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Conventional pap v/s colposcopic scrape cytology as screening tool in early cervical lesions.

AIMS AND OBJECT: Evaluation of pap v/s colposcopic scrape cytology in screening cervical lesion in tertiary hospitals.

INTRODUCTION: In 1928, Dr. Papanicolaou discovered that cells in the cervix changes in appearance before they become cancerous. Hence the Pap's smear named after Dr. Papanicolaou, is used to check changes in the cervix, it is a screening tool to find out early warning signs, from this cancer develops in future, cells are collected by using Ayre's spatula from cervix & examined in laboratory for any unusual findings. If changes are found in screening, further test will be done to see whether treatment is needed. This test is not for diagnosing cancer but rather finding early changes which may become cancer. (1, 2)

Pap smear is not 100% accurate cervical cancer may be missed in small number of cases most of the times as cervical cancer grows very slowly & follow-up, smears are required to identify changes in time. (2, 3)

Sometimes a single smear in life time if appropriately timed is sufficient. If extended to high risk groups, the mortality from cancer death can be reduced to 70%. (3-5)

COLPOSCOPE: First introduced by Hinselmann in 1925, (3) colposcope is a binocular instrument providing a magnification of 10-12 times and Colpmicroscope. 100 to 200 times. It is a complicated instrument and designed to magnify the surface epithelium of vaginal part of the cervix including entire transformation zone. Usually the low power magnification is used to visualize the cervix and vagina. (6-16 fold), green filter high magnification can also be used.for visualization. Cervix is cleared of using normal saline soaked swab, now cervix is wiped by 3% Acetic acid & examination is repeated. Acetic acid causes coagulation of nuclear proteins which is increased in CIN, more long lasting coagulated area, more chances of malignancy risk. Coagulated proteins prevent transmission of light through the epithelium. This is called acetowhite area. Similarly Cervix can also be painted by Schiller's iodine which differentiate the darker glycogen loaded cells from pale glycogen free cells. (2-4)

Abnormal group to be examined are: (5)

1. Abnormal smear.

2. Clinically suspicious cervix especially with history of contact bleeding, despite of negative smear.

3. Patients in whom Conservative treatment can be effectively done.

Colposcopic Terminology: (6)

1. Normal findings:

a. Squamaous epithelium

b. Columnar epithelium

c. Transformation zone

2. Abnormal Colposcopic findings

a. Atypical transformation zone

b. Punctuate area

c. White epithethilium

d. Keratosis

e. Atypical vessels.

3. Frank invasive cancer, it is evident only colposcopically.

4. Unsatisfactory Squamo-columnar junction.

5. Condyloma & Papilloma--are also of importance.

SCRAPE CYTOLOGY: It is a simple & harmless procedure, which is a controversial technique according to its real validity in oral pathologies. Lately it has re-emerged due to its application in oral precancerous, cancerous lesions, as predictive method as well as for monitoring the patients. (7) New diagnostic techniques have been developed, such as brush biopsy and multiple molecular studies using collected material which is examined in laboratory under microscope High Specificity and high positive and negative predectivity, value of oral scrape cytology makes it ideal screening test for early detection of oral cancer. However low sensitivity means that it can miss cases of carcinomas & should be followed up with biopsy with strong clinical suspicion, also there is statistically significant difference between Histopathology & Cytopathological diagnosis. (7, 8)

But very few studies use of colposcopy directed scrape cytology for screening and diagnosing cervical precancerous or cancerous lesions are existing at present. In view of efficacy of abnormal area scrape cytology in screening oral precancers and cancers by many researchers' sensitivity and specificity of pap & colposcopic scrape cytology were compared to conventional punch biopsy in present study in detecting cervical abnormalities above atypia.

MATERIAL AND METHOD: Sixty multiparious women of 25 to 55 age group, who reported for different gynecological problems at L.N. Medical College & J.K. Hospital outpatients department, formed the study subjects. Each patient was subjected to Pap smear, colposcopy directed scrape cytology from abnormal/ suspicious areas and colposcopy directed punch biopsy from abnormal/ suspicious areas after Colposcopic VIA (Visual inspection with acetic acid).

