Chapters

Introduction

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

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-operated 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

Infection prevention

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

Case study

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

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

Treatment of cervical precancer using cryotherapy (ablative technique):

Excision of the transformation zone using large loop excision of the transformation zone (LLETZ):

The basic principles of treatment of cervical intraepithelial neoplasia (CIN) are the following.

The decision about treatment may be based on the outcome of the screening test (all screen-positive women are treated) or on the colposcopy diagnosis (all women suspected to have high-grade CIN on colposcopy may be treated) or the histopathology diagnosis.
Whatever the decision-making process is, the treatment of cervical precancer involves either of the two types of technique: ablative techniques or excisional techniques.
The entire transformation zone undergoes HPV-induced clonal change and is at risk of developing CIN. Therefore, the whole transformation zone should be treated (either ablated or excised), irrespective of the size of the lesion.
High-grade CIN lesions often extend into the crypts present in the transformation zone. The depth of the crypts can be up to 5 mm. During ablative treatment, the tissue destruction must extend up to 7–8 mm to ensure complete clearance of disease. Similarly, during excisional treatment the specimen to be excised should be fashioned in such a way that the entire transformation zone, including the full length of the crypts, is removed.
CIN1 lesions detected on histology or colposcopy may not be treated, because they rarely progress to higher grades. Such low-grade lesions should be treated only if the lesions increase in size or in severity during follow-up, persist beyond 2 years, or are associated with high-grade cytological abnormalities, or when follow-up is not guaranteed.
CIN2 and CIN3 lesions should always be treated in women aged 30 years and older.
No treatment of CIN should be performed during pregnancy. Wait for 3 months after childbirth before recalling the patient for treatment.

To learn more about the different treatment techniques, access the Atlas of Colposcopy: Principles and Practice.

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