During colposcopic examination of a woman with high-grade squamous intraepithelial lesion on cytology, the lesion shows coarse punctuation and mosaicism. Which single colposcopic feature, if present, is the strongest predictor of invasive cancer?

• A Dense acetowhite epithelium extending into the endocervix
• B Coarse mosaic pattern with wide intercapillary distance
• C Atypical vessels with irregular course, corkscrew and comma-shaped patterns ✓
• D Iodine-negative area after Schiller's test

Explanation

Atypical vessels arise when tumour tissue disrupts the normal stromal architecture and produces irregularly branched, corkscrew, comma-shaped or hairpin vessels that fail to conform to any orderly pattern. This is the most specific colposcopic sign of invasion. Coarse punctuation, coarse mosaicism and dense acetowhitening indicate high-grade CIN but can occur without invasion, and iodine negativity merely reflects glycogen-deficient epithelium seen even in benign immature metaplasia.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.