Analysis of abnormal cervical cytology and its

Clinicopathological correlation in Papanicolaou smears at tertiary care center - A prospective observational study

 

 

Abstract               Objective: To study the role of Pap smear in detecting premalignant and malignant lesions as well as non-neoplastic lesions of cervix. Materials and Methods: This prospective, observational study was conducted in the Department of Obstetrics and Gynecology, Pacific Medical College and Hospital, Udaipur, Rajasthan. A total of 840 patients were included in the study within the duration of one year period. Pap smears were taken from women between ages of 18 to 75 years presenting with different Gynaecological complaints and as a routine beyond the age of 45 years by using Ayres Spatula. Smears were reported as per the Bethesda system. Results: A total of 576 abnormal pap smears were found, with only 58cases reported to have epithelial cell abnormalities. In this study, ASCUS(Atypical squamous cells of undetermined significance) was most common with 41 cases followed by LSIL(Low grade squamous intraepithelial lesion) with11 cases than HSIL (High grade squamous intraepithelial lesion) with 4 cases. Squamous cell carcinoma diagnosed on 2 cases. Conclusion: Pap smear is a simple, cheap,safe and practical diagnostic tool for early detection of cervical cancer , so it should be established as a routine screening procedure

Key Words: Papsmear, cervical cancer, The Bethesda system.

 

 

INTRODUCTION

Cervical carcinoma is more common in developing countries than in developed ones, particularly in parts of Asia, South America and Africa.¹ Although worldwide cervical cancer rates have decreased dramatically with the increase in screening efforts, incidence and prevalence in developing countries remains high due to lack of screening programs, with approximately 80% of all cervical cancer deaths occurring in the developing world. ² In India, the annual incidence of carcinoma of cervix is estimated to be 5,00,000 new cases per year. Carcinoma of cervix accounts for 25-50% of total cancers while for 86-90% of all genital cancers in Indian women.³ Cervical infections are one of the commonly encountered problems in women of reproductive age group. They usually present with white discharge, foul smelling odor and pruritis.⁴ Also vaginal discharge or leucorrhoea is the commonest complaint seen in women reporting to gynecological clinic. The common agents causing vaginitis include anaerobic bacteria leading to bacterial vaginosis (BV), vulvovaginal candidiasis and trichomonal vaginitis.^5,6 The mainstay of cervical cancer screening for the last 7 decades has been the Papanicolaou test. Most of these infections can be easily diagnosed on routine Pap smear examination. It is a simple test. The Papanicolaou test, also known as the Pap test or the Pap smear, was developed in the 1940’s by Georgios Papanikolaou. It involves exfoliating cells from the transformation zone of the cervix to enable examination of these cells microscopically for detection of cancerous or precancerous lesions. The Pap test is indicated to screen for malignant and premalignant lesions of the cervix. The recommended age at initiation of cervical cancer screening has undergone significant revision over time as the natural history of HPV infection and subsequent cervical dysplasia has been elucidated. Although former guidelines recommended starting Pap smear screening at age 18 or the onset of sexual activity, these guidelines were revised in 2006 to recommend initiation 3 years after the onset of sexual activity or age 21, whichever comes first. In 2009, these were further revised to recommend that cervical cancer screening begin at age 21, regardless of sexual history. This recommendation was confirmed in 2012 and again in January 2016. ⁷Pap smear screening has its own drawbacks. It has low sensitivity i.e. between 47-62%, low predictive value and the subjective interpretation of the results.⁸ On the other hand, Pap smear testing also has strengths, such as wide acceptance, meeting most of the criteria for a good screening test in settings with adequate resources, obtaining a permanent record of the test in the form of a slide, and having a high specificity of 60-95%.^8,9

 

M ATERIAL AND METHODS

This prospective, observational study was conducted in the Department of Obstetrics and Gynecology, Pacific Medical College and Hospital, Udaipur, Rajasthan. A total of 840 patients were included in the study within the duration of one year period. Pap smears were taken from women between ages of 18 to 75 years presenting with different Gynaecological complaints and as a routine beyond the age of 45 years by using Ayres Spatula. Smears were reported as per the Bethesda system.

