Chapters

Introduction

Introduction

Visual inspection after application of acetic acid (VIA)

VIA as a screening test for cervical cancer Advantages of VIA Limitations of VIA VIA to triage women positive on the HPV test

Determining eligibility for ablative treatment after application of acetic acid

In the context of VIA screening In the context of HPV screening

Anatomical considerations

Anatomical considerations Gross anatomy of female genital organs

External genitalia Internal genitalia

Gross anatomy of cervix

Cervical epithelium

Cervical epithelium Squamous epithelium Columnar epithelium Squamocolumnar junction

Physiological changes of cervical epithelium

Ectropion Squamous metaplasia Transformation zone of the cervix Pregnancy Atrophic changes Congenital transformation zone (CTZ)

Neoplastic changes of the cervical epithelium

Genesis of cervical cancer Cervical intraepithelial neoplasia (CIN) Adenocarcinoma in situ (AIS) Cervical cancers

Changes in the cervical epithelium after application of acetic acid

Pathophysiological basis

Instruments, consumables, and setup required for examination after application of acetic acid

Instruments and consumables required Preparation of 5% dilute acetic acid Setup for the procedures

VIA procedure

As a screening test or a triage test Counselling History taking Preparation for VIA procedure Steps for inspection of the external genitalia Steps for insertion of the speculum and exposure of the cervix Steps for examination before application of acetic acid

Steps Normal findings

Normal cervicovaginal discharge Bleeding through the external os Nabothian cyst Ectropion

Abnormal findings

Cervicovaginal inflammation Cervical Polyp Leukoplakia Cervical condyloma Growth or ulcer

Examination after application of acetic acid

Steps for applying acetic acid to the cervix Detecting changes in the cervical epithelium after application of acetic acid Normal findings

Squamous epithelium Columnar epithelium Squamocolumnar junction (SCJ) Transformation zone (TZ)

Features during pregnancy Abnormal features

Abnormal features Rapidity of onset of acetowhitening Intensity of acetowhitening Margin of acetowhite area Location of acetowhite area Surface of acetowhite area Size of acetowhite area Conclusion of examination Post-VIA counselling Documentation of findings

Interpretation of VIA test results

Interpretation of VIA test results VIA Negative

No acetowhite area Columnar epithelium appearing white Polyps with faint acetowhite change Nabothian cysts appearing white Line-like acetowhitening at the SCJ Patchy acetowhite areas without any definite margin Thin acetowhite areas with tongue-shaped projections towards the external os Acetowhite areas away from the SCJ

VIA Positive

Dense acetowhite areas in the TZ with well-defined margins Dense acetowhite area on columnar epithelium Entire cervix appearing dense acetowhite Leukoplakia becoming acetowhite CTZ appearing acetowhite

Suspicious of invasive cancer

Preventing errors in VIA

Preventing errors in VIA Inadequate exposure of the cervix Inadequate visualization of the transformation zone Inadequate visualization of the margins of acetowhite areas Errors in assessment

Errors in assessment of acetowhite areas Errors in recognizing cervical cancer Errors in assessment of the postmenopausal cervix

Management of women with an abnormal VIA test

Management of women with an abnormal VIA test

Steps to determine eligibility for ablative treatment

Principles Principles of treating cervical precancerous lesions Criteria used to determine eligibility for ablative treatment Steps to determine eligibility for ablative treatment

Role of Lugol’s iodine in identifying the transformation zone for treatment

Role of Lugol’s iodine in identifying the transformation zone for treatment Steps for applying Lugol’s iodine to the cervix Lugol’s iodine for pre-treatment assessment Preparation of Lugol’s iodine

Treatment by cryotherapy

Principles Cryosurgical unit Ancillary instruments and consumables Steps Side-effects and complications Post-treatment advice and follow-up Video

Treatment by thermal ablation

Principles The benchtop model The battery-driven model Complications Video

Videos

Steps of applying acetic acid for VIA and identifying the transformation zone (VIA negative) Steps of applying acetic acid for VIA, determining eligibility for ablation and treatment with thermal ablation

Preparation of Monsel’s solution

Preparation of Monsel’s solution

Infection prevention

Standard procedures for protection from infection Essential steps for infection prevention in VIA screening or triage Preparation of 0.5% chlorine solution

VIA-negative cases VIA-positive cases VIA-suspicious of cancer cases

Quiz Acknowledgement Suggested citation Copyright

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Atlas of visual inspection of the cervix with acetic acid for screening, triage, and assessment for treatment

VIA procedure – Examination after application of 5% acetic acid – Normal features – Transformation zone (TZ)

The transformation zone (TZ) is the area on the cervix where metaplastic changes take place. The TZ can be identified by the presence of the metaplastic epithelium, nabothian cysts, crypt openings, and islands of columnar epithelium. In the fully mature squamous epithelium, none of the features of metaplasia may be visible. In the presence of a CIN lesion, extent of TZ is determined by the extent of the lesion. The TZ may be completely or partially inside the endocervical canal, if the SCJ moves inside the canal. This is frequently seen in postmenopausal women.

How to identify the extent of the TZ:

The proximal or inner limit of the TZ is the SCJ (the new SCJ).

The distal or outer limit of the TZ (the original SCJ) is identified by locating the nabothian cyst or the crypt opening that is farthest away from the SCJ on the ectocervix.

Once the farthest crypt opening or nabothian cyst is identified, the distal limit of the TZ can be delineated by drawing an imaginary circle with the farthest crypt opening or nabothian cyst on it.

In mature squamous epithelium, the above-mentioned features may be absent. In such situations, the distal limit of the TZ (the original SCJ) cannot be demarcated.

If there is a CIN lesion, the entire lesion should be considered as incorporated in the TZ.
The TZ is classified as type 1, type 2, or type 3, depending on its extension to the endocervix and the visibility of the SCJ. The details are described in later sections describing treatment.

Squamous metaplastic epithelium appears pale pinkish and is present towards the external os. It is often visible as tongue-shaped projections of pinkish epithelium projecting and coalescing towards the external os. Sometimes the metaplastic epithelium may be faintly acetowhite without any distinct outside border.

Metaplastic epithelium may also appear as a thin transparent acetowhite patch extending outwards from the external os with a diffuse or feathery margin.

Nabothian cysts are a feature of the TZ. A nabothian cyst looks like a raised pearly white or ivory white pimple on the squamous epithelium, and it becomes prominent after application of acetic acid.

Crypt openings (usually visible with magnification) are present only in the TZ. After application of acetic acid, the tiny crypt opening appears as a small black dot surrounded by a thin acetowhite rim. During VIA, crypt openings may look like small white spots on the squamous epithelium.

A skip area or an island of columnar epithelium is visible as a small pocket of red columnar epithelium on the metaplastic squamous epithelium. The process of replacement of columnar epithelium by metaplastic epithelium is not always uniform, and small islands of red columnar epithelium may be left behind on the original ectropion.

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