|Year : 2013 | Volume
| Issue : 2 | Page : 131-135
Cervical smear cytology on routine screening in a semi urban population in New Delhi: A review of 610 cases
Safia Rana, Zeeba S Jairajpuri, Sujata Jetley
Department of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, Hamdard Nagar, New Delhi, India
|Date of Web Publication||13-Dec-2013|
Department of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, Hamdard Nagar, New Delhi - 110 062
Source of Support: None, Conflict of Interest: None
Background: Cervical cancer is an important public health problem among adult women in many developing countries. Cervical cytology became the standard screening test for cervical cancer and premalignant cervical lesions with the introduction of the Papanicolau (Pap) smear. The most widely used system for describing PAP smear result is the Bethesda System 2001. Material and Methods: This study was aimed at evaluating the entire spectrum of types and frequencies of cervical cytological abnormalities i.e. infective, pre-cancerous and cancerous, in women who underwent routine cytological cervical screening at our hospital which caters largely to women of low socio-economic status. Results: A total of 610 cases of cervical pap smears were received in our cytology laboratory during this two year period, 348(57%) abnormal Pap smears, and 238(39%) cases which were normal. Out of the 348 cases, 306(50.2%) cases were reported to have inflammatory/reactive/reparative changes whereas epithelial cell abnormality was reported in 42 cases. Discussion: Cervical smear cytology also plays an important role in the diagnosis of cervical infections which are common in women of the reproductive age group. Conclusion: Hence, the need of the hour is an effective screening programme that is based on available resources and is readily available to the low socio-economic and disadvantaged sections of our society.
Keywords: Bethesda, cervical, cytology, Papanicolau smear
|How to cite this article:|
Rana S, Jairajpuri ZS, Jetley S. Cervical smear cytology on routine screening in a semi urban population in New Delhi: A review of 610 cases. Arch Med Health Sci 2013;1:131-5
|How to cite this URL:|
Rana S, Jairajpuri ZS, Jetley S. Cervical smear cytology on routine screening in a semi urban population in New Delhi: A review of 610 cases. Arch Med Health Sci [serial online] 2013 [cited 2020 Mar 31];1:131-5. Available from: http://www.amhsjournal.org/text.asp?2013/1/2/131/123025
| Introduction|| |
Cervical cancer is an important public health problem among adult women in many developing countries and is the second most common cancer among females worldwide. , In the developing countries, factors like low socio-economic status, early age of marriage and sexually transmitted infections are closely associated with cervical cancer where it is the leading cancer in women.  The National Cancer Registry Programme in India has reported that cancer of the cervix is the most important cancer in women in India, over past two decades and that the estimated number of new cancers during 2007 in India was 90,708. 
Cervical cytology became the standard screening test for cervical cancer and premalignant cervical lesions with the introduction of the Papanicolaou (Pap) smear in 1941.  The addition of HPV to cervical cancer screening strategies has now improved detection of cervical neoplasia and allowed further risk stratification.
The goal of cytologic screening is to sample the transformation zone, the area where physiologic transformation from columnar endocervical epithelium to squamous (ectocervical) epithelium takes place and where dysplasia and cancer arise. A meta-analysis of randomized trials supported the combined use of an extended tip spatula to sample the ectocervix and a cytobrush to sample the endocervix. 
A conventional Pap smear is the mainstay screening system for cervical cancer in most developing countries with low resource settings. It is considered to be safe, simple and a cost effective method for detection of various benign, pre-cancerous and cancerous lesions of cervix and vagina. The most widely used system for describing PAP smear result is TBS (2001, The Bethesda System) with standardized terminologies for reporting which was adopted by us.  This study was aimed at evaluating the entire spectrum of the types and frequencies of cervical cytological abnormalities, i.e. infective, precancerous and cancerous, in women who underwent routine cervical screening at our hospital which caters largely to women of low socioeconomic status.
| Materials and Methods|| |
It was basically an observational study of available Pap smears received in the cytopathology lab from January 2011 to December 2012 of women attending the gynecological out-patient department at the Hakeem Abdul Hameed Centenary hospital, catering to the populace who live in the slums located around it in New Delhi. The smears were of patients attending Gynaecological outpatient department and in whom Pap was advised by the treating gynecologist for clinical indications. We analyzed the clinical records and cervical smears of all patients who had undergone Papanicolaou test during this 2 year period.
