Cervical cancer is an important global health concern and it is also one of the leading causes of cancer-related morbidity and mortality in females in low- and middle-income countries [1]. As per the World Health Organization (WHO), cervical cancer is the fourth most commonly diagnosed cancer in women [2]. It is estimated that approximately 604000 new cases and about 342000 deaths occur worldwide in 2020 because of cervical cancers [2]. Human papillomavirus is an important etiological cause of cervical cancer. Initial infection of HPV leads to the development of precancerous lesions known as cervical intraepithelial neoplasia (CIN) [3]. Early detection is crucial for effective management which can prevent progression to invasive carcinoma. The Papanicolaou (Pap) smear test has been used extensively for cervical cancer screening programs since the time it was introduced in 1940 [4]. It is based on the cytological examination of the exfoliated cells of the cervix to detect cellular abnormalities. The Pap smear has significantly reduced the incidence and mortality of cervical cancers. This is due to the effective implementation of screening programs [5]. However, Pap smear has its limitations which include false-negative and false-positive results. This could be due to sampling errors, the presence of coexisting inflammation or infection, and interpretation variability [6]. Histopathology is the gold standard for examining the tissue samples obtained by colposcopy-guided biopsies. This method allows for the assessment of cellular changes in the cervical epithelium. It also enables the classification of lesions into specific grades of CIN or invasive carcinoma. Because histopathology is an invasive procedure it is reserved for those cases showing abnormal Pap smear findings or clinical suspicion of malignancy. The comparison of Pap smear testing outcomes to histopathological examinations stands as an essential component in cervical cancer diagnosis procedures. Histopathology together with Pap smears enables to determination of proper treatment options through definitive assessment of lesions. Studies in this field indicate that there are different levels of agreement regarding the results from Pap smear cytology compared to histopathology examinations due to the fundamental constraints of cytological examination practices [7, 8]. Understanding these discrepancies is essential for improving diagnostic accuracy and optimizing patient outcomes. Based on these observations the current study was done to evaluate the histopathological spectrum of uterine cervical lesions and correlate the findings with Pap smear results. The results of the diagnostic accuracy of Pap smear in detecting abnormalities this research will enhance the effectiveness of cervical cancer screening programs.

This study was conducted at the Department of Pathology, Mahavir Institute of Medical Sciences, Vikarabad, Telangana. Institutional Ethical approval was obtained for this study. Informed consent was obtained from all participants after explaining the nature of the study in vernacular language. Cervical smears were obtained from the Department of Gynaecologists, Ayres Spatula. The smear was covered with Biofix Spray, and the slides were taken to the Department of Pathology. These smears were immersed in Papanicolaou fixative (equal volumes of 95% ethanol and ether) for a minimum of 30 min and stained with Papanicolaou stain using the standard protocol. The cytological features of the smears were examined in detail. Histopathological specimens were ground and processed, and blocks were made. Sections of 3-5 microns were prepared, stained with H&E, and examined microscopically. Satisfactory smears that consisted of well-preserved and well-visualized squamous cells that were spread over more than 10% of the slide surface and with adequate endocervical/ transformation zone components (minimum of two clusters of well-preserved endocervical and/or squamous metaplastic squamous cells) were included in the study. Biopsy and hysterectomy specimens were fixed in 10% formalin, were processed by routine procedure to obtain paraffin sections, and were stained with Haematoxylin and Eosin. Histopathology reporting was performed separately without knowledge of the cytology reports. Later, cytological features were correlated with histopathological findings. To substantiate this correlation, the results of the present study were calculated using the methodology of Galen and Gambino.

Statistical analysis: All the available data was refined, segregated, and uploaded to an MS Excel spreadsheet and analyzed by SPSS version 22 in Windows format. The continuous variables were represented as mean, standard deviation, and percentages. The categorical variables were calculated by application of Pearson's Chi-square test. The values of p which were less than 0.05 were considered as significant. The level of agreement was calculated by Sensitivity, Specificity, positive predictive values (PPV) and negative predictive value (NPV).

