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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 100-104

Prevalence and characteristics of abnormal Papanicolaou smear: A retrospective study from Sikkim, India

1 Department of Pathology, STNM Multi-Specialty Hospital, Gangtok, Sikkim, India
2 Department of Medical Laboratory Technology, Assam Down Town University, Guwahati, Assam, India

Date of Submission19-Oct-2021
Date of Decision02-Nov-2021
Date of Acceptance11-Nov-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. Lhakit Lepcha
Faculty of Paramedical Sciences, Assam Down Town University, Guwahati, Assam
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aort.aort_23_21

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BACKGROUND: Cervical intraepithelial neoplasia and cervical cancer remain chief health complications for women globally. Cervical cytology by Papanicolaou (Pap)-stained smears is an effective means of screening for cervical premalignant and malignant situations. This study was designed to determine and assess the prevalence and characteristics of abnormal Pap smears in this region of Sikkim, India.
MATERIALS AND METHODS: This retrospective study was conducted in the Departments of Pathology at Multi-Specialty Hospital in Gangtok, Sikkim. All Pap smears screened during 2018 and 2020 were included in this study. Approximately 1256 Pap smears were reported based on Bethesda III System (2001). All abnormal smears patients' data were collected and evaluated accordingly.
RESULTS: Most of the patients screened during the 2 years belonged to the ethnic group of Bhutias (15.45%), followed by Rai (12.90%), and the majority were aged 31–40 years (43.78%). Epithelial abnormalities categorized as atypical squamous cells of undetermined significance, atypical squamous cells-high-grade lesions, low grade squamous intraepithelial lesion, and high grade squamous intraepithelial lesion were found in 18.07%, 15.04%, 7.25%, and 4.77% of the women, respectively. The majority of the women with abnormal Pap smear were associated with inflammatory response, with moderate inflammation (33.07%), followed by severe (30.75%) and mild (24.36%) inflammation. The most common pattern was inflammatory which includes neutrophilic infiltration and reactive cellular changes with 66.6% of the case having irregular uterine bleeding (P = 0.002) followed by abnormal vaginal discharge (P = 0.3) and lower abdominal pain (P = 0.005).
CONCLUSION: Prevalence of abnormal Pap smears in Sikkim, India is relatively low compared with other states of India. In contrast, the prevalence of progressive glandular anomalies with inflammation was observed to be high.

Keywords: High-grade squamous intraepithelial lesion, low grade squamous intraepithelial lesion, papanicolaou

How to cite this article:
Bhutia TW, Lepcha L, Sherpa AT, Pradhan PD. Prevalence and characteristics of abnormal Papanicolaou smear: A retrospective study from Sikkim, India. Ann Oncol Res Ther 2021;1:100-4

How to cite this URL:
Bhutia TW, Lepcha L, Sherpa AT, Pradhan PD. Prevalence and characteristics of abnormal Papanicolaou smear: A retrospective study from Sikkim, India. Ann Oncol Res Ther [serial online] 2021 [cited 2022 Aug 8];1:100-4. Available from: http://www.aort.com/text.asp?2021/1/2/100/333306

  Introduction Top

Carcinoma cervix is one of the major causes of death among women population in developing countries.[1] Global cancer statistics 2020 stated that cervical cancer is the fourth-most frequently diagnosed cancer and the fourth-leading cause of cancer death in women, with an estimated 604,000 new cases and 342,000 deaths worldwide.[2] Malignancy of the cervix can be easily identified even in its preinvasive stage and if treated in the earlier stages the patient can often be cured of the disease. Poor living conditions, lack of hygiene, primary age of first sexual intercourse, multiple sexual partners, and human papillomavirus (HPV) infections are the main etiological factors.[3],[4] India contributes one-fifth of the world's load of cervical cancer cases. More than 100,000 new cases are identified every year in India, which is responsible for 20% of cancer-associated female mortality in the country.[5] The main factor in reducing cervical cancer morbidity and mortality is early detection and treatment of premalignant lesions. Of all the malignant tumors, cervical cancer is the one that can be most efficiently controlled by organized screening programs. An organized screening program can reduce incidence and mortality by 80%, as the evidence from the developed countries shows. Despite being operative, most of the female population in developing and under-developed countries do not have access to Papanicolaou (Pap) smear screening.[5],[6]

It has been found that cervical cancers can be analyzed at the preinvasive stage with adequate, repetitive cytological screening.[7] According to Bethesda 2001/2014 classification of cervical cytology, epithelial cell abnormalities are categorized as atypical squamous cells, low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), and Squamous cell carcinoma.[8],[9],[10]

