Sultan Qaboos University Med J, February 2015, Vol. 15, Iss. 1, pp. e112–115, Epub. 21 Jan 15 Submitted 22 May 14 Revision Req. 14 Aug 14; Revision Recd. 21 Aug 14 Accepted 2 Oct 14 1Department of Pathology and 2Health Science Centre, Faculty of Medicine and 4Faculty of Allied Health Sciences & Nursing, Kuwait University, Safat, Kuwait; 3Cytopathology Laboratory, Mubarak Al-Kabeer Hospital, Safat, Kuwait *Corresponding Author e-mail: kkapila@gmail.com االجتاهات احملّددة يف تشّوهات اخلاليا الظهارية احملّددة عند إجراء املسحات الُعنقّية ملدة 21 سنة يف مستشفى للرعاية العالية االختصاص يف الكويت كو�ضوم كابيل، برمي ن. �ضارما، �ضاره �س.جورج، عّزة ال�ضاهني، اأحلم اجلوي�رض، رنا العو�ضي abstract: Objectives: This study aimed to analyse trends in epithelial cell abnormalities (ECAs) in cervical cytology at a tertiary care hospital in Kuwait. Methods: ECAs in 135,766 reports were compared over three seven-year periods between 1992 and 2012. Conventional Papanicolaou (Pap) smear tests were used in the first two periods and ThinPrep (Hologic Corp., Bedford, Massachusetts, USA) tests were used in the third. Results: Significant increases in satisfactory smears, atypical squamous cells of undetermined significance (ASCUS) and atypical glandular cells of undetermined significance/atypical glandular cells (AGUS/AGCs) were seen in the second and third periods (P <0.001). No significant increases were observed among low-grade squamous intraepithelial lesions (LSILs) or high-grade squamous intraepithelial lesions (HSILs) (P >0.05). An increase was noted in carcinomas between the first and second periods although a significant decline was seen in the third (P <0.014). Conclusion: Satisfactory smears, ASCUS and AGUS/AGC increased during the study period although no significant increases in LSILs, HSILs or carcinomas were observed. Keywords: Cytological Techniques; Papanicolaou Smear; Epithelial Cells; Retrospective Study; Kuwait. داخل العنقّية اخلليا فح�س يف )اإي.�ضي.اإيي( الظهارية اخلليا ت�ضّوهات اجتاهات حتليل اإىل الدرا�ضة هذه تهدف الهدف: امللخ�ص: يف الواردة )اإي.�ضي.اإيي( الظهارية اخلليا ت�ضّوهات اجتاهات مقارنة مّتت الطريقة: الكويت. يف االخت�ضا�س العالية للرعاية م�ضت�ضفى 135,766 حالة فيما بينها على مّر واحٍد وع�رضين �ضنة بني الفرتة املمتدة من العام 1992 وحتى العام 2102م. وقد ا�ضتخِدَمت فحو�ضات لطاخة عنق الرحم بابا نيكوالو التقليدّية يف الفرتتني االأوىل والثانية ثم مّتت اال�ضتعانة باختبارات عنق الرحم )هولوجيك كوربوري�ضن، بيدفورد، م�ضات�ضو�ضت�س، الواليات املتحدة االأمريكية( يف الفرتة الثالثة. النتائج: اأظهرت هذه االختبارات زيادًة كبرية يف امل�ضحات العنقية /AGUS( اإ�ضافة اإىل خليا ُغّدية �ضاذة وغري حمّددة/خليا غدّية �ضاذة )ASCUS( وارتفاًعا يف اخلليا ال�ضاذة ال�ضدفّية غري املحّددة الظهارة داخل احلرف�ضية االآفات �ضعيد على ُتذَكر زيادة اأية ل ُت�ضجَّ مل .)P >0.001( والثالثة الثانية الفرتتني يف حتديدها مّت )AGCs منخف�ضة الدرجة )LSILs( اأو االآفات احلرف�ضية داخل الظهارة املرتفعة الدرجة )P <0.05 )HSILs(. مت ت�ضجيل ارتفاع يف ال�رضطان الغّدي بني الفرتتني االأوىل والثانية على الرغم من ت�ضجيل انخفا�س هام خلل الفرتة الثالثة )P >0.014(. اخلال�صة: �ضّجلت امل�ضحات العنقية نتيجة ُمر�ضية ومقبولة مع زيادة يف ASCUS و AGC/AGUS طوال مدة الدرا�ضة على الرغم من عدم ت�ضجيل اأية زيادة ملحوظة بالن�ضبة اإىل LSILs و HSILs اأو حتى ظهور اأّي �رضطان غدّي. مفتاح الكلمات: تقنيات فح�س اخلليا؛ لطاخة عنق الرحم؛ خاليا ظهارية؛ دراسة استعادية؛ الكويت. Trends in Epithelial Cell Abnormalities Observed on Cervical Smears over a 21-Year Period in a Tertiary Care Hospital in Kuwait *Kusum Kapila,1 Prem N. Sharma,2 Sara S. George,1 Azza Al-Shaheen,3 Ahlam Al-Juwaiser,3 Rana Al-Awadhi4 Cervical cancer is the fourth most frequently occurring cancer affecting women worldwide after breast, colorectal and lung cancers; it is also the seventh most common form of cancer overall, with an estimated 528,000 new cases worldwide in 2012.1 Approximately 70% of the global burden of cancer falls on