evaluation of pap smear and acetic acid test as cervical cancer screening tools

114 Pages·2013·1.32 MB·English

EVALUATION OF PAP SMEAR AND ACETIC ACID TEST
AS CERVICAL CANCER SCREENING TOOLS –
WITH HISTOPATHOLOGICAL CORRELATION

by
Dr. SUMAN K.,
M.B.B.S.
Dissertation Submitted to the
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore
In partial fulfillment
of the requirements for the degree of

DOCTOR OF MEDICINE
in
PATHOLOGY

Under the guidance of

Dr. SREENIVAS N.,
MD
Associate Professor

DEPARTMENT OF PATHOLOGY
MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE
MYSORE-570 001

APRIL 2013
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “EVALUATION OF PAP
SMEAR AND ACETIC ACID TEST AS CERVICAL CANCER SCREENING
TOOLS – WITH HISTOPATHOLOGICAL CORRELATION” is a bonafide and
genuine research work carried out by me under the guidance of Dr. SREENIVAS N., ,
MD
Associate Professor, Department of Pathology, Mysore Medical College and Research
Institute, Mysore, Karnataka.

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CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “EVALUATION OF PAP
SMEAR AND ACETIC ACID TEST AS CERVICAL CANCER SCREENING
TOOLS – WITH HISTOPATHOLOGICAL CORRELATION” is a bonafide
research work done by Dr. SUMAN K., in partial fulfillment of the requirement for the
degree of Doctor of Medicine in Pathology.

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ENDORSEMENT BY
THE HEAD OF THE DEPARTMENT AND
THE DEAN AND DIRECTOR

This is to certify that the dissertation entitled “EVALUATION OF PAP
SMEAR AND ACETIC ACID TEST AS CERVICAL CANCER SCREENING
TOOLS – WITH HISTOPATHOLOGICAL CORRELATION” is a bonafide
research work done by Dr. SUMAN K., under the guidance of Dr. SREENIVAS N.,
Associate Professor, Department of Pathology, Mysore Medical College and Research
Institute, Mysore.

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COPYRIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore shall have the rights to preserve, use and disseminate this dissertation in print
or electronic format for academic/research purpose.

 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

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ACKNOWLEDGEMENTS

I would like to begin by expressing my gratitude to the Almighty for His
blessings.
I express my deep sense of gratitude and indebtedness to my most respected guide
and teacher, Dr. Sreenivas N., Associate Professor, Department of Pathology, Mysore
Medical College and Research Institute, Mysore as my guide and also for his constant
help, valuable advice and able guidance throughout the study. His everwilling keenness
to help and guide was a constant source of inspiration to me.
I am extremely thankful to Dr. A.L. Hemalatha, Professor and Head, Department
of Pathology, Mysore Medical College and Research Institute, Mysore, for her valuable
suggestions and constant support during the study period.
I heartily thank Dr. Bharathi M., Professor, Department of Pathology, Mysore
Medical College and Research Institute, Mysore, for her help, valuable advice and
suggestions.
I owe my sincere thanks to Dr. Nataraju G., Professor, Department of Pathology,
Mysore Medical College and Research Institute, Mysore for his suggestions and advice.
My thanks to Dr. Shilpa K., Dr. Sharath Kumar and Dr. Shashidhar H.B.,
Associate Professors, Department of Pathology, Mysore Medical College and Research
Institute, Mysore for their help and support.
My thanks to Dr. Umarani M.K., Dr. Vani D, Dr. Adil S.A.K, Dr. Gayathri
M.N., Dr. Vidya Vasudev and Dr. Sumana, Assistant Professors and Dr. Yadav
Kumar, Tutor, Department of Pathology, Mysore Medical College and Research
Institute, Mysore, for their advice and suggestions.
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I thank the ever helpful postgraduates and all the technical and non-technical staff
members of the department for their help.
I am grateful to Dr. Avadhani K. Geeta, Dean and Director, Mysore Medical
College and Research Institute, Mysore; Dr. B.G. Sagar, Medical Superintendent,
Krishna Rajendra Hospital and Cheluvamba Hospital, Mysore, for permitting me to carry
out this study.
I thank my Parents, Mr. G.K. Bhat and Mrs. Krishnaveni K., for their constant
presence, encouragement and for being the source of inspiration in all my endeavours.
I thank my brother, Mr. Navanit, for his love and support.
I take this opportunity to thank my husband, Mr. Nayan Khare and my son
Pratham Khare, for their love, care and support.
I owe my thanks to my in-laws, Mr. Narahari Khare and Mrs. Usha N. Khare,
for their support.
I thank my friend, Dr. Shaktiprasad Hiremath, for his help and suggestions.
I also thank Dr. Sumanth M.M., for helping me with statistical analysis.
I thank Mr. B.K. Venkatesh, M/S Kowshik DTP Centre for his efficient and
excellent DTP work in preparing this dissertation.
Above all, I thank the Almighty and all the patients without whom this study
would not have been possible.

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LIST OF ABBREVIATIONS

AGUS (cid:198) Atypical Glandular Cells of Undetermined Significance
AIS (cid:198) Adenocarcinoma in situ
ASCUS (cid:198) Atypical Squamous Cells of Undetermined Significance
CGIN (cid:198) Cervical Glandular Intraepithelial Neoplasia
CIN (cid:198) Cervical Intraepithelial Neoplasia
CP (cid:198) Conventional preparation
H&E (cid:198) Hematoxylin and Eosin
HLA (cid:198) Human Leucocyte Antigen
HP (cid:198) Histopathology
HPV (cid:198) Human Papilloma Virus
HSIL (cid:198) High Grade Squamous Intra-epithelial Lesion
HSV (cid:198) Herpes Simplex Virus
LSIL (cid:198) Low Grade Squamous Intra-epithelial Lesion
MMMT (cid:198) Malignant Mixed Mullerian Tumor
NILM (cid:198) Negative for Intra-epithelial Lesion/ Malignancy
NOS (cid:198) Not Otherwise Specified
Pap (cid:198) Papanicolaou
SCC (cid:198) Squamous Cell Carcinoma
SIL (cid:198) Squamous Intraepithelial Lesion
TBS (cid:198) The Bethesda System
VIA (cid:198) Visual Inspection with Acetic Acid
WDPV (cid:198) White Discharge Per Vagina

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ABSTRACT

BACKGROUND AND OBJECTIVES
Carcinoma cervix is one of the most common cancers in women. The
Papanicolaou smear test is a common screening method for cervical cancer detection.
Acetic acid test may be considered as an alternative screening modality in locations
where Papanicolaou smear test is not feasible.
The objectives of the present study were to evaluate the roles of Pap smear and
acetic acid test as cervical cancer screening tools and to compare the performances of the
above mentioned tests keeping histopathology as the gold standard.
METHODOLOGY
Seventy women subjects presenting with complaints of white discharge per
vagina, pelvic pain and post coital bleeding were included in the study. Cervical smears
were collected with Ayre’s spatula. Acetic acid test was done and the results were
categorized as VIA positive and VIA negative. The Pap smears were reported according
to The Bethesda System 2001. Cervical biopsy was done for all the cases. Cervical
cytology and acetic acid test results were correlated with histopathology findings.
RESULTS
The mean age of the study subjects was 35.7 years. The presenting complaint in
majority of the subjects was white discharge per vagina. Pap smear was positive in
47.14% of the cases. VIA was positive in 71.42% of the cases.
In the present study, the ratio of pre-malignant to malignant lesions on cytology
was 32:1. Among the pre-malignant lesions, LSIL constituted 69.69% of the cases and
HSIL constituted 27.27% of the cases.
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Among the 70 cases, 1 case (1.42%) was malignant.
The diagnostic accuracy of cytology for low grade lesions was 71.42%. It was
64.28% for high grade lesions and 100% for carcinoma.
The sensitivity, specificity, positive predictive value and negative predictive value
for Pap smear were 69.77%, 88.89%, 90.91% and 64.86% respectively.
The sensitivity, specificity, positive predictive value and negative predictive
value for acetic acid test were 88.37%, 55.6%, 76% and 75% respectively.
The sensitivity of acetic acid test was higher than that of cytology. However, the
specificity of acetic acid test was lower as compared to cytology.
The overall diagnostic accuracy by Pap smear was 77.14% and that by acetic acid
test was 75.1%.
INTERPRETATION AND CONCLUSION
The Pap smear test is an effective screening modality for detecting cervical
pre-cancerous and cancerous lesions. In resource-poor settings, acetic acid test may be
considered as an alternative screening method. The main drawback of acetic acid test is
its low specificity as compared to cervical cytology. In areas where cytology based
screening is available, acetic acid test may be used as an adjunct to improve the
sensitivity of cervical cytology.
KEY WORDS: Carcinoma cervix; Screening; Papanicolaou smear; Acetic acid test;
Cervical biopsy; The Bethesda System 2001

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