Shccla L. Caikrvadr. Arvincl G. \'aland2. Ncha \r. Agaru,alr.,

rAssociate Prolbssor', 2HOD. r.lunior Resirlent,

fjlyo.ds, Histopatholffil3lllgLogl{glvical lesions, Maharashh.a, Hospitat.

AbstractBackground: Ainr of thc sttrdy rvas to I<trow valious histopatholoeical valiants in ccrvical lcsion. its incidcncc with respcct to ascin Arrrbe.jouai city of Maharashtr-a.N{atcrials & Methods: A totill of6 1 8 cascs 01'cL'rvical lesions wele analysed prospcctively in a pcriod of2 years during Septc,rbcr.2013 to August 20-l5 to asscss vatious pattcru o1'cervical lesron. Cases were stu<tiecl in cietail about l-ristory. clinical exar-,i,atio,ancl otlrer findings.Results: of the total 618 cases, -5 l6 (83.50'%) werc non ncoplastic all of which wcrc inflarmatcrry ancl lo2(16.s,%)wcrc nc.plasticolivhich celvical Dralignancies, benign lesions and cervir:al intraepithelial neoplasia (ClN) r:onstitLrred g0(12.94%). )2tJ.9zl!zi,) and

fbllorvcd by papillary cndQccrlicitis 88(17.059/o). Thc associatcd c,hangcs of chronic nonspccitic ccr.vicitis u.,cr.c nabotlrian cysr

serr:all1' acrii'e period of lvonren i.e ll-50 years ra,ith a peak incidence in the age qroLrp of 3l-40 years. Cervical nraliqnirncies

thc agc g|ouP of '11-50 yca|s *'ith cINII as thc prcdonr.inant grlrJc having,.,'hit" dis.hrrgc as thc rrost corjlnlon synrpronr.conclusions:-Nou-ncolrlastic wcrc thc' corlllnoncst lcsions oi thc cerrixlworlcn in thc otclcr.agc groLlp with blcccling lrcr vaginashorrld bc suspc'ctc'd lol ccrvical nralignarrcy and shoLrld bc cxanrrncd for thc sanre.

clinico-histopathological analysis of lesions of uterineMaharashtra: A 2 year study at tertiary

IntroductionCervix is tlre lotver part ol uterus which connects

tlris organ to the vagina thr.ough the errclocervical canal.r)The celvix is both a serrtinel tbr potentially serious utr.lpergenital tract infectiotrs anrl a target for vir.uses anrl othercarcinogens which rray lead to invasive car.cinor.na of theuterinc ccrvix.(2) Invasivc sqLralroLrs cell carcinorna ofthe cervix is still the most common malignant tuntor ofthe f'enlale genital h'act in ntost couutr"ies ancl the nrostfrcqucnt ncoplasm alllorlg wonlclt in rnany of thcm.r)

Srlith and Penrberton (1934) reportecl a r.elationshipbctwccrr CIS (Carcinorrra irr situ) anrl irrvasivc canccrwherr they tbund that rhe changes tlescribecj as (.lS byBrodels \vere present in a r.etr-os1-lecti\ e r.evie,,\, ofbiopsics fionr paticnts who subsoqucntly clcvclopcclinvasive cancer. This collbination of' histologicobselvations and rutrospcctivc clinical analysis lcd to thcconcept that invasive squalnous cell carcinotta developsfi'onr prccur sor lcsitlts that carr bc itlcutilictl bv thcpathologist.(r)

Rcalizing its importancc, tlrough tJris srLrdy wc hopcto gct a bcttcr Llndcrstancling o1'thc rvlroic spcctrunt oflesions affecting the uterine cervix.

Material and MethodOn approval fi.om ethical cornrtrittee, in oul.

pros;tcctivc stucl1,. g I 8 cascs wcrc analyzccl fbr a pcrioclof 2 ycars dr-rring Sc1rtcrtrbcr 20l3 to ALrgust 20 i 5 inpathology departnrent ar SRTR Anrbe.jogai. It inclrrclesspccintcns ancl rct'crc-rrcc r-natcrial subnrittccl t(.)

cervix in Ambejogai city oflevel hospital

departr.nerrt of patlrology in the fbr-nr of triopsy speciurensand hystr:rccton-ry spccrmcus. Data ,,vas obtainccl tl"r_rurhospital records and specirrer.ls sent fr.or.n var.ior,rsdcparhnents. A11 thc lcsions of ccrvix involvingectocervix and endocer-r,ix rvere .iuclr.rded. VarioLrslcsions arising fiom thc utcnrs, vulva, vasina andparanretriuur wcrc excluded. Also thc lesions arisingfiont neighboulirrg or-gans extending to the cet.vical canalbut not int,olving thc ccrvical tissuc wcre cxciudcd.Every patient was evaluated by using a prelbrtrredprofonla.