less developed countries, with more than one-fifth of all new diagnosed cases from India.1 In developing areas, the highest age- standardised rates (ASRs) of cancer per 100,000 are in South and central America (33.5), sub-Saharan Africa (31.0) and south central and southeast Asia (26.5).2 The lowest rates of cancer are reported in China (6.8) and in developed regions such as North America, Japan and Europe, which has an ASR of 4.5. Low incidences have also been observed in some developing areas, such as the Middle East, including Iran and Turkey.2 Cancer of the uterine cervix is the fifth most common cancer in Kuwaiti females (4.6%), with an ASR of 6.8.3 Invasive cervical cancer is preceded by a spectrum of heterogeneous epithelial cell abnormalities (ECAs) over a long period. Identification of the relevant risk factors and prompt management of the precancerous lesions are important in the brief communication Kusum Kapila, Prem N. Sharma, Sara S. George, Azza Al-Shaheen, Ahlam Al-Juwaiser and Rana Al-Awadhi brief communication | e113 prevention of invasive cancer of the uterine cervix. Several studies from Saudi Arabia, including a study of sub-fertile Saudi females, showed a low prevalence of ECAs; however, there was still a wide range of distribution (2.9–17.3%).4,5 This range strongly correlates with the actual difference in the distribution of invasive carcinomas of the cervix in Saudi Arabia.6 Other studies from the Arab world have also reported a significant variation in the rate of ECAs: 3.3–3.6% in the United Arab Emirates,7,8 4.2% in Kuwait,9 7.8% in Egypt10 and 11.9% in Nablus, Palestine.11 Most of these studies were completed using conventional Papanicolaou (Pap) smear tests, where the cervical smears were reclassified according to the revised 2001 Bethesda system.12 Mubarak Al-Kabeer Hospital is a tertiary care hospital which provides cytological diagnostic services to 15 hospitals, 17 clinics and practitioners both in the Hawally area and elsewhere in Kuwait. The aim of this study was to analyse the changing trends of ECAs observed in cervical smears at this hospital over a period of 21 years compared in three periods of seven years each. Methods This retrospective study was designed to review cervical cytology reports performed in the cytology laboratory of Mubarak Al-Kabeer Hospital over a 21-year period from January 1992 to December 2012. The first two seven-year periods (1992–2005) used conventional Pap smear tests whereas the third period (2006–2012) used ThinPrep (Hologic Corp., Bedford, Massachusetts, USA) smear tests. A comparison was made between the trends of ECAs seen in the three seven-year periods (1992–1998, 1999–2005 and 2006–2012). Unsatisfactory cytology reports were excluded from the study. These included smears with very few epithelial cells or those where the morphology of the cells was obscured by blood or severe inflammation. Smears were categorised as “satisfactory” when an adequate number of epithelial cells were clearly visualised, as per the guidelines of the Bethesda system.12 Cytological diagnoses were changed where required to the modified Bethesda classification system.12 The following categories were used: normal/ negative for intraepithelial lesions or malignancy (NILM); atypical squamous cells of undetermined significance (ASCUS); atypical glandular cells of undetermined significance/atypical glandular cells (AGUS/AGCs); low-grade squamous intraepithelial lesions (LSILs), including changes induced by human papillomavirus (HPV) infection; high-grade squamous intraepithelial lesions (HSILs), which included ASCUS results with possible HSIL (ASC-H), and carcinomas. Epithelial cell abnormalities comprising of ASCs, LSILs, HSILs were considered as cervical precursor lesions. Data management, analysis and graphical presentation were completed using the Statistical Table 1: Spectrum