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Pathological Pattern of Cervical Smears in A Tertiary Hospital in Northeastern Nigeria.

 

*MA Bakari1, U Inuwa1, Audu BM1 N Raheem2, M.C Dahiru2, A. Ukaobasi3

                                                                 

1. Department of Obstetrics and Gynecology, College of medical sciences, Modibbo Adama University, Yola, Adamawa State.

2. Department of Obstetrics and Gynaecology, College of Medical Sciences, Federal University of Health Sciences, Azare

3. Department of Pathology, College of medical sciences, Modibbo Adama UniversityTeaching Hospital, Yola, Adamawa State.

 

Abstract

Background: Cervical intraepithelial neoplasia (CIN) is a premalignant lesion of the cervix that progresses into cervical cancer if untreated. An early diagnosis which determines the treatment of CIN is a preventive measure of cervical cancer. Diagnosis in a developing setting like Nigeria lacks screening programmes which may affect early detection of the disease. Objectives: The study is aimed at determining the prevalence and pattern of cervical cytology of smears received in the Department of Pathology, Modibbo Adama University Teaching Hospital, Yola. Methods: A retrospective study of all cervical smears received, processed and reported at the Department of Pathology, Modibbo Adama University Teaching Hospital, Yola between January 2015 to December 2019. Classification was by the Bethesda system and analysis was by simple statistical methods. Results: The overall prevalence of CIN was 12% during the study period, While the percentage of normal smears was 74.5%, Unsatisfactory smears 11.4% and the percentage of cytological abnormality was ASC-US 4.6%, AG-US: 4.6%, LGSIL 44.4%, HGSIL 31.8% and 14.6% for Invasive lesions. 33.3% of women aged 35-44 years had CIN, which was the highest age group. Conclusion: Premalignant lesion are common, and a need for regular cervical screening programme to identify and monitor women with these lesions is recommended for early treatment. 

 

Keywords: Cervical intraepithelial neoplasia, Atypical squamous cells, Atypical glandular cells MAUTH, Yola


Abbreviations:

AGUS: Atypical glandular cells of undetermined significance; ASC-US: Atypical squamous cells of undetermined significance; CIN: Cervical intraepithelial neoplasia; HSIL: High grade squamous intraepithelial lesion; LSIL: Low grade squamous intraepithelial lesion; MAUTHY: Modibbo Adama University Teaching Hospital, Yola


*Corresponding author

 Dr. Maisaratu A. Bakari

Department of Obstetrics and Gynecology, 

College of medical sciences, 

Modibbo Adama University, Yola, Adamawa State

maisaratu_bakari@yahoo.com

Tel: +2347068758423


Introduction: 

Cervical cancer is  the 4th most common cancer among women worldwide1. It is the commonest malignancy in the developing world2 and the second leading cause of gynecological cancer deaths in Nigeria3. The premalignant phase is detected by studying the cellular characteristics of the exfoliated cells and therefore vital in reducing cervical cancer3. Cervical intraepithelial neoplasms (CIN) are characterized by abnormal cellular proliferation, maturation and chromatin distribution4. It is a premalignant precursor of cervical cancer requiring treatment to prevent and control the development of cervical cancer5. The study therefore aimed at determining the prevalence and pattern of cervical smear cytology among women in our region.

 

Methodology

 

Study design 

This is a retrospective study of all cervical smears received and processed at the Department of Pathology, Modibbo Adama University Teaching Hospital , Yola over a five- year period   (1STJanuary 2015 and 31STDecember 2019). 

 

Study Area 

The study was conducted at the Modibbo Adama University Teaching Hospital (MAUTH), Nigeria. The hospital is located in Yola, the capital of Adamawa state; one of the states in north-eastern Nigeria. The hospital renders tertiary health care services to the populace of the entire region and neighbouring states and Cameroon.

 

Study population

This study included all women who had cervical Papanicolaou (PAP) smears done and reported by Pathologist within the study period. Their bio data and diagnosis were retrieved and classified using 2014 Bethesda classification.

 

Sample analysis 

Specimen adequacy was properly assessed based on presence of endocervical cells and/or metaplastic cells as well as adequate number of squamous epithelial cells i.e. more than 10% of the slide contain squamous cells. The slides were reported according to the 2014 Bethesda System for reporting Pap smear results. This adopts descriptive diagnoses, including - Benign cellular reactive changes including infections, inflammation, atrophy (Negative) and finally epithelia cell abnormalities which are classified as atypical squamous cells of undetermined significance (ASCUS); Low-grade squamous intraepithelial lesion (LSIL); High-grade squamous intraephielial lesion (HSIL); atypical glandular cells of undetermined significance (AGUS) and invasive carcinoma. 

