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Table of Content - Volume 20 Issue 2 - November 2021


 

Study of cytological pattern of cervical Papaincolaou smear by application of Bethesda system in a tertiary care centre

 

Abhilash N P1, Anil J2*, Shashank K J3, Mahesh V4

 

{1Assistant Professor, 2Senior Resident, Department of Pathology} {3Assistant Professor, 4Associate Professor, Department of Community Medicine} Chamarajanagar Institute of Medical Sciences, Chamarajanagar., INDIA.

Email: shashank.kj@gmail.com

Abstract              Background: Cancer cervix as become a leading cause of morbidity and mortality in developing countries like India. In women, among developing countries, the cervical cancer as become the most common cancer for the cause of death. About 80% of the global burden has been accounted by developing countries. Aim: To study cervical cytology in 300 cervical Pap smears and classify smears according to Bethesda 2014. To show the importance of this Pap smear study in differentiating premalignant and malignant lesions. Materials and MethodsIn this retrospective study, a total of 300 Papaincolaou smears with age group of 22 to 80 years coming to the cytology section of Pathology department, Chamarajanagara Institute of Medical Science, Chamarajanagara, during the time period of November 2020 to June 2021. Results: In this study, out of 300 cases maximum cases were of negative for intraepithelial lesion or malignancy 247 cases (82.3%) followed by atypical squamous cells of undetermined significance 16 cases (5.33%) followed by low-grade squamous intraepithelial lesion with 8 cases (2.66%), followed by high-grade squamous intraepithelial lesion with 3 cases (1%) then carcinoma cases 03 (1% - including, 1% of squamous cell carcinoma and 0% of adenocarcinoma) and minimum number of atypical glandular cells of undetermined significance 2 cases (0.6%). Conclusions: For an early detection of premalignant and malignant lesions of cervix, cervical cytology by Pap smear acts as an important tool. It is thus recommended that regular Pap smear screening should be conducted in all vulnerable age groups.

Keywords: Pap smear, Cervical cancer and Bethesda system.

 

INTRODUCTION

Cancer cervix as become a leading cause of morbidity and mortality in developing countries like India. Carcinoma cervix has been reported to be the commonest cancer by nine out thirteen population based cancer registries in India.1 The Papaincolaou (Pap) smear was introduced in 1941 and now it has become standard screening test for premalignant lesions and malignant lesions of cervix.2The current cytological terminology “The Bethesda System” was the result of an expert panel in 1988 under the despises of the National Cancer Institute.3For reporting the results of cervical cytology, Bethesda system 2014 was developed it gives a clear guidance for clinical management of the patient4. After starting of Papaincolaou (Pap) method as cervical cancer screening tool, it decreased the cervical cancer in most developed countries5.Pap smear cytology helps to detect and evaluate the degree of cellular alterations present in uterine cervical lesions. Due to the simplicity and cost effectiveness, which are essential characteristics of methods applicable to mass screening programmes, cytopathological analysis of these smears has stood out amongst other tests6.

The present study was done to study the cervical cytology in 300 cervical Pap smears and to classify the smears according to Bethesda 2014 and to show the importance of Pap smear study in differentiating premalignant and malignant lesions.

 

MATERIALS AND METHODS

Study design: A retrospective study was conducted in the department of Pathology at Chamarajanagara Institute of Medical Sciences.

Source of data: In this study, women of age group 20 to 80 years were included and conducted during the time period from 1st November 2020 to April 2021.

Specimen collection and examination: Pap smears were taken around mid-cycle to ensure the reliability of the test. With the help of Ayre’s spatula smears were taken from the transformation zone and stroked gently and evenly spread on a glass slide. The smears were fixed by dipping the glass slide in Coplin jar containing isopropyl alcohol and fixed for about 30minutes. After fixation smears were stained by rapid Pap method. A total of 300 Pap smears were studied. All the smears were reported as per the 2014 Bethesda system and all the cases were assigned a category according to Bethesda system 2014.All SIL were named: Atypical squamous cell of undetermined significance(ASCUS), low grade intraepithelial lesion(LSIL), high grade intraepithelial lesion(HSIL), atypical glandular cells of undetermined significance (AGUS) and other atypical cells not otherwise specified .The malignant cases were SCC, adenocarcinoma and other malignancy not otherwise specified.

 

