Cytological profile of Pap smears in a tertiary care hospital of West Bengal, India

Abstract

Background: Among Indian women cancers of cervix and breast account for a very large proportion of malignancies. Majority of the cancer patients present themselves to the doctor at an advanced and incurable stage. Screening for cervical cancer can be done by Pap test which is a very simple and inexpensive test. Early detection and treatment of pre-cancerous conditions and cancers provide the best possible protection against cancer for the individual and the community.
Methods: A descriptive study with cross-sectional design was conducted in the laboratory of the Department of Pathology at Bankura Sammilani Medical College, Bankura in West Bengal during January 2014 to December 2014. Analysis of cervical cytology was done for neoplastic cells.
Results: Out of 288 smears 8.3% samples were unsatisfactory, 77.9% were without epithelial cell abnormality while 13.8% were abnormal comprising of atypical squamous cells of undetermined significance (ASCUS) 1.4%, low grade squamous intra-epithelial lesion (LSIL) 8.3%, had high grade squamous intra-epithelial lesion (HSIL) 3.5% and squamous cell carcinoma, and post-radiation effect 0.3% each. Abnormality of smear was significantly associated with age group and religion of the cases (p

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December 2016 · Volume 5 · Issue 12 Page 4397
International Journal of Reproduction, Contraception, Obstetrics and Gynecology
Bhattacharyya NB et al. Int J Reprod Contracept Obstet Gynecol. 2016 Dec;5(12):4397-4400
www.ijrcog.org
pISSN 2320-1770 | eISSN 2320-1789
Original Research Article
Cytological profile of Pap smears in a tertiary care hospital of West
Bengal, India
Nandini Bhaduri Bhattacharyya1, Dinobandhu Naga2, Aditya Prasad Sarkar3*,
Sabitri Mandy1, Purna Chandra Das4
INTRODUCTION
Cervical cancer in the females can be prevented by early
detection of the precursor lesions which can be easily
identified in cervicovaginal preparations. Eradication of
such lesions can prevent the occurrence of invasive
cancer. It has been repeatedly documented that invasive
carcinoma of the uterine cervix, regardless of type,
develops from precursor lesions or abnormal surface
epithelium, which, in its classic form, is known as
carcinoma in situ (International Stage O). The precursor
lesions do not produce any specific alterations of the
cervix visible to the naked eye. Therefore, before the
introduction of cervicovaginal cytology and colposcopy,
these lesions were a rarity and their discovery was
incidental in biopsies of the cervix and in hysterectomy
specimens.1
Since the introduction of mass screening by smears, and
with accumulated experience, it has been shown that
these lesions are quite common. The investigations of the
precursor lesions is facilitated by the accessibility of the
1Department of Pathology, Bankura Sammilani Medical College, Bankura, West Bengal, India
2Department of Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
3Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
4Department of Pathology, Murshidabad Medical College, Murshidabad, West Bengal, India
Received: 08 October 2016
Accepted: 03 November 2016
*Correspondence:
Dr. Aditya Prasad Sarkar,
E-mail: dradityaprasadsarkar@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background:
Among Indian women cancers of cervix and breast account for a very large proportion of malignancies.
Majority of the cancer patients present themselves to the doctor at an advanced and incurable stage. Screening for
cervical cancer can be done by Pap test which is a very simple and inexpensive test. Early detection and treatment of
pre-cancerous conditions and cancers provide the best possible protection against cancer for the individual and the
community.
Methods:
A descriptive study with cross-sectional design was conducted in the laboratory of the Department of
Pathology at Bankura Sammilani Medical College, Bankura in West Bengal during January 2014 to December 2014.
Analysis of cervical cytology was done for neoplastic cells.
Results:
Out of 288 smears 8.3% samples were unsatisfactory, 77.9% were without epithelial cell abnormality while
13.8% were abnormal comprising of atypical squamous cells of undetermined significance (ASCUS) 1.4%, low grade
squamous intra-epithelial lesion (LSIL) 8.3%, had high grade squamous intra-epithelial lesion (HSIL) 3.5% and
squamous cell carcinoma, and post-radiation effect 0.3% each. Abnormality of smear was significantly associated
with age group and religion of the cases (p<0.05).
