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Visual inspection of cervix


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Methods of inspection of the cervix

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Visual inspection of cervix

  1. 1. Visual Inspection of the cervix Aboubakr Elnashar Benha university Hospital Aboubakr Elnashar
  2. 2. CIN (%) No StudyUniversityYearAuthor 1.074458HospitalCairo1987Hammad et al 3.15453CommunitySuez canal2007Abd El All et al 3.125522HospitalAin Shams2004- 2010 Shalakany (2012) 7.73600HospitalMinia2014Sanad et al Prevalence of CIN in Egypt (Elnashar, 2014) invasive cx ca in Egypt: 0.04% (AbdelAll et al, 2007) Aboubakr Elnashar
  3. 3. Cervical cancer is a preventable disease 1. Characteristic natural course with a slow progression through a premalignant stage. 2. Premalignant stage can be detected by noninvasive means (Pap smear, HPV DNA & VIA). 3. An effective treatment for the premalignant lesions Aboubakr Elnashar
  4. 4. Screening in developing countries Difference between developing & developed countries I. Higher incidence: 80% II. Higher mortality: 90% III. Different risk factors IV. Poor financial, human & technical resources V. Inadequate follow up Screening as used in the developed world is inappropriate in developing countries Aboubakr Elnashar
  5. 5. Pap smear: limitations 1. Requires: microscopes, laboratory, trained technicians, pathologists, transport of specimens, reporting, and supplies. 2. Immediate results are not possible: time consuming 3. Only 50% of abnormal findings (CIN and cancers) are detected—relies on periodic re-scanning. Sensitivity 60-70% Aboubakr Elnashar
  6. 6. 4. Lesions may be missed if: Not exfoliating. There is a barrier to exfoliation. Cells are not sampled properly from SCJ and TZ Abnormal cells are not transferred to the slide. Slide cannot be read effectively {obscured by blood or pus}. The technician misses the precancerous cells. Aboubakr Elnashar
  7. 7.  In developing countries: Not appropriate or adequate Not practical as a nationall screening method:  In developed countries: ongoing supervision refresher training continued supplies Aboubakr Elnashar
  8. 8. Comparison of Screening Methods 1. Sensitivity and specificity Method Sensitivity (%) Specificity (%) Cytology 45-85 80-98 VIA 60-90 66-96 HPV DNA 65-95 70-96 NEJM Nov17,2005 Aboubakr Elnashar
  9. 9. 2. Screening Costs Aboubakr Elnashar
  10. 10. Visual Inspection Techniques 1. Unaided Visual Inspection 2. Visual inspection with acetic acid (VIA) 3. Visual inspection with acetic acid and magnification (VIAM) 4. Visual inspection with Lugol’s Iodine (VILI) Aboubakr Elnashar
  11. 11. 1. Unaided Visual Inspection Aboubakr Elnashar
  12. 12. Normal Smooth, pink Clear mucoid secretion Central hole-'external os‘: Nulliparours-round Multiparous-slit or criciate Cervix in postmenopausal women is atrophic Abnormal Clinical interpretation: Can be; Infection Ectopy (erythroplasia) Benign tumour 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 Prolapsed uterus Suspicious of Malignancy Erosion that bleeds on touch or friable Growth, with an irregular surface or friable Aboubakr Elnashar
  13. 13. Normal cervix No medical intervention required. Call for re-screening, if 35 years or above, according to established policy. Aboubakr Elnashar
  14. 14. Abnormal cervix Take swab for culture and send to laboratory (if facilities available). Refer the patient Aboubakr Elnashar
  15. 15. Suspicious of Malignancy Aboubakr Elnashar
  16. 16. Good for Clinical Down staging Misses Precancerous lesions Dx at stage III & IV: ↓from 85% to 55% Dx at stage I & II: ↑ from 15% to 45% 60% of early disease could be identified 11% were false positive Only 15 of pre-cancerous lesions could be detected (Singh et al 1992) Aboubakr Elnashar
