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Cite this article: Kalyani R, Sharief N, Shariff S (2016) A Study of Pap Smear in a Tertiary Hospital in South India. J Cancer Biol Res 4(3): 1084.

*Corresponding author

Kalyani R, MVJ Medical College & Research Hospital, Bangalore, Karnataka, India, Tel: 9448402775; Email:

Submitted: 18 April 2016

Accepted: 23 June 2016

Published: 24 June 2016

Copyright© 2016 Kalyani et al.

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Keywords•Cervical cancer•Cervical cytology•Pap smear

Research Article

A Study of Pap Smear in a Tertiary Hospital in South IndiaKalyani R*, Najmunnisa Sharief, and Shameem ShariffDepartment of Pathology, MVJ Medical College & Research Hospital, India

Abstract

Background: Cervical cancer accounts for the fourth most common cancer in women worldwide. Pap smear test is one of the best tests to screen for cervical cancer and enables detection in its premalignant stage. The objective of this study was to find out the prevalence of abnormal Pap smears in a tertiary care hospital and correlate with histology wherever possible.

Methods: Cases were collected from archives of Department of Pathology from Jan 2013 to June 2015. A total of 1501 Pap smears were analyzed.

Results: The mean age of the patients was 40.26 ± 10.72 years. Most of them were of age group 30-39 years (32.06%) followed by 40-49, 20-29 and 50-59 years (28.13%, 17.33% and 11.53% respectively). A total of 1234 (82.2%) samples were adequate for evaluation, whereas 267 (17.8%) samples were inadequate for evaluation due to low cellularity and obscurement by inflammatory cells and blood. Of 1234 smears, 1197 smears (96.92%) were negative for intraepithelial lesion and 38 smears (3.08%) were positive for intraepithelial lesion. These 38 cases included ASC-US (1.46%), ASC-H (0.32%), LSIL (0.24%), HSIL (0.41%), AGC (0.24%) and carcinoma (0.41%). ASC/SIL ratio was 2.75. Transformation zone with intraepithelial lesion was seen in 65.79% cases. About 109 biopsies could be retrieved and co-related with corresponding Pap smear, for which sensitivity was 45%, specificity 87.6%, false positive rate 12.4%, false negative rate 55%, positive predictive value 0.45% and negative predictive value 0.67%.

Conclusion: Pap smear is still a relatively good method in screening cervical cancers in developing countries. Smears positive for intraepithelial lesions has to be co-related with histopathology for further management.

INTRODUCTIONCervical cancer is the fifth most common cancer in humans,

the fourth most common cancer in women worldwide. It is the most common cancer death in women in the developing countries [1]. Screening of cervical cancer in effective, feasible and affordable way for early detection and management is a public health priority. Five screening methods namely; naked eye visual inspection of the cervix with application of diluted acetic acid (VIA), examination with Lugol’s Iodine (VILI) or with a magnifying device (VIAM), the Pap smear and Human Papilloma Virus (HPV) testing with high-risk probe of the Hybrid Capture-2 assay (HC2) is used to detect the cervical cancer in precancerous stage [2].

Cytology is a simple and inexpensive diagnostic method and is therefore useful especially in areas with limited resources. Even though the Pap smear test alone does not have a high sensitivity and specificity, it is the most commonly used test in most screening programs. The diagnostic utility of cervicovaginal cytology (Pap test) as a first line of investigation has assumed

importance in screening of cervical cancer. It is a simple, safe, cost effective and reliable technique. Its accuracy and cost effectiveness can be compromised by inadequate samples [3]. The present study was conducted to find out the prevalence of abnormal Pap smears in a tertiary care hospital in a semi-urban / rural population and correlate with histology wherever possible.

MATERIALS AND METHODSCases were collected from archives of department of

pathology from 1st Jan 2013 to 10th June 2015. A total of 1501 conventional Pap smears were analyzed. The smears were classified according to The Bethesda System (TBS) 2001 by two pathologists. The results were analyzed by descriptive statistical analysis. Corresponding cervical biopsy in the available cases were co-related (Figures 1-6).