Conclusions:
Majority of the cases cervical cytology were reported to be without any epithelial cell abnormality
followed by LSIL. Age and religion were significantly associated with the abnormality of smears.
Keywords: Cytology, Pap smear, Tertiary care hospital
DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20164351

Bhattacharyya NB et al. Int J Reprod Contracept Obstet Gynecol. 2016 Dec;5(12):4397-4400
International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 5 · Issue 12 Page 4398
cervix to clinical examination and inspection by the
colposcope and the ease of cytologic and histologic
sampling that could be subjected, not only to microscopic
scrutiny, but also to cytogenetic and molecular biologic
analysis. The success of these programs has been
confirmed because, over the past half century, the rate of
invasive cancer of the uterine cervix has been reduced by
about 70% in the United States and other developed
countries (summaries in Koss, 1989; Cannistra and
Niloff, 1996). In developing countries, however, cancer
of the cervix remains a common disease with a high
mortality rate.1
The Pap test is considered by many to be the most cost-
effective cancer reduction program ever devised. Credit
for its conception and development goes to George
N.Papanicolaou, an anatomist and Greek immigrant to
the United States. In 1928 he reported that malignant
cells from the cervix can be identified in vaginal smears.
Later, in collaboration with the gynecologist Herbert
Traut, who provided him with a large number of clinical
samples, Papanicolaou published detailed descriptions of
preinvasive cervical lesions. Pathologists and physicians
initially greeted this technique with skepticism, but by the
late 1940s Papanicolaou’s observations had been
confirmed by others. The Canadian gynecologist J. Ernest
Ayre suggested taking samples directly from the cervix
with a wooden spatula rather than from the vagina with a
pipette as originally described by Papanicolaou.
Eventually, cytologic smears were embraced as an ideal
screening test for preinvasive lesions, which, if treated,
would be prevented from developing into invasive
cancer.2
Cancer of the cervix is a global health problem,
comprises approximately 12% of all cancers among
women globally. Incidence and mortality of cancer cervix
in world is 530232 and 275008 per year while in India it
is 134420 and 72825 per year respectively.3 With this
background the study was conducted to study the socio-
demographic characteristics of the adult women attending
the Pathology Department of Bankura Sammilani
Medical College and Hospital, West Bengal for cervical
pap smear examination, to assess the cervical smears and
to identify any factor(s) associated with abnormal pap
smear.
METHODS
It was a descriptive study with cross-sectional design.
The study was conducted in the laboratory of the
Department of Pathology of Bankura Sammilani Medical
College and Hospital in West Bengal during one year i.e.
from January 2014 to December 2014.The samples were
examined from those female patients who were referred
by the Department of Gynaecology of the Medical
College for abnormal cervical discharge. The samples
were collected with the help of a wooden or plastic
spatula called Ayre’s spatula .The spatula after
introduction into the vagina was rotated through 3600 to
get material from ectocervix and squamocolumnar
junction. Smears were made on glass slides from the
spatula. Then the smear was immersed directly into a
Coplin jar filled with 95% ethanol for fixation. This part
of the collection was done by the gynaecologists and the
glass slides were sent to the Pathology Department,
where the smears were stained by Leishman and Giemsa
method and examined under light microscope. The
reporting was done following Bethesda method 2001.4
RESULTS
Out of 288 cases majority were in 31-40 years age group
(28.1%) followed by 41-50 years (26.4%), whereas
women aged 71 years or more contributed only 2.1%.
(Table 1)Women of More than 50% of the cases were
comprised of women of 31-50 years. Majority of the
cases were Hindu (91.3%) while only 8.7% were Muslim
(Table 2).
Table 1: Distribution of cases according to age
(n=288).
Age (yrs)
Number
Percentage
≤30
75
26.0
31-40
81
28.1
41-50
76
26.4
51-60
31
10.8
61-70
19
6.6
≥71
6
2.1
Total
288
100.0
Table 2: Distributions of the cases according to
religion (n=288).
Religion
Number
Percentage
Hindu
263
91.3
Muslim
25
8.7
Total
288
100.0
Table 3: Distribution of cases according to type of
lesion (n=288).