of cervical cytology smear diagnoses during three seven-year periods between 1992 and 2012 (N = 135,766) Period P value 1 1992–1998 2 1999–2005 3 2006–2012 Total 1992–2012 Period 1 versus 2 Period 2 versus 3 Period 1 versus 3 Total, n 40,806 52,728 46,870 140,404 Satisfactory smears, n (%) 38,079 (93.3) 51,990 (98.6) 45,697 (97.5) 135,766 (96.7) 0.001 0.001 0.001 Cytological diagnosis, n (%) ASCUS 587 (1.54) 1,363 (2.62) 1,262 (2.76) 3,212 (2.37) 0.001 0.183 0.001 AGUS/AGC 160 (0.42) 543 (1.04) 389 (0.85) 1,092 (0.80) 0.001 0.002 0.001 LSIL 400 (1.05) 487 (0.94) 410 (0.90) 1,297 (0.95) 0.094 0.540 0.026 HSIL 92 (0.24) 106 (0.20) 96 (0.21) 294 (0.22) 0.262 0.887 0.375 Carcinoma 28 (0.07) 60 (0.12) 30 (0.07) 118 (0.09) 0.060 0.014 0.764 ASCUS = atypical squamous cells of undetermined significance; AGUS = atypical glandular cells of undetermined significance; AGCs = atypical glandular cells; LSIL = low-grade squamous intraepithelial lesion; HSIL = high-grade squamous intraepithelial lesion. Italics indicate percentages from satisfactory smear tests. Trends in Epithelial Cell Abnormalities Observed on Cervical Smears over a 21-Year Period in a Tertiary Care Hospital in Kuwait e114 | SQU Medical Journal, February 2015, Volume 15, Issue 1 Package for the Social Sciences (SPSS), Version 20.0 (IBM Corp., Chicago, Illinois, USA). Descriptive statistics were presented as numbers, percentages and means ± standard deviations. The normal Z-test was used to test the difference in proportions and the Chi-squared test was used to determine if there was any trend in the proportion of cases over the 21-year period. The two-tailed probability value P <0.05 was considered statistically significant. This study was performed according to the guidelines of the Combined Ethics Committee of the Faculty of Medicine, Health Science Centre and Ministry of Health in Kuwait, which conforms to the World Medical Association Declaration of Helsinki. Results During the 21-year period, a total of 140,404 cervical cytology smears were analysed in the cytology laboratory of Mubarak Al-Kabeer Hospital. Of these, 135,766 (96.7%) were found satisfactory for reporting [Table 1]. Overall, ECAs were observed in 4.43% of satisfactory smears; ECAs from the first, second and third seven-year periods were present in 3.32%, 4.92% and 4.79% of the smears, respectively. ASCUS were seen in 3,212 cases (2.37%), AGUS/AGCs in 1,092 cases (0.80%), LSILs in 1,297 cases (0.97%), HSILs in 294 cases (0.22%) and carcinomas in 118 cases (0.09%). A significant increase (P <0.001) was noted in the proportion of satisfactory smears in the second and third period compared to the first (98.6% and 97.5% versus 93.3%, respectively) [Table 1]. Additionally, a significant increase was also observed between the first two combined periods (1992–2005) of conventional Pap smears in comparison to the third period (2006–2012) of ThinPrep smears (96.3% ver- sus 97.5%, respectively). With regard to cytological diagnoses, a significant increasing trend (P <0.001) was found among ASCUS and AGUS/AGC cases in the later periods compared to the first; AGUS/AGC cases were found to be more accurately identified using ThinPrep smears than with conventional Pap smears. No significant increase was observed among the number of LSILs and HSILs during the study (P >0.05). In carcinoma cases, an increase was observed between the first and second periods but a significant decline (P <0.014) was noted between the second and third periods [Figure 1]. Discussion The distribution of ECAs in 140,404 cervical cytology smears analysed over a 21-year period did not show any significant change in LSIL, HSIL or carcinoma cases. The introduction of liquid-based cytology (LBC) during the final seven-year period (2006–2012) showed an increasing trend in satisfactory smears and the detection of ASCUS and AGUS/AGC cases. In