Cross exarrrination was done and leatures such assizc. consistcncy. cxtcrnal apltcaratlcc anti oppcarancc ot'cut surf)ce were notetl. The specintetls were alloi.verl rofix in 10u/o lblmalin for 24 - 48 hoLus. Thc scctions wcr.cdchydratcd in alcohol, clcarcd in rylol and cnibedclcd inparaffin wax to plepal-e the paraflin blocl<s. Multiple thinscctions of 4 -5 microns in thickncss wcl.c cr.rr. MLrltiplcblocks fionr diflerent areas oflesion were stucliecl in eachcase. For histopathologioal stucly. the paraffin entbetlcledsections were stained by Henratoxylin and Eosin (H &E)stain.

ResultsOur hospital is tcr-tiary lcvcl and thc only govr.

rnetlical collcge in rlris area which rlrainetl the putientsfi-orrr all over thc- Anrbejogai region. The total nnirber o1.lcn.ralc gcnital tract lcsions w,as 2020. oLrt 0l' wltichcervical lesi<lns fiu'nieil a nta.jor. part c()nstttllting 6l ii(3tJ.59tYo) Icsrons. ln thc prcscnl stLrdy lrvstcr.cctomy \\,.as

i'Corresponding Author:

/tt11y17r,1 .f Diugtrttstit Pt.rlh.lttgt.untl Ortt..lrtg.t,, Ot,t.ltct._I)r,rrl,,rb* i)t6li),.i,-i5 32

Original Research Article

t't4taJ et ttl. C I i n i cr t' lt i.; tr4ttt t h o I r -'al anttl.ttsi-q of le.sions of utetine c,et.rti.t in Antbe.fogai cit.r..

thc rnost colnnton typc i.c. 512(g2.g50,1,) of sltcciurcnsrcceived fol histopathological exanlination follor,vecl bythc spccinrcns tionr cervical pr-rnch biopsy tt6( l3.L)2%),polypcctorny 1l(l .78%) ancl Fottrcigills opcrarion9(1.4s%).

Arnong the total 6l 8 lesions 5 I 6(g3.50926) were non_ncoplastic and 102(16.50%) u,cre ncoplastic. All thenon-neoplastic lesions _5 I6(g3._5%) were foundrntlalrxratory typc Among the total 102(16.5o/,,)ncoplastic lesions, nlost comlron u,as tl.rc malignantlesicrrrs 80(12.94'%) fbllowed by benign lesiorrst2(1.94%) & CiN as 10(1.62%). (Tablc t)

Chronic nonspeciljc cervicifis \^/as the conlulonestinflamnratory lesion foLrncl in 42g(g2.9-5o/i,) casestbllowed by papillary endocer.vicitis totind in88( I 7.05%) cases. lnllarrmatory Iesions both chronicnonsltccific cer-vicitis and paprllary cndoccrvicitis wer.ccorlnronly for"urd in the sexnally active period of womeni e. 31-50 years with a peak inciclence in tlie age groLrpof 3l -40 years. (Tabte 2) (Fig. I )

Chronic nonspecific ccrvicitis (CINSC) wasassociated with other histological changes likekoilocytosis 96(22.43%), nabothian cysr -5lal 1.92%),and squanrous mctaplasia 50(l l.6g%).

. Endocervical polyp rvas the tlost collnlon benisnlesion in the age gr.oup of3l-40 years. The occurrenceof cer-vical intraepithelial neoplasia in tlris study was l0out of 618 (1.62%) cases. The cer.r,icul intraepithelialneoplasia was rrainly of squaurous cell origin, Therewcrc lto oascs of ccn,ical intracpitliclial glandularnct-rplasia fbLurd in this stutly. CIN was rlost ccrillorr inthc aqc glrlirp of'41-50 (50%) ycars wirb CINII as thcprc'dourinaur gladc. (Tablc .3)

OLrt of l0 cases of CIN, 6(60.0%,) cases pr.esentcdwith wlritc dischargc. 4140.(),%) hiicl ntass pcr. r,aginLrnr,3(30.0%) had pain in abdonren, t(10.0%) hal post_menopausal bleeding and l(10.0%) case hacl complaintof post coital bleeding. (Multiple patients had rnore thanone syntptolr which has been added in the present Iist.Hence that total is ntore than lOO,nt).

