Biology and colposcopic features of human papillomavirus-associated cervical disease

Target biopsy and transformation zone ablation on excision is the mainstay of management for cervical lesions that can be adequately visualized. For the physician who does not progress beyond whimsical estimates of lesion prominence (which cannot differentiate minor- from major-grade lesions), the colposcope will never be more than a simple aid to the collection of directed biopsy specimens. Unfortunately, in situations in which the clinician's only option is passive response to the histopathology report, optimal management of the patient's disease will not occur. Indeed, the best prospect for diagnosing or prognosticating confusing disease patterns can sometimes be lost by blind precipitous intervention. Because the most prominent areas of colposcopic change do not necessarily coincide with the areas of greatest histologic abnormality, less experienced colposcopists may not be able to select the most abnormal sites for target biopsy. Peripheral areas of prominent aceto-whitening tend to be overinterpreted, and the subtle acetowhitening of high-grade cervical intraepithelial neoplasia near the canal tends to be easily overlooked. This problem is best solved by using colposcopic criteria that are based on critical analysis, rather than "pattern recognition." It is easy to derive the four proven colposcopic criteria, and they can be quickly compiled into an index that helps the clinician recognize lesion severity while he or she is performing the colposcopy. Of course, using the colposcopic index to infer approximate histologic findings does not eliminate the importance of biopsy. Skilled physicians will conscientiously follow the triage rules, including the need to collect carefully sited target biopsy specimens.