J Gynecol Oncol.  2011 Sep;22(3):145-151. 10.3802/jgo.2011.22.3.145.

Visual inspection with acetic acid for detection of high grade lesion in atypical squamous cells and low grade squamous intraepithelial lesions from cervical Pap smear

• Pothisuwan M
• Pataradool K
• Tangjitgamol S
• Srijaipracharoen S
• Manusirivithaya S
• Thawaramorn T

• KMID: 2055701
• DOI: http://doi.org/10.3802/jgo.2011.22.3.145

Abstract

OBJECTIVE
To evaluate the value of visual inspection with acetic acid (VIA) test to detect high grade lesion in women with atypical squamous cells or low grade squamous intraepithelial lesions cervical cytology.
METHODS
Women with atypical squamous cells or low grade squamous intraepithelial lesions who were scheduled to undergo colposcopy at Vajira Hospital and met inclusion criteria were included. All participants underwent VIA test prior to usual steps of colposcopy. The VIA results were interpreted as positive or negative using the criteria by the International Agency for Cancer Research. The standard colposcopic examination and appropriate investigations for cervical pathology were then continued. The diagnostic values of VIA test including sensitivity, specificity, positive predictive value, and negative predictive value were determined using high grade lesion including cervical intraepithelial neoplasia 2-3 and squamous cell carcinoma as a threshold.
RESULTS
Total of 106 women was included. The VIA test was positive in 33 women (31.1%) and negative in 73 women (68.9%). Among the women with VIA test positive, 14 had high grade lesion (42.4%) while 19 had no significant lesions. Only 2/73 (2.7%) cases with negative VIA test had high grade lesion (both had cervical intraepithelial neoplasia 2). The sensitivity, specificity, positive predictive value and negative predictive value with 95% confidence interval were 87.5% (81.2 to 93.8%), 78.8% (71.1 to 86.7%), 42.4% (33.0 to 51.8%), and 97.2% (94.2 to 1.0%) respectively.
CONCLUSION
VIA as the intermediate test in atypical squamous cells and low grade squamous intraepithelial lesions cytology may reduce the necessity to refer some women for colposcopy.

Keyword

Atypical squamous cells; High grade lesion; Low grade squamous intraepithelial lesions; Visual inspection with acetic acid

MeSH Terms

Acetic Acid
Carcinoma, Squamous Cell
Cervical Intraepithelial Neoplasia
Colposcopy
Female
Humans
International Agencies
Sensitivity and Specificity
Acetic Acid

Reference

1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010. 127:2893–2917.

2. Solomon D, Davey D, Kurman R, Moriarty A, O'Connor D, Prey M, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002. 287:2114–2119.

3. Limpvanuspong B, Tangjitgamol S, Manusirivithaya S, Khunnarong J, Thavaramara T, Leelahakorn S. Prevalence of high grade squamous intraepithelial lesions (HSIL) and invasive cervical cancer in patients with atypical squamous cells of undetermined significance (ASCUS) from cervical Pap smears. Southeast Asian J Trop Med Public Health. 2008. 39:737–744.

4. Kantathavorn N, Kietpeerakool C, Suprasert P, Srisomboon J, Khunamornpong S, Nimmanhaeminda K, et al. Clinical relevance of atypical squamous cells of undetermined significance by the 2001 bethesda system: experience from a cervical cancer high incidence region. Asian Pac J Cancer Prev. 2008. 9:785–788.

5. ASCUS-LSIL Traige Study (ALTS) Group. Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance. Am J Obstet Gynecol. 2003. 188:1383–1392.

6. Cheung AN, Szeto EF, Ng KM, Fong KW, Yeung AC, Tsun OK, et al. Atypical squamous cells of undetermined significance on cervical smears: follow-up study of an Asian screening population. Cancer. 2004. 102:74–80.

7. Barreth D, Schepansky A, Capstick V, Johnson G, Steed H, Faught W. Atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H): a result not to be ignored. J Obstet Gynaecol Can. 2006. 28:1095–1098.

8. McHale MT, Souther J, Elkas JC, Monk BJ, Harrison TA. Is atypical squamous cells that cannot exclude high-grade squamous intraepithelial lesion clinically significant? J Low Genit Tract Dis. 2007. 11:86–89.

9. Kietpeerakool C, Srisomboon J, Tantipalakorn C, Suprasert P, Khunamornpong S, Nimmanhaeminda K, et al. Underlying pathology of women with "atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion" smears, in a region with a high incidence of cervical cancer. J Obstet Gynaecol Res. 2008. 34:204–209.

10. ASCUS-LSIL Traige Study (ALTS) Group. A randomized trial on the management of low grade squamous intraepithelial lesion cytology interpretations. Am J Obstet Gynecol. 2003. 188:1393–1400.

11. Chute DJ, Covell J, Pambuccian SE, Stelow EB. Cytologic-histologic correlation of screening and diagnostic Papanicolaou tests. Diagn Cytopathol. 2006. 34:503–506.

12. Phongnarisorn C, Srisomboon J, Siriaungkul S, Khunamornpong S, Suprasert P, Charoenkwan K, et al. Women in a region with high incidence of cervical cancer warrant immediate colposcopy for low grade squamous intraepithelial lesion on cervical cytology. Int J Gynecol Cancer. 2006. 16:1565–1568.

13. Khuakoonratt N, Tangjitgamol S, Manusirivithaya S, Khunnarong J, Pataradule K, Thavaramara T, et al. Prevalence of high grade squamous intraepithelial lesion (HSIL) and invasive cervical cancer in patients with low grade squamous intraepithelial lesion (LSIL) at cervical Pap smear. Asian Pac J Cancer Prev. 2008. 9:253–257.

