Understanding Of Visual Inspection

Acetic Acid (VIA), Cervical Cytology

And HPV-DNA Testing
Junita Indarti, M.D. , Ph.D

Asia Oceania Research Organization on Genital Infections and Neoplasia

Virtual Meeting
April, 9th 2021
Outline
• Cervical Cancer Problem In Indonesia
• Anatomy and Histology of the Cervix
• Screening Methods
• VIA
• Pap smear
• HPV DNA Test
• Management of Positive Screening Result
• Implementation of Positive Screening Result
Cervical Cancer Problem in
Indonesia
Cervical Cancer Problem In Indonesia

Estimated Cervical Cancer Estimated Cervical Cancer

Incidence Worldwide (2018) Mortality Worldwide (2018)

Indonesia: 13.6-20.6 per 100.000 Indonesia: 5.8-9.8 per 100.000

IARC, Globocan 2018

Cervical Cancer Problem In Indonesia
10 Most Women Cancer in Jakarta
Skin 3.78%

Thyroid Gland 4.18%

Leukemia 4.42%

Corpus Uteri 7.19%

Nasopharyngeal 7.29%

Ovary 7.56%

Bronchus and Lung 7.65%

Colorectal 11.68%

Cervix Uteri 17.60%

Breast 31.10%
Registrasi kanker HOGI: National Data
http://www.inasgo.org
Ministry of Health, 2007

Indonesia Screening Coverage 7.3% (ideal 80%)

J Gynecol Oncol. 2020;31(3): e55

Aoki E S, Yin R, Li, K, Bhatla N, Singhai S, Ocviyanti D, Saika K, Suh M,Kim Miseon , Termrungruanglert W
Anatomy and Histology of Cervix
 Cervix

Histology of cervix:
• Epithelium
• Basal membrane
• Stroma: smooth muscle and fibromuscular tissue, ground
substance, blood vessels, lymphatic drainage, and nerve
Ectocervix

• Non-keratinizing squamous cell

• Layers:
✓ Basal: one layer, ,mitotic phase
✓ Parabasal
✓ Intermediate
✓ Superficial: various thickness (estrogen- dependent)
Endocervix

• Columnar epithelium →
secreting mucinous fluid
• Cervical cytology (Pap Smear):
evaluating ectocervical and
endocervical
Squamo Columnar Junction (SCJ)
Natural History of HPV infection

Wright and Schiffman (2003) NEJM

Natural History of HPV infection

Cancer
HPV Mild Moderate Severe Carcinoma
Dysplasia Dysplasia In situ Carcinoma
Infection Dysplasia

3 years 3 - 20 years

Wright and Schiffman (2003) NEJM

Screening Methods
• VIA
• Pap Smear
• HPV-DNA Test
Cervical Cancer Screening Method

Pap Smear
Pap Net
Thin Prep / LBC

VIA HPV DNA Test

Cervicography Tru Scan Polar Probe

Ginoscopy Colposcopy

Lugol Test

Speculoscopy
Cervical Cancer Screening Method
CYTOLOGY NON CYTOLOGY
PAP SMEAR VISUAL
• Conventional • VIA
• Liquid Based Cytology • Cervicography
• Speculoscopy

NON- VISUAL
• HPV-DNA test
• TruScan
(The Polar Probe)
 VIA
Visual Inspection of Acetic Acid
Mechanism of Acetowhite in VIA Test

Pre-cancer lesion→ Reflective

Normal → Reflective light light distracted by dysplastic cells
pink colour→ negative VIA
→ Acetowhite ephithellium (+)
→Positive VIA
VIA TEST
• First introduced by Hinselman (1925)
• Application with Acetic Acid 3%

VIA Pap Smear

Author Test Sensitivity Spesificity
Author
Sensitivity Spesificity Sensitivity Spesificity

Gaffikin (97)& 76-90% 64-92% 44-86% 90-91%

RCT; Wang et al 93.1% 80.2%
Sankaranayan (98) IVA + HPV
(2019) (78-98.1%) (78.7-81.7%)
Mustafa R, et al 77% 82% 84% 88%

Vahedpoor Z,et all 94% 81,6% 29.7% 85,5%

Meta analysis; Li et 93.7% 85.8%
LBC + HPV
al (2016) (92.5-94.8%) (85.5-86%)
Bhattacharyya, et all 89% 87% 52% 95%

76-94% 64-92% 29,7-86% 85,5-95%

VIA Examination Technique
Inspeculo

1. Suspicious of cancer Didn’t suspect cancer

2. SCJ
Biopsy

Not visible Visible

Pap 3. IVA
Smear

Negative Positive
VIA Test Result
Negative Positive

Normal Cervix Cervix with Acetowhite

VIA Result

NABOTHIAN OVULA

NORMAL

ECTROPION
 VIA Screening Algorithm
(+)VIA

Management
according to available
facilities

Immediate
Triage by second Evaluation with ablative
1st Visit test (HPV) colposcopy management if
needed

Immediate LEEP, if the

Evaluate by
2nd Visit colposcopy if the
Biopsy of treatment if a ablation is not
suspected lesions high grade lesion appropriate
test is positive
is suspected
Biopsy of Management
Immediate the lesion if
3rd Visit definitive according to
suspicious histopathological
management if
lesions are of results
high grade

4th Visit Management

according to
histological results
PAP SMEAR
• Conventional
• Liquid Base Cytology
Pap Smear
• An examination to evaluate exfoliating epithelial in order
to detect precancerous lesion
• Prerequisite:
– Before bimanual examination
– Avoid contamination with lubrication
– Avoid sexual contact or vaginal medication before
examination in 48 hours

Feldman S. Making Sense of the New Cervical-Cancer Screening. NEJM. 2011;352:2145-7.

