Chapter 1

Anatomical and pathological basis of visual

inspection with acetic acid (VIA) and with
Lugol’s iodine (VILI)

Introduction the skills and competence in administering

Naked-eye visual inspection of the and reporting the results of these tests by
uterine cervix, after application of 5% describing their basis and practice.
acetic acid (VIA) and/or of Lugol’s iodine
(VILI), provides simple tests for the early Gross anatomy of the uterine
detection of cervical precancerous lesions cervix
and early invasive cancer. VILI is similar The cervix, constituting the lower portion
to the Schiller’s iodine test, which was of the uterus, is cylindrical or conical in
used for early detection of cervical shape, and measures 3-4 cm in length and
neoplasia in the third and fourth decades 2.5-3.5 cm in diameter. It varies in size and
of the 20th century, but discontinued after shape depending on the age, parity and
the advent of cervical cytology testing. hormonal status of the woman. The lower
The potential difficulties in implementing half of the cervix, called portio vaginalis,
cervical cytology-based screening in low- protrudes into the vagina through its
resource settings have prompted the anterior wall, and the upper half, called
investigation of the accuracy of the supravaginal portion, remains above
alternative low-technology tests such as the vagina (Figure 1.1). The cervix opens
VIA and VILI in the early detection of into the vagina through the external os.
cervical neoplasia. The supravaginal portion meets the body
The results of VIA and VILI are of the uterus at the internal os. In parous
immediately available and do not require women, the cervix is bulky and the
any laboratory support. The categorization external os appears as a wide, gaping,
of the results of VIA or VILI depends upon transverse slit. In nulliparous women, the
the colour changes observed on the cervix. external os resembles a small circular
A clear understanding of the anatomy, (pinhole) opening.
physiology and pathology of the cervix is The portion of the cervix that is
absolutely essential to understand the exterior to the external os is called the
basis and to interpret the outcome of ectocervix, which is readily visible during
screening using VIA and VILI. The objective speculum examination. The portion
of this manual is to help a range of health- above the external os is called the
care providers such as doctors, nurses, endocervix. The endocervical canal,
midwives and health workers to acquire which traverses the endocervix, connects

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A Practical Manual on Visual Screening for Cervical Neoplasia

Fundus

Fallopian tube

Body of uterus

Supravaginal cervix

Internal os

Endocervix
Endocervical canal
Lateral fornix
Portio vaginalis
External os

Ectocervix

Vagina

Uterus
Cervix
Posterior fornix
Bladder
Rectum
Anterior fornix
Sacrum
Pubic bone
Vagina
Urethra

FIGURE 1.1: Gross anatomy of the uterine cervix

the uterine cavity with the vagina and supplies to the cervix. The arteries of the
extends from the internal to the external cervix, derived from internal iliac arteries
os. The portion of the upper vaginal through the cervical and vaginal branches
cavity that surrounds the portio vaginalis of the uterine arteries, descend in the
is called the fornix. lateral aspects of the cervix at 3 and 9
The stroma of the cervix is composed of o’clock positions. The veins run parallel
dense, fibro-muscular tissue traversed by to the arteries and drain into the
the vascular, lymphatic and nerve hypogastric venous plexus. The lymphatic

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 Chapter 1

Superficial cell layer

Intermediate cell layer

Stromal
papilla
Parabasal layer

Basement Basal cell layer

membrane Stroma

FIGURE 1.2: Stratified squamous epithelium (x20)

Columnar cells

Stroma

Basement membrane

FIGURE 1.3: Columnar epithelium (x40)

vessels from the cervix drain into the or fainting attacks.

common, internal and external iliac Microscopic anatomy
nodes, obturator and the parametrial Squamous epithelium
nodes. The nerve supply is derived from The cervix is covered by two types of
the hypogastric plexus. The endocervix epithelium, stratified squamous
has extensive sensory nerve endings, epithelium and columnar epithelium,
while there are very few in the which meet at the squamocolumnar
ectocervix. Hence, procedures such as junction. A large area of ectocervix is
biopsy and cryotherapy are well tolerated covered by the stratified, non-
in most women, without local keratinizing, glycogen-containing
anaesthesia. Since sympathetic and squamous epithelium. It is opaque, has
parasympathetic fibres are also abundant multiple (15-20) layers of cells (Figure 1.2)
in the endocervix, manipulation of the and appears pale pink in colour on visual
endocervix may stimulate these nerve examination. It consists of a single layer of
endings, occasionally leading to giddiness round basal cells with a large dark-staining

