Epidemiological profile of cervical lesion on pap smear cytology and histopathological finding in kosi region of Bihar

Introduction: Cervical lesions are extremely common particularly inflammation of cervix which includes non specific and specific inflammatory conditions like syphilis, trichomonos vaginalis, tuberculosis, candidacies. Besides these lesion of cervix is extremely vulnerable to development of preinvasive and invasive lesion. The incidence and mortality due to cervical carcinoma had declined in North America and Europe during last 50 Years as an outcome of cervical screening1. In developing countries like India, China, Bangladesh, Pakistan its incidence is high and accounts for one of the most common cause of death of women due to cervical carcinoma in India2,3. Nationwide, the disease accounts for an estimated 24% of cancer in India among women compared with 20 % for breast cancer4. India National cancer control programme emphasizes the importance of early detection and treatment. The increasing incidence is attributed to illiteracy, poverty, early age of marriage and pregnancy high parity and lack of awareness of proper screening test and concern for the symptoms and rural health practices involving indigeous medical quackery5. The pap smear cytology and subsequent histopathology in carcinoma patents was done. Pap smear screening test is done to pick up inflammatory and preinvasive changes in cervical lesion so that treatment at these early stages will prevent future development of invasive cervical cancer. The pap smear evaluation for cervical lesion was classified on CIN and Betheseda system6.The present study was aimed at identifying the major risk factors involved in predisposition of cervical lesion by using pap smear as screening method and histopathology done in carcinoma

patients thus helping the society in reducing morbidity and mortality due to cervical carcinoma.

Material & Method:
The present study was done over the period of 2 years 8 months (June 2007 to March 2010).The study was conducted among the patients attending the Gyanecological OPD and IPD, and referred to Pathology department for Pap smear screening & histopathology in suspicious cases at Katihar medical college Katihar, Bihar.Patients enrolled in this study were assessed for following parameters with respect to age, socioeconomic status, parity, age at first pregnancy, clinical presentation by using pap smear and histopathology findings.Among 154 patients 41 patients were diagnosed as dysplasia, LGSIL, HGSIL and carcinoma cervix 7 .There was no exclusion criteria in this study, so all the smear were included in the study.The samples were collected using Ayer's spatula.The smears were then fixed in alcohol and stained using the Papanicolau's technique.All the smears of 154 patients were analyzed and categorized for different age groups in this study.

Results:
Table 1 Majority of patents were in age group 21-40 years, accounting for 79.21% (122).The youngest case was 18 year old girl with LGSIL.Mean age of presentation in the study was 34.03 years.Table 2.
Since majority of patient were from rural areas (81%), socio-economic status of these patients were low constituting 72.08% (111).Only 8 patient (5.19%) were from high socio-economic status.Modified Prasad's Classification adjusted with current price index was used to determine socio-economic status 8 .Table 3 maximum numbers of cases 70.78% were with parity 4 or more, only 6.67% were nulliparous and 22.73% were with parity less than 4.Among patients with parity 4 or more, 33 patients were with parity more than 6 who have on pap smear and histopathology findings suggestive of premalignant, malignant lesion corroborating the finding that increase parity was one of the major risk factor for cervical lesion.Table 4 Maximum numbers of patients 66.80% (103) have their first pregnancy at age less than 20 years.23.38% (36) had first pregnancy between 21-30-years.6.49% (10) patient never conceived.

7.14% Table 5: Distribution of cases according to symptoms
common symptom in this study.Dysuria and dyspareunia was seen in 7.14% (11) patients.Haematuria was seen mostly in 41 patients diagnosed with premalignant and malignant lesions on pap smear and histopathology findings.Table 6 Findings suggest 51.29% (79) patients were diagnosed with inflammatory changes specific to underlying etiology.22.07 % (34) patients were with normal or non specific cervicitis, 26.61% (41) patients were diagnosed with premalignant and malignant changes on pap smear and histopathology findings.Discussion: Cytology of cervical lesions detect preinvasive, invasive carcinoma in addition to specific, nonspecific inflammatory condition.Thus cervical cytology is now a well established component of preventive health protocols for women.The purpose of doing cytology of cervical lesion and histopathology in suspicious cases is to detect cervical cancer in its precursor stage.Natural progression of these precursor is unclear some regress, some remain static for considerable period of time while other have carcinogenic potential giving rise to invasive carcino-ma.As cytology is only screening procedure, abnormal smears must be confirmed by cervical biopsy.The determinants of age trends at presentation for preinvasive and invasive cervical lesion help in identification of target age groups for the implementation of cervical screening.The mean age of presentation in this study was 34.03 years, which was lower than other study done in India 9 .It is lower than the mean age for cancer cervix reported from north east Nigeria 10 .Presentation at early age in this study correlates with multiple risk factors like younger age of marriage, age at first pregnancy as reported in earlier study 11 .Majority of patients from low socioeconomic status were from rural areas and illiterate, unaware of cervical screening, poor hygiene, indigeous medical quackery which correlates with other study 12 .In the present study women with high parity more the six was seen in 33 patients out of 41 patients diagnosed with preinvasive and invasive cervical lesions 13,14 .The finding of dysplasia, LGSIL, HGSIL, carcinoma in present study is 26.61% ( 41) patients.The high percentage of cases in present study is different from earlier study which is 6.8% (15).The study by Mishra2009 also reports 11.24% of the cases 16 .The findings in this study is different from other study considering that women enrolled in this study had high incidence of sexually transmitted disease, parity more than 6, early age of marriage and pregnancy.

Conclusion:
An awareness and education programmes need to be implemented to target high risk women about preinvasive and invasive cervical lesion by pap smear screening.The goal of any screening programme should be to pick up majority of the precursor lesion not frank cancer with minimum cost.It is advisable to initiate pap smear screening in women from low socioeconomic status before age of 40 years.This should be combined with HPV vaccination for the young women and public health education for all 17 .

Table 5
About 69.4% (107) had foul smelling vaginal discharge and pelvic pain as most common presenting complain.23.37% (36) had haematuria accounting for the second most cervical lesion on pap smear cytology and histopathological finding