1. Introduction to colposcopic grading systems
2. Coppelson Grading System
3. Reid Colposcopic Index

Introduction to colposcopic grading systems

Several colposcopic grading systems have been developed to quantify the examiner's impression regarding the severity of a lesion. All are based on the fact that the more abnormal the colposcopic appearance, the greater the probable histologic abnormality.

The nature of the abnormal colposcopic lesion depends on the degree of whiteness of the epithelium, the rapidity with which the whiteness occurs, the nature of the surface contour (whether flat or irregular), the fineness or coarseness of the caliber of the punctate vessels and their intercapillary distances, the irregularity and pleomorphism of the mosaic pattern, and the presence or absence of atypical blood vessels.

Helpful distinguishing features:

1. Indicators of minor changes

 
• Acetowhite epithelium
• Fine mosaicism
• Fine punctation
• Thin leukoplakia

 
2. Indicators of major changes

 
• Dense acetowhite epithelium
• Coarse mosaicism
• Coarse punctation
• Thick leukoplakia
• Atypical vessels
• Erosions

(Carreiro, Burghardt )

Coppelson Grading System

• Color tone judged normal or slightly whiter than normal
• Smooth surface, flat lesion
• Border of lesion diffuse
• White appearance of lesion takes a moderate time to develop, stays white for a short time, and disappears rapidly
• If any vascular changes are present, they are typically fine punctation or mosaicism or both, without increase in intercapillary distances
• Could represent human papilloma virus (HPV) disease, pregnancy, metaplasia, inflammation, or regeneration and repair

Grade II

• More intense whiteness
• Appears in normal time span, tends to stay white for several minutes, disappears with average speed
• Sharp border dividing it from surrounding normal epithelium
• Usually some vascular pattern present in form of irregular punctation or mosaicism, with slight increase in intercapillary distance
• May represent mild to moderate intraepithelial neoplastic changes or HPV infection

Grade III

• Very coarse white epithelium
• Clear-cut elevation of surface pattern
• Border sharp and distinct
• Irregular surface contour
• Marked rapidity and intensity of epithelial whiteness; lesion stays white longer and fades more slowly
• Punctation or mosaicism present—intercapillary distances usually increased
• Application of acetic acid causes epithelium to roll up like wet cigarette paper, because of loss of intercellular bonds
• Possible loss of surface epithelium and ulceration
• Atypical blood vessels may be bizarre in invasive lesions
• May represent severe intraepithelial neoplastic changes or microinvasive or invasive cervical disease

Reid Colposcopic Index

An overall improvment in sensitivity (increasing the detection rate) and specificity (reducing the overestimation rate) can be achieved by applying a weighted scoring system such as described by Reid and colleagues in 1985.

Assign from 0 to 2 points to each colposcopic sign:

• 0-2 : benign HPV infection or cervical intraepithelial neoplasia (CIN) 1
• 3-5 : CIN 1 or CIN 2
• 6-8 : CIN 2 or CIN 3

Colposcopic grading in general correlates well with the underlying histology. Again, the more pronounced the colposcopic findings, the greater the anticipated histologic abnormality. A colposcopic grade I lesion correlates with a histologic grade I lesion (such as mild dysplasia) (Burke, Wright).

It is possible for an experienced colposcopist to differentiate among the various forms of intraepithelial neoplasia and early invasive cancer on the basis of the colposcopic findings. A final diagnosis is reached by using the results of the cytologic examination, colposcopy, and colposcopic-directed biopsies and the evaluation of the endocervical canal.