Abstract
Background
Though Atypical squamous cells of undetermined significance (ASCUS) are not always precursors of cervical pre-malignancy but they need timely diagnosis and careful periodical follow-up.
Aim
The present study was carried out to investigate the incidence of ASCUS and SIL (squamous intraepithelial lesion of cervix) in women under rural setting.
Materials and Methods
Cervical cancer screening is in progress in rural population of West Lucknow, India, since May 2013 under auspices of Era’s Lucknow Medical College and Hospital, Lucknow, and a total of 2478 women have been cytologically examined till October 2017.
Results
The incidence of ASCUS was found to be 8.8%, which was approximately less than half of the squamous intraepithelial lesions of cervix (SIL) rate (17.9%). The ASCUS rate was higher in the symptomatic women (9.4%) than (7.4%) seen in women without symptoms. The ASCUS incidence was higher in younger sexually active group up to 40 years after which it declined. The ASCUS rate was higher in all parity groups and was commonly associated with pain in lower abdomen and vaginal discharge. The ASCUS rate was higher with erosion cervix, while the commonly associated sexually transmitted diseases (STD) were found to be Candida albicans (2.4%). Follow-up after 18–24 months was available in 40 cases of ASCUS, and progression to low-grade SIL (LSIL) was seen in 7 (17.5%) and to high-grade SIL (HSIL) in one case (2.5%).
Conclusion
The findings suggest that the ASCUS are not always precursors of SIL, but they need periodical follow-up after every 6 months. This will be ideal management of ASCUS under low-resource settings.
Keywords: ASCUS, SIL, Rural women
Introduction
Since its introduction in 1988, ASCUS has been focus of great interest to pathologists, clinicians, patients and society because it is a problematic lesion categorized somewhere between the inflammatory conditions and LSIL of cervix. Because the cellular changes in the ASCUS category may reflect an exuberant benign change or a potentially serious lesion which are unequivocally classified, they are interpreted as being “undetermined significance.” Since we have sufficient data of cervical cytology in rural women obtained from cervical cancer screening program, we thought it interesting to also report the ASCUS findings considering high incidence of SIL observed in these women.
Materials and Methods
During cervical cancer screening program carried out in Kakori and Malihabad block of west Lucknow between May 2013 and October 2017, 142 camps have been organized for early detection of cervical cancer after proper counseling and motivation. Prior approval has been obtained from the Ethical Committee of the Institution for carrying out this Rural Screening Program. The rural women were explained about the objective of the study, i.e., early detection of cervical cancer, and their informed consent was taken for participating in the study and collection of pap smears for cytological evaluation. A total of 4442 women in the risk age-group attended these camps, out of which only 2478 (55.7%) consented for pap smear examination. The cervical smears were taken by the junior resident of gynecology department after performing per speculum examination. The cervical smears were immediately fixed in absolute alcohol and transported to Department of Pathology of the College for staining according to the Papanicolaou’s technique. The cytopathological changes observed in the cervical smears were graded according to the Revised Bethesda system of reporting cytological changes in the cervical smears [1].
ASCUS is morphologically heterogeneous owing to the context of the atypical cells, and their four main types are described by the International Academy of Cytology Task Force on ASCUS and ASCUS criteria [2]. These four types found in the cervical smears have been described in the literature in detail as follows [3].
Atypical Squamous Cell with “Mature” Intermediate Type of Cytoplasm
There is nuclear enlargement in squamous cell with mature superficial-/intermediate-type cytoplasm. The nuclei are enlarged 2.5–3 times the size of a normal nucleus and may have slight hyperchromasia with finally granular, evenly distributed chromatin. The nuclear membrane irregularities are not common (Fig. 1).
Fig. 1.
Ectocervical smear showing atypical squamous intermediate cells with nuclear enlargement and mild hyperchromasia (Pap × 400)
Atypical Metaplastic Cells
It is also known as atypical immature metaplasia; these squamous cells have scanty, dense amphophilic cytoplasm with rounded short border and increased N/C ratio. The nuclear enlargement is 1.5–2 times than normal nucleus. The nuclei are usually hyperchromatic and may have slight irregular nuclear membrane, but the chromatin is finally granular and evenly distributed (Fig. 2).
Fig. 2.
Ectocervical smear showing a cluster of atypical immature metaplastic squamous cells with nuclear enlargement and mild hyperchromasia (Pap × 400)
Atypical Squamous Cells in the Setting of Atrophy
A spectrum of reactive and atypical changes may be seen in the background of atrophy and includes nuclear enlargement, hyperchromasia, abnormalities in the chromatin distribution and nuclear membrane and pleomorphism (Fig. 3).