Ccrv-ical mallgnancics fbmrcd a nra jor partconstituting 8l)(7,\.4401,) out of 102 malignancics rn thcfernale genital tr.act. Squanror-rs cell carcinonra was tlrepredominant histologic type ot' cenrical rraligtlalrcyconstituting l6(95%) cases. Cases of aclcnocarcrnonraand a case of' adenosquantous carcinorla were alsoencountered in this study which accounted for 3(3.15%)cascs ancl 1(1 .25%) casc r.cspcctivcly. (Tablc 5)

In the present strtly, it was evitlent that the incidenceof irrvasirre carcinonra was nrost collltlon ilr the aeegroup ol40-[0 ),.ats trlllorvccl by agc gr.oLrp grcatcr tirtin60 years. [r was obser.ved that r,vith an ini,.lase i,r lgetlrcrc was an incrcasc in thc nLrnrbcr of utalignancics.(Fig 2 )

. In the preseut study sqrrarnous cell car.cinorna wasclas.sitlcd. according fo Broclcr.,s grading s1,stct.n inrowell. rrodelately and poor)y diil'erentiateJat ihe trrne olinitial cliagnosis ancl crlnstitutinc cases as 9( I 1.g4,%).

54(71.05o/i') and 13(17.1 l,l{,) rcspcctivcly. Squarnor_rscell carcinonta lnost col.llltlotrly pr.esentec.l rvith bleedingpcr vagina and post coital blcccling. Mosl of thc paricntswith adcnocarcinonla prcscntctl u,ith blccdiirg pcrvagiDa.

Table 1: Histopathological distribution of cervicallcsion s

(Here CIN- Cervical i'rtraepithelial n-pl,rsi4

inflammator.y lcsions

:r:i::

I [i,:

a:

i3i :q

:C irl

::._.: : ..j.

Age in,/enrs

:6 (r

.cI

8 Chrrn,< nc., :ptg .; -

li, e I t'5

trt')*cz:',' c:. s

Fig. I : Age rvise distribution of cervicatinflammatory Iesions

Tablc 3: A cl ist

Cen,ical lesions Total No. ofcases

Percentage(ul'l

Non-ncoplasficInfli.rr-nr-natory ,s l6 83.50

Ncoplasric 102 16.5Bcnisn t2 1.94

CIN l0 1.62Malignant 80 t2.94

Total 6r8 100

Table 2: Age-rvise distribution of cervical

Agc Iullatnmatoly Cc.i,ic"t t-.smn Total Pcl.ccntagc

(n=S I 6)

ChronicNon-

spcciticccrVicitis

Papillarl,cn doccrvicitis

2 30 28 l0 38 7.309,,3 -40 r83 IA

22.s 13.60,,/o4 50 112 28 t50 29.070/o5 -60 56 4 60 I L6i%,>60 39 4 rl3 8 31%

Total 42ir 8E 516 r00Pcrccn t

aqc

,!2.9-ro i, l7 .05v(,

rsc dlstribution of CINAgc irr lcars CIN

-ICIN-II

CIN.III

Toral PcIcc n tagc

2l-i0 0 I 0 I I0,r,,3l-40 () 0 2 10,,04 t-.s0 l 2. I 5{)o5l-60 I 0 0 I

>60 0 0 I

Tota I l 5 ) l0 ( 1000,,0 )Pcrccltta{c 3o% 50"1 )0'ri,

./rt111 17111 of Ditrgrro.stit. pulholog), u,rd {),,r.,,1ug. I)rt,,lrenDn.,i;_r0lrr-G trr:r_ jJ-1-.'

1

Nelta V ASaru'al et al. Cliniut'histr4tatlto/ogic'ttl ttnal.ysis of lesions of uterine cervix in ,lg!e.fogai t:it.t,......

1n= | {.))

Table Histo types of invasive carcinonrasHistologic type Cases Pcrcentage

(n=80)Squamous cell calcinoma 16 95%Atlenocalcinorna

-) 3.15%Allenosquarnous calcinornrr I I ]<U,

a

': :.- i.i .i:Ag. ir IeEr!

