VARIATION OF CERVICAL CYTOLOGY BY PAP SMEAR AND ITS CORRELATION WITH CERVICAL BIOPSY IN PATIENTS ATTENDING BIRAT MEDICAL COLLEGE TEACHING HOSPITAL , MORANG , NEPAL

Varia on of Cervical Cytology by Pap Smear and its Correla on with Cervical Biopsy in Pa ents A ending Birat Medical College Teaching Hospital, Morang, Nepal. Amrita Sinha, Santosh Upadhyaya Kafle, Mrinalini Singh, Neeta Kafle. BJHS 2021;6(3)16. 1615 1620. Introduc on Carcinoma cervix is the second most common cause of death in women worldwide and the most common cause in developing countries. Cervical pap smear is a simple, safe, noninvasive, outdoor and low cost effec ve screening method for detec on of cervical lesion but has limita ons and needs confirma on by histopathology. Cervical biopsy is a gold standard but invasive technique.


INTRODUCTION
Carcinoma cervix is the second most common cause of death in women worldwide and the most common cause in 1 developing countries. It has been considered preventable because it has a long pre-invasive state and the availability of screening programs and treatment of pre-invasive lesion is 2 effec ve. The pre-invasive stages consists of cellular altera ons in the cervix which compromise the epithelium of the region and translate into cervical intraepithelial neoplasia 3 (CIN), divided into grades I, II and III (carcinoma in situ). The premalignant lesions of cervix commonly involve transforma on zone of the uterine cervix. Histopathological terminologies used to describe the grades of the disease are: low grade CIN (cervical intraepithelial neoplasia) comprises CIN I lesions with koilocy c atypia and, high grade CIN consist of CIN II and III. In histopathology, mild dysplasia (CIN I) corresponds to low-grade squamous intraepithelial lesions (LSIL) in cytology whereas moderate and severe dysplasia (CIN II and CIN III) corresponds to high grade intraepithelial lesions (HSIL) in cytology. High grade lesions 4 are true precursors of invasive cancer. The exfolia ve cytology has proven to be an efficacious technique in detec on of cancerous and precancerous 5 lesions of the cervix. The Papanicolaou (Pap) smear is a simple, safe, noninvasive and low cost effec ve method for detec on of precancerous, cancerous and non-cancerous 6 changes in the cervix. The cytology offers certain advantages over histology in the assessment of cervical dysplasia. It provides exquisite nuclear detail, making early nuclear abnormali es easier to appreciate. Broad area is sampled by a good Pap collec on, where only a por on of the 7 squamocolumnar junc on may be sampled by biopsy. However, pap smear fails to localize the lesion and even though pap smear has become a standard screening test, cervical biopsy remains the 'gold standard' for the diagnosis 8 of precancerous cervical lesion. Abnormal cervical pathology are common findings. Some mes, a diagnos c dilemma occurs which can be minimized a er having cervical biopsy. So we need to find correla on between cervical cytology and biopsy in our 4 se ngs. This type of study has been done by Dhakal et al in 11 Nepal and B et al in India however not done in amanikar SA our setup so this study is done in our se ngs. The general objec ve of this study is to find the changes of cervical cytology by pap smear and the specific objec ve is to correlate the changes observed in cervical cytology with cervical biopsy.

METHODOLOGY
This is a hospital based prospec ve cross-sec onal study th st carried out from 15 September 2020 to 31 May 2021 in the department of Pathology, Birat Medical College and Teaching Hospital. Ethical clearance was obtained from the Ins tu onal Review Commi ee (IRC) of the ins tute to carry out the study. The informed consent was taken from the pa ents. All samples requested for pap-smear were studied during this period. In total 550 samples were studied. However, the cases who had undergone both pap-smear and cervical biopsy were compared. Papanicolaou's method was used for staining pap smears. The new 2014 Bethesda system was used for cytological interpreta on of the smears. The cervical biopsies were fixed in 10% formalin, processed and stained with Haematoxylin and Eosin stain for histopathological examina on. The data were entered into Microso Excel and then transferred to sta s cal package of social science (SPSS) version 16 for the analysis. Frequencies and percentages were used to present the data. Sensi vity, specificity and posi ve predic ve value were calculated. Women >65 years and <20 years, those female with frank cancer, pregnant women, post total hysterectomy pa ent and smears unsa sfactory for evalua on were excluded from the study.

