Original Article

Detection of abnormal cervical cytology in Papanicolaou smears

ABSTRACT
Background: Cervical cytology by Papanicolaou (Pap) smears is an effective means of screening for cervical premalignant
and malignant conditions. Cervical intra‑epithelial neoplasia (CIN) and cervical cancer remain important health problems
for women worldwide.
Aim: To study the role of Pap smear in detecting premalignant and malignant lesions of cervix; and to determine the
prevalence of various lesions.
Materials and Methods: This study is based on 300 patients who attended the out‑patient Department of Obstetrics and
Gynaecology. Pap smears were prepared from patients presenting with complaints like vaginal discharge, post‑coital
bleeding, inter‑menstrual bleeding, dyspareunia, and pain lower abdomen. After fixation and staining, each smear was
carefully examined.
Results: Epithelial cell abnormalities were found in 5% smears, atypical squamous cells of undetermined significance
(ASCUS) in 0.3%, squamous intraepithelial lesion (SIL) in 3.4% which includes low grade squamous intraepithelial lesion
(LSIL) (2.7%) and high grade squamous intraepithelial lesion (HSIL) 0.7%. Invasive carcinoma was seen in 1.3% cases.
Mean age of the patients with diagnosis of LSIL was 32.3 years and for HSIL, it was 40.5 years. The mean age of the patients
with invasive carcinoma was 57 years.
Conclusion: Premalignant and malignant lesions of cervix are not uncommon in our set up and can be diagnosed early by
Pap smears.

Key words: Cervical cancer; cervical intraepithelial neoplasia; papanicolaou smear.

Introduction with five‑year survival rate of about 48%.[2] It is estimated that

in India 1,26,000 new cases occur each year.[3] Unlike most
Cancer cervix is the second most common cancer in women other malignancies, cancer of cervix is readily preventable
in the world, while it is the leading cancer in women in the when effective programmes are conducted to detect and
developing countries. Globally, 15% of all cancers’ in females treat its precursor lesions. Since the introduction of Pap test,
are cervical cancers’, while in Southeast Asia, cancer cervix a dramatic reduction has been observed in the incidence and
accounts for 20%‑30% of all cancers’. Cancer of cervix is a major mortality of invasive cervical cancer worldwide.[4]
cause of death in women living in developing countries.[1] In
2007, the estimated number of new cases of cancer cervix Materials and Methods
according to national cancer registry of India was 90,708
This study was conducted on 300 Pap smears prepared from
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patients presenting with complaints like vaginal discharge,
Quick Response Code post‑coital bleeding, inter‑menstrual bleeding, dyspareunia
Website: and pain lower abdomen. Relevant history of illness was
www.jcytol.org obtained from the patient and recorded on the proforma.

DOI: It was ensured that no local douche, antiseptic cream and no

10.4103/0970-9371.93222 local internal examination was done on the day of test. The
patient was placed in dorsal lithotomy position and a Cusco’s

Manjit Singh Bal, Rishu Goyal, Anil Kumar Suri, Manjit Kaur Mohi1
Departments of Pathology, and 1Obstetrics and Gynaecology, Government Medical College, Patiala, Punjab, India

Address for correspondence: Dr. Manjit Singh Bal, Department of Pathology, Government Medical College, Patiala ‑ 147 001, Punjab, India.
E‑mail: balmanjit1953@yahoo.co.in

