Introduction
Cervix uteri is a Latin word meaning neck of the uterus. Cervix consists of ecto cervix, endo cervix and a transformation zone or the squamocoloumnar junction. This zone is susceptible to numerous microrganisms, and is a common site of squamous metaplasia, dysplasia, intraepithelial lesions and cervical cancer.1
Nonneoplastic cervical lesions are mainly acute and chronic cervicitis, cervical erosions, polyps, hyperplasia and cysts. The infective etiology is commonly due to staphylococcus, N. gonocooci, Trichomonas vaginalis, Clamydia, Candidia to Herpes simplex (HSV), human papilloma virus (HPV) and even HIV.1
Among the neoplastic lesions, in India, Cervical cancer contributes to approximately 6-29%of all cancers in women.2 It is the second most common cancer seen after breast cancer Epidemiological and molecular studies have shown that HPV is the causative organism for condylomas, CIN-I-III and eventually cervical cancer. PCR, hybrid capture assay and p16 IHC are now commonly used to diagnose HPV infections. 3
Immunostaining with p16 plays an important cooperative role with histopathology and helps in reducing the inter and intraobserver variability in diagnosis of preinvasive lesions of cervix.4
Cervical punch biopsies are used widely in gynaecology practice. They are less expensive and average time taken is 2 to 3 minutes.5 Histopathology provides a final diagnosis and forms the basis of treatment plan. It not only serves as a gold standard for quality control of cytology and colposcopy, but is also a valuable source of diagnostic data for cancer registry. It is very helpful in evaluation of screening programs.
The present study was undertaken to analyse the histopathological spectrum of various cervical lesions across various age groups and their clinical correlation in past seven years. It also aimed at studying the role of p16 immunohistochemistry in subset of pre invasive lesions of cervix.
Materials and Methods
This seven year Hospital based retrospective study was conducted in Department of Pathology from January 2013 to December 2019. Approval from the Ethical committee was taken. Clinical history, demographic details, histopathology slides and reports of cervical punch biopsies of the patients of 279 patients were retrieved from past records and analyzed and wherever necessary new sections were prepared and stained with Haematoxylin and Eosin stain. The cervical lesions were classified according to WHO classification of tumours of cervix.6
Six paraffin blocks, 3 each reported as LSIL and HSIL were analysed for p16 immuno histochemical staining.The standard guidelines of IHC staining of the institute were followed. p16 positive squamous cell carcinoma of cervix served as the positive control. The staining pattern (focal or diffuse), percentage positivity and intensity of the staining were observed.
A Scoring system proposed by Vinyuvat S et al7 was followed:
A. Percentage of positive cells: 0: 80% positive cells
B. Intensity of reaction: 0: No reaction, 1: weak reaction, 2: variable (both weak and strong) reaction, 3: Strong reaction
C. Cellular reaction pattern: 0: No reaction, 1: Focal reaction, 2: Diffuse reaction.
Results
The most common age group involved in non- neoplastic lesions was 30-40 years and among neoplastic lesions it was found to be 40-50 years (Table 1, Table 2).
Table 1
Age wise distribution ofnon-neoplastic cervical lesions
Table 2
Age wise distribution of pre invasive and neoplastic Cervical Lesions
Table 3 White discharge per vaginum was the most common presentation seen in122 (43.7%) cases, followed by backache in 50patients (17.9%). Abdominal pain was reported in37 (13.2%) cases. Bleeding per vaginum was noted in 60 (21.5%) cases and lastly post coital bleeding was observed in 10 cases (3.5%).
Table 3
Distribution of cases in relation to symptoms
|
Chief Complaints |
No. of cases |
Percentage |
|
White discharge per vaginum |
122 |
43.72 |
|
Bleeding per vaginum |
60 |
21.50 |
|
Backache/ |
50 |
17.92 |
|
Abdominal pain |
37 |
13.26 |
|
Postcoital bleeding |
10 |
03.58 |
On histo pathological examination, 163 cases (58.42%) were non-neoplastic, 68 (24.37%) were found to be pre-invasive and 48 (17.20%) cases were malignant.
