Via

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Via

  1. 1. VIA
  2. 2. <ul><li>Cervical cancer is a preventable disease </li></ul><ul><li>Primary prevention: </li></ul><ul><ul><li>Education to reduce high risk sexual behaviour </li></ul></ul><ul><ul><li>Measures to reduce/avoid exposure to HPV and other STIs </li></ul></ul><ul><li>Secondary prevention: </li></ul><ul><ul><li>Treatment of precancerous lesions before they progress to cervical cancer (implies practical screening test) </li></ul></ul>
  3. 3. <ul><li>“ Down staging” </li></ul><ul><li>A good screening method </li></ul><ul><li>Alternatives to Pap Smear </li></ul>
  4. 4. CERVIX
  5. 5. Types of visual inspection tests: <ul><li>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). </li></ul><ul><li>Visual inspection with Lugol’s iodine (VILI), also known as Schiller’s test, uses Lugol’s iodine instead of acetic acid. </li></ul>
  6. 6. <ul><li>Colposcopy / Digital Colposcopy </li></ul><ul><li>Cervicography </li></ul><ul><li>Automated pap smears </li></ul><ul><li>Molecular (HPV/DNA) tests </li></ul>
  7. 7. <ul><li>Naked eye (or low power magnification) inspection of cervix to detect acetowhite abnormalities after applying dilute (3-5%) acetic acid </li></ul>Cervix with ACETO-WHITE lesion Negative
  8. 8. <ul><li>“ VIA ..represents a proven, simple means of identifying cervical intraepithelial neoplasia in developing countries.” </li></ul>Commentary: P. Blumenthal. Detection of cervical intraepithelial neoplasia in developing countries. The Lancet March 13, 1999
  9. 9. <ul><li>Unmagnified Visual inspection of the cervix to detect abnormalities after applying acetic acid </li></ul><ul><li>Acetic acid is used to enhance and “mark” the acetowhite change of a precancerous lesion or actual cancer </li></ul><ul><li>Sensitivity and specificity of VIA - 70-92% </li></ul><ul><li>Positive Predictive Value - 15-20% </li></ul>
  10. 10. <ul><li>The screening method before advent of Pap Smear </li></ul><ul><li>Due to expense & inconvenience VIA can be adjunct to cytology patients in need of colposcopy could be identified more effectively and efficiently </li></ul><ul><li>Cheaper , Easier & Effective means to identify a “normal” transformation zone or detecting “precancerous” lesions of the cervix </li></ul><ul><li>Studies conducted to compare the efficacy of “naked eye” inspection & “Colposcopy magnification” as a primary screening method </li></ul>
  11. 11. VIA IMAGES NORMAL CERVIX Cervix with ACETO-WHITE lesion
  12. 12. VIA Category Clinical Findings <ul><ul><li>Test-negative </li></ul></ul><ul><ul><li>No acetowhite lesions or faint acetowhite lesions; polyp, cervicitis, inflammation, Nabothian cysts. </li></ul></ul><ul><ul><li>Test-positive </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Suspicious for cancer </li></ul></ul><ul><ul><li>Clinically visible ulcerative, cauliflower-like growth or ulcer; oozing and/or bleeding on touch. </li></ul></ul>
  13. 13. <ul><li>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 &quot;down staging&quot; technique. </li></ul><ul><ul><li>VIA was found to be effective in identifying women with cancer at an earlier, more treatable stage. </li></ul></ul>
  14. 14. SQJ <ul><li>Squamous epithelium is smooth and pink </li></ul><ul><li>Columnar epithelium appears red </li></ul><ul><li>There are no aceto white changes </li></ul>
  15. 15. Squamocolumnar Junction with Squamous Metaplasia <ul><li>Normal Junction </li></ul><ul><li>Minimal white ring at junction </li></ul><ul><li>Squamous Metaplasia </li></ul><ul><ul><li>normal variant </li></ul></ul>
  16. 16. Categories for VIA tests results: Suspicious for cancer Photo source: PAHO, Jose Jeronimo
  17. 17. <ul><li>Aceto-white area far from squamocolumnar junction (SCJ) and not touching it is insignificant. </li></ul><ul><li>Aceto-white area adjacent to SCJ is significant. </li></ul>Negative Positive Photo source: JHPIEGO