Sikkim is a tiny state of the Indian union located in the eastern Himalayas. The major population of Sikkim is different in their culture, religion, customs, and traditions from other states of India. Nepalis, Bhutias, and Lepchas are the three different communities living in Sikkim. With two main hospitals in Sikkim, Central Referral Hospital of Sikkim Manipal Institute of Medical Sciences, and the STNM at Gangtok, there are four district hospitals, primary health centers (24) and subcenters in Sikkim (147) that accommodate and provide health care to the residents of different societies of State.[5] Sikkim stands 2nd in cervical cancer cases among women, accounting for roughly 10% of all female cancer cases. Many factors are associated with the current surge of cervical cancer in the state, such as the absence of reliable and comprehensive cancer care facilities and specialists in the state or a small number of cases in the state.

To battle the current increase in cases of cervical cancer, the state government of Sikkim has also introduced the Human Papilloma Virus vaccine in its population from July 30, 2018. The aim of this study was to evaluate women for precancerous and cancerous lesions using the Pap smear test and to determine the importance of abnormal cytopathological findings in identifying the preinvasive stage of cervical cancer

  Materials and Methods Top

The present study was carried out in the Department of Pathology in a Multi-Specialty Hospital at Gangtok, Sikkim, India, with effect from January 2018 to December 2020. The study has been approved by the Institutional Ethics Committee of the institute where this study was conducted. This retrospective study was on 1256 patients who attended medicine specialists or gynecologists with cervical cancer screening. All patients were screened with Pap smears, which were collected by trained professionals utilizing cytobrush to collect the samples from the uterine cervix transformation zone. All the smears were screened by the pathologist. Any cellular abnormality was recorded for further reference. Reporting of Pap smear was done based on the Bethesda III system 2001 classification.

Smears were taken of all the patients who presented with complaints of vaginal discharge, postcoital bleeding, intermenstrual bleeding, and pain in the abdominal pain, and those who had no complaints and had come for routine cervical screening. Relevant clinical data and Pap smear reports were obtained and data were noted in the structured pro forma. Two smears were prepared for each case. The glass slide was then fixed in the Coplin jar containing 95% alcohol. The smear was stained with Pap stain. After mounting the slides with Distrenedibutyl phthalate xylene, slides were examined under high-power microscope and were reported by the pathologist.

  Results Top

The maximum number of study subjects were in the age group of 31–40 years (43.78%), followed by the group of 41–50 years old (29.37%). The maximum number of samples was collected in the year 2018, followed by 2019 and 2020 [Table 1]. Most women in the study were Bhutia, followed by rai, sharma, chettri, lepcha, and others [Table 2].
Table 1: Age distribution of patients

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Table 2: Distribution of smear test according to ethnicity

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The majority of the women with abnormal Pap smear were associated with inflammatory response, maximum of the studied population found to have moderate form of inflammation (33.07%), followed by severe (30.75%) and mild (24.36%). The most common pattern was inflammatory which includes neutrophilic infiltration and reactive cellular changes [Table 3].
Table 3: Distribution pattern of different grade of inflammation

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Throughout the study period, 1256 pap smears were performed, of which 1104 women were found with abnormal results including mild to severe inflammation and were considered as the study's cases (group I) and 82 were used as a control group (group II). The control group smears were selected randomly out of the normal pap smears performed during the study period and the remaining 70 were asked for repeat since it was inadequate. [Table 4] represents various clinical manifestations recorded in both Group I and Group II. In Group I, 66.6% (odds ratio [OR] = 1.99; 95% confidence interval [CI] = 1.271–3.129; P = 0.002) presented with irregular uterine bleeding followed by abnormal vaginal discharge (54.74%) (OR = 0.81; 95% CI = 0.516–1.301; P = 0.3) and lower abdominal pain (34.96%) (OR = 2.21; 95% CI = 1.266–3.882; P = 0.005), respectively. In Group II, the majority of cases was presented with abnormal vaginal discharge, irregular uterine bleeding, and lower abdominal pain respectively [Table 4].
Table 4: Symptoms of women attending gynecological outdoor