Fig. 3.
Ectocervical smear showing atrophic squamous cell with nuclear enlargement, hyperchromasia and pleomorphism (Pap × 400)
Atypical Parakeratotic Squamous Cells
This type includes changes described as dyskeratosis or atypical parakeratosis and is characterized by miniature polygonal squamous cells with dense organophilic cytoplasm and pyknotic nuclei. There may be increased nuclear/cytoplasmic ratio and mostly irregularly distributed chromatin.
Results
Cytological evaluation of cervical smears in 2478 women revealed the following pattern of ASCUS and SIL findings
ASCUS—218 (8.8%)
SIL—445 (17.9%)
No case of frank carcinoma was seen.
The incidence of ASCUS was low (8.8%) as compared to that of SIL (17.9%). This difference was statistically highly significant (p < 5.0). The ASCUS incidence in the four categories of cells involved was found to be as follows:
Intermediate cell type—179 (7.2%)
Atrophic type—31 (1.2%)
Metaplastic type—7 (0.2%)
Parakeratotic—Nil
Most common type of ASCUS found was those involving intermediate cells (7.2%) followed by those associated with atrophic changes (1.2%). The cytological changes seen in the metaplastic cells were found low only in seven cases (0.2%), while no case of parakeratotic type of cells was seen.
Follow-up after 12–24 months was possible in 40 of the 218 ASCUS cases, and the lesion was found to have progressed to LSIL in seven cases (17.5%) and to HSIL in one case (2.5%), while regression to normal was seen in the remaining 32 cases. On the other hand, follow-up was available after 12–24 months in 172 LSIL cases, which reveal progression to high grade in one (0.5%) persistence of the lesion in 54 (31.3%) and SIL was found to have reverted back to normal in the remaining 117 cases.
Of the 2478 women registered for the study, 1662 were symptomatic while remaining 816 were asymptomatic. The incidence of ASCUS in these two groups has been analyzed and is shown in Table 1. The incidence was higher in symptomatic women (9.4%) than 7.2% seen in the asymptomatic women. Individually, similar trend was seen in three types of ASCUS. The incidence of SIL was, however, identical in both the groups. The SIL incidence was more than double than that seen in ASCUS in both groups of women.
Table 1.
Incidence of ASCUS and SIL in symptomatic women and those without symptoms
| Group | Total number of cases | SIL incidence | ASCUS incidence | ASCUS | ||
|---|---|---|---|---|---|---|
| Intermediate type | Atrophic type | Metaplastic type | ||||
| Asymptomatic | 816 | 140 (17.1%) | 61 (7.4%) | 51 (6.2%) | 9 (1.1%) | 1 (0.1%) |
| Symptomatic | 1662 | 305 (18.3%) | 157 (9.4%) | 129 (7.7%) | 22 (1.3%) | 6 (0.3%) |
Age wise, the distribution of ASCUS is shown in Table 2 from which it is evident that the ASCUS incidence was higher in younger and sexually active women between 20–40 years after which it declined. However, SIL rate was found to be identical in all age-groups.
Table 2.
ASCUS incidence in relation to age
| Group | Total number of cases | SIL incidence | ASCUS incidence |
|---|---|---|---|
| Up to 20 years | 89 | 15 (16.8%) | 11 (12.3%) |
| 21–30 | 946 | 178 (18.8%) | 88 (9.3%) |
| 31–40 | 820 | 149 (18.1%) | 83 (10.1%) |
| Above 40 years | 623 | 103 (16.5%) | 36 (5.7%) |
The incidence of ASCUS was also analyzed in relation to parity (Table 3). The SIL rate showed rise with increasing parity being maximum in multiparous women. The ASCUS rate, on the other hand, showed a fluctuating trend being higher in women with low parity of one.
Table 3.
ASCUS incidence in relation to parity
| Group | Total number of cases | SIL incidence | ASCUS incidence |
|---|---|---|---|
| Po | 149 | 10 (6.7%) | 5 (3.3%) |
| P1 | 230 | 38 (16.5%) | 34 (14.7%) |
| P2 | 408 | 69 (16.9%) | 39 (9.5%) |
| P3 and above | 1691 | 328 (19.3%) | 140 (8.2%) |
As regards the gynecological symptoms, the incidence of ASCUS was high in women with vague pain in the lower abdomen (10.2%) and vaginal discharge (9.3%—Table 4). On the contrary, the SIL incidence was found higher in women with all symptoms specially contact bleeding and postmenopausal bleeding.