RESULTS The preliminary analysis showed the mean age of the patients

was 40.26 ± 10.72 years (ranging from 17 to 89 years). Most of them were of age group 30 – 39 years (32.06%) followed by

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lesion / malignancy (NILM) and 38 (3.08%) were positive for intraepithelial. Further categorization of NILM is shown in Table (2). The 38 cases positive for intraepithelial lesion were further classified as; atypical squamous cell of undetermined significance, (ASC-US, n=18, 1.46%), atypical squamous cells, cannot exclude HSIL (ASC-H, n=4, 0.32%), low grade squamous intraepithelial lesion (LSIL, n=3, 0.24%), high grade squamous intraepithelial lesion (HSIL, n=5, 0.41%), atypical glandular cell (AGC, n=3, 0.24% ) and 5 cases of squamous cell carcinoma (SCC, n=5, 0.41%). 65.79% showed and 34.21% did not show transformation zone (TZ) in intraepithelial lesion (Table 3). ASC/SIL ratio was 2.75.

About 109 biopsies could be retrieved and co-related with corresponding Pap smear, for which sensitivity was 45%, specificity 87.6%, false positive rate 12.4%, false negative rate 55%, positive predictive value 0.45% and negative predictive value 0.67%. Cytology of 83 pap smears were correlating with the corresponding histopathological biopsies, whereas 26 smears showed discrepancy with histology (Table 4,5).

DISCUSSIONCervical cancer is the fourth most common cancer affecting

women worldwide after breast, colorectal, and lung cancers. Every year 528,000 new cases are reported. It is most common in the low resource developing countries constituting 70% of the global burden. Approximately one fifth of all new cases are reported in India. It is the fourth most common cause of cancer death (266,000 deaths in 2012) in women worldwide. In sub-Saharan Africa, 34.8 new cases of cervical cancer are diagnosed per 100,000 women annually and 22.5 per 100,000 women die from the disease. These figures were compared with 2.5-6.6 per

Figure 1 Microphotograph showing inflammatory Smear. (Pap stain X400).

Figure 2 Microphotograph showing Clue cells (arrow) and Trichomonas vaginalis organism (arrow head). (Pap X400).

Figure 3 Microphotograph showing features of ASC-US. (Pap X400).

B

Figure 4 (A) Microphotograph shows features of ASC-H. (Pap X400). (B) Corresponding biopsy of ASC-H given as CIN II/III. (H&E X400).

40-49, 20-29 and 50-59 years (28.13%, 17.33% and 11.53% respectively). A total of 1234 (82.2%) samples were adequate for evaluation, whereas 267 (17.8%) samples were inadequate for evaluation due to low cellularity and obscurement by inflammatory cells and blood (Table 1).

Of 1234 cases, 1196 (96.92%) were negative for intraepithelial

Figure 5 (A) Microphotograph shows features of HSIL. (Pap X400). (B) Corresponding biopsy showing features of Squamous cell carcinoma. (H&E X400).

Figure 6 (A) Microphotograph showing features of Squamous cell carcinoma. (Pap X400). (B) Corresponding biopsy showing Squamous cell carcinoma. (H&E, 400x).

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Table 1: Shows age distribution, satisfactory smears and transformation zone of present study.

Age Total cases Unsatisfactoy smears Satisfactory smears T Zone Present T Zone absent NILM

17 - 19 yrs 3 0.20% 3 0.20% 3 0.24% 3 0.24%20 - 29 yrs 260 17.32% 40 2.66% 220 14.66% 131 10.62% 89 7.21% 229 18.56%30 - 39 yrs 489 32.58% 80 5.33% 409 27.25% 258 20.91% 149 12.07% 404 32.74%40 - 49 yrs 432 28.78% 81 5.40% 342 22.78% 232 18.80% 108 8.75% 335 27.15%50 - 59 yrs 178 11.86% 28 1.87% 145 9.66% 104 8.43% 42 3.40% 126 10.21%60 - 69 yrs 103 6.86% 28 1.87% 75 5.00% 49 3.97% 29 2.35% 71 5.75%70 - 79 yrs 26 1.73% 6 0.40% 20 1.33% 11 0.89% 9 0.73% 20 1.62%80 - 89 yrs 10 0.67% 2 0.13% 8 0.53% 3 0.24% 5 0.41% 8 0.65%Total (n) 1501 100% 267 17.8% 1234 82.2% 800 64.83% 434 35.17% 1196 96.92%Abbreviations: T Zone: Tranformation Zone Component; NILM: Negative for Intraepithelial Lesion or Malignancy.

