Spectrum of cervicovaginal Pap smears in newly established tertiary care medical institute

INTRODUCTION

In India and worldwide, cervical cancer is the second and fourth most commonly diagnosed cancer in females respectively and one of the leading causes of cancer death.^[1,2] In India, cervical cancer is the second most common cause of cancer death.^[2] Papanicolaou (Pap) is a universal stain for gynecologic and non-gynecologic cytology smears and is commonly used for oral and cervical cancer screening.^[3] In developed countries, there is a decrement of 70% in the incidence of cervical cancer using Pap test.^[3]

Due to effective primary (human papilloma virus [HPV] vaccine) and secondary (screening) precautionary measures, cervical cancer is considered a nearly utterly preventable disease.^[1]

The World Health Organization (WHO) made a call for the global elimination of cervical cancer in 2018 using the triple-intervention approach of (a) vaccination, (b) screening of women, and (c) treating all the precancerous lesions detected during screening.^[1] A cervical Pap smear examination is an easy, non-invasive, and effective screening method for cervical carcinoma.^[4] The cervical Pap smears examination was started in our institute in April 2021.

MATERIAL AND METHODS

The present study was a retrospective observational study of all the Pap smear cases received from April 12, 2021, to October 31, 2022. The Institute’s Ethical Committee approved this study vide letter number – IEC Ref No: AIIMS/ BBN/IEC/July/2022/191. All the Pap smears cases with their clinical findings mentioned on the requisition form and cytopathology observations were retrieved from the archives of the department of pathology of our institute. In addition, the age and the findings of clinical presentation and examination were recorded for each case. All the Pap smears were of conventional method and stained using Pap stain. The cytological interpretation was reported according to the 2014 Bethesda System for reporting cervical cytology.

RESULTS

Five hundred and ninety-four cervicovaginal Pap smear cases were identified during the study period. The patient’s ages ranged from 21 to 80 years, and the mean, median, and mode were 38.89, 38, and 40 years, respectively. The most common age group was 36–40 (148/594, 24.92%), followed by 31–35 (104/594, 17.51%) and 41–45 (96/594, 16.16%) [Table 1]. From clinical presentation and examination, white discharge per vaginum (36.87%, 219/594) was the most common clinical presentation, followed by cervical erosion (30.81%, 183/594) [Table 2].

On cytological evaluation, the unsatisfactory smears accounted for 8.92% (53/594), with a higher percentage in age >45 (9.92%, 12/121) than 8.67% (41/473) when age was <45 years. The common causes of unsatisfactory smears were low squamous cell cellularity and the cell morphology obscured by inflammation or blood.

The negative for squamous intraepithelial lesions or malignancy (NILM) was the most common interpretation category accounting for 86.87% (516/594) of all Pap smears [Figure 1]. On the other hand, the epithelial cell abnormality (both squamous epithelial cells and glandular epithelial cells) was observed in 4.62% (25/541) of satisfactory smears.

Close

Figure 1:

Distribution of cytological category.

Export to PPT

Epithelial cell abnormality was seen in 7.34% (8/109) of cases with age >45, and when age <45 years, the epithelial cell abnormality was observed in 3.94% (17/432) patients. No epithelial cell abnormality was observed in ages ≤25 years and between 61 and 65 years [Table 1]. The white discharge per vaginum (8/25) was the most common clinical presentation, followed by cervical erosion (7/25) and hypertrophied cervix (5/25) in cases with epithelial cell abnormality. In addition, atypical squamous cells (ASCs) of undetermined significance (ASC-US) (36%, 9/25), ASC cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-H) (12%, 3/25), low-grade squamous intraepithelial lesion (LSIL) (8%, 2/25), HSIL (28%, 7/25), and atypical glandular cell (not otherwise specified, NOS) (16%, 4/25) were observed [Figure 2].

Close

Figure 2:

(a) Negative for squamous intraepithelial lesions or malignancy: Superficial squamous cells without any cytological atypia (Papanicolaou Stain ×400). (b) Atypical squamous cells of undetermined significance: Occasional atypical cell in the inflammatory background (Papanicolaou Stain ×400). (c) Low-grade squamous intraepithelial lesion: Variable sized atypical cell, irregular nuclear membrane with inconspicuous (Papanicolaou Stain ×400). (d) Atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (HSIL): Cells with coarse chromatin, irregular nuclear membrane, high nucelo: cytoplasmic ratio (Papanicolaou Stain ×400). (e) HSIL: Syncytial sheet of parabasal type cells, variation in the size and the shape of the nuclei, hyperchromatic nuclei, irregular nuclear membrane, and high nucelo:cytoplasmic ratio (Papanicolaou Stain ×400). (f) Atypical glandular cell – Endocervical cell: Round to oval atypical cell with high nucelo: Cytoplasmic ratio. (Papanicolaou Stain ×400).

