Final Thesis Report Aji

8/10/2019 Final Thesis Report Aji

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TO STUDY THE ROLE OF

COLPOSCOPY IN CERVICAL

EROSION

A Dissertation submitted for the degree of

Diplomate of National Board Delhi

Obstetrics and Gynaecology

December 2014


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CERTIFIED BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled "To Study the

Role of Colposcopy in cervical erosion" is a bonafide and genuine research

work carried out by me under the guidance ofDr. Ujjwala S Patki, M.D,

Consultant Gynecologist , Patki Hospital and Research Foundation,

Kolhapur, Maharashtra. This dissertation has been prepared in fulfilment to

the requirement of the DNB programme in accordance with standards and

guidelines set by the National Board of Examinations.

This has not been submitted by me previously for the award of any

Di l /D t th i it


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CERTIFICATE BY THE GUIDE

This is to certify that Dr.Priyanka T.Suryawanshi

(DNB Reg. No. 125-31181-121-103940)

Has prepared this dissertation entitled "To Study the Role of Colposcopy

in cervical erosion" under my guidance and to my satisfaction, in the

fulfilment of the requirement for the DNB Programme in accordance and

guidelines set by the National Board of Examinations.


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CERTIFICATE BY HEAD OF DEPARTMENT

This is to certify that the dissertation entitled "To Study the Role of

Colposcopy in cervical erosion" is bonafiede research work done by

Dr.Priyanka T.Suryawanshi in partial fulfilment of the requirement for the

DNB Programme in accordance and guidelines set by the National Board of

Examinations.


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ACKNOWLEDGEMENTS

I attribute the successful completion of my dissertation to the

guidance and support of many people to whom I am very grateful and I take

this opportunity to thank everyone who made it possible.

I take this opportunity to express my profound gratitude and

overwhelming respect to HODDr. Satish M Patki (MD) ,whose esteemguidance helped me in successful completion of the study. It is indeed my

greatest fortune in my life to his student.

I am extremely grateful toDr. Ujjwala S. Patki(MD)for her constant

supervision with great encouragement and learned guidance.


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ABSTRACT

Background and Objective:

This was a prospective Observational study conducted from

Jan 2012-Jan 2013 at Patki Hospital and Research

Foundation, Kolhapur, Maharashtra.

The study was performed on 100 women between 20-60years

of age presenting with complaints of chronic leucorrhoea,

postcoital bleeding, intermenstrual bleeding etc.

The objective of study were to study the various pathological

findings on colposcopy , also cytological and Histopathological

observations in patients of cervical erosion under colposcopic

guidance. Also to compare and correlate the colposcopy , HPE

d i l fi di


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specificity, positive predictive value. Negative predictive value,

Accuracy and Strength of correlation were calculated.

Results:

Majority 70.5% CIN occurred in age group 3 0-49 years.

Incidence of CIN increases among multipara.

Women having CIN 70.5% complained of excessive

discharge.

Pap smear had sensitivity 29% and Specificity 88%,

accuracy 78%.

Colposcopy showed sensitivity 83%,specificity 81%.

Accuracy was found to be 82%.

Strength of Agreement between colposcopy and

Histopathology is moderate., while strength of agreement

b l d


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TABLE OF CONTENTS

PARTICULARS PAGE

1 INTRODUCTION 1

2 AIMS AND OBJECTIVES 4

3 REVIEW OF LITERATURE 5

4 MATERIAL AND METHOD 42

5 OBSERVATIONS AND RESULTS 50

6 DISCUSSIONS 65


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LIST OF TABLES

1.

Colposcopic Reid Index

2.

Distribution of cases according to Age

3. Distribution of cases according to parity

4.

Distribution of cases according to symptoms

5.

Distribution of cases according to contraceptives

6. Colposcopic findings according to age

7.

Colposcopic findings according to Parity

8. Colposcopic findings according to Complaints

9.

Colposcopic findings according to contraceptives

10.

Pap smear findings according to Age

11. Pap smear findings according to parity

12.

Pap smear findings according to Complaints

13 P fi di di t C t ti


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INTRODUCTION

INTRODUCTION

Cervical cancer is the commonest malignancy found

amongst Indian women and third most common cancer in the

world1. Over 5,00,000 new cases of invasive cervical cancer are

diagnosed annually worldwide2.Cervical cancer is serious

health problem in India which accounts for the worlds onesixth of the worlds population. There are approximately

130,000 new cases of cervical cancer every year and the

disease is responsible for 20% of all the female death.

As carcinoma of cervix is the most frequent of all the

genital tract cancers. it is very common for the Gynaecologist

who work in tertiary care institutes in the developing countries

to get referrals from practitioners and peripheral health centres

f ti t f li i l di i f h lth i3

C i l


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INTRODUCTION

A colposcopic evaluation and guided biopsy remains a

critical diagnostic step for women with squamous

intraepithelial lesion, in order to identify the women who

require treatment .Simultaneous use of cytological studies and

screening colposcopy has been shown to increase the rate of

cervical cancer detection.6

Colposcopy performs better in differentiation of low

grade disease from normal cervix.7

And Correlated with directed biopsy is described as the

reference investigation as Gold standard for the diagnosis of

cervical cancer.8

Colposcopy is close examination of vagina and cervix. It

is medical diagnostic procedure to examine an illuminated


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INTRODUCTION

are intrinsic to the in vivo tissues, have lead to development of

a useful adjunct to improve the colposcopic detection of a high

grade CIN.

The additional of the LUMATM(medispectra,Inc MA USA)cervical

imaging system to colposcopy has been shown in two

prospective, to a result in a25% or greater increase in the true

positive biopsy rate of the colposcopy for patients with atypical

squamous cell or low grade intraepithelial lesion on pap smear

examinations, with only 4% increase in the false positive rate,

versus that of colposcopy alone.10

Present study will be undertaken to evaluate the role of

colposcopy in patients having cervical erosion. The earlier

diagnosis of CIN and of invasive cervical cancer in women is a

d i bl l H l i l ti f h lth


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AIMS AND OBJECTIVES

AIMS AND OBJECTIVES

1.

To Study various Pathological finding on Colposcopy of

patients having Cervical Erosion.

2.

To Study various Cytological findings of the Smear of

Patients of Cervical Erosion

3.

To Study various Histological Observations of the Cervical

Biopsy in patient of cervical erosion under colposcopy

guidance


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RIVIEW OF LITERATURE

REVIEW OF LITERATURE

Cervical cancer is one of the well understood human

cancers and potentially the most preventable. The anatomic

accessibility of cervix to direct examination and long pre-

clinical stage during which 95% of precursor lesion can be

treated conservatively and successfully make cervical cancer

an ideal target for screening and treatment.

The basic purpose of screening is to sort out from large

group of healthy person those likely to have disease or at

increased risk of disease under study and to bring those who

are apparently abnormal under medical supervision.