 

RESULTS AND OBSERVATIONS

In our study we analysed 830 pap smears taken from women presenting to Gynecology OPD of Pacific medical college and hospital, Udaipur, Rajasthan. Women presenting with different Gynecological complaints between 18 to 75 and as routine beyond the age of 45 years. In our study we have taken 830 women, in them 15 were less than 20 years, 234 women were between 21 to 30 years, 313 women were between 31 to 40 years, women between 51 to 60 years were 41, 23 women were between 61 to 70 years and 4 women were above 65 years. (Table 1)

Table 1: Age distribution of patient

 

Table 2 shows that patients who attended OPD had come with various complaints like lower abdominal pain (44.56%), white discharge (57.83%), bleeding per vagina (13.49%), post coital bleeding (3.73%) and post menopausal bleeding (1.32%). Some patients had single complaints and some patients had multiple complaints.

Table 2: Distribution of symptoms amongst patients

 

Table 3 shows distribution of patients according to vaginal examination. Out of 830 patients 156 (18.79%) were having no obvious abnormal pathology in cervix on per speculum examination. Rest of the patients had vaginitis (8.31%), nabothian follicles (6.75%), cervical erosion (43.01%), ectropion (1.33%), senile vaginitis (0.96%), bleeding on touch (1.81%) and cervical polyp (2.04%) like cervical changes present.

Table 3: Distribution of patients according to vaginal examination

 

Table 4 shows cervical cytology findings There were abnormal Pap smears (epithelial cell abnormalities as well as benign cellular changes of inflammation, repair, etc.), with normal cases. Microscopy of inflammatory smears showed bacterial vaginosis, specific infections like trichomoniasis, candidiasis, herpes zoster and other non specific infections.

Table 4: Cervical cytology findings

 

Table 5 shows Epithelial cell abnormalities and were categorized according to revised Bethesda system 2001, 11(1.33%) smears showing LSIL and 41(4.94%) showing ASCUS (Atypical squamous cells of undetermined significance) representing maximum number among the screening. Abnormal cell has enlarged, hyperchromatic nuclei and altered N:C ratio. Cells of LSIL(Low grade squamous intraepithelial lesion)has perinuclear clearing which is termed as koilocytes. HSIL (High grade squamous intraepithelial lesion) reported in 04 (0.48%) patients. Squamous cell carcinoma clear cut diagnosed on 02(0.24%) clinical cases.

Table 5: Epithilial cell abnormalities

 

Table 6 shows Epithelial cell abnormalities which are classified on the basis of age. 225 patients (27.10%) of age group 21-30 yrs, 293 patients (35.30%) of 31-40 yrs, 192 patients (23.13%) of 41-50 yrs , 41 patients (4.93%) of 51-60 yrs and 17 patients (2.04%) of age group 61-70 yrs. Most of the pap smear detected ASCUS and LSIL. Pap Smear Screening show that Pap smear screening is very important to detect pre-cancerous cell in cervix.