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A Practical Manual on Visual Screening for Cervical Neoplasia

Ectropion External os Original SCJ Metaplastic Columnar

squamous epithelium
Columnar Original epithelium
epithelium squamous
epithelium New SCJ External os

a b

c d

Mature metaplastic External os New SCJ External os Mature metaplastic squamous

squamous epithelium epithelium

FIGURE 1.4: Location of squamocolumnar junction (SCJ)

(a) Original squamocolumnar junction (SCJ) in a young woman in the early reproductive age group. The SCJ is located
far away from the external os. Note the presence of everted columnar epithelium occupying a large portion of the
ectocervix producing ectropion.
(b) The new SCJ has moved much closer to the external os in a woman in her 30s. The SCJ is visible as a distinct
white line after the application of 5% acetic acid due to the presence of immature squamous metaplastic
epithelium adjacent to the new SCJ.
(c) The new SCJ is at the external os in a perimenopausal woman.
(d) The new SCJ is not visible and has receded into the endocervix in a postmenopausal woman. Mature metaplastic
squamous epithelium occupies most of the ectocervix.

nucleus and little cytoplasm at the divide and differentiate to form the
basement membrane. The basement parabasal, intermediate and superficial
membrane separates the epithelium from layers. From the basal to the superficial
the underlying stroma. The basal cells layer, the cells undergo an increase in

4
 Chapter 1

cytoplasm and a reduction of nuclear size. does not change colour after the
The intermediate and superficial layer application of Lugol’s iodine, or remains
cells contain abundant glycogen in their slightly discoloured with a thin film of
cytoplasm. Since iodine readily stains with iodine solution.
glycogen, application of Lugol’s iodine on
the squamous epithelium will result in Squamocolumnar junction
mahogany brown or black coloration. In The squamocolumnar junction (Figure 1.4)
postmenopausal women, the cells in the appears as a sharp line. The location of the
squamous epithelium do not mature squamocolumnar junction in relation to the
beyond the parabasal layer, and do not external os varies, depending upon factors
accumulate as multiple layers of such as age, hormonal status, birth trauma
intermediate and superficial cells. and certain physiological conditions such as
Consequently, the squamous epithelium pregnancy (Figure 1.4). During childhood
becomes thin and atrophic. Thus, it and perimenarche, it is located at, or very
appears pale and brittle, with sub- close to, the external os. After puberty and
epithelial petechiae, as it is easily prone during the reproductive period, the female
to trauma. genital organs grow under the influence of
estrogen. Thus, the cervix enlarges and the
Columnar epithelium endocervical canal elongates. This leads to
The endocervical canal is lined by the the eversion of the columnar epithelium
columnar epithelium (sometimes referred onto the ectocervix, particularly on the
to as glandular epithelium), composed of a anterior and posterior lips, resulting in
single layer of tall cells with dark-staining ectropion or ectopy. Thus, the
nuclei (Figure 1.3). On visual examination, squamocolumnar junction is located in the
it appears as a grainy, strikingly reddish ectocervix, far away from the external os
area because the thin single cell layer during the reproductive years and
allows the coloration of the underlying pregnancy (Figure 1.4a). On visual
stroma to be seen more easily. It forms inspection, ectropion is seen as a strikingly
several invaginations into the substance of reddish ectocervix (Figure 1.4a).
the cervical stroma, resulting in the The buffer action of the mucus covering
formation of endocervical crypts the columnar cells is interfered with when
(sometimes referred to as endocervical the everted columnar epithelium is exposed
glands). The columnar cells secrete the to the acidic vaginal environment. This
mucus that lubricates the cervix and leads to the destruction and eventual
vagina. At its upper limit, it merges with replacement of the columnar epithelium by
the endometrial epithelium in the body of the newly formed metaplastic squamous
uterus, and at its lower limit, it meets with epithelium. Metaplasia refers to the change
the squamous epithelium at the or replacement of one type of epithelium
squamocolumnar junction. A localized by another. As a woman passes through her
proliferation of the columnar epithelium in reproductive life to the perimenopusal age
the form of a polyp may occasionally be group, the location of the squamocolumnar
visible as a reddish mass protruding from junction progressively starts moving on the
the external os (Figure 1.5). As columnar ectocervix towards the external os (Figures
epithelium does not produce glycogen, it 1.4b and c). Thus, it is located at variable