Export to PPT

The statistical analysis was performed for the association between epithelial abnormality and age group and provided clinical parameters. Since unsatisfactory smears were not considered as NILM or other epithelial abnormality, hence not included for statistical analysis here. We observed a statistically significant association of cervical mucoid discharge and inflammation with “no epithelial cell abnormality” cases when compared with “epithelial cell abnormality” cases, while postmenopausal bleeding was associated with epithelial cell abnormality [Table 2].

The fungal organism morphologically consistent with Candida spp. was observed in 7.24% (43/594), shift of flora suggestive of bacterial vaginosis in 13.13% (78/594), inflammation in 22.56% (134/594), and trichomonas in 0.67% (4/594) [Table 2 and Figures 3].

Close

Figure 3:

Bacterial vaginosis: Change in normal vaginal bacterial flora from lactobacilli to cocco-bacilli (Papanicolaou Stain ×400). Inflammatory Smear: Predominantly neutrophils obscuring cell morphology – unsatisfactory smear (Papanicolaou Stain ×400). Candida Infection: Eosinophilic to gray-brown-Yeasts and pseudohyphae of organisms (Papanicolaou Stain × 400). Trichomonas: Gray-blue, “pear-shaped,” small, round-to-oval organisms with an eccentric nucleus (Papanicolaou Stain × 400).

Export to PPT

We also performed statistical analysis for the association between satisfactory and unsatisfactory smears with age, clinical presentation, and clinical examination. The cervical erosion showed a statistically significant association with unsatisfactory smears, while bacterial vaginosis was associated with satisfactory smears [Table 2].

DISCUSSION

A Pap smear test is the foremost screening technique for identifying precancerous cervical intraepithelial neoplasia and the early stage of carcinoma.^[5] Although the Pap smear test prevents cervical cancer, the community’s knowledge of the test is relatively low.^[1] Because there is a protracted preinvasive stage, screening for cervical cytology is valuable and is one reason to consider invasive cervical carcinoma a preventable carcinoma.^[6] To eliminate cervical cancer (4/100,000 women worldwide), the WHO recommends screening 70% of women twice between the ages of 35 and 45.^[1] Forty-one percentages of cases belonged to the generation of 36–45 years in our study, the recommended age group by the WHO to achieve the target of cervical cancer’s elimination. Similarly, Tummidi et al. observed most common age group of screening patients was 31– 40 years, followed by 41–50 years.^[7] Sharif YH and Baamer et al. observed that mean age of the study population was 31.55 ± 6.66 years (ranging from 21 to 60 years) and 45.12 ± 6.66 years (ranging from 21 to 75 years), respectively.^[6,8] The age range in our study was 21–80 years, with a mean age of 38.89 years.

After excluding asymptomatic and healthy cervix cases, the most commonly reported clinical symptoms and examination findings are white discharge per vaginum, abdominal pain, abnormal bleeding, postcoital bleeding, irregular cycle, postmenopausal bleeding, intermenstrual bleeding, hypertrophied cervix, cervical erosion, bleed on touch cervix, and uterovaginal prolapse.^[5,6,8,9] We observed white discharge per vaginum, abdominal pain, cervical mucoid discharge, and irregular cycle as common clinical symptoms, and cervical erosion, cervical hypertrophy, and bleed on touch cervix as common examination findings. In 2014 Bethesda System, the “Epithelial cell abnormality: Squamous” includes squamous intraepithelial lesion (SIL) category, which comprises a spectrum of squamous cell lesions starting from the precancerous lesions of LSIL to HSIL and invasive squamous cell carcinoma (SCC).^[10] Depending on the qualitative and quantitative constraints of the material, certain ambiguous morphological characteristics that are indicative of squamous cell abnormalities may fall under an equivocal category: “Atypical Squamous Cells” (ASCs), which are categorized into two categories; ASCs undetermined significance (ASCUS) or ASCs cannot exclude HSIL (ASC-H).^[10] The NILM is the most common category reported in cervicovaginal Pap smears ranging from 68% to 96.31%.^[5-7,9] In accordance with the results of earlier studies, we also found NILM in 86.87% of the cases (the most common interpretation category). However, it conflicts with the findings of Baamer et al., who found that ASC-US (26.1%) was the most frequent interpretation category, and NILM was seen in only 8.9% of their cases.^[8] NILM is a general category that may or may not be associated with organisms or other non-neoplastic cellular findings (such as squamous or tubal metaplasia, atrophy, and reactive cellular changes) but have no cellular evidence of neoplasia.^[10]