Fig. 2: Age-wise distribution of histologic typcs ofinvasive carcinoma

Tablc 5: Clinical tati

0

z

Squima!! ti'l c6,( rlaE a

idani(e.c nori,e

ld.tr*quaFc u1 co. i ncflE

Discussionln prcsct.rt study, ccn,ical lcsions constitLttC 30. I lJ,l1,

ot'total t'enrale genital tt-act lesions. This lincling nratchwith tliat fbLrnd in stLrdy bl,poste p et al (32..1 I%; ,.r 1,.,

the present study hysterectomy (82.g5?,,) was the rtrclstconlrlron type ol spec i nren recei vecl tbr lr i stopatho I ogi ca I

cxanrination fbllowcd by cervical biopsy (13.1)2oh)spccirnens. This u,as in accordance witli thc study doneby Pallipady A et al.(s) Overall non-neoplastic lesions(83.501,) wcrc l11ot'c than thc ncoplastic. This finding rvasin kccpin.g u,ith prcr,,ious reports by Sar.avanarr S ct al.(79.1'7'o1 tt't In this study, chror.ric non-speciiic ccn,ie itisaccor"urtcd lor 82 95% of all ccryicrtis. Thrs tilding rvassimilar to prcvious work donc b), Orrorrrr,-Usan ct a1.(7)ra,lrele chror.ric non-specific cervicitis accountecl fot glukof all non-neoplastic lesions. Maxinrurl r.rumber of caseswas found in 3l-50 years of age group present stndycorlclatcd u,cll r.r,ith thc stucly of Onroniyi_[,san ct al.(7)

Chronic non-specrfrc cervicitis was associatecl r,vithothcr histological changcs likc sqLramoLrs r.netaplasi:r.koiiocyt.osis anri nabothiarr cyst. C'hronic nonspeeilicccrvicrtis wrth nabothian cyst was foLrncl in 5l( I I .92g1,)cascs. 'fhc rcsults liruntl in tlris sturly wcr.c slightly highcrthan those fbLrnd in rhe stLuly conciLrcrecl by .lyothi .1 o1.rsrand Postc P ct al.('rr Chronic nonsltccific ccrvicitis withsqLlarl.rous ntetaplasia u,as lbr-rnd in -50( | l.(rg9;) cases.The results lbuncl in this stuciy wer.e slighrly hisher tharrthc study colldLlctcd try .lyothi ct al,(tr and post} ct al.(rlChronic nonspecilic ccrvicitis wrth koilocytic changcu,as forrrrtl it 96(22.43ok) e ases. T'lris iln.linq was alsotbirnd slightly hi-rhcl than that for,rncl in thc studyconductcd by .lyothi ct al.,s, and postc- p ct al.,r) Thiscor-rlcl bc dr-re to clitl'er.ences in sarnple size ancl health

awareuess allongst the stuciy population.Endoccrrrioal polyps wcrc lrost corlltl1only sccn in

thc agc group o1'3 l -40 ycars in thc prcscnt study. postcP et al.(a) ciocunrentecl enilocen,ical polyps in il.r. ng.group tll'41-50 1,cars. This variatiog ntay bc dlrc te slltalisarnplc sizc.

Occurrencc of CIN was lou, ().62%) whcncornpared to otlier cf g(jsq.r6.ri.e.r{t) A low inciclence ol'ClNand high incidence of cervical malignancy seen in thisstudy rrray bc duc to thc rcluctancc on part of ruralwonren to under"go physical examination and probabledue to ignolance ancl lacl< of pr.oper fircilities. In thepresent study rloderate clysplasia [CIN-ll] ntade up thernaxirr-rr-ul numbcr oI dysplasia cascs as rn accorclanccwith the study of Poste P et al.(1)) rvho founcl rt as 49.0I ,2,.

I(arim A.l et al.(ll)documcntcd highest tlLlllbct of CINcascs it.l thc agc. goup of 41-50 ycars. In thc prcscntstudy also rnaxirnull cases wet.e noted in the age gr.oupof 41--50 ycars. In tl.rc prcscrrt stucly whitc discharec u,astlre n.rost cor.tlnlon cornplainl in the patients with CINwhich r.r'as in accordance u,ith poste p et al.(.)l

In the preseltt stucly cer.vical nralignarrcy wilsrroticcablc in 80 cilscs uncl constitutc:tl i r\.41yArrralignancies of f'enrale genital tr-act. This wits a verysisnilicant tlndine.

