This document discusses the definition of a clinically suspicious cervix and how visual inspection with acetic acid (VIA) can help provide an objective definition. It outlines the advantages of VIA over Pap smear testing for cervical cancer screening in low resource settings. The document also summarizes experiences using VIA for screening in Egypt, finding it identified preinvasive lesions but HPV was not the main cause of cervical cancers detected. The conclusion is that VIA can distinguish between less concerning causes of abnormalities from more serious pre-cancers or cancers and should be a routine part of cervical exams to identify suspicious lesions for biopsy or treatment.

1. The clinically suspicious
cervix-uteri In low resource
countries in the Era of VIA.
By
Mohammad Emam
Prof. of Obstetrics and Gynecology
Director of Early Cancer Detection Unit.
Mansoura Faculty of Medicine.
Egypt
2015

2. Def.of clinically suspicious cervix?
Is abnormally looking portio-
vaginalis on inspection:
(Ectopy , White or red patches, polypi
nodular cervix with retention cyst,
warts, ulcer, purulent,or persistent
discharge, bleeding on touch or PCB
and hypertrophy)…..(Noseir et al.1980,
Sammour et al, 1985;Ghali etal 1988,
Milingos et al, 2010).

3. The clinically suspicious cervix--how often is it cancer?
Milingos DS1, Harry VN, Cruickshank ME.
J Low Genit Tract Dis. 2010 Jul;14(3):196-9. doi: 10.1097/LGT.0b013e3181cb4c7d
 CONCLUSION:
 women referred with a clinically suspicious cervix
should be assessed in a general gynecology clinic
rather than Colposcopy because most will not
have cancer.
 The small number of women with a clinical
cancer can then be referred onto Colposcopy.
 whereas women with benign pathological result
can be treated appropriately in the general clinic.

4. Disadvantages of this definition
Is :
 Hazy
 Subjective .
 Diagnosis of the cause need Thoroughly
history , exam & investigation.

5. How to obtain an objective def.?
 In high resource countries:
 By application of a well established Screening
programme ( smear test): annually in USA and every
3 years in the UK ( has limitations in low resources
countries) .
 Now by HPV screening every 5 years.
 In low resource countries:
 Visual inspection with acetic acid (VIA) is the
hope …… Era of VIA?!!!!

6. Gold standard Screening test
For Cancer Cervix
☼ PAP smear test is
considered to be the
gold standard .
☼ Has limitations ?

7. •Collection
•Reading
•Reporting
Limitations Associated with Pap
Smear

8. What is VIA?
 Is visual inspection of the cervix-uteri
by using 3-5% acetic acid.
 Is an alternative screening method
for PAP smear( advantages &
disadvantages)

9. inexpensive&1. Simple & quick
2. Immediate results
3. Not need cytopathologist .
4. One step diagnosis and ttt.
5. Sensitive
6. Specific??????
Advantages of VIA over PAP

10. Disadvantages Of VIA
 Lower specificity than the smear
test. (May be an advantage for women,
through more cheap investigations).
 Not suitable for endocervical lesions.

11. VIA DISCOVERS
THE CRIME
LOCATE THE
CULPRIT at the
same time
And can
Cytology
discovers
the crime
And need
Colposcopy
for locating
the culprit.

12. ERA of VIA
 Screening programmes utilizing VIA have
been started since 2002 in some low resources
countries ( India ,Indonesia ,Pakistan,
Neigeria, SA ……etc.
 In Egypt Only sporadic Projects utilizing VIA have
started in some governorates ( Dakahlia, sharkia ,
Assuit, and minia ),. , but without national
organization

13. WHO 2012 & VIA
 VIA is an attractive alternative to
cytology-based screening in low-
resource settings. Cryotherapy has
been selected as the treatment option
for the eligible positive cases .
 (A demonstration project in six African countries: Malawi,
Madagascar, Nigeria, Uganda, the United Republic of Tanzania, and
Zambia,2012).

14. WHO 2013 & VIA
 VIA ….should be an integral
step of inspection of cervix –
uteri on routine pelvic
examination in developing
countries.
 As recommended by WHO project for the developing
countries 2013 (field studies in India & South Africa).

15. Objective
To highlight :
How VIA can pinpoint suspicious cervical lesions?
To show Mansoura ( Egyptian) Experience
regarding this topic .

16. `
Colposcopy
How to do VIA ?

