Kathmandu University Medical Journal (2007), Vol. 5, No.

4, Issue 20, 461-467

Original Article
Correlation of PAP smear findings with clinical findings and
cervical biopsy
Pradhan B1, Pradhan SB2, Mital VP3
1
Lecturer, Department of Community Medicine, 2Lecturer, Department of Pathology, 3Professor and Head,
Department of Pathology, Kathmandu Medical College & Teaching Hospital, Sinamangal, Kathmandu, Nepal

Abstract
Objectives: Carcinoma of the cervix is the most common cause of the death in Nepal. Cervical carcinoma does not
develop suddenly from normal epithelium but is presented by a spectrum of intraepithelial neoplastic changes that
are precancerous lesion and were termed as cervical intraepithelial neoplasia (CIN). Cervical cytological screening
is designed to detect over 90% of cytological abnormalities. It has also been established that most cervical cancers
can be diagnosed at the preinvasive stage with adequate and repetitive cytological screening. Keeping in view of the
importance of carcinoma and the precancerous lesion (CIN) of cervix, study of different methods for the early
detection of abnormalities in cervix, correlation with the clinical findings and comparison between the techniques
was carried out.
Material and methods: Patients with suspicious cervix attending Gynaecology OPD of TUTH and Western
regional hospital (Pokhara) who have undergone for pap smear cytology test along with biopsy were selected. Detail
history with clinical examination was performed and the findings were correlated.
Results and conclusion: Unhealthy cervix with discharge was found to be common even in chronic cervicitis
however bleeding and tenderness were associated with more advanced lesions. Pap smear test was found to be
equally sensitive to histopathological examination for the early detection of different cervical lesions. However, it is
advised to perform biopsy if any abnormalities are detected in pap smear for correlation and confirmation.

Key words: Pap smear, CIN

C arcinoma of the cervix is the most common

cause of the death in Nepal. In a study carried
out in the Teaching Hospital in the year 1998, 9.76%
then, cervical cytological testing has become the
standard screening test for cervical neoplasm. 8
Cervical cytological screening is designed to detect
of all cancers were carcinoma cervix the third most over 90% of cytological abnormalities6.
common of all cancers. Mortality due to carcinoma of
the cervix world wide is 195,000 numbers of deaths
per year. Incidence of the carcinoma cervix in the
developed world is 90,000 numbers of the cases and
in the developing world is 340,000 numbers of
cases1. Almost 50% of the death from cervical
carcinoma occurs in the two decades of life from 45
to 65 years with a range from 20 to over 85 years. It
has been estimated that an average women under 40
years of age has a 2% chance of developing cervical
carcinoma 2. Subsequent studies showed that cervical
carcinoma does not develop suddenly from normal
epithelium but is presented by a spectrum of
intraepithelial neoplastic changes which are
precancerous lesion and were termed as cervical
intraepithelial neoplasia (CIN).3, 4, 5 Several reports
stated that if these lesions were untreated, up to one- Correspondence
Dr. Binita Pradhan
third of these precancerous cases developed in Lecturer,
carcinoma.6, 7 Department of Community Medicine
Duwakot Community Hospital,
The concept of preinvasive disease of the cervix was Kathmandu Medical College,
E-mail: [email protected]
first introduced by Papanicolaou in 1947 and since

461
It has also been established that most cervical The original terminology of dysplasia and carcinoma
cancers can be diagnosed at the preinvasive stage in situ (WHO) classification was replaced by the
with adequate and repetitive cervical cytological cervical intraepithelial neoplasia (CIN terminology)
screening. Thus it is felt that an organized screening proposed by Richart, 5 in order to emphasise a
programme, aimed at the entire female population, continuum of disease. Recently the Bethesda system
should significantly reduce the mortality. Treatment of terminology has been introduced to sub-classify
of precancerous lesion is simple, safe, very often the lesions into grades: high grade and low grade
non-destructive and usually curative.9 Squamous Intraepithelial Lesions (SIL). 10 The
terminologies are compared in the table below:
CIN is defined as a spectrum of intraepithelial
cellular atypia of mild degree at the base of the Keeping in view of the importance of carcinoma and
cervical squamous epithelium or squamous like the precancerous lesion (CIN) of cervix, study of
metaplastic columnar epithelium of cervix to severe different methods for the early detection of
degree involving the full thickness of the epithelial abnormalities in cervix and comparison between the
lining 3. techniques was carried out.