Pap Smear
IVA Pap smear

Peneliti Sensitivity Spesificity Sensitivity Spesificity

Gaffikin (97)& 76-90% 64-92% 44-86% 90-91%

Sankaranayan (98)
Mustafa R, et al 77% 82% 84% 88%

Vahedpoor Z,et all 94% 81,6% 29.7% 85,5%

Bhattacharyya, et all 89% 87% 52% 95%

Pap smear Sensitivity Specificity False negative False Positive

CIN 1 51%(37-84%) 98%(86-100%) 5-50% 3-15%
CIN 3 >90% 85.5%
False Negative and False Positive
False Negative False Positive
Has a high percentage of false negatives Less likely (3-15%)
(2-62%) ❖ Can induce stress in Patient
❖ 60% Sampling error ❖ Overtreatment
❖ 40% Screening Error: ❖ Misinterpretation:
23 % interpretation error – Inflammatory cell
Atrophy – Metaplastic Cell
Congregated hyperchromatic – Endometrium Cell
Dyskaryosis camouflage because of
Inflammation
15% screening error

Approximately two thirds of false-negative results are caused by sampling errors, and
the rest are caused by screening errors
Normal Cytology

Normal squamous cell Normal endocervical cell Metaplastic epithelial cell

Abnormal Cytology

Infeksi HPV CIN 3 / HGSIL Squamous cell carcinoma

 Problems & Solutions

Conventional Liquid Based Cytology

Sensitivity → 51% Sensitivity → 55.3%
Specificity → 80-90% Specificity → 93%

Mojgan Karimi-Zarchi FP, Neda Karimi, Mitra Rohi, Zohre Chiti. A Comparison of 3 Ways of Conventional Pap Smear, Liquid-Based Cytology and Colposcopy vs
Cervical Biopsy for Early Diagnosis of Premalignant Lesions or Cervical Cancer in Women with Abnormal Conventional Pap Tes. Int J Biomed Sci. 2013;9(4):205-10.
 Terminology of Pap Smear Result
Pap I II III IV V

Normal
Mild Mod Sev
Displasia Inflam Cancer
Dysplasia CIS
Normal CIN I CIN II
CIN Atypia CIN III Cancer
Koilocytosis
Benign
TBS WNL Cellular ASCUS LGSIL HGSIL HGSIL Carcinoma
Changes

TBS 2001 NEGATIF ASCUS LGSIL HGSIL HGSIL Carcinoma

Illustration

Microscopic
View
HPV-DNA TEST
HPV
• There are more than 100 types of HPV, of which at least 15
are cancer- causing (also known as high risk type)
• 99.7% cervical cancer caused by oncogenic HPV
• Oncogenic HPV: – HPV 16, 18 → >70%
– HPV 16, 18, 31,45 → >80%

HPV-DNA Test Co-testing (Pap Smear+HPV-DNA)

Sensitivity Specitifity Sensitivity Specitifity

94,6% 94,1% 100% 92.5%

(95% CI 84,2-100) (95% CI 93,4-94,8)

WHO. 2018. Human papillomavirus (HPV) and cervical cancer. Accessed: https://www.who.int/news-room/fact- sheets/detail/human-
papillomavirus-(hpv)-and-cervical-cancer (17 January 2019)
HPV Sensitivity-CIN 2+ (all ages)
Methods

• Identify high-risk types of HPV

• Methods:
– Hybrid Capture 2:
– Cervista HPV HR™
– COBAS® HPV Test
– GenoFlow HPV Array (DiagCor)

1. Kulmala S-M, Syrjänen S, Shabalova I, Petrovichev N, Kozachenko V, J. Podistov, et al. Human Papillomavirus Testing with the Hybrid Capture 2 Assay and PCR as Screening Tools. J Clin
Microbiol. 2004;42(6):2470-75.
2. Youens K, Hosler G, Washington P, Jenevein E, Murphy K. Clinical Experience with the Cervista HPV HR Assay. J Mol Diagn. 2011;13(2):160-66.
3. Rao A, Young S, Erlich H, Boyle S, Krevolin M, Sun R, et al. Development and Characterization of the cobas Human Papillomavirus Test. J Clin Microbiol. 2013;51(5):1478-84.
4. DiagCor. DiagCor: HPV-HR screening kit (FT-PRO) 2018 [cited 2019 18 January]. Available from: http://www.diagcor.com/en/.
Digene Hybrid Capture II (HC 2)
• 2000 → FDA approved the use of Digene HC2 HPV DNA testing as follow
up test for women with abnormal Pap Tests
• 2002 → ASCCP for the Management of women with cervical cytological
abnormalities listed Digene HC2 HPV DNA testing as preferred
management protocol for women with cytology diagnosis of ASC-US as
a triage prior colposcopy
• 2003 FDA cleared use of Digene HC2 as screening test to be used in
conjunction with liquid based cytology for women > 30 years
HPV-DNA Testing Methods
High Risk HPV Low Risk HPV
No Product FDA-approved
N Type N Type
1 HybridCapture II (HC2) 13 16, 18, 31, 33,35, 39, 45, 51, 52, 56, 5 6, 11, 42, 43 & 44 Approved
58, 59, & 68