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A Practical Manual on Visual Screening for Cervical Neoplasia

a (x40) b (x20)

c (x10) d (x10)

Immature squamous metaplasia Immature squamous Mature squamous Original squamous

metaplastic epithelium metaplastic epithelium epithelium

FIGURE 1.5: Development of squamous metaplastic epithelium

(a) The arrows indicate the appearance of the subcolumnar reserve cells.
(b) The reserve cells proliferate to form two layers of reserve cell hyperplasia beneath the overlying layer of columnar
epithelium.
(c) The reserve cells further proliferate and differentiate to form immature squamous metaplastic epithelium. There is
no evidence of glycogen production.
(d) Mature squamous metaplastic epithelium is indistinguishable from the original squamous epithelium for all
practical purposes.

distances from the external os, as a result of the squamocolumnar junction towards
of the progressive formation of the new the external os and into the endocervical
metaplastic squamous epithelium in the canal is further accelerated (Figure 1.4c).
exposed areas of the columnar epithelium In postmenopausal women, the squamo-
in the ectocervix. From the perimenopausal columnar junction is located in the
period and after the onset of menopause, endocervical canal and, hence, often
the cervix shrinks, due to the lack of cannot be seen on visual examination
estrogen, and, consequently, the movement (Figure 1.4d).

6
 Chapter 1

Squamous metaplasia Columnar epithelium

The earliest event in squamous metaplasia
is the appearance of small, round, sub-
Immature squamous metaplasia
columnar cells in the exposed areas of the
columnar epithelium, called reserve cells
Infection
(Figure 1.5a). These reserve cells with
proliferate (Figure 1.5b) and differentiate oncogenic
HPV types
to form a thin, non-stratified, multicellular
epithelium called immature squamous
epithelium (Figure 1.5c). The cells in the
Normal glycogen Atypical or dysplastic
immature squamous metaplastic containing mature squamous epithelium
epithelium do not produce glycogen and, squamous metaplastic
epithelium
hence, do not stain brown or black with
Lugol’s iodine solution. Numerous foci of
immature squamous metaplasia may arise
at the same time. FIGURE 1.6: A schematic diagram of
Further development of the newly formed further maturation of immature squamous
immature metaplastic epithelium may take metaplasia.
either one of two directions (Figure 1.6). In
the vast majority of women, it develops epithelium showing precancerous cellular
into a mature, stratified, glycogen- changes), due to infection with certain
producing, squamous metaplastic human papillomavirus (HPV) types
epithelium, which is similar to the (Figure 1.6).
squamous epithelium found on the
ectocervix, for all practical purposes Transformation zone
(Figure 1.5d). Thus, it stains brown or black The transformation zone is the area of
after the application of Lugol’s iodine. the cervix where the columnar epithelium
Several cysts, called nabothian cysts, may has been replaced and/or is being
be observed in the mature metaplastic replaced by the metaplastic squamous
squamous epithelium (Figure 2.3). These epithelium. With the naked eye, one can
are retention cysts that develop as a result identify the inner border of the
of the occlusion of the crypt openings in the transformation zone by tracing the
trapped columnar epithelium by the squamocolumnar junction and the outer
overlying metaplastic squamous border by locating the distal most
epithelium. The buried columnar nabothian cysts (if present) or crypt
epithelium in the cysts may continue to openings (usually visible under
secrete mucus, which eventually distends magnification). In premenopausal
the cysts. The entrapped mucus gives an women, the transformation zone is
ivory-white hue to the cyst on visual primarily located on the ectocervix. After
examination. menopause, and through old age, the
In a very small minority of women, the cervix shrinks with the decreasing levels
immature squamous metaplasia may turn of oestrogens. Consequently, the
into a dysplastic epithelium (an altered transformation zone may move partially,

