VIA

Cervical cancer is a preventable disease

Primary prevention:

Education to reduce high risk sexual behaviour

Measures to reduce/avoid exposure to HPV and other STIs

Secondary prevention:

Treatment of precancerous lesions before they progress to cervical cancer (implies practical screening test)

“Down staging”

A good screening method

Alternatives to Pap Smear

CERVIX

Types of visual inspection tests: Visual inspection with acetic acid (VIA) can be done with the naked

eye (also called cervicoscopy or direct visual inspection [DVI), or with low magnification (also called gynoscopy, aided VI, or VIAM).

Visual inspection with Lugol’s iodine (VILI), also known as Schiller’s test, uses Lugol’s iodine instead of acetic acid.

Colposcopy / Digital Colposcopy

Cervicography

Automated pap smears

Molecular (HPV/DNA) tests

Naked eye (or low power magnification) inspection of cervix to detect acetowhite abnormalities after applying dilute (3-5%) acetic acid

Cervix with ACETO-WHITE lesionNegative

“VIA ..represents a proven, simple means of identifying cervical intraepithelial neoplasia in developing countries.”

Commentary: P. Blumenthal. Detection of cervical intraepithelial neoplasia in developing countries. The Lancet March 13, 1999

Unmagnified Visual inspection of the cervix to detect abnormalities after applying acetic acid

Acetic acid is used to enhance and “mark” the acetowhite change of a precancerous lesion or actual cancer

Sensitivity and specificity of VIA - 70-92%

Positive Predictive Value - 15-20%

The screening method before advent of Pap Smear

Due to expense & inconvenience VIA can be adjunct to cytology patients in need of colposcopy could be identified more effectively and efficiently

Cheaper , Easier & Effective means to identify a “normal” transformation zone or detecting “precancerous” lesions of the cervix

Studies conducted to compare the efficacy of “naked eye” inspection & “Colposcopy magnification” as a primary screening method

VIA IMAGES

NORMAL CERVIX Cervix with ACETO-WHITE lesion

VIA Category Clinical Findings

Test-negative No acetowhite lesions or faint acetowhite lesions; polyp, cervicitis, inflammation, Nabothian cysts.

Test-positive Sharp, distinct, well-defined, dense (opaque/dull or oyster white) acetowhite areas—with or without raised margins touching the squamocolumnar junction (SCJ); leukoplakia and warts.

Suspicious for cancer Clinically visible ulcerative, cauliflower-like growth or ulcer; oozing and/or bleeding on touch.

World Health Organization (WHO) supported a study in India between 1988 and 1991 in which unmagnified visual inspection with acetic acid washing was evaluated as a "down staging" technique.

VIA was found to be effective in identifying women with cancer at an earlier, more treatable stage.

SQJ

Squamous epithelium is smooth and pink

Columnar epithelium appears red

There are no aceto white changes

Squamocolumnar Junction with Squamous Metaplasia

Normal Junction

Minimal white ring at junction

Squamous Metaplasia

normal variant

Categories for VIA tests results:

Suspicious for cancer

Photo source: PAHO, Jose Jeronimo

Aceto-white area far from squamocolumnar junction (SCJ) and not touching it is insignificant.

Aceto-white area adjacent to SCJ is significant.

Negative Positive

Photo source: JHPIEGO

"VIA is a safe, simple and effective adjunct to the Papanicolaou smear for cervical cancer screening” and can be helpful in reducing referrals for colposcopy without compromising quality of care

Requirements: VIA can be performed easily in any clinical setting

Examination table

Good light source / torch

Sterile gloves

Cusco’s speculum

Cotton swabs

Acetic acid in dilution 3-5 %

VIA is not performed: During menses

During treatment with vaginal pessary

When suspicious mass is seen, acetic acid application is avoided & patient referred for further oncology management

Procedure: Informed consent

Relevant OBG history

Reassure pt – painless procedure

Ensure pt is fully relaxed

Modified lithotomy position

Observed

Vaginal discharge

Ext genitalia

Introduce speculum

Adjust light Source

Under adequate light & under all aseptic precautions Cusco’s speculum is inserted to visualise the cervix clearly