Table 4.
ASCUS incidence in relation to different gynecological symptoms
| Symptoms | Total number of cases | SIL incidence | ASCUS incidence |
|---|---|---|---|
| Leucorrhea | 864 | 141 (16.3%) | 81 (9.3%) |
| Pain in lower abdomen | 656 | 118 (17.9%) | 67 (10.2%) |
| Menstrual disorders | 199 | 25 (12.5%) | 13 (6.5%) |
| Contact bleeding | 5 | 1 (20%) | – |
| Postmenopausal bleeding | 5 | 2 (40%) | – |
Analysis of ASCUS in different clinical lesions of cervix revealed its higher incidence with cervicitis (12.5%) and erosion cervix (11.2%) followed by the hypertrophied cervix (5.2%—Table 5). Hence, cytological monitoring is mandatory in these clinical lesions to investigate ASCUS. Moreover, these clinical lesions mostly harbor inflammatory changes in the cervix, which in severe cases may lead to ASCUS. On the other hand, the SIL rate was higher with all types of cervical lesions, especially cervix bleeds on touch (35.2%).
Table 5.
ASCUS incidence in relation to different types of clinical lesions of cervix
| Clinical lesions of cervix | Total number of cases | SIL incidence | ASCUS incidence |
|---|---|---|---|
| Erosion and unhealthy cervix | 197 | 46 (23.3%) | 22 (11.2%) |
| Hypertrophied cervix | 38 | 10 (26.3%) | 2 (5.2%) |
| Cervix bleeds on touch | 17 | 6 (35.2%) | – |
| Cervicitis | 8 | 2 (25.0%) | 1 (12.5%) |
| Others (endocervical polyp, rectocele and cystocele) | 108 | 18 (16.6%) | 2 (1.8%) |
The ASCUS was found associated only with the infection of Candida albicans (2.4%), while no association was seen with trichomonal infection, condyloma and herpes simplex (Table 6). On the contrary, the SIL rate was very high with all types of STDs except TV infection, being extremely higher with viral STDs.
Table 6.
ASCUS incidence in relation to different STDs
| STDs | Total number of cases | SIL incidence | ASCUS incidence |
|---|---|---|---|
| Candida albicans | 121 | 28 (23.2%) | 3 (2.4%) |
| Trichomonal infection | 28 | 5 (17.8%) | – |
| Condyloma (HPV) | 12 | 9 (75.0%) | – |
| Herpes simplex | 3 | 1 (33.3%) | – |
Discussion
The incidence of ASCUS was found to be 8.8% in the present series (218/2478 women). It has been documented that ASCUS rate is less than 5% in the low-risk population and less than two to three times the SIL rate in the high-risk population [3]. Since the women of rural population, which form the subject matter of the study, practice poor hygiene and consequently harbor persistent vaginal infection, they are considered to be high-risk group for developing cervical cancer. In these women, the SIL rate was found to be 17.9% and the ASCUS rate was less than half of SIL (8.8%). This is in concordance with the recommended rate of ASCUS in the high-risk population. However, some other Indian workers have reported a low incidence of ASCUS in rural community. Srivastava et al. have reported an incidence of 4.9% of ASCUS in the pap smears of women attending outdoor department of Pravara Rural Hospital, Loni [4]. Ganeshan et al. [5] have found a very low incidence of 2% of ASCUS in a cytological study performed in 250 women of coastal area of Tamil Nadu. Ambedkar et al. in a pap smear study of postmenopausal rural women of Chennai have seen 4.2% of ASCUS [6]. A high incidence of SIL than that seen with ASCUS in the present series, in all probabilities, demonstrates that the ASCUS is precursor of LSIL. The reporting of ASCUS in the cervical smears thus leads to be detection of SIL in a significant number of cases. Hence, further periodical evaluation of ASCUS is essential [7]. Most of the investigators agree that ASCUS warrants frequent monitoring due to the increased detection of SIL. The cytological follow-up is acceptable mode of management, and repeat pap smear after every 3–6 months is recommended for a period of 2 years. If a worse lesion or persistent borderline abnormality is detected, the patients should be referred for colposcopy [8]. It is felt so because the ASCUS lesions are mostly benign and hence do not need further treatment, and a high percentage of them will regress spontaneously. The whole procedure is cost-effective than doing immediate colposcopy [9]. Putting the patients to unnecessary anxiety could also be avoided, and it appears to be one of the potential benefits of cytological surveillance [10].