  18. 18. <ul><li>&quot;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 </li></ul>
  19. 19. Requirements: <ul><li>VIA can be performed easily in any clinical setting </li></ul><ul><li>Examination table </li></ul><ul><li>Good light source / torch </li></ul><ul><li>Sterile gloves </li></ul><ul><li>Cusco’s speculum </li></ul><ul><li>Cotton swabs </li></ul><ul><li>Acetic acid in dilution 3-5 % </li></ul>
  20. 20. VIA is not performed: <ul><li>During menses </li></ul><ul><li>During treatment with vaginal pessary </li></ul><ul><li>When suspicious mass is seen, acetic acid application is avoided & patient referred for further oncology management </li></ul>
  21. 21. Procedure: <ul><li>Informed consent </li></ul><ul><li>Relevant OBG history </li></ul><ul><li>Reassure pt – painless procedure </li></ul><ul><li>Ensure pt is fully relaxed </li></ul><ul><li>Modified lithotomy position </li></ul><ul><li>Observed </li></ul><ul><ul><li>Vaginal discharge </li></ul></ul><ul><ul><li>Ext genitalia </li></ul></ul><ul><li>Introduce speculum </li></ul><ul><li>Adjust light Source </li></ul>
  22. 22. <ul><li>Under adequate light & under all aseptic precautions Cusco’s speculum is inserted to visualise the cervix clearly </li></ul><ul><li>Fix the cusco’s so that cervix is stabilized </li></ul><ul><li>Any excess mucous or discharge is cleaned with sterile swab using normal saline </li></ul><ul><li>Cervix is Inspected & looked at for any abnormality </li></ul>
  23. 23. <ul><li>Inspection of cervix done & findings described as </li></ul><ul><ul><li>Hypertrophy </li></ul></ul><ul><ul><li>Redness or congestion </li></ul></ul><ul><ul><li>Irregular surface </li></ul></ul><ul><ul><li>Distortion </li></ul></ul><ul><ul><li>Simple erosions (do not bleed on touch) </li></ul></ul><ul><ul><li>Cervical polyps (with smooth surface) </li></ul></ul><ul><ul><li>Abnormal discharge: foul smelling, dirty / greenish, cheesy white, blood stained </li></ul></ul><ul><ul><li>Nabothian follicles </li></ul></ul>
  24. 24. <ul><li>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 </li></ul><ul><li>5 % acetic acid = 5ml glacial acetic acid + 95ml distilled water </li></ul><ul><li>Wait for 1 whole minute </li></ul><ul><li>Inspect cervix for aceto white areas </li></ul>
  25. 25. Normal VIA <ul><li>Normal appearing cervix </li></ul><ul><li>No aceto-white changes seen </li></ul><ul><li>Minimal translucent or very pale white epithelium at SCJ is normal and may indicate squamous metaplasia </li></ul><ul><li>Record result </li></ul><ul><li>No further testing needed </li></ul>
  26. 26. Acetic Acid – Aceto-white Areas <ul><li>Acetic acid </li></ul><ul><ul><li>Dissolves mucus </li></ul></ul><ul><ul><li>Induces intracellular dehydration </li></ul></ul><ul><ul><li>Causes coagulation of protein </li></ul></ul><ul><li>As a result cells with increased </li></ul><ul><ul><li>Nuclear / Cytoplasmic ratio ratio </li></ul></ul><ul><ul><li>Nuclear density </li></ul></ul><ul><ul><li>Chromosomal aneuploidy </li></ul></ul><ul><li>Become opaque – aceto-white area – test positive </li></ul>
  27. 27. Acetic Acid <ul><li>Helps locate Squamocolumnar junction </li></ul><ul><li>Identifies the lesion & its limits </li></ul><ul><li>Decide whether the lesion is CIN </li></ul><ul><li>Determine whether invasion is possible </li></ul><ul><li>Select a site or sites for biopsy if appropriate </li></ul>
  28. 28. Result
  29. 29. After application - Note <ul><li>Aceto–white areas </li></ul><ul><li>Margins </li></ul><ul><li>Surface </li></ul><ul><li>Gland openings </li></ul><ul><li>Mosaic & punctations </li></ul><ul><li>Abnormal vessels </li></ul>
  30. 30. Interpretation of “Aceto-white” <ul><li>Following epithelial changes become aceto-white </li></ul><ul><ul><li>Healing or regenerating epithelium </li></ul></ul><ul><ul><li>Congenital transformation zone </li></ul></ul><ul><ul><li>Inflammation </li></ul></ul><ul><ul><li>Immature squamous metaplasia </li></ul></ul><ul><ul><li>HPV infection </li></ul></ul><ul><ul><li>CIN / CGIN </li></ul></ul><ul><ul><li>Adenocarcinoma </li></ul></ul><ul><ul><li>Invasive squamous cell carcinoma </li></ul></ul>
