Article ID: WMC001971 2046-1690 Evaluation of Visual Inspection with Acetic Acid (Via) & Visual Inspection with Lugol's Iodine (Vili) as a Screening Tool for Cervical Intraepithelial Neoplasia in Comparison with Cytologic Screening Corresponding Author: Dr. Parul Garg, Assistant Professor, Dept. of Obstetrics & Gynaecology, Subharti Medical College, Meerut, 250004 - India Submitting Author: Dr. Parul Garg, Assistant Professor, Dept. of Obstetrics & Gynaecology, Subharti Medical College, Meerut, 250004 - India Article ID: WMC001971 Article Type: Research articles Submitted on:08-jun-2011, 12:05:21 PM GMT Article URL: http://www.webmedcentral.com/article_view/1971 Subject Categories:OBSTETRICS AND GYNAECOLOGY Published on: 10-Jun-2011, 08:01:24 PM GMT Keywords:Visual Inspection with Acetic Acid (via), Visual Inspection with Lugol\'s Lodine (Vili), Transformation Zone (TZ), Endocervical Curettage (ECC), Cervical Intraepithelial Neoplasia (CIN). How to cite the article:garg P. Evaluation of Visual Inspection with Acetic Acid (Via) & Visual Inspection with Lugol's Iodine (Vili) as a Screening Tool for Cervical Intraepithelial Neoplasia in Comparison with Cytologic Screening. WebmedCentral OBSTETRICS AND GYNAECOLOGY 2011;2(6):WMC001971 WebmedCentral > Research articles Page 1 of 10
Evaluation of Visual Inspection with Acetic Acid (Via) & Visual Inspection with Lugol's Iodine (Vili) as a Screening Tool for Cervical Intraepithelial Neoplasia in Comparison with Cytologic Screening Author(s): Garg P Abstract Objective: To study and compare efficacy of visual inspection with Acetic acid (VIA) /Visual inspection with Lugol's Iodine (VILI) and Pap smear as screening test in terms of "Sensitivity" and "Specificity" for Cervical cancer and pre cancerous lesions. Method : Seven Hundred and sixty sexually active women between 25 60 years of age underwent pelvic examination by both pap smear and VIA/ VILI. Colposcopic/ Histodiagnosis was considered as gold standard against which the sensitivity & specificity of cytology, acetic acid and Lugol's iodine application as screening tool were evaluated. Result: Sensitivity of VIA/VILI was 94.3 % versus 74.3 % for cytology. VIA/VILI specificity was 82.6 % versus 93.7 % for cytology. Conclusion: Visual inspection with acetic acid (VIA) & Lugol's iodine (VILI) is more sensitive but less specific than cytology in detection of cervical cancer and its pre cancerous lesions. VIA/ VILI has acceptable test qualities and may in low resource settings be implemented as a large scale screening method. Introduction Cervical cancer is the leading malignancy amongst Indian women. It is estimated that every year about 90,000 new cases arise in India. India bears 18% of the brunt of invasive cancer cervix in the world. The initiating event in cervical dysplasia and carcinogenesis is infection with Human Papilloma virus (HPV). Invasive cervical cancer is preceded by a long pre malignant phase known as cervical intraepithelial Neoplasia (CIN). The goal of cervical cancer screening is detection and treatment of precancer before cancer develops. In developed countries cervical cytologic screening of every women is part of National Health policy. In India, due to other more rampant problems of reproductive health including population control, cytologic screening for cervical cancer and its precancerous lesions is not being focussed. Thus, we need alternative tests which can be offered to every women for detecting cervical precancerous lesions before invasive cancer develops. These problems have stimulated research on VIA/VILI as screening method for cervical precancerous lesions. VIA is based on acetowhitening, with the CIN tissue turning white when exposed to 5% acetic acid (vinegar) due to high nuclear protein content and in VILI, the dysplastic tissue does not take up iodine due to poor glycogen content. The present study aims to compare efficacy of VIA/VILI and Pap smear as a screening tool for cervical cancer and precancerous lesions. Methods and Materials The present study was conducted on 760 sexually active women attending Gynae O.P.D. of S.V.B.P. Hospital, L.L.R.M. Medical College, Meerut from August 2006 to July 2007. Each case was subjected to thorough history taking, complete physical and pelvic examination. Then, all women were subjected to Pap smear and to VIA/VILI tests after explaining the procedure. VIA involved gentle application of freshly prepared 5% acetic acid to ectocervix and endocervix (to include TZ). VIA was considered positive when an acetowhite area either consistent with low grade or high grade lesion was observed within the TZ. VILI was considered positive if there was any area which took light yellow or orangish stain (saffron) in comparison to deep mahogany brown stained area of normal cervix and vagina. Those who had abnormal results in one or both of the screening tests were referred for colposcopic examination and directed biopsy, if needed. Colposcopic/ Histodiagnosis was considered as gold standard against which sensitivity and specificity of cytology, VIA and VILI application as screening tests were evaluated. If colposcopy remained unsatisfactory, ECC was performed. Thirty patients were randomly selected from Pap smear and VIA/VILI negative group and subjected for colposcopic examination as control. WebmedCentral > Research articles Page 2 of 10