Different Criteria's of abnormal lesion on VIA:

1. Well defined lesion: Well circumscribed aceto white lesion.

2. Ill defined: Poorly, defined aceto white lesion.

3. Scattered lesion: Punctuated areas of aceto whitening usually involving the transformation zone.

4. No lesion: No aceto white lesion visible.

5. Suspicious ulcer or growth.

Areas observed:

1. Well defined, well circumscribed as aceto white lesions.

2. III-defined areas

3. Poorly defined areas

4. No lesions--No aceto white area seen

RESULTS: Sensitivity and Specificity of Pap's and Colposcopy directed Scrape Cytology as compared to confirmatory histopathology (punch biopsy) are as follows:
                   Pap's Smear         Colposcopic Scrape
                                            Cytology

Sensitivity        41%, r = + 1           66%, r = +1
              (coefficient of linear
                   correlation)
Specificity        58%, r = + 1           83%, r = + 1


OBSERVATION AND DISCUSSION: Pap smear is the single most widely used valid cervical screening test at present--Pap's smear is not 100% accurate cervical cancer detection technique. It may miss small number of cancer cases, most of times (1-4) as cervical cancer develops very slowly & follow up pap smear is required, to identify changes in time for treatment. Some of the well accepted screening test for cervical lesions are: (9, 10)

1. Pap smear

2. VIA/ VIL I

3. Colposcopic VIA/ VIL I

Bharti Jha et al observed that scrape cytology can replace punch biopsy in diagnosing oral lesions, because oropharyngeal carcinoma is one of the leading cause of mortality in Indian population, due to increased use of tobacco chewing products, mucosal biopsy is widely regarded a gold standard for detecting oral carcinomas but exfoliative cytology are increasingly used for early detection of malignancy & strict follow up to check the sensitivity, specificity and to see whether this can replace the punch biopsy for diagnosing premalignant and malignant and lesions. (7)

Ramesh G. et all discussed Colposcopic evaluation of unhealthy cervix. The pap smear is a primary tool for cervical intra epithelial neoplasm (CIN) and invasive cancer of the uterine cervix. Recently the assumed accuracy of Pap's smear was found to be 80% to 95%.

Hence there is an obvious need to subject the women with colposcopy and directed biopsy. (10)

According to Acha A. Martinez et al, early detection of oral cancer is most important weapon in out fight against oral cancer. For this screening by scrape cytology is proved to be very useful technique survival rate in this cancer is only 40% over all but this rate increases to a greater than 80% if this is detected early. (8)

Kavita Nanda et al, concluded after analysis of twelve studies on Pap test that Pap tests are mostly biased and is only moderately accurate with sensitivity of 30-87% and specificity 86-100%. (11)

Lieberman RW et al On comparing Colposcopic brush cytology with Colposcopic biopsy found brush cytology to be 98% sensitive and 74% specific and concluded that in absence of lesions suspicious for cancer, colposcopic cytology is safe substitute for directed biopsy in pregnancy. (12) SA, pimply et all also evaluated colposcopy vs Cytology as secondary test to triage women found positive on visual inspection test and concluded that colposcopy were more sensitive & specific than cytology. (13)

Michel T et al did meta analysis of 62 studies of pap & revealed high negative correlation of sensitivity and specificity of Pap r = - 0.63. (14)

Kim SJ et al in a multi institutional study of pap concluded that sensitivity & specificity of Pap is in range of 56.6 - 83.1% respectively. (15)

Here we have conducted this study to evaluate Colposcopic guided scrape cytology as a screening method in the present study and yielded a sensitivity of 66% & 83%, r (coefficient of linear correlation)= +1 respectively with colposcopic cytology as compared to 41% Sensitivity and 58% specificity with Pap, r = +1 in our study. Other workers as mentioned above evaluated Pap cytology and summed up that pap smear has varied subjective range of sensitivity/ specificity and associated with high degree of false negatives, on the other hand study of abnormal area scrape cytology in oral lesions and in one or two study of colposcopic scrape cytology in cervix resulted to high sensitivity & specificity comparable to punch biopsy.

CONCLUSION: Colposcopic scrape cytology which shows much higher sensitivity & specificity in our study as compared to pap smear can be considered as more effective screening method for cervical lesions in institutions with facilities of colposcopy and trained colposcopist.

Sensitivity and specificity of Colposcopic Scrape cytology is comparable to punch biopsy and if appropriately done can replace punch biopsy in absence of lesions suspicious of cancer, it being associated with negligible pain, blood loss, complications and less cost.

DOI: 10.14260/jemds/2014/2332

REFERENCES:

(1.) American College of Obstretician & Gynecology Practice Bulletin No. 99: Management of abnormal cervical cytology and Histology. Obstet & Gynaecol 2008; 12: 1419-1444.

(2.) American College of Obst & Gynaecologist Committee Opinion No. 463: Cervical Cancer in Adolescents Screening, evaluation, and management. Obstet Gynaecol 2010, 116:469-472.

(3.) Richard W. Telende's; Epidemiology of cancer. Text BOOK OF OP GYNEC.J.B.LippincottCO:4th ed; p722-24.

