Jaspal Pathology

ROLE OF MORPHOMETRY IN
DIAGNOSING PREMALIGNANT AND

MALIGNANT LESION IN LIQUID BASED
CYTOLOGY CERVICAL [PAPANICOLAOU
(PAP) SMEAR]
A Thesis submitted to
BABA FARID UNIVERSITY OF HEALTH SCIENCES FARIDKOT
IN THE PARTIAL FULFILLMENT
For the Award of Degree of
M.D. (PATHOLOGY)
2022
Submitted By
DR. JASPAL SINGH SAINI
DEPARTMENT OF PATHOLOGY,
GOVT. MEDICAL COLLEGE, AMRITSAR
i
DECLARATION BY THE CANDIDATE
I hereby declare that the thesis entitled “ROLE OF MORPHOMETRY IN

DIAGNOSING PREMALIGNANT AND MALIGNANT LESION IN LIQUID
BASED CYTOLOGY CERVICAL [PAPANICOLAOU (PAP) SMEAR]”
submitted towards partial fulfillment of the requirements for the award of M.D.
(Pathology) degree to BFUHS is a compilation of original work carried out by me
under the supervision of Dr. Permeet Kaur Bagga, Professor and Head,
Dr. Jaspreet Singh, Professor, Department of Pathology, Govt. Medical
College, Amritsar. No part of this thesis has formed the basis for the award of
any degree previously.
Signature of Candidate
DR. JASPAL SINGH SAINI

Department of Pathology,
Govt. Medical College,
Amritsar
Date:
Place:
ii
CERTIFICATE OF SUPERVISOR
This is to certify that the work incorporated in this thesis entitled “ROLE OF
MORPHOMETRY IN DIAGNOSING PREMALIGNANT AND MALIGNANT
LESION IN LIQUID BASED CYTOLOGY CERVICAL [PAPANICOLAOU
(PAP) SMEAR]” has been carried out by Dr. Jaspal Singh Saini under our
direct supervision. The data incorporated in this thesis is original and genuine
and has been carried out by the candidate herself.
DR. PERMEET KAUR BAGGA, DR. JASPREET SINGH

M.D.,FIMSA., MAMS., M.D.,
Professor and Head, Professor,
Department of Pathology, Department of Pathology,
Govt. Medical College, Amritsar Govt. Medical College, Amritsar.
(SUPERVISOR) (CO-SUPERVISOR)
DATE:………………
iii
ENDORSEMENT BY THE HEAD OF THE INSTITUTION
This is to certify that the thesis entitled “ROLE OF MORPHOMETRY IN

BASED CYTOLOGY CERVICAL [PAPANICOLAOU (PAP) SMEAR]” is a
bonafide research work done by Dr. Jaspal Singh Saini under thesupervision
of Dr. Permeet Kaur Bagga, Professor & Head,Department of Pathology,
Dr. Jaspreet Singh, Professor, Department of Pathology, in this institution.
Signature
Head of Institute (Director Principal)
DATE:…………….
iv
ENDORSEMENT BY THE HEAD OF THE DEPARTMENT
This is to certify that the thesis entitled “ROLE OF MORPHOMETRY IN

BASED CYTOLOGY CERVICAL [PAPANICOLAOU (PAP) SMEAR]” is a
bonafide research work done by Dr. Jaspal Singh Saini under thesupervision
of Dr. Permeet Kaur Bagga, Professor & Head,Department of Pathology, Dr.
Jaspreet Singh, Professor, Department of Pathology, in this institution.
DR. PERMEET KAUR BAGGA,

M.D., FIMSA., MAMS.,
Professor and Head,
Govt. Medical College, Amritsar
Place: AMRITSAR
Dated:
v
COPYRIGHT
Declaration by the Candidate

I hereby declare that the Baba Farid University of Health Sciences, Faridkot,
shall have the rights to preserve & use this thesis in print or electronic format for
academic/study purpose by the research scholar/students.
Signature
Dr. Jaspal Singh Saini
Amritsar
DATE:
© Baba Farid University of Health Sciences, Faridkot
vi
Acknowledgements
It is most appropriate that I begin by expressing my undying

gratitude to the Almighty God for giving me strength both mentally and
physically to complete this task. At the end of my thesis work, it is a pleasant
task to express my thanks to all those who contributed in many ways to make
this possible and made it an unforgettable experience for me.
I would like to express my deep sense of gratitude to respected guide

and supervisor, Dr. Permeet Kaur Bagga, Professor and Head, Department
of Pathology, Government Medical College, Amritsar for her sagacious
guidance, constructive criticism, professional expertise, prudent counsel and
moral support throughout the course of this study. I am indebted to her for
giving me golden opportunity to perform this study. Her guidance and advice
carried me though all stages of writing my thesis. She has been my constant
inspiration. Without her constant feedback, this thesis work would not have
been achievable. I will be forever grateful to her support and kindness.
With utmost sense of regard, I express my indebtedness to my co-

supervisor Dr. Jaspreet Singh, Professor Department of Pathology,
Government Medical College, Amritsar for his constant encouragement,
invaluable guidance, immense patience, great care and attention to detail
that he has shown throughout the course of this study. He provided with
encouraging and constructive feedback, valuable comments and suggestions.
He has been a friend, authority and guide, all rolled into one person.
A debt of gratitude is owed to Dr. Mandeep Randhawa, Dr.Navjot

Kaur , Dr. RK Sharma,Department of Pathology, Govt. Med. College,
Amritsar who shared their pearls of wisdom with me to make this project
come to its fruition.
Words are inadequate in expressing my deep sense of gratitude

towards my parents, Mr. Surinder Singh and Mrs. Gurshant Kaur giving
up so much to make my career a priority in their lives; my brother
Gurpreet singh and Sister in law Georgia Singh for their blessings, love,
care and constant encouragement during the study. They have been a
source of love and energy ever since.
vii
I would like to acknowledge my seniors, Dr. Rimple Khatri, Dr.Anum
Khullar, Dr.Swati Setia, Dr. Aditi Mehra, Dr.Rajdeep Kaur for their
guidance and showing me the right path always and my Co-Pg Dr.Davinder,
Dr. Kiran, Dr. Kamal, Dr. Manpreeet, Dr. Siami and who were always
with me at any times of need. Thank you all, for always being there for me.
I am thankful to all my dear juniors for their help and support. I am thankful
to Mr.Arun Sharma and other lab technicians, Multidisciplinary Research
Unit,Government Medical College,Amritsar for their utmost co-operation.
I would like to express my gratitude towards my co resident and

brother Dr.Vivek Bharmota for being my constant support and keeping me
motivated through tough times.
I am also thankful to Sh. Ramesh Rajpoot (Billa), Mr. Sunil

Rajpoot, Mrs. Kavita Rajpoot, Mr. Aryan Sharma and Mr. Raj kumar of
Billa Computers for typing this manuscript with sincerity and dedication.
Last but not least, without the patients' involvement, this

dissertation would not have been feasible. I am very grateful to them for
their collaboration. Above all, I want to express my gratitude to God the
Almighty for helping me to complete my task. And last, I'm responsible for
any remaining mistakes and flaws.
Amritsar
Dated: _________
(DR. JASPAL SINGH SAINI)
viii
TABLE OF CONTENTS
S. NO. PARTICULARS PAGE NO.
1. INTRODUCTION 1
2. REVIEW OF LITERATURE 4
3. AIMS & OBJECTIVES 15
4. MATERIALS AND METHODS 16
5. OBSERVATIONS AND RESULTS 23
6. DISCUSSION 46
7. SUMMARY AND CONCLUSION 56
8. BIBLIOGRAPHY 59
9. APPENDIX-I Master chart
10. APPENDIX-II Plan of thesis
ix
LIST OF TABLES AND GRAPHS
PAGE
Sr. No. TITLE
NO.
1. AGE DISTRIBUTION OF THE CASES 23
DESCRIPTIVE STATISTICS OF DIFFERENT STUDY
2. 24
PARAMETERS
3. MORPHOMETRIC ANALYSIS BETWEEN THE GROUPS 25
4. MORPHOMETRIC ANALYSIS BETWEEN THE ECA 26
MEAN DIFFERENCE BETWEEN NORMAL AND
5. 27
REACTIVE
6. MEAN DIFFERENCE BETWEEN NORMAL AND ASCUS 27
7. MEAN DIFFERENCE BETWEEN NORMAL AND LSIL 28
8. MEAN DIFFERENCE BETWEEN NORMAL AND ASC-H 28
9. MEAN DIFFERENCE BETWEEN NORMAL AND HSIL 29
10. MEAN DIFFERENCE BETWEEN NORMAL AND SCC 29
11. MEAN DIFFERENCE BETWEEN REACTIVE AND ASCUS 30
12. MEAN DIFFERENCE BETWEEN REACTIVE AND LSIL 30
13. MEAN DIFFERENCE BETWEEN REACTIVE AND ASC-H 31
14. MEAN DIFFERENCE BETWEEN REACTIVE AND HSIL 31
15. MEAN DIFFERENCE BETWEEN REACTIVE AND SCC 32
16. MEAN DIFFERENCE BETWEEN ASCUS AND LSIL 32
17. MEAN DIFFERENCE BETWEEN ASCUS AND ASC-H 33
18. MEAN DIFFERENCE BETWEEN ASCUS AND HSIL 33
19. MEAN DIFFERENCE BETWEEN ASCUS AND SCC 34
20. MEAN DIFFERENCE BETWEEN LSIL AND ASC-H 34
21. MEAN DIFFERENCE BETWEEN LSIL AND HSIL 35
22. MEAN DIFFERENCE BETWEEN LSIL AND SCC 35
23. MEAN DIFFERENCE BETWEEN ASC-H AND HSIL 36
24. MEAN DIFFERENCE BETWEEN ASC-H AND SCC 36
25. MEAN DIFFERENCE BETWEEN HSIL AND SCC 37
26. SOFTWARES USED BY THE STUDIES 47
27. COMPARISON OF CELL AREA 48
28. COMPARISON OF CELL PERIMETER 48
29. COMPARISON OF NUCLEAR AREA 49
30. COMPARISON OF NUCLEAR PERIMETER 50
31. COMPARISON OF NUCLEAR DIAMETER 51
32. COMPARISON OF NUCLEAR TO CYTOPLASMIC RATIO 52
x
LIST OF FIGURES
PAGE
Sr. No. FIGURES
NO.
1. COMPUTER ASSISTED IMAGE ANALYSIS SYSTEM 17
2. VORTEXING CAUSES CELL DISPERSION 20
CENTRIFUGATION OF THE SAMPLE WITH THE

3. ADDITION OF DENSITY GRADIENT MIXTURE HELPS 21
TO ENRICH THE CELLS
THE VIALS ARE KEPT IN THE SETTLING CHAMBER

4. 21
TO SETTLE THE CELLS BY GRAVITY
5. MORPHOMETRY IMAGE ANALYSIS REPRESENTATION 38
6. MORPHOMETRIC ANALYSIS OF A NORMAL CASE 39
MORPHOMETRIC ANALYSIS OF A CASE SHOWING

7. REACTIVE CELLULAR CHANGES
40
MORPHOMETRIC ANALYSIS OF A CASE DIAGNOSED AS

8. 41
ASCUS

9. LSIL
42

10. ASC-H
43

11. HSIL
44
MORPHOMETRIC ANALYSIS OF A CASE DIAGONOSED AS

12. SCC
45
xi
LIST OF ABBREVIATIONS
HPV : Human Papilloma Virus
NIS : Nikon Instruments Software
LBC : Liquid Based Cytology
ECA : Epithelial Cell Abnormality
DNA : Deoxyribose Nucleic Acid
NA : Nuclear Area
NP : Nuclear Perimeter
SD : Standard Deviation
xii
KEY TO MASTERCHART
LBC : Liquid Based Cytology

ASCUS : Atypical Squamous Cells of Undetermined
Significance
LSIL : Low Grade Squamous Intraepithelial Lesion
ASC-H : Atypical Squamous Cells-cannot Exclude HSIL
HSIL : High Grade Squamous Intraepithelial Lesion
SCC : Squamous Cell Carcinoma
CIN : Cervical Intraepithelial Neoplasia
xiii
INTRODUCTION
Cervical cancer is the fourth most common cancer in women worldwide and
second most common cancer in women living in less developed regions.1 It is the
most common gynecological cancer in developing countries like India and one of
the leading causes of deaths amongst women. Cervical cancer begins with a
precancerous stage, known as dysplasia which takes many years to develop from
a normal cell.
Rural women are at higher risk of developing cervical cancer as compared

to their urban counterparts and is a cause of cancer mortality in India accounting
for nearly 10% of all cancer related deaths in the country.2
Human papillomavirus (HPV) is the main causal factor of cervical carcinoma.

HPV 16 is one of the most prominent oncogenic types. If detected early, cervical
cancer is curable and the 5-year survival rate is as high as 92%.3
Cervical cancer results from a persistent infection by a high-risk subset of

human papillomavirus (HPV).
Low-Risk: 6, 11, 42, 43, 44, 53, 54, 57, 66
High-Risk: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68
Most women’s immune systems will eliminate HPV infection spontaneously,

however, for a very small proportion of women, the infection will persist and can
cause pre-cancerous changes in cells.
In the precancerous state i.e. Cervical intraepithelial neoplasia (CIN) occurs

along various grades from low (CIN1), moderate (CIN2) to severe (CIN3).
1
The pathogenesis from low-grade CIN to cervical cancer takes from about
10 to 20 years, during which timely screening for pre-cancerous lesions and early
treatment is highly effective in preventing overt disease. The incidence of cervical
cancer has been declining in last three or four decades in most developed countries
predominantly due to the introduction of cervical screening programmes.
The introduction of cervicovaginal cytology as a means to detect

precancerous lesions of the uterine cervix has been milestone in the study of cancer
of uterine cervix. A diagnosis of cancer and a precancerous condition depends on
the detection of abnormal cells on a Pap smear.3
Pap smear screening is still the primary modality in detecting premalignant

lesions and carcinoma of cervix, due to which there has been marked reduction in
incidence and mortality of cervical cancer by 85%.4
Liquid-based cytology (LBC) has been introduced into cytopathology mainly

in the field of cervical cytology with the aim of improving diagnostic accuracy. The
advantages of liquid based cytology compared with conventional smears include an
optimal viewing of cellular features attributed to the reduction in air-drying artifact
and obscuring background elements thus reducing the number of unsatisfactory
smears.5
The liquid-based cytology include
 ThinPrep (TP) and
 SurePath (SP)
In these preparation systems, instead of smearing cells on a slide, cells are

rinsed into a liquid collection media containing fixatives. This ensures the capture
of an entire sample from the collection devices.6
Morphometry is the quantitative description of geometric features of

structures such as tissues, cells, nuclei, or nucleoli. One of the most important
2
functions of morphometry in pathology is the study of nuclear morphometry in
differentiating benign lesions from malignant lesions based on their cellular, nuclear
parameters.
The morphological criteria are mainly based on descriptive nuclear changes.
As some of the benign and reactive conditions can produce significant

nuclear alterations that can mimic neoplasia, false positive results may sometimes
occur.
Objective techniques can be helpful in preventing false interpretation, in

distinguishing borderline cases and thus better and timely treatment of patient.
Computer assisted image analysis such as nuclear morphometry provides a

powerful tool for high-precision measurement of several variables characterising
the size and shape of cancer cell nuclei in cervical smear.
The general abnormality criteria for cell morphology are :
 Enlargement of the nucleus.
 Increase of N/C ratio.
 Nuclear hyperchromasia.
 Clumping of chromatin.
 Nuclear membrane irregularities.
 Increase in size and number of nucleoli.
 Multinucleation and multilobulation.
 Abnormal mitoses.
 Variations in size and shape of nucleus and cytoplasm.
3
REVIEW OF LITERATURE
Globally, cervical cancer is the fourth most commonly diagnosed cancer

amongst women, and it is especially common in low- and middle-income
countries.7,8,9 The second most common cause of cancer mortality among Indian
women is this largely preventable condition.10
By far the most important determinant in the development of cervical cancer

is high-risk HPVs. HPVs are DNA viruses that, based on their genotypes, are
classified as having a high or low carcinogenic risk. There are currently 15 high-risk
HPVs identified, but HPV-16 alone accounts for about 60% of cervical cancer
occurrences, with HPV-18 accounting for another 10% of cases; other HPV types
account for less than 5% of instances separately. Squamous cell carcinomas have
been linked to high-risk HPVs in a variety of different areas, including the vagina,
vulva, penis, anus, tonsil, and other oropharyngeal regions. The majority of HPV
infections are transient; 50% of infections clear in 8 months, and 90% disappear in
2 years. Infections with high-risk HPVs take longer to resolve on average than
infections with low-risk HPVs (13 months vs. 8 months, respectively). Chronic
infection raises the likelihood of cervical precursor lesions and eventually cancer.
Viral penetration into young basal epithelial cells is required for productive,
long-term HPV infection. As a result, sites like the ectocervix, vagina, vulva, penis,
and oropharynx that have mature, intact squamous epithelium are typically
resistant to HPV infection. Squamous epithelial trauma and repair, where the virus
may gain access to basal cells, and immature metaplastic squamous cells located
at the squamocolumnar junction of the cervix are among the sites in the female
genital tract that are susceptible to infection. The cervix is particularly susceptible
to HPV infection because of its extensive regions of immature squamous
metaplastic epithelium. The squamocolumnar junction of the anus and the
squamous cells of oropharyngeal tonsillar crypts, both relatively prone to HPV
infection, are two more places in the body that are vulnerable to HPV infection. The
viral E6 and E7 proteins, which interfere with the activity of the important tumour
suppressor proteins p53 and RB, respectively, are required for HPV to behave as
4
a carcinogen. HPV infects immature squamous cells, although the virus replicates
in mature squamous cells. Normally, these more mature cells are arrested in the
G1 phase of the cell cycle, but when infected with HPV, which uses the host cell
DNA synthesis machinery to reproduce its own genome, they continue to actively
advance through the cell cycle. The viral E7 protein binds to the
hypophosphorylated (active) form of RB and promotes its degradation via the
proteasome route, as well as p21 and p27, two key cyclin dependent kinase
inhibitors, and inhibits them. The removal of these regulators not only speeds up
cell cycle progression, but it also hinders cells' ability to repair DNA damage. E6
proteins encoded by high-risk HPV subtypes bind p53 and enhance its degradation
by the proteasome, exacerbating the DNA repair deficiency in infected cells.
Furthermore, E6 increases the expression of telomerase, resulting in cellular
immortality. The net result is greater cell proliferation, which makes them more likely
to pick up further mutations, which could lead to cancer formation. 11
In a study done by Bobdey S et al in 201612 found that Cervical cancer

accounts for between 6 and 29 percent of all cancers in women in India. The
greatest age-adjusted incidence rate of cervical cancer is 23.07/100,000 in
Mizoram state, while the lowest is 4.91/100,000 in Dibrugarh district.
In 2020 Globocan estimated 123,907 new cases and 77,348 fatalities based
on an age-standardized incidence rate of 18 per 100,000 women and a cumulative
risk of 2.01% in cervical cancers.13
The 5-year relative survival rate of around 46% (range 34–60%) is

significantly lower than in other Asian countries.14 Cervical cancer also accounts
for 17% of all cancer deaths in Indian women aged 30-69.
The age-standardized incidence and death rates for women worldwide are
13.1 and 6.9 per 100,000, respectively.15 However, as compared to global
estimates, these rates are far higher among Indian women. The age-standardized
incidence rate for women in India is 14.7 per 100,000, whereas the age-
standardized mortality rate is 9.2 per 100,000.15
5
The origins of history of cervical cytology can be traced back to history of
man. Reagan JW et al, in 1953, coined the term "dysplasia”. 16 In 1976-78,17,18
carcinoma in situ surface differentiation was demonstrated.
Cervix (Cx) preinvasive lesions have been known for more than a
century.19Colposcopy concepts were described in the mid-twentieth century. In
1920, Papanicolaou,20 the inventor of the pap smear, worked extensively on
cervical cytology.
The role of cervical cytology in diagnosing preinvasive cervix disease was stated
by Papanicolaou and Traut.
Cervical cancer was first identified as a sexually transmitted illness in the