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A Practical Manual on Visual Screening for Cervical Neoplasia

a b

FIGURE 1.7:
(a) An inflamed cervix, with ulceration, bleeding, necrosis, greenish-yellow discharge and inflammatory exudate.
(b) A reddish angry-looking, inflamed cervix with loss of the villi in the columnar epithelium and covered with
inflammatory exudate.

and later fully, into the endocervical trachomatis, Escherichia coli, streptococci,
canal. Almost all cervical neoplasia occurs and staphylococci; and viral infections such
in this zone, close to the squamocolumnar as Herpes simplex.
junction. Columnar epithelium is more prone to
infection than squamous epithelium. We
Inflammation of the uterine cervix use the term cervicitis in this manual to
(Figure 1.7) denote all cervicovaginal inflammatory
The most common pathological condition conditions. Clinically, cervicitis may be
affecting a woman’s cervix is inflammation. associated with symptoms such as
This is caused mostly by infection (usually excessive discharge, itching of the vulva
polymicrobial) and, less commonly, by and vagina, pain and a burning sensation
foreign bodies (retained tampon, etc.), during sexual intercourse and lower
trauma and chemical irritants such as gels abdominal pain. Clinical signs include
and creams. The infectious agents causing excessive, coloured (greyish, greyish-
inflammation in the cervix include: white, curdy-white (in the case of candidial
Trichomonas vaginalis; Candida albicans; infection), yellow or greenish-yellow),
overgrowth of anaerobic bacteria such as malodorous or non-odorous, frothy or non-
Gardnerella vaginalis, G. mobilluncus and frothy secretions, tender, reddish cervix
peptostreptococcus; other bacterial with or without vesicles, ulcerations
infections such as Haemophilus ducreyi, and/or fibrosis; the columnar epithelium
Neisseria gonorrhoeae, Chlamydia may look flattened; and there may be

8
 Chapter 1

excoriation marks on the vulva, vulval as well as cervical tenderness. Women with
erythema and oedema, vagina and inner non-candidial cervicitis may be treated
thigh and perineum. Microscopically, with a combination of metronidazole 400
cervicitis is characterized by cellular debris mg plus doxycycline 100 mg orally, two
and excessive secretions covering the times a day for seven days. Those with
epithelium, swollen and inflamed cells, candidial cervicitis may be treated with
desquamation of the glycogen-containing clotrimazole or micanazole 200 mg
superficial and intermediate cells, intravaginally, daily for three days.
epithelial denudation, superficial or deep
ulceration and congestion of the underlying Cervical neoplasia
cervical stroma. Chronic inflammation Invasive cervical cancers are usually
results in recurrent ulceration and may preceded by a long phase of preinvasive
lead to healing by fibrosis. disease, characterized microscopically as a
A diagnosis of cervicitis can be made spectrum of precursor lesions progressing
based on the clinical features. On visual from cellular atypia to various grades of
examination, cervicitis due to non- cervical intraepithelial neoplasia (CIN)
candidial infection may be characterized before progression to invasive carcinoma.
by vulval erythema and oedema, Epidemiological studies have identified a
excoriation marks in the vulva and vagina number of risk factors that contribute to
and a reddish, tender cervix with the development of CIN and cervical
malodorous, greenish yellow or greyish- cancer. These include infection with
white mucopurulent discharge, with or certain types of human papillomavirus
without ulceration. In the case of (HPV), sexual intercourse at an early age,
gonococcal cervicitis, painful urethral multiple sexual partners, multiparity, long-
discharge is also observed. Candidial term oral contraceptive use, tobacco
cervicitis is characterized by vulval oedema smoking, low socioeconomic status,
and erythema, excoriation, and thick, infection with Chlamydia trachomatis,
curdy-white, non-odorous discharge. micronutrient deficiency and a diet
Herpes infection is associated with the deficient in vegetables and fruits. HPV
presence of vesicles and ulcers in the types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56,
external genitalia, vagina and the cervix, 58, 59 and 68 are strongly associated with