During the period of our study, we studied 75 women in whom both cytological and histopathological samples were obtained. This included n=40 cases of punch biopsies, n=30 total hysterectomies, and n=5 pan-hysterectomies. The age range of the women in the study was 24 – 74 years and the mean age of the cases was 28.55 ± 8.5 years. The maximum number of cases were from the age group of 21 – 30 years with n=30(40%) samples were obtained.  In this study, the overall cytological diagnosis showed 60 cases with benign lesions, n=12 cases with epithelial cell abnormalities, and n=3 cases with normal cells. In the smears within the normal limits among the n=3 cases histopathology showed features of chronic cervicitis in two cases and n=1 case of chronic papillary endocervicitis.

Table 1: Depicting the Benign cellular changes in the cases of the study

In the benign cellular changes depicted in Table 1. It was found that 68.3% of cases were with features of chronic cervicitis. These smears showed the admixture of superficial and intermediate squamous epithelial cells, marked cytolysis, and inflammatory exudate consisting of neutrophils, lymphocytes, and macrophages. Lactobacilli were visible in all cases and clue cells were visible in 1 case. In one smear there were Trichomonas vaginalis organisms which had pear-shaped appearance and pale blue to green in color, with an eccentric, slightly basophilic nucleus (Table 2).

Table 2: Histopathological diagnoses in cytologically diagnosed cases of chronic cervicitis(N=41)

In the cytologically diagnosed cases of chronic cervicitis with squamous metaplasia, the additional features were the presence of varying numbers of immature, maturing, and mature metaplastic squamous cells. Immature metaplastic cells were observed in sheets and had dense hydrophilic cytoplasm with occasional cytoplasmic vacuolations. Maturing metaplastic squamous cells were recognized by cytoplasmic elongations, indicating spider cells. Mature metaplastic squamous cells have a doubly thick border.

Table 3: Epithelial cell abnormalities in cytological study

The findings from Table 3 show that the abnormalities range from benign inflammatory changes to premalignant and malignant lesions. The presence of chronic cervicitis in most cases highlights the role of inflammation as a precursor or coexisting condition in cervical pathology. Premalignant lesions (LSIL and HSIL) were observed in 23.1% of cases, emphasizing the importance of early detection and intervention to prevent progression to invasive carcinoma. Invasive squamous cell carcinoma was the most common malignant finding (30.8%), underscoring the need for effective screening programs to detect cervical cancer at earlier, treatable stages. Glandular abnormalities, including endocervical dysplasia and endometrial hyperplasia, were also notable.

One case of chronic cervicitis with atypical squamous metaplasia showed clusters of endocervical cells, along with immature and mature metaplastic squamous cells. Some atypical metaplastic cells had large, hyperchromatic nuclei with thick cytoplasm. Histopathology revealed features of chronic papillary endocervicitis. LSIL smears displayed parabasal, intermediate, and superficial squamous cells with slightly enlarged nuclei. HSIL smears showed scattered squamous cells, with some exhibiting hyperchromatic nuclei and coarse chromatin. Invasive keratinizing carcinoma cases had abnormal squamous cells with marked nuclear pleomorphism, tadpole cells, and multinucleated tumor giant cells, with dyskeratosis and tumor diathesis in the background. Histopathology confirmed all cases. One case of invasive large-cell non-keratinizing squamous carcinoma exhibited abnormal squamous cells with cyanophilic cytoplasm, vesicular nuclei, and occasional nucleoli, with sparse mitoses. Smears of chronic cervicitis with endocervical glandular cell dysplasia showed overlapping endocervical cells with hyperchromatic nuclei and increased nuclear-cytoplasmic ratio.

Table 4 depicts the Statistical values of detecting malignant lesions by cervical cytology using the Galen and Gambino method, and summarizes the performance of cervical cytology in detecting malignant lesions. The Galen and Gambino method is a statistical approach used to evaluate the diagnostic accuracy of a test by calculating key metrics such as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Table 4: Statistical values of detecting malignant lesions by cervical cytology using Galen and Gambino method

Table 5 shows the sensitivity, specificity, PPV, and NPV of Pap smears. The Pap smear was excellent at confirming cervical abnormalities when the result is positive (100% PPV) and ruling out abnormalities in healthy individuals (100% specificity). However, the test misses 20% of true positive cases, which may lead to delayed diagnosis and treatment. This underscores the importance of combining Pap smears with other screening methods (HPV testing) to improve sensitivity. The test is reliable for ruling out cervical abnormalities when the result is negative (98.5% NPV), though the lower bound of the 95% CI (91.4%) suggests some variability in performance.

