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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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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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RIVIEW OF LITERATURE
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
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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
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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
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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
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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.
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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
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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
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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
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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.
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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
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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%
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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%
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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
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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
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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
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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
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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
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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
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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.
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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.
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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,
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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.
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BIBLIOGRAPHY
BIBILOGRAPHY
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Usha B Saraiya. Cytology and Colposcopy in
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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
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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
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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
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-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
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ODELLS DIAGRAM AND HAMMONDS GRAPH
MASTER CHART
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[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
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[Type the company name] | KEY OF MASTER CHART 95
-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
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[Type the company name] | KEY OF MASTER CHART 96
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
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108/112
[Type the company name] | KEY OF MASTER CHART 97
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
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109/112
[Type the company name] | KEY OF MASTER CHART 98
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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110/112
[Type the company name] | KEY OF MASTER CHART 99
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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111/112
[Type the company name] | KEY OF MASTER CHART 100
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
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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