Screening test should be simple, minimally invasive, easy to

f ff i d hi hl i i P i i i i


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at variable level relative to the Cervical Os and changes with

hormonal variations that occurs during a womens life .It is in

this active area of cellular transition that the cervix is most

susceptible to malignant transformation12. The squamo-

columnar junction (SCJ) is the point at which the squamous

and columnar cells meet. It typically found between the centralectocervix and the lower cervical canal, but location varies

throughout a womans life, from fetal development to

menopause.

In reproductive aged women, the original SCJ moves outinto the portio of the cervix with hormonal influence. The

acidic vaginal pH plus mechanical irritation likely induces the

process of squamous metaplasia, resulting in a new SCJ. The

area between the original and new squamocolumnar junction


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1.Basal layer(Stratum Germinatum): It rests on the

basement membrane. It consist of single row of cuboidal or

columnar cells with scanty basophilic cytoplasm and centrally

placed round to oval large nucleus.

2.Parabasal or Prickle cell layer: It is above the basal layer,4-

10 cells in thickness consisting of large polyhydral cells with

basophilic cytoplasm and centrally placed nucleus, arranged in

irregular mosaic pattern.

3.Intermediate cell layer: It forms the bulk of the epithelium.

The cells are large oval to polygonal with irregular vesicular

nuclei. The cytoplasm is rich in glycogen.

4.Superficial layer: It is made up of flattened, elongated or

polygonal cells with acidophilic cytoplasm and small pyknotic


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3.

Oral contraceptives: There is significantly increased

risk of cervical cancer in patient who have used oral

contraceptives, the incidence increasing with duration of

use.

4.

Infectious agents: Human papilloma virus- HPV

infection has been demonstrated in almost 100% ofinvasive cervical carcinoma. HPV types are 6, 11, 42, 44 ,

subtype 16 and 18 are found in 62% of cervical

carcinoma. The mechanism by which HPV affects cellular

growth and differentiation is through the interaction of

viral E6 and E7 proteins with tumour suppressor genes

p53 and Rb, respectively. Inhibition of p53 prevents cell

cycle arrest and cellular apoptosis, which normally occurs

when damaged DNA is present. Whereas inhibition of Rb

di i i f E2F l i i l d


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Premalignant and Malignant squamous lesion of

cervix

1.Low Grade Squamous intraepithelial lesion(LSIL) (CIN 1

and HPV changes )-

In CIN 1 or LSIL , only the lower third of epithelium is involvedand above this the mucosa shows maturation to a normal

surface layer.17 The cumulative rate of progression of mild

dysplasia to moderate and severe dysplasia at 2,5,and 10 years

were 11.1%, 20.4% , and 28.8% respectively, and for

progression to severe dysplasia, rates of progression at 2,

5,and 10 years were 2.1%, 5.5%, 9.9% respectively.18

2. High Grade Squamous intraepithelial lesion HSIL(CIN 2

d CIN 3)


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squamous epithelium. Proximally CIN involves the cervical

clefts and this area tends to have more severe lesions.

CIN is most likely to begin either during menarche or

after first pregnancy when metaplasia is more active.

Conversely a woman who has reached menopause without

developing CIN has little metaplasia and is at a lower risk.

CIN Terminology

Richart recommended use of the term cervical neoplasia

(CIN) to replace dysplasia and carcinoma in situ. CIN isclassified into grades 1, 2 and 3 in which the artificial

distinction between severe dysplasia and carcinoma in situ is

avoided by including them both in CIN 3.20

Th h d S


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I.Negative for Intra epithelial lesion or malignancy

II.Epithelial cell abnormalities

a)

Squamous cells

i)

Atypical squamous cells of undermined significance

cannot exclude high grade squamous intraepithelial

lesions. (HSIL).

ii)

Low grade squamous intra epithelial lesions

(encompassing human papilloma virus/mild

dysplasia/ cervical intraepithelial neoplasia )

iii)

HSIL ( moderate and dysplasia, carcinoma in situ, CIN

2,and CIN 3.)

iv) Squamous cell carcinoma.

b)

Glandular cells

i) i l l d l ll ( if d i l


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Screening Techniques

Screening techniques for cervical cancer include 24

i)

Conventional exfoliative cervicovaginal cytology ,that is

cervical PAP smear

ii) Fluid sampling techniques with automated thin layerpreparation (Liquid based cytology)

iii) Automated cervical screening techniques

v) Neuromedical systems

vi)

HPV -DNA testing

vii) Polar probe

viii) Laser induced Fluorescence


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Cytology

Papanicolaou and Traut first reported the use of

exfoliative cervical cytology for the diagnosis of cervical cancer

and precancer. They obtained cellular material from vaginal

pool. Ayre reported the use of wooden spatula to scrap cellular

material directly from cervical transformation zone. Centre of

cytology in Vancouver, British Columbia published data which

confirmed that cytological screening leads to a reduction in the

rate of invasive cancer of uterine cervix.25 The indigenous

technique of collecting exfoliated cells from the cervix, placingthem on a glass slide and examining under a microscope

remained largely unchanged for more than 50 years.26

Advantage of cytology are ideal for mass screening, high

f f l k b h


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Changes in cervix after application of acetic acid(3-5%)

1.

It coagulate the cytoplasmic and nuclear protein of the cells.

The abnormal epithelium has increased nuclear

:cytoplasmic ratio leading to an increased amount of

protein in the cells, which are coagulated and thereby

hinders light transmission. The lesion appear white. This

coagulation is progressive, superficial, reversible and

reproducible.

2.

It dissolves the mucous.

3.

It causes intracellular dehydration due to osmotic changes.4.

It causes swelling of the individual villi of the columnar

epithelium.

Intensity of whiteness, speed of appearance, duration of stay

and speed of disappearance are directly related to severity of


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Cervicography

Developed by Adolf Stafl . Cervicography involve taking

photographs of the cervix with a specially designed camera

called cervicoscope following the application of 5%acetic acid.

The photographs are then developed, projected and viewed by

an expert colposcopist.32

Six hundred and fifty three women attending a family

planning clinic in Kenya underwent four concurrent methods

; pap smear, visual inspection with acetic acid, PCR for high

risk HPV and cervicography. The pap smear had the highest

specificity and HPV testing had highest sensitivity. The visual

methods and cervicography were similar and showed an

accuracy in between the former two tests.33


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Speculoscopy

Speculoscopy involves inspection of cervix following application

of 5% acetic acid with Chemiluminiscent and a low power

magnification.