WHO system CIN Bethesda

(Dysplasia terminology) terminology terminology

Mild dysplasia CIN I Low grade SIL

Moderate dysplasia CIN II High grade SIL
Severe dysplasia CIN III High grade SIL
Carcinoma in situ CIN III High grade SIL

Aims and objectives Hospital (Pokhara), who have undergone for pap
General smear cytology test along with biopsy, were selected.
To correlate between Pap smear cytology Detail history with clinical examination is performed
and cervical biopsy with clinical findings and the findings were correlated.
Specific
To correlate the Pap smear cytology with Results
histological reports 15% of the cases were found to have malignancy and
To correlate the Pap smear cytology with seen even in younger age group 21-30 years however
clinical findings it was found to be less common among the age group
of >71 . It could be due to the higher screening
Inclusion criteria modalities.
All of the patients with suspicious cervix having
abnormality either in pap smear or in biopsy P/V discharge is found to be the commonest
Symptomatic patients with normal cervix having complaints in different lesions of the cervix however
abnormality either in pap smear or in biopsy. p/v bleeding is found to be more specific for cervical
malignancy.
Exclusion criteria
Clinically asymptomatic with normal cervix Unhealthy cervix with discharge was found to be
Suspicious cervix within normal Pap smear or biopsy common even in chronic cervicitis however bleeding
reports and tenderness are associated with more advance
lesions.
Materials and methods
All the patients with suspicious cervix attending Unhealthy cervix with PV bleeding and discharge are
Gynaecology OPD of TUTH and Western Regional found to be more common in advance lesions

462
however tenderness is found to be associated with abnormalities are detected in pap smear because
malignancy. technical errors like sampling error was found to be
the number one cause of false negative reports. This
Considering the histopathology reports as the gold can be overcome by following strictly the instructions
standard, pap smear test is also found to be equally of technique of pap smear and performing biopsy if
sensitive. But it is advised to perform biopsy if any any abnormalities are detected in pap smear.

Table 1: Prevalence of abnormal cervical smears in different age group

Age Diagnosis
Group
(years) Chronic Mild Moderate Severe Ca. in Situ Malignancy Total
Cervicitis Dysplasia Dysplasia Dysplasia
21-30 7 2 1 1 11
31-40 1 6 1 1 2 11
41-50 1 5 3 2 2 13
51-60 1 1 2
61-70 1 1
>71 1 1 2
Total 3 19 6 5 1 6 40

Table 2: Correlation between clinical findings with various lesions of the cervix
Signs/
Symptoms Chronic Mild Moderate Severe Ca. in Situ Malignancy
Cervicitis Dysplasia Dysplasia Dysplasia
Pain 33.33% 100% 83.33% 80% 100% 66.66%
P/V Discharge 100% 100% 100% 80% 100% 100%
P/V Bleeding 26.3% 50% 60% 100%
Wt. loss 33.3% 15.79% 33.33% 60% 100% 66.66%
Dysuria 33.33% 52.6% 50% 80% 100% 66.66%

Table 3: Correlation of pap smear findings with clinical finding

Diagnosis Clinical Findings

Tenderness PV Bleeding Discharge Unhealthy Cervix

Chronic 0/15 3/15 15/15 15/15
Cervicitis
Mild Dysplasia 2/12 7/12 9/12 11/12
Moderate 2/3 3/3 3/3 3/3
Dysplasia
Severe 4/7 6/7 7/7 7/7
Dysplasia
Malignancy 3/3 3/3 3/3 3/3

