Visualization of the cervix with acetic acid and Lugol

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Visualization of the cervix withacetic acid and
Lugols iodineto improve sensitivity of
detecting cervical dysplasia

• Instruction material adapted from
• International Agency for Research on Cancer
  (IARC)
• World Health organization (WHO)
• Program for Appropriate Technology in Health
  (PATH)
• ASCCP

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Outline

1. Anatomy of the cervix
2. Procedure visualization of the cervix with
   acetic acid and Lugols iodine
3. Identifying lesions
4. VIA-negative
5. VIA-positive
6. Invasive carcinoma
7. Epic documentation for data collection.

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Cervical epithelium

• Squamous epithelium
• Vagina and outer ectocervix
• Columnar epithelium
• Upper and middle endocervical canal
• Squamous metaplasia transformation zone
• Central ectocervix and lower endocervical canal

Almost all cervical neoplasia occurs in the
transformation zone
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Transformation zone

• The area of the cervix between the original and
  the new sqamocolumnar junction
• Where the columnar epithelium has been replaced
  or is being replaced by the metaplastic squamous
  epithelium.

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Original Squamocolumnar Junction

• Placement determined between 18-20 weeks
  gestation
• Childhood and perimenarche it is located at or
  very close to the cervical os.
• After puberty the endocervical canal elongates.
  This leads to the eversion of the columnar
  epithelium onto the ectocervix, resulting in
  ectropion or ectopy.
• (Can be found in vagina or vaginal fornices in
  DES exposed women)
• Less apparent over time with maturation of
  epithelium

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Squamous metaplasia

• Progressive replacement of columnar epithelium by
  squamous epithelium
• Stimulated by
• Acidic environment with puberty
• Obliteration of original columnar cells
• Subsequent maturation into well-differentiated,
  glycogenated squamous epithelium

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New SCJ

• As metaplastic changes occur, the location of
  the SCJ moves on the ectocervix towards the
  cervical os
• During menopause the cervix shrinks due to the
  lack of estrogen, resulting in the progression of
  the SCJ into the endocervical canal
• Adequate colposcopy requires visualization of the
  entire squamocolumnar junction

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Transformation zone

• The area of the cervix between the original and
  the new sqamocolumnar junction
• where the columnar epithelium has been replaced
  or is being replaced by the metaplastic squamous
  epithelium.
• With the naked eye, one can identify the inner
  border of the transformation zone by tracing the
  squamocolumnar junction and the outer border by
  locating the distal most nabothian cysts (if
  present) or crypt openings.
• Majority of dysplasia is in the transformation
  zone or the leading edge of the squamous
  metaplasia, abutting the SCJ.

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Visualization inspection tests

• Visual inspection with acetic acid (VIA) done
  with the naked eye
• also called cervicoscopy or direct visual
  inspection DVI, or with low magnification
  called gynoscopy, aided VI, or VIAM.
• Visual inspection with Lugols iodine (VILI),
  also known as Schillers test

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Visualization of the cervix with acetic acid
(VIA)

• When to perform?
• Anytime during the menstrual cycle including
  during menses (providing flow is not too heavy)
• During pregnancy, at a postpartum examination
• For STI screening
• Intended for ages 20 to 50

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Categories for VIA test results
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 areaswith 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.
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VIA test performance
Sensitivity Specificity
Minimum 65 64
Maximum 96 98
Median 84 82
Source Adapted from Gaffikin, 2003
Pap test performance
Sensitivity Specificity
Minimum 37 86
Maximum 84 100
Median 51 89

• These results are from a meta-analyses of
  cross-sectional studies
• (US department of health and human services
  Agency for Health Care Research and Quality
  1999).
• Several ACCP studies have also found Pap test
  sensitivity in the range of 50 at best.