14. Wright TC Jr, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D, et al. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. Am J Obstet Gynecol. 2007. 197:346–355.

15. Stoler MH, Schiffman M. Atypical Squamous Cells of Undetermined Significance-Low grade Squamous Intraepithelial Lesion Triage Study (ALTS) Group. Interobserver reproducibility of cervical cytologic and histologic interpretations: realistic estimates from the ASCUS-LSIL Triage Study. JAMA. 2001. 285:1500–1505.

16. Aggarwal P, Batra S, Gandhi G, Zutshi V. Comparison of Papanicolaou test with visual detection tests in screening for cervical cancer and developing the optimal strategy for low resource settings. Int J Gynecol Cancer. 2010. 20:862–868.

17. Visual inspection with acetic acid for cervical-cancer screening: test qualities in a primary-care setting. University of Zimbabwe/JHPIEGO Cervical Cancer Project. Lancet. 1999. 353:869–873.

18. Gaffikin L, Blumenthal PD, Emerson M, Limpaphayom K. Royal Thai College of Obstetricians and Gynaecologists (RTCOG)/JHPIEGO Corporation Cervical Cancer Prevention Group. Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project. Lancet. 2003. 361:814–820.

19. Sankaranarayanan R, Basu P, Wesley RS, Mahe C, Keita N, Mbalawa CC, et al. Accuracy of visual screening for cervical neoplasia: results from an IARC multicentre study in India and Africa. Int J Cancer. 2004. 110:907–913.

20. Ngoma T, Muwonge R, Mwaiselage J, Kawegere J, Bukori P, Sankaranarayanan R. Evaluation of cervical visual inspection screening in Dar es Salaam, Tanzania. Int J Gynaecol Obstet. 2010. 109:100–104.

21. Goel A, Gandhi G, Batra S, Bhambhani S, Zutshi V, Sachdeva P. Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions. Int J Gynaecol Obstet. 2005. 88:25–30.

22. Doh AS, Nkele NN, Achu P, Essimbi F, Essame O, Nkegoum B. Visual inspection with acetic acid and cytology as screening methods for cervical lesions in Cameroon. Int J Gynaecol Obstet. 2005. 89:167–173.

23. Bhatla N, Mukhopadhyay A, Kriplani A, Pandey RM, Gravitt PE, Shah KV, et al. Evaluation of adjunctive tests for cervical cancer screening in low resource settings. Indian J Cancer. 2007. 44:51–55.

24. Muwonge R, Walter SD, Wesley RS, Basu P, Shastri SS, Thara S, et al. Assessing the gain in diagnostic performance when two visual inspection methods are combined for cervical cancer prevention. J Med Screen. 2007. 14:144–150.

25. El-Shalakany A, Hassan SS, Ammar E, Ibrahim MA, Salam MA, Farid M. Direct visual inspection of the cervix for the detection of premalignant lesions. J Low Genit Tract Dis. 2004. 8:16–20.

26. Qureshi S, Das V, Zahra F. Evaluation of visual inspection with acetic acid and Lugol's iodine as cervical cancer screening tools in a low-resource setting. Trop Doct. 2010. 40:9–12.

27. The International Agency Research on Cancer (IARC). A practical manual on visual screening for cervical neoplasia. 2003. Lyon: IARC Press.

28. Turkish Cervical Cancer And Cervical Cytology Research Group. Prevalence of cervical cytological abnormalities in Turkey. Int J Gynaecol Obstet. 2009. 106:206–209.

29. Davey DD, Woodhouse S, Styer P, Stastny J, Mody D. Atypical epithelial cells and specimen adequacy: current laboratory practices of participants in the college of American pathologists interlaboratory comparison program in cervicovaginal cytology. Arch Pathol Lab Med. 2000. 124:203–211.

30. Shastri SS, Dinshaw K, Amin G, Goswami S, Patil S, Chinoy R, et al. Concurrent evaluation of visual, cytological and HPV testing as screening methods for the early detection of cervical neoplasia in Mumbai, India. Bull World Health Organ. 2005. 83:186–194.

31. Cremer M, Conlisk E, Maza M, Bullard K, Peralta E, Siedhoff M, et al. Adequacy of visual inspection with acetic acid in women of advancing age. Int J Gynaecol Obstet. 2011. 113:68–71.

32. Denny L, Kuhn L, Pollack A, Wainwright H, Wright TC Jr. Evaluation of alternative methods of cervical cancer screening for resource-poor settings. Cancer. 2000. 89:826–833.

33. Gaffikin L, Lauterbach M, Blumenthal PD. Performance of visual inspection with acetic acid for cervical cancer screening: a qualitative summary of evidence to date. Obstet Gynecol Surv. 2003. 58:543–550.

34. Arbyn M, Sankaranarayanan R, Muwonge R, Keita N, Dolo A, Mbalawa CG, et al. Pooled analysis of the accuracy of five cervical cancer screening tests assessed in eleven studies in Africa and India. Int J Cancer. 2008. 123:153–160.

35. Sritipsukho P, Thaweekul Y. Accuracy of visual inspection with acetic acid (VIA) for cervical cancer screening: a systematic review. J Med Assoc Thai. 2010. 93:Suppl 7. S254–S261.

36. Sauvaget C, Fayette JM, Muwonge R, Wesley R, Sankaranarayanan R. Accuracy of visual inspection with acetic acid for cervical cancer screening. Int J Gynaecol Obstet. 2011. 113:14–24.