Table 1: Correlation between CIN, dysplasia and the Bethesda

CIN 1 CIN 2 CIN 3

Mild dysplasia Moderate dysplasia Severe dysplasia

Carcinoma in situ

Low-grade squamous High-grade squamous High-grade squamous

intraepithelial lesion (LSIL) intraepithelial lesion (HSIL) intraepithelial lesion (HSIL)

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A Practical Manual on Visual Screening for Cervical Neoplasia

CIN and invasive cancer. Persistent after application of Lugol’s iodine solution.
infection with one or more of the above The final diagnosis of CIN is established
HPV types is considered to be a necessary
cause for cervical neoplasia.
Infection with one or more of the
oncogenic HPV types may result in the
integration of the viral genome into the
host cellular genome resulting in the
formation of cervical neoplastic cells, the
proliferation of which leads to various
grades of CIN (synonyms: dysplasia or
squamous intraepithelial lesions (SIL)), a b
which may progress to invasive cervical
cancer. The correlation between the CIN
terminology, used in this manual, and other FIGURE 1.9:
terminologies is given in Table 1. Histology of CIN 2: Atypical cells are found
mostly in the lower two-thirds of the
Cervical intraepithelial neoplasia epithelium x10.
There are no specific symptoms or visible
signs associated with CIN. However, the
presence of CIN may be suspected by the
naked-eye detection of well defined,
acetowhite areas in the transformation
zone, close to or abutting the
squamocolumnar junction, after the
application of 3-5% acetic acid or of well
defined mustard or saffron yellow iodine
non-uptake areas in the transformation zone

FIGURE 1.8: FIGURE 1.10:

Histology of CIN 1: The dyplastic cells are Histology of CIN 3: Dysplastic cells are
confined to the lower third of the epithelium distributed in the full thickness of the
x20. epithelium with loss of polarity of cells x20.

10
 Chapter 1

by histopathological examination of tissue Women with CIN 1 may be advised to

specimens from the cervix. The undifferen- undergo immediate treatment (e.g., in
tiated cells in CIN are characterized by situations where follow-up of women
enlarged nuclei, increased intensity of cannot be assured) or treated later if two
nuclear staining, nuclear polymorphism follow-up visits at six or nine months apart
and variation in nuclear size, and a reveal persistent or progressive disease.
decreased amount of cytoplasm, resulting The precursor lesion that arises from the
in a higher nuclear cytoplasmic ratio. The columnar epithelium is referred to as
proportion of the thickness of the adenocarcinoma in situ (AIS). In AIS,
epithelium showing undifferentiated cells normal columnar epithelium is replaced by
is used for grading CIN. In CIN 1 the undif- abnormal epithelium showing abnormal,
ferentiated cells are confined to the irregularly arranged cells with increased
deeper layers (lower third) of the size of cells and nuclei, nuclear
epithelium (Figure 1.8). Mitotic figures are hyperchromasia, mitotic activity, reduction
present, but not very numerous. CIN 2 is of cytoplasmic mucin expression and
characterized by dysplastic cellular cellular stratification.
changes mostly restricted to the lower half
or the lower two-thirds of the epithelium, Invasive cancer
with more marked nuclear abnormalities In very early phases of invasion, cervical
than in CIN 1 (Figure 1.9). Mitotic figures cancer may not be associated with obvious
may be seen throughout the lower half of symptoms and signs, and, therefore, is
the epithelium. In CIN 3, differentiation known as preclinical invasive cancer.
and stratification may be totally absent or Women with moderately advanced or
present only in the superficial quarter of advanced invasive cervical cancer often
the epithelium with numerous mitotic present with one or more of the following
figures (Figure 1.10). Nuclear symptoms: intermenstrual bleeding,
abnormalities extend throughout the postcoital bleeding, excessive seropurulent
thickness of the epithelium. Many mitotic discharge, recurrent cystitis, backache,
figures have abnormal forms. lower abdominal pain, oedema of the lower
It is well established that most CIN 1 extremities, obstructive uropathy, bowel
lesions are transient; most of them regress obstruction, breathlessness due to severe
to normal, within relatively short periods, anaemia and cachexia.
or do not progress to higher grades. High- As the stromal invasion progresses, the
grade CIN (CIN 2-3), on the other hand, disease becomes clinically obvious,
carries a much higher probability of showing several growth patterns, which
progressing to invasive cancer, although a are visible on speculum examination.
large proportion of such lesions also regress Early lesions may present as a rough,
or persist. It is assumed that the mean reddish, granular area that bleeds on
interval for progression of cervical touch (Figure 1.11) More advanced
precursors to invasive cancer may be as cancers may present as a proliferating,
long as 10 to 20 years. bulging, mushroom- or cauliflower-like
Women with CIN are treated with growth with bleeding and foul-smelling
cryotherapy, loop electrosurgical excision discharge (Figure 1.12). Occasionally
procedure (LEEP) or cold-knife conization. they may present without much surface