19th century. Surgery was introduced to address the disorder.Early 20th century
Cervical cancer was shown to be frequent among female sex workers and those
whose husbands had several sexual partners, especially prostitutes. Papanicolaou
created his eponymous technique in the 1920s. The colposcope is a device that
was created. Pap smear screening started in the 1940s. Human Papillomavirus
(HPV) and cervical cancer were linked in the 1980s. The use of tobacco has been
connected to cervical cancer.21
Early cervical cancer prevention initiatives were founded on the assumption

that Cx diseases begin from precursor lesions that advance from mild to moderate,
then to severe CIN, and finally to cervical malignancies. Cervical cancer has been
linked to sexual activity in many studies.22 Young age at first intercourse < 20 years,
several sexual partners, high parity, low socio-economic position, smoking, Human
Papillomavirus (HPV).23 infection, and immunosuppression are among the other
risk factors. The major risk factors include higher parity and lower social and
economic status.24
The Bethesda system (TBS) was first introduced in 1988 as a way to

describe cervical or vaginal cytologic findings. It was seen as a method of
6
standardising screening results. The first human papillomavirus (HPV) vaccination
was released in the year 2000.
LIQUID BASED CYTOLOGY :
Techniques based on inserting the sample into a vial containing a liquid

medium that retains the cells have been more popular since the mid-1990s. The
majority of the media is made up of ethanol.
In 1996, The ThinPrep (Hologic, Marlborough, MA) was approved by the US

Food and Drug Administration (FDA) as an alternative to the traditional
cervicovaginal smear. After that, the AutoCyte Prep (now SurePath) was approved
three years later (BD TriPath, Burlington, NC).
ThinPrep (TP) and SurePath (SP) are two liquid-based cytology methods:
Instead of smearing cells on a slide, they are washed into a liquid collection
solution containing fixatives in both of these techniques. This ensures that the
collection devices capture a full sample.
In traditional smears, the sampling instrument discards the majority of the

sample (80 percent).
Important features by which liquid-based preparation improves accuracy:
 Complete cellular capture - when compared with the preparation of a

conventional slide, in which, on average, only about 35% of sampled
material is transferred to the glass slide for review, liquid-based technology
captures most of the cells sampled. This diminishes the likelihood of false-
negative tests due to “transfer” error in which positive cells are left on the
sampling device following the making of a conventional smear
 Specimen randomization- Liquid-based slides contain a subsample of cells

that have been randomized during the preparation process. Randomization
7
allows for a more representative cell pattern being present on the slide,
containing all the types of cells sampled from the patient.
 Improved cellular preservation-Cells are sampled and then immediately

immersed in liquid fixative transport media which shows on average, better
fixation, and thus better visual preservation, than when smeared cellular
material on a conventional slide. This helps in elimination of artifacts such
as air-drying and other cellular degeneration changes.
 Improved individual cell visualization (improved segmentation)- Due to lack

of overlapping or piling up of cells helps in better visualization of cells
 Decrease in obscuring factors (blood and inflammation)- The liquid-based

processes generally improves cellular visualization by decreasing
physiologic obscuring factors such as blood or inflammation as compared to
conventional smears in which cells may be obscured, leading to
unsatisfactory or limited specimens when such factors are present. 25
Consistent cell location and viewing size area- As liquid-based methods

place cellular material in a limited area of the glass slide, always in the same place,
screening is more efficient and is associated with less viewer fatigue, leading to
fewer “habituation,” or inattention, lapses.
MORPHOMETRY INTRODUCTION :
The quantitative description of geometric properties of entities such as

tissues, cells, nuclei, or nucleoli is known as morphometry. The study of nuclear
morphometry in identifying benign from malignant lesions based on their nuclear
properties is one of the most important uses of morphometry in pathology.
The morphological criteria are primarily based on nuclear alterations that are
descriptive.False positive results can occur because some benign and reactive
diseases can cause considerable nuclear changes that mimic neoplasia.
8
Objective procedures can aid in avoiding erroneous interpretations,
differentiating borderline instances, and thereby providing better and more timely
patient care.Nuclear morphometry, for example, is a powerful tool for high-precision
measurement of several variables that characterise the size and shape of cancer
cell nuclei in cervical smears.
HISTORICAL CONTEXT :
Morphometric analysis was first used in 1925. In 1925, Jacobi W discovered

that before cell division, the volume of a typical cell doubles.26
In 1929, Heiberg KH and Kemp T were perhaps the first to substantiate the
subjective perception that cancer nuclei are larger than normal cell nuclei. 27
An increase in interest among anatomists and biologists in the 1950s and

1960s fuelled morphological and stereological study in biomedicine. 28
The use of morphometric analysis to pathologically altered tissues became

increasingly popular and frequently used in the late 1970s and early 1980s,
particularly in cancer.28
Advanced computer-assisted image analysis systems, in which the camera

records a microscopic image and displays it on a computer screen, allowing users
to trace the outlines of nuclei on the screen and then compute Nuclear Areas and
shape using dedicated software, have recently improved morphometric
assessments.
Many studies have been done using morphometry to analyse nuclear

features in different organs such as the breast, exfoliated buccal mucosal cells,
squamous neoplasms, colon, and thyroid.
In 1982 Diamond DA and colleagues established nuclear morphometry in

as a tool for predicting prognosis in prostate cancer patients.29 Nuclear roundness,
he and his colleagues discovered, was particularly beneficial in distinguishing long-
9
term survivors from those who developed metastases among stage B patients.
There was no overlap in nuclear roundness between the two groups, according to
the researchers. Since then, nuclear morphometry has been employed in several
histological studies30-33 to predict prognosis in patients with prostate cancer.
Eichenberger and colleagues34 in 1987, for example, calculated 12 shape

descriptors such as nuclear roundness, ellipticity factors, and concavity factors.
They chose the primary morphometric criteria that best separated patients with a
good or worse prognosis using discriminant analysis. In this case, elliptical form
measurement was found to be the most accurate.
Pienta KJ and Coffey DS in 1991, In a blinded retrospective investigation of

60 individuals, used the DynaCell Analysis System to quantify changes in nuclear
morphology. They discovered that the Nuclear Area increases from 252 in normal
patients to 592 in patients with metastatic disease, suggesting that larger Nuclear
Area correlates with increased metastatic potential.35,36
In a study done by Bacus JW in 1995 it was demonstrated that

morphometric image analysis is equivalent to experienced human observers in
ability to recognize isolated cells from cervical smears.37
In 1999,Ikeguchi M et al. looked at morphometric nuclear features (Nuclear

Area, perimeter, and shape) in 343 patients with colorectal carcinoma and 57
patients with colorectal adenoma, and discovered that the mean Nuclear Area grew
larger as the patients progressed from normal colorectal mucosa to adenoma and
carcinoma.38
In 2000 by Buhmeida A et al39, found that the nuclear size features were
found to be useful in distinguishing between different atypia groups of the prostate
gland in fine needle aspiration biopsies especially when the sample-associated
means of the size features (area, diameter, perimeter, short and long axes) were
used for data interpretation. If the sample-associated mean nuclei area was less
than 27m2, they found that they were most likely dealing with benign cells. It was
10
conceivable that the sample contains malignant cells if the upper range limit was
more than 39m2. Values greater than 52m2, on the other hand, were almost always
cancerous samples.
In 2013 Mudaliar K and Hutchens K analysed morphometric images of 60

cases of Irritated Seborrheic Keratoses, Verruca Vulgaris, Hypertrophic Actinic
Keratoses, and Squamous Cell Carcinoma (15 cases of each) and discovered
statistically significant differences in nuclear size and cellularity between benign,
pre-malignant, and malignant neoplasms.40
In 2014 a study done by Wesoła M, Department of Pathomorphology and

Oncological Cytology Wroclaw Medical University, The largest cells in the surface
layer are normal cells. Atrophic cells from the categories containing atypical
squamous cells of unknown significance (ASC-US), low-grade squamous
intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL),
and tumour cells tend to shrink in size in comparison to these cells, with minor
differences. The cells in the LSIL group are larger than those in the ASC-US group
when the mean values of the parameters studied are taken into account. Normal
cells have the smallest nucleus, while HSIL cells and tumour cells have the largest,
according to the mean values.41
In a study done by Rani D et al in 2014, 60 cases were studied for cervical

cytology and showed that when comparing premalignant and carcinoma lesions,
there was a gradual increase in Nuclear Area and perimeter. Nuclear Area,
perimeter, diameter, and radius were the nuclear morphometric parameters that
could considerably distinguish LSIL from HSIL. These four metrics were helpful in
determining the statistical significance of LSIL and SCC. In order to distinguish
premalignant from malignant cervical smears, Nuclear Area, perimeter, and
diameter were particularly significant.42
Laishram S and Shariff S in 2015 investigated nuclear morphology in terms

of Nuclear Diameter, Nuclear Area, coefficient of variation of Nuclear Area,
nuclear/cytoplasmic ratio, and the ratio of largest to smallest Nuclear Diameter (L:S
11
ratio) in 60 breast FNAC and found that nuclear parameters were significantly
higher in malignant lesions than benign lesions.43
In a study done by Vijayashree R, Rao K in 2015, the results for five

parameters (area, perimeter, breadth, width and Feret) of 200 nuclei obtained with
macro were correlated with manual assessment of the same 200 nuclei using
Pearson’s correlation coefficient. The nuclear assessments of normal and
abnormal smears were done u. The mean values along with the standard deviations
were obtained. As expected, there is progressive decrease in the dimensions of the
nuclei as the cell matures from parabasal to superficial cell. The nucleus of
parabasal cell measured on an average about 3 times larger area-wise than
superficial cell. Similarly, the perimeter of parabasal cell was 1. 8 times as long as
the perimeter of superficial cell. However, these cells showed little variation in size
as reflected by low standard deviations. In an inflammatory smear rich in
intermediate cells, the latter were found to be similar in size to the Intermediate cell
in a normal smear but the standard deviation was more than double indicating a
greater variation in cell size (anisonucleosis). The normal parabasal cell nuclei, on
an average, were larger than nuclei of ASCUS and LSIL but they were more
uniform with lesser variation. Both HSIL and squamous cell carcinoma had cells,
whose nuclei were not only larger but also exhibited marked variation in size. This
was reflected in high standard deviation. The greater degrees of abnormality
appeared to be associated with greater anisonucleosis. More than the increase in
overall dimensions, high SD (reflecting anisocytosis) appears to be an important
characteristic of abnormal cells.44
In 2017,Kashyap A et al. explored the role of nuclear morphometry on the

cytology of benign and malignant breast lesions and discovered that nuclear
morphometry could distinguish between benign and malignant aspirates with the
use of gradually increasing nuclear size parameters such as Nuclear Area,
equivalent diameter, minimum feret, maximum feret, and perimeter.45
Yashaswini R et al. in 2017 studied Bethesda and thyroid morphometry and

discovered that the malignant group had larger Nuclear Diameters, maximal
12
Nuclear Diameters, Nuclear Perimeters, and Nuclear Areas than the nonneoplastic
and benign groups.46
In 2017 Deka L et al. examined nuclear morphometry and texture analysis

on cytological smears of thyroid neoplasms, including 20 colloid goitre, 20 follicular
neoplasms, and 10 papillary carcinoma, and discovered that papillary carcinoma
had the highest perimeter, area, radius, and elongation factor, while the roundness
factor was the lowest of the three groups.47
In another study done by Tiwari AK et al in 2019 on cervical cytology, 163

cases out of which 85 cases (26 retrospective and 59 prospective) of epithelial cell
abnormality (83 cases) and malignant cases (2 cases) and 78 reactive cases (all
prospective) were analysed. Nuclear parameters were analysed and compared in
the normal control group, reactive cases, and ECA cases. For the normal control
group, Cell Area, Cell Perimeter, Nuclear Diameter, Nuclear Area, and N:C ratio
were examined; for the reactive cellular alterations group, ASC-US, ASC-H, LSIL,
HSIL, and SCC, Cell Area, Cell Perimeter, Nuclear Diameter, Nuclear Area, and
N:C ratio were examined. The standard deviation (SD) and mean were determined.
From normal cell to dysplastic cell to SCC, there was a gradual rise in Nuclear Area
and Nuclear Diameter. Except for LSIL, which was lower than ASC-H, the N:C ratio
increased gradually from normal to SCC. The Cell Area decreased gradually from
normal to dysplastic to SCC, except for LSIL, which was greater than ASC-H, and
the Cell Perimeter decreased gradually from normal to SCC, except for ASC-H,
which was greater than LSIL, HSIL, and SCC.48
In a study done by Sindhu C and Shariff S in 2020 showed that when

compared to premalignant lesions, there was a progressive rise in Nuclear Area
and perimeter in carcinoma (LSIL and HSIL). Nuclear Area, perimeter, diameter,
and radius were the nuclear morphometric metrics that could tell the difference
between LSIL and HSIL. These four variables helped to distinguish LSIL from SCC,
which was statistically significant. With a ‘p’ value of 0.0001, Nuclear Area,
perimeter, and diameter were highly significant in distinguishing premalignant from
malignant cervical smears.49
13
In a study in 2021 by Osman SE et al, morphometric analysis was performed
on 142 consecutive cervical Pap smears from women with gynecological clinical
complaints, they calculated nuclear diameter, cell diameter and nuclear to
cytoplasmic ratio and found that there were no significant differences in the N/C
ratio of superficial and intermediate cells and The nuclear diameter, cell diameter,
and the nuclear to cytoplasmic ratio were significantly higher in women with clinical
complaints than in women without clinical complaints.50
In a study done by Hasija S et al in 2022, Nuclear morphometric analysis

showed increase in the nuclear area, perimeter, radius, and compactness between
ASCUS and LSIL, LSIL and HSIL, HSIL and SCC, and the difference among the
means of each nuclear parameter of these groups was discovered to be statistically
significant (P < 0.05).51
In another study in 2022 by Mishra S et al, The nuclear area, nuclear

perimeter, and nuclear diameter were found to be maximum for HSIL, followed by
LSIL, ASC-H, ASC-US, SCC, and NILM groups in decreasing order . The cell area,
cell perimeter, and cell diametr were found to be maximum for NILM, followed by
LSIL, ASC-US, HSIL, ASC-H, and SCC in decreasing order. Mean Nuclear to
cytoplasmic ratios were maximum for SCC, followed by ASC-H, HSIL, LSIL, ASC-
US, and NILM.52
14
AIM AND OBJECTIVES
1. To study the morphometric parameters of the LBC Pap smear by using

Nikon Instruments Software (NIS-Elements Documentation(D) 5.01.00) and
correlate the LBC Pap smear cytology with morphometric parameters.
2. To explore the possible role of nuclear morphometric analysis to improve the

sensitivity and specificity for detection of pre-cancerous and cancerous
conditions.
15
MATERIAL AND METHODS
The present study was conducted in 200 liquid based cytology (LBC)
cervical samples which included normal cases and abnormal case findings in the
Department of Pathology, Government Medical College, Amritsar. 20 intermediate
squamous cells per slide were evaluated.
INCLUSION CRITERIA:
1. Cases which were screened by liquid based cytology and reported as

squamous epithelial cell abnormality.
2. LSIL, HSIL, SCC of confirmed histopathological diagnosis were chosen for

study.
3. Cases showing reactive cellular changes.
4. Cases having normal cytology.
EXCLUSION CRITERIA:
1. Inflammatory samples.
2. Unsatisfactory samples.
3. Patients on intravaginal drugs.
4. Already diagnosed squamous cell carcinoma on treatment (Radiotherapy).
METHODS:
The assessment of morphometric features was done using the Nikon

Instruments Software (NIS)-Elements Documentation (D) 5.01.00. Using this
imaging system the Cell Area, Cell Perimeter, Nuclear Area, Nuclear:Cytoplasmic
16
Ratio and Nuclear Diameter was measured. The scale was set at 50 micrometre
square The material consisting of cervical samples prepared by liquid based
cytology technique from the Government Medical College, Amritsar institute were
taken. Cells were viewed and measured under 40X magnification. The cells with
minimum overlapping excluding degenerated cells were selected. Intermediate
cells were selected for the measurement.
FIG .1 Computer Assisted image analysis system
Morphometric assessments was done by advanced computer-assisted

image analysis system where the microscopic image was recorded by the camera
and displayed on the computer screen, which made it possible to trace the outlines
of cells, nuclei on the screen and then compute Nuclear Areas as well as nuclear
shape using Nikon Instruments Software.
17
Smears were classified as:
1. Normal or NILM
2. Reactive cellular changes
3. ASC-US (Atypical squamous cells of Undetermined Significance)
4. ASC-H (Atypical cells-Cannot exclude High Grade Lesion)
5. LSIL (Low Grade squamous intraepithelial lesion)
6. HSIL(High Grade Squamous Intraepithelial lesion)
7. SCC (Squamous cell carcinoma)
Following morphometry parameters were noted:
1. Cell area: area within the outlined cell perimeter.
2. Cell perimeter: length around the cell border.
3. Nuclear area: area within the outlined nuclear perimeter
4. Nuclear perimeter: length around nuclear border
5. Nuclear diameter: The diameter within the same area as the measured
nucleus.
6. N:C Ratio: Ratio of nuclear area and cytoplasmic area.
18
METHOD OF LIQUID BASED CYTOLOGY:-
The LBC technique used was SurePath Test :
Steps:
1. Vortexing-At first with the help of vortexing, the cells were mechanically
dispersed.
2. Cell enrichment :
 Mix the sample with PrepStain Density Reagent and centrifuge :
 Decant the supernatant elements containing blood, mucus and necrotic

debris by applying vacuum suction.
 Recentrifuge the remaining fluid to have a cell-rich pellet.
3. Resuspension -Re-vortex the cell-rich pellet :
 Resuspend the cells.
 Transfer the solution in the PrepStain slide processor.
a. Cell sedimentation :
- Pour the cell suspension in the PrepStain.
b. Settling Chamber :
- With the help of gravitational force, the cells were sedimented

on the pre-coated slide.
The major advantages of LBC over conventional preparation (CP) include:
• Majority of the collected cells are available in the liquid medium of the
collection vial, whereas the major part of the collected cells is sticked in the
19
spatula of the convention smear preparation and the cells are thrown in the
waste basket.
• LBC preparation is completely free of any airdrying artefact.
• There is almost complete absence of any blood, mucus or necrotic debris in