Table 2: Shows categorization of NILM.Total NILM Smears 1196 96.92%

Normal 170 13.78%Inflammatory smears 1026 83.14%

Inflammatory smears Inflammation NOS 850 68.88%BV 121 9.81%TV 26 2.11%Candida 25 2.03%Actinomycosis 1 0.08%Herpes 1 0.08%BV, TV 1 0.08%BV, TV, Candida 1 0.08%

Abbreviations: NILM: Negative for Intraepithelial Lesion or Malignancy; BV: Bacterial Vaginosis; TV: Trichomonas vaginalis

Table 3: Categorization of Intraepithelial Lesions.Age ASC-US ASC-H LSIL HSIL SCC AGC Total smears

17 - 19 yrs20 - 29 yrs 1 130 - 39 yrs 3 1 2 640 - 49 yrs 10 2 3 2 1750 - 59 yrs 2 2 2 1 1 860 - 69 yrs 1 2 2 570 - 79 yrs 1 180 - 89 yrs

Total 18 (1.46%) 4 (0.32%) 3 (0.24%) 5 (0.41%) 5 (0.41%) 3 (0.24%) 38 (3.08%)TZ present 10 3 3 4 2 3 25 (65.79%)TZ absent 8 1 0 1 3 13 (34.21%)

Abbreviations: ASC-US: Atypical Squamous Cell of Undetermined Significance; ASC-H: Atypical Squamous Cells, Cannot Exclude HSIL. LSIL: Low-Grade Squamous Intraepithelial Lesion; HSIL: High-Grade Squamous Intraepithelial Lesion; SCC: Squamous Cell Carcinoma; AGC: Atypical Glandular Cell; TZ: Transformation Zone Component

Table 4: Pap smears Showing Correlation with Corresponding Histology.Cytology Histology

Inflammatory (n=74) Chronic cervicitisHSIL(n=4) SCCHSIL (n=1) CIN II/IIISCC (n=2) SCC

ASC-H (n=1) CIN I/IIAdenocarcinoma (n=1) Adenocarcinoma

Abbreviations: n: Number of Pap Smears, HSIL: High Grade Squamous Intraepithelial Lesion, SCC: Squamous Cell Carcinoma, CIN: Cervical Intraepithelial Lesion, ASC-H: Atypical Squamous Cells, HSIL Cannot be Ruled Out.

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100,000 women in North America. The drastic differences can be explained by lack of access to effective screening and to services that facilitate early detection and treatment [1].

Cervical cancer has been the most important cancer in women in India over the past two decades. The current estimates indicate approximately 132,000 new cases diagnosed and 74,000 deaths annually in India, accounting to nearly 1/3rd of the global cervical cancer deaths [4]. However all the urban population based cancer registries (PBCR) at Bangalore, Bhopal, Chennai, Delhi and Mumbai have shown a statistically significant decrease in the Age Standardized Incidence Rates (AARs) of this site of cancer [5]. A study at South India has shown prevalence of 17% [6].

Conventional cervical cytology is the most widely used cervical cancer screening test in the world and cytology screening programmer in several developed countries have been associated with impressive reductions in cervical cancer burden [4]. However the screening coverage in India is 2.6-5% and it is mainly an opportunistic screening. Even though the cancer registries show decline in cervical cancer incidence, it is mainly urban statistics. In rural areas cervical cancer still ranks number one in India [7]. The WHO recommends that in developing countries, women aged between 18-69 years should be screened for cervical cancer every 3 years. In our study, the youngest age screened was 17 years and oldest age was 88 years. Unlike many other cancers, cervical cancer occurs early and strikes at the productive period of a woman’s life. The incidence rises in 30–34 years of age and peaks at 55–65 years, with a median age of 38 years (age 21–67 years) [4]. In our study, cervical cancer was noted between 47- 65 years.

The rate of unsatisfactory smear was high in the present study i.e., 17.8%. In other studies it is 1.36%, 4.1% and 24.42% (Table 6) [3,8,9]. The unsatisfactory rate is an important quality assurance indicator in cervical cytology as it identifies women who are being inadequately screened. High rate of unsatisfactory smears could be due to sampling errors. Hence regular training and feed back is essential.

The positive / abnormal Pap smear cytology (3.08%) in our study was close to the international and Indian studies done by Sherpa et al., (3.6%) and Sankaranarayanan et al., (3.4%) respectively [8-10]. But it was higher than studies done by Dharbhadel et al., and Tamrakar et al., as our study was done on high risk semi-urban population of lower socio-economic status [2,11]. However, our figures were lower than Pradhan, it could be attributed to the fact that our study is a part of routine gynecology check-up (opportunistic sampling) and annual checkup [12] (Table 7). The relationship between the transformation zone and intraepithelial lesion is always controversial. The Bethesda System for Reporting Cervical Cytology states; “Specimens that lack EC/TZ elements are not more likely to have a squamous lesion on follow up”. Similar reports are many studies [13-20]. However in our study 65.79% of intraepithelial lesions showed presence of transformation zone which suggests that presence transformation zone component increases the detection of intraepithelial lesion (Table 8).