  17. 17. 2. Visual inspection with acetic acid (VIA) Aboubakr Elnashar
  18. 18. Pathophysiological basis of VIA  Application of 5% acetic: 1. Coagulates the proteins of the nucleus & cytoplasm :makes the protein opaque & white. 2. Dehydrates the cells: cytoplasmic volume is reduced & the reflection is increased.  Duration: Variable Appears: after 20 sec & Disappears: after 2 min. Aboubakr Elnashar
  19. 19. Effects of a.a.: 1.on the mucous: It coagulates mucous which can then easily removed (mucolytic). 2.on the mature glycogen-producing epithelium: no effect {a.a. does not penetrate below the outer one-third of the epithelium. The cells have very small nuclei & a large amount of glycogen (not protein)} 3.on the col. epi.: swell & slightly opaque particularly if the beginning signs of metaplasia are present: makes its recognition easier. Aboubakr Elnashar
  20. 20. 4.on the immature metaplastic epi.: gray & filmy. {very thin & have large nuclei}: 5.on dysplastic cells: white and opaue {contain large nuclei & large amounts of chromatin (protein)}: 6.on gland openings of the TZ.: better outlined. Aboubakr Elnashar
  21. 21.  When to perform? Anytime during the menstrual cycle Not during menstruation Not using intravaginal medication During pregnancy, at a postpartum examination Intended for ages 20 to 50 Aboubakr Elnashar
  22. 22.  Prior to application of acetic acid 1. Inspect the external genitalia: papules, vesicles, ulcerations, condylomata, discharge, redness, swelling, excoriation. 2. Inspect the cervix: unaided  Normal  Abnormal:  Suspicious 3. Use a dry cotton swab to wipe away any discharge, blood, or mucus from the cervix. Aboubakr Elnashar
  23. 23. Procedure 1. Wash the cervix with a 3%–5% acetic acid solution. 2. Carefully inspect the cervix, especially the TZ, with the naked eye. Aboubakr Elnashar
  24. 24. Categories Category Clinical Findings Negative No acetowhite lesions or faint acetowhite lesions; polyp, cervicitis, inflammation, Nabothian cysts. Positive Sharp, distinct, well-defined, dense (opaque/dull or oyster white) acetowhite with or without raised margins touching SCJ; leukoplakia and warts. Suspicious for cancer ulcerative, cauliflower-like growth or ulcer; oozing and/or bleeding on touch. Aboubakr Elnashar
  25. 25. Reporting of lesions 1. VIA negative  No significant acetowhite lesions.  The most challenging category in VIA  Acetowhite: 1. Nabothian cysts and polyps 2. Faint line at SCJ 3. Away from SCJ 4. Streak like 5. Dotlike areas on the columnar epithelium 6. Diffuse with columnar epithelium staining Aboubakr Elnashar
  26. 26. Aboubakr Elnashar
  27. 27.  Negative: Acetowhite area far from SCJ and not touching it is insignificant. Aboubakr Elnashar
  28. 28. VIA negative. The mild acetowhite staining in a linear pattern at the lower edge of SCJ and around the two glandular crypt openings is the typical appearance of immature metaplasia Aboubakr Elnashar
  29. 29. VIA negative. The button-like, acetowhite area with ill-defined margins is due to a Nabothian cyst. Other ill-defined acetowhite areas are due to squamous metaplasia. Aboubakr Elnashar
  30. 30. Nabothian cysts appear as spot or button-like areas after the application of a a. There is dot-like acetowhitening in the columnar epithelium in the anterior lip. The SCJ is fully visible. Negative Aboubakr Elnashar
  31. 31. Negative: The cervix is unhealthy, inflamed with ulceration, necrosis, bleeding and inflammatory exudate. ill-defined, diffuse, pinkish-white acetowhitening with indefinite margins blending with the rest of epithelium (arrows). Aboubakr Elnashar