LBC preparation, and the cells are present in small area which is easy to
screen.
• Monolayered preparation of the cells is present in certain LBC preparation.
• HPV test is possible for the residual material of LBC sample.
• The monolayered cell preparation may be useful in automated detection of

malignant cells in the smear.
FIG 2: VORTEXING CAUSES CELL DISPERSION
20
FIG 3: CENTRIFUGATION OF THE SAMPLE WITH THE ADDITION OF
DENSITY GRADIENT MIXTURE HELPS TO ENRICH THE CELLS
FIG 4: THE VIALS ARE KEPT IN THE SETTLING CHAMBER TO SETTLE THE
CELLS BY GRAVITY
21
The results were recorded in prescribed performa with photographic
recording.
STATISTICAL ANALYSIS
The results obtained by computerized Cyto-morphometry were compared

between the normal Pap smears and abnormal Pap smears groups. The most
distinctive morphometric features among the various morphometric features were
analyzed with the data obtained. Parameters between the normal Pap smears and
abnormal Pap smear groups were compared using ANOVA test and individual
groups were compared by UNPAIRED t-test. Statistical analysis was performed on
SPSS Version 21. Data was summarized as mean ±SD (Standard Deviation) A p-
value < 0.05 was considered as statistically significant
22
RESULTS AND OBSERVATIONS
This prospective study was carried out in the Department of Pathology,

Government Medical College, Amritsar with the aim of exploring the role of
morphometry in liquid based cytology pap smear.
TABLE 1
SHOWING AGE WISE DISTRIBUTION
Age Normal Reactive ASCUS LSIL ASC-H HSIL SCC Total

(yrs) n % n % n % n % n % n % N % n %
20-30 27 36.00 30 36.59 5 25.00 3 37.50 0 0.00 0 0.00 0 0.00 65 32.50
31-40 42 56.00 49 59.76 14 70.00 5 62.50 1 25.00 0 0.00 0 0.00 111 55.50
41-50 6 8.00 3 3.66 1 5.00 0 0.00 3 75.00 4 66.67 0 0.00 17 8.50
51-60 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 2 33.33 3 60.00 5 2.50
61-70 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 2 40.00 2 1.00
Total 75 100.00 82 100.00 20 100.00 8 100.00 4 100.00 6 100.00 5 100.00 200 100.00
n=number of cases
50
45
40
35
No. of cases
30
25
20
15
10
5
0
20-30 31-40 41-50 51-60 61-70
AGE GROUP (YEARS)
Normal Reactive ASCUS LSIL ASC-H HSIL SCC
Maximum number of cases belonged to 31-40 yrs age group(55%), normal

group cases ranged from 20 -40 years , reactive cases ranged from 20 to 50 years.
Epithelial cell abnormality cases ranged from 20 to 70 years.
23
TABLE 2
DESCRIPTIVE STATISTICS OF DIFFERENT STUDY PARAMETERS
Features Normal Reactive ASCUS LSIL ASC-H HSIL SCC
N 75 82 20 8 4 6 5
Mean 2061.79 1514.43 1291.91 1084.20 603.46 698.06 674.09
Cell Area ±SD 263.96 304.48 256.83 298.81 75.87 199.94 93.21
Min 1490.59 963.41 872.66 802.03 515.28 534.37 586.67
Max 2754.42 2100.45 1818.65 1718.20 700.68 1000.17 799.73
N 75 82 20 8 4 6 5
Mean 502.78 421.27 404.73 483.09 311.52 311.97 336.15
Cell Perimeter ±SD 32.23 54.44 44.24 390.41 45.62 21.84 36.07
Min 422.88 310.56 339.03 289.27 246.99 288.46 290.74
Max 587.07 521.50 492.08 1445.24 350.78 350.59 374.19
N 75 82 20 8 4 6 5
Mean 40.33 79.27 100.12 104.14 82.91 112.49 152.81
Nuclear Area ±SD 2.91 9.91 11.81 13.89 9.42 21.58 24.58
Min 34.50 57.44 81.30 85.94 69.84 85.35 134.44
Max 45.98 99.98 128.99 124.92 90.60 147.28 196.02
N 75 82 20 8 4 6 5
Mean 67.72 91.48 105.21 108.97 105.75 111.01 132.52
Nuclear
±SD 2.85 9.54 5.67 8.07 11.20 11.53 7.34
Perimeter
Min 61.98 70.18 95.40 97.23 95.31 93.58 120.18
Max 72.30 118.00 119.57 123.91 118.80 125.82 139.57
N 75 82 20 8 4 6 5
Mean 7.16 10.02 11.19 11.58 10.31 12.27 14.12
Nuclear
±SD 0.26 0.63 0.59 0.69 0.46 1.10 0.97
Diameter
Min 6.50 8.55 10.17 10.45 9.69 11.39 12.82
Max 7.65 11.28 12.34 12.60 10.70 13.89 15.45
N 75 82 20 8 4 6 5
Mean 0.020 0.054 0.083 0.102 0.130 0.160 0.222
Nuclear:Cytopl
±SD 0.003 0.012 0.019 0.030 0.008 0.028 0.033
asmic Ratio
Min 0.012 0.033 0.052 0.063 0.120 0.120 0.170
Max 0.028 0.086 0.113 0.144 0.140 0.200 0.260
24
TABLE 3
MORPHOMETRIC ANALYSIS BETWEEN THE GROUPS
Normal Reactive ASCUS LSIL ASC-H HSIL SCC
Features F-ratio ‘p’ value
Mean ±SD Mean ±SD Mean ±SD Mean ±SD Mean ±SD Mean ±SD Mean ±SD
Cell Area 2061.80 263.96 1514.40 304.48 1291.90 256.83 1084.20 298.81 603.46 75.87 698.06 199.94 674.09 93.21 73.281 <0.001
Cell Perimeter 502.78 32.23 421.27 54.44 404.73 44.24 483.09 390.41 311.52 45.62 311.97 21.84 336.15 36.07 12.942 <0.001
Nuclear Area 40.33 2.91 79.27 9.91 100.12 11.81 104.14 13.89 82.91 9.42 112.49 21.58 152.81 24.58 267.2 <0.001
Nuclear Perimeter 67.72 2.85 91.48 9.54 105.21 5.67 108.97 8.07 105.75 11.20 111.01 11.53 132.52 7.34 172.44 <0.001
Nuclear Diameter 7.16 0.26 10.02 0.63 11.19 0.59 11.58 0.69 10.31 0.46 12.27 1.10 14.12 0.97 378.4 <0.001
Nuclear:Cytoplasmic Ratio 0.020 0.003 0.054 0.012 0.083 0.019 0.102 0.030 0.130 0.008 0.160 0.028 0.222 0.033 345.58 <0.001
Morphometric analysis between the groups:
Significant difference in cell area of abnormal groups when compared with normal
Significant difference in cell perimeter of abnormal groups when compared with normal
Significant difference in nuclear area of abnormal groups when compared with normal
Significant difference in nuclear perimeter of abnormal groups when compared with normal
Significant difference in nuclear diameter of abnormal groups when compared with normal
Significant difference in N:C ratio of abnormal groups when compared with normal
25
TABLE 4
MORPHOMETRIC ANALYSIS BETWEEN EPITHELIAL CELL ABNORMALITIES
On comparing the parameters between epithelial cell abnormalities cell perimeter

was found to be statistically not significant.
26
TABLE 5
MEAN DIFFERENCE BETWEEN NORMAL AND REACTIVE
Features Normal Reactive Un-paired
‘p’ value
t-test
Mean ±SD Mean ±SD
Cell Area 2061.80 263.96 1514.40 304.48 11.984 <0.001
Cell Perimeter 502.78 32.23 421.27 54.44 11.282 <0.001
Nuclear Area 40.33 2.91 79.27 9.91 -32.737 <0.001
Nuclear
-20.728 <0.001
Perimeter 67.72 2.85 91.48 9.54
Nuclear Diameter 7.16 0.26 10.02 0.63 -36.79 <0.001
Nuclear:Cytoplas
-24.673 <0.001
mic Ratio 0.020 0.003 0.054 0.012
p<0.001(Highly Significant); p<0.05 (Significant); p>0.05 (Not Significant)
Comparison of all the parameters were found to be statistically significant

between normal and reactive.
TABLE 6
MEAN DIFFERENCE BETWEEN NORMAL AND ASCUS
Un-
Normal ASCUS ‘p’
paired
Features value
t-test
Mean ±SD Mean ±SD
Cell Area 2061.80 263.96 1291.90 256.83 11.653 <0.001
Cell Perimeter 502.78 32.23 404.73 44.24 11.125 <0.001
Nuclear Area 40.33 2.91 100.12 11.81 -40.015 <0.001
Nuclear
67.72 2.85 105.21 5.67 -41.263 <0.001
Perimeter
Nuclear:Cytoplas
0.020 0.003 0.083 0.019 -28.648 <0.001
mic Ratio
Comparison of the parameters between normal and ASCUS were

statistically significant
27
TABLE 7
MEAN DIFFERENCE BETWEEN NORMAL AND LSIL
Un-
Features Normal ISIL ‘p’
paired
value
Mean ±SD Mean ±SD t-test
Cell Area 2061.80 263.96 1084.20 298.81 9.839 <0.001
Cell Perimeter 502.78 32.23 483.09 390.41 0.446 0.657
Nuclear Area 40.33 2.91 104.14 13.89 -34.717 <0.001
Nuclear
67.72 2.85 108.97 8.07 -30.682 <0.001
Perimeter
Nuclear:
Cytoplasmic 0.020 0.003 0.102 0.030 -24.186 <0.001
Ratio
Comparison of the parameters between normal and LSIL were statistically

significant except for cell perimeter.
TABLE 8
MEAN DIFFERENCE BETWEEN NORMAL AND ASC-H
Un-
Features Normal ASC-H ‘p’
paired t-
value
Mean ±SD Mean ±SD test
Cell Area 2061.80 263.96 603.46 75.87 10.964 <0.001
Cell Perimeter 502.78 32.23 311.52 45.62 11.344 <0.001
Nuclear Area 40.33 2.91 82.91 9.42 -24.357 <0.001
Nuclear
-20.789 <0.001
Perimeter 67.72 2.85 105.75 11.20
Nuclear:Cytoplas
-64.739 <0.001
mic Ratio 0.020 0.003 0.130 0.008
Comparison of all the parameters were statistically significant between

normal and ASC-H.
28
TABLE 9
MEAN DIFFERENCE BETWEEN NORMAL AND HSIL
Un-
Features Normal HSIL ‘p’
paired t-
value
Cell Area 2061.80 263.96 698.06 199.94 12.345 <0.001
Cell Perimeter 502.78 32.23 311.97 21.84 14.198 <0.001
Nuclear Area 40.33 2.91 112.49 21.58 -27.805 <0.001
Nuclear
-25.483 <0.001
Perimeter 67.72 2.85 111.01 11.53
Nuclear:Cytoplasm
-44.126 <0.001
ic Ratio 0.020 0.003 0.160 0.028
Comparison of all the parameters were statistically significant between

normal and HSIL
TABLE 10
MEAN DIFFERENCE BETWEEN NORMAL AND SCC
Un-
Features Normal SCC ‘p’
paired
value
Cell Area 2061.80 263.96 674.09 93.21 11.647 <0.001
Cell Perimeter 502.78 32.23 336.15 36.07 11.12 <0.001
Nuclear Area 40.33 2.91 152.81 24.58 -38.978 <0.001
Nuclear
-43.338 <0.001
Perimeter 67.72 2.85 132.52 7.34
Nuclear:Cytoplas
-54.06 <0.001
mic Ratio 0.020 0.003 0.222 0.033
29
TABLE 11
MEAN DIFFERENCE BETWEEN REACTIVE AND ASCUS
Un-
Features Reactive ASCUS ‘p’
paired
value
Cell Area 1514.40 304.48 1291.90 256.83 3.014 0.003
Cell Perimeter 421.27 54.44 404.73 44.24 1.26 0.211
Nuclear Area 79.27 9.91 100.12 11.81 -8.114 0.000
Nuclear
-6.164 0.000
Perimeter 91.48 9.54 105.21 5.67
Nuclear Diameter 10.02 0.63 11.19 0.59 -7.554 0.000
Nuclear:Cytoplas
-8.766 0.000
mic Ratio 0.054 0.012 0.083 0.019
Cell perimeter was found to be not statistically significant on comparing mean

difference of reactive and ASCUS
TABLE 12
MEAN DIFFERENCE BETWEEN REACTIVE AND LSIL
Un-
Reactive ISIL ‘p’
Features paired
value
Cell Area 1514.40 304.48 1084.20 298.81 3.82 0.000
Cell Perimeter 421.27 54.44 483.09 390.41 -1.369 0.174
Nuclear Area 79.27 9.91 104.14 13.89 -6.527 0.000
Nuclear
91.48 9.54 108.97 8.07 -5.009 0.000
Perimeter
Nuclear:Cytoplas
0.054 0.012 0.102 0.030 -9.206 0.000
mic Ratio
Cell perimeter was found to be not statistically significant on comparing

reactive with lsil
30
TABLE: 13
MEAN DIFFERENCE BETWEEN REACTIVE AND ASC-H
Un -
Features Reactive ASC-H paired t- ‘p’ value
test
Mean ±SD Mean ±SD
Cell Area 1514.40 304.48 603.46 75.87 5.943 0.000
Cell Perimeter 421.27 54.44 311.52 45.62 3.959 0.000
Nuclear Area 79.27 9.91 82.91 9.42 -0.718 0.475
Nuclear
-2.902 0.005
Perimeter 91.48 9.54 105.75 11.20
Nuclear:Cytoplas
-12.706 0.000
mic Ratio 0.054 0.012 0.130 0.008
Cell area, cell perimeter, nuclear perimeter and N:C ratio were found to be
statistically significant but nuclear area and nuclear diameter were not statistically
significant.
TABLE 14
MEAN DIFFERENCE BETWEEN REACTIVE AND HSIL
Un-
Features Reactive HSIL ‘p’
paired t-
value
Cell Area 1514.40 304.48 698.06 199.94 6.447 0.000
Cell Perimeter 421.27 54.44 311.97 21.84 4.868 0.000
Nuclear Area 79.27 9.91 112.49 21.58 -7.18 0.000
Nuclear
-4.779 0.000
Perimeter 91.48 9.54 111.01 11.53
Nuclear:Cytoplas
-18.939 0.000
mic Ratio 0.054 0.012 0.160 0.028
All parameters were statistically significant on comparing reactive with HSIL
31
TABLE 15
MEAN DIFFERENCE BETWEEN REACTIVE AND SCC
Un-
Reactive SCC ‘p’
Features paired
value
Cell Area 1514.40 304.48 674.09 93.21 6.124 0.000
Cell Perimeter 421.27 54.44 336.15 36.07 3.44 0.001
Nuclear Area 79.27 9.91 152.81 24.58 -14.447 0.000
Nuclear
-9.432 0.000
Perimeter 91.48 9.54 132.52 7.34
Nuclear:Cytoplas
-26.8 0.000
mic Ratio 0.054 0.012 0.222 0.033
All parameters were statistically significant on comparing reactive with SCC.
TABLE 16
MEAN DIFFERENCE BETWEEN ASCUS AND LSIL
ASCUS ISIL Un-
Features paired t- ‘p’ value
Cell Area 1291.90 256.83 1084.20 298.81 1.847 0.076
Cell Perimeter 404.73 44.24 483.09 390.41 -0.909 0.372
Nuclear Area 100.12 11.81 104.14 13.89 -0.776 0.445
Nuclear
-1.405 0.172
Perimeter 105.21 5.67 108.97 8.07
Nuclear:Cytoplas
-2.02 0.054
mic Ratio 0.083 0.019 0.102 0.030
there was no significant difference between ASCUS and LSIL except for N:C
ratio with p value- 0.05
32
TABLE 17
MEAN DIFFERENCE BETWEEN ASCUS AND ASC-H
Un-
ASCUS ASC-H ‘p’
Features paired
value
Cell Area 1291.90 256.83 603.46 75.87 5.23 0.000
Cell Perimeter 404.73 44.24 311.52 45.62 3.83 0.001
Nuclear Area 100.12 11.81 82.91 9.42 2.728 0.012
Nuclear
-0.147 0.884
Perimeter 105.21 5.67 105.75 11.20
Nuclear Diameter 11.19 0.59 10.31 0.46 2.82 0.010
Nuclear:Cytoplas
-4.844 0.000
mic Ratio 0.083 0.019 0.130 0.008
There was significant difference between the cell area, cell perimeter,
nuclear area, nuclear diameter, N:C ratio (p value<0.05) except for nuclear
perimeter which was not statistically significant(p value-0.884).
TABLE 18
MEAN DIFFERENCE BETWEEN ASCUS AND HSIL
Un-
ASCUS HSIL ‘p’
Features paired
value
Cell Area 1291.90 256.83 698.06 199.94 5.185 0.000
Cell Perimeter 404.73 44.24 311.97 21.84 4.907 0.000
Nuclear Area 100.12 11.81 112.49 21.58 -1.845 0.077
Nuclear
-1.712 0.100
Perimeter 105.21 5.67 111.01 11.53
Nuclear:
Cytoplasmic -7.910 0.000
Ratio 0.083 0.019 0.160 0.028
There was significant difference in cell area, cell perimeter, nuclear diameter,
N:C ratio (p value<0.05) but in nuclear area and nuclear perimeter there was no
significant difference(p value>0.05)
33
TABLE 19
MEAN DIFFERENCE BETWEEN ASCUS AND SCC
Un-
ASCUS SCC ‘p’
Features paired
value
Cell Area 1291.90 256.83 674.09 93.21 5.221 0.000
Cell Perimeter 404.73 44.24 336.15 36.07 3.194 0.004
Nuclear Area 100.12 11.81 152.81 24.58 -7.100 0.000
Nuclear
-9.119 0.000
Perimeter 105.21 5.67 132.52 7.34
Nuclear:Cytoplas
-12.626 0.000
mic Ratio 0.083 0.019 0.222 0.033
All parameters were significant on comparison between ASCUS and SCC (p