(4.) Lentz GM, Lobo, RA Gershenson DM. Katz VL. Intraepithelial neoplasias of the lower genital tract (C x & Vulva): etiology, Screening, diagnostic techniques management: Comprehensive Gynecology. 6th ed Philadelphia; PA: Elsevier Mosby; 2012: Chap 28.

(5.) D.C.Dutta's Text book of gynaecol including contraception.Examination of gynaecological patients. .Central book agency Pvt Ltd, Calcutta: 3rd edn. ;p90-108

(6.) Saslow D, Solomon D, Lawson HW, et all American Cancer Society, American Society of Colposcopy and cervical pathology and American, society for clinical pathology screening guideline for the preventions and early detection & cervical cancer. Ca, Cancer, J clin. 2012; 62 (3): 147-72.

(7.) Jha Bharti, Roy A, Sayanta H Jane, Patel C, Vaghela P, Gupta S. Scrape Cytology Oral cavity, can it replace punch biopsy in diagnosing oral lesion ? Int J, Med Sci Public Health, Cited February 13, 2014], On line first: 12 Dec, 2013.

(8.) Acha A, Ruesga MT, Rodriguez MJ, Martinez de, Pancarbo MA, Aguirre JM. Applications of scrape cytology in oral cancers and precancers. Oral pathologia orally ciruguia Buccal [2005, 10(2):95-102].

(9.) American College of Obstet & Gynecology Practice Bulletin No. 109: Cervical Cytology Screening. Obstet & Gynaecop 2009: 1409-142010.

(10.) Ramesh G: Sudha, R, Jaishree A.K. PadminiCcolposcopic evaluation of unhealthy cervix. A Journal of Clinical and diagnostic Research, August, 2012, Vol. 6. Issue 6, P 1026.

(11.) Kavita Nanda, Donglas Mc Crory. Accuracy of pap test in screening of cervical abnormalities Annals of Internal Med. 2000: 132 (10); 810-19.

(12.) Lieberman RW, Henry MR--Colposcopy in pregnancy, directed brush cytology compared with biopsy Obs & Gynecol. 1999 Aug: 94 (2); 198-203

(13.) SA Pimple G. Amin, Evaluation of Colposcopy VS cytology as secondary test to triage women found positive on visual inspection list. Ind. J of Cancer 2010: 47 (3); 308-13.

(14.) Michael T. Fahey, Lesderwig. Metaanalysis of Pap last accuracy AM J. of Epidemiology 141 (7), 680-89.

(15.) Kim SJ, Parik CK, Multi institutional study for development of Cervical Cancer Screening Korean J of 0 & G. 2001 May: 44 (5); 911-937.

Veena Khare [1], Vandana Agarwal [2], Gopa Ghosh [3]

AUTHORS:

[1.] Veena Khare

[2.] Vandana Agarwal

[3.] Gopa Ghosh

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of Obstetrics and Gynaecology, J. K. Hospital, L. N. Medical College, Bhopal.

[2.] Associate Professor, Department of Pathology, J. K. Hospital, L. N. Medical College, Bhopal.

[3.] Consultant, Department of Oncology, J. K. Hospital, L. N. Medical College, Bhopal.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Veena Khare, Plot #11, Sarvadharam, C-Sector, Kolar Road, Bhopal.

E-mail: drveenakhare@gmail.com

Date of Submission: 05/03/2014.

Date of Peer Review: 06/03/2014.

Date of Acceptance: 12/03/2014.

Date of Publishing: 02/04/2014.
COMPARATIVE FINDING'S OF PAPCYTOLOGY,SCRAPE CYTOLOGY, COLPOSCOPIC
PUNCH BIOPSY

Sl.    No. of     Follow up       Colposcopic      Colposcopic
No.    Cases     Pap's Smear    Scrape Cytology    Punch Biopsy

1     Two        CIN I          CIN II            CIN III
2     Thirteen   LSIL           Mild Dyspepsia    Dysplasia with
                                                    a types
3     Five       Chronic        CIN I             CIN I
                   Cervicitis
4     Twelve     Inflammatory   Koliococytosis    Koliococytosis
                   Changes
5     Eight      Chronic        Cervicitis        Normal
                   cervicitis
6     Ten        Inflammatory   Dysplasia         Dysplasia
                   changes
7     Ten        Inflammatory   Inflammatory      Inflammatory
                   changes        Changes           changes
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Title Annotation:ORIGINAL ARTICLE
Author:Khare, Veena; Agarwal, Vandana; Ghosh, Gopa
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Apr 7, 2014
Words:2028
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