In a prospective study, a total 1000 patients were subjected to

cytology and speculoscopy examinations. Among these women,

10 had abnormal pap smear findings whereas 144 had an

abnormal speculoscopic pattern. Only three of 59 patients with

a histological diagnosis of cervical intraepithelial neoplasia

grade I (CIN 1)/HPV and only three of seven patients with CIN

2/CIN 3 had a positive Pap test. This concludes that

speculoscopy combined with a Pap test can significantly

increase the detection of cervical lesion when included in a


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and its popularity increased. This was further aided by the

manufacture of this instrument in all parts of world.35

Colposcopy introduced by Prof. Hinselmann (1925) is an

optical method for visualizing the lower female genital tract

with bright illumination using stereoscopic vision, at a

magnification between 4 and 40 fold. It has many advantages

over cytology. it permits the topographical study of lesion

during clinical examination. It is an important tool which

complements cytology and histopathology in early detection

various cervical lesions.

Thus, colposcopy is the traditional method for evaluation of

abnormal Pap smears and today colposcopy has a central role

in the cervical screening programs. Initially, colposcopy was


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tool for the diagnosis of CIN. Its integral role in the

management of early cervical cancer was justified.37

Basics of colposcopy

Colposcopy is a clinical method which evaluates changes in theterminal vascular network of cervix that reflects the

biochemical and metabolic changes in the tissue. It consist of

examination of connective tissue of the cervix, across the

mucosa using stereoscopic vision.

The following factors are assessed38.

1.Colour, tone and opacity of the mucosa

2.

Surface contour


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The Objectives of colposcopic assessment are

To further assess of colposcopic assessment .

To confirm diagnosis by colposcopically directed biopsy

To exclude invasive disease

Colposcopic Technique

Favourable period for colposcopic examination is 8-10thday of

a cycle as the external os is widely open during this time and

abundance of watery secretions serves as a good refractory

medium and facilitates examination of endocervix.

If the upper limit of TZ is not visible, the examination may be

rescheduled and the patient is instructed to take Ethinyl


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2.Coloumner epithelium

Irregular surface with atypical grape like or villus appearance .

Each Villus contains fine capillary that is visualised with

saline. Under high magnification colour appears reddish

because of underlying stromal vessels.

3.Normal transformation zone

Area between the original SCJ and new SCJ in which

metaplastic epithelium has replaced the pre existing columnar

epithelium. Coppleson and Reid in 1967, described the

features of immature metaplasia in three stages after acetic

acid application.


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Components of TZ are-

1.Branching vessels- Large Capillaries showing tree like

branching pattern found only in TZ in the walls of retention

cysts.

2.Nabothian follicles-Mucous filled retention cyst

3.

Gland opening-small holes from which mucous seems to

pour, representing areas where the new squamous

epithelium has covered incompletely and underlying

columnar cleft is in continuity with the surface.

Abnormal Colposcopic Findings

CIN tend to be confined to the TZ. On contrast, subclinical

papilloma virus infection is not so limited and may involve the


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3.

Acetowhite epithelium-It is a focal colposcopic lesion

visible after application of acetic acid as a transient change.The surface contour may be flat or may have papillary

projection or brain like convolutions42.

4.Leukoplakia-This plaque is white epithelium visible before

application of acetic acid. This is due to hyperkeratosis and

parakeratosis resulting in keratin on the surface and may

overlie normal as well as abnormal epithelium. It may be

thin which is usually not significant or thick with irregular

surface usually seen in pronounced atypical lesion.42

5.

Atypical vascular pattern- are characteristic of invasive

cervical cancer and include looped vessels, branching


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2.

Exophytic condyloma- it is seen in HPV which occurs

either inside/outside the TZ. Surface is micropapillary ormicroconvoluted AW areas may be flat or dense and

irregular vessels may be present.

3.Inflammation (vaginocervicitis)-Diffuse pattern of

hyperaemia, characterized by alterations in capillaries

that may be coiled, dilated or duplicated. Occur like

punctuate, mosaic like pattern as seen in trichomoniasis.

More marked inflammation produces yellow spots due to

lymphocytes collection, white spots, minute papillae. No

change on acetic acid application Iodine staining

produces partial uptake.


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8.

Deciduosis- Change during pregnancy in which stroma

becomes oedematous and hyperplastic.

9.

Leukoplakia-White epithelium, that is present before the

application of acetic acid. It is a focal colposcopic lesion in

which hyperkeratosis or parakeratosis is present. It is

identified both inside or outside TZ.

Inflammatory lesions

Nonspecific acute inflammation

Cervix and Vagina appear red due to congestion of

connective tissue.

Increase in number as well as calibre of terminal vessels.

Fine regular, diffuse punctations may be seen often


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SCREENING INTERVALS

ACS-American Cancer Society 2002 Guidelines45

1.

Age to initiate screening-Three years after the onset of

sexual activity, not later than the age 21 years.

2.

Screening frequency-Annually with conventional cytology

or every 2 years with liquid based cytology. After the age of

30, women with 3 consecutive normal tests may be screened

every 2-3 years.

3.

Discontinuation- after age 70 years.

4.

Routine screening for HPV infection- Not yet FDA

approved conventional or liquid based cytology combined


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Colposcopic Combined IndexTable 1Colposcopic

sign

0 (zero) 1(one) 2(two)

Margine Condylomatous or

micropappilary

Contour,indistinct

acetowhitening

Flocculated or

feathered margin

Angular jasgged

lesions.Satellite

Lesions and

acetowhitening

Regular

lesions

With

straight

outlines

Rolled peeling

edges.Internal

demarcation

between areas

of

Differing

appearance


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Modified forms of Colposcopy

Telecolposcopy

A video colposcope is used to record video clips which

were subsequently transmitted to a interpretation. This

is used to develop a secondary screening technique for

use in primary care.

Digital Colposcopy

Real time or downloaded for later review. Additionally,

the image may be subsequently modified which may

enhance visualization of potential abnormality, to allow

measurement of lesion.


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Problems encountered in colposcopy may arise due to

1.Inadequate expertise:- An inexperienced colposcopist may

find difficulty in assessment of various lesions. Recognition of

squamocolumnar junction is crucial to identify the upper limit

of lesion. A novice colposcopist may give more importance to

minor grades of mosaic or punctuation than major grades of

acetowhite epithelium leading to biopsy from a wrong area.

2.Interpretive problems and limitations:- There are various

conditions which create confusion in colposcopicdifferentiation. Immature or active metaplastic epithelium may

be difficult to differentiate from early grades of CIN. Vascular

pattern may lead to confusing picture. Colposcopy may be

unsatisfactory at times.


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overlaid on a colour image of tissue to help the clinician

determine the presence and grade of lesion .DySIS consist of an optical head with white light emitting

diode for uniform illumination and magnification optics

coupled to a digital colour charged-coupled device, camera for

image capture. It also include a computer and control

electronics .The optical head does not come into contact with

the tissue. It magnifies images between 10 and 27 times. It is

mounted on a mechanical arm to position and stabilize it., and

locked into an extension shaft attached to the speculum, to

ensure a stable field of view during image acquisition. For this

reason, the speculum used with DySIS is different from the

standard speculum used in colposcopy. The average duration

of use per examination is less than 15 minutes.