value<0.05)
TABLE 20
MEAN DIFFERENCE BETWEEN ISIL AND ASC-H
Un-
‘p’
ISIL ASC-H paired
Features value
t-test
Mean ±SD Mean ±SD
Cell Area 1084.20 298.81 603.46 75.87 3.098 0.011
Cell Perimeter 483.09 390.41 311.52 45.62 0.855 0.412
Nuclear Area 104.14 13.89 82.91 9.42 2.726 0.021
Nuclear
0.577 0.577
Perimeter 108.97 8.07 105.75 11.20
Nuclear Diameter 11.58 0.69 10.31 0.46 3.303 0.008
Nuclear:Cytoplas
-1.812 0.100
mic Ratio 0.102 0.030 0.130 0.008
There was significant difference between cell area, nuclear area and nuclear
diameter (p value <0.05) but no significant difference between cell perimeter,
nuclear perimeter and N:C ratio
34
TABLE 21
MEAN DIFFERENCE BETWEEN ISIL AND HSIL
Un-
ISIL HSIL paired ‘p’
Features
t-test value
Mean ±SD Mean ±SD
Cell Area 1084.20 298.81 698.06 199.94 2.937 0.014
Cell Perimeter 483.09 390.41 311.97 21.84 0.826 0.427
Nuclear Area 104.14 13.89 112.49 21.58 -4.613 0.001
Nuclear
-5.285 0.000
Perimeter 108.97 8.07 111.01 11.53
Nuclear:Cytoplas
-6.766 0.000
mic Ratio 0.102 0.030 0.160 0.028
Cell perimeter was not significant on comparing LSIL and HSIL (p value-
0.427)
TABLE 22
MEAN DIFFERENCE BETWEEN ISIL AND SCC
Un-
ISIL SCC ‘p’
Features paired
value
Cell Area 1084.20 298.81 674.09 93.21 2.937 0.014
Cell Perimeter 483.09 390.41 336.15 36.07 0.826 0.427
Nuclear Area 104.14 13.89 152.81 24.58 -4.613 0.001
Nuclear
108.97 8.07 132.52 7.34 -5.285 0.000
Perimeter
Nuclear:Cytoplas
0.102 0.030 0.222 0.033 -6.766 0.000
mic Ratio
Cell perimeter was not significant on comparing LSIL and SCC.(p value-
0.427)
35
TABLE 23
MEAN DIFFERENCE BETWEEN ASC-H AND HSIL
Un-
‘p’
ASC-H HSIL paired
Features value
t-test
Mean ±SD Mean ±SD
Cell Area 603.46 75.87 698.06 199.94 -0.890 0.400
Cell Perimeter 311.52 45.62 311.97 21.84 -0.021 0.984
Nuclear Area 82.91 9.42 112.49 21.58 -2.544 0.034
Nuclear
105.75 11.20 111.01 11.53 -0.715 0.495
Perimeter
Nuclear:Cytoplas
0.130 0.008 0.160 0.028 -2.078 0.071
mic Ratio
There was significant difference in nuclear area and nuclear diameter but no
significant difference was found in cell area (0.4), cell perimeter (0.98), nuclear
perimeter(0.49) and N:C ratio (0.071).
TABLE 24
MEAN DIFFERENCE BETWEEN ASC-H AND SCC
Un-
ASC-H SCC ‘p’
Features paired
value
Cell Area 603.46 75.87 674.09 93.21 -1.221 0.261
Cell Perimeter 311.52 45.62 336.15 36.07 -0.908 0.394
Nuclear Area 82.91 9.42 152.81 24.58 -5.322 0.001
Nuclear
105.75 11.20 132.52 7.34 -4.341 0.003
Perimeter
Nuclear:Cytoplas
0.130 0.008 0.222 0.033 -5.304 0.001
mic Ratio
There was significant difference in nuclear area, nuclear perimeter, nuclear

diameter , N:C ratio but no significant difference in cell area and cell perimeter.
36
TABLE 25
MEAN DIFFERENCE BETWEEN HSIL AND SCC
Un-
‘p’
HSIL SCC paired
Features value
t-test
Mean ±SD Mean ±SD
Cell Area 698.06 199.94 674.09 93.21 0.245 0.812
Cell Perimeter 311.97 21.84 336.15 36.07 -1.376 0.202
Nuclear Area 112.49 21.58 152.81 24.58 -2.900 0.018
Nuclear
111.01 11.53 132.52 7.34 -3.592 0.006
Perimeter
Nuclear:Cytoplas
0.160 0.028 0.222 0.033 -3.376 0.008
mic Ratio
There was significant difference in nuclear area, nuclear perimeter, nuclear

diameter and N:C ratio but no significant difference in cell area (0.812) and cell
perimeter (0.202).
37
FIG 5 MORPHOMETRY IMAGE ANALYSIS REPRESENTATION
38
Fig 6. MORPHOMETRIC ANALYSIS OF A NORMAL CASE
1.Area=55.08µm2
3 2.Area=1900.27µm2
6
3.Area=36.27µm2
1 4 5
2 4.Area=1785.91µm2
5.Area=38.73µm2
6.Area=1215.42µm2
MEASURING CELL AREA AND NUCLEAR AREA (LBP, BD

SUREPATH 40X)
1.Diameter=8.06µm
2.Diameter=6.76µm
3.Diameter=6.86µm
2
1 3
MEASURING NUCLEAR DIAMETER (LBP, BD SUREPATH

40X)
1.Perimeter=78.83µm
4
1 6
3 3.Perimeter=58.76µm
2 5 4.Perimeter=441.00µm
MEASURING CELL PERIMETER AND NUCLEAR

PERIMETER (LBP, BD SUREPATH 40X)
39
Fig 7. MORPHOMETRIC ANALYSIS OF A CASE SHOWING REACTIVE CELLULAR
CHANGES
1.Diameter=11.63µm

40X)
1 2
MEASURING CELL AND NUCLEAR PERIMETER (LBP, BD

SUREPATH 40X)
1.Area=1916.28µm2
2.Area=95.41µm2
MEASURING CELL AND NUCLEAR AREA (LBP, BD

SUREPATH 40X)
40
Fig 8. MORPHOMETRIC ANALYSIS OF A CASE DIAGNOSED AS ASCUS
1.Area=1573.73µm2
2.Area=145.96µm2
1
2

SUREPATH 40X)
1.Diameter=13.23µm

40X)
2 1
MEASURING CELL AND NUCLEAR PERIMETER (LBP, BD

SUREPATH 40X)
41
Fig 9. MORPHOMETRIC ANALYSIS OF A CASE DIAGNOSED AS LSIL
1 1.Area=95.64µm2
2 2.Area=911.38µm2
3.Area=1641.29µm2
4.Area=123.54µm2

SUREPATH 40X)
1
1.Diameter=10.45µm
2.Diameter=11.49µm
MEASURING NUCLEAR DIAMETER (LBP, BD

SUREPATH 40X)
4
MEASURING CELL AND NUCLEAR PERIMETER (LBP,

BD SUREPATH 40X)
42
Fig 10.MORPHOMETRIC ANALYSIS OF A CASE DIAGNOSED AS ASC-H
1.Area=599.89µm2
2.Area=82.30µm2
MEASURING CELL AND NUCLEAR AREA (LBP, BD SUREPATH 40X)
1.Diameter=9.73µm
MEASURING NUCLEAR DIAMETER (LBP, BD SUREPATH 40X)
1
2
MEASURING CELL AND NUCLEAR PERIMETER (LBP, BD SUREPATH 40X)
43
Fig 11. MORPHOMETRIC ANALYSIS OF A CASE DIAGNOSED AS HSIL
1.Area=535.55µm2
2.Area=107.15µm2
1
2
1.Diameter=11.90µm
1
2
MEASURING CELL AND NUCLEAR PERIMETER (LBP, BD SUREPATH 40X)
44
Fig 12. MORPHOMETRIC ANALYSIS OF A CASE DIAGNOSED AS SCC
1.Area=1436.04µm2
2.Area=180.13µm2
3.Area=146.76µm2
4.Area=608.83µm2
4
3
1.Diameter=15.52µm
2.Diameter=14.22µm
2
2
3
4
MEASURING CELL AND NUCLEAR PERIMETER (LBP,
BD SUREPATH 40X)
45
DISCUSSION
Carcinoma cervix is the second most frequently occurring cancer amongst

women globally.53 An estimated 3,71,000 new cases of cervical cancers are
identified every year and accounts for about 1,90,000 deaths annually. Developing
countries like India account for 80% of these cases. 54 Pap smear screening is an
essential part of a woman’s routine health care. It is a useful screening test to detect
abnormal cells, including precancerous lesions, as well as malignant cancer cells.
Both can be treated successfully if diagnosed at early stages. Routine cervical
cancer screening has been shown to greatly reduce the number of new cervical
cancers diagnosed each year and deaths from this disease. 53 A wide range of
reactive, infectious and inflammatory conditions may give rise to cells which closely
mimic that of pre-cancerous or malignant lesion which may lead to misdiagnosis,
thus endangering patient lives. This may ultimately have a major impact on the
management of disease.55,56 The advantage of cytology in differentiating abnormal
cells from normal cells has been widely recognized and accepted in cervical
screening program. However, the false negative results may unnecessarily
postpone the required treatment.55 Hence, care should be emphasized while
reporting Pap smears.
Despite well-established screening programs, nearly half of the cervical

cancers come to light only in locally advanced stages. In developing countries like
India, the disease is usually advanced at the time of diagnosis leading to increased
mortality among women.57 Hence, our study aimed to explore the possible role of
nuclear morphometric analysis to improve the sensitivity and specificity for
detection of pre-cancerous and cancerous conditions. Cytological criteria for
differentiating normal cells from abnormal cells were based on change in nuclear
size, irregularity of nuclear shape and granularity of nuclear chromatin which were
assessed by cervical smears based on subjective criteria. In contrast, in computed
morphometry, the subjective criteria are turned into quantitative parameters. 58 The
most widely used parameters in various malignancies include mean nuclear area,
46
perimeter, diameter and N/C ratio.59,60 In our study, we had confirmed
histopathological diagnosis for all selected cervical pap smears. LSIL – Mild
dysplasia, HSIL – moderate to severe dysplasia and SCC – squamous cell
carcinoma on histopathology.
Based on the statistical analysis, it can be concluded that all the groups
differ from each other enough to permit the use of their morphometric characteristics
for diagnostic purposes.
Comparing ASCUS with Reactive group cell area, nuclear area, nuclear
perimeter, nuclear diameter and N:C ratio can be used to differentiate but not cell
perimeter. Similarly, these parameters could be used for comparing Reactive group
with LSIL except cell perimeter.
To compare Reactive with ASC-H cell area, cell perimeter, nuclear perimeter
and N:C ratio were found to be significant as compared to nuclear diameter and
nuclear area.
Comparing the ASC-US and LSIL groups, it was seen that the cell perimeter,
nuclear area, nuclear diameter, nuclear perimeter of these groups of cells were too
similar to each other and best parameters found were cell area and N:C ratio.
COMPARISON OF COMMON PARAMETERS OF DIFFERENT STUDIES WITH

THE PRESENT STUDY
TABLE 26
SOFTWARES USED BY THE STUDIES

Studies Software used
Present NIS-Elements
Nikon
Mishra et al Image J 1.52
Hasija S et al Image -pro 2.0 motic
Vijayshree et al Image J
Tiwari et al Motic image plus 3.0
Divya Rani et al Image J 1.44C
Sindhu C Image J 1.50a
Wesola et al dotslide system(Olympus,Poland)
47
TABLE 27
COMPARISION OF CELL AREA
Studies Normal Reactive ASCUS LSIL ASC-H HSIL SCC

(Mean±SD) (Mean±SD) (Mean±SD) (Mean±SD) (Mean±SD) (Mean±SD) (Mean±SD)
Present 2061± 1514± 1291.9± 1084.2± 603.46± 698.06± 674.09±

(µm) 263.96 304.48 256.83 298.81 75.87 199.94 93.2
Tiwari AK 4954.46± 3388.52± 2292.46± 2308.2± 1471.65± 1975.9± 1644.15±

(µm) 1461.32 922.84 663.23 124.09 791.63 687.69 294.21
Wesoła - - 457.46± 539.55± - 421.62± 254.5±

M(µm2) 284.38 245.56 207.78 67.87
Mishra S - - 596.47± 615.45 267.94± 316.32± 202.05±

et al(µm2) 266.99 ±320.31 135.97 105.75 62.71
In the present study it was found that there was gradual decrease in cell area
from normal to dysplastic and SCC with ASC-H having the smallest mean cell area.
Similarly, Tiwari AK et al found that there was gradual decrease in cell area from
normal cell to dysplastic cell to SCC except for LSIL which was more than ASCUS. 48
Wesola M et al also found gradual decrease in mean cell area from from
LSIL to SCC with tumor cells being the smallest.41
Mishra S et al found LSIL having the highest mean cell area and SCC having
the lowest mean cell area in the epithelial lesions.52
TABLE 28
COMPARISON OF CELL PERIMETER

Studies NORMAL REACTIVE ASCUS LSIL ASC-H HSIL SCC
Present 502.75 421.27 404.73 483.09± 311.52± 311.97± 336.15±

(µm) ±32.23 ±54.44 ±44.24 39.41 45.62 21.84 36.07
Tiwari AK 352.27± 258.69± 214.65± 219.15± 175.75± 205.96± 183.55±

(µm) 48.45 43.99 36.59 6.32 50.19 33.54 18.24
Mishra et al - - 91.76 ± 96.39 ± 59.64 ± 68.89 ± 56.43±

20.05 27.18 14.35 11.73
9.44
48
In the present study it was found that there was decrease in cell perimeter
from normal to dysplastic to SCC with ASC-H having the lowest mean cell
perimeter, Tiwari AK et al also found decrease in cell perimeter from normal to
dysplastic to SCC with ASC-H having the lowest mean cell perimeter.48
However Mishra S et al found SCC cells having the lowest mean cell
perimeter.52
TABLE 29
COMPARISION OF NUCLEAR AREA

40.33± 79.27± 100.12± 104.14± 82.91± 112.49± 152.81±

Present(µM)
2.91 9.91 11.81 13.89 9.42 21.58 24.58
Tiwari AK 97.31± 165.51± 183.3± 188.68± 182.18± 237.14± 314.23±

23.35 35.91 42.76 23.59 76.93 74.19 26.17
967.98± 2640.45± 4563.38± 4348.84±

Sindhu C - - -
386.93 800.75 1595.92 1641.3
109.54± 132.7± 142.27±

Divya Rani et al - - - -
11.13 17.31 26.62
1089.17± 974.317± 1866.57± 1784.73± 2486.16± 2340.19±

Vijayshree et al -
132.563 329.56 1169.33 1187.11 1229.84 1515.57
98.25 ± 110.2 ± 137.4± 150.35 ±

Hasija S et al - - -
0.80 2.39 2.5 4.30
84.19± 104.32± 100.08± 108.29± 78.94±

Mishra et al
19.77 46.58 39.53 39.07 24.52
In our study we found that there was increase in nuclear area from normal to
SCC with SCC having the highest mean nuclear area, ASC-H was found having
low mean nuclear area as compared to ASCUS, LSIL ,HSIL and SCC.
Similary Tiwari AK et al also found SCC cells having the largest mean
nuclear area and ASC-H having lower mean nuclear area than ASCUS,LSIL,HSIL
and SCC.48
Hasija S et al also found increase in nuclear area from ASCUS to SCC with
SCC having the highest mean nuclear area.51
49
Sindhu C et al found mean nuclear area of cells in abnormal pap smears
much higher than corresponding nuclear area in normal smears, however in their
study they found HSIL having the largest mean nuclear area. 49
Mishra S et al found HSIL having the highest mean nuclear area and SCC
having the lowest mean nuclear area in squamous epithelial lesions. 52
Rani D et al also compared mean nuclear areas of LSIL,HSIL and SCC and
found gradual increase in mean nuclear area from LSIL to SCC with SCC having
the highest mean nuclear area.42
Vijayshree R et al found that the nuclear area of cells in abnormal pap

smears were in general significantly much higher than the corresponding nuclear
measurements in normal smears with HSIL having the highest mean nuclear area.
But the most important characteristic appeared to be the variability in the nuclear
area in abnormal cells as reflected by high standard deviations.44
TABLE 30
COMPARISION OF NUCLEAR PERIMETER

67.72± 91.48± 105.21± 108.97± 105.75± 111.01± 132.52±

Present
2.85 9.54 5.67 8.07 11.2 11.53 7.34
109.1± 184.88± 243.66± 238.91±

Sindhu C et al - - -
21.74 29.69 46.21 47.97
24.69± 27.12± 28.18±

Divya Rani et al - - - -
1.143 1.49 2.72
138.66± 129.308± 167.395± 167.62± 194.47± 191.15±

Vijayshree et al -
11.641 28.42 49.67 56.67 49.44 62.44
22.36 ± 25.7 ± 27.9 ± 29.02 ±

Hasija S et al - - -
0.64 1.22 0.86 0.94
33.31± 36.74 ± 35.51 ± 37.62 ± 32.54 ±

Mishra et al - -
3.70 7.86 5.95 6.53 5.21
In the present study we found the nuclear perimeter of SCC cells having the
highest mean nuclear perimeter,similar findings were found in the study of Rani D
et al with SCC cells having the highest mean nuclear perimeter.42
50
Hasija S et al also found increase in nuclear perimeter from ASCUS to
SCC.51
However Sindhu C et al49 found HSIL having the highest mean nuclear
perimeter. Vijayshree R et al also found increase in mean nuclear perimeter from
normal to scc with HSIL having the maximum value.46
Mishra S et al found HSIL having the maximum nuclear perimeter and SCC
having the lowest mean nuclear perimeter in squamous epithelial lesions. 52
TABLE 31
COMPARISON OF NUCLEAR DIAMETER

7.16± 10.02± 11.19± 11.58± 10.31± 12.27± 14.12±

Present (µm)
0.26 0.63 0.59 0.69 0.46 1.1 0.97
12.92± 15.93± 16.69± 18.13± 16.72± 20.04± 26.98±

Tiwari AK (µm)
1.87 2.26 1.96 1.41 1.58 4.13 2.02
Sindhu C (max 39.25± - - 66.01± - 87.98± 87.15±

diameter) 8.14 11.14 18.0 19.96
- - - 7.72± - 8.48± 9.06±

Divya Rani et al
0.45 0.56 0.86
37.17± 35.208± 48.73± 47.65± - 56.24± 54.57±

Vijayshree et al
2.12 20.46 38.57 38.86 39.54 43.91
8.48± - 12.87± 13.21± - 15.71± 13.3±

Marta Wesola
2.0 2.87 2.71 2.9 2.44
- - 9.95 ± 11.00± 10.79± 11.26± 9.66 ±

Mishra et al
1.13 2.38 1.83 2.03 1.6
In the present study it was found there was gradual increase in nuclear
diameter from normal to reactive to SCC except for ASC-H which had lower nuclear
diameter from ASCUS and LSIL.
Similarly, Tiwari AK et al found increase in mean diameter with lesion except

for ASC-H which had lower nuclear diameter than LSIL.48
51
Similarly, Rani D et al also found increase in mean nuclear diameter from
LSIL to SCC with SCC having the highest value.42
However Vijayshree R et al in their study found that the mean nuclear

diameter of LSIL was smaller than ASCUS and of SCC was less than HSIL. 44
Wesola M et al also observed increase in mean nuclear diameter from

normal to dysplastic cell, however they found HSIL having more nuclear diameter
than SCC.41
Mishra S et al also found HSIL having the highest mean nuclear diameter. 52
TABLE 32
COMPARISON OF NUCLEAR TO CYTOPLASMIC RATIO

Present 0.02± 0.054± 0.083± 0.102± 0.13± 0.16± 0.222±

0.003 0.012 0.019 0.03 0.008 0.028 0.033
Tiwari AK 0.02± 0.05± 0.1± 0.09± 0.16± 0.16± 0.25±