Fix the cusco’s so that cervix is stabilized

Any excess mucous or discharge is cleaned with sterile swab using normal saline

Cervix is Inspected & looked at for any abnormality

Inspection of cervix done & findings described as

Hypertrophy

Redness or congestion

Irregular surface

Distortion

Simple erosions (do not bleed on touch)

Cervical polyps (with smooth surface)

Abnormal discharge: foul smelling, dirty / greenish, cheesy white, blood stained

Nabothian follicles

After noting the abnormalities, it is washed liberally with diluted 5 % acetic acid using a cotton swab on a sponge holding forceps or sterile stick with cotton

5 % acetic acid = 5ml glacial acetic acid + 95ml distilled water

Wait for 1 whole minute

Inspect cervix for aceto white areas

Normal VIA Normal appearing cervix

No aceto-white changes seen

Minimal translucent or very pale white epithelium at SCJ is normal and may indicate squamous metaplasia

Record result

No further testing needed

Acetic Acid – Aceto-white Areas Acetic acid

Dissolves mucus

Induces intracellular dehydration

Causes coagulation of protein

As a result cells with increased

Nuclear / Cytoplasmic ratio ratio

Nuclear density

Chromosomal aneuploidy

Become opaque – aceto-white area – test positive

Acetic Acid Helps locate Squamocolumnar junction

Identifies the lesion & its limits

Decide whether the lesion is CIN

Determine whether invasion is possible

Select a site or sites for biopsy if appropriate

Result

After application - Note Aceto–white areas

Margins

Surface

Gland openings

Mosaic & punctations

Abnormal vessels

Interpretation of “Aceto-white” Following epithelial changes become aceto-white

Healing or regenerating epithelium

Congenital transformation zone

Inflammation

Immature squamous metaplasia

HPV infection

CIN / CGIN

Adenocarcinoma

Invasive squamous cell carcinoma

Reporting in VIA Naked eye Visualisation of cervix is described as

Normal

Appearance-smooth, pink

Discharge-clear mucoid

External OS

In postmenopausal-atrophic

Abnormal

Hypertrophy

Redness or congestion

Irregular surface

Distortion

Simple erosions (do not bleed on touch)

Cervical polyps (with smooth surface)

Abnormal discharge: foul smelling, dirty / greenish, cheesy white, blood stained

Nabothian follicles

Interpretation of “ABNORMAL” Infection

Ectopy

Benign tumour

Suspicious Of Malignancy:

Erosion that bleeds on touch or friable

Growth, with an irregular surface or friable

Cervical Dysplasia Opaque white epithelium

Occurs at SCJ

Cervical Dysplasia Aceto white epithelium surrounds cervical OS

Internal margins of more densely white epithelium

Cervical Dysplasia Diffuse aceto white changes

Most prominent at 6 & 10’o clock

Severe Dysplasia Marked aceto-white epithelium

Abnormal raised contour

Carcinoma in Situ

Features of early cancer lesions Oyster shell white

Rolled edges

Abnormal vessels

Friable

Uneven surface

Invasive Cancer Raised lesion

Rolled edges

Raised white epithelium

Abnormal vessels

Important to biopsy

VIA test performance (n=7):

* Weighted median and mean based on study sample size

Source: Adapted from Gaffikin, 2003

Sensitivity Specificity

Minimum 65% 64%

Maximum 96% 98%

Median* 84% 82%

Mean* 81% 83%

Management – VIA Positive If infection is suspected /present

Take a swab and send for analysis

Treat the patient accordingly

Re-examine after six weeks

If no signs of infection:

Perform Pap-smear and / or Colposcopy

Pap-smear / Colposcopy negative: re call for follow-up in 6-12 months

Pap-smear / Colposcopy positive: call the patient for appropriate treatment

Limitations of VIA: Moderate specificity results in resources being spent on

unnecessary treatment of women who are free of precancerous lesions in a single-visit approach

No conclusive evidence regarding the health or cost implications of over-treatment, particularly in areas with high HIV prevalence

There is a need for developing standard training methods and quality assurance measures

Likely to be less accurate among post-menopausal women

Rater dependent

VIA Advantages Non invasive, quick

Easy to perform

Can be performed by all levels of health workers

No sophisticated gadgets required

No special skills / training required

Reporting is simple, results available immediately

Can be very useful for mass screening across the entire length & breadth of our country

Requires only one visit

Excellent sensitivity

Thank You