Type of cytology
Number
Percentage
Unsatisfactory smear
24
8.3
NILM*
224
77.9
Abnormal smear
40
13.8
ASCUS
4
1.4
LSIL
24
8.3
HSIL
10
3.5
Post-radiation
1
0.3
SCC
1
0.3
* Negative for intraepithelial lesion or malignancy
Smears were subdivided into three general categories i.e.
unsatisfactory, Normal or abnormal. Out of total 288
cervical smears collected 24 (8.3%) were unsatisfactory

Bhattacharyya NB et al. Int J Reprod Contracept Obstet Gynecol. 2016 Dec;5(12):4397-4400
International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 5 · Issue 12 Page 4399
(Table 3). Examination of 266 satisfactory samples
revealed that in 224 (77.9%) smears no intraepithelial cell
lesion or malignancy (NILM) was found. On the other
hand, 40 (13.8%) of the cervical smears were abnormal.
Abnormal smears were subdivided into ASCUS (atypical
squamous cell of unknown significance), LSIL (low
grade squamous intra epithelial lesion) and HSIL (high
grade squamous intra epithelial lesion), SCC (squamous
cell carcinoma) and post radiation. Out of the abnormal
smears, majority were LSIL 24 (8.3%), followed by
HSIL 10 (3.5%), ASCUS 4 (1.4%) and 0.3% was
contributed by post-irradiation and squamous cell
carcinoma each.
Table 4: Distribution of cases according to age and type of cervical cytology (n=288).
Age group
(years)
Type of cytology
Total
Unsatisfactory
NILM
ASCUS
LSIL
HSIL
SCC
Post-
irradiation
≤ 30
5(6.7)
60(80)
0(0.0)
7(9.3)
3(4.0)
0(0.0)
0(0.0)
75
31-40
6(7.4)
63(77.8)
1(1.2)
10(12.3)
1(1.2)
0(0.0)
0(0.0)
81
41-50
7(9.2)
58(76.3)
2(2.6)
5(6.6)
3(3.9)
0(0.0)
1(1.3)
76
51-60
4(12.9)
25(80.6)
0(0.0)
0(0.0)
1(3.2)
1(3.2)
0(0.0)
31
61-70
1(5.3)
15(78.9)
1(5.3)
1(5.3)
1(5.3)
0(0.0)
0(0.0)
19
≥71
1(16.7)
3(50.0)
0(0.0)
1(16.7)
1(16.7)
0(0.0)
0(0.0)
6
Total
24(8.3)
224(77.8)
4(1.4)
24(8.3)
10(3.5)
1(0.3)
1(0.3)
288
* Figures in the parentheses indicate percentage.
Table 5: Distribution of cases according to age and
type of lesion (n=264).
Age group
(in years)
Cervical cytology
Total
NILM
Abnormal
≤ 50
181(80.8)
22(19.2)
203
≥ 51
43(21.2)
18(78.8)
61
Total
224(100.0)
40(100.0)
264
* Figures in the parentheses indicate percentage.
Table 4 reveals that NILM smears were majority in all
age groups. LSIL was mostly in 51-60 years age group
(22.7%) while HSIL was mostly found among women
aged 71 years or more (16.7%). One case of post-
radiation was found in 61-70 years age group while the
lone case of cervical carcinoma was found in 51-60 years
age group.
Table 6: Distribution of cases according to religion
and type of lesion (n=264).
Religion
Cervical cytology
Total
NILM
Abnormal
Hindu
212(86.2)
34(13.8)
246(100.0)
Muslim
11(61.1)
7(38.9)
18(100.0)
Total
223(100.0)
41(100.0)
264
* Figures in the parentheses indicate percentage.
Abnormality of cervical smear was significantly
associated with the age group of the women where the p
value <0.05 (χ2 = 7.18, d.f.= 1) (Table 5).The abnormality
of cervical smear was also significantly associated with
the religion of the women where the p value < 0.05 (χ2 =
8.0, d.f.= 1) (Table 5).
DISCUSSION
In this study it was observed that among 288 patients,
women from all age groups between 20 years to 90 years
were present. All of them attended Gynaecology and
Obstetrics OPD due to some complaints of reproductive
tract. Thus routine screening among women was not
practiced.