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Niris device consist of an image-management console and

docking station, a laptop computer user interface , 2.7mmfront viewing screen, flexible optical probe and accessories. The

image acquisition and measurement tools are sufficiently fast

to allow image data to be analysed in real time and at the site

of care. According to the manufacture the average duration of

use per treatment for Niris alone is 2 minutes.

Niris probes can be used for around 200 procedures, and may

be processed for reuse. A disposable probe sheath can be used

to provide physical stability and help prevent cross-

contamination.

LuViva - Cervical scan52

LuViva is a technologically advanced diagnostic device that


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Managing Histological abnormalities

Ones a lesion has been identified on colposcopy and biopsy

has been completed , a decision must be made regarding

management. The aim of treatment is to remove a potentially

precancerious lesion to prevent development of carcinoma. The

initial classification of cervical intraepithelial neoplasia as CIN

1,2 or 3 was proposed by Richart in 1973 and reinforced by the

World Health Organization in 1994.

Treatment modalities include excision and ablative approaches

(cryotherapy or laser ablation).Treatment is tailored to the

lesion identified on the cervix by either removal or ablation of

the entire transformation zone.

The International Federation of Cervical Pathology and


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Cryotherapy is not recommended for treatment of CIN 3.

If excision with LEEP is used the size of loop electrode must be

adjusted depending on the lesion : a type 2 TZ requires larger

loop electrode than type 1 TZ to ensure the lesion is fully

excised. If the lesion is not seen in its entirety, colposcopy is

unsatisfactory and ablative therapies should not be used. Type

3 TZ with a lesion that extends into the endocervical canal or a

glandular lesion require a larger or longer excision for

adequate evaluation or treatment. Currently, cone biopsy,

diagnostic excisional procedure, Laser excision and LEEP maybe used but have different meanings to individuals

colposcopists.

Managing CIN 1


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and colposcopy is unsatisfactory, an excisional procedure

should be performed. If the deep margins are involved,consideration should be given to repeat excision. Most women

should have colposcopy repeated at 6 months. Hysterectomy is

not recommended as initial therapy for CIN 2 or 3 but may be

performed for women with persistent CIN.

Managing CIN 2 or 3 in women Less Than 25 years old

The evidence suggest that CIN 2 in the adolescent can be

observed with repeat colposcopy and cytology every 6 months

for up to 24 months. if dysplasia persists, patient should be

treated, with either ablative method or LEEP. If colposcopy is

unsatisfactory, treatment should consist of an excisional

procedure.


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Studies conducted in this field by different researchers and

their opinion-

Hans Hinselmanstarted performing colposcopies in Germany

in the 1924.He saw cervix under magnification in good light

and did many biopsies. In 1957 he was honoured in Brazil as

Doctor Honoris Causa.55

Khodakarami N et al 201156 of the total 100 women with

the mean age 36 years, the sensitivity, specificity, PPV, NPV

and accuracy of the Pap test, the VIA and the DC were studied.

The Pap test had low sensitivity but high specificity. Whereas

VIA had a high sensitivity in addition to being to being easy

and low cost.

Cantor et al 572008 recruited 1,850 patients into a diagnostic


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that MIS colposcopy had 1.7% false diagnostic rate as

compared to PAP test and conventional colposcopy which hadfalse diagnostic rates of 24.4% and 22% respectively.

Divya Hegade et al 201160 out of 225 patients, on biopsy,

there were 15 mild dysplasia,4 severe dysplasia and 3

squamous cancers. Pap smear had a sensitivity of 83%, of

specificity of 98%, and positive predictive value of 80% and

negative predictive value of 97.9%.VIA had a sensitivity of

70.8%, specificity of 95% and positive predictive value of 62.9%

and negative predictive value of 96.5%.since diagnostic valuesof VIA is comparable to Pap smear, it is a good alternate to

cytology.

Allard et al(2005)61 conducted a study to determine if sites


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concluded that both cytology and colposcopy have high

sensitivity but low to moderate specificity. Colposcopy is mostaccurate in identifying high grade disease. colposcopic

impression correlates closely with the cytology diagnosis and

combining the two produces optimum results.

Basu et al(2003)63

determined the role of visual inspection

with acetic acid in the early detection of cervical neoplasia.

They found in there study that the sensitivity of visual

inspection with acetic acid(VIA) is higher than cytology in

detection of CIN2 -3 lesions.

Gerber et al (2001)64 determined the clinical significance

and the prediction of neoplasia among the patients with

persistent findings of ASCUS in a repeat Pap smear through a


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compounding NPV were 80%, 80%, 88.9% , 77.5%. Overall

accuracy of high threshold VIA was comparable to VILI. Highthreshold VIA and VILI have higher accuracy for detection of

precancerious lesions of cervix than pap smear indicating that

these test to be implicated for cancer screening which is more

cost effective.

Belinson JL et al (2001)67 ,in this study- visual inspection of

cervix with 5% acetic acid was done women aged 35-45years in

rural China. Women with doubtful lesions, had colposcopy and

cervical biopsy. The sensitivity of visual inspection equalled orexceeded reported rates for conventional cervical cytology.

Visual inspection and colposcopy have similar profiles. The

benefit of an inexpensive point of care diagnosis and treatment

algorithm will be a powerful incentive to per visual inspection


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MATERIAL AND METHOD

MATERIAL AND METHOD

1.Source of DataWomen attending Gynaecological OPD at

Patki Hospital and Research foundation, Kolhapur.

2. Method of collection of Data

A.Study design-prospective study

B.

Study period- one year(Jan 2013- Jan2014)

C.

Sample size- 100 cases who fulfilled selection criteria.

Total Gynaecology OPD patient visited in Patki Hospital per

year are 10,000 out of which 30% of patient come with

complains of leucorrhoea, pv discharge, spotting or routine

check-up, that is 3000.


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MATERIAL AND METHOD

INCLUSION CRITERIA

1.

Symptoms suggestive of cervical disease, chronic

leucorrhoea, backache, postcoital bleeding, postmenopausal

bleeding etc.

2.Suspicious looking cervix

3.

Abnormal pap smear

EXCLUSION CRITERIA

1. HIV infected patient

2. Pregnant women

3. Clinically visible growth on cervix

4. Unmarried


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MATERIAL AND METHOD

specimen fixed on a slide with 95% Ethanol and transported to

laboratory. smears are reported with Bethesda system ofcervical cytology classification.