Table 5: Diagnostic accuracy of Pap smear based on the final histopathological findings

This study was done to determine the diagnostic utility of cervical cytology in identifying various cervical lesions on Pap smear. The value of cytological diagnosis depends on having a good correlation with histopathology which is considered as gold standard. Sodhani et al. [9] in their cyto-histological correlation study, concluded that cyto-histological correlation is a measure of quality assurance of a cytology laboratory. Our study evaluated the correlation of cervical lesions in 75 women. This study found that chronic cervicitis is the most commonly noted benign lesion and invasive squamous carcinoma is the most common malignancy. The findings of our study are in concordance with other similar studies. The Bethesda System for cervical cytology reporting investigated by Solomon et al. [10] demonstrated that although the Pap smear serves as vital in cervical cancer screening it performs differently across patients with sensitivity rates between 50% and 80%. The sensitivity detected in our study reached 80% and matched results obtained in Solomon et al. [10] and Schiffman et al. [11]. The diagnostic value of Pap smears for cervical malignancies is demonstrated by their 100% specificity and PPV (100%) that we measured in our study. The diagnosis of chronic cervicitis occurred in 68.3% of cases which matches Gupta et al. [12] study that reported 65% inflammatory changes in their study population. Chronic papillary endocervicitis showed up in 18.3% of cases to emphasize infection maintenance as a cervical disease contributor. Squamous metaplasia appeared in both Nayar and Wilbur's [13] study about chronic cervicitis as well as in our research. Among 75 examined cases our research detected 12 epithelial cell abnormalities amounting to 16% of total findings with LSIL and HSIL constituting 23.1% of the abnormal results. A similar LSIL and HSIL prevalence rate was detected in cytological studies by Cibas et al. [14]. Early detection and intervention become crucial factors because invasive squamous cell carcinoma exists in 30.8% of analyzed cases.

Early detection is critical because invasive squamous cell carcinoma exists in 30.8% of cases, according to Akinfolarin et al. [15], who reported a comparable 28% prevalence in their cervical malignancy histopathological study. The investigation of pathologic cell changes in the Pap smear results demonstrated that two out of three cases initially diagnosed as normal by the smear method contained chronic cervicitis upon histological examination. The low sensitivity rate (80%) of Pap smear testing indicated that possible underdiagnosis occurred because the method showed 100% specificity. Sankaranarayanan et al. [16] found similar results by indicating a Pap smear sensitivity range from 75–85% which they proposed that HPV co-testing would improve early detection. The interpretation of chronic cervicitis with squamous metaplasia at a rate of 6.7% matches previous research that documented equivalent metaplastic alterations in cases of chronic cervicitis [17]. Research data have shown that extended inflammation can act as a factor for creating premalignant cell changes [18]. Statistical analysis using the Galen and Gambino method established positive Pap smear results as highly reliable indicators of malignant lesions because they showed a perfect specificity of 100% and a positive predictive value of 100%. Supplementary screening approaches should be implemented because both false-negative rates and low sensitivity levels were observed in this study. Nayar et al. conducted a meta-analysis and showed that Pap smears continue to be efficient screening methodologies, yet their advanced screening requirements call for coexistent testing approaches, such as HPV DNA testing or liquid-based cytology

In conclusion, cervical cytology is a valuable tool for detecting cervical abnormalities, with high specificity and PPV. However, its moderate sensitivity highlights the need for complementary diagnostic methods to improve early detection and reduce false-negative rates. The integration of cytological and histopathological findings provides a comprehensive approach to cervical cancer diagnosis and underscores the importance of multidisciplinary collaboration in optimizing patient outcomes.

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