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Table 4: Correlation between histopathological findings with clinical findings
Clinical Findings

Diagnosis Tenderness PV Bleeding Discharge Unhealthy

Cervix
Chronic Cervicitis - - 33.33% 66.66%

Mild Dysplasia 5.26% 26.32% 95% 100%

Moderate Dysplasia 16.67% 83.33% 100% 100%
Severe Dysplasia 40% 100% 100% 100%
Ca. in situ 100% 100% 100% 100%
Malignancy 100% 100% 100% 100%

Table 5: Comparison of PAP smear with biopsy reports

Diagnosis Pap smear Biopsy report
Chronic Cervicitis Mild dysplasia- 14
15 Moderate Dysplasia- 1
Ch. Cervicitis- 2
Mild dysplasia- 4
Mild Dysplasia 12
Moderate dysplasia- 4
Severe Dysplasia- 2
Mild dysplasia- 1
Moderate Dysplasia 3
Malignancy- 2
Ch. Cervicitis- 1
Severe dysplasia- 2
Severe Dysplasia 7 Ca in situ- 1
Malignancy- 3
Ca. in situ
moderate dysplasia- 1

Malignancy 3 Severe dysplasia- 1

Malignancy- 1

Total 40 40

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 Table 6: Comparison of biopsy with PAP smear reports
Diagnosis Biopsy Pap smear report
Chronic Cervicitis Mild dysplasia- 2
3 Severe dysplasia- 1
Ch. Cervicitis- 4
Mild dysplasia- 14
Mild Dysplasia 19

Moderate Dysplasia- 1

Ch. Cervicitis- 1
Moderate Dysplasia Mild dysplasia- 4
6
Malignancy- 1
Mild dysplasia- 2

Severe Dysplasia 5
Severe dysplasia- 2
Malignancy- 1
Ca. in situ 1 Severe dysplasia 1
moderate dysplasia- 2

Malignancy 6 Severe Dysplasia- 3

Malignancy- 1
Total 40 40

Discussion
Carcinoma of the cervix is the most common As the cervix is relatively easily accessible organ, the
frequent of all the genital cancers and after the breast, logistics for screening cervical cancer are also
the second most common site of malignancy in the simple. Screening programmes have reduced the
female body. In a study carried out in the Teaching incidence and mortality from cancer cervix in many
Hospital in the year 1998, 9.76% of all cancers were developed countries. It is well accepted that pap
carcinoma cervix, the third most common of all smear has been the most effective cancer screening
cancers 1. test ever introduced. This screening test has achieved
a reduction in the death rate of more than 70% for a
Mortality due to the carcinoma of the cervix world prevalent cancer. 11
wide is 195,000 numbers of deaths per year.
Prevalence of the carcinoma cervix worldwide is To date the cervical cancer prevention effort
3,955,000 numbers of cases 1. It has been estimated worldwide have focused on screening sexually active
that that an average women under 40 years of age has women using cytology smear and treating
2% chance of developing cervical cancer 2. precancerous lesion thus by decreasing the incidence
Subsequent studies showed that cervical carcinoma and mortality from cervical cancer. The diagnosis is
does not develop suddenly from normal epithelium made by screening an asymptomatic population, the
but is presented by a spectrum of intraepithelial test in use are cervical cytology, and histological
changes which are precancerous lesion and were examination of the biopsy material added by
termed as CIN. 3, 4, 5 If these lesions were untreated, numerous technique such as Cervicography and
up to 1/3 of these precancerous cases develop in assessment of HPV DNA type. In most developed
carcinoma. 6, 7 countries, women are advised to have their first test
soon after becoming sexually active and subsequently