4. This is followed by application of 3 to 5% freshly prepared

Acetic acid to the cervix using sterile cotton swab. The cervix is

inspected after one minute and results noted as either positive

if there are acetowhite areas seen. Also note down

- location of AW area in relation to

-Squamocolumnar junction,

-Intensity of AW patch

-Margin of AW patch

5. Examination through Green filters


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MATERIAL AND METHOD

Video recording

EXAMINATION TABLE

Cuscos speculum

Gloves

swab holder

bowls for saline, acetic acid, Lugols solution

Endocervical Retractor

Biopsy forcep

For Cryocauterisation-cryocautery unit

Nitrous oxide cylinder

LEEP and LLETZ-Cautery

loops


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FIGURES

Figure No.1Colposcope


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FIGURES

Figure No.3Squamocolumnar Junction

Figure No. 4Normal Colposcopy


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FIGURES

Figure No. 5Acetowhite changes


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FIGURES

Figure No. 7Punctation


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RESULTS

OBSERVATIONS AND RESULTS

Table 2: Distribution of cases according to age

AGEGroup

HPE findingsTotal Chi Square

TestCIN Normal

20-29 1 12 13Chi square=

0.9175d.f.=2

p=0.6321

30-39 6 32 38

40-49 6 25 31

50-59 4 14 18

Total 17 83 100

30

35

40


62/112

RESULTS

Table 3: Distribution of cases based on Parity

ParityHPE findings

TotalChi Square

testCIN Normal

1 1 7 8Chi Sqare=

0.5154

d.f.=2p=0.7728

2 7 27 34

3 6 32 38

>4 3 17 20

Total 17 83 100

25

30

35

40


63/112

RESULTS

Table 4: Distribution of cases based on symptoms

ComplaintsHPE Findings

TotalChi square

testCIN Normal

WD 12 44 56

Chi square=3.483d.f.=5

P=0.626

PCB 2 5 7

IMB 1 10 11PMB 2 3 5

Ohers - 16 16

Loss Wight - 5 5

Total 17 83 100

40

50

60


64/112

RESULTS

Table 5 :Distribution of cases based on contraceptives used

ContraceptionHPE findings

TotalChi square

testCIN Normal

Barrier - 5 5Chi square

test=3.528d.f.=2

p=0.1714

O C pills 2 7 9

IUCD 1 16 17Permanent 10 29 39

Nil 4 26 30

Total 17 83 100

40


65/112

RESULTS

Table 6 : Colposcopic findings according to Age

Age

Normal

Erosion

Inflmation

polyp

Leukoplakia

AW

punctate

mosaic

U

nsatisfactory

20-29 1 5 - 2 - 3 - 1 1

30-39 2 16 5 1 - 7 3 1 3

40-49 - 7 9 2 2 3 4 1 3

50-59 - 3 2 - - 4 1 1 7

Total 3 31 16 5 2 17 8 4 14

Among 31 patients of cervical erosion, 16 patients were found

in age group of 30-39 years. While 17 patients having

Acetowhite epithelium on acetic acid application , 7 were in age

group30-39 years.


66/112

RESULTS

Maximum number of abnormal colposcopic findings were seen

in para 2 and 3 patients.

Table 8: colposcopic findings according to complaints

co

mplaints

Normal

Erosion

Inflammation

polyp

leu

koplakia

AW

P

unctate

mosaic

Unsatisfactor

WD2 15 7 3 1 15 6 - 7

PCB- 3 1 - - 1 1 1 -

IMB - 4 2 1 - - - 1 3

PMB- 3 - - - 1 - 1 -

others 1 4 3 1 1 - 1 1 4


67/112

RESULTS

Table 9:Colposcopic findings according to contraceptives

Contrac

eptive

normal

Erosion

Inflam

mation

polyp

Leukop

lakia

AW

unctat

e

Mosaic

Unsatis

factory

Barrier- 2 - - - 3 - - -

OC pill- - 1 1 1 2 1 - 3

IUCD- 8 4 1 - 3 - - 1

Permanen

t 1 11 5 1 1 6 6 1 7

Nil 2 10 6 2 - 3 1 3 3

Total 3 31 16 5 2 17 8 4 14


68/112

RESULTS

Table 10 : PAP smear findings according to Age

Age Normal IAMild

dysplasiaModeratedysplasia

SevereDysplasia

20-29 1 11 - - 1

30-39 - 30 5 1 2

40-49 2 23 4 1 1

50-59 - 16 1 1 -Total 3 80 10 3 4

Among 10 patients of mild dysplasia on pap smear test,5

patients in age group 30-39 years, and 4 were in 40-49.

Table 11 : PAP test findings according to Parity

Parity Normal IAMild

dysplasiaModerateDysplasia

SevereDysplasia


69/112

RESULTS

Table 12: PAP test findings according to Complaints

Complaints Normal IAMild

dysplasiaModeratedysplasia

SevereDysplasia

WD 1 48 4 1 2

PCB - 4 2 1 -

IMB - 10 1 - -

PMB - 4 1 - 1Others 2 12 - 1 -

Lossweight

- 2 2 - 1

Total 3 80 10 3 4

Among 10 patients of Mild dysplasia on pap smear,4 women

had complaint of white discharge.


70/112


71/112


72/112

RESULTS

Table 16 : HPE findings

HPE findings No. ofcases

Chronic cervicitis 46

Cervicitis+ Erosion 28

Erosion of cervix 2

Epithelial hyperplasia 2Polyp 5

Mild dysplasia(CIN 1) 8

Moderate dysplasia 5

Severe dysplasia 4

HPE Findings

Chronic Cervicitis


73/112

RESULTS

Table 17: Correlation between Pap smear and Biopsy

Pap testHPE findings

Totalpositive Negative

Positive 7 10 17

Negative 12 71 83

Total 19 81 100

PAP test

Sensitivity 36.84%

Specificity87.65%

Positive predictiveValue 41.18%


74/112

RESULTS

Table 18: Correlation between Colposcopy and Biopsy

ColposcopyHPE findings

TotalPositive Negative

Positive 14 15 29

Negative 3 68 71Total 17 83 100

Biopsy

Sensitivity 100%

Specificity 4.225%

Positive predictive value 29.9%

Negative predictive value 100%

Diagnostic accuracy 32%


75/112

RESULTS

Table 19: Correlation between colposcopy and pap test

Colposcopy PAP test Total

Positive Negative

Positive 29 68 97

Negative 0 3 3

Total 29 71 100

Colposcopy

Sensitivity 82.35%Specificity 81.93%

Positive predictive value 48.28%

Negative predictivevalue

95.77%

Diagnostic accuracy 82%

Likehood ratio of 4.557


76/112

DISCUSSION

DISCUSSION

Cervical cancer was the second most frequent cancer

worldwide, in women after breast carcinoma. However, invasive

cancer of cervix was consider to be a preventable condition

as its associated with long pre invasive stage(CIN) making it

amenable to screening and treatment.

Present study was carried out in OPD at Patki Hospital

and Research Foundation, Kolhapur from January 2012-

January 2013.Hundread cases who fulfilled the selection

criteria were recruited for the study.