The patients were instructed by the gynecologists prior to the procedure , for example avoid coitus, use of local douching and antiseptics before the cytological examination. After per speculum examination of the patient, the longer projection of Ayre's spatula was inserted in cervix near squamo-columnar junction and rotated through 360 0 . The material obtained was quickly smeared on glass slide and put in the fixative jar containing 95% ethyl alcohol. The pap staining was done by trained cytotechnologists followed by light microscopy and slide interpretation by cytopathologists, according to new Bethesda system, 2001.
| Results|| |
A total of 610 cases of cervical pap smears were received in our cytology laboratory during this two year study period. There were 348 (57%) abnormal Pap smears (including epithelial cell abnormalities, reparative and reactive cellular changes of inflammation and infections), and 238 (39%) cases which were normal. 24 (4%) smears were inadequate or unsatisfactory for evaluation [Table 1]. Out of the 348 cases, 306 (50.2%) cases were reported to have inflammatory/reactive/reparative changes [Table 2] whereas epithelial cell abnormality was reported in 42 cases (6.8%) [Table 3].
|Table 1: Cytological diagnosis of Pap smears with percentage distribution |
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|Table 3: Age-wise distribution of cases with epithelial cell abnormalities |
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In the present study, 242 cases showed moderate to severe non specific inflammation and no definite etiology was identifiable on the smears. Candidial infection was the most common specific etiology observed in this study, in 28 cases. Pseudohyphae in a box-car like pattern and small budding yeast forms (3 to 4 μm) are typically generically identified as Candida species. The smears showed Candidial hyphae which were closely related to groups of squamous cells in a background of acute inflammation. Infection by other fungi such as Actinomyces and Aspergillus was not seen in this study. Trichomonas vaginalis infection was seen in 15 patients, all of whom presented clinically with complaints of a foul smelling vaginal discharge. Smears showed degenerating squamous cells and aggregates of neutrophils in the background in which the characteristic pear shaped organisms with a slight cyanophilic tinge and faint eccentric nuclei were lying scattered or in small clusters. Cytopathic changes suggestive of HSV infection [Figure 1] were seen in 4 cases with characteristic features such as large multi-nucleated cells with eosinophilic nuclear inclusions and ground glass appearance. In 10 cases, cells with koilocytic change, suggestive of HPV infection were seen. No dysplastic/atypical features were noted in any of these cases. Atrophic vaginitis was seen in 7 females, all of whom were postmenopausal and in the age range of 50 to 70 years.
Epithelial cell abnormalities were seen in 42 cases out of which the diagnoses in 12 cases (1.9%) was ASCUS(Atypical Squamous Cells of Undetermined Significance), 8 cases (1.3%) were reported as ASC-H (Atypical Squamous Cells cannot exclude HSIL), 10 cases (1.7%) as HSIL [Figure 2] (High-grade Squamous Intraepithelial Lesion), 8 cases (1.3%) as LSIL (Low-grade Squamous Intraepithelial Lesion) and 4 cases (0.6%) as SCC (Squamous cell carcinoma) [Figure 3].
|Figure 2: Smear showing High grade squamous intraepithelial lesion. (Pap, 40×)|
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|Figure 3: Smear showing squamous cell carcinoma with tumour diathesis. (Pap, 40×)|
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Maximum number of patients, i.e. 256 (41.9%) were in the age group of 31-40 years followed by 166 (27.21%) in second decade, 104(17.04)% in fourth decade and 58 cases(9.5%) in fifth decade and 26 cases (4.2%) in seventh decade respectively [Figure 4].