17. Reporting Visual Inspection Findings
Negative Aceto-white area(s) not
present
Positive Aceto-white area(s)
present
1)Density of whiteness
2)Time needed for whiteness to appear
3) Time needed for disappearance
4)Sharpness of demarcation.
5) Surface contour

18. Cases with Positive VIA
 Minority: (suspicious of SIL or cancer.
 Majority :(Not suspicious of cancer or SIL )
 Healing cervical epithelium.
 Inflammation.
 Physiological squamous Metaplasia.
 HPV infection.

19. Positive VIA (suspicious
for SIL OR cancer)
Positive VIA (Not suspicious
for SIL OR cancer)
Rapid uptake of acetic acid+
glazed white (less than 20 seconds).
Slow uptake of acetic acid+
faint white (more than 20 seconds).
Slow release of acetic
acid( more than 2 minutes)
Rapid release of acetic
acid( less than 2 minutes)
Sharp raised edges.Hazy borders.
Irregular surface.Regular surface .

20. Two steps :
1)VIA + biopsy
2) Colposcopic- guided ttt for +ve biopsies
One step :
See ( screen ) and treat :(Colposcopic-
guided ttt for suspicious +ve VIA )
What To Do if VIA is Positive &
suspicious?

21. Punch biopsy

22. Colposcopic –guided ttt.
Local destructive therapy :
1. Cryo cautery .
2. LEEP diathermy.
3. Cold coagulation.
4. Photodynamic.

23. WHO( 2013) guidelines for screening and ttt in
developing countries of CIN
Screen-and-treat strategies
involve ttt with
cryotherapy, or LEEP
when the patient is not
eligible for cryotherapy.

24. Egyptian (Mansoura) experience
 J Exp Ther Oncol. 2014;10(4):247-53.
 Human papillomavirus (HPV) is not the
main cause of preinvasive and invasive
cervical cancer among patients in Delta
Region, Egypt.
 Thabet M, Hemida R, Hasan M, Elshamy M,
Elfaraash M, Emam M.

25. Egyptian (Mansoura) experience
 Int J Gynaecol Obstet. 2006
May;93(2):118-22. Epub 2006 Mar 20.
 Screening for cervical carcinoma using visual
inspection with acetic acid.
 Abdel-Hady ES1, Emam M, Al-Gohary A, Hassan
M, Farag MK, Abo-Elkheir M

26. Egyptian ( Mansoura ) Experience
192 Cases with suspicious +ve via
were correlated to Bethesda ,
CIN & Papanicolou systems:
 172cases ( low grade SIL).
 12 cases ( High grade SIL).
 4 cases (stump carcinoma).
 4 cases ( invasive exocervical c).

27. PapanicolaouCIN
Classificati
on
Bethesda
System
VIA
suspicious
Atypia:
koilocytotic, warty,
condylomatous
HPV changeLow-grade
SIL
Rapid uptake
of acetic acid.
Slow release of
acetic acid.
Glazed whiteness
Mild
dysplasia
CIN I
Moderate
dysplasia
CIN II
High-grade SILRapid uptake of
acetic acid.
Slow release of
acetic acid.
Glazed whiteness.
Sharp raised
edges.
Contour irregular
Severe
dysplasia,
carcinoma-in-
situ
CIN III

28. Conclusions
 As recommended by WHO :
 VIA should be a routine
step ,on inspection of
cervix – uteri to pick up
+ve suspicious cases
 ( i.e discover the crime
and locate the culprit)

29. Conclusions
 The definition of suspicious
cervix should be revised
and revived in the Era of
VIA to be an objective ,
not subjective.

30. Take home message: Regarding suspicious
cervix
 VIA , can clarify differences between:-
 The lower extremity (Simple causes) as
Cervico vaginitis ( majority of cases ).
 The upper extremity ,SIL or cervical
carcinoma (Minority).

31. :An objective definitionTake home message
of suspicious cervix in the era of VIA:
Any cervical lesion with more than two of the following
criteria on VIA :
Rapid uptake of acetic acid (less than 20 seconds).
Slow release of acetic acid( more than 2 minutes)
Glazed whiteness.
Sharp raised edges.
See ( screen) & treat can be applied in these conditions .

32. :An objective definitionTake home message
of suspicious cervix in the era of VIA:
If Irregular contour is added to the previous
suspicious criteria , invasive cancer may be
suspected.
Screen and treat is not suitable if irregular contour
is present , but taking biopsy is mandatory in these
conditions before treatment.

33. Telfax 002/050/2319922
Mobile: 002/01223475579
@hotmail.com335maeEmail.
Copy protected with Online-PDF-NoCopy.com