Regarding Age distribution high incidence of CIN was

found among the age group of 30-49 years, with mean age 41

years which was seen in 19% of cases. Incidence of CIN was


77/112

DISCUSSION

Regarding parity, study showed increased incidence of

CIN among multiparous women 20.5% were para two, 15.7%

were para three.15% were para four or more. Similar study by

Ramesh G,Sudha R., Jayashree A.K., Padmini J.(2011) showed

the incidence of CIN more in multipara.73

P.Ghosh, G.Gandhi, P.K.Kocchar, Zutshi V. showed theprevalence of CIN was significantly higher in parity more than

two.71

Relation between oral contraceptives and development of

CIN had been investigated by IARC-International agency for

Research in cancer and they concluded that the use of oc pills

increases the risk of CIN up to 4 fold after 5 or more years.

Among the 100 women studied 5% practiced barrier method


78/112

DISCUSSION

11% had intermenstrual Bleeding among them 9% had

CIN. 5% had postmenopausal bleeding out of them 40% had

CIN. Other complaints include loss of weight, loss of appetite,

UTI, Backache among them none had CIN.

Excessive vaginal discharge playing a role in contributing

to the development of CIN, was also proved to be risk factor instudy conducted by Anuja Bhalerao75et al. and also by Asmita

D, et al.70

Pap smear was taken for all cases. It showed mild

dysplasia in 10%, moderate dysplasia in 3% and severe

dysplasia in 2%. 3% of smear were found to be normal. 80%

showed inflammatory atypia.

Sensitivity of PAP was found to be very low36% compared


79/112

DISCUSSION

Strength of agreement between Pap test and Colposcopy

weighted by kappa statistic was 0.0249 indicates slightly

correlate with each other. Same results showed in studies by

Asmita D et al.70

While in our study strength of agreement between

cytology & HPE is (kappa=0.2552) indicate fair agreement.

Simillar results showed in other studies by Rajeshwar

Jyothi et al.(2013)76

In study (2014) agreement between these two tests are

0.516 i.e. showing moderate agreement.79

Among the 100 cases studied ,29% were diagnosed as

colposcopically abnormal. Among abnormal cases AW areas

were diagnosed in 17%,punctuate pattern of vessels was seen


80/112

DISCUSSION

to be inflammatory, immature metaplasia and latent HPV

infections.

Moss EL et al80, in 2009 study on 469 patients to

determine whether colposcopy is reliable in diagnosing cervical

intraepithelial neoplasia in women who have undergone a

previous cervical exicion biopsy. The sensitivity and specificityof colposcopy were 93% and 51.9% respectively.

Pimple S A et al6.,in 2010 made an evaluation of

colposcopy Vs cytology as secondary triage women .The

estimates of sensitivity for colposcopy were 74% and specificity

92.9%.

In our study predictive accuracy of colposcopy is 82%.

When interpreting values from different studies we might


81/112

DISCUSSION

Similar findings showed by study demonstrate high

accuracy and correlation between colposcopy and

histopathology .81

In present study, pap smear and colposcopy were slightly

correlated statistically and pap smear had low sensitivity it

would be prudent to add colposcopy as a complementarymethod to make screening more effective.


82/112

DISCUSSION

Limitations of study

1.

In this study ,sample is selected from the population

attending OPD. This population is not representative of

general population. Hence when tests are used for screening

in general population the estimated sensitivity and

specificity may not be achieved.2.

Colposcopy has no standard criteria or scoring system,

therefore the colposcopic interpretation are relatively

subjective.


83/112

SUMMARY

SUMMARY

This study was a prospective observational study conducted in

the department of Patki Hospital and Research Foundation

during the period from Jan 2012-2013

100 women who fulfilled the inclusion criteria were included in

our study

The objective of this study was to correlate the findings in

women with unhealthy cervix by cytology, Colposcopy and

colposcopic guided biopsies and to assess the utility of

colposcopy in detecting the premalignant and malignant

lesions of cervix.

To summarize,


84/112


85/112

CONCLUSION

CONCLUSION

Aim of reducing the incidence of cervical cancer by

identifying the cause and risk factor is indeed an uphill

task. Cancer Screening is the main weapon for early

detection of cervical cancer at pre-maliganant and

malignant stage. Invasive cancer of cervix is considered tobe preventable since it is associated with long pre-invasive

stage making it amenable for screening and treatment.

From the results of our study , it is evident that

colposcopy is definitely more sensitive and accurate than

pap smear. By combining pap smear, Colposcopy and

colposcopic guided Biopsy, we can maximise the sensitivity

and specificity of cancer cervix screening.


86/112

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Dasari P.A. Grossly abnormal cervix. Evidence for using

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Ramon M. Cestero, Benson W. Efficient triage of the

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De Vuyst H, Claeys P, Nijuru S. Comparison of pap

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34. Boselli F., Martis S., Rivasi F., Toni A., Abbiati R.,

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Usha B Saraiya. Cytology and Colposcopy in

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40. Usha B Saraiya. Cytology and Colposcopy in

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45.

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ANNEXURE I


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U

INFORMED CONSENT FORM

Subject identification number for this

trial_________________________________

Title of the Project

________________________________________________

_____________________________________________

Name of the Principle Investigator ___________________Tel.No.

_________________

I have received the information sheet on the above study and have read

and/or understood the written information.

I have been given the chance to discuss the study and ask questions.

I consent to take part in the study and I am aware that my participation is

voluntary.

ANNEXURE I


101/112

Printed name of the subject in capitals

______________________________ Date of

Signature

Signature /Thumb Impression of legally

Accepted representative

____________________________________________________

Printed name of legally acceptable representative in capitals

___________________________________________________________

Relationship of legally accepted representative to subject in capitals

____________________________

Signature of the person conducting the

ANNEXURE II


102/112

STUDY PROFORMA

1.Name of patient

2.Date of admission

3.Record number

4.Age

5.Tel.no

.

6.Address

7.Education

8. Socioeconomic status

ANNEXURE II


103/112

-H/O Hormonal theropy

-abnormal vaginal bleeding

14.Family history-H/O circumcision of husband

-H/O malignancy in family

15.General examination

16.Local Examination-

17.Systemic examination-

Speculum examination-

Discharge-normal/Bloody/foul smelling/Greenish/curdywhite

Appearance of cervix before acetic acid-

ANNEXURE II


104/112

ODELLS DIAGRAM AND HAMMONDS GRAPH

MASTER CHART


105/112

[Type the company name] | KEY OF MASTER CHART 94

KEY OF MASTER CHARTA- Serial number

B-

OPD numberC- Name

D-

Age in years

E- Parity

P-para

L-living

F-Inclusion criteria

-

WD-white discharge

- IMB-intermenstrual bleeding

-

PMB-postmenopausal bleeding

- PCB-postcoital bleeding

- Suspicious cervix

G-PAP results

- N- Normal

-INF-inflammatory

-Mild dysplasia

-moderate dysplasia

H-Colposcopy result-

MASTER CHART


106/112


-Normal

-Inflammation

-polyps

-Erosion of cervix

-leukoplakia

-AW areas

Punctate pattern

-mosaic pattern

-Atypical vessel

-unsatisfactory

I-Biopsy results- cervicitis

-erosion of cervix

-polyp

-mild dysplasia

-moderate dysplasia

-severe dysplasia

MASTER CHART


107/112


Sr.No.

