A clinicopathological study on cervix.
The etiology of cervicitis is variable. Chronic nonspecific cervicitis is the commonest non-neoplastic lesion in all age groups, usually between 20-60 yrs, but rare before menarche or after menopause. The bacterial and viral agents are the etiological agents along with the STD's causing the cervicitis. The other associated features causing cervicitis are bad hygiene tampons etc. tuberculous cervicitis though not common, can also contribute to 2-6% of infections among women.
Apart from bacterial, viral and metabolic diseases like diabetes mellitus, the infections are also due to local trauma, parturition, foreign bodies, diaphragm, pessaries and intrauterine contraceptive devices.
The human pailloma virus and Herpes simplex virus play a major role and strongly associated with carcinoma. The HPV causes spectrum of changes ranging from condyloma acuminatum, cervical intraepithelial neoplasia to invasive sqamous cell carcinoma. There are more than 100 human papilloma viruses, about 40 viruses infect the female genital tract and 15 of them cause cervical cancer.
The neoplastic lesions of cervix are also commonly encountered in young women. The age of first coitus, smoking, parity are other etiological factors. These etiological factors causes dysplastic changes in epithelium leading to carcinoma.
The advancement of investigative procedures like Pap smear examination, colposcopy are very helpful to identify the non-neoplastic diseases of cervix. The Pap test is the simple and easy procedure to detect the inflammation and neoplastic diseases of cervix. The cervical biopsy plays an important contribution for much understanding of the disease process and clinicopathological correlation of the disease. The present study is undertaken in view of disease sequelae of chronic cervicitis, Ca.in situ & Carcinoma cervix.
MATERIAL AND METHODS: The present prospective study is done for a period of 3 years (Jan 2012-Dec. 2014) in the Dept. of pathology, RIMS, Kadapa. During the above period all the gynecological cervix biopsies obtained were analysed. In this study 603 cases were analysed pathologically. Relevant clinical data were collected. The specimens were received in 10% formalin. These specimens were subjected to detailed microscope study by hematoxylin and eosin staining. The lesions were analysed according to WHO classification. This study includes all non-neoplastic and neoplastic lesions of uterine cervix. The hysterectomy specimens were excluded in the present study.
RESULT: During this period of 3 yrs (Jan. 2012-Dec. 2014), 6634 surgical specimens were received among them the total of 3828 gynecological specimens were received, among which total cervical biopsies were 603(15.75%). 268 cases (44.44%) of squamous cell carcinoma were noted. In them 223 cases (36.98%) were large cell non keratinizing squamous cell carcinoma, 40 cases (6.6%) were small cell and 2 cases (0.33%) were large cell keratinizing type.260 cases (96.2%) were multi parous and 8 cases (3.8%) were nulliparous women.203 cases (75.11%) showed poor personal hygiene. The common age group was 50-60 years. There were 2 cases (0.33%) of adenocarcinomas noted in the age group of more than 60 yrs, both were multiparous. One case (0.16%) of adenosquamous carcinoma was noted in 60 yr old multiparous women.
154 cases (25.5%) showed chronic nonspecific cervicitis. In them 14 cases (2.29%) showed koilocytic change, 3 cases (0.49%) showed nabothian cyst and 2 cases (0.33%) showed squamous metaplasia. 120 (78.2%) were multiparous, and 34 cases (21.7%) were nulliparous women, 97 patients (62%) were with poor personal hygiene. In 87 cases (14.4%) of endocervicitis, 79 cases (90.7%) were multiparous and 8 cases (9.3%) were nulliparous women and 65 cases (74.6%) were with poor hygiene. The common age group for all the inflammatory condition was between 20-40 yrs. 34 cases (5.63%) showed squamous intraepithelial lesion (SIL). 18 cases (2.9%)of low grade SIL, and 16 cases (2.64%) of high grade SIL. Among these dysplastic cases 31 cases (91.1%) were multi parous and 3 cases (8.8%) were nulliparous women. The common age group was 30-40 yrs. Poor hygiene was noted in 19 cases (55.8%).
There were 25 cases (4.14%) of endocervical polyps with common age group of 40-50 yrs and 9 cases (1.49%) of leiomyoma of cervix. With common age group of 30-40 yrs. 4 cases (0.66%) of tuberculous cervicitis were noted in 20-30yrs age group presented with infertility. And one rare case of actinomycosis was noted in 35 yrs old women with history of long term use of IUCD's.
Type of lesion Total no. Percentage of cases Chronic nonspecific cervicitis 154 25.5% Chronic cervicitis with nebothian cyst 15 2.4% Chronic cervicitis with squamous metaplasia 2 0.33% Chronic cervicitis with koilocytic change 14 2.3% Chronic endocervicitis 87 14.42% TB cervicitis 4 0.66% Actinomycotic endocervicitis 1 0.16% Squamous intraepithelial lesion: 34 5.6% Low grade SIL 18 2.9% High grade SIL 16 2.6% Endocervical Polyp 25 4.1% Leiomyoma of cervix 9 1.4% Squamous cell Carcinoms: 268 44.4% Large cell keratinizing 2 0.33% Large cell nonkeratinising 223 36.9% Small cell carcinoma 40 6.6% Adeno carcinoma 2 0.33% Adeno squamous carcinoma 1 0.16%
DISCUSSION: In the present study majority of uterine cervical lesions were neoplastic (44.4%), followed by non-neoplastic lesions. Most of the epidemiological studies of cervical neoplasia suggested direct relation with multiple sexual partners, early onset of sexual activity and HPV.  Chronic cervicitis was the commonest non neoplastic lesion (25.5%). It was observed in all age groups between 20-60yrs. This was diagnosed by the presence of heavy mixed infiltrate consisting of lymphocytes and histiocytes. It is rare before menarche or after menopause. 