In thc prcscnt study ccrvical canccr accountcd t'r-rr.

l2 94% c.rses of all cer-vical lesions which wirscornpalablc to thc stLrdy donc by Saravanan S c1 al r,,) anciSinha P et al.(ll) rvher.eas it was less wlren cornparetl toJyothi et al.{rt

In the present study sqnantous cellthe cornnronest of the invasive lesionstlris study, accourrting tbr 95()/o of the

carctnollla \,vas

encounteled intotal iuvusive

lcal prcscntationlnvasive

carcinomaBleeding

plj t'

vaginu rn

Dischargepcr

vaginurn

PostcoitaI

bleeding

Pain inabdomcn

Cervicalgrowth

Masspcr

vaginum

Constitutionalsl,mptonrs

Squarlous cr:llcarcinotna

53 -10 9 l5 7 3 II

A d en o carc itr orna 2 I 0 l 1 0 3Adenosquarnous

carclnomaI 0 0 I I 0 l

Total

1n=80)56

170,)i,)

3l38.75,%)

9

Il,.15't/o)t'7

/l I a<l)/ \

()

( I I.25yo)3

3.7 5",/u)

l_s

18.75'7u)

Ittl7'1141 ttf Diugnrts/it Pctlhrtlogt'cr.rtt.l ontolrtg.t', ot.tobar-Dtt.crrrbar )0t;; U2I.32-J5

of with

34

Aielta V 'Ag'aru'al et al Clinitn'histt4tathological unal.tsis of lesions of'utet.ine cetyir in Antbe.fog.ai cit1,......

carciuolna which was colnparablc with thc study ofShlLrthi PS et al.(li)and Oguntayo et al.{r'tt present stirclyrcportcd highcst uunrber ol cascs of squantous ccl)carcinornas in thc agc gror-rp of 40-60 ycars. Shrutlii pSet al (r1) and.lyothi e1 al.(s)also fburcl ir as highesr in thealle gl'or"lp of 40-(r0 years Kaarthiteyan, rsr in 20llrcportcrl that thc incidcncc riscs in 30-34 ycars ofagc antlpeaks at -55-65 yeals. r,vith a rnedian age ol'31( year-s. Intl.rc prcsent snrdv 54(71.0502i,) cascs of sqiramoLts ccllcarcinoura wcrc o1' thc nroclcratcly clillcrcntiatcd typc.This finding was in accordance lvith the study of Shr.uthict al.(r'i) who also found tr-ra.joriry (55.90%) of cascs ofsqualllous celi calcinorna ol' nroderately difl'erentiatecltype. ln the present stucly 11es1 of the patients pr-esenteclwith bleeding per rzagina whicl.r was similar to theIindin-u ol'I.jaiya et al.(l6r

In thc prcsent study 3 cases of adenocarcirrorla wcrcerrcourrter"ed. Two cases were of papillaryaclenocarcinoma and one case was of mucinouscndoccrvical typc which conclated with tlic study ofShrLrtlri pg c1 nl.ttll All tlrrec cascs wcrc sccu ir1 the agegroup of 5l-60 years and presenteil with lrleetling pervagina. Shnrthi PS ct al.ll:\) c'locumcnted agc ofadcrrocarciltorria tj-ont 40-60 years. prescnt stuclycorrc-lated rvell rvith the studv of ShrLrthi et al.(rrr

ConclusionCervical rrralignancies fbr.med a nra.jor part of the

f'enraie genital tracr r.nalisnancies constitLrting 78.430.,i,.Non-ncoplastic r.i,crc tlic corltloncst lcsions of tlrccervix. Endocervical polyp was the nrost conlllo11[renign cervical lesion. CINIT was tlre prcdominantgradc. Conlmoncst ccrvical malignancy was sqLtamouscell carcinoma. rnotlerately tliffer-entiaterl beitrg tlieconlr-rlonest type. I nfl a nrntatory lesions wer-e cortrnton lyfbund in thc sexually activc period of womcn. CIN wasnlost common in the age gror+) of 4l--50 years and themost connron associated symptonl rvas whitc dischar.gc.Ccrvical malignancics were common in the agc group bf40-60 years and presented most commonly with bleeclingper vagina. Hcncc women in the olcler age groLrp withbleeding per vagina should be sr.rspected for cervicalmaliunancy ancl slroLrlcl bc cxaminod for.thc sanrc.

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t2

I.l

t4

I5

t6

loLrrttulo/Ditrgttostit.Pulholog.t,turtl Ont.olrtg.t.,Ot.toltcr.-Dct.t:ltl-tar20t6,l(2).j2-j5 35

7.

8

9