  32. 32. 2. VIA-Positive  Acetowhite areas: Sharp, distinct, well-defined, dense (opaque/dull or oyster white), with or without raised margins close SCJ  identify: 1. Extension 2. Intensity of whiteness 3. Borders and demarcations 4. Size 5. Location Aboubakr Elnashar
  33. 33. Leukoplakia (hyperkeratosis) well demarcated white area (before the application of aa), due to keratosis, visible to the naked eye. Usually leukoplakia is idiopathic, but it may also be caused by chronic foreign body irritation, HPV infection, or squamous neoplasia. Condylomata found on the cervix, associated with HPV types 6 and 11. Condylomata are usually obvious to the naked eye (before aa ). Aboubakr Elnashar
  34. 34.  Positive Acetowhite area adjacent to SCJ is significant. Aboubakr Elnashar
  35. 35. VIA-positive well-defined, opaque acetowhite area, with regular margins, in the anterior lip, adjacent to SCJ, which is fully visible. satellite lesions in the lower lip. well-defined, opaque acetowhite area, with regular margins, in the anterior lip, adjacent to SCJ, which is fully visible. ill-defined white area in the lower lip. The lesion is extending into cervical canal.Aboubakr Elnashar
  36. 36. 3. Suspicious for cancer  Dull, opaque, dense acetowhite area, with raised and rolled-out margins, irregular surface and bleeding on touch in the posterior lip. The lesion is extending into the cervical canal. The bleeding obliterates acetowhitening.  proliferative growth with dense acetowhitening and bleeding Aboubakr Elnashar
  37. 37. VIA Performance: Sensitivity Specificity Minimum 65% 64% Maximum 96% 98% Median 84% 82% Source: Adapted from Gaffikin, 2003 Sensitivity Specificity Minimum 37% 86% Maximum 84% 100% Median 51% 89% Pap test performance: Aboubakr Elnashar
  38. 38. Strengths of VIA:  Simple, easy-to-learn, minimally dependent upon infrastructure.  Low start-up and sustaining costs. Requires only acetic acid, a speculum, and a light source (flashlight).  Can be performed by nurses and midwives.  Results are available immediately.  Requires only one visit.  Accuracy is comparable to Pap smear.  Can be followed by VILI. Aboubakr Elnashar
  39. 39. Limitations:  False-positives may overload the referral system: unnecessary tt of women who are free of precancerous lesions in a single-visit approach.  Standard training and quality assurance measures are required  Less accurate among post-menopausal women.  Rater dependent. Aboubakr Elnashar
  40. 40. Management:  VIA: Negative:  follow-up after 3-5 years acc to the decided policy.  VIA test: positive  Offer to treat immediately. or  Refer for colposcopy and biopsy and then offer tt if a precancerous lesion is confirmed.  VIA : suspicious for cancer: Refer for colposcopy and biopsy and further management Aboubakr Elnashar
  41. 41. Visual Inspection with Acetic Acid Using Magnification (VIAM) Aboubakr Elnashar
  42. 42. Visual Inspection with Acetic Acid Using Magnification (VIAM)  visualization of cervix after application of aa using low power magnification (2.5x to 4x) Magnascope (4X) Aboubakr Elnashar
  43. 43. 4. Visual inspection with Lugol’s iodine (VILI) Aboubakr Elnashar
  44. 44. Pathophysiological basis of VILI Glycogen rich tissues: mahogany brown or black Glycogen rich: Squamous epithelium Squamous metaplasia (mature) Glycogen poor tissues do not take up iodine: mustard-yellow or saffron-color. Glycogen poor: Columnar epithelium CIN invasive cancer Laukoplakia (hyperkeratosis) Condylomata Lugol’s iodine is glycophillic Aboubakr Elnashar