Journal of Cytology / January 2012 / Volume 29 / Issue 1 45

 Bal, et al.: Detection of abnormal cervical cytology in Pap smears

bivalve speculum was introduced through vagina and cervix

was visualized. The longer projection of the Ayre’s spatula
was placed in the cervix near squamo‑columnar junction and
rotated through 360°. The cellular material thus obtained was
quickly, but gently smeared on a clean glass slide. The glass
slide was then immediately put into the coplin jar containing
95% ethyl alcohol which acted as a fixative.
Figure 1: (a) Koilocytic atypia showing perinuclear halo, hyperchromatic
The prepared smears were then stained according to nuclei with prominent nucleoli (Pap, ×400); (b) Squamous cell carcinoma
Papanicolaou’s technique. The cytological interpretation of showing strap cells signifying stromal invasion (Pap, ×400)
the smears was made according to the New 2001 Bethesda
system. Table 1: Categorisation of cytodiagnosis
Cytodiagnosis No. of patients Percentage
Results NILM n=273
Normal 50 16.7
Maximum number of patients (45.3%) were in the age group Inflammatory
Non‑specific 214 71.3
of 31‑40 years (fourth decade) followed by 33.3% in third,
Gardnerella 08 2.7
17.7% in fifth, 2% in sixth decade and 1.7% in seventh decade.
Trichomonas 01 0.3
The most common presenting complaint was discharge per ASCUS 01 0.3
vaginum present in 177 (59%) patients. History of pain in the SIL
lower abdomen was present in 58 (19.3%), inter menstrual HSIL O2 0.7
bleeding in 30 (10%), and 17 (5.7%) patients had complaint LSIL 08 2.7
of dyspareunia. Post‑coital bleeding was the chief complaint Carcinoma
in 15 (5%) patients. Only three patients (1%) presented with SCC 03 1
post menopausal bleeding. ADC 01 0.3
Inadequate 12 4
NILM ‑ Negative for intraepithelial lesion or malignancy; ASCUS ‑ Atypical squamous
Fifteen cases were positive for malignancy, 273 were negative, cell of undetermined significance; SIL ‑ Squamous intraepithelial lesion; HSIL ‑ High
and in 12 smears, the material was inadequate. Out of grade squamous intraepithelial lesion; LSIL ‑ Low grade squamous intraepithelial lesion;
the 273 smears negative for any intra epithelial lesion or SCC ‑ Squamous cell carcinoma; ADC ‑ Adenocarcinoma

malignancy, 50 (16.7%) showed normal cytological findings

and 223 (74.3%) were inflammatory. Out of 223 inflammatory Mean age at marriage for patients with LSIL, HSIL and
smears, 214 (71.3%) showed non‑specific inflammation, invasive carcinoma was 18.5 years, 19.5 years, and 18.3 years,
8 (2.7%) had features of Gardnerella infection, and 1 (0.3%) respectively. A total of 92.9% (13 out of 14) patients with SIL
had evidence of Trichomonas infection. Diagnosis of atypical and invasive carcinoma had parity.
squamous cells of undetermined significance (ASCUS) was
made in one (0.3%) case. Squamous intraepithelial lesion was The most common presenting complaint associated with SIL
seen in 10 (3%) patients, out of which, 8 (2.7%) had low grade and carcinoma was vaginal discharge (71.4%) followed by post
squamous intraepithelial lesion (LSIL) exhibiting koilocytic menopausal bleeding (14.4%). Most common clinical lesion
atypia in majority of the smears [Figure 1a]. In two cases seen in patients with SIL and carcinoma was erosion (35.7%)
(0.3%) of high grade squamous intraepithelial lesion (HSIL), followed by cervix bleeding on touch (28.6%). Inflamed and
the smears showed severely dyskaryotic cells with irregular congested cervix seen in 21.5%, hypertrophied cervix in 7.1%,
hyperchromatic nuclei with coarsely clumped chromatin. and 7.1% had healthy cervix.
Invasive cancer was detected in four (1.3%) cases. Three (1%)
smears showed squamous cell carcinoma [Figure 1b] and one Discussion
(0.3%) smear showed adenocarcinoma. Twelve (4.1%) smears
were found to be inadequate [Table 1]. Cancer cervix is considered to be an ideal gynaecological
malignancy for screening as it meets both test and disease
Mean age of cases with low grade squamous intraepithelial criteria for screening. It has a long latent phase during which
lesion (LSIL) was 32.3 years and those with HSIL and invasive it can be detected as identifiable and treatable premalignant
carcinoma were 40.5 years and 57 years, respectively. There lesions which precede the invasive disease and the benefit
was sequential progression in the development of LSIL to of conducting screening for carcinoma cervix exceeds the
HSIL to invasive carcinoma with advancing age. cost involved.[5]

46 Journal of Cytology / January 2012 / Volume 29 / Issue 1

 Bal, et al.: Detection of abnormal cervical cytology in Pap smears

In our study, mean age of patients with LSIL was 32.3 years, Acknowledgement
and those with HSIL and invasive carcinoma were 40.5 years
and 57 years, respectively. Elhakeem et al.,[6] also recorded We thank the patients and technical staff of Pathology Department
a progressive increase in development of LSIL to invasive GMC Patiala for processing the Pap smears.
carcinoma with increasing age. LSIL had peak between
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and malignant lesions of cervix at an early stage, and thus How to cite this article: Bal MS, Goyal R, Suri AK, Mohi MK. Detection of
abnormal cervical cytology in Papanicolaou smears. J Cytol 2012;29:45-7.
help the clinicians in early and more efficient management
of the patients. Source of Support: Nil, Conflict of Interest: None declared.

Journal of Cytology / January 2012 / Volume 29 / Issue 1 47

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