Study protocol used for follow up of cases (Illustration-1). Discussion VIA/VILI is more sensitive but less specific than cytology in detecting precancerous lesions of cervix. Likewise, University of Zimbabwe/JHPIEGO cervical cancer project (1999) 1 concluded that the high sensitivity of VIA shows that the test could be valuable in detection of precancerous lesions of cervix. Singh et al (2001) 2 concluded that screening for cervical precancerous and cancerous lesions using visual inspection aided by acetic acid may be a suitable low cost and a feasible alternative modality for control of cervical cancer in a resource poor setting. Sankaranaryanan et al (2003) 3 concluded that VIA/VILI are suitable alternate screening tests to cytology for detecting cervical neoplasia. Doh et al (2005) 4 stated that VIA has acceptable test qualities and may in low resource settings be implemented as a large scale screening method. Abdel-Hady et al (2006) 5 concluded that VIA/VILI, although associated with a relatively high rate of false positive results, is a valuable test for the screening of cervical carcinoma. References 1.University of Zimbabwe /JGPIEGO Cervical cancer project (1999). Visual Inspection with acetic acid for cervical cancer screening: test qualities in a primary care setting. Lancet; 353(9156): 869-73. 2.Singh V, Sehgal A, Parashari A, Sondhani P, Satyanarayana L. (2001) Early detection of cervical cancer through acetic acid application an aided visual inspection. Singapore Med J.; 42: 351-54. 3.Sankaranarayanan R, Wesley R, Thara S, Dhakad N, Chandralekha B, Seastian P, Chithrathara K, Parkin DM, Nair MK. (2003) Test characteristics of visual inspection with 4% acetic acid (VIA) and Lugol's iodine (VILI) in cervical cancer screening in Kerala, India. Int J. Cancer 106(3): 404-8. 4.Doh AS, Nikele NN, Achu P, Essimbi F, Essame O, Nkegoum B. (2005) Visual Inspection with Acetic acid and cytology as screening methods for cervical lesions in Cameron. Int J Gyanecol Obstet; 89(2): 167-73. 5.Abedl-Hady ES, Emam M, Al-Gohary A, Hassan M, Farag MK, Abo Elkheir M. (2006) Screening for cervical carcinoma using visual inspection with acetic acid. Int J Gynaecol Obstet; 93(2): 118-22. WebmedCentral > Research articles Page 3 of 10
Illustrations Illustration 1 Study Protocol Used for Followup Illustration - 1 Study Protocol used for Follow Up Pap smear (+ve) & VIA Pap smear ( ve) & VIA Pap smear (+ve) & VIA Pap smear ( ve) & VIA Colposcopy Normal Colposcopy Repeat VIA/VILI after antibiotic course Directed Biopsy Negative Positive If VIA/VILI still positive Histopathological examination Normal Directed Biopsy Colposcopy Repeat smear Histopathological examination Ngative Positive Normal Biopsy WebmedCentral > Research articles Page 4 of 10 If colposcopy remained unsatisfactory then ECC were performed 30 patients were randomly selected from Pap smear negative and VIA/VILI negative group as control and
Illustration - 2 Distribution of Cases According to Screening by Pap Smear and VIA/VILI Pap Smear VIA/VILI No. of Patients Percentage + + 63 8.3 + 9 1.2 + 96 12.6 592 77.9 Total 760 100 WebmedCentral > Research articles Page 5 of 10
Illustration - 3 Colposcopic findings in screen positive cases S.No. Colposcopic findings No. of Patients Percentage 1. Normal 38 22.6 2. Unsatisfactory 6 36 3. Inflammatory 32 19.0 4. Acetowhite 70 41.7 5. Mosaic 14 8.3 6. Punctations 5 3.0 7. Atypical vessels 3 1.8 Total 168 100 WebmedCentral > Research articles Page 6 of 10
Illustration - 4 Histopathological diagnosis in colposcopic directed biopsy cases S.No. Histopathological diagnosis No. of Patients Percentage 1. Chronic cervicitis 18 18.4 2. Acute on chronic cervicitis 8 8.2 3. Squamous metaplasia 37 37.7 4. Mild dysplasia (CIN I) 29 29.6 5. Moderate dysplasia (CIN II) 6 6.1 6. Severe dysplasia (CIN III) - - 7. Carcinoma - - Total 98 100 WebmedCentral > Research articles Page 7 of 10
Illustration - 5 Screen tests findings of cases in study Pap Smear VIA/ VILI No. Refer to Colpo -scopy Colposcopy Normal & satis-fa ctory Unsatisfactory Positive colpo-sc opy In need of biopsy or ECC Biopsy result + + 63 63 - - 63 63 24 18 (CIN-I) 6 (CIN-II) + - 9 9 2-7 7 2 (CIN-I) - + 96 96 68 6 22 28 9 (CIN-I) - - 592 30 30 - - - - Total 760 198 100 6 92 98 35 WebmedCentral > Research articles Page 8 of 10
Illustration - 6 Validity of screening tests for cases in present study Sensitivity Specificity PPV NPV Pap smear 74.3% 93.7% 36.1% 98.7% VIA/VILI 94.3% 82.6% 20.8% 99.7% WebmedCentral > Research articles Page 9 of 10
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