  45. 45. Procedure:  Vaginal speculum exam  Apply Lugol’s iodine solution to the cervix.  Viewing the cervix with the naked eye to identify color changes on the cervix.  The 5% solution consists of 5% (wt/v) iodine and 10% (wt/v) potassium iodide(KI) mixed in distilled water and has a total iodine content of 126.5 mg/mL. Potassium iodide renders the elementary iodine soluble in water through the formation of the triiodide ion.  It is not to be confused with tincture of iodine solutions, which consist of elemental iodine, and iodide salts dissolved in water and alcohol. Lugol's solution contains no alcohol.  Schiller iodine composition is same as lugol s iodine, latter been more concentrated Aboubakr Elnashar
  46. 46. Procedure involving VIA and VILI 1. Soak a clean swab in 5% aa and apply to the cervix liberally. 2. Wait 1 minute. 3. Focus on TZ. 4. Note any acetowhite lesions: location, extension, intensity of whiteness, borders. 5. Soak a clean swab in Lugol’s iodine solution and apply to cervix liberally 6. Note the uptake in the areas of concern noted after acetic acid. Aboubakr Elnashar
  47. 47. Categories for VILI test results: Category Clinical Findings Negative Squamous epithelium turns brown columnar epithelium does not change color; or irregular, partial or non-iodine uptake areas. Positive Well-defined, bright yellow iodine non- uptake areas touching SCJ or close to the os if SCJ is not seen. Suspicious for cancer ulcerative, cauliflower- like growth or ulcer; oozing and/or bleeding on touch. Aboubakr Elnashar
  48. 48. Reporting of lesions VILI: test-negative  The squamous epithelium turns brown  columnar epithelium does not change color.  scattered and irregular, partial or non-iodine uptake areas associated with immature squamous metaplasia or inflammation. Aboubakr Elnashar
  49. 49.  VILI: test-positive  Well-defined, bright yellow iodine non-uptake areas touching the SCJ Aboubakr Elnashar
  50. 50. VILI: Suspicious for cancer  Clinically visible ulcerative, cauliflower- like growth or ulcer; oozing and/or bleeding on touch. Aboubakr Elnashar
  51. 51. Test performance: (Sankaranarayanan et al., 2008). SpecificitySensitivity 85.576.8VIA 85.491.7VILI Aboubakr Elnashar
  52. 52.  Strengths of VILI:  Simple, easy-to-learn that is minimally dependent upon infrastructure.  Low start-up and sustaining costs. Requires only Lugol’s iodine in addition to the equipment for VIA.  Can be performed by nurses and midwives.  Test results are available immediately: Decreased loss to follow-up.  High sensitivity results in a low proportion of false negatives.  VILI appears to offer improved accuracy and reproducibility over use of VIA alone. Aboubakr Elnashar
  53. 53. Limitations of VILI:  Moderate specificity may result in over-referral and over-treatment in a single-visit approach.  Less accurate when used in post-menopausal  standard training and quality assurance measures are required  Rater dependent.  Lugol’s solution stains underwear and other objects but is washable..  Lugol’s iodine is more expensive than acetic acid, but less is needed for the test. Aboubakr Elnashar
  54. 54.  Management options  VIA: Negative:  follow-up after 3-5 years acc to the decided policy.  VILI: positive:  Offer to treat immediately, (without colposcopy or biopsy, known as the “test-and-treat” or “single-visit” approach).  Refer for colposcopy and biopsy and then offer treatment if a precancerous lesion is confirmed.  VILI: suspicious for cancer:  Refer for colposcopy and biopsy and further management:  Surgery  Radiotherapy  Chemotherapy  Palliative care Aboubakr Elnashar
  55. 55. Conclusions Visual Inspection Techniques in Low resource setting  Noninvasive, easy to perform, inexpensive  All requirements are available locally  Can be performed by all levels of healthcare workers, in almost any setting  Accuracy is comparable to Pap smear.  Results are available immediately  Initial treatment can be provided at the time of the examination Aboubakr Elnashar
  56. 56. Thank you Aboubakr Elnashar