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[Table 5] shows that 49.28% of the participants were negative for malignancy and but the maximum of the sample had inflammation. The epithelial abnormalities atypical squamous cells of undetermined significance (ASCUS), atypical squamous cells-high-grade lesions (ASC-H), LSIL, and HSIL were found in 18.07%, 15.04%, 7.25%, and 4.77% of the women, respectively [Figure 1]. Unsatisfactory reporting occurred for 5.57% since it was found adequate for sample reporting.
Figure 1: (a) Normal cervical smear (Pap X400), (b) HSIL - high-grade squamous intraepithelial lesions (Pap X400), (c) LSIL - low-grade squamous intraepithelial lesions (Pap X400), (d) Inflammatory smear (Pap X400)

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Table 5: According to epithelial cell abnormality

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  Discussion Top

Cancer of the cervix is preventable, and one of the important aspects in prevention is the detection of the premalignant lesions by screening to reduce the cancer mortality rate. A total of 1256 Pap smears were examined in a period of 2 years, which is slightly low compared with other states of India according to the total number of female populations in the state. Rahman and Kar, 2015 also stated similar findings wherein the knowledge of cancer cervix and Pap smear screening is low among the participant nursing staff in Sikkim. This is indicative of the lack of overall awareness about cancer cervix and Pap smear screening is lower among Sikkimese healthcare providers as compared to developed countries.[5] In our study, the most represented age group was 31–40 years (43.78%). These data are similar to those of the previous studies such as of Shaki et al., 2018[11] and Diouf et al., 2020[12] was average age was 38.6 years and 41 ± 11.16 years, respectively.

The present study also found variation based on ethnic groups, were the maximum number of the Bhutias population approached to hospital for cervical screening (15.45%) followed by rai (12.90%), Sharma (10.19%), chettri (9.87%), lepcha (9.32%), and others (42.28%). This is possibly because the orthodox Christians and Buddhists could have benefitted from the health awareness programs or discussions at their religious institutions or cancer cases is found more prominent in Bhutia (AAR 147.4 per 100 000) and Rai (AAR 87.8 per 100 000) in females, respectively, according to PBCR report from Sikkim.[13]

In our study, we have found the maximum number of cases with inflammation on Pap smear, 33.07% of the cases show moderate inflammation, 30.75% showed severe inflammation, and 24.36% were mild inflammation. Inflammation on Pap smear is considered a relatively benign finding. However, persistent inflammatory changes on Pap smear could be the first indication of premalignant changes in the cervix or genital tract infection. Persistent inflammation can progress to cervical intraepithelial neoplasia if not treated in the early stage.[14],[15]

In our study, 66.6% (OR = 1.99; 95% CI = 1.271–3.129; P = 0.002) presented with irregular uterine bleeding followed by abnormal vaginal discharge (54.74%) (OR = 0.81; 95% CI = 0.516–1.301; P = 0.3) and lower abdominal pain (34.96%) (OR = 2.21; 95% CI = 1.266–3.882; P = 0.005) respectively. This was found similar to the study of Rahman and Kar, 2015 who reported the common symptoms being offensive foul-smelling discharge (63.8%), irregular bleeding (50.6%) and postmenopausal bleeding (26%) while a study by Sachan et al., 2018[16] found that the white vaginal discharge (36.96%) was the most common complaint of the women.

In this study, cytologists reported 4.77% cases of women with HSIL, 7.25% of LSIL, 15.04% with ASC-H, 18.07% with ASCUS, 49.28% negative for malignancy, and 5.57% sample were found inadequate for malignancy which is similar to the finding of Chikhaoui et al., 2020 were epithelial cell abnormality was seen in 19 (1.54%) smears which includes 3 (0.24%) ASCUS, 2 (0.16%) LSIL, 1 (0.08%) HSIL, 5 (0.41%) ASCH and 8 (0.65%) Atypical glandular cells (AGC).[17] In our study, cases with HSIL and were further advised cervical biopsy, but the follow-up data were not found in the histology section of the hospital, which is very alarming. This indicates the lack of proper counseling of the patients. Such results highlight the need for a national HPV vaccination program and the need to assess the suitability of the already available vaccines to our Indian population.

This study was conducted to understand the scale and characteristics of abnormal pap smears in recorded in the Department of Pathology, Super Specialty Hospital, Gangtok, Sikkim, India. The pap smear results in this study revealed a relatively low prevalence of abnormal smears as compared with other states of India.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Altaf FJ. Cervical cancer screening with pattern of pap smear. Review of multicenter studies. Saudi Med J 2006;27:1498-502.  Back to cited text no. 4
Rahman H, Kar S. Knowledge, attitudes and practice toward cervical cancer screening among Sikkimese nursing staff in India. Indian J Med Paediatr Oncol 2015;36:105-10.  Back to cited text no. 5
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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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