0.01 0.03 0.04 0.01 0.06 0.09 0.08
Mishra et - - 0.24± 0.27± 0.77± 0.74± 0.8±

al 0.09 0.05 0.13 0.13 0.12
In our study we found increase in nuclear to cytoplasmic ratio from normal to

abnormal pap smears with SCC having the maximum N:C ratio,
Similar findings were found in the study done by Tiwari AK et al. 48
Mishra S et al also found SCC having the maximum N:C ratio , however in
their study ASC-H was having more N:C ratio than HSIL.52
The difference in numerical values of our study and other studies of different
parameters are due to different softwares used in the studies. Also many of the
studies have used conventional pap staining and we have used LBC BD surepath.
52
Cell area and cell perimeter of the epithelial cell abnormalities are the two
perimeters that are least observed by morphometry till date. Cell area and cell
perimeter are generally large in ASC-US as it is observed in large mature cells and
gradually decreases to HSIL as it is observed in small immature cells. 61 In present
study, mean cell area and mean cell perimeter of different lesion gradually
decreased in size except for ASC-H which has lowest mean cell area and cell
perimeter. The reason behind lower mean area of ASC-H could be because of lower
sample size of ASC-H cases which makes it incomparable with other categories.
We could not find any study in the literature to our best knowledge to compare the
results of mean cell area and cell perimeter.
In present study, on comparing normal control group with reactive cases,

normal with ECA cases, all the five parameters observed i.e., cell area, cell
perimeter, nuclear area, nuclear diameter and N:C ratio were found to be
statistically significant. Rani D et al,42 found that nuclear diameter showed a
significant difference (p<0.01) between LSIL and HSIL, LSIL and SCC, LSIL and
HSIL and nuclear area showed a significant difference in comparing LSIL with HSIL
and LSIL with SCC. However, statistically no significant difference was seen on
comparing mean nuclear area of HSIL and SCC in their study. Vijayshree R and
Rao KR, and Chen YF et al., also found a significant difference in comparing mean
of nuclear area, nuclear diameter, N:C ratio between normal cervical cells and
dysplastic cells.44,62
In the present study, the size related parameters (cell area, cell perimeter,
nuclear area, perimeter, diameter, N:C ratio) were appropriate parameters to
differentiate between normal from reactive to ECA cervical smears.
Some of the breast studies have also measured long axis and short axis as
nuclear morphometric parameters, but among the nuclear parameters, nuclear area
and perimeter are important.63,64,65
In a study done by Po Chi Huang et al., on cervical smears by PC based

Cyto pathologic Image Analysis System and Support Vector Machine(SVM)
53
showed that in dysplastic cells, the morphometric parameters like perimeter,
nuclear area, maximum length, maximum width, N/C ratio were all found to be
statistically significant with p-value of 0.001. These statistics showed that dysplastic
cells have larger size (i.e. larger perimeter, area, maximum length, and maximum
width), higher nuclear proportion (i.e. N/C ratio).66
In our study, cell perimeter was not statistically significant in differentiating

between ASCUS, ASC-H, LSIL, HSIL ,SCC with p-value >0.05.
Many studies were conducted in analyzing the nuclear features by

morphometry in other organs like breast, exfoliated buccal mucosal cells,
squamous neoplasms, colon and thyroid.38,43,45,46
A large number of parameters have been studied by morphometry, but the

nuclear parameters related to size like NA, NP, and ND have consistently been
found to be significant both in histology and cytology in distinguishing benign versus
malignant lesions.52
In our study we found HSIL having more cell area and perimeter than SCC
but it was not statistically significant (p value>0.05) but nuclear area, nuclear
perimeter, nuclear diameter, N:C ratio were more in SCC than HSIL and were found
to be statistically significant. The Bethesda system also mentions that cells of SCC
may be somewhat smaller than those of HSIL and nuclei of SCC demonstrates
marked variaton in nuclear area.67
We found on comparing ASC-H with HSIL nuclear area and nuclear diameter
to be statistically significant with nuclear area and nuclear diameter more in HSIL,
other parameters like cell area, cell perimeter , nuclear perimeter , N:C ratio were
more in HSIL but were not statistically significant(p value>0.05)
On comparing LSIL with HSIL, cell area and cell perimeter were more in
LSIL, the Bethesda system also mentions that cells of HSIL are smaller than those
of LSIL. Also seen nuclear area, nuclear perimeter, nuclear diameter and N:C ratio
more in HSIL than LSIL, the Bethesda system mentions degree of nuclear
54
enlargement is more variable than that seen in LSIL and N:C ratio is high in HSIL
compared to LSIL.68
On comparing ASCUS with LSIL, we found cell area, cell perimeter to be

more in ASCUS but nuclear area, nuclear diameter, nuclear perimeter and N:C ratio
were more in LSIL.
Based on the statistical analysis, it can be said that all the groups differ from
each other enough to permit the use of their morphometric characteristics for
diagnostic purposes. The results of the tests show that there are many differences
between the various groups of cells. This is confirmed by the statistical analysis as
well. The cells belonging to each group of cytological changes can be identified on
the basis of the morphometric characteristics measured, and this can be applied in
diagnostic cytology.
55
SUMMARY AND CONCLUSION
The present study was conducted in Department of Pathology, Government

Medical College, Amritsar. 200 liquid based cytology (LBC) cervical samples which
included normal cases and abnormal case findings 20 intermediate squamous
cells per slide were evaluated.
75 cases were normal ,82 cases showing reactive cellular changes, 20

ASCUS, 8 LSIL, 4 ASC-H, 6 HSIL and 5 SCC.
 Age of the patients in normal group and reactive cellular changes ranged
from 20- 50 years.
 Age of the patients in ECA ranged from 20-70 years with LSIL in 20-40 years,
HSIL in 41-60, SCC in 51-70 years.
 ASCUS ranged in 20-50 years and ASC-H in 31-50 years.
 It was observed there was gradual decrease in mean cell area, mean cell
perimeter from normal group to SCC, ASC-H had the lowest mean cell area
and perimeter.
 There was gradual increase in mean nuclear area from normal group to SCC,
ASC-H mean nuclear area was lower than ASCUS and LSIL.
 There was gradual increase in mean nuclear perimeter from normal group to
SCC.
 There was gradual increase in mean nuclear diameter from normal group to
SCC, ASC-H mean nuclear diameter was lower than ASCUS and LSIL.
56
 Mean N:C ratio showed gradual increase from nomal group to SCC with
values normal ( 0.020),Reactive(0.054),ASCUS(0.083 ),LSIL (0.102),ASC-
H (0.130),HSIL(0.160), SCC(0.222)
The present study showed that the morphometric parameters related to cell
and nuclear size like area, perimeter, diameter, N:C ratio significantly larger in
abnormal Pap smears group than the Normal Pap smears group. It can be
concluded that all the groups differ from each other enough to permit the use of
their morphometric characteristics for diagnostic purposes.
Nuclear morphometry is thus a useful objective tool in differentiating

premalignant and malignant cervical smears. It is also helpful in diagnostic
dilemmas which are encountered especially in gray zones on cervical smears. By
combining the findings of clinical examination, cytomorphological and morphometric
parameters, we can improve the diagnostic accuracy of cervical cancer screening
and hence aid clinicians to apply appropriate treatment modalities. However, no
reference range of morphometric parameters is available. The spectrum of
morphometric parameters of cervical lesions must be established through more in-
depth research in order to use morphometry to increase the accuracy of cervical
smear screening.
Routine pap smear examination is time consuming and is based on

descriptive morphological assessment so chances of false positive and false
negative are high. Semiautomated morphometric assessment comes to aid in the
situation and saves time with improved accuracy.
Diagnosis of cervical pre neoplastic and neoplastic lesions is subjective and

requires a trained pathologist. Morphometry aims to make this process more
objective with distinction being made on specifically selected parameters. So, this
process can be automated and this technique can act as adjunct for use by clinical
pathologist or for providing provisional diagnosis in remote areas with unavailability
of trained pathologist.
57
However there are limitations of this study due to small sample size besides
glandular cell abnormalities were not studied and no reference ranges of
morphometric parameters are available.
58
BIBLIOGRAPHY
1. Human Papillomavirus and Related Diseases Report, India, ICO Information

Centre on HPV and Cancer (HPV Information Centre) 2015.
www.hpvcentre.net/statistics/reports/IND.pdf
2. Statistics: India against cancer [homepage on internet]. Available from

www.cancerindia.org.in/index.php/know-aboutcancer/statistics.
3. Cervical Cancer Prognosis and Survival Rates. https://www.cancer.gov/

types/cervical/survival
4. Koss LG. The Papanicolaou test for cervical cancer detection. A triumph and
a tragedy. JAMA. 1989;33:215-18.
5. Victor Lee, Siok-Bian Ng, Manuel Salto-Tellez. New techniques. In:

Diagnostic Cytopathology (Third Edition); Chapter 34. Churchill Livingstone,
2010; pp.891-902,
6. Hoda RS, Hoda SA, Hoda RS, Hoda SA. Liquid-Based Preparations.
Fundamentals of Pap Test Cytology. 2007:31-6.
7. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M et al.

Cancer incidence and mortality worldwide: sources, methods and major
patterns in GLOBOCAN 2012. International Journal of Cancer. 2015;
136(5):E359-86.
8. Idehen EE, Koponen P, Härkänen T, Kangasniemi M, Pietilä AM, Korhonen

T. Disparities in cervical screening participation: A comparison of Russian,
Somali and Kurdish immigrants with the general Finnish population. Int J
Equity Health. 2018;17:56.
9. Swanson M, Ueda S, Chen LM, Huchko MJ, Nakisige C, Namugga J.

Evidence-based improvisation: Facing the challenges of cervical cancer care
in Uganda. Gynecol Oncol Rep. 2018;24:30–35.
59
10. Mehrotra R, Yadav K. Cervical Cancer: formulation and Implementation of
Govt of India guidelines for screening and management. Indian Journal of
Gynecologic Oncology. 2022;20:1-8..
11. Ellenson LH and Pirog EC. The Female Genital Tract. In: Robbins and
Cotran Pathologic Basis of Disease, Ch. 22; 10th Edition, Elsevier Saunders,
Philadelphia. 2021; pp.996-7.
12. Bobdey S, Sathwara J, Jain A, Balasubramaniam G. Burden of cervical

cancer and role of screening in India. Indian Journal of Medical and
Paediatric Oncology. 2016;37(04):278-85.
13. Sung H, Ferlay J, Seigel RL, Laversanne M, Soerjomataram I, Jemal A, et

al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and
mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin.
2021;71:209–49.
14. Sankaranarayanan R, Swaminathan R, Lucas E. Cancer survival in Africa,

Asia, Caribbean and Central America: database and attributes. IARC Sci
Publ. 2011;162:23–31.
15. ICO Information Centre on HPV and cancer. Human papillomavirus and
related diseases in India (summary report 2019-06-17) 2019.
16. Reagan JW, Hicks DJ. A study of in situ and squamous-cell cancer of the
uterine cervix. Cancer. 1953;6(6):1200-14.
17. Manjit SB, Rishu G, Anil KS, Manjit KM. Detection of abnormal cervical
cytology in Papanicolaou smears. J Cytol. 2012;29(1):45–7.
18. Mulazim HB, Kanwal, Samina Q, Muhammad MM, Shahida N, Samina N.

Clinicopathological importance of Papanicolaou smears for the diagnosis of
premalignant and malignant lesions of the cervix. J Cytol. 2012;29(1):20–5.
19. Sreedevi A, Reshman J , Avani D. Epidemiology of cervical cancer with

special focus on India. Int J Womens Health. 2015;7:405–14.
60
20. American Cancer Socity. History of cancer screening and early detection.
2014.
21. Rashid A, Naz U, Sarwar A. Historical perspective of cervical cytology: A

review. Journal of University Medical & Dental College. 2017;8(4):1-6.
22. Plummer M, Peto J, Franceschi S, International Collaboration of

Epidemiological Studies of Cervical Cancer. Time since first sexual
intercourse and the risk of cervical cancer. International Journal of Cancer.
2012;130(11):2638-44.
23. Zahid B, Khawaja N, Tayyeb R. Prevalence of abnormal cervical cytology

and its relation with age and parity. Ann King Edward Med Coll 2005;11:524-
5.
24. Sohail R, Nazir R, Latif Y, Farrukh Zaman. Evaluation of cervical smear in

women attending gynaecological OPD. J Surg Pak 2008;13:121-3
25. Marluce Bibbo, Joseph F. Nasuti,Chapter 5 - Evaluation of the Sample in

Smears and Liquid-Based Preparations,Editor(s): Marluce Bibbo, David
Wilbur,Comprehensive Cytopathology (Third Edition),W.B. Saunders,2008.
26. Jacobj W. Über das rhythmische Wachstum der Zellen durch Verdopplung
ihres Volumens: Beitrag X zur synthetischen Morphologie aus dem
Anatomischen Institut zu Tübingen. Wilhelm Roux'Arch. Entwickl.-Mech.
Org. 1925;106:124-92.
27. Heiberg KA, Kemp T. über die Zahl der Chromosomen in Carcinomzellen
beim Menschen. Virchows Archiv für pathologische Anatomie und
Physiologie und für klinische Medizin. 1929;273:693-700.
28. Buhmeida A. Quantitative Pathology: Historical background, clinical

research and application of nuclear morphometry and DNA image cytometry.
Lib J Med 2006; 1:127-36.
61
29. Diamond DA, Berry SJ, Umbricht C, Jewett HJ, Coffey DS. Computerized
image analysis of nuclear shape as a prognostic factor for prostatic cancer.
Prostate 1982a, 3(4):321-32.
30. Epstein JI, Berry SJ, Eggleston JC. Nuclear roundness factor. A predictor
of progression in untreated stage A2 prostate cancer. Cancer 1984, 54:666-
71.
31. Clark TD, Askin FB, Bagnell CR. Nuclear roundness factor: a quantitative
approach to grading in prostatic carcinoma, reliability of needle biopsy
tissue, and the effect of tumour stage on usefulness. Prostate 1987;10:199-
206.
32. Mohler JL, Partin AW, Epstein JI, Lohr WD, Coffey DS. Nuclear roundness
factor measurement for assessment of prognosis of patients with prostatic
carcinoma. II. Standardization of methodology for histologic sections. J Urol
1988;139:1085-90.
33. Partin AW, Walsh AC, Pitcock RV, Mohler JL, Epstein JI, Coffey DS. A
comparison of nuclear morphometry and Gleason grade as a predictor of
prognosis in stage A2 prostate cancer: a critical analysis. J Urol. 1989;142:
1254-8.
34. Eichenberger T, Mihatsch MJ, Oberholzer M, Gschwind R, Rutishauser G.

Are nuclear shape factors good predictors of the disease course in patients
with carcinoma of the prostate. Progress in clin boil res. 1987;243:533-7.
35. Pienta KJ, Coffey DS. Correlation of nuclear morphometry with progression
of breast cancer. Cancer. 1991;68(9):2012-6.
36. Dong L, Zieren RC, Xue W, de Reijke TM, Pienta KJ. Metastatic prostate
cancer remains incurable, why? Asian J Urol. 2019;6(1):26-41.
37. Bacus JW. Cervical cell recognition and morphometric grading by image
analysis. Journal of Cellular Biochemistry. 1995;59(S23):33-42.
62
38. Ikeguchi M, Sakatani T, Endo K, Makino M, Kaibara N. Computerized
nuclear morphometry is a useful technique for evaluating the high metastatic
potential of colorectal adenocarcinoma. Cancer. 1999;86(10):1944- 51.
39. Buhmeida A, Kuopio T, Collan Y. Nuclear size and shape in fine needle
aspiration biopsy samples of the prostate. Analytical and Quantitative
Cytology and Histology. 2000;22(4):291-8.
40. Mudaliar K, Hutchens K. Morphometric image analysis as a tool in the

diagnosis of transected squamous neoplasms. J Clin Anat Pathol. 2013; 1:1-
5.
41. Wesoła M, Lipiński A, Jeleń M. Morphometry in the cytological diagnosis of

cervical smears. Adv Clin Exp Med. 2014;23(2):289-93
42. Rani D, Narasimha A, Ml HK, Sheela SR. Evaluation of pre-malignant and

malignant lesions in cervico vaginal (PAP) smears by nuclear morphometry.
Journal of clinical and diagnostic research: JCDR. 2014 Nov;8(11):FC16.
43. Laishram S, Shariff S. Significance of nuclear morphometry on fine needle

aspirates of breast lesions. The Journal of Medical Research. 2015; 1(3):72-
5.
44. Vijayashree R, Rao K. A semi-automated morphometric assessment of

nuclei in pap smears using Imagej. Journal of Evolution of Medical and
Dental Sciences. 2015;4(53):63
45. Kashyap A, Jain M, Shukla S, Andley M. Study of nuclear morphometry on

cytology specimens of benign and malignant breast lesions: A study of 122
cases. J Cytol. 2017; 34:10- 15.
46. Yashaswini R, Suresh TN, Sagayaraj A. Cytological evaluation of thyroid

lesions by nuclear morphology and nuclear morphometry. J Cytol. 2017;
34:197-202
63
47. Deka L, Gupta S, Gupta R. Nuclear morphometry and texture analysis on
cytological smears of thyroid neoplasms: a study of 50 cases. Malaysian J
Pathol. 2017; 39(1):33-7.
48. Tiwari AK, Khare A, Grover SC, Bansal R, Sharma S.Role of Nuclear
Morphometry in Screening of Cervical Pap Smear.J Clin of Diagn
Res.2019; 13(5):EC13-EC16.
49. Sindhu C, Shariff S. Role of nuclear morphometry in cervicovaginal

Papanicolaou smears and its utility in diagnosing cervical lesions. Int J Clin
Diagn Pathol. 2020;3(1):227-34.
50. Osman SE, Elmadenah EM, Elmahi OM, Alkarsani ME, Eltayeb LB,
Waggiallah HA. Cytomorphometric Analysis of Cervical Papanicolaou Smear
for Females with Gynecological Clinical Complaints. Int J Biomed.
2021;11(1):46-9.
51. Hasija S, Kalhan S, Garg S, Sharma P, Singh P, Sethi B. Role of

morphometry as diagnostic adjunct in evaluating premalignant and
malignant cervical cytology. Middle East J Cancer. 2022;13(1):56-8.
52. Mishra S, Khurana U, Kapoor N, Joshi A, Joshi D. Evaluation of the

cytonucleomorphometric parameters for cases diagnosed as squamous cell
abnormality on conventional cervico-vaginal pap smears. J Cytol. 2022;
53. American Cancer society, Cancer facts and figures – 2002, http: //
www.Cancer. Org, 2002
54. Kim SJ. Role of Colposcopy and Cervicography in screening and

management of precancerous lesions and early Invasive Cancer of Uterine
Cervix. J Obstet Gynecol India. 2000;50:134-46.
55. Nemec E, Vandeputte S, Van Pachterbeke R, Vokaer R, Budel V, Deprez C,

et al. Ploidy and Chromatin Analysis as an Aid for Cervical Smear Diagnosis.
Histopathol. 2002;17:403-09.
64
56. Poulin N, Boiko I, MacAulay C, Charles B, Nishioka K, Hittelman W, et al.
Nuclear Morphometry as an Intermediate End point Biomarker in chemo
prevention of Cervical Carcinoma using α Difluoromethylornithine.
Cytometry. 1999;38:214-23.
57. Arulponni TR, Janaki MG, Nirmala S, Ramesh BS, Rishi KS, Kirthi K.
Carcinoma Cervix Treated with Radiotherapy: Our Experience with
Emphasis on our Concerns. J Obstet Gynecol India. 2010;60:61-5.
58. Po Chi Huang, Yung Kuan Chan, Po Chou Chan, Yung –Fu Chen, Rung
Ching Chenm Yu–Ruei Huang. Quantitative Assessment of Pap Smear Cells
by PC Based Cytopathologic Image Analysis System and Support Vector
Machine. Lecture Notes in Computer Science. 2007;4901:192-9.
59. Arora B, Setia S, Rekhi B. Role of Computerized Morphometric Analysis in

diagnosis of Effusion specimens. Diagn Cytopathol. 2006;34:670-5.
60. Kirillov V, Stebenyaeva E, Paplevka A, Demidchik E. A Rapid method for

diagnosing regional metastasis of Papillary Thyroid Cancer with
Morphometry. Microsc Res Tech. 2006;96:338-43.
61. Nayar R, Wilbur DC. The Pap Test and Bethesda 2014. Acta Cytologica.
2015;59:121-32.
62. Chen YF, Huang PC, Lin KC, Wang LE, Cheng CC, Chen TP, et al.
Semiautomatic segmentation and classification of Pap smear cells. IEEE J
Biomed Health Inform. 2014;18(1):94-108.
63. Yan Cui, Esther AK, van Diest PJ, Kandel RA, Rohan TE. Nuclear
Morphometric features in Benign Breast tissue and risk of subsequent breast
cancer. Breast Cancer Res Treat. 2007;104:103-07.
64. Abdalla F, Boder J, Buhmeida A, Hashmi H, Elzagheid A, Collan Y. Nuclear