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Preparing for VIA(at Swedish Family Medicine)

• Provide the explanation of the procedure in
  writing at the time of rooming.
• opt out policy
• Additional equipment needed for set up
• Reporting form, dot phrase (Epic based)
• Cotton swabs which are soaking in cups of
• 5 acetic acid (white table vinegar)
• Lugols iodine solution

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Patient information (draft)

• Patient Handout for VIA Project
• Cervical cancer affects over 10,000 women in the
  U.S. each year. Our clinic is doing a project
  that may improve our ability to detect
  abnormalities of the cervix before they turn into
  cancer. In addition to doing a pap smear today,
  we would like to put vinegar and an iodine
  solution on your cervix to look for abnormalities
  that a pap smear might miss. You will probably
  not even notice that the doctor is doing this
  extra step.  There are no side effects, but it
  may add about 5 minutes to your visit.
• You may also have some discharge that is
  iodine-color (brown).  If we see anything
  abnormal with this exam, or if your Pap smear is
  abnormal, we will recommend that you schedule a
  colposcopy. A colposcopy is a procedure in which
  we take a closer look at your cervix.  If we
  still see any abnormal areas during the
  colposcopy, we may recommend taking a sample
  (biopsy) of your cervix.  Ask your doctor if you
  have questions about this procedure.
• Please let your doctor know if you do not want us
  to do take a closer look at your cervix using
  these solutions, or if you have an allergy to
  iodine.
• Thank you for helping us to improve the quality
  of care we provide to our patients!-Drs
• - Alyson Feigenbaum (at large) and Xandra Rarden.
  

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Procedure prior to application of acetic acid

• Inspect the external genitalia papules,
  vesicles, ulcerations, condylomata, discharge,
  redness, swelling, excoriation.
• Inspect the cervix cervicitis, nabothian cysts,
  ulcers, condylomata, polyps, leukoplakia
  (thickened, white patches), vesicles, papules,
  or ulcers on the cervix, easy bleeding?
• Perform Pap and HPV test as indicated
• Perform wet mount and STI screening as indicated
• Use a dry cotton swab to wipe away any discharge,
  blood, or mucus from the cervix.

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Procedure involving VIA and VILI

• Soak a clean swab in 5 acetic acid and apply to
  the cervix liberally.
• Wait 1 minute. Tell the woman that she might feel
  a slight burning sensation especially if the
  tissue looks inflamed or friable.
• Focus your view on the transformation zone.
• Note any acetowhite lesions location,
  extension, intensity of whiteness, borders.
• Soak a clean swab in Lugols iodine solution and
  apply to cervix liberally
• Note the uptake in the areas of concern noted
  after acetic acid.

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Pathophysiological basis of VIA

• Application of 5 acetic acid causes
• A reversible coagulation of the cellular
  proteins which obscures the color of the
  underlying stroma. Thus the increased nuclear
  activity and DNA content exhibit the most
  dramatic white color change
• swelling of the epithelial tissue
• dehydration of the cells and clearing the mucous
  secretions on the cervix.

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Pathophysiological basis of VILI
Lugols iodine is glycophillic

• Glycogen-containing tissue stains mahogany brown
  or black
• Glycogen rich
• Squamous epithelium
• Squamous metaplasia

• Glycogen poor tissues do not take up iodine
• and appear mustard-yellow or saffron-colored
  areas.
• Glycogen poor
• Columnar epithelium
• CIN and invasive cancer
• Laukoplakia (hyperkeratosis)
• condylomata

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Reporting of lesionsVIA negative

• No significant acetowhite lesions.
• This is the most challenging category in VIA
  because there are many variations of acetowhite
  areas that can appear.
• Closely consider
• Nabothian cysts and polyps may also turn
  acetowhite
• There may be a faint line, appearing to be
  acetowhitening at the junction of columnar and
  squamous epithelium.
• There may be acetowhite lesions far away from the
  squamocolumnar junction or streaklike
  acetowhitening.
• There may also be dotlike areas on the columnar
  epithelium, which are due to areas of metaplasia
• Diffuse acetowhitening with columnar epithelium
  staining