Table 6: Age distribution pattern in different types of lesion

DISCUSSION

In our study we analysed 830 pap smears taken from women presenting to Gynecology OPD of Pacific medical college and hospital, Udaipur, Rajasthan. Women presenting with different gynecological complaints between 18 to 75 and as routine beyond the age of 45 years. In our study we have taken 830 women, in them 15 were less than 20 years, 234 women were between 21 to 30 years, 313 women were between 31 to 40 years, women between 51 to 60 years were 41, 23 women were between 61 to 70 years and 4 women were above 65 years (Table 1) . Whereas, Sharma et al¹⁰ studied abnormal smears were seen mainly among the age group more than 21 and less than 65 years of age. In a study done by Pradhan¹¹ in 800 samples, the abnormal smears were seen mainly among age group of 21-40 years and carcinoma was also found mainly in this group. Lakshmi et al¹² in their study found that maximum number of women were between 45 to 55 years age group (34%). In study conducted by Sunita et al¹³ maximum number of women were between 31 to 40 years age group (32.68%). In study conducted by Mandakini et al¹⁴ between 15 to 30 years maximum number of women were studied. Table 2 in our study shows that patients who attended OPD had come with various complaints like lower abdominal pain (44.56%), white discharge (57.83%), bleeding per vagina (13.49%), post coital bleeding (3.73%) and post menopausal bleeding (1.32%). Some patients had single complaints and some patients had multiple complaints. The most common clinical presentation in all cases in study conducted by Sabina et al¹⁵ were lower abdominal pain 763(76.3%) followed by abnormal vaginal bleeding 352(35.2%) and whitish discharge per vagina 391(39.1%). Moghal¹⁶ in his study observed menorrhagia (41%) as the most common symptoms. Table 3 in our study shows distribution of patients according to vaginal examination. Out of 830 patients 156 (18.79%) were having no obvious abnormal pathology in cervix on per speculum examination. Rest of the patients had vaginitis (8.31%), nabothian follicles (6.75%), cervical erosion (43.01%), ectropion (1.33%), senile vaginitis (0.96%), bleeding on touch (1.81%) and cervical polyp (2.04%) like cervical changes present. Table 4 in our study shows cervical cytology findings. There were abnormal Pap smears (epithelial cell abnormalities as well as benign cellular changes of inflammation, repair,etc.), with normal cases. Microscopy of inflammatory smears showed bacterial vaginosis, specific infections like trichomoniasis, candidiasis, herpes zoster and other non specific infections. Lakshmi et al¹² found abnormal Pap smear reports which were 187(93.5%), whereas in study conducted by Sunita et al¹³ 433(77.32%) reports were abnormal. In study conducted by Mandakini et al¹⁴ abnormal Pap smear reports were 689(69.2%). In study conducted by Sabina et al¹⁵ 106(10.6%) cases of abnormal epithelial lesions. The percentage of epithelial abnormalities is 2.3%to 6.6% in USA, from 1.6% to 7.9% in the Middle East and 1.87% to 5.9% in India.¹⁷ Inflammatory smear reports were 134(67%) in study conducted by Lakshmi et al12, whereas in study conducted by Sunita et al13 403(71.96%) reports were inflammatory and in study conducted by Mandakini et al¹⁴ inflammatory Pap smear reports were 572(57.5%). In study done by Sabina et al¹⁵, a total 1000 patients were included in the study. Predominance of inflammatory smears was noticed in 894 (89.4%) cases. Cronje et al¹⁸ (2001) reported similar preponderance of inflammatory smears in their study. In another study conducted by Sharma S¹⁹ (2000) higher frequency of inflammatory smears of 302 cases (45.3) was noted out of 667 cases. Microscopy of inflammatory smears in our study showed bacterial vaginosis, specific infections like trichomoniasis, candidiasis, herpes zoster and other non specific infections. The incidence of candidiasis in study by Naina et al²⁰ was 2.50% of all cases. Another similar study reported candidiasis in 11.16% of total population observed.²¹ The overall incidence of infectious vaginitis on Pap smear in study by Naina et al²⁰ was 22.57% (1292/5725) as compared to 50.07% reported by a similar study.²¹ They also found similar pattern of infections on Pap smear with bacterial vaginosis (68.78%) being most common followed by Trichomonas infection (20.05%) and candidiasis (11.07%) of total 1292 cases with infections on Pap smear. HPV infection related changes were observed in only two cases (0.15%). Another study also reported same pattern of infections with predominance of bacterial vaginosis on Pap smear.