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A Practical Manual on Visual Screening for Cervical Neoplasia

FIGURE 1.11: FIGURE 1.12:

Early invasive cervical cancer: note the Advanced invasive cervical cancer: note the
irregular, granular, nodular surface with bulging, cauliflower-like, ulceroproliferative
bleeding on touch. growth with bleeding and necrosis.

growth, resulting in a grossly enlarged, countries are squamous cell cancers

irregular cervix with a rough, granular (Figure 1.13) and 2-8% are adenocarcinomas
surface. (Figure 1.14). It is obligatory that all
As the invasion continues further, it may invasive cancers be clinically staged. The
involve the vagina, parametrium, pelvic most widely used staging system for
sidewall, bladder and rectum. Compression cervical cancer was developed by the
of the ureter, due to advanced local disease, International Federation of Gynecology and
causes ureteral obstruction, which results in Obstetrics (FIGO) (see Appendix 1). This is
hydronephrosis and, ultimately, renal primarily a clinical staging system based on
failure. Regional lymph node metastasis tumour size and extension of the disease in
occurs along with local invasion. Metastatic the pelvis. The extent of growth of cancer
cancer in para-aortic nodes may extend is assessed clinically, as well as by various
through the node capsule and directly investigations, to categorize the disease
invade the vertebrae and nerve roots stages I through IV. Stage I represents
causing back pain. Direct invasion of the growth localized on the cervix, while stage
branches of the sciatic nerve roots causes IV represents the growth phase in which the
low back pain and leg aches, and cancer has spread to distant organs by
encroachment of the pelvic wall veins and metastasis.
lymphatics causes oedema of the lower Women with early invasive cancers
limbs. Distant metastases occur late in the (stages I and II A) may be treated with
disease, usually involving para-aortic nodes, radical surgery and/or radiotherapy.
lungs, liver, bone and other structures. Those with stage IIB and III cancers may be
Histologically, approximately 90-95% of treated with radiotherapy with or without
invasive cervical cancers in developing cisplatinum-based chemotherapy. Women

12
 Chapter 1

↓
↓
↓

FIGURE 1.13: FIGURE 1.14:

Histology – Keratinizing well differentiated Histology – Well differentiated invasive
invasive squamous cell carcinoma. Note adenocarcinoma. Note the malignant cells
the stroma is infiltrated by sheets of malignant lining the cervical crypts x20.
cells x10.