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VIA-negative
VIA negative. The mild acetowhite staining in a
linear pattern at the lower edge of the
squamocolumnar junction and around the two
glandular crypt openings is the typical
appearance of immature metaplasia. Used with
permission from Program for Appropriate
Technology in Health (PATH). Seattle, WA PATH.
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VIA-Negative
There are no acetowhite areas on the polyp and
the cervix after the application of acetic acid.
No acetowhite area seen. Note the advancing edges
of squamous metaplasia in the anterior and
posterior lips (arrows).
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VIA-negative
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. (Program for Appropriate
Technology in Health (PATH). Seattle, WA PATH.)
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VIA-negative
The nabothian cysts appear as pimple- or
button-like areas after the application of acetic
acid.
There is dot-like acetowhitening in the columnar
epithelium in the anterior lip. The
squamocolumnar junction is fully visible.
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VIA-negative

• There is an ill-defined pinkish-white hue with
  indefinite margins blending with the rest of the
  epithelium. The squamocolumnar junction is fully
  visible.

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VIA-negative

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VIA-negative

• There is dense, thick, mucus on the cervix before
  the application of acetic acid. After the
  application of acetic acid, the mucus is cleared
  and the squamocolumnar junction becomes
  prominent.

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Inflammation of the cervix - cervicitis

• Common agents Trichomonas, Candida albicans,
  anaerobes (Gardnerella vaginalis, G. mobilluncus
  and peptostreptococcus) Neisseria gonorrhea,
  Chlamydia trachomatis, Escherichia coli,
  streptococci, staphylococci, herpes simplex
• Columnar epithelium is more prone to infection
  than squamous epithelium.
• Pay attention to symptoms excessive discharge,
  itching of the vulva and vagina, pain and a
  burning sensation during sexual intercourse and
  lower abdominal pain

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Visual inspection-cervicitis

• Candidial vulvar edema and erythema,
  excoriation, and thick, curdy-white, non-odorous
  discharge.
• Non-candidial vulval erythema and edema,
  reddish, tender cervix with malodorous, greenish
  yellow or greyish-white mucopurulent discharge,
  with or without ulceration.
• Gonococcal painful urethral discharge is also
  observed.
• Herpes infection vesicles and ulcers in the
  external genitalia, vagina and the cervix, as
  well as cervical tenderness.

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VIA-negative
The cervix is unhealthy, inflamed with
ulceration, necrosis, bleeding and inflammatory
exudate.There is ill-defined, diffuse,
pinkish-white acetowhitening with indefinite
margins blending with the rest of epithelium
(arrows).
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VIA-Positive

• Pay attention to
• Sharp, distinct, well-defined, dense (opaque/dull
  or oyster white) acetowhite areas, with or
  without raised margins, close to the
  squamocolumnar junction.

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Other conditions

• Condylomata found on the cervix, and occasionally
  in the vagina and on the vulva, associated with
  HPV types 6 and 11. Condylomata are usually
  obvious to the naked eye (before the application
  of acetic acid).

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Other conditions

• Leukoplakia (hyperkeratosis) is a well demarcated
  white area on the cervix (before the application
  of acetic acid), 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.
  

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VIA-Positive
moderately opaque, sharply bordered, wide band of
acetowhite staining around the cervical os,
touching the squamocolumnar junction. There is
mild acetowhite staining of the immature
metaplastic epithelium extending onto the
endocervical polyp. (Program for Appropriate
Technology in Health (PATH). Seattle, WA PATH.)
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VIA-positive

• There is a well-defined, opaque acetowhite area,
  with irregular digitating margins, in the
  anterior and posterior lips abutting the
  squamocolumnar junction and extending into the
  cervical canal.

• There is a well-defined, opaque acetowhite area,
  with bleeding on touch, in the anterior lip,
  abutting the squamocolumnar junction, which is
  fully visible.

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VIA-positive
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VIA-positive

• There is a well-defined, opaque acetowhite area,
  with regular margins, in the anterior lip,
  abutting the squamocolumnar junction, which is
  fully visible. Note the somewhat ill-defined
  white area in the lower lip. The lesion is
  extending into the cervical canal.

• There is a well-defined, opaque acetowhite area,
  with regular margins, in the anterior lip,
  abutting the squamocolumnar junction, which is
  fully visible. Note the satellite lesions in the
  lower lip.

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VIA-positive
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VIA-positive

• There is a well-defined, dull, dense, opaque
  acetowhite area in the posterior lip extending
  into the endocervical canal.