²¹ In the study by Jha et al²² five cases had bacterial vaginosis and in three cases it was candidiasis. In the study by Ranabhat et al²³ candidiasis, trichomonisis, bacterial vaginosis and herpes simplex infections were detected in nine cases (1%), four cases (0.45%), 67 cases (7.6%) and in three cases (0.34%) respectively unlike present study. In the study Shurbaji et al²⁴ Candida was identified in 309 (3.0%) of the 10,370 smears. Ninety-nine (72%) patients were asymptomatic, 29 (21%) had symptoms typical of candidasis, and nine (7%) had nonspecific symptoms.²⁴ In present study although the number of cases was not comparable to the study of Shurbati et al²⁴, however, the percentage of detection of candida in cervical smears was similar and patient was asymptomatic. Epithilial cell abnormality in the conducted by Kalpana singh et al²⁵ negative for intraepithelial lesions were found in 156(83.9%) and epithelial cell abnormality were seen in 30 (16.1%). Another study conducted by Sarma U et al (2012)²⁶ showed epithelial cell changes in 11.95% of cases. In study by Jha et al²² 10% of the cervical smears showed epithelial cell abnormalities. In our study Table 5 shows epithelial cell abnormalities which were categorized according to revised Bethesda system 2001, 11(1.33%) smears showing LSIL and 41(4.94%) showing ASCUS (Atypical squamous cells of undetermined significance) representing maximum number among the screening. Abnormal cell has enlarged, hyperchromatic nuclei and altered N:C ratio. Cells of LSIL(Low grade squamous intraepithelial lesion) has perinuclear clearing which is termed as koilocytes. HSIL (High grade squamous intraepithelial lesion) reported in 04 (0.48%) patients. Squamous cell carcinoma clear cut diagnosed on 02(0.24%) clinical cases. Smears showing ASCUS (Atypical squamous cells of undetermined significance) were 5(2.5%) in study conducted by lakshmi et al¹². In study conducted by Sunita et al¹³ 13(2.3%) reports showed ASCUS and in study conducted by Mandakini et al¹⁴ reports showing ASCUS were 41(4.1%). Sharma et al10 in their study found proportion of ASCUS (3.2%) is similar to the report given in Evidence Based Medicine (4%)27 and Vaghela et al28 (2.8%). In study conducted by lakshmi et al¹² smears show LSIL (Low grade squamous intraepithelial lesion ) as ¹⁵(7.5%). In study conducted by Sunita et al¹³ 11(1.9%) reports gave LSIL and in study conducted by Mandakini et al¹⁴ reports showing LSIL were 41(0.1%). Lakshmi et al¹² found HSIL (High grade squamous intraepithelial lesion ) from reports which were 12(6%), whereas in study conducted by Sunita et al¹³ 2(0.3%) reports gave HSIL. In study conducted by Mandakini et al¹⁴ HSIL reports were 1(0.1%). Smears shown in study conducted by Lakshmi et al¹² revealed squamous cell carcinoma amongst 2(1%). Whereas, study conducted by Sunita et al13 3(0.5%) reports gave squamous cell carcinoma and in study conducted by Mandakini et al¹⁴ reports showing squamous cell carcinoma were 7(0.7%). Table 6 in our study shows epithelial cell abnormalities which are classified on the basis of age. 225 patients (27.10%) of age group 21-30 yrs, 293 patients (35.30%) of 31-40 yrs, 192 patients (23.13%) of 41-50 yrs , 41 patients (4.93%) of 51-60 yrs and 17 patients(2.04%) of age group 61-70 yrs. Most of the pap smear detected ASCUS and LSIL. Pap Smear Screening show that Pap smear screening is very important to detect pre-cancerous cell in cervix. Among the patients examined by the study conducted by Kalpana et al²⁵, 30-39 yrs age group 12(11.11%) showed LSIL and 10 (9.25%) ASCUS , 40-49 yrs age group 10 (9.25%) showing LSIL and 8 (7.4%) showed ASCUS in their smears. HSIL present in higher age group patients 45 to 60 years. Study conducted by Asotic A et al ²⁹ (2014) showed the highest percentage of patients with LSIL and HSIL findings was in the age group under 29 yrs, not similar to our study. In another study done by Gupta et al³⁰ (2013), maximum cases 40.37% in age group of 30-39 yrs followed by 35.96% in age group of 20-29 yrs .LSIL found in largest no. 1.36% while HSIL found 0.91%11.

 

CONCLUSION

Cervical cancer is one of the most common malignancy in women of developing country. Pap smear is a simple, cheap, safe and practical diagnostic tool for early detection of cervical cancer, so it should be established as a routine screening procedure.

 

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