Among non-neoplastic lesions which includes both inflammatory and tumor like lesions, endo cervical polyps were seen in 90 cases (32.2 %), followed by 34cases (12.1%) of chronic nonspecific cervicitis, 24 cases of chronic cervicitis with koliocytosis (8.6%). Only 10 (3.5%) were chronic nonspecific cervicitis with squamous metaplasia and only 3 cases of chronic cervicitis with micro glandular hyperplasia (1.07%) were reported.
We divided the neoplastic into pre invasive intraepithelial lesions and invasive lesions. LSIL was seen in 30 (10.7%) HSIL (CINII &CIN III) in 37cases (13.2%) and condyloma in 1 case (0.35%). Squamous cell carcinoma was diagnosed in 44 cases (15.2%). Adenocarcinoma was seen only in 4 cases (1.4%) (Table 4, Table 5).
Table 4
Spectrum of non-neoplastic lesions
Table 5
Spectrum of pre invasive and invasive neoplastic lesions
Squamous cell carcinoma was most common neoplastic lesion.
The frequency of Cervical Intraepithelial neoplasia (CIN) in this study was 24.3%with majority of cases falling in the age group of 31-40 years, followed by age group of 41-50 years. All the intraepithelial lesions found were squamous in origin. Squamous cell carcinoma was the commonest malignancy
Discussion
In the present study, age of patients ranged from 21 years to 70 years with a mean age of 45.5 years, Sriknath S, Omoniyi –Esan et al and Nwachokor F N, also found the peak age incidence of 40 to 49 years in their studies on non-neoplastic lesions of cervix. 8, 9, 10
The commonest presenting symptom was white discharge per vagina 122 (43.7%). It is the second most common complaint after menstrual disorders. One out of ten women complain of vaginal discharge over a year.11 Most common microbial causes of abnormal white discharge are bacterial vaginosis, trichomoniasis and candidiasis, mixed infections of candida and trichomonas.
Among the non-neoplastic lesions of cervix, endo cervical polyp was the most common lesion seen in 90(32.2%) of total cases. Endocervical polyps are common benign proliferations composed of fibro vascular core and endocervical glandular or metaplastic squamous epithelium.1 Sixty nine (76.6%) cases were seen in the age group of 21 to 40 years with a mean age of 30.5 years. Tirlapur et al studied the clinicopathological spectrum of cervical polyps and found that there was no case of malignanacy, majority are seen in parous women and they can recur in 12.6% of women.12
Chronic non-specific cervicitis was next common lesion seen in 30(12.1%) cases. The incidence of chronic non-specific cervicitis in our study is quite low as compared to other studies. The exclusion of hysterectomy samples in present study could be the reason for the lower incidence of chronic non- specific cervicitis. The reason to exclude out hysterectomy samples was that in majority of the cases the indications of hysterectomy are not due to cervical pathology, but are chiefly endometrial or myometrial in nature and the majority of hysterectomy samples do not show morphologically changes of cervix.13 Diagnosis of chronic non-specific cervicitis was made on the presence of lympho plasmacytic infiltrate, some cases showed loss of surface columnar epithelium and three cases showed microglandular hyperplasia. Infective causes of cervicitis include a wide spectrum of organisms ranging from bacterial, viral, protozoan and fungal. According to Paavonen et al14 the etiology of chronic non-specific cervicitis is variable. If untreated it may lead to endometritis, salphingitis and chorioamnionitis and pelvic inflammatory disease through ascending intraluminal spread. It may also lead to the initiation or progression of cervical neoplasia.