It has been seen the women above the age of 30 years diagnosed with the ASCUS significantly predict the presence of high-risk HPV types. Hence, a strategy of limiting HPV testing in older women and referring those below 30 years for colposcopic assessment appears more effective [11]. Similar suggestion has also being made by Selvaggi et al. [12]. However, low predictive value of HPV testing with ASCUS smear suggests that HPV positivity should not be used for predicting CIN 2 or 3 [13]. On the other hand, Yarandi et al. [14] have suggested that considering the high sensitivity of HPV-DNA testing, it may be useful as an alternative to the current policy of 6-month repeat cytology. Yoon et al. [15] have also found that HPV-DNA testing is useful for predicting the severity of lesions of uterine cervix and formulate decisions with regard to treatment plans. Del Mistro et al. [16] have also found HPV testing showing best performance in high sensitivity and specificity in ASCUS patients. Barcelos et al. [17] have also seen that HPV-DNA testing in ASCUS patients is associated with increased risk of SIL. Though HPV-DNA testing is most suitable method for detecting SIL among ASCUS patients, in low-resource setting where the procedure is unaffordable, threshold for colposcopic and follow-up cytology appears to be best alternative method for the management of ASCUS [18].
In the present study, the ASCUS was found most prevalent in symptomatic women than in without symptoms. Similar trend was also seen with SIL, but the incidence figure was just double than ASCUS in both symptomatic and asymptomatic cases. In the present series, the ASCUS was found more common in the perimenopausal than in the postmenopausal patients. This has also being reported by Lavazzo et al. [19]. However, the SIL rate was found to be higher in all age-groups. Misra et al. [20] have, however, found that SIL rate is increasing with high age in urban population of Lucknow. As regards parity, the ASCUS was more prevalent with low parity of 1 and 2. This has also been reported by Lavazzo et al.
The ASCUS was more prevalent in patients with cervical lesions like cervicitis, erosion and hypertrophied cervix in the present study. Tokmak et al. [21] have also reported cervicitis as common finding with ASCUS. The authors have found 2.4% of ASCUS associated with Candida infection, while no case of koilocytosis and herpes simplex infection was seen in ASCUS smears. Lavazzo et al., on the other hand, have seen Candida in 25% and koilocytosis in almost half of the ASCUS smears.
Conclusion
The findings of the present study suggest that ASCUS cases are not always the precursors of SIL, but they need periodic follow-up after every 6 months. This is the most suitable arrangement for developing countries like India where fund crunch is the main problem for HPV-DNA testing. However, HPV testing may be conducted in those cases who develop the SIL on follow-up which is preferential than cervical biopsy. The aggressive treatment of such cases will check the progression of SIL to malignancy.
Further, ASCUS should be specially investigated in women showing clinical lesions of cervix like cervicitis, cervical erosion and hypertrophic cervix which mostly harbor inflammatory lesions, the severity of which may lead to ASCUS.
Acknowledgements
Sincere thanks to Secretary, Era’s Educational Trust of Era’s Lucknow Medical College And Hospital, Lucknow, for the financial support.
Dr. J. S. Misra
is a Cytologist and has worked in this field from 1971 to November 2005 at Queen Mary’s Hospital, K.G. Medical University, Lucknow, in Indian Council of Medical Research service. He was engaged in cervical cytological screening with special reference to the cytological evaluation of oncogenic potential of different new hormonal and IUD contraceptives on trial by ICMR. He developed cytology services of the hospital and has screened cervical smears of more than 38 thousand women during a span of 35 years. He has published 66 original papers, 19 in international and 47 in Indian journals. Currently, he is carrying out rural cytological screening since May 2013 in West Lucknow by organizing camps under Era’s Lucknow Medical College and Hospital, Lucknow.
Compliance with Ethical Standards
Conflict of interest
The authors declared that they have no conflict of interest.
Ethical Approval
This was obtained from the Ethical Committee of the college before starting the Rural Cancer Screening Program.
Footnotes
Anand N. Srivastava, M.D, Director, Research in Department of Pathology, Era’s Lucknow Medical College and Hospital, Lucknow. Jata S. Misra, Ph.D. Cytologist, in Department of Pathology, Era’s Lucknow Medical College and Hospital, Lucknow.
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