  31. 31. Reporting in VIA <ul><li>Naked eye Visualisation of cervix is described as </li></ul><ul><ul><li>Normal </li></ul></ul><ul><ul><li>Appearance-smooth, pink </li></ul></ul><ul><ul><li>Discharge-clear mucoid </li></ul></ul><ul><ul><li>External OS </li></ul></ul><ul><ul><li>In postmenopausal-atrophic </li></ul></ul>
  32. 32. <ul><li>Abnormal </li></ul><ul><ul><li>Hypertrophy </li></ul></ul><ul><ul><li>Redness or congestion </li></ul></ul><ul><ul><li>Irregular surface </li></ul></ul><ul><ul><li>Distortion </li></ul></ul><ul><ul><li>Simple erosions (do not bleed on touch) </li></ul></ul><ul><ul><li>Cervical polyps (with smooth surface) </li></ul></ul><ul><ul><li>Abnormal discharge: foul smelling, dirty / greenish, cheesy white, blood stained </li></ul></ul><ul><ul><li>Nabothian follicles </li></ul></ul>
  33. 33. Interpretation of “ABNORMAL” <ul><li>Infection </li></ul><ul><li>Ectopy </li></ul><ul><li>Benign tumour </li></ul><ul><li>Suspicious Of Malignancy: </li></ul><ul><ul><li>Erosion that bleeds on touch or friable </li></ul></ul><ul><ul><li>Growth, with an irregular surface or friable </li></ul></ul>
  34. 34. Cervical Dysplasia <ul><li>Opaque white epithelium </li></ul><ul><li>Occurs at SCJ </li></ul>
  35. 35. Cervical Dysplasia <ul><li>Aceto white epithelium surrounds cervical OS </li></ul><ul><li>Internal margins of more densely white epithelium </li></ul>
  36. 36. Cervical Dysplasia <ul><li>Diffuse aceto white changes </li></ul><ul><li>Most prominent at 6 & 10’o clock </li></ul>
  37. 37. Severe Dysplasia <ul><li>Marked aceto-white epithelium </li></ul><ul><li>Abnormal raised contour </li></ul>
  38. 38. Carcinoma in Situ
  39. 39. Features of early cancer lesions <ul><li>Oyster shell white </li></ul><ul><li>Rolled edges </li></ul><ul><li>Abnormal vessels </li></ul><ul><li>Friable </li></ul><ul><li>Uneven surface </li></ul>
  40. 41. Invasive Cancer <ul><li>Raised lesion </li></ul><ul><li>Rolled edges </li></ul><ul><li>Raised white epithelium </li></ul><ul><li>Abnormal vessels </li></ul><ul><li>Important to biopsy </li></ul>
  41. 42. 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%
  42. 43. Management – VIA Positive <ul><li>If infection is suspected /present </li></ul><ul><ul><li>Take a swab and send for analysis </li></ul></ul><ul><ul><li>Treat the patient accordingly </li></ul></ul><ul><ul><li>Re-examine after six weeks </li></ul></ul><ul><li>If no signs of infection: </li></ul><ul><ul><li>Perform Pap-smear and / or Colposcopy </li></ul></ul><ul><ul><li>Pap-smear / Colposcopy negative: re call for follow-up in 6-12 months </li></ul></ul><ul><ul><li>Pap-smear / Colposcopy positive: call the patient for appropriate treatment </li></ul></ul>
  43. 44. Limitations of VIA: <ul><li>Moderate specificity results in resources being spent on unnecessary treatment of women who are free of precancerous lesions in a single-visit approach </li></ul><ul><li>No conclusive evidence regarding the health or cost implications of over-treatment, particularly in areas with high HIV prevalence </li></ul><ul><li>There is a need for developing standard training methods and quality assurance measures </li></ul><ul><li>Likely to be less accurate among post-menopausal women </li></ul><ul><li>Rater dependent </li></ul>
  44. 45. VIA Advantages <ul><li>Non invasive, quick </li></ul><ul><li>Easy to perform </li></ul><ul><li>Can be performed by all levels of health workers </li></ul><ul><li>No sophisticated gadgets required </li></ul><ul><li>No special skills / training required </li></ul><ul><li>Reporting is simple, results available immediately </li></ul><ul><li>Can be very useful for mass screening across the entire length & breadth of our country </li></ul><ul><li>Requires only one visit </li></ul><ul><li>Excellent sensitivity </li></ul>
  45. 46. Thank You

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