• There is an acetowhite area in the columnar
  epithelium in the anterior and posterior lips.

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VIA-positive

• There is a dense acetowhite area all over the
  cervix involving all the four quadrants and
  extending into the cervical canal.

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Invasive cancer
Early lesions may present as a rough, reddish,
granular area that bleeds on touch
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Invasive cancer

• There is a 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.

• There is a proliferative growth with dense
  acetowhitening and bleeding

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Invasive cancer

• There is a dense acetowhite area with irregular
  surface contour.

• There is an ulceroproliferative growth with
  acetowhitening and bleeding

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Invasive cancer
More advanced cancers may present as a
proliferating, bulging, mushroom- or
cauliflower-like growth with bleeding and
foul-smelling discharge
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Characteristics ofAcetowhiteLesions Comments
Location Is the acetowhite lesion near, abutting/touching, or far away from the SCJ?How much of the TZ does it occupy?
Extension Does the acetowhite area extend into the endocervical canal?Does it extend out toward the vaginal fornix?
Intensity of color Is the acetowhite area shiny white, pale white, or dull white?Are the lesions uniform in color?Does the color intensity vary across the lesion?Are there areas of erosion within the acetowhite lesion?
Borders and demarcation Are the borders clear and sharp or indistinct diffuse margins?Are they raised or flat margins?Are they regular or irregular margins?
Size Describe the extent or dimensions of the lesion and the number of lesions
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Distribution of findings

• A sufficiently skilled examiner will categorize
  8-15 of women examined as VIA-positive
• 20-30 of the VIA-positive lesions identified on
  VIA by the test provider harbor CIN of any grade

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Epic dot phrase

• The first block of information would be entered
  by the data enter only.
• Location of clinic (standard clinic, medical home
  model)
• Data collection
• Date of service
• Name
• Age
• Type of visit
•  
• Pap results
• Colposcopy results

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Epic dot phrase

• Added to the chart note
• Did the patient agree to have VIA after reading
  the information provided? Y / N /
• Did the patient have any concerns about this
  test? Y / N /
• How long did you spend counseling the patient
  about this supplemental test? 1/3/5/10/
  minutes
• Findings VIA negative / VIA positive / neoplasm
• Lugols iodine used Y / N /
• Evidence of cervicitis on exam Y / N, tested Y /
  N, treated Y / N
• Screening for SDIs Y / N
• Pap done? Y/N
• HPV done? Y/N

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Epic dot phrase

• Were VIA results discussed with the patient? Y /
  N
• Was colposcopy recommended at the time of the
  screening test? Y / N
• If yes, did the patient elect to schedule
  colposcopy or wait for pap results?
• If yes, what concerns did the patient have about
  undergoing colposcopy?
• Was this test uncomfortable for the patient in
  any way?
• No / yes it was physically uncomfortable /
  patient felt psychologically uncomfortable about
  visualizing the cervix / the patient felt that it
  took time away from the rest of the visit /
  
• Was the provider uncomfortable in any way?
• No / the provider felt uncomfortable counseling
  the patient / performing the visualization /
  making recommendations /

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References
ACCP. Visual screening approaches Promising
alternative screening strategies. Cervical Cancer
Prevention Fact Sheet. (October 2002). ACCP
World Health Organization. Cervical cancer
prevention in developing countries A review of
screening and programmatic strategies.
(Forthcoming, November 2003). Gaffikin L,
Lauterbach M, Blumenthal PD. Performance of
visual inspection with acetic acid for cervical
cancer screening A qualitative summary of
evidence to date, Obstetrical and Gynaecological
Review 58(8)543-550. (August 2003). McIntosh N,
Blumenthal PD, Blouse A, eds. Cervical cancer
prevention guidelines for low-resource settings.
Baltimore, MDJHPEIGO. (2001). Riegelman RK and
Hirsch RP. Studying a study and testing a test
How to read the medical Literature (2nd
Edition).  Boston, MALittle, Brown and Company.
(1989). International Agency for Research on
Cancer (IARC) World Health organization
(WHO) Program for Appropriate Technology in
Health (PATH) ASCCP