Name OPDNo.

Age Parity complaint ContraceptionUsed

PAP test ColposcopyFindings

HPE Findings

1 Kamal T.Jadhav 232 30 P2L2A1 WD PERMANENT ATYPIA NORMAL CERVICITIS

2 Meena M.Gokhale 255 48 P3L2 OTHERS PERMANENT ATYPI POLYP POLYP

3 Shanti R.Mane 278 32 P2L2 WD BARRIER ATYPIA AW CERVICITIS

4 Rani S. Thorat 283 45 P3L3A2 IMB IUCD ATYPIA EROSION CERVICITIS+EROSION

5 Manda T.Kambale 302 40 P4L2A1 WD PERMANENT ATYPIA EROSION CERVICITIS

6 Veena B.Shete 316 30 P3L3 PCM NIL ATYPIA INFLAMMATION CERVICITIS

7 Neeta V.Gongane 328 20 P4L3A2 WD OC PILL ATYPIA POLYP POLYP

8 Girija N.Joshi 349 31 P2L2 WD NIL ATYPIA AW CERVICITIS+EROSION

9 Mukta G.Parage 374 47 P5L4A3 PCB IUCD MILDDYSPLASIA

EROSION EROSION

10 Aasma M.Mujawar

389 41 P3L3 WD PERMANENT ATYPIA INFLAMMATION CERVICITIS

11 BindiyaN.Gangvani

398 56 P2L2A1 WD PERMANENT ATYPIA AW CERVICITIS+EROSION

12 Vasanti D.Vaidya 406 22 P2L2A2 IMB NIL ATYPIA EROSION CERVICITIS

13 Seema M.Patrawale

420 32 P2L2 WD OCPILL MILDDYSPLASIA

AW CIN 1

14 Ujjwala B.Kambale

448 31 P3L3 LOSS WT NIL SEVEREDYSPLASIA

EROSION CIN 3

15 Dipali S.Satpute 468 42 P5L3A1 WD PERMANENT ATYPIA LEUCOPLAKIA CERVICITIS

16 Malvika J.Shende 475 57 P2L2 PCB PERMANENT MODERATE PUNCTATE CIN 2

17 Pradnya L. Patil 493 21 P4L4 WD NIL NORMAL EROSION CERVICITIS+EROSION

MASTER CHART


108/112


18 Shabana B.Attar 500 33 P3L3A2 WD BARRIER ATYPIA EROSION CERVICITIS

19 Mrunal L.Kulkarni 510 43 P2L1A2 WD NIL ATYPIA EROSION CERVICITIS+EROSION

20 Deepika B.Shaha 527 32 P2L2 PMB IUCD ATYPIA EROSION CERVICITIS+EROSION

21 Neeta G. Bhurat 537 49 P3L3 WD PERMANENT ATYPIA AW CIN 1

22 VaishaliA.Bansode

543 24 P4L3 WD NIL ATYPIA POLYP POLYP

23 Gauri H.Madane 562 34 P4L4 WD OC PILL ATYPIA AW CERVICITIS+EROSION

24 Shanti G.Godbole 579 59 P3L3A2 WD NIL ATYPIA EROSION CERVICITIS

25 Anjali J.Patwane 590 44 P5L4A2 PCB IUCD ATYPIA EROSION CERVICITIS+EROSION

26 Shobha S.Dardare 597 33 P2L2 IMB PERMANENT ATYPIA MOSAIC CIN 2

27 Meenakshi D.kale 601 31 P4L3 WD NIL ATYPIA POLYP POLYP

28 Nur A.Bagwaan 611 24 P5L3A2 WD IUCD ATYPIA EROSION CERVICITIS+EROSION

29 Savita B.Varje 625 35 P4L4A2 WD PERMANENT ATYPIA EROSION CERVICITIS+EROSION

30 Revati K Navale 638 45 P4 WD PERMANENT ATYPIA UNSATISFACTORY CERVICITIS+EROSION

31 AnaghaG.Deshpande

658 53 P3L3 WD PERMANENT ATYPIA EROSION CERVICITIS+EROSION

32 Aarati S. Kalambe 672 32 P2L2 WD OC PILL ATYPIA UNSATISFACTORY CERVICITIS

33 Nutan M.Shahane 685 45 P2L1A2 WD PERMANENT ATYPIA INFLAMMATION CERVICITIS

34 Sarika S. Bobade 692 54 P3L3 WD IUCD ATYPIA INFLAMMATION CERVICITIS

35 Hemangini 704 36 P1A4 WD PERMANENT ATYPIA PUNCTATE CIN 1

MASTER CHART


109/112


G.Suryawanshi

36 Vijaya H.Rokade 710 25 P2L2A3 OTHERS NIL ATYPIA EROSION CERVICITIS+EROSION

37 Mangal R.Ghate 726 33 P2L2 IMB NIL ATYPIA INFLAMMATION CERVICITIS

+EROSION38 Savita K. Patil 740 46 P3L3 WD IUCD MILD

DYSPLASIAAW CIN1

39 Shanta B.Patil 769 34 P1L1 WD NIL ATYPIA INFLAMMATION CERVICITIS EROSION

40 Nilofar J. Jamadar 776 57 P3L3 WD BARRIER ATYPIA AW CERVICITIS

41 Naina G. Baraskar 782 37 P2L2 WD PERMANENT ATYPIA UNSATISFACTORY CERVICITIS

42 Anju H. Sharma 793 26 P3L3 WD NIL ATYPIA NORMAL CERVITIS

43 Janaki R. Basate 799 46 P1L1 LOSS WT PERMANENT MILD

DYSPLASIA

INFLAMMATION EPITHELIAL

HYPERPLASIA44 Madurip.Kumbhar

806 35 P2L2 WD OC PILL ATYPIA PUNCTATE CIN1

45 Komal H.Raut 817 47 P2L2 IMB PERMANENT ATYPIA UNSATISFACTORY CERVICITIS+EROSION

46 Sonali B.Bhende 828 33 P3L3 WD BARRIER SEVEREDYSPLASIA

EROSION EROSION

47 Pankaja P.Gurav 846 44 P2L2 OTHER NIL NORMAL INFLAMMATION CERVICITIS

48 Kamala R.Patil 852 38 P3L3A2 WD OC PILL ATYPIA UNSATISFACTORY CERVITIS

49 Rohini

D.Savarkar

858 27 P2L2 PCB PERMANENT ATYPIA AW CERVICITIS+

EROSION50 Meena D. Raut 864 47 P3L3A2 WD NIL ATYPIA EROSION CERVICITIS

51 Nandini G.Bhsale 870 31 P2L2A1 OTHERS IUCD ATYPIA EROSION CERVICITIS+EROSION

MASTER CHART


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52 Shweta H.Rane 884 48 P3L3A2 LOSS WT PERMANENT MILDDYSPLASIA