Kiviat et al found that the loss of surface coloumnar epithelium seen in chlamydial, gonococcal and HSV infections may be responsible for possible association of risk of HIV in such cases.15
Microglandualr hypeplasia is a benign condition seen in women of reproductive age and can be confused with adenocarcinoma.16, 17
Koiliocytic change and squamous intraepithelial lesions (LSIL&HSIL) are considered as morphological hallmarks of Human Papilloma Virus (HPV) infection.
Sometimes reactive squamous cells with vacoulated appearance also look like koiliocytes. The identification of koliocytosis should prompt further testing for HPV.18 The American Society for Colposcopy and Cervical Pathology (2019) guidelines have aligned the management with natural history of HPV and cervical carcinogenesis It recommends more frequent surveillance in high risk cases and longer intervals for lower risk.19
In the present study 23.8% of the cases showed cervical squamous intraepithelial lesions which is comparable to the study done by Badge et al.20 Majority of them present in the fourth decade which is comparable to the study done by Badge etal Kumari and Tamboli et al.20, 21, 22 (Supplementary Information Table 7)
The problem of inter observer variability and reproducibility for diagnosis has made a paradigm shift from routine haematoxylin and eosin staining to immunohistochemistry and genotyping.5
P16 is cyclin dependant kinase inhibitor (CDKN2) and is up regulated in HPV related lesions. Lesnikova et al evaluated the usefulness of p16 in diagnosis of cervical neoplasia in 796 tissue micro array specimens and concluded that p16INK4a is useful diagnostic tool and found that its expression correlated with degree of dysplasia.23 Agoff et al studied the possible utility of p16 IHC in differentiating LSIL from HSIL They found that use of p16 was statistically significant to differentiate between the two and suggested it as a tool to H&E histopathology.24 Murphy et al studied 149 cases with different histopathological diagnosis, and found that p16 displayed good sensitivity and specificity to differentiate the various dysplastic lesions. p16 was also found to be better than proliferation markers MCM5and CDC6.25 The presence of positive p16 IHC suggest increase risk of progression in these patients. (Supplementary Information Table 8)
Among different histopathological types of cervical cancer, squamous cell carcinomas account for 75-80% of cervical cancers, adenocarcinoma 15-25%, and adenosquamous carcinomas 3-5%.26 In the present study, among malignant lesions squamous cell carcinoma (SCC) was the commonest (91.6%) lesion.
Incidence of adenocarcinoma is increasing since the 1970s; especially in females younger than 35 years of age, partly attributed to increasing prevalence of human papilloma virus (HPV) infection. 27
The limitations of the present study are, small sample size for p16 immuno staining. However, in future this can be taken up as a prospective study on a larger scale.
Table 7
Comparison of pre invasive and malignant lesion with various studies
|
STUDY |
LSIL (%) |
HSIL (%) |
SCC (%) |
|
Badge et al 20 |
16 |
10 |
15.3 |
|
Kumari et al 21 |
6.3 |
9 |
33 |
|
Tamboli et al 22 |
33 |
12 |
17.7 |
|
Present study |
10.7 |
13.2 |
15.7 |
Table 8
I.2:Various studies showing percentage positivity of p16
|
Study |
CIN 1 |
CIN 2 |
CIN 3 |
|---|---|---|---|
|
Lesnikova et al 23 |
72.3% |
91% |
98.3% |
|
Agoff et al 24 |
57% |
75% |
91% |
|
Murphy et al 25 |
100% |
100% |
98% |
|
Hu L et al 28 |
44% |
93% |
100% |
|
Gupta et al 29 |
50% |
60% |
70% |
|
Srivastava etc al 30 |
80% |
100% |
100% |
|
Kumariet al 31 |
62.5% |
75% |
81.25% |
|
Kishore et al 26 |
25% |
50% |
75% |
Conclusion
Cervical lesions are the major source of morbidity and mortality among females, especially cervical cancer. Histopathological diagnosis of cervical biopsy is an important diagnostic test for the timely treatment and management of the patients. Larger scale prospective studies with use of HPV-DNA and p16 studies are required to give more comprehensive analysis of cervical lesions.
