* Dr. K. Vishala Guide –M.D. Ph.D. * Amruta Shirke – M.S. Scholar
*Y.A.C.P.G.T.& R.C., Kodoli
Cervical cancer is the second most common cancer among women worldwide. It is the most common cause of death among middle-aged women. Despite it’s public health importance, there are no effective prevention programmes in most developing countries & hence the risk of disease and death uncontrolled.
In developing world, the incidence of cervical cancer continues to be high. It is reported to be between 18,34 per 1,00,000 women from various cancer registries. Due to cervical cancer 200 patients are dying per day according to W.H.O. Invasive cervical cancer are preceded by a long phase of pre cancerous lesions. That early cell changes in the cervix can be detected by screening.
Cytology- based screening means pap smear is effective but in a low resource country like India, Visual method of screening like visual inspection of cervix with Acetic acid & Lugol’s iodine (VIA & VILI) is good screening test for early detection of cervical cancer.
- Visual Inspection with Acetic Acid (5%) (VIA)
Application of 5% Acetic acid causes reversible coagulation or precipitation of the cellular proteins. It also causes smelling of the epithelium (Columnar & abnormal squamous epithelium, It causes dehydration of cells & it helps in coagulating & clearing the mucous secretions on the cervix. The normal cells do not contain sufficient proteins hence even after application of acetic acid the normal squamous epithelium appears red due to the reflection of light from the underlying stroma, which is rich in blood vessels. The actively proliferating premalignant & malignant epithelial cells contain a lot of cellular proteins. So, acetic acid coagulates these proteins, which obliterate colour of stroma. That results in aceto whitening of cells. Which is commonly visible to the naked eye. Areas of CIN (Cervical Intracpithelial Neoplasia) & Invasive cancer undergo maximal coagulation due to their higher content of nuclear protein.
b) Reporting the Outcome Of VIA
i) VIA Positive
- Distinct, well defined dense (opaque, dull or oyster white) acetowhite ares with regular or irregular margins, close to or abulting SCJ (Squamo Columnar Junction)
- Strikingly dense aceto white areas in the columnar epithelium
- Entire cervix becomes density white.
- Condyloma & leukoplakia occur close to the SCJ & turns intensely white.
ii) VIA Negative
- No aceto white lesions are observed on the cervix.
- Polyp protride from the cervix with blueish white ace to white areas.
- Nabothian cysts appear as button like areas.
- Dot like areas in the endocervix which are due to grape like columnar epithelium staining with acetic acid.
- Shiny, pinkish-white, cloudy-white, blueish white, faint patchy or doubtful lesions with ill-defined, indefinite margins, blending with the rest of cervix.
- Angular, irregular, digitating ace to white lesions, distant (detached) from SCJ (Satellite Lesions)
- Faint line like or ill-defined ace to whitening is seen at the SCJ.
- Streak like ace to whitening in columnar epithelium
- Ill defined, patchy, pale discontinuous scattered ace to white areas.
2. Visual Inspection with Lugol’s Iodine (VILI) (VIA)
Iodine is glycophilic & hence the application of iodine. solution result in uptake of iodine in glycogen containing epithelium. Therefore, the normal. glycogen containing squamous epithelium stains mahogany brown or black after application of iodine. Columnar epithelium does not take up iodine & remains unstained, but may look slightly discoloured due to a thin film of iodine solution. Areas of immature squamous metaplastic epithelim may remain unstained. Areas of CIN & invasive cancer cells. contain little or no glycogen so do not take up iodine & appear as thick mustard-yellow or saffron coloured areas. Areas with leukopakia (hyperkeratosis) do not stain with iodine either and condytomata may not or occasionally may only partially stain with iodine.
b) Reporting the outcome of VILI
i) VILI Positive: Thick, bright, mustard-yellow or saffron yellow iodine non-uptake areas are seen in the transformation zone. Close to or abulting the squamocolumnar junction is not seen or when entire cervix turns densely yellow.
ii) VILI Negative: Following observation after iodine application are VILI negative. A normal cervix, the squamous epithelium turns mahogany brown or black & the columnar epithelium does not change colour. Patchy, indistinct, ill-defined, colour less or partially brown areas are seen Pale areas of no or partial iodine uptake are present on polyps. A leopard skin appearance is associated with T. Vaginalis infection. Pepper like non-iodine uptake areas are seen in the squamous epithelium, for away from the SCJ. Satellite, Thin, yellow, non-iodine uptake areas with angular or digitizing margins resembling geographical areas, are seen far away from SCJ.
Advising the women
It the test is positive, she should be referred for further investigation such as colonoscopy, HPV DNA testing & biopsy as well as treatment for any confirmed lesions. If invasive cancer is suspected, she should be referred to a cancer diagnosis & treatment.
Advantages of naked eye screening with VIA & VILI
- Procedure is simple, inexpensive.
- This screening can be done in OPD setting.
- Result available immediately.
- Does not require sophisticated equipment. In India where women do not F/U women with positive test result may be treated in the same sitting with conservative approaches & Coryotheropy or LEEP.