The unsatisfactory smears were 8.92% in the present study, with a higher percentage in age >45 years (9.92%, 12/121) than 8.67% (41/473) when the age was <45 years. However, this difference was not statistically significant. The unsatisfactory smears ranged from 1% to 12.1% in the previous studies.^[5,7,11] Tummidi et al. observed the most unsatisfactory smears in cases with only one Pap smear slide.^[9] Patients with unsatisfactory smears should undergo a careful evaluation since they may have benign or preneoplastic or neoplastic diseases.^[12] Sharma et al. conclude that older age groups and cervical erosion are predictors for unsatisfactory conventional Pap smears.^[12] They also observed that white discharge and lower abdominal pain are associated with unsatisfactory Pap smears.^[12] We also observed a significant difference in satisfactory and unsatisfactory Pap smears in cases with cervical erosion and bacterial vaginosis. The unsatisfactory smears could be due to cell obscuration by mucus, inflammatory cells, or blood and low squamous cell cellularity.^[12] Similar findings were also observed in the present study. To decrease the rate of unsatisfactory smears in conventional Pap smears, gynecologists must take extra precautions with proper sampling techniques. They should also keep in mind the predictors for unsatisfactory conventional Pap smears. However, the rate of unsatisfactory Pap smears significantly reduces in LBC compared to conventional Pap smears.^[13] However, in resource-constrained settings such as in developing countries, the issue of unsatisfactory Pap smears exists as conventional Pap smears test is used at most screening centers. Therefore, it is crucial to determine the clinical factors linked to unsatisfactory Pap smear results.

Epithelial cell abnormality ranged from 1.2% to 32%.^[5-7,9,11] However, Baamer et al. observed 91% of cases with epithelial cell abnormality.^[8] The different epithelial cell abnormalities in the previous studies ranged as ASC-US 0.5–26.1%, ASC-H 0.1–16.7%, LSIL 0.1–19.4%, HSIL 0.2–9.2%, SCC 0.3–0.9%, and glandular cell abnormality including adenocarcinoma 0.2–18.6%.^[5-11] We observed ASC-US, ASC-H, LSIL, HSIL, and atypical glandular cells (NOS) in 1.52%, 0.5%, 0.34%, 1.18%, and 0.67%, respectively, within the range reported in the previous studies. We have not categorized any Pap smear as SCC or adenocarcinoma during the duration of the study. We have also compared clinical and a few cytological parameters for epithelial cell abnormality. We observed a statistically significant association between cervical mucoid discharge, postmenopausal bleeding, and inflammatory Pap smears with epithelial cell abnormality versus no epithelial cell abnormality. This suggests that the cervicovaginal Pap smear should be carefully examined in these cases to ensure that epithelial cell abnormalities are not overlooked.

We could not find any study in PubMed search that established a similar association of epithelial cell abnormality with clinical and cytological parameters.

The virus-associated cytopathic changes were also not observed in the present study. However, the American Cancer Society’s new guideline recommends the human papillomavirus test as a preferred type of cervical cancer screening test.^[14] In addition, they recommend all women between the age of 25 and 65 get screened every 5 years with an HPV test alone.^[14] Women can be tested with an HPV/Pap cotest every 5 years or a Pap test every 3 years if HPV testing alone is not available.^[14] However, p16 and ProExC are immunomarkers related to aberrant cell cycle due to the oncogenic effects of HPV along with Ki-67, cellular proliferation immunomarker may be used on cell block of LBC to improve the accuracy of cervical cancer screening and reduce unnecessary invasive examinations.^[15] Ours is a newly established center; therefore, HPV or immunocytochemistry testing is not currently available in our institution.

Due to the non-availability of LBC and HPV tests, we tried to find factors affecting the quality of conventional Pap smears to reduce the rate of unsatisfactory smears. Furthermore, finding the clinical and cytological parameters suggests the possibility of epithelial cell abnormality.

CONCLUSION

The unsatisfactory Pap smear was the second most common observed category after NILM in the present study. In the presence of clinical factors like cervical erosion, which may affect the quality of Pap smear, proper sampling techniques are to be used by health-care providers to reduce the unsatisfactory smear rate. We also suggest careful evaluation of cervicovaginal Pap smears in cases of cervical mucoid discharge, postmenopausal bleeding, and inflammatory Pap smears to ensure that epithelial cell abnormalities are not overlooked.