 

Statistical Analysis

Frequencies were determined according to normal and abnormal smears as well as age groups. Percentages were calculated and the prevalence of cervical intraepithelial neoplasia reported. The data were analysed using IBM Statistical Package for Social Sciences (SPSS) package version 22.0, April 2020 (SPSS 22.0, IBM, United States of America). 

 

Results

 

The total number of pap smears received was 1251. One hundred and forty- three (11.4%) were unsatisfactory. The prevalence of abnormal cervical epithelial neoplasia was 151 (12.1%).  

 

Table 1. The ages of patients whose samples were reviewed

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Figure 1. Pie chart showing the Pattern of Cervical smears according to pathological diagnosis

 

 Table 2: Prevalence of Cervical abnormalities 

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The age range of the women screened were between 15years and 89years. The largest number of smears was between ages 35- 44years (33.3%). Majority of the smears were normal 957 (76.5%) and regarded as negative smears  while 143 (11.4%) were unsatisfactory. Abnormal smears were seen in 151 (12.1%). 

These abnormal epithelial changes were made of ASCUS 7 (4.6%), AGUS 7 (4.6%), LSIL 67 (44.4%), HSIL was found in 48(31.8%) while invasive carcinoma was found in 22 (14.6%) patients.

 

Discussion

 

Cervical intraepithelial neoplasia are precursor lesions for cervical cancer, need to be identified early and treated to prevent its development into cervical cancer. 

This study indicates that the prevalence of cervical cytological abnormalities is 11.4%. It is significantly less than 13% reported in Ibadan6, while 12.2%, 17.9% and 39.7% were reported from Enugu7, Gombe8 and Jos9.

Majority (76.5%) of the women in this study had normal smear. This is within the reported range worldwide but higher than the reported normal smear rates of 71% in the United State of America10. However, is also higher than the 36.5% reported from Lagos were cancer mortality among patients admitted were observed11. This may be due to the large sample size in this study. The high rate of the abnormal smear in this study shows the need for routine cervical smear screening among our women which is vital for reduction of cervical cancer in our environment12.

Abnormal cervical smears occurred mostly in women over the age 25 years, with a 40-44 years age range being the most common. The age group with the highest prevalence of CIN (36.1%) was 35-44 years followed by 25-34 years (25.1%). CIN prevalence was seen in age group 40-49 years, with a mean age 0f 37.6 years13 in Zaria. This similar to our study.

In this study, we observed that ASC-US and AGUS were both 4.6% of the abnormal smears which is less than reported in Benin (30.8%)14. During monitoring of women with ASC-US lesions, 10-30% of LGSIL and HGSIL were reportedly diagnosed15. In view of these findings, Barcelos’ study of analysis of ASC-US and cytologic criteria, advocates for serious monitoring of patients with ASC-US lesions16. 

The overall distribution pattern of the precursor lesions shows LGSIL (44.4%), HSIL (31.8%) and invasive carcinoma (14.6%). This specific distribution pattern is similar to the findings found in another Nigerian study17. Several studies in Nigeria and other parts of the world reported LGSIL as the commonest premalignant cervical abnormality observed in women studied5,18,19. Contrary to the present finding, Duru et al., found HGSIL as the commonest abnormality among the women studied20. LGSIL is a precancerous lesion characterized by a shorter and less observable clinical course, with cell changes associated with HPV. Several studies suggest that LGSIL is mainly caused by low-risk HPV infection21. While LGSIL may regress spontaneously in a significant number of patients, HGSIL progresses to invasive cancer if left untreated5,22.

The present finding shows that risk of premalignant changes and consequently cervical cancer increases with age with the highest prevalence among 35-44 years followed by 25-34 years. Women can develop CIN at any age, however, women generally develop it between the ages of 25 to 35 years5,23.

 

Conclusion

 

More than 12% of the women studied had abnormal Papanicolaou (PAP) smears. These findings underscore the need for well- organized cervical cancer screening programs so that more women can be detected earlier and treated to avoid progression to cervical cancer.

 

Acknowledgement: We appreciate the management of MAUTHY and the department of Pathology and Obstetrics & Gynecology for supporting the study. 

 

Conflict of interest: We declare no conflict of interest by any of authors.

 

Sponsorship: The authors funded this study.

 

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