Morphometry in FNAB of breast disease in Libyans. Anticancer Research.
2008; 28:3985-90.
65
65. Kalhan S, Dubey S, Sharma S, Dudani S, Preethi, Dixit M. Significance of
Nuclear Morphometry in Cytological aspirates of Breast masses. Jr of
Cytology. 2010;27:16-21.
66. Po Chi Huang, Yung Kuan Chan, Po Chou Chan, Yung –Fu Chen, Rung
Ching Chenm Yu–Ruei Huang. Quantitative Assessment of Pap Smear Cells
by PC Based Cytopathologic Image Analysis System and Support Vector
Machine. Lecture Notes in Computer Science. 2007;4901:192-99
67. Henry MR, Russel DK. Epithelial cell abnormalities:squamous. In: The
Bethesda System for Reporting Cervical Cytology. Ch. 5th, Ed. 3rd., pp. 179-
82.
68. Henry MR, Russel DK. Epithelial cell abnormalities:squamous. In: The
Bethesda System for Reporting Cervical Cytology. Ch. 5th, Ed. 3rd., pp. 147.
66
Average nuclear to cytoplasmic ratio
Average nuclear perimeter
Average nuclear diameter

Average cell perimeter
Average nuclear area
Histopathology report
Average cell area
LBC report
Sr. no.
Name
Age
1 S 30 1694.340 450.600 36.300 62.100 6.790 0.021 normal -

2 P 30 1745.560 465.450 42.340 68.760 7.340 0.024 normal -
3 R 40 2003.300 498.560 39.300 66.780 7.070 0.019 normal -
4 SD 49 2213.560 523.450 45.100 70.540 7.580 0.020 normal -
5 BK 40 2123.340 520.560 39.340 66.440 7.080 0.018 normal -
6 RK 38 2215.450 524.670 36.230 61.980 6.790 0.016 normal -
7 MK 33 1900.450 506.450 44.230 69.780 7.500 0.023 normal -
8 HK 32 1856.670 478.670 40.450 68.760 7.170 0.021 normal -
9 SK 32 1945.340 490.670 38.450 63.450 7.000 0.019 normal -
10 RK 36 1990.900 500.450 41.450 69.780 7.260 0.028 normal -
11 SK 30 2012.230 510.230 39.980 67.980 7.130 0.019 normal -
12 RK 32 2200.560 515.340 37.540 64.340 6.910 0.017 normal -
13 SK 30 1980.780 502.340 36.450 62.130 6.810 0.018 normal -
14 SK 30 1870.340 490.560 42.450 68.780 7.350 0.022 normal -
15 P 30 2123.890 510.340 40.870 69.760 7.210 0.019 normal -
16 R 41 2222.780 520.450 43.240 69.560 7.410 0.019 normal -
17 MK 34 2210.780 522.300 42.150 67.890 7.320 0.019 normal -
18 P 30 1789.450 460.400 37.560 64.560 6.910 0.020 normal -
19 DK 40 1696.356 454.609 39.290 67.857 7.032 0.023 normal -
20 AK 34 1719.921 458.723 43.348 69.962 7.379 0.025 normal -
21 RK 40 2229.642 526.290 44.465 70.836 7.606 0.020 normal -
22 HK 30 1490.589 422.884 36.115 62.921 6.495 0.024 normal -
23 AK 40 2026.283 500.120 38.062 64.508 6.935 0.019 normal -
24 JK 30 2754.420 587.066 35.278 62.710 6.780 0.012 normal -
25 TA 36 1856.261 499.013 45.375 71.115 7.599 0.025 normal -

Average cell area
LBC report
Sr. no.
Name
Age
26 DK 40 2234.900 526.560 45.000 70.780 7.560 0.020 normal -

27 SK 34 2345.890 530.560 37.980 63.450 6.950 0.016 normal -
28 S 35 1982.300 501.340 36.120 61.980 6.780 0.018 normal -
29 S 23 1985.340 512.320 42.670 68.980 7.370 0.021 normal -
30 G 30 2100.500 511.230 44.870 71.230 7.550 0.021 normal -
31 RK 28 2479.600 550.560 39.890 67.980 7.120 0.016 normal -
32 S 30 2367.800 540.320 44.230 71.220 7.500 0.018 normal -
33 A 31 2134.780 512.450 41.250 69.780 7.240 0.019 normal -
34 B 48 2167.000 507.560 38.980 65.340 7.040 0.017 normal -
35 K 35 2645.600 568.230 43.570 70.980 7.440 0.016 normal -
36 AK 39 2387.000 534.670 45.120 71.980 7.570 0.018 normal -
37 AK 30 1569.450 430.450 39.870 67.560 7.120 0.025 normal -
38 KK 30 1657.780 450.230 36.980 62.980 6.860 0.022 normal -
39 PS 33 1498.780 430.200 38.670 65.120 7.010 0.025 normal -
40 C 33 1798.450 460.760 40.980 68.780 7.220 0.022 normal -
41 GK 35 2257.670 525.340 43.560 70.030 7.440 0.019 normal -
42 V 30 2489.980 540.230 42.450 68.670 7.350 0.017 normal -
43 PK 40 1567.870 430.450 40.160 68.780 7.150 0.025 normal -
44 LD 30 2678.780 578.230 37.890 63.120 6.940 0.014 normal -
45 AR 40 2178.560 511.230 35.980 63.230 6.780 0.016 normal -
46 PK 40 2198.670 515.450 42.450 68.980 7.350 0.019 normal -
47 RK 40 2435.760 560.450 41.230 69.230 7.240 0.016 normal -
48 MK 32 1789.560 462.440 45.980 72.100 7.650 0.025 normal -
49 GK 42 2265.760 525.340 44.340 70.560 7.510 0.019 normal -
50 GK 39 2145.560 510.560 36.560 65.650 6.830 0.017 normal -

Average cell area
LBC report
Sr. no.
Name
Age
51 RK 45 2215.600 510.700 37.800 68.600 7.100 0.017 normal -

52 S 32 1989.600 490.800 39.600 67.900 7.100 0.019 normal -
53 DK 29 2047.800 500.800 40.800 68.900 7.200 0.019 normal -
54 KK 33 1867.800 480.800 39.800 70.600 7.110 0.021 normal -
55 R 34 1897.700 510.800 41.800 72.300 7.290 0.022 normal -
56 MK 40 2289.900 511.500 42.780 69.400 7.370 0.018 normal -
57 NK 38 2100.400 513.500 39.900 67.890 7.120 0.018 normal -
58 KK 29 2108.800 479.800 36.900 68.800 6.850 0.017 normal -
59 P 33 1797.460 466.700 44.780 66.700 7.550 0.024 normal -
60 SD 43 1894.700 498.600 37.700 65.700 6.920 0.019 normal -
61 KK 38 1988.700 490.800 38.700 68.700 7.010 0.019 normal -
62 PK 37 2100.600 510.400 40.500 67.560 7.180 0.019 normal -
63 SK 27 2056.700 502.800 38.560 69.700 7.000 0.018 normal -
64 MK 30 1678.800 480.600 40.140 70.030 7.140 0.020 normal -
65 HK 31 2309.600 532.700 43.700 71.800 7.450 0.018 normal -
66 MK 26 2103.400 502.300 41.500 68.600 7.260 0.019 normal -
67 RS 31 1889.400 511.500 42.400 67.700 7.340 0.022 normal -
68 PK 28 1987.600 499.900 40.900 65.700 7.210 0.020 normal -
69 N 29 2105.500 501.500 36.800 63.800 6.840 0.017 normal -
70 DK 29 1980.400 498.900 35.600 64.500 6.730 0.017 normal -
71 NK 31 2102.200 499.980 34.500 66.700 6.620 0.016 normal -
72 AK 32 2398.500 529.900 40.600 70.700 7.180 0.016 normal -
73 V 30 2100.400 498.600 38.600 69.700 7.000 0.018 normal -
74 MK 35 2276.500 510.600 39.700 67.700 7.100 0.017 normal -
75 RK 27 2109.560 506.700 38.700 67.800 7.010 0.018 normal -

Average cell area
LBC report
Sr. no.
Name
Age
76 RK 30 1893.130 472.980 77.690 90.532 9.924 0.045 reactive -

77 RK 45 1107.190 390.350 82.460 94.070 10.350 0.080 reactive -
78 S 26 1209.440 397.605 71.460 90.540 10.040 0.077 reactive -
79 HS 29 1278.960 368.560 78.130 81.950 9.970 0.061 reactive -
80 RK 32 1738.860 430.530 83.110 86.490 10.290 0.047 reactive -
81 JJ 37 1983.400 480.500 78.480 84.600 10.000 0.039 reactive -
82 JK 39 1751.600 475.480 95.630 105.860 11.030 0.054 reactive -
83 GK 40 2004.310 463.040 82.760 94.850 10.270 0.041 reactive -
84 PK 30 1624.810 457.790 81.670 89.420 10.200 0.050 reactive -
85 J 30 1998.610 471.510 76.510 95.090 9.870 0.038 reactive -
86 N 36 1788.550 430.560 72.800 81.410 9.630 0.040 reactive -
87 BK 30 2047.340 521.500 81.580 92.980 10.190 0.039 reactive -
88 MK 33 1865.860 471.420 65.800 89.540 9.150 0.035 reactive -
89 NK 32 1734.970 457.740 83.820 87.840 10.330 0.048 reactive -
90 S 30 2023.450 485.620 76.810 81.500 9.890 0.037 reactive -
91 P 40 1201.880 476.670 57.440 77.800 8.550 0.047 reactive -
92 AK 40 1551.450 434.770 81.720 81.920 10.200 0.052 reactive -
93 P 30 1981.750 470.150 89.950 104.510 10.700 0.045 reactive -
94 MK 32 1214.390 399.480 82.860 79.300 10.270 0.068 reactive -
95 HK 40 1567.500 431.690 76.300 95.310 9.860 0.048 reactive -
96 B 40 1780.380 447.660 90.800 100.060 10.750 0.051 reactive -
97 N 36 1676.790 468.130 89.710 116.290 10.690 0.053 reactive -
98 KK 32 1339.770 376.400 85.240 93.020 10.420 0.063 reactive -
99 GK 40 1581.210 434.340 73.290 98.490 9.700 0.046 reactive -
100 MK 40 1490.220 425.890 92.840 101.640 10.870 0.062 reactive -

Average cell area
LBC report
Sr. no.
Name
Age
101 JK 40 1755.520 499.060 89.240 98.160 10.660 0.050 reactive -

102 RK 30 1658.600 376.510 90.760 102.810 10.750 0.054 reactive -
103 HK 30 1115.170 351.900 96.130 101.590 11.060 0.086 reactive -
104 P 40 1153.610 384.640 66.210 83.850 9.067 0.063 reactive -
105 S 30 1024.640 353.720 71.090 93.840 9.510 0.069 reactive -
106 R 21 1072.300 369.780 69.700 86.850 9.320 0.065 reactive -
107 BK 32 1023.200 346.700 69.900 86.450 9.430 0.068 reactive -
108 MK 30 1340.000 380.500 87.600 92.300 10.500 0.065 reactive -
109 SK 33 1245.500 380.200 70.400 80.300 9.460 0.056 reactive -
110 AR 32 1345.700 360.200 83.200 93.200 10.200 0.061 reactive -
111 KK 32 1568.000 420.300 74.300 86.400 9.710 0.047 reactive -
112 RK 37 1679.000 450.200 89.400 95.400 10.660 0.053 reactive -
113 SR 38 1245.000 400.400 69.700 78.000 9.410 0.055 reactive -
114 NK 30 1123.200 350.500 75.400 85.400 9.790 0.067 reactive -
115 K 30 1556.700 430.100 78.560 82.200 10.000 0.050 reactive -
116 BK 42 1467.800 412.400 90.560 100.500 10.700 0.061 reactive -
117 J 37 1203.400 398.400 70.600 78.400 9.470 0.058 reactive -
118 JK 30 1987.300 460.500 96.500 110.300 11.000 0.048 reactive -
119 S 32 1462.400 410.400 92.800 99.700 10.800 0.063 reactive -
120 AK 30 1324.500 370.500 85.600 93.400 10.430 0.064 reactive -
121 HK 34 1206.300 368.400 76.600 85.400 9.800 0.063 reactive -
122 SV 40 1267.400 380.500 72.300 82.400 9.590 0.057 reactive -
123 MK 39 1564.300 430.500 80.500 88.700 10.120 0.051 reactive -
124 SK 30 1539.500 440.600 82.500 97.500 10.200 0.053 reactive -
125 MK 29 1604.300 500.400 75.800 80.670 9.820 0.047 reactive -

Average cell area
LBC report
Sr. no.
Name
Age
126 S 40 1843.100 460.700 70.670 80.670 9.480 0.038 reactive -

127 UD 40 1203.400 310.560 90.890 97.780 10.750 0.075 reactive -
128 A 30 1365.700 399.800 78.770 88.780 10.010 0.049 reactive -
129 HK 33 1745.500 480.780 70.780 82.900 9.490 0.040 reactive -
130 JD 36 1632.540 510.400 79.790 80.780 10.070 0.048 reactive -
131 SK 33 1908.400 499.780 77.980 90.450 9.960 0.040 reactive -
132 S 30 1543.400 430.980 79.670 96.670 10.070 0.051 reactive -
133 SS 40 1335.670 380.890 76.890 87.900 9.880 0.057 reactive -
134 S 35 1289.600 330.780 98.890 110.670 11.220 0.076 reactive -
135 S 30 1123.400 360.670 68.900 80.780 9.360 0.061 reactive -
136 SK 31 2100.450 510.560 99.980 118.000 11.280 0.047 reactive -
137 MK 35 1268.600 318.800 97.700 102.800 11.150 0.077 reactive -
138 JK 37 1564.560 430.800 78.120 98.900 9.970 0.049 reactive -
139 S 40 1864.720 489.700 69.460 92.100 9.400 0.037 reactive -
140 N 33 1814.880 446.550 84.200 98.680 10.350 0.046 reactive -
141 P 28 1602.170 504.350 74.090 78.460 9.710 0.046 reactive -
142 M 30 1473.440 415.080 91.560 104.120 10.790 0.062 reactive -
143 PK 41 1393.700 392.330 77.230 88.830 9.910 0.055 reactive -
144 RK 38 1750.700 472.460 64.640 83.980 9.070 0.036 reactive -
145 R 35 1624.850 478.130 80.670 91.100 10.100 0.049 reactive -
146 B 30 1512.220 422.800 77.120 96.990 9.900 0.050 reactive -
147 SK 40 1159.900 374.850 64.000 84.420 9.020 0.055 reactive -
148 RK 28 1877.390 469.940 67.410 84.430 9.260 0.035 reactive -
149 AK 30 1471.850 367.290 86.220 94.020 10.470 0.058 reactive -
150 L 30 1274.410 320.990 97.990 110.200 11.160 0.076 reactive -

Average cell area
LBC report
Sr. no.
Name
Age
151 GK 32 1152.580 356.100 67.650 87.380 9.280 0.058 reactive -

152 TK 30 1601.300 436.210 67.880 92.940 9.290 0.042 reactive -
153 KK 38 963.410 337.360 64.650 103.560 9.070 0.067 reactive -
154 KK 35 967.580 345.200 65.080 79.010 9.100 0.067 reactive -
155 M 34 1042.620 337.340 62.880 92.450 8.940 0.060 reactive -
156 S 37 1943.970 484.090 65.470 70.180 9.120 0.033 reactive -
157 S 26 1798.300 500.300 88.700 92.300 10.620 0.049 reactive -
158 AR 37 1220.260 397.838 97.190 103.860 11.130 0.082 ascus -
159 SK 25 1260.290 407.750 95.250 103.160 11.030 0.092 ascus -
160 R 40 1818.650 479.500 119.810 119.570 12.340 0.069 ascus -
161 RD 40 872.660 339.033 88.210 101.370 10.590 0.113 ascus -
162 DK 40 998.050 357.190 97.880 105.390 11.160 0.106 ascus -
163 M 30 1019.390 363.809 108.280 108.560 11.610 0.110 ascus -
164 S 28 1200.600 386.640 90.850 101.930 10.700 0.079 ascus -
165 GK 40 1575.800 440.830 117.400 112.300 12.180 0.074 ascus -
166 HK 30 1776.270 492.080 92.770 99.510 10.810 0.052 ascus -
167 G 31 1212.700 380.510 96.860 103.180 10.980 0.079 ascus -
168 L 40 1400.150 411.120 128.990 111.070 12.310 0.092 ascus -
169 S 30 917.300 344.070 97.080 103.090 11.140 0.110 ascus -
170 M 31 1370.960 406.690 107.370 106.310 11.600 0.081 ascus -
171 AR 37 1220.260 397.830 97.190 103.860 11.130 0.082 ascus -
172 PK 39 1431.320 407.960 81.300 95.400 10.170 0.056 ascus -
173 MK 40 1078.780 370.440 103.200 107.630 11.400 0.095 ascus -
174 HK 43 1490.150 437.980 92.930 100.220 10.780 0.065 ascus -
175 SK 40 1187.960 365.776 106.120 108.400 11.080 0.101 ascus -

Average cell area
LBC report
Sr. no.
Name
Age
176 RK 36 1345.800 430.700 85.700 97.800 10.440 0.060 ascus -