RESULTS
A total of 550 cervical pap smears were received in the Department of Pathology. Age of the pa ents ranged from 21 to 78 years with the majority of cases belonging to the age group of 31-40 years. On cytology, total 514(93.4%) cases were nega ve for intra epithelial lesion or malignancy (NILM), 329 (59.8%) were normal smear and 185(33.6%) were inflammatory smears. Total 36(6.5%) cases were squamous epithelial cell abnormali es (ECA), 20(3.6%) were atypical squamous cells of undetermined significance (ASCUS), 9 (1.6%) were LSIL, 5 (0.9%) were HSIL and 2 (0.4%) were Squamous cell carcinoma (SCC). (Table 1)  Thirty cases had both pap smear and cervical biopsy. In the biopsy findings, Chronic cervici s was the most common finding which comprised of 18(60.0%) cases. Normal cases were seen in 1 (3.3%) biopsies. Cervical intra-epithelial neoplasia I (CIN I), CIN II and CIN III cases were seen in 5(16.7%), 1 (3.3%) and 2 (6.7%) biopsies respec vely. Malignancy was seen in 3 (10.0%) cases which comprised of Squamous cell carcinoma. (Table 2) Table 3: Correla on between cervical pap smear and cervical biopsies findings  (Table 3) The sensi vity, specificity and posi ve predic ve value of pap smear were 90.9%, 89.5% and 83.3% respec vely in our study. (Table 4)  years. This indicates that premalignant lesions precedes the development of malignancy by a decade and prompt iden fica on by appropriate screening reduces the mortality and morbidity associated with cervical cancer. Pap smear cytology findings were categorized into NILM and ECA. In this study, Pap smear reported as NILM was the most common findings with 93.4% of all smears examined which was in accordance with the study conducted by Bamanikar et 11 al. where 88.02% cases were reported as NILM. In our study, among 514 cases reported as NILM, normal smear (n=329; 59.8%) was the most common observa on followed by inflammatory smear (n=185; 33.6%). The result of our finding was very similar to the finding in a study done by Dhakal et al where 67.9% were normal smear and 27.9% were inflammatory smear and Mainali et al where 59.51% 4,8 were normal smear and 39.12% were inflammatory smear. In our study, ECA was found in 6.5% cases which was in accordance with the study conducted by Bamanikar et 11 alwhere 5.99% cases were reported as ECA. ECA group were categorized as ASCUS, LSIL, HSIL and SCC. In this study, ASCUS, LSIL, HSIL and frank malignancy cases were 20(3.6%), 9 (1.6%), 5 (0.9%) and 2 (0.4%) respec vely which was similar to the study done by Bamanikar et al who reported ASCUS, LSIL, HSIL and frank malignancy in 2.98%, 11 1.19%, 0.66% and 0.95% respec vely. However, findings in the study done by Gandavaram et al revealed ASCUS, LSIL, HSIL and frank malignancy in 13.6%, 9.6%, 6.4% and 3.2% 12 respec vely. These differences in pap smear repor ng can be due to the differences in sampling, staining, fixa on technique and repor ng errors. On histopathological examina on, out of 30 pa ents, on whom pap smear and biopsy were taken, majority of the cases (n=18; 60.0%) had chronic cervici s followed by mild dysplasia (n=5; 16.7%), moderate to severe dysplasia (n=3;10%), malignant lesion (n=3;10%) and normal case (n=1; 3.3%). Findings of our study coincide with the reports of Bamanikar et al who reported chronic cervici s in 59% of cases, mild dysplasia in 16.5% cases, moderate to severe dysplasia in 11.5% cases, malignant lesion in 10% cases and 11 normal findings in 3% cases in his study. Similar finding was also seen in a study conducted by Gandavaram et al, where chronic cervici s, mild dysplasia, moderate to severe dysplasia and malignant lesion were reported in 56.8%, 19.2%, 14.4% and 9.6% of cases in his 12 study. In this present study, out of 2 cases diagnosed as ASCUS on cytology, one was non neoplas c and one was CIN I in histopathology. Fi y percent of ASCUS on cytology revealed the diagnosis of CIN on histopathology sta ng that all cases of ASCUS should be followed up periodically and biopsy is must in this condi on. Out of 5 cases diagnosed as LSIL on cytology, one was non-neoplas c, three were CIN I and one was CIN III on histopathology. The false posi ve cases of ASCUS and LSIL on pap smear were due to regenera ve changes whose evalua on therefore becomes more important. The regenera ve changes can be divided into typical and atypical and the atypical regenera ve changes should be added to the ASCUS group. Also to decrease false posi ve rate, adequate sampling and avoiding technical errors like air drying, fixa on artefacts is necessary. In this study, out of 3 cases diagnosed as HSIL on cytology, one was CIN II, one was CIN III and 1 case was diagnosed as SCC on biopsy, hence biopsy from representa ve area would minimize the errors. The chances of HSIL progressing to invasive cancer is only 2% well documented in literature, however, up to 20% with HSIL will develop cancer if it is le untreated. Therefore to prevent HSIL from developing into cancer, the precancerous cells are removed or destroyed. In our study, sensi vity, specificity and posi ve predic ve value of pap smear were 90.9%, 89.5% and 83.3%  13,14 88.9% respec vely. The sensi vity and specificity of pap smear can be increased by adop ng proper technique and adequate sampling from the transforma on zone. In this study, pap smears were sampled by conven onal method and therefore use of liquid based cytology is advised to improve the sensi vity and specificity of pap smear.

CONCLUSION
Cervical pap smear is a cost-effec ve and reliable screening test for early detec on of premalignant and malignant cervical lesions. Therefore, it should always be done as a rou ne outpa ent screening test as per guidelines. However, cervical biopsy is the gold standard for its confirma on, which should be carried out to confirm the findings of pap smear and in case of strong clinical suspicion.

RECOMMENDATIONS
In the view of high probability of carcinoma cervix, screening for carcinoma cervix on a regular basis needs to be considered.

LIMITATION OF THE STUDY
An important limita on to our study is the small number of pa ents. Definite categoriza on of inflammatory smear is not done in our study. Special stains and Immunocytochemistry is not done.