2 KalGen HPV DNA 15 16,18, 31, 33,35, 39, 45, 51,52, 53, 6 6,11,42, 44, No Data
genotyping 56, 58,59, 66, 68 81

3 GenoFlow 17 16, 18, 31, 33, 35, 39, 45, 51, 52, 53, 16 6, 11, 40/61, 42, 43/44, No Data
HPV Array 56, 58, 59, 66/68,73, 82 54/55, 70, 57/71, 72, 81,
(DiagCor) 84/26
Plus universal HPV

Malloy et al. PATH, 2000

 HPV-DNA Testing Methods
High Risk HPV Low Risk HPV
No Product FDA-approved
N Type N Type
4 Linear- 14 16,18, 31, 33, 35, 39, 23 6, 11, 26, 40, 42, 53, 54, 55,
array® 45,51, 52, 56, 58, 59, 66, 61, 62, 64, 67, 69, 70, 71, 72, Not Approved
(Roche) 73, 81, 82, 83, 84, IS39, and Research Use Only
68
CP6108

5 Cobas® 14 Channel 1- 31,

HPV Test 33, 35, 39,
(Roche) 45, 51, 52, 56,
Approved
58, 59, 66,
(for confirmed abnormal
and 68
cytology result, It is not
Channel 2-
approved as single
HPV 16 screening method)
Channel 3-
HPV 18

6 Cervista 14 16, 18, 31, 33,35, 39, 45,

HPV HR 51,52,56, 58, 59, 66,68
Approved
Potential Role of HPV DNA Testing

• Primary screening
– Adjunct to cytology
• Higher Sensitivity
• Longer screening interval
• Reduced inadequate rate
– Sole Primary Test
• Use of cytology for triage
– Self Sampling
• Improved coverage
2-3 years follow-up
MANAGEMENT OF POSITIVE
SCREENING RESULT
MANAGEMENT OF POSITIVE VIA RESULT
VIA Positive

HPV-DNA Test

Negative Positive High Risk

Routine Screening
Colposcopy

Normal Abnormal

Targeted Biopsy
Histopathology
 Cervical Cancer Screening

VIA Pap Smear HPV-DNA Test

VIA (-) VIA (+)

(-) ASCH ASCUS
HGSIL LGSIL (+) High Risk
HPV-DNA test

(-)/Low risk HPV HPV

(-) (+)
16/18 Non 16/18

Cytology
abnormal
Routine Screening

Cytology
Normal

Colposcopy
Cytology (-) and HR-HPV (-)
Co-testing in 3-5 years Co-testing in 1 yrs
NCCN, Cervical cancer screening.2012
IMPLEMENTATION POSITIVE
SCREENING RESULT
Implementation in USA

• Women should begin cervical cancer testing (screening) at age 21

• Aged 21-29 → Pap smear every 3 years
• Beginning at age 30-65 → co-testing (Pap smear+ HPV test)
every 5 years or just Pap smear every 3 years

American Cancer Society. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer.
https://www.cancer.org/cancer/cervical-cancer/prevention-and-early-detection/cervical- cancer-screening-guidelines.html
Implementation in USA

Primary hrHPV screening should begin 3 years after the last negative cytology and
should not be performed only one or two years after a negative cytology result
at 23 to 24 years of age

Huh WK, et al, Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance,
Gynecol Oncol (2015), http://dx.doi.org/10.1016/j.ygyno.2014.12.022
Implementation in Indonesia

Cervical cancer screening was performed based on the level of health facilities :
• Primary health care: VIA, Pap Smear
• Proposed Guideline for VIA positive:
– First perform VIA, if positive → HPV-DNA test
– HPV DNA test positive → refer for colposcopy
• Private practice: co-testing (Pap smear and HPV-DNA)
Indication for Colposcopy
• Abnormal screening • Positive HR-HPV test
test: • Positive VIA test
▪ Cytological
abnormalities: • Abnormal Cervix
• LSIL • Post Coital Bleeding
• ASCUS (HPV + or 2
times) • Post treatment follow
• ASC-H up
• HSIL
• AGC/AIS
• Vaginal/vulvar lesions
• Carcinoma
Take Home Messages
1. Cervical screening method can be performed by early detection : VIA,
Pap Smear, and HPV-DNA test

2. Screening method can be used based on health facilities, health

physician, trained midwife/nurse, and patient social background

3. HPV-DNA test can reduced unnecessary colposcopy referral

4. Co-testing can lengthen screening interval (3 – 5 years)

THANK YOU