177 SR 33 1440.820 476.760 97.950 111.540 11.170 0.067 ascus -
178 GK 30 902.980 335.470 85.940 97.230 10.450 0.103 lsil CIN 1
179 S 34 850.740 320.460 118.760 113.540 12.240 0.144 lsil CIN 1
180 A 39 802.030 289.270 109.390 109.340 11.800 0.130 lsil CIN 1
181 NK 28 1202.570 395.460 89.360 112.720 11.450 0.074 lsil CIN 1
182 SK 32 1181.300 374.490 98.930 104.180 11.220 0.083 lsil CIN 1
183 SK 30 1110.440 380.580 95.920 107.910 11.020 0.089 lsil CIN 1
184 V 34 1718.200 1445.240 109.910 102.950 11.830 0.063 lsil CIN 1
185 U 40 905.360 323.740 124.920 123.910 12.600 0.130 lsil CIN 1
186 K 50 599.890 313.690 82.300 95.310 10.230 0.130 asc-h -
187 K 48 515.280 246.990 69.840 111.280 9.690 0.130 asc-h -
188 RK 39 700.680 350.780 90.600 118.800 10.700 0.120 asc-h -
189 BK 50 598.000 334.600 88.900 97.600 10.600 0.140 asc-h -
190 SD 50 615.710 303.510 97.610 93.580 11.390 0.150 hsil CIN 2
191 KK 47 534.370 288.460 85.350 111.910 11.490 0.150 hsil CIN 2
192 AD 58 604.730 300.670 113.630 112.010 11.520 0.180 hsil CIN 2
193 JK 49 535.550 306.200 107.150 103.030 11.900 0.200 hsil CIN 3
194 S 54 897.850 322.370 147.280 119.730 13.890 0.160 hsil CIN 2
195 K 47 1000.170 350.590 123.900 125.820 13.450 0.120 hsil CIN 3
196 S 60 608.830 313.360 146.760 120.180 14.220 0.240 scc SCC
197 SD 61 586.670 290.740 134.440 139.570 12.820 0.220 scc SCC
198 UR 51 629.740 370.210 143.400 135.940 13.660 0.220 scc SCC
199 B 53 745.480 332.270 196.020 133.650 15.450 0.260 scc SCC
200 GK 65 799.730 374.190 143.440 133.270 14.460 0.170 scc SCC
DIAGNOSING PREMALIGNANT AND
MALIGNANT LESION IN LIQUID BASED
CYTOLOGY CERVICAL
[PAPANICOLAOU (PAP) SMEAR]
PLAN OF THESIS
FOR APPROVAL OF SUBJECT OF THESIS
TO BE SUBMITTED
IN PARTIAL FULFILMENT OF THE REQUIREMENTS
FOR THE DEGREE OF
M.D. (PATHOLOGY)
OF
THE BABA FARID UNIVERSITY OF HEALTH SCIENCES,
FARIDKOT
2020 DR. JASPAL SINGH SAINI
GOVERNMENT MEDICAL COLLEGE, AMRITSAR
1
BABA FARID UNIVERSITY OF HEALTH SCIENCES, FARIDKOT
APPLICATION FORM FOR APPROVAL OF SUBJECT OF PLAN OF THESIS
FOR M.D. (PATHOLOGY)
1. Name of the candidate Dr. Jaspal Singh Saini
2. Father’s name Mr. Surinder Singh
3. Mother’s name Mrs. Gurshant Kaur
4. Address of the candidate for H.No. 661/14, Street No. 1, Preet

correspondence Nagar, Hoshiarpur (Pb) - 146001.
5. Month & year of passing March, 2014

M.B.B.S.
6. Name of University from which Baba Farid University of Health

graduated Sciences, Faridkot
Post-Graduate student in the

7. Present occupation
Government Medical College,
Amritsar.
3 years 10 months experience
8. Experience of medical work
PCMS-1, as a Medical Officer,
Hoshiarpur.
9. Date of joining M.D. Course 1st September, 2020
10. Likely date of appearing in the May-June 2023

M.D. Examination
11. Proposed subject of thesis ROLE OF MORPHOMETRY IN

DIAGNOSING PREMALIGNANT
AND MALIGNANT LESION IN
LIQUID BASED CYTOLOGY
2
CERVICAL [PAPANICOLAOU
(PAP) SMEAR]
12. Detailed scheme according to Plan attached

which the candidate proposes to
work
13. Name & address of the DR. PERMEET KAUR BAGGA

Supervisor MD., FIMSA, MAMS.,
Professor,
Govt. Medical College, Amritsar.
14. Name & address of the Co- DR. JASPREET SINGH,
supervisor MD.,
Associate Professor,
SIGNATURE OF THE CANDIDATE

DATED: ________________
3
CERTIFICATE
OF
SUPERVISORS
This is to certify that the facilities for the work on the subject of thesis
titled “ROLE OF MORPHOMETRY IN DIAGNOSING PREMALIGNANT AND
MALIGNANT LESION IN LIQUID BASED CYTOLOGY CERVICAL
[PAPANICOLAOU (PAP) SMEAR]” do exist in the Department of Pathology,
Government Medical College, Amritsar and will be provided to the candidate,
Dr. Jaspal Singh Saini. We will see that the data being included in the thesis is
genuine and is collected by the candidate himself under my supervision and
guidance.
DR, JASPREET SINGH, DR. PERMEET KAUR BAGGA,

MD., MD., FIMSA., MAMS.,
Associate Professor, Professor ,
Govt. Medical College, Government Medical College,
Amritsar. Amritsar.
( CO-SUPERVISOR ) ( SUPERVISOR )
Place: Amritsar
Dated: ___________
4
GOVERNMENT MEDICAL COLLEGE,
AMRITSAR
This is to certify that the facilities for work on the subject of thesis titled
“ROLE OF MORPHOMETRY IN DIAGNOSING PREMALIGNANT AND
[PAPANICOLAOU (PAP) SMEAR]” do exist in the Department of Pathology,
Government Medical College, Amritsar and will be provided to the candidate.
DR. VIJAY MEHRA,

MD.,
Professor and Head,
Amritsar.
PLACE: Amritsar
DATED:
5
UNDERTAKING
The topic submitted by the candidate “ROLE OF MORPHOMETRY IN

BASED CYTOLOGY CERVICAL [PAPANICOLAOU (PAP) SMEAR]” for
approval is not already used by anyone and its own topic/research.
DR. JASPREET SINGH, DR. PERMEET KAUR BAGGA,

MD., MD., FIMSA., MAMS.,
Associate Professor, Professor,
Govt. Medical College, Government Medical College,
Amritsar. Amritsar.
(CO-SUPERVISOR) (SUPERVISOR)
DR. JASPAL SINGH SAINI,

Junior Resident,
Amritsar
Dated:
Amritsar
6
GOVERNMENT MEDICAL COLLEGE, AMRITSAR
Name of the candidate Dr. JASPAL SINGH SAINI
Department Pathology
Topic DIAGNOSING PREMALIGNANT AND
MALIGNANT LESION IN LIQUID
BASED CYTOLOGY CERVICAL
Examination M.D. (Pathology)
Date of enrolment 1 Sep 2020
In which research committee has Thesis Members Committee of Govt.

the plan of thesis been presented Medical College, Amritsar
and approval
DR. VIJAY MEHRA,
Professor and head of Specialty MD.,
Professor & Head,
Amritsar.
DR. JASPREET SINGH,
Co-Supervisor of thesis MD.,
MEMBERS OF THESIS Signature with stamp
RESEARCH COMMITTEE
(1) Head of the Institute/college
(2) Chairman of thesis Committee
 Member Thesis Committee
(3) Chairman Ethical Committee
 Member Ethical Committee
7
ABSTRACT OF PLAN OF THESIS
Title ROLE OF MORPHOMETRY IN DIAGNOSING
PREMALIGNANT AND MALIGNANT LESION
IN LIQUID BASED CYTOLOGY CERVICAL
For the degree of MD., (PATHOLOGY)
Name of the candidate Dr. Jaspal Singh Saini
Supervisor DR. PERMEET KAUR BAGGA,
MD.,FIMSA., MAMS.,
Professor,
Government Medical College, Amritsar.
Co-Supervisor of thesis DR. JASPREET SINGH,
MD.,
Institution Department of Pathology, Government
Medical College, Amritsar
Cervical cancer is a major cause of cancer mortality in women and more than
a quarter of its global burden is contributed by developing countries. India
accounts for nearly one-third of the global cervical cancer deaths, with women
facing a 1.6% cumulative risk of developing cervical cancer and 1.0%
cumulative death risk from cervical cancer. Cervical cancer screening is an
important tool in prevention and early treatment because of window of
opportunity during the longstanding pathogenesis of the cervical cancer. Pap
smear continues to be one of the most important screening procedures for
carcinoma cervix. In India and other developing countries, the pap smears are
still evaluated qualitatively using descriptive nuclear morphological features.
This approach carries certain inherent drawbacks. It is subjective and besides,
several benign conditions may induce nuclear changes that mimic neoplastic
condition. In this study, significance of morphometry pattern in differentiating
between various cervical lesions, to determine the morphometric
characteristics of cells found in cervical smears by measuring the cell area, cell
perimeter, nuclear area, nuclear perimeter, Nuclear:Cytoplasmic ratio and
nuclear diameter in order to identify which clinical group the cells belong to,
which facilitates diagnosis. The data collected will be analysed statistically.
INTRODUCTION AND REVIEW OF LITERATURE
8
Cervical cancer results from a persistent infection by a high-risk subset
of human papillomavirus (HPV). Most women’s immune systems will eliminate
HPV infection spontaneously, however, for a very small proportion of women,
the infection will persist and can cause pre-cancerous changes in cells. In the
precancerous state i.e. Cervical intraepithelial neoplasia (CIN) occurs along
various grades from low (CIN1), moderate (CIN2) to severe (CIN3). The
pathogenesis from low-grade CIN to cervical cancer takes from 10 to 20 years,
during which timely screening for pre-cancerous lesions and early treatment is
highly effective in preventing overt disease.1,2
In India, Carcinoma cervix remains the most common type of cancer in
women.3 The incidence of cervical cancer has been declining in last three or
four decades in most developed countries predominantly due to the introduction
of cervical screening programmes. The introduction of cervicovaginal cytology
as a means to detect precancerous lesions of the uterine cervix has been
milestone in the study of cancer of uterine cervix.4 The Bethesda System for
reporting the results of cervical cytology was developed as a uniform system of
terminology that would provide clear guidance for clinical management. The
2014 Bethesda system terminology reflects important advances in biological
understanding of cervical neoplasia and cervical screening technology.5 Pap
smears have 98% specificity and 51%sensitivity of diagnosing the cervical
lesions. Inflammatory conditions mimic the features of malignancy.6 It is
important to differentiate the nuclear features in inflammatory and malignant
conditions, which increases the sensitivity of the Pap smears.
The liquid-based cytology (LBC) is an increasingly popular technique of
the preparation of the cervical sample.
Liquid-based cytology (LBC) preparation provides clean, monolayered
smear in small area of the slide. As the smear is free of blood, mucus and drying
artefact, so it is easy to interpret.7,8 The major advantages of LBC over
conventional preparation (CP) include:
 Majority of the collected cells are available in the liquid medium of the
collection vial, whereas the major part of the collected cells is sticked in
the spatula of the convention smear preparation and the cells are thrown
in the waste basket.
9
 LBC preparation is completely free of any airdrying artefact.
 There is almost complete absence of any blood, mucus or necrotic
debris in LBC preparation, and the cells are present in small area which
is easy to screen.
 Monolayered preparation of the cells is present in certain LBC
preparation.
 HPV test is possible for the residual material of LBC sample.
 The monolayered cell preparation may be useful in automated detection
of malignant cells in the smear.
The morphological criteria are mainly based on descriptive nuclear

changes. As some of the benign and reactive conditions can produce significant
nuclear alterations that mimic neoplasia, false positive results may sometimes
occur. Objective techniques can be helpful in preventing false interpretation, in
distinguishing borderline cases and thus better and timely treatment of patient.9
Computer assisted image analysis such as nuclear morphometry provides a
powerful tool for high-precision measurement of several variables
characterising the size and shape of cancer cell nuclei in conventional Pap
smear.10
Morphometry is the quantitative description of geometric features of
structures such as tissues, cells, nuclei, or nucleoli. One of the most important
functions of morphometry in pathology is the study of nuclear morphometry in
differentiating benign lesions from malignant lesions based on their nuclear
parameters. Morphometric techniques are fairly simple and inexpensive. In this
study, an attempt is made to examine the significance of nuclear morphometry
in the quantitative evaluation of cervical smears prepared by lbc technique.
As early as 1925, morphometric analysis started. Jacobi W, in 192511,
found that the volume of a normal cell doubles before cell division. Heiberg KH
and Kemp T, in 192912, were probably the first to substantiate the subjective
impression that cancer nuclei are larger than those of normal cells. In the 1950s
and 1960s, an increased interest amongst anatomists and biologists gave a
strong impetus to morphological and stereological analysis in biomedicine. In
the late 1970s and early 1980s, the application of morphometric analysis to
10
pathologically changed tissues became increasingly popular and widely
applied, particularly in cancer.
Most cases of cervical cancer are preceded by dysplastic changes with
different degrees of progression. These changes involve an increase in the size
of the cell nucleus and number of mitotic divisions and structural changes at the
tissue and cell level.13,14 Dysplastic changes, not always, but change into
cervical cancer.13,15 The cell nuclei of in situ cancer are pleomorphic. Chromatin
is abundant and spread all over the surface of the nuclei. Invasive cancer cells
are characterized by a significant increase in pleomorphism. Nuclear
membrane of cells has uneven edges. In the nucleus there occurs one or more
prominent nucleoli. There are changes in the size and shape of the nucleus, as
well as changes to its structure.16 Morphometry of cells found in cervical smears
allows one to assess the size and diameter of cells and their nuclei. The values
obtained by measuring morphometric characteristics provide information about
anomalies and origin of the cells.
Computer-assisted image analysis (nuclear morphometry) provides a
new powerful tool for high-precision measurement of several variables
characterising the size and shape of cancer cell nuclei in conventional tissue
sections.17,18 Several of these nuclear profiles seem to be useful prognostic
predictors in various human malignancies. Not unexpectedly, the nuclear size
is usually larger and its shape is more often irregular in cancer cells 19,20].
In 1982, Diamond and associates introduced nuclear morphometry to
aid in prediction of prognosis among patients with prostate cancer.21,22 He and
his colleagues observed that nuclear roundness was very useful in separating
long survivors among stage B patients from those who develop metastasis.
They observed no overlap in nuclear roundness between the two groups.
In a study done by Nemec E et al23 in 2002, used ploidy and chromatin
pattern analysis as an aid for cervical smear diagnosis to analyse the
morphology of Feulgen stained cell nuclei in cell populations. They showed
efficient results to discriminate between normal and HSIL groups with 97%
specificity and 88% sensitivity.
Another study done by Huang PC et al24 in 2007, on cervical smears by
PC based Cyto pathologic Image Analysis System and Support Vector
Machine(SVM) showed that in dysplastic cells, the morphometric parameters
11
like perimeter, nuclear area, maximum length, maximum width, N/C ratio were
all found to be statistically significant with p-value of 0.001. These statistics
showed that dysplastic cells have larger size (i.e. larger perimeter, area,
maximum length, and maximum width), higher nuclear proportion (i.e. N/C
ratio).
In a study done by Tiwari AK et al25 in 2019, it was observed that there
was a gradual increase in nuclear area from normal cell to dysplastic cell to
SCC alongwith the gradual increase in mean diameter with lesion.
12
AIMS AND OBJECTIVES
1. To study the morphometric parameters of the LBC Pap smear by using

Nikon Instruments Software (NIS-Elements Documentation (D) 5.01.00)
and correlate the LBC Pap smear cytology with morphometric parameters.
2. To explore the possible role of nuclear morphometric analysis to improve
the sensitivity and specificity for detection of pre-cancerous and cancerous
conditions.
13
MATERIAL AND METHODS
The present study will be conducted in 200 liquid based cytology (lbc)
cervical samples which will include normal cases and abnormal case findings
in the Department of Pathology, Government Medical College, Amritsar. 20
squamous cells per slide will be evaluated. Institutional Ethics committee
clearance will be obtained for the study. Informed consent will be obtained in
all the cases.
INCLUSION CRITERIA:
1. Cases which will be screened by liquid based cytology and reported as
squamous epithelial cell abnormality.
2. LSIL, HSIL, SCC of confirmed histopathological diagnosis will be chosen
for study.
3. Cases showing reactive cellular changes.
4. Cases having normal cytology.
EXCLUSION CRITERIA:
1. Inflammatory samples.
2. Unsatisfactory samples.
3. Patients on intravaginal drugs.
4. Already diagnosed squamous cell carcinoma on treatment
(Radiotherapy).
METHODS:
The assessment of morphometric features will be done using the Nikon
Instruments Software (NIS)-Elements Documentation (D) 5.01.00. Using this
imaging system the cell area, cell perimeter, nuclear area, Nuclear:Cytoplasmic
ratio and nuclear diameter will be measured. The material consisting of
cervical samples prepared by liquid based cytology technique from the
Government Medical College, Amritsar institute will be taken. Cells will be
viewed and measured under 40X magnification.
Morphometric assessments will be done by advanced computer-
assisted image analysis system where the microscopic image will be recorded
by a camera and displayed on a computer screen, which will makes it possible
14
to trace the outlines of cells, nuclei on the screen and then compute nuclear
areas as well as nuclear shape using Nikon Instruments Software.
METHOD OF LIQUID BASED CYTOLOGY:-

