Cytomorphological spectrum of cervical smears in a tertiary hospital

Introduction: Cervical cancer is one of the leading causes of mortality and morbidity in women worldwide. Invasive cervical carcinomas are preceded by a stage in which the abnormal cells are confined to the epithelium (Intraepithelial stage). Women can be routinely screened for intraepithelial stage with cervical cytology smears and hence invasive stage can be prevented by early diagnosis. Cervical cytology smears also an useful tool in aiding the diagnosis of infectious and inflammatory conditions of the cervix. Objectives: To evaluate the cytomorphological spectrum of cervical smears referred to a tertiary hospital. Materials and Methods: It is a retrospective observational study. Clinical data and pap smear cytology reports were obtained from the archives during the period of May 2018-May 2019(1 year study). All smears were reported as per “Bethesda system of reporting cervical cytology ” 2001. Results : A total of 1241 cases were examined. The age group of patients ranged between 18yrs to 75 yrs. A total of 1203 cases (97%) were reported as Negative for intraepithelial lesions/malignancy, out of which 124 cases(0.1%) showed vaginal candidiasis, 56 cases (0.05%) were reported as Trichomonas vaginalis infection, 321 cases (0.26%) as Bacterial vaginosis, 1 case of HSV infection associated changes, 67 cases(0.05%) were reported as inflammatory smears. 38 cases showed abnormality, out of which 29 cases were of ASC-US,3 cases of LSIL, 3 cases were reported as HSIL, 2 cases as Squamous cell carcinoma and 1 case with adenocarcinoma cervix. Conclusion: Cervical inflammatory lesions (including infections) and neoplastic lesions (includes intraepithelial and epithelial malignancies) can be diagnosed by Cervical cytological smears. © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by/4.0/)


Introduction
World wide data shows that cervical cancer is the second most common cancer in women, comprising of approximately 12%of all cancers. Approximately 85% of women who died due to cervical cancer belonged to low-and middle-income countries. 1 All invasive cervical carcinomas are preceded by a stage in which the abnormal cells are confined to the epithelium(Intraepithelial stage). A continuous range of morphological abnormalities exists among these lesions which provide a rough indication of the likelihood of evolving into invasive carcinoma if left untreated. This intraepithelial stage can be diagnosed with cervical cytology smears and invasive stage can be prevented by early diagnosis through routine screening. Cervical cytology smears also help in diagnosing infections and inflammatory conditions of the cervix. This study aims at portraying the morphological spectrum observed which include inflammatory, infective, premalignant and malignant lesions over a period of one year in a tertiary care hospital

Objectives
To evaluate the cytomorphological spectrum of cervical smears referred to a tertiary hospital.

Materials and Methods
The retrospective study was carried out at J.J.M medical college and Chigateri government hospital, Davangere during may 2018-may 2019 (1 year study), total 1241 patients were screened. Smears with inadequate sample were excluded from the study. The patients were in the a ge range of 18yrs-75yrs, who presented with complaints of vaginal discharge were included .
Smears were taken from ectocervix and endocervix. Slides were prepared by conventional method, labeled, fixed in 95% ethyl alcohol immediately and subsequently stained by Papanicolaou stain( PAP stain). After staining, slides were mounted ,screened and reported by 3 cytopathologists according to the 2001 Bethesda system.
The data obtained were entered in Microsoft excel format and were used for sta tistical analysis. The total number of smears, age wise distribution and distribution according to case were entered. Percentages were calculated.

Results
A total of 1241cases were reported during may2018-may2019.The age of the patients ranged from 18-75years with mean age group of 46.5years.
The category of Negative for Intraepithelia l Lesion or Malignancy (NIL/M) were also found to have the following findings:

Discussion
In developing countries non communicable diseases are emerging as an important health problem which demands appropriate control programme before they assume epidemic propogation. 2   Our study showed that there were 45.67% benign and inflammatory conditions, 2.3 % of premalignant lesions (ASCUS) which may progress to malignancy .0.48% of LSIL & HSIL cases and 0 .24 % 0f frank malignancies in the form of squamous cell carcinoma and adenocarcinoma. ASCUS turned out to be positive for LSIL in 20 cases on biopsy.
ASCUS was found to be highest in age group >40years and percentage of it correlated with the other studies done by Amne. E. Radar et al, Shazli N. Malik et al [2][3][4][5] In our study, inflammatory lesions were more common in females <40years of age and premalignant and malignant lesions were more in females >40years of age.
There are various screening tests for cervical cancer like Pap smear,Liquid pap cytology, automated cervical screening techniques, visual inspection of cervix after Lugol's Iodine and acetic acid application, speculoscopy, cervicography. Out of all these, exfoliative cytology has been regarded as the gold standard for cervical screening programs. 6 If Pap screening is associated with HPV-DNA testing, then the sensitivity is increased. 2 World Health Organisation 1992 recommended screening every women once in her life time at 40 years. 7 The American Cancer Society recommends that all women should begin cervical cancer screening after 3years of being sexually active. It is also recommended every 1-2 years in women who have crossed the age of 30years and Women who have had 3 consecutive normal pap results may be screened after 2-3 years.
Our study was seen to be in accordance with the study conducted by Atla B et al 8 and Balaha M H et al 9 whereas the studies conducted by Das et al, 10 Pun RG et al 11 and Rawat K et al 12 showed maximum number of smears having negative for intraepithelial lesion or malignancy with lesser prevalence of inflammatory, intraepithelial lesion and frank carcinomas. The discrepancies with these studies could be due to the sample size which were comparatively higher in these studies and also the study period in the study conducted by Rawat et al and Pun RG et al were longer than the present study.

Conclusion
Cervical inflammatory lesions (including infections) and neoplastic lesions (includes intraepithelial and epithelial malignancies) can be diagnosed by Cervical cytological smears easily, efficiently and cost effectively by using Bethesda Nomenclature.
Similar studies with larger sample size and longer study period are required to know much representative data of the community for early diagnosis, better management and for development of national programs or policies to reduce the morbidity and mortality associated with cervical carcinoma.

Source of funding
None.

Conflict of interest
None.