Cytological pattern of cervical pap smears

Results: Out of 1999 smears, 56 cases (2.8%) were unsatisfactory/inadequate, 1884 (94.25%) smears were negative for intraepithelial lesion/malignancy, 115 (5.75%) smears showed epithelial cells abnormalities and 439(21.96%) smears were with reactive cellular changes associated with inflammation. Bacterial vaginosis (55.35%) was the most common etiology identified in 439 cases inflammatory smears. Total 310 (15.5%) cases showed moderate to severe atrophic changes in smear cytology. Among 18 follow up cases of carcinoma cervix, one case (0.2%) was identified as relapse case.


INTRODUCTION
The world wise incidence of cervical cancer is 15.3/100,000 women per year with about 86% occurring in developing countries.According to World Health Organization, global cancer rate would increase by 50% by 2020.The frequency of cervical cancer in developing countries is variable due to the differences in screening programs and the prevalence of risk factors.Human papilloma virus attribute as cause of cervical cancer in 99% cases.In Nepal, Cervical cancer, breast and lung cancer are common cancer with cervical uteri cancer showing highest crude incidence of 5.35 at age of 65-69.1-3  Cervical cancer is preventable by detecting it in premalignant stages by exfoliative cytology such as papanicolaous (pap) smear examination .Screening with pap smear test has helped to reduce the incidence of cervical cancer in many countries .Pap smear test was first introduced in 1943 by George Papanicolaou to detect abnormal cancer cell in cervix.On global scale, the Pap test remains the single best cancer screening procedure and cervical cancer the most preventable form of cancer related death among women.To date, Conventional and liquid based cytology are two methods of Pap test in use.Conventional Pap test is the mainstay screening system in Nepal. 2,4,5rvicitis and vaginitis are common health problem in women, caused by microbial agents.Candida albican, Gardenella vaginalis and Trichomonas vaginalis are the most commonly identified infectious agent for vaginitis.Bacterial vaginalis is characterized by foul smelling vaginal discharge caused by Gardenella vaginalis.The pap smear finding of Bacterial vaginitis is the substitution of normal vaginal flora which is dominated by lactobacilli by the abundant anaerobic bacteria and presence of clue cells .Infection with candida present with itchy vagina and thick fetid vaginal secretion.Trichomonas is considered to be sexually transmissible flagellate protozoa.These are the spectrum of infections that are routinely identified in routine pap smear test. 5,6 Nepal, the funded regular cervical screening programs are not uniform, therefore, data on prevelance of cervical abnormalities in various populations is also lacking.The present study was conducted in Kantipur dental college, Basundhara,lagankhel polyclinic, Nivarak polyclinic and Grande city clinic and hospital services, Kantipath to initiate the findings in cervical pap smear of women of Kathmandu city.Most of these women have taken part in preventive health checkup which included cervical Pap

MATERIALS AND METHODS
The present study is a retrospective study, carried out at Kantipur Dental College, Lagankhel polyclinic, Nivarak polyclinic and Grande city clinic and hospital services.Permission was obtained from ethical committee, prior to data collection.A total 1999 cases were screened in two years period from shrawan 2072 to shrawan 2074.Pap smear was taken by endocervical cytobrush/Ayres spatula in women attending to gynaecology OPD for screening program and for the gynaecological complain of pain abdomen, per vaginal discharge and bleeding or spotting.The pap smears were fixed by using Kinetik cytospray and pap staining was done by trained staff in the laboratory.Pap smear Reporting was done by consultant pathologist according to the Bethesda system 2001.
The epithelial abnormalities according to the Bedestha system 2001 were classifies as atypical squamous cells of udetermined significance (ASC-US), Atypical squamopus cells cannot exclude HSIL (ASC-H), Low -grade squamous intraepithelial lesion (LSIL), High-grade squamous intraepithelial lesion (HSIL) and squamous cell carcinoma; Atypical endocervical cells / glandular cells /endometrial cells -NOS ,favor neoplastic; Adenocarcinoma in situ and Adenocarcinoma .
Collected data were arranged in Microsoft excel format and were used for statistical analysis (SPSS version).Descriptive and frequency statistics were obtained for variable studies.Total number of pap smears, percentages of abnormal pap smears analyses and correlation with different age groups was done.

RESULTS
A total of 1999 cases of cervical pap smear were received during the two years period,age ranging from 19 to 79 years.(fig. 1) Out of 1999 smears, 56 cases (2.8%) were unsatisfactory /inadequate, 1884 (94.25%) smears were negative for intraepithelial lesion/malignancy (NILM), 115 (5.75%) smears showed epithelial cells abnormalities and 439(21.96%)smears were with reactive cellular changes associated with inflammation.A total 310 (15.5%) cases showed moderate to severe atrophic changes in smear cytology .Among 18 follow up cases of carcinoma cervix, one case (0.2%) was identified as relapse case.
The age distribution of total 1999 cases is shown in figure 1 with mean age 44.51 and median age 43.Most of these patients (86%) visited the hospital for screening purpose and few patients (14%) visited the hospital with the complaint of pruritis, lower abdominal pain, vaginal discharge and spotting.(fig.2) Bacterial vaginosis (55.35%) was the most common etiology identified in 439 cases inflammatory smears.Most of these cases presented with homogenous vaginal discharge with presence of clue cells in smear and absence of lactobacilli in background.Fungal infection was seen in 74 cases (16.86%).The smears showed pseudohyphae with small budding yeast, closely related to groups of squamous cells in a background of acute inflammation.Non motile trichomonas were identified with increased neutrophils in background in 24 smears (5.47%).Most of the Trichomoniasis cases presented with mal-odoured discharge per vagina.Chronic lymphocytic cervicitis was the finding in 4 smears (0.91%) suggestive of chlamydial infection.Leptothix vaginalis was identified in 1 smear (0.23%).Lepthotrix in smear was seen in the form of thin filament in loose clusters in background of smear.93 smears (21.18%) were nonspecific inflammation.(Table 1

CONCLUSION
The present study found the Bethesda system classification 2001 very useful screening method for early detection of epithelial cells abnormalities of cervix in Nepalese population.All the cases of epithelial cells abnormities were of age above 30 years.Therefore Pap smear examination should begin in women at least at the age of 30 years.It is also a simple and inexpensive tool for diagnosing cervical infection and help in early institution of specific treatment.Large studies are required to estimate the pattern of cervical cytological abnormalities along with Human papilloma virus (HPV) strain detection in nepali population.