a population-based cervical cancer screening programme in Japan, disease detection rates were compared between specimens prepared by LBC and those prepared by conventional methods.13 With the LBC method, the researchers found a significantly lower percentage of unsatisfactory specimens and a significantly higher positive rate of detection of tumour lesions.13 However, Siebers et al. demonstra- ted in a large randomised controlled trial that the most common LBC method was not more effective in detecting cervical cancer precursors than well- performed conventional Pap smears; the prevalence of cervical intraepithelial neoplasms was equal in both study groups.14 In a systematic review and meta- analysis comparing the two techniques, no incremen- tal improvement in accuracy was demonstrated for the detection of high-grade cervical intraepithelial neoplasms using LBC versus conventional methods.15 This was also observed in the current study as no statistically significant changes were observed for cervical precursors between cytology performed using conventional Pap smear tests and those performed using ThinPrep tests. Furthermore, Schiffmann et al. reported that both cytology methods provided similar risk stratification in predicting cervical cancer precursors.16 They concluded that the choice of Figure 1: Trends in cervical cytology smear diagnoses in a tertiary care hospital in Kuwait between 1992 and 2012 (N = 135,766). ASCUS = atypical squamous cells of undetermined significance; AGUS = atypical glandular cells of undetermined significance; AGCs= atypical glandular cells; LSIL = low-grade squamous intraepithelial lesion; HSIL = high-grade squamous intraepithelial lesion. Kusum Kapila, Prem N. Sharma, Sara S. George, Azza Al-Shaheen, Ahlam Al-Juwaiser and Rana Al-Awadhi brief communication | e115 cervical cancer screening method should be chosen on the basis of cost-effectiveness related to laboratory productivity, slide adequacy and the ease of ancillary molecular testing.16 Conclusion Overall, ECAs were observed in 4.43% of cervical cytology smears analysed in a tertiary care hospital in Kuwait over a 21-year period. Satisfactory smears and the detection of ASCUS and AGUS/AGC cases were significantly increased during the seven-year period when ThinPrep smears were used. There were no statistically significant changes in the detection of LSILs, HSILs and carcinomas when LBC preparations were used as compared to conventional Pap smears. References 1. International Agency for Research on Cancer and World Health Organization. GLOBOCAN 2012: Estimated cancer Incidence, mortality and prevalence worldwide in 2012. From: globocan. iarc.fr Accessed: Aug 2014. 2. Altaf FJ, Mufti ST. Pattern of cervical smear abnormalities using the revised Bethesda system in a tertiary care hospital in Western Saudi Arabia. Saudi Med J 2012; 33:634–9. 3. Kuwait Cancer Registry. Annual Report 2001. Kuwait: Ministry of Health, 2001. P. 30,85. 4. Altaf FJ. Cervical cancer screening with pattern of pap smear: Review of multicenter studies. Saudi Med J 2006; 27:1498–502. 5. Al-Jaroudi D, Hussain TZ. Prevalence of abnormal cervical cytology among subfertile Saudi women. Ann Saudi Med 2010; 30:397–400. doi: 10.4103/0256-4947.68550. 6. Al-Eid HS, Manalo MS. Cancer Incidence Report in Saudi Arabia. Riyadh, Saudi Arabia: National Cancer Registry, Ministry of Health, 2007. Pp. 91–6. 7. Al Eyd GJ, Shaik RB. Rate of opportunistic pap smear screening and patterns of epithelial cell abnormalities in pap smears in Ajman, United Arab Emirates. Sultan Qaboos Univ Med J 2012; 12:473–8. 8. Ghazal-Aswad S, Gargash H, Badrinath P, Al-Sharhan MA, Sidky I, Osman N, et al. Cervical smear abnormalities in the United Arab Emirates: A pilot study in the Arabian Gulf. Acta Cytol 2006; 50:41–7. 9. Kapila K, George SS, Al-Shaheen A, Al-Ottibi MS, Pathan SK, Sheikh ZA, et al. