Original article / research
Year :
2020 |
Month :
October
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Volume :
9 |
Issue :
4 |
Page :
PO05 - PO09 |
Full Version
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Histomorphological Spectrum of Cervical
Lesions: A Three Year Retrospective Study in
Rural Area Bastar Region, Chhattisgarh, India
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Kalpana Nayak, Nitya Thakur, Deepika Dhruw, Kasturi Chikhlikar, B. P. Singh 1. Assistant Professor, Department of Pathology, LT. BRKM Govt Medical College Dimrapal C.G., Dimrapal, Jagdalpur Dist- Bastar, Chhattisgarh, India.
2. Assistant Professor, Department of Pathology, LT. BRKM Govt Medical College Dimrapal C.G., Dimrapal, Jagdalpur Dist- Bastar, Chhattisgarh, India.
3. Assistant Professor, Department of Pathology, LT. BRKM Govt Medical College Dimrapal C.G., Dimrapal, Jagdalpur Dist- Bastar, Chhattisgarh, India.
4. Professor and Head, Department of Pathology, LT. BRKM Govt Medical College Dimrapal C.G., Dimrapal, Jagdalpur Dist- Bastar, Chhattisgarh, India.
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Correspondence
Address :
Kalpana Nayak, Nitya Thakur, Deepika Dhruw, Kasturi Chikhlikar, B. P. Singh, Nitya Thakur,
LT.BRKM Govt Medical College Dimrapal C.G., Dimrapal, Jagdalpur Dist.- Bastar, Chhattisgarh, India.
E-mail: drnityathakur20@yahoo.com
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| ABSTRACT | | : Introduction: Uterine cervix is vulnerable for both non neoplastic and neoplastic lesions of the female genital tract. Histopathological examination of cervical lesions is essential to make early diagnosis for premalignant and malignant conditions.
Aim: To study various histomorphological patterns and age distribution of cervical lesions.
Material and Methods: A retrospective study of total 349 cases of cervical lesions was studied in the Department of Pathology over a period of 3 years at Late BRKM Government Medical College Dimrapal, Bastar (CG). The study included both hysterectomy and cervical biopsy. Various histomorphological patterns were assessed and classified and mean age distribution of cervical lesions were calculated.
Results: A total of 349 cases were retrieved from the register of Department of Pathology. The youngest patient was 20 years and oldest patient was 77 years with a mean age of 48.5 years. Out of 349 cases studied, non-neoplastic lesions were 259(74.21%), Preinvasive (Cervical Intraepithelial Lesions) were 11(3.15%) and 79 (22.63%) cases were malignant. Among non-neoplastic cervical lesions, Chronic non-specific Cervicitis was the most common histopathological finding and Squamous Cell Carcinoma was the commonest variant in malignant cervical lesions.
Conclusion: Cervical biopsy is valuable in early diagnosis and management of premalignant and malignant lesions. |
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Keywords
: Cervicitis, Non-neoplastic, Chronic non-specific Cervicitis, Squamous cell Carcinoma |
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DOI and Others
: DOI: 10.7860/NJLM/2020/44802:2403
Date of Submission: Apr 24, 2020
Date of Peer Review: May 02, 2020
Date of Acceptance: Jun 24, 2020
Date of Publishing: Oct 01, 2020
b#bAuthor Declaration:b?b
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes |
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INTRODUCTION |
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The cervix is prone to develop many Non-neoplastic and Neoplastic gynaecological lesions in women of reproductive age group (1). The transformation zone of the cervix specifically squamo-columnar junction is vulnerable to Human Papilloma Virus (HPV) (2). The HPV causes wide spectrum of changes which ranges from Condyloma acuminatum, Cervical Intraepithelial Neoplasia to Invasive Squamous cell carcinoma (3). Carcinoma cervix is the second most common malignancy in women which accounts 12% of all cancers in the world (4).
In Indian women Carcinoma of cervix is the most common cancer that is 20% of all malignant tumours in the females (5). The Cervical cancer in urban areas constitutes 40% of cancers while in rural areas it accounts for 65% of cancers. In the rural area it is difficult to carry out screening and follow-up due to lack of awareness among people (6). There was a related study done on Hysterectomy specimen in our department (7). One literature is available related to this topic in Bastar region (8). The aim of this study was to classify various histomorphological patterns and age distribution of cervical lesions.
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Material and Methods |
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This is a retrospective study conducted at Department of Pathology at Late BRKM Medical College Dimrapal, over a three years period from 1st January 2017 to 31st December 2019. Sample size represents the data retrieved from register which were 349 cases. Retrospective analysis is commonly used to assess clinical outcomes, treatment patterns or in cases where the required parameters are not captured in large data sets. Therefore, there is no perfect method for calculating the sample size. Three commonly used sampling methods are convenience, quota and systematic sampling. It is the likelihood that the test is correctly rejecting the null hypothesis (i.e., proving our hypothesis). The study has 80% power means that the study has an 80% chance of test having significant results. The data of total 349 cases were retrieved from past records that were diagnosed with various cervical lesions.
Relevant and available clinical information regarding age, parity, clinical features and provisional diagnosis were obtained from the histopathology requisition forms and register.
All the slides of the cases were retrieved and examined. Tissue block of cervical tissue were retrieved wherever required, sections cut into 5 μ thickness using rotatory microtome and subsequently sections stained with Haematoxylin and Eosin (H&E). The present study classified cervical tumor according to WHO classification of tumours of the uterine cervix 2014 at 400x magnification (9).
Inclusion criteria: All the cervical biopsies and hysterectomy specimens received in Department of Pathology from January 2017-December 2019.
Exclusion criteria: Cervical biopsies found to be unsatisfactory for evaluation on microscopic examination (Autolysed specimen and disrupted or crushed sample).
Statistical Analysis
Data was compiled in MS excel sheet and descriptive data are presented in the form of frequencies and percentage.
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Results |
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Out of 349 cases, a majority 259 (74.21%) were non-neoplastic, 11 (3.15%) were preinvasive cervical intraepithelial lesions and 79 (22.63%) cases were malignant (Table/Fig 1). This is a retrospective study so no follow up was done and mortality cannot be commented.
Age of patients ranged from 20 to 77 years. The youngest patient was 20 years and oldest patient was 77 years with a mean age of 48.5 years. Maximum number of cases 145 (41.55%) were found in 41-50 years age group, 126 (36.10%) cases in 31-40 years age group, 30(8.6%) cases in 51-60 years of age group,29 (8.30%) cases in 20-30 years age group,15 (4.3%) cases in 61-70 years age group with minimum no. of cases 4 (1.15%) in >70 years of age (Table/Fig 2).
Out of 349 cases, Chronic non-specific cervicitis 223 (63.89%) was the most common finding. In Preinvasive (Cervical Intraepithelial Lesions), HSIL constituted maximum cases. In malignant lesion the most predominant malignancy was Squamous cell carcinoma 66 cases (18.9%) (Table/Fig 3).
In non- neoplastic lesions maximum cases seen in both Chronic non-specific cervicitis and Chronic cervicitis with squamous metaplasia were in 41-50 years. In Preinvasive (Cervical Intraepithelial Lesions) maximum number of cases of Low Grade Squamous Intraepithelial Lesion was seen in 3rd decade and maximum number of cases of High Grade Squamous Intraepithelial Lesion in 4th decade. Maximum no. of cases of Squamous cell Carcinoma were in 4th decade (Table/Fig 4).
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Discussion |
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Cervical specimens either from Hysterectomies or punch biopsies were the main bulk of specimens which were reterived in the Department of Pathology. Among 349 cases, Hysterectomy 212(60.7%) was the most common type followed by the cervical punch biopsy specimens i.e., 137(39.3%) which was similar to the studies done by Upadhyay et al., (10) and Gupta N et al., (1).
The youngest patient was 20 years and the oldest patient was 77 years with a mean age of 48.5 years. This age range was comparable with the study done by Bagde S et al., (6). Maximum number of cases 145 (41.55%) in the age group seen in 41-50 years (Table/Fig 2) with these findings are comparable with the study done by Bhagyashree et al., (11).
The present study shows Non-neoplastic lesions are more common than Malignant lesions in the Bastar region which was similar to the studies done by Poste et al., (14), Saravanan S et al., (13) and Bagde S et al., (6) (Table/Fig 5). But on the contrary the study done by Ali EF et al., showed Malignant condition (51.2%) were more common than Non-neoplastic (46.34%) (12).
The present study showed that maximum number of Non-neoplastic lesions were in the age group 41-50 year which were well corroborated with findings of Bhagyashree et al., (11). While Kumari K et al., (15) showed maximum number of cases in 31-40 year age group (Table/Fig 6).
