branches are generally at acute angles, with the caliber of vessels becoming smaller after branching, much like the arborization of a tree. The abnormal branching blood vessels seen with cancer tend to form obtuse or right angles, with the caliber sometimes enlarging after branching. Sharp turns, dilations, and luminal narrowing also characterize these vessels. The surface epithelium may be lost in these areas, leading to irregular surface contour and friability.
Abnormal reticular vessels represent the terminal capillaries of the cervical epithelium.
Normal capillaries are best seen in postmenopausal women with atrophic epithelium. When cancer involves this epithelium, the surface is eroded, and the capillary network is exposed. These vessels are very fine and short and appear as small comma-shaped vessels without an organized pattern. They are not specific to invasive cancer; atrophic cervicitis may also have this appearance.
Irregular Surface Contour Abnormal surface patterns are observed as tumor growth proceeds. The surface epithelium ulcerates as the cells lose intercellular cohesiveness secondary to loss of desmosomes. Irregular contour may occur as a result of papillary characteristics of the lesion. This finding can be confused with a benign HPV papillary growth on the cervix. For that reason, biopsies should be performed on all papillary cervical growths to avoid missing invasive disease.
Color Tone Color tone may change as a result of increasing vascularity, surface epithelial necrosis, and in some cases, production of keratin. The color tone is yellow-orange rather than the expected pink of intact squamous epithelium or the red of the endocervical epithelium.
Adenocarcinoma Adenocarcinoma of the cervix does not have a specific colposcopic appearance. All of the aforementioned blood vessels may be seen in these lesions. Because adenocarcinomas tend to develop within the endocervix, endocervical curettage is required as part of the colposcopic examination, and traditional screening methods are less reliable (10).