INFLAMMATION CERVICITIS

53 Payal M. Meheta 890 34 P3L3A1 WD NIL ATYPIA AW CERVICITIS

54 Nikita M.Khopre 899 48 P2L2 IMB IUCD ATYPIA POLYP POLYP

55 Versha G. Ukhane 909 36 P5L3 OTHERS NIL ATYPIA NORMAL CERVICITIS+EROSION

56 Rajeshwari H.Patil 918 39 P3L3 WD IUCD ATYPIA EROSION CERVICITIS

57 Diya V. Bafna 922 46 P3L3 WD P ATYPIA EROSION CERVICITIS

58 Tulasi H.Sharma 950 35 P2L2 LOSS WT NIL ATYPIA EROSION CERVICITIS

59 Lakshmi V.Shinde 968 49 P2L2 OTHER NIL ATYPIA UNSATISFACTORY CERVICITIS

60 Meenal T.Hakane 978 55 P3L3A1 WD PERMANENT ATYPIA AW CIN 1

61 Shilpa S.Votkar 985 52 P3L3A1 IMB IUCD ATYPIA INFLAMMATION CERVICITIS+EROSION

62 Prajkata R.Shevate

992 36 P3L2A3 PMB PERMANENT ATYPIA EROSION CERVICITIS

63 Manda G.Borate 1010 50 P2L2 PMB PERMANENT ATYPIA UNSATISFACTORY CERVICITIS+EROSION

64 MarthaA.Fernandiz

1023 29 P5L5 PMB NIL SEVEREDYSPLASIA

MOSAIC CIN 3

65 SnehalG.Boravankar

1039 49 P3L2A3 WD PERMANENT ATYPIA PUNCTATE CIN 1

66 Lalita j. Chogule 1048 43 P3L3A1 OTHER OC PILL ATYPIA LEUCOPLAKIA CERVICITIS

67 Harshita D.Shetti 1056 39 P2L2 PMB PERMANENT MILDDYSPLASIA

EROSION CERVICITIS

68 Amrita M. Chavala 1062 41 P4L3 OTHER NIL NORMAL INFLAMMATION CERVICITIS

MASTER CHART


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69 RuchikaH.Bhalerao

1070 35 P2L2 WD PERMANENT ATYPIA AW CIN 1

70 Radhika S.Nene 1087 42 P2L2A1 OTHER IUCD ATYPIA INFLAMMATION CERVICITIS

71 Mayuri B. Mane 1107 39 P3L3 WD PERMANENT MILD

DYSPLAIA

EROSION CERVICITIS

72 Aanjana C.Nakate 1123 28 P2L2 WD BARRIER ATYPIA AW CERVICITIS

73 JanviF.Sahstrabuddhe

1145 44 P3L3 LOSS WT PERMANENT ATYPIA INFLAMMATION EPITHELIALHYPERPLASIA

74 Saraswati N.Gune 1150 36 P2L2 IMB PERMANENT MILDDYSPLASIA

EROSION CERVICITIS

75 JayashreeA.Sankpal

1169 43 P4L3A2 WD OC PILL ATYPIA INFLAMMATION CERVICITIS

76 NupurH.Golwankar

1176 34 P3L2A1 OTHER IUCD MODERATEDYSPLASIA

EROSION NORMAL

77 Gayatri M Gosavi 1190 51 P4L2 PCB PERMANENT MILDDYSPLASIA EROSION CERVICITIS

78 Mayuri S.Singh 1205 38 P3L3 WD IUCD ATYPIA INFLAMMATION CERVICITIS+EROSION

79 Rupa J. Munde 1230 52 P3L3 PMB PERMANENT ATYPIA AW CIN 2

80 Jaya V.Mandalik 1246 29 P5L4 IMB NIL ATYPIA UNSATISFACTORY CERVICITIS+EROSION

81 Suvarna U.Khote 1288 37 P3L3 OTHERS NIL ATYPIA EROSION CERVICITIS+EROSION

82 Sharvari M.Ponatil 1292 45 P4L4 WD PERMANENT MODERATEDYSPLASIA

PUNCTATE CIN 2

83 AnandiD.Zambare

1310 53 P1L1 WD IUCD ATYPIA UNSATISFACTORY CERVICITIS

84 Kshma G. Nimkar 1350 54 P1L1 OTHER PERMANENT ATYPIA UNSATISFACTORY CERVICITIS+EROSION

MASTER CHART


112/112

85 Kusum N.Modi 1367 38 P2L2 OTHER PERMANENT ATYPIA PUNCTATE CIN 2

86 Sonia D. Pande 1388 56 P1L1 IMB PERMANENT ATYPIA UNSATISFACTORY CERVICITIS

87 Yamini H. Bhat 1401 55 P3L3 OTHER OC PILL ATYPIA UNSATISFACTORY CERVICITIS

88 Sahyadri P.Mone 1415 37 P3L3 WD NIL MILDDYSPLASIA

EROSION CERVICITIS

89 Sukanya G Kamat 1445 58 P1L1 WD PERMANENT ATYPIA UNSATISFACTORY CERVICITIS+EROSION

90 Uma G. Bapat 1455 50 P1L0 WD NIL ATYPIA UNSATISFACTORY CERVICITIS

91 ReshmaG.Inamdar

1489 51 P6L5 OTHER NIL ATYPIA MOSAIC CERVICITIS

92 Esha S.Rajput 1510 37 P2L2 WD NIL ATYPIA AW CERVICITIS+EROSION

93 Madhvi G,

Vedpathak

1547 29 P3L3 WD IUCD ATYPIA AW CERVICITIS

94 Amruta V.Kawale 1556 40 P3L3A3 WD PERMANENT ATYPIA PUNCTATE CERVICITIS

95 Anita G.Dabholkar

1566 38 P2L1 IMB PERMANENT ATYPIA EROSION CERVICITIS+EROSION

96 Savita Khapre 1598 40 P3L3A4 PCB NIL ATYPIA MOSAIC CIN 3

97 Vrunda B.Rokade 1606 29 P2L2 WD PERMANENT ATYPIA EROSION CERVICITIS+EROSION

98 Reena U. Khot 1632 41 P3L3 WD IUCD ATYPIA AW CERVICITIS

99 Manasi V. Kadam 1686 39 P4L2A2 WD NIL ATYPIA INFLAMMATION CERVICITIS

100 Nayan J.Raghav 1697 42 P2L2A3 WD NIL SEVEREDYSPLASIA

PUNCTATE CIN 3

Documents

Final Thesis Report Aji