Among Non-neoplastic lesions, Chronic non-specific cervicitis constituents highest percentage (Table/Fig 7). Due to a lack of health awareness, early marriage, and poor personal hygiene in Bastar tribal region, Chronic non-specific cervicitis accounts for the majority of disease burden in this study. Kumari K et al., (15) and Saravanan S et al., (13) also had similar finding. Maximum number of cases of Chronic non-specific cervicitis was in 41-50 years which was comparable with previous studies done by Bhagyashree et al., (11) and Patel et al., (16). Tuberculosis of the cervix is almost invariably secondary to tuberculous salpingitis and endometritis and is typically associated with pulmonary tuberculosis (17). The incidence of cervical tuberculosis in the general population is 2-6% (18). The present study, showed one case of Cervical Tuberculosis (0.29%) and that patient was a known case of Pulmonary Tuberculosis.
Maximum number of cases of cervical polyp and Papillary endocervicitis were in 31-40 years (Table/Fig 8). Preinvasive (Cervical intraepithelial lesion) accounts for 11(3.15%) which was comparable with findings in 51(4.04%) cases in Poste et al., (14).
LSIL is associated with HPV infection and does not progress directly to invasive carcinoma. Mostly LSILs regress and only a small percentage progress to HSIL (19). The hallmark of infection with HPV is koilocytic change in the epithelial cells (18).
Out of 11 cases (3.15%), of Pre invasive (Cervical intraepithelial lesion), majorities were High-Grade Squamous Intraepithelial Lesions seen 7in the age group 31-40 years (Table/Fig 9). Low-Grade Squamous Intraepithelial Lesions were seen in 21-30 years. While Kumari K et al., (15) showed the most common age group 31-40 years both in LSIL and HSIL.
The present study showed LSIL were seen in the 3rd decade while HSIL were observed in the 4th decade therefore HSIL can be prevented by early screening of the diseases and educating people. The specificity of diagnosis of HPV has increased by techniques like polymerase chain reaction, HPV genotyping, in situ hybridization and molecular studies (20)(21). HPV vaccine plays a key role in the prevention of cervical cancer in developing countries (20), (22).
Malignant lesions comprise of 79 (22.63%) and findings were comparable with the study done by Jain A et al., which showed 25(23.7%) cases (5). The malignancy spectrum, most common malignancy was Squamous cell carcinoma 66 (18.91%). Adenocarcinoma was the second most common epithelial neoplasm constituting 11 cases (3.15%). The maximum number of cases both for Squamous Cell Carcinoma and Adenocarcinoma occurred in the 4th decade and this was comparable with Jain A et al., (5). The present study showed the youngest patient of Squamous Cell Carcinoma was 28 years and the oldest patient was at 72 years. Out of 66 cases of Squamous Cell Carcinoma, 40 cases were Well-differentiated Squamous Cell Carcinoma (Table/Fig 10), 20 cases were of Moderately differentiated Squamous Cell Carcinoma (Table/Fig 11) and Poorly differentiated Squamous Cell Carcinoma were 6 cases (Table/Fig 12).
Papillary Squamous Cell Carcinoma is a rare variant of Squamous Cell Carcinoma of cervix (17). The present study showed one case of Papillary Squamous Cell Carcinoma aged 50 years (Table/Fig 13).
This study found one case each of the Endocervical adenocarcinoma of villoglandular type and Endometrial carcinoma metastasizes to Cervix was seen [Table/Fig-14,15].
Adenosquamous carcinoma of the cervix is rare. It is defined as having both glandular and squamous cell differentiation, each component malignant (23). The present study, reported one case of Adenosquamous Carcinoma aged 72 years (Table/Fig 16).
The present study show Non-neoplastic lesions were more common than Malignant lesion followed by Preinvasive lesion. Chronic cervicitis was the major inflammatory lesions and Squamous Cell Carcinoma was the most common Malignant lesions.
Authors came across less number of cases of malignancy compared to other studies because this is a tribal area where fewer people come to the hospital and in advanced stage or referred to higher centers for further treatment. People usually treat chronic conditions indigenously at their home.
Limitation(s)
The present study revealed a wide spectrum of cervical lesions in a small study population. Follow-up could not be done in cases of malignant lesions as they are referred to the higher center. In this study, Low Grade Squamous Intraepithelial Lesions could not be followed up with HPV DNA testing and HSIL with LEEP, conization because of their unavailability in our setup and high cost.
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Conclusion |
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The present study showed that the non-neoplastic lesions were more common than Neoplastic lesions and Chronic cervicitis being the most common. In Bastar region Squamous cell carcinoma was most common among cervical malignancy. Present study found two rare cases one was Papillary Squamous cell carcinoma and another was Adenosquamous carcinoma. Histopathological examination of cervical biopsy is gold standard for diagnosis of cervical lesion and helps clinician for further management. Adequate screening procedure with follow up cervical biopsies helps in early diagnosis and management of premalignant and malignant lesions.
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