RESULTS

Minimum number of cases (1%) were in age group of 71-80 years. Maximum numbers of cases (38.33%) were in age group 41-50 years, followed by 36.3% in age group 31-40 years. A progressive rise was seen in the frequency of cytopathological abnormalities with increasing age. It increased from 2% in the 41-50 year (Table 1). In our study 279 (93%) smears were satisfactory according to the Bethesda system. 21 (7%) smears were Unsatisfactory for evaluation - 08 were obscured by blood, 05 were obscured by inflammation, 04 were obscured by blood and inflammation and 04 due to low squamous cellularity. The epithelial cell abnormalities (squamous cell abnormalities: 30(10%) and glandular cell abnormalities: 02(0.6%) constituted 10.6% of all cases and rest of 247 cases (82.3%) fell in the category of NILM. Maximum no of cases (n-247) 82.3 % are in the category of NILM. Cancer incidence found to be 0.6 %. Precursor lesion (intraepithelial lesion) found to be 04%. Rate of epithelial cell abnormality is 10.6 %. (Table 2). Highest frequency of epithelial cell abnormalities (squamous as well as glandular) was seen in 41-50year age-group (Table 3). Incidence of NILM, SIL and invasive carcinoma are comparable to other studies. In various studies SIL rate varies from 3%-13% and carcinoma incidence from 0.1% -6%. In our study SIL rate is 4% and carcinoma incidence 0.6% comparable to other study (Table 4). Photographs of smears classified as High Grade Squamous Intraepithelial Lesion (HSIL), Low grade Squamous Intraepithelial Lesion (LSIL) and Squamous Cell Carcinoma (SCC) are shown in Figure 1, 2 and 3 respectively.


Table 1: Age wise distribution of total number of patients

Age group(years)

No. of cases

Percentage

21-30

21

7

31-40

109

36.33

41-50

115

38.33

51-60

33

11

61-70

19

6.33

71-80

03

1

 

Table 2: Findings of Pap smear cytology

Diagnosis

No. of cases

Percentage

Unsatisfactory for evaluation

21

7

Negative for intra epithelial lesion or malignancy (NILM)

247

82.33

ASCUS

16

5.33

LSIL

09

3

HSIL

03

1

Squamous cell carcinoma (SCC)

02

0.6

AGCUS

02

0.6

Adenocarcinoma

0

0

 

 

 

 

 

Table 3: Age wise abnormal findings

Age group

No. of cases

ASCUS

LSIL

HSIL

SCC

AGCUS

Adenocarcinoma

Total abnormal findings

%

21-30

20

00

00

00

00

00

00

00

00

31-40

109

02

02

00

00

00

00

04

1.33

41-50

117

11

03

01

00

00

00

15

05

51-60

33

02

03

01

00

01

00

07

2.33

61-70

19

01

01

01

01

01

00

05

1.66

71-80

02

00

00

00

01

00

00

01

0.33

Total

300

16

09

03

02

02

00

32

10.6

 

                   Figure 1                                                            Figure 2                                                       Figure 3

Figure 1: Low grade intraepithelial lesion, smear is cellular and shows mature squamous cells with enlarged nuclei, variable chromatin and background shows inflammatory cells. (PAP stain 40x); Figure 2: High Grade intraepithelial lesion, smear is moderately cellular showing cluster of cells with variable in nuclear size, nucleocytoplasmic ratios against hemorrhagic background (Pap Stain 40x); Figure 3: Squamous cell carcinoma, smear is cellular and shows malignant squamous cells with prominent nucleoli. (PAP stain 40x)

 


DISCUSSION

From past two decades the most important cancer among women is carcinoma cervix7. These cervical lesions progress with time and end up ultimately as invasive stage where 4% reach the invasive stage by end of 1year and 11% by end of 3years; as much as 22% become invasive by 5 years and 30% by 10years8.It has a long latent phase during which it can be detected as identifiable and treatable premalignant lesion9 In India the peak age for cervical cancer incidence is 55-59 years. In our study maximum number of epithelial cell abnormality seen in women age group of 41-50 years, similarly reported by Benedet et al.10. And by Algotar et al.11. In a study of Goyal et al.12.the mean age was 39. 38years.Women aged 45 years or above have the risk of premalignant and malignant lesions. From the inception of TBS in 1988; it has been well received by the pathology and clinical communities. Although explanations for such a quick acceptance of TBS are many, one of the leading reasons is, most certainly, the sound and thoughtful basis for all of the elements of TBS. These include: (1) nomenclature that provides uniform diagnostic terminology to facilitate unambiguous communication between the laboratory and the clinician; (2) diagnostic categories that incorporate the latest scientific information on the pathogenesis and prognosis of cervical lesions; and (3) incorporation of the evaluation of specimen adequacy as an integral part of the report13.


 

Table 4: Comparision with other studies

Studies

No.of cases

Unsatisfactory smears

NILM%

SIL%

Invasive CA

Chauhan14

5778

69.19

2.28

 

Spinilla15

1483

9.64

 

 

Tabrizi16

460

8.30

23.30

12.58

1.66

Thomas17

85

5.88

 

20

 

Karuma18

100

 

12

 

Mishra19

764

 

 

11.3

 

Sherwani20

160

 

 

11.2

3.7

Kulkarni21

640

14.8

72.3

10.5

0.2

Bal MS22

300

4

88

3.4

1.3

Present study

300

7

82.3

4

0.6

 


 

 

CONCLUSION

One of the most common malignancies in India is cervical carcinomas. By doing mass screening and awareness programs the incidence of cervical carcinomas has reduced significantly, Pap smear helps in early detection of premalignant and malignant lesions of cervix. The Bethesda system used for cervical cytology is a uniform and standard method and gives a descriptive diagnosis which help gynecologist in patient management. It is thus recommended that regular Pap smear screening should be conducted in all vulnerable age groups.

 

REFERENCES

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