with stage IV cancers are usually treated precipitation of the cellular proteins. It
with palliative radiotherapy and/or also causes swelling of the epithelial
chemotherapy and with symptomatic tissue, columnar and any abnormal
measures. squamous epithelial areas in particular,
dehydration of the cells, and it helps in
Other conditions coagulating and clearing the mucous
Leukoplakia (hyperkeratosis) is a well secretions on the cervix. The normal
demarcated white area on the cervix squamous epithelium appears pink and the
(before the application of acetic acid), due columnar epithelium red, due to the
to keratosis, visible to the naked eye. reflection of light from the underlying
Usually leukoplakia is idiopathic, but it may stroma, which is rich in blood vessels. If the
also be caused by chronic foreign body epithelium contains a lot of cellular
irritation, HPV infection, or squamous proteins, acetic acid coagulates these
neoplasia. Condylomata or genital warts proteins, which may obliterate the colour
are often multiple, exophytic lesions that of the stroma. The resulting
are usually found on the cervix, and acetowhitening is seen distinctly as
occasionally in the vagina and on the vulva, compared with the normal pinkish colour of
caused by infection with certain HPV types the surrounding normal squamous
such as 6 and 11. They may also present as epithelium of the cervix, an effect that is
a diffuse, greyish-white lesion involving commonly visible to the naked eye. Thus,
areas of the cervix and vagina. the effect of acetic acid depends upon the
Condylomata may be obvious to the naked amount of cellular proteins present in the
eye (before the application of acetic acid). epithelium. Areas of increased nuclear
activity and DNA content exhibit the most
Pathophysiological basis of VIA dramatic white colour change.
Application of 5% acetic acid is believed to When acetic acid is applied to normal
cause a reversible coagulation, or squamous epithelium, little coagulation

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A Practical Manual on Visual Screening for Cervical Neoplasia

occurs in the superficial cell layer, as this is The acetic acid effect reverses much more
sparsely nucleated. Although the deeper slowly in CIN lesions and in early preclinical
cells contain more nuclear protein, the invasive cancer than in immature squamous
acetic acid may not penetrate sufficiently metaplasia and inflammation. It appears
and, hence, the resulting precipitation is rapidly and may last for 3-5 minutes in the
not sufficient to obliterate the colour of case of CIN 2-3 and invasive cancer.
the underlying stroma. Areas of CIN and
invasive cancer undergo maximal Pathophysiological basis of VILI
coagulation due to their higher content of Squamous metaplastic epithelium is
nuclear protein (in view of the large glycogenated, whereas CIN and invasive
number of undifferentiated cells contained cancer cells contain little or no glycogen.
in the epithelium) and prevent light from Columnar epithelium does not contain
passing through the epithelium. As a result, glycogen. Immature squamous metaplastic
the sub-epithelial vessel pattern is epithelium usually lacks glycogen or,
obliterated and the epithelium appears occasionally, may be partially
densely white. In CIN, acetowhitening is glycogenated. Iodine is glycophilic and
restricted to the transformation zone close hence the application of iodine solution
to the squamocolumnar junction, while in results in uptake of iodine in glycogen-
cancer it often involves the entire cervix. containing epithelium. Therefore, the
The acetowhite appearance is not unique normal glycogen-containing squamous
to CIN and early cancer. It is also seen in epithelium stains mahogany brown or black
other conditions when increased nuclear after application of iodine. Columnar
protein is present, as in immature epithelium does not take up iodine and
squamous metaplasia, in healing and remains unstained, but may look slightly
regenerating epithelium (associated with discoloured due to a thin film of iodine
inflammation), leukoplakia (hyperkeratosis) solution; areas of immature squamous
and condyloma. While the acetowhite metaplastic epithelium may remain
epithelium associated with CIN and early unstained with iodine or may be only
invasive cancer is more dense, thick and partially stained. If there is shedding (or
opaque with well demarcated margins from erosion) of superficial and intermediate cell
the surrounding normal epithelium, the layers associated with inflammatory
acetowhitening associated with immature conditions of the squamous epithelium,
squamous metaplasia, inflammation and these areas do not stain with iodine and
regenerating epithelium is less pale, thin, remain distinctly colourless in a surrounding
often translucent, and patchy with ill- black or brown background. Areas of CIN
defined margins. Acetowhitening due to and invasive cancer do not take up iodine
inflammation and healing is usually (as they lack glycogen) and appear as thick
distributed widely in the cervix, not mustard-yellow or saffron coloured areas.
restricted to the transformation zone and Areas with leukoplakia (hyperkeratosis) do
may quickly disappear (within a minute). not stain with iodine either, and
Leukoplakia and condylomata appear condylomata may not, or occasionally may
intensely greyish-white after the only partially, stain with iodine.
application of acetic acid.

14