The lbc technique used is SurePath Test :
Steps:
1. Vortexing - At first with the help of vortexing, the cells are mechanically
dispersed.
2. Cell enrichment :
- Mix the sample with PrepStain Density Reagent and centrifuge :
- Decant the supernatant elements containing blood, mucus and
necrotic debris by applying vacuum suction.
- Recentrifuge the remaining fluid to have a cell-rich pellet.
3. Resuspension -Re-vortex the cell-rich pellet :
- Resuspend the cells.
- Transfer the solution in the PrepStain slide processor.
a. Cell sedimentation :
- Pour the cell suspension in the PrepStain.
b. Settling Chamber :
- With the help of gravitational force, the cells are sedimented on
the pre-coated slide.
The results shall be recorded in prescribed performa with photographic

recording. Data observed shall be analysed at the end of study and statistical
evaluation will be done accordingly.
DESIGN:
Prospective analytical study.
15
BIBLIOGRAPHY
1. World Health Organization (WHO). International Agency for Research

on Cancer. India factsheet. Lyon: IARC; 2018
2. Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah
KV, et al. Human papillomavirus is a necessary cause of invasive
cervical cancer worldwide. J Pathol.1999;189(1):12-19.
3. Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD,
Cunningham FG. Gynecologic Oncology, Cervical Cancer. In; Schorge
J, Schaffer J, Halvorson L, Hoffman B, Bradshaw K, Cunningham F,
William’s Gynaecology, 1st Edn., Mc Graw Hill Company; 2008, pp. 646-
662
4. Koss LG, Melamed MR. Squamous arcinoma of the Uterine Cervix and
its Precursors. In; Koss LG, Melamed MR. Koss’ Diagnostic Cytology
and its Histopathological Bases. 5th edn., Philadelphia: Lippincott
Williams and Wilkins, 2006, pp. 282-394.
5. Solomon D, Davey D, Kurman R, Moriarty A, O'Connor D, Prey M, et al.
The 2001 Bethesda System: terminology for reporting results of cervical
cytology. JAMA. 2002 Apr 24;287(16):2114-9.
6. Ellenson LH, Pirog EC. The Female Genital Tract. In; Kumar V, Abbas
AK, Aster JC. Pathologic Basis of Diseases. 7th Edition. New Delhi:
Elsevier, 2005, pp. 1002- 7.
7. Luthra UK, Chishti M, Dey P, Jolly SV, Abdulla M, Das DK, et al.
Performance of monolayered cervical smears in a gynecology outpatient
setting in Kuwait. Acta Cytologica. 2002;46(2):303-10.
8. Moseley RP, Paget S. Liquid‐based cytology: is this the way forward for
cervical screening?. Cytopathology. 2002;13(2):71-82.
9. Ikeguchi M, Oka S, Saito H, Kondo A, Tsujitani S, Maeta M, et al.
Computerized nuclear morphometry: a new morphologic assessment for
advanced gastric adenocarcinoma. Annals of surgery. 1999
Jan;229(1):55-61.
16
10. Deans GT, Hamilton PW, Watt PCH, Heatley M, Williamson K, Patterson
CC, et al. Morphometric analysis of colorectal cancer. Dis Colon Rectum.
1993;36(5):450-56.
11. Jacobj W. Über das rhythmische Wachstum der Zellen durch
Verdopplung ihres Volumens. Wilhelm Roux'Archiv für
Entwicklungsmechanik der Organismen. 1925;106(1-4):124-92.
12. Heiberg KA, Kemp T. über die Zahl der Chromosomen in
Carcinomzellen beim Menschen. Virchows Archiv für pathologische
Anatomie und Physiologie und für klinische Medizin. 1929;273(3):693-
700.
13. Kumar V, Abbas A, Aster JC. Neoplasias. In: Kumar V, Abbas A, Aster
JC. Robbins, Patologia Humana, 10th Edn. Elsevier. Iberoamericana,
Mexico, 2018, pp. 256.
14. Fu SY, Reagan WJ, Ralph MR. Definition of precursors. Gynecol Oncol
1981;12:220-234.
15. Scully RE. Definition of precursors in gynecologic cancer. Cancer.
1981;48(S1):531-7.
16. González-Oliver A, Echeverria BO, Hernández-Pando R, Vazquez-Nin
GH. Ultrastructural study of the nuclei of normal, dysplastic, and
carcinomatous epithelial cells of the human cervix uteri. Ultrastructural
pathology. 1997;21(4):379-92.
17. Deans GT, Hamilton PW, Watt PC, Heatley M, Williamson K, Patterson
CC, et al. Morphometric analysis of colorectal cancer. Diseases of the
colon & rectum. 1993;36(5):450-6.
18. Dundas SA, Laing RW, O'Cathain A, Seddon I, Slater DN, Stephenson
TJ, et al. Feasibility of new prognostic classification for rectal cancer.
Journal of clinical pathology. 1988 Dec 1;41(12):1273-6.
19. Buhmeida A, Kuopio T, Collan Y. Nuclear size and shape in fine needle
aspiration biopsy samples of the prostate. Anal Quant Cytol Histol.
2000;22(4):291–8.
20. Kazanowska B, Jelen M, Reich A, Tarnawski W, Chybicka A. The role
of nuclear morphometry in prediction of prognosis for
rhabdomyosarcoma in children. Histopathology. 2004;45(4):352–9.
17
21. Diamond DA, Berry SJ, Umbricht C, Jewett HJ, Coffey DS.
Computerized image analysis of nuclear shape as a prognostic factor for
prostatic cancer. Prostate. 1982a;3(4):321–32.
22. Diamond DA, Berry SJ, Jewett HJ, Eggleston JC, Coffey DS. A new
method to assess metastatic potential of human prostate cancer: relative
nuclear roundness. The Journal of urology. 1982;128(4):729-34.
23. Nemec E, Vandeputte S, Van Pachterbeke C, Vokaer R, Budel V,
Deprez C, et al. Ploidy and chromatin pattern analysis as an aid for
cervical smear diagnosis. Histology and histopathology. 2002;17:403-
09.
24. Huang PC, Chan YK, Chan PC, Chen YF, Chen RC, Huang YR.
Quantitative assessment of Pap smear cells by PC-based
cytopathologic image analysis system and support vector machine.
InInternational Conference on Medical Biometrics. 2008;4901:192-99.
25. Tiwari AK, Khare A, Grover SC, Bansal R, Sharma S. Role of Nuclear
Morphometry in Screening of Cervical Pap Smear. Journal of Clinical &
Diagnostic Research. 2019;13(5):1-7.
18
PROFORMA
Name:
Address:
Pathology Number: Cr. No.
Age:
Religion Hindu Muslim Christian Others
LMP:
Obstetric Score:
LCB:
Menstrual cycle:
Contraception:
Relevant history of the patient:
Investigations:
Examination
P/V: P/S
PAP Smear
H/P report
Morphometry:
- Cell area
- Cell perimeter
- Nuclear area
- Nuclear perimeter
- Nuclear diameter
- Nuclear: Cytoplasmic Ratio
19
INFORMED CONSENT
I_________________________, S/o, D/o, W/o _______________________

R/o___________________________________________________________
exercising my free power of choice, hereby give my consent to be included in
the study entitled: “ROLE OF MORPHOMETRY IN DIAGNOSING
PREMALIGNANT AND MALIGNANT LESION IN LIQUID BASED CYTOLOGY
CERVICAL [PAPANICOLAOU (PAP) SMEAR]” I have been informed to my
satisfaction by the attending doctor, in a manner and language that I
understand, the purpose of the study and safety of procedures. I am also aware
of my right to opt out of the trial at any time during the course of the study
without having to give the reason for doing so. I have been told about the
procedures of the study and agree to take part in the investigations as required.
Patient’s Name __________________ Date_________________

Signature ______________________
Doctor’s Name Dr. JASPAL SINGH SAINI

Date_________________
Signature ______________
20
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hsqwKr: ______________ imqI :
21
सूचित सहमचत पत्र
मै ___________________________________________________
पुत्र//पुत्री//पत्नी//अभििावक ___________________________________ भिवासी
____________________________ अपिी मर्जी के साथ मै अपिे मरीर्ज के भिए अध्ययि
“ROLE OF MORPHOMETRY IN DIAGNOSING PREMALIGNANT AND
[PAPANICOLAOU (PAP) SMEAR]” शाभमि हो की सहमभि दे िा हूँ /दे िी हूँ l मुझे उपस्थथि
भिभकत्सक द्वारा मे री मािृ िाषा/भवभशस्टा शब्दाविी में अध्ययि के उद्दे श्य और प्रकृभि, दवा
उपिार की प्रकृभि और प्रभिया की सुरक्षा और दवाओं से र्जु ड़े दु ष्प्रिावों को समझाया गया
है /. मु झे अपिी सहमभि दे िे के भिए कोई प्रोत्साहि राभश िहीं दी गई है और ि ही भकसी
प्रकार का दबाव डािा गया है . मु हे अध्ययि की प्रभिया के बारे में समझाया गया है और मैं
अपिी मर्जी से इस र्जाूँ ि मैं िाग िे िे के भिए अपिी सहमभि दे िा हूँ /दे िी हूँ . मैं भकसी िी
प्रकाशि या पभत्रका मे वितमाि अध्ययि को प्रकाभशि करिे के भिए अपिी सहमभि िी दे िा/दे िी
हूँ . मु झे अध्ययि के दौराि भकसी िी समय कारण बिाये भबिा अध्ययि से बहार भिकििे के
अपिे अभिकार के बारे में पिा है , ऐसा करिे से मे रे उपिार पर कोई प्रिाव िहीं पड़े गा.
रोगी / अभििावक का िाम डॉक्टर का िाम

हस्ताक्षर हस्ताक्षर
भदिां क भदिां क
रोगी के साथ सम्बन्ध

गवाह का िाम
हस्ताक्षर हस्ताक्षर
भदिां क भदिां क
22
PATIENT INFORMATION SHEET
Title: ROLE OF MORPHOMETRY IN DIAGNOSING PREMALIGNANT
AND MALIGNANT LESION IN LIQUID BASED CYTOLOGY
CERVICAL [PAPANICOLAOU (PAP) SMEAR] .
Principal Investigator: Dr. Jaspal Singh Saini
Designation: Post Graduate, Department of Pathology, Government Medical
College, Amritsar.
Please read this form carefully. If you don’t understand the language or any
information in this sheet, please discuss with the concerned doctor.
Purpose of the study: ROLE OF MORPHOMETRY IN DIAGNOSING
PREMALIGNANT AND MALIGNANT LESION IN LIQUID BASED
CYTOLOGY CERVICAL [PAPANICOLAOU (PAP) SMEAR] .
Information about the study: It will be a onetime observational study approved
by the Ethics Committee, GMC, Amritsar
Patient’s role in the study:
1. To provide accurate information and cooperation during the study.
2. To allow patient’s hospital medical records to be accessed for the
purpose of this study.
What are the potential benefits of participating in the study?
 The recommendations derived based on the outcome of this study has
the potential to explore the possible role of nuclear morphometric
analysis to improve the sensitivity and specificity for detection of pre-
cancerous and cancerous conditions.
What are the potential risks due to participating in the study:
 This study does not pose any significant risk to the patient.
Confidentiality:
Personal data and medical records shall be used only for research
purpose and shall be kept confidential. Patients shall be identified with the ID
No.
Voluntary participation:
Entering a research study is voluntary. If you volunteer for a research
study, you have the right to opt out at any time.
For any queries:

Contact:
Dr. Jaspal Singh Saini
Amritsar, Punjab.
PH: 7696862395
23
wohi ikDekoh FhN
;ob/yL “ROLE OF MORPHOMETRY IN DIAGNOSING PREMALIGNANT AND
[PAPANICOLAOU (PAP) SMEAR].”
gqw[Zy iKueoskL vkeNo i;gkb f;zx ;?Dh.
njdkL g';N r?qi[J/N, g?E'bi' h ftGkr, ;oekoh w?vheb ekbi, nzfwqs;o.
feogk eoe/ fJ; ckow B{z fXnKB Bkb gV' i/ s[;hI fJ; FhN ftubh GkFk iK e'Jh ikDekoh
BjhI ;wMd/, sK feogk eoe/ nfXnB eoB tkb/ vkL Bkb ftuko eo'.
nfXn?B dk T[d/FL “ROLE OF MORPHOMETRY IN DIAGNOSING
CERVICAL [PAPANICOLAOU (PAP) SMEAR].”
nfXn?B pko/ ikDekohL fJj B?fse ew/Nh, ihHn?wH;hH, nzfwqs;o d[nkok wBi{o fJe ;w/I dk
fBohyD nfXn?B j't/rk.
nfXn?B ftu wohi dh G{fwskL
1H nfXn?B d[okB ;jh ikDekoh ns/ ;fj:'r gqdkB eoBk.
2H fJ; nfXn?B d/ T[d/F bJh s[jkv/ j;gskb d/ w?vheb foekovK sZe gj[zu dh nkfrnk
d/Dk.
nfXn?B ftu fjZ;k b?D d/ ;zGkfts bkG eh jB<
 fJ; nfXnB s/ BshfinK d/ nXko s/ gqkgs BshfinK ftu vkeNoK d/ d[nkok bhiaBk
dh ftnkfynk eoB d/ Yzr B{z pdbD dh ;zGktBK j? fJ; Bkb wohia d/ nrb/ f;js
gqpXz ftu bkG j' ;edk j?.
nfXn?B ftu fjZ; b?D ekoB ;zGkts i'yw eh jBL
 fJ; nfXn?B Bkb wohi B{z e'Jh wjZst g{oB ysok BjhI j[zdk.
r[gsskL fBZih vkNk ns/ vkeNoh foekovK dh tos' f;oc y'i we;d bJh ehsh ikJ/rh ns/
r[gs oZyh ikJ/rh, wohiK dh gSkD f;oc nkJh vhH Bkb ehsh ikJ/rh frDsh.
;t?fJZfSe Gkrhdkoh L fJZe y'i nfXn?B eoBk ;t?fJZS[e j?. i/ s[;h y'Ii nfXn?B bJh tbzNhno
j', sK s[jkB{z fe;/ th ;w/I o[eD dk nfXeko j?. H
fe;/ th gqFB bJh ;zgoeL
vkH i;gkb f;zx ;?Dh
g?E'b'ih ftGkr,
r'ofwzN w?vheb ekbi, nzfwqs;o
PH: 7696862395
24
मरीज सुिना पत्र
शीर्ष क: “ROLE OF MORPHOMETRY IN DIAGNOSING PREMALIGNANT

AND MALIGNANT LESION IN LIQUID BASED CYTOLOGY
CERVICAL [PAPANICOLAOU (PAP) SMEAR]”
प्रधान अन्वे र्क: डॉ. र्जसपाि भसंह सैणी
पदनाम: पोस्ट ग्रेजुएट छात्र, पैथोिॉर्जी विभाग, गिनष मेंट मे वडकल कॉले ज, अमृ तसर।
कृपया इस फॉमष को ध्यान से पढें । यवद आप इस पत्रक में भार्ा या वकसी भी जानकारी
को नहीीं समझते हैं , तो कृपया अध्ययन विवकत्सक से ििाष करें ।
अध्ययन का उद्दे श्य: “ROLE OF MORPHOMETRY IN DIAGNOSING
CERVICAL [PAPANICOLAOU (PAP) SMEAR]”
अध्ययन के बारे में जानकारी: यह आिार सवमवत, जी.एम.सी., अमृ तसर द्वारा अनु मोवदत एक
समय पार अनु भागीय अिलोकन अध्ययन होगा।
अध्ययन में रोगी की भू वमका:
1. अध्ययन के दौरान सटीक जानकारी और सहयोग प्रदान करने के वलए।
2. इस अध्ययन के उद्दे श्य से अपने अस्पताल के भिभकत्सा दस्तावेर्जों की र्जािकारी िे िे
की अिु मभि दे िा ।
अध्ययन में भाग लेने के सींभावित लाभ क्या हैं?
• इस अध्ययन के पररणाम के आधार पर प्राप्त की गई र्जािकारीयों से अध्ययि मैं
िाि होिा है , वजससे रोगी के आगे के उपिार में िाि होिा है ।
अध्ययन में भाग लेने के कारण सींभावित जोखिम क्या हैं :
• यह अध्ययन रोगी को कोई महत्वपूणष जोखिम नहीीं दे ता है ।
गोपनीयता:व्यखिगत र्जािकारी और मे वडकल ररकॉडष का उपयोग केिल अनु सींधान उद्दे श्य के
वलए वकया जाएगा और इसे गोपनीय रिा जाएगा। पहिाि पत्र / पहिाि संख्या के
साथ मरीजोीं की पहिान की जाएगी।
स्वैखिक भागीदारी: एक शोध अध्ययन में प्रिेश करना स्वैखिक है । यवद रोगी एक शोध
अध्ययन के वलए स्वेिा से काम करता है , तो उसे इस अध्यि से स्वेछा बहार होिे का
अभिकार है ।
वकसी भी प्रश्न के वलए:

सींपकष करें :
डॉ. र्जसपाि भसंह सैणी
पैथोिॉर्जी विभाग,
गिनष मेंट मे वडकल कॉलेज,
अमृ तसर - पींजाब।
फोन नीं बर: +91-7696862395
25
THROUGH PROPER CHANNEL
To
The Controller of Examination,
Baba Farid University of Health Sciences,
Faridkot.
SUB: SUBMISSION OF PLAN OF THESIS.
Respected Sir,
Please find enclosed herewith copy of plan of thesis titled “ROLE OF
MORPHOMETRY IN DIAGNOSING PREMALIGNANT AND MALIGNANT
LESION IN LIQUID BASED CYTOLOGY CERVICAL [PAPANICOLAOU (PAP)
SMEAR]” along with one compact disc for the degree of M.D. (PATHOLOGY)
for approval and necessary action.
(DR. JASPAL SINGH SAINI)

No. _______________/ Dated: _______

Forwarded in original to the Professor & Head, Department of Pathology, Govt.
Medical College, Amritsar for information and necessary action.
Professor,
No. _______________/ Dated: _______

Forwarded in original to the Principal, Govt. Medical College, Amritsar for
information and necessary action.
Professor & Head,

No. _______________/ Dated: _______

Forwarded in original to the Controller of Examination, Baba Farid University of
Health Sciences, for information and necessary action.
Principal,
Amritsar.
26

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ROLE OF MORPHOMETRY IN

DIAGNOSING PREMALIGNANT AND

I hereby declare that the thesis entitled “ROLE OF MORPHOMETRY IN

DR. JASPAL SINGH SAINI

DR. PERMEET KAUR BAGGA, DR. JASPREET SINGH

This is to certify that the thesis entitled “ROLE OF MORPHOMETRY IN

This is to certify that the thesis entitled “ROLE OF MORPHOMETRY IN

DR. PERMEET KAUR BAGGA,

Declaration by the Candidate

© Baba Farid University of Health Sciences, Faridkot

It is most appropriate that I begin by expressing my undying

I would like to express my deep sense of gratitude to respected guide

With utmost sense of regard, I express my indebtedness to my co-

A debt of gratitude is owed to Dr. Mandeep Randhawa, Dr.Navjot

Words are inadequate in expressing my deep sense of gratitude

I would like to express my gratitude towards my co resident and

I am also thankful to Sh. Ramesh Rajpoot (Billa), Mr. Sunil

Last but not least, without the patients' involvement, this

S. NO. PARTICULARS PAGE NO.

3. AIMS & OBJECTIVES 15

4. MATERIALS AND METHODS 16

5. OBSERVATIONS AND RESULTS 23

7. SUMMARY AND CONCLUSION 56

9. APPENDIX-I Master chart

10. APPENDIX-II Plan of thesis

1. COMPUTER ASSISTED IMAGE ANALYSIS SYSTEM 17

2. VORTEXING CAUSES CELL DISPERSION 20

CENTRIFUGATION OF THE SAMPLE WITH THE

THE VIALS ARE KEPT IN THE SETTLING CHAMBER

5. MORPHOMETRY IMAGE ANALYSIS REPRESENTATION 38

6. MORPHOMETRIC ANALYSIS OF A NORMAL CASE 39

MORPHOMETRIC ANALYSIS OF A CASE SHOWING

MORPHOMETRIC ANALYSIS OF A CASE DIAGNOSED AS

MORPHOMETRIC ANALYSIS OF A CASE DIAGNOSED AS

MORPHOMETRIC ANALYSIS OF A CASE DIAGNOSED AS

MORPHOMETRIC ANALYSIS OF A CASE DIAGNOSED AS

MORPHOMETRIC ANALYSIS OF A CASE DIAGONOSED AS

HPV : Human Papilloma Virus

NIS : Nikon Instruments Software

LBC : Liquid Based Cytology

ECA : Epithelial Cell Abnormality

DNA : Deoxyribose Nucleic Acid

LBC : Liquid Based Cytology

Rural women are at higher risk of developing cervical cancer as compared

Human papillomavirus (HPV) is the main causal factor of cervical carcinoma.

Cervical cancer results from a persistent infection by a high-risk subset of

Low-Risk: 6, 11, 42, 43, 44, 53, 54, 57, 66

Most women’s immune systems will eliminate HPV infection spontaneously,

In the precancerous state i.e. Cervical intraepithelial neoplasia (CIN) occurs

The introduction of cervicovaginal cytology as a means to detect

Pap smear screening is still the primary modality in detecting premalignant

Liquid-based cytology (LBC) has been introduced into cytopathology mainly

The liquid-based cytology include

 ThinPrep (TP) and

In these preparation systems, instead of smearing cells on a slide, cells are

Morphometry is the quantitative description of geometric features of

The morphological criteria are mainly based on descriptive nuclear changes.

As some of the benign and reactive conditions can produce significant