In a low-risk population, it was suggested that the rate of

Table 5: Cytohistology Discrepancies.Cytology Histology

Inflammatory (n=15) CIN (I / II)ASC-US (n=8) Chronic cervicitis

HSIL (n=1) Chronic cervicitisLSIL (n=2) Chronic cervicitis

Abbreviations: N: Number of Pap Smears; CIN: Cervical Intraepithelial Neoplasia; ASC-US: Atypical Squamous Cells of Undetermined Significance; HSIL: High Grade Intraepithelial Lesion; LSIL: Low Grade Intraepithelial Lesion.

Table 6: Shows various parameters of Pap smear in present study compared with other studies.

Diagnoses Present study

Crasta et al [7]

Narasimha et al [3]

Sankarana-rayana et

al [8] Unsatisfactory 17.80% 1.36% 24.42% 4.10%

ASCUS 1.46% 0.37% 4.14% 8.80%LSIL 0.24% 0.19% 2.70% 6.20%HSIL 0.41% 0.61% 2.50% 1.60%

ASCUS/SIL ratio 0.5 0.7 0.9 2.75

Table 7: Shows positive pap smears in current study compared to other studies.

Author Sample size Positive pap smears (%)

Pradhan [11] (2002) n = 800 4.80%Sherpa et al. [9] (2009) n=932 3.60%

Sankaranayanan et al. [8] (2003) n =4444 3.40%

Current study n = 1501 3.08%Tamrakar et al. [2] (2012) n = 1506 1.70%

Dharbhadel et al. [10] (2004) n =350 times

Table 8: Comparison of Endocervical component (ECC) with other studies.STUDY ECC SIL The Bethesda System [12] ECC (-) Less likely Tacken MA [13] ECC (-) No abnormality Siebers AG [14] ECC (-) Low rate of lesions YL Hock [15] ECC (-) Less likelySelvaggi SM [17] ECC (-/+) No significant difference Mitchell HS [18] ECC (-/+) No significant differenceBos AB [19] ECC (-/+) No significant differenceCurrent study ECC (-) Less likelyAbbreviations: ECC(-): No Endocervical Cells; ECC(+): Endocervical Cells Present; SIL: Squamous Intraepithelial Lesion

ASCUS should be less than 5%. The rate of ASCUS is not a reliable indicator of quality control. ASC/SIL is a quality indicator. ASC/SIL ratio should be between 2 and 3. Our study involved high-risk population involving opportunistic screening and screening women who presented with symptoms and showed ASCUS rate of 1.46% with an ASC/SIL ratio of 2.75. ASC/SIL ratio should be between 2 and 3 even in high risk population where both ASC and SIL will be increased [21]. Comparison of ASC/SIL ratio in various studies is shown in Table (6).

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Considering cytohistology correlation, in our study out of six HSIL cases, four were diagnosed as squamous cell carcinoma, one as CIN II/III and the other one as chronic cervicitis. The discrepancies could be probably due to sampling error. Hence both cytology and histopathology samples should be from the same site. With the introduction of the term ASC-US in cervical cytology, there has been a great controversy among pathologists and clinicians concerning its definition, its significance, and its role in patient management. The prevalence rate of biopsy-proven SIL in a patient with a previous diagnosis of ASC-US on a Pap smear varies (range; 10–61.3%). Kurman et al., stated that; “follow up of a diagnosis of ASC-US smears is acceptable when the diagnosis is not further qualified or a reactive process is favored” [20]. This explains our discrepancies of ASC-US as chronic cervicitis on histology, that it could be reactive / regenerative process. Our study had a sensitivity of 45%, specificity 87.6%; false positive rate 12.4%, false negative rate 55%, positive predictive value 45% and negative predictive value 83.1%. The comparison in various studies is shown in Table (9) [22-25].

CONCLUSIONPap smear is still a relatively good method in screening

cervical cancers in developing countries. Smears positive of intraepithelial lesions has to be co-related with histopathology for further management.

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Table 9: Comparison of Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value, False Positive Rate and False Negative Rate in Various Studies with Present Study.

Various Studies Sensitivity Specificity PPV NPV FNR FPR

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Abbreviations: PPV: Positive Predictive Value; NPV: Negative Predictive Value; FNR: False Negative Rate; FPR: False Positive Rate.

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Cite this article

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