465
every 1-5 years. The current recommendation of the as malignancy in pap smear were found to be only
American Cancer Society, National Cancer Institute, moderate dysplasia in biopsy.
American College of Obstetrics & Gynaecologists
and others 12, 13 is that all women who are sexually Reports of cytology sensitivity in detecting cervical
active above the age of 18 years should have annual neoplasia ranged from 50%-98% 17. Review of
pap smear for 3 years. If the women have 3 negative smear taken from patient who present with
consecutive negative pap smear, the physicians may invasive cancer showed that sampling error and
consider extending the interval of 3-5 years. The laboratory error are responsible in approximately
Canadian Task Force report (1976) recommended equal numbers 18. Many different approaches have
that sexually active women should have a cervical been studying to improve the accuracy of cervical
smear every 3 years after 2 negative smears. 14 screening e.g. Colposcopy, cervicography etc.

The abnormal smears were seen mainly among the Biopsy report is considered as the gold standard
age group 21-50 years which is sexually active age provided biopsy is taken from the appropriate site. In
group. In a study done by Pradhan P15, the abnormal our study some of the case which was reported as
smears were seen mainly among age group of 21-40 malignancy in biopsy was reported to have moderate
years and carcinoma was also found mainly among dysplasia in pap smear.
that age group. In our study carcinoma was found
mainly among the age group of 21-50 years. Pap smear test is found to be cheap, non-invasive and
equally sensitive to biopsy however it is advised to
As per WHO 1996, 80% of cases present late in the perform biopsy if any abnormalities are detected in
incurable stage. Adenna & Okeke, 1995 reported that pap smear. Sampling error was found to be the
late presentation is related to the inherent shyness of number one cause of false negative report.
the average women in the developing country in
reporting or discussing matters related to the sex 16. Conclusion
In our study, it was seen mainly in the zonal hospital Carcinoma of the cervix is the most common cause of
and one carcinoma cervix was detected probably death in Nepal. Cervical carcinoma does not develop
because of unawareness, negligence and shyness. suddenly from normal epithelium but is presented by
However, abnormal smears were detected mainly in a spectrum of intraepithelial neoplastic changes
the Kathmandu Valley. which are precancerous lesions and were termed as
cervical intraepithelial lesion.
The most common presentation with cervical lesion
in order of frequency are irregular vaginal bleeding, Keeping in view of the importance of carcinoma and
whitish discharge per vagina, bleeding/pain on coitus, the precancerous lesion (CIN) of the cervix, study of
cachexia, lower abdominal pain, dysuria. painful different methods for the early detection of
defecation and anorexia. In our study, P/V discharge abnormalities in cervix, comparison between the
was found to be the commonest complaints in technique and correlation of the abnormalities with
different lesions of the cervix however pain and P/V the clinical findings was carried out. 40 patients with
bleeding were found to be more specific for cervical suspicious cervix attending Gynaecology OPD of
malignancy. TUTH and WRH (Pokhara), who have underwent for
pap smear cytology test along with biopsy were
Bleeding and tenderness were the main signs that selected. Detail study with clinical examination was
were found to be associated with more advance performed and the findings were correlated.
lesions however none of the signs were specific.
Pradhan P 15 also found the similar findings. Cervical intraepithelial lesion and malignancy were
found to be common among the age group of 21-50
Abnormalities either in pap smear or in biopsy years however malignancy was found to be less
reports were correlated with their corresponding among the older age group. Pain and P/V discharge
biopsy and pap smears. were found to be the most common complaints
among different lesions of the cervix however most
Some of the cervix which were diagnosed as severe of the signs and symptoms were not specific for
dysplasia in pap smear were turned out to be malignancy. Unhealthy cervix with discharge was
malignancy which were confirmed by the biopsy. found even in chronic cervicitis however tenderness
Even moderate dysplasia was turned out to be along with P/V bleeding were found to be associated
malignancy. Similarly, cases which were diagnosed with more advance lesions.

466
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