Nabothian cyst was seen in 1.8% cases, showed cystically dilated endocervical glands, lined by flattened epithelium, filled with mucoid material and associated with chronic cervicitis.  Squamous metaplasia can sometimes be found in the endocervix, as it is composed of simple columnar epithelium, whereas the ectocervix is composed of stratified squamous non-keratinized epithelium. 
Koilocytosis or koilocytic atypia  was seen in 2.3% of cases, histologically shows squamous cells with nuclear enlargement (two to three times normal size), irregularity of the nuclear membrane contour, hyperchromatic nucleus with perinuclear halo, Collectively, these types of changes are called a cytopathic effect; various types of cytopathic effect can be seen in many different cell types infected by many different types of virus.  
Tuberculous cervicitis was noted in 0.66% cases in the age group of 20-30yrs. It is significant that its gross appearance often closely resembles that of carcinoma. Tuberculosis of the cervix is rare and accounts for 0.1-0.65% of all cases of tuberculosis and 5-24% of genital tract TB.  These cases presented with infertility. It is involved in about 5-16%of cases of infertility among Indian women, though the actual incidence may be under-reported due to asymptomatic presentation of genital tuberculosis and paucity of investigations. [9, 10, 11]
One case of actinomycosis cervix (0.16%) was noted in 35yrold women, related with long lasting IUCD usage. [12, 13]
Squamous intraepithelial lesions showed mitotic activity in the parabasal layer noted in the age group of below 40yrs.  The World Health Organization classification [15, 16] system was descriptive of the lesions, naming them mild, moderate or severe dysplasia or carcinoma in situ (CIS). The term, Cervical Intraepithelial Neoplasia (CIN) was developed to place emphasis on the spectrum of abnormality in these lesions, and to help standardize treatment 
Endocervical polyps occur in 2-5% multigravida women in the age range of 30-59 yrs. The cause of cervical polyps is uncertain, but they are often associated with inflammation of the cervix.  Leiomyoma of cervix constitute 8% of uterine leiomyomas, appear as pedunculated masses in the endocervix. [18, 19]
Large group of cases were neoplastic, common histological type was squamous cell carcinoma (44.44%) with sub-types, [20, 21] large cell non-keratinising squamous cell carcinoma (36.9%), large cell keratinizing squamous cell carcinoma (0.33%), small cell carcinoma (6.6%), less common were adenocarcinoma (0.33%), and adenosquamous carcinoma (0.16%). Most of the cases were noted in the age group of 40-60yrs. 2 cases of adenocarcinoma (0.33%) were noted in the age group of 60 yrs.  One case of adenosquamous carcinoma was noted showing both glandular and squamous component  Pre-cancerous and cancerous cervical lesions showed increased incidence in parous women  and also increase in age, illiteracy, poor sexual hygiene.  The prevalence and burden of cervical cancer is much higher among women of low Socioeconomic status, as well as among rural women in India. [26, 27]
The primary reason given for this is lack of access to screening and health services, and lack of awareness of the risk factors of cervical cancer. HPV infection and precancerous lesions go unnoticed and develop into full blown cancer before women realize they need to go for medical help. Moreover, due to difficulties of access and affordability, compliance to, and follow up of, treatment is much. Cervical cancer remains the second leading cause of cancer deaths among women in developing countries.  By 2030, WHO predicts that virtually all cervical cancer deaths-fully 98% -will occur in developing countries, furthering disparities between richer and poorer countries. 
CONCLUSION: The results reported here reflect a limited view of uterine cervical lesions and represent only an experience rather than true incidence. Cervical cancer still remains the major cause of cancer death worldwide. Meanwhile, scientific advancements have continued to improve secondary prevention methods. For example, a liquid-based Pap test with better detection results became available. Another significant development was the invention of an HPV DNA test to identify high-risk HPV strains in vaginal or cervical samples. The biggest technological game-changer has been the introduction of the HPV vaccine as a primary prevention tool. The U.S. Food and Drug Administration (FDA) has approved two variations--Gardasil in 2006 and Cervarix in 2009-that provide protection against the viral strains that cause the large majority of cervical cancers.
Among the most important strategies being promoted in developing countries are single-visit or "screen-and-treat" approaches. Although screening efforts based on Pap smears have been introduced in several developing countries, many have achieved only limited success, for a number of reasons, including limited cytologic services and lack of follow-up diagnostic and treatment services. Despite much advancement, there remain serious challenges to lowering rates of cervical cancer cases and deaths. Still, the fact remains that cervical cancer is highly preventable and treatable, and many of the medical and technological tools to radically reduce--if not eliminate--cervical cancer as a killer of women are now in place and affordable. What is needed going forward is the leadership and commitment--among developed and developing country policymakers and donor agencies alike--to activate and sustain them.
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Jyothi V (1), V. Manoja (2), Sridhar Reddy K (3)
(1.) Jyothi V.
(2.) V. Manoja
(3.) Sridhar Reddy K.
PARTICULARS OF CONTRIBUTORS:
(1.) Assistant Professor, Department of Pathology, RIMS, Kadapa, A. P.
(2.) Senior Resident, Department of Pathology, KMC, Kurnool, A. P.
(3.) Assistant Professor, Department of Pathology, RIMS, Kadapa, A. P.
FINANCIAL OR OTHER COMPETING INTERESTS: None
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Jyothi V. H. No. 1/2618, LIG, APHB Colony, Kadapa-516004, A. P.
Date of Submission: 20/01/2015.
Date of Peer Review: 21/01/2015.
Date of Acceptance: 04/02/2015.
Date of Publishing: 10/02/2015.
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Jyothi, V.; Manoja, V.; Sridhar, Reddy K.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Feb 12, 2015|
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