The present study revealed that NILM was 20.5% while it
was 29.0 in a study at Western maharashtra5 while it was
16.96% in a study at Pune.3But a study at Guwahati
reported NLIM of more than 80%.6 ASCUS was only
1.3% in the present study while it was slightly more in
Pune study and much more in Guwahati study.5,6 LSIL
was reported to be in 8.3% smears. It was less in Pune
and Guwahati while it was much more in Maharashtra.
HSIL was present in 3.5% cases whereas it was less in
Pune and Maharashtra study but much more in Guwahati
study.3,5,6
Proportion of cases with cervical carcinoma was more in
a study by Bamanikar A S et al and Deshpande J D while
much more in the study by Sarma U et al.The type of
cytology was statistically associated with age group of
women. Similar finding was found in the study by Sarma
U at Guwahati.6
Jason Poole, Head of Cancer Analysis at Trent Cancer
Registry summarizes the key findings: “There has been

Bhattacharyya NB et al. Int J Reprod Contracept Obstet Gynecol. 2016 Dec;5(12):4397-4400
International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 5 · Issue 12 Page 4400
an increase in the incidence of cervical cancer in women
aged under 35 since the late 1990s. Over this time there
has also been a steady fall in the coverage in women of
this age group. “Increasing coverage in these age groups
will be important to stop this trend. While screening older
women leads to a substantial reduction in cervical cancer,
screening in women aged 20 – 24 has been shown to have
little or no impact on rates of invasive cervical cancer at
ages 25 – 29.7 Indeed, the upward trend in incidence
rates began from 2000 following several years of decline
in coverage.” Jason concludes: “It is clear that as
screening coverage decreases in younger women,
incidence of cervical cancer rises. It is important that the
recent upward trend in screening coverage continues, so
that the number of women who develop cervical cancer
can be reduced. I would hope that this message gets
through to all women and young women in particular, to
encourage them to take up cervical screening when
invited.”7
The incidence of carcinoma of the cervix is very low in
women aged less than 25 years, but then begins to climb.
However, in an extension of the British Columbia cohort
study, the incidence of carcinoma in situ at age 20–24
was of the order of 16 per 100 000, encouraging a
national workshop in Canada to recommend that
screening should start at the age of 20 years. For
developing and some middle income countries, in order
to maximize use of resources, and given the infrequency
of cervical cancer below the age of 35 years, it is
generally recommended to start screening at 35 years and
only extend screening to younger ages when resources
permit (WHO, 1986). It has been pointed out that age is
the most important risk factor for cervical cancer and that
screening should aim to target high-risk women. A good
guide would be to take the age at the beginning of the rise
in incidence of cervical cancer and begin screening five
years before this age. In most countries, this would be at
about 30–35 years of age .8
Thus we can conclude that majority of the samples of
cervical discharge (60%) received by the Pathology
Department from Gynaecology and Obstetrics OPD were
negative for any intra-epithelial lesion and reported as
NILM. Cases which were reported as positive for intra-
epithelial lesion were mostly low grade squamous intra-
epithelial lesion(LSIL) (8.3%) followed by high grade
lesions(3.5%). Abnormality of smears was significantly
associated with the age group and religion of the cases.
Routine screening for cervical cancer by pap smear
should be religiously followed to reduce its incidence.
CONCLUSION
Taking into the consideration of endocrine and age
specific changes, postmenopausal women face sexual
dysfunctions. Physicians should provide them with the
opportunity to express their thoughts, offering them
alternatives for both evaluation and treatments. It is
mandatory to increase recognition and perceptions of
female sexual dysfunction and dismiss taboo and
improper thoughts which will help in the better
management of patients allowing them to lead good
quality of life.
ACKNOWLEDGEMENTS
Authors would like to thanks to Prof. (Dr.) Swapan
Pathak, Head of the Department, Department of
Pathology, Bankura Sammilani Medical College,
Bankura, West Bengal, India.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
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Cite this article as: Bhattacharyya NB, Naga D,
Sarkar AP, Mandy S, Das PC. Cytological profile of
Pap smears in a tertiary care hospital of West Bengal,
India. Int J Reprod Contracept Obstet Gynecol
2016;5:4397-4400.