|Figure 4: Bar chart representing age-wise distribution of cervical screening patients (n=610)|
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| Discussion|| |
The uterine cervix, like other organs can be affected by both inflammation and malignancy. Chronic cervicitis is a very common condition in adult females, at least at the microscopic level. It affects preferentially the squamocolumnar junction and the endocervix and is often accompanied by metaplastic changes in the epithelium. On the other hand, cancer of the cervix has been recognized as the leading cause of cancer in women in India.  Medical literature is replete with studies in which cytology screening has resulted in a reduction of the cervical cancer burden in women and cancer cervix is considered to be an ideal malignancy for screening, aimed at detecting premalignant conditions before they progress to invasive cancer. ,
Out of the 610 cases in this observational study of available Pap smears received in the cytopathology laboratory we found 306 (50.8%) had an inflammatory Pap smears and 42 (6.8%) women had epithelial cell abnormalities. In contrast, a Turkish primary health centre based study showed atypical epithelial cells in only 0.8% of the cases.  Cervical cancer is relatively less prevalent in Turkey and is the eighth most common cancer type, in terms of both incidence and cause of death in Turkey which was reflected in a study  Cervical smear cytology also plays an important role in the diagnosis of cervical infections which are common in women of the reproductive age group. A Dutch study conducted by Roeters et al. which over 1 million cervical smears were analyzed, concluded that cervical smear examination is a valuable tool in the diagnosis of cervical infections.  Trichomonas vaginalis was seen in 15 women in our study. Previous studies have reported the association of ASCUS (Atypical Squamous Cells of Undetermined Significance) in a significant proportion of women with Trichomonas vaginalis infection. , In our study, out of the 12 cases of ASCUS, an inflammatory etiology was favored in 7 cases, though no causative agent was identified in any of them. We found 28 cases of Candidial infection seen along with a dense neutrophilic infiltrate and a necrotic background. No other fungal infections were detected in this study. Four cases were suggestive of HSV and a similar incidence was noted in the Pakistan based study of Bukhari et al.  However a much higher incidence of HSV was observed in a study of cervical cytology of women in their third trimester of pregnancy.  Ten cases showed koilocytosis without atypia, features suggestive of HPV infection. In an attempt to improve the sensitivity of cytologic diagnosis of HPV infections, Schneider et al. described five important criteria i.e. mild koilocytosis, mild dyskeratocytosis, hyperchromatic nuclei, bi and multinucleation and cleared cytoplasm used in combination which identified majority of HPV infected cases. 
In this cervical cytology screening study of 610 cases we found the mean age of patients with ASCUS to be 37.6 years, which correlated with similar findings in other studies , The latest recommendations by the U.S. Preventive Services Task Force (USPTF) issued in June 2012 advise screening for cervical cancer in women aged 21 to 65 years with cytology (Papanicolaou smear) every 3 years or, for women aged 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years. 
The cytological manifestations of HPV infection which are very common in sexually active women of the reproductive age group range from koilocytosis to features of HSIL with which the risk of progression to cancer, if not detected and treated is high. Fortunately for us, this progression takes years and here lies the all important role of routine cervical cytology screening in the timely detection of precancerous/cancerous lesions. The peak incidence of HPV infection occurs about age 20, the peak incidence/detection of CIN-3 occurs about age 30, and the peak incidence of cancer occurs in the 40s. It is estimated that without secondary prevention, cervical cancer would occur in around 1% of women who acquire an HPV infection, although for every cancer that occurs a far larger number of CIN lesions develop, of which the majority probably regress. Most of the pre-malignant and malignant lesions are of the squamous type but around 15% are of the glandular type. HPV types 16 and 18 are the dominant oncotypes in squamous lesions but type 18 is relatively more important in glandular lesions. 
The mean age of presentation in cases of LSIL was 33.4 years, and those with HSIL and invasive cancer were 44 years and 59 years respectively. Studies have reported an increase in the progression of LSIL to invasive carcinoma with an increasing age.  The range of age ASCUS and LSIL showed peak incidence in 30-40 years, HSIL in 41-50 years and invasive carcinoma in 51-60 years, in our study thus proving to be in concordance with earlier studies. 
The incidence of abnormal epithelial cell lesion in the present study was 6.8%. The prevalence rates published in previous studies ranged from 1.66-7.9%. ,, Studies done on the prevalence of epithelial cell abnormality have shown 4.3% in Kuwait,  7.9% in South west Saudi Arabia  and 4.95% in Eastern Saudi Arabia.  These studies showed an overall prevalence of the epithelial abnormalities similar to the current study. In the present series, ASCUS was seen in 12 (1.9%) cases, ASC-H in 8 (1.3%) HSIL in 10 (1.7%), LSIL in 8 (1.3%) and invasive carcinoma in 4(0.6%) cases. An Indian study done on a large group supported our data showing an overall epithelial cell abnormality about 5.64%. ASCUS, HSIL, LSIL, carcinoma comprised about 3.36%,1%,0.34%,0.41% respectively. 
In the present study, 24 slides were considered to be inadequate for evaluation, probably due to poor technique or sampling by junior or untrained staff. The error usually exists at the level of sampling, preparation or transport. Poor sampling is one of the main reasons for inadequacy. 
| Conclusion|| |
The Papanicolaou (Pap) test is widely regarded as a cost-effective cancer screening test and as a simple method to detect cervical lesions at an early stage. Cervical cancer is also one of the leading malignancies in Indian women. This study highlights that women in the 40 to 50 years age group harbor the bulk of pre-neoplastic and neoplastic lesions detected on Pap smears. Most of them are presently under-screened for lack of knowledge, awareness or absence of screening facilities. Hence, the need of the hour is an effective screening programme that is based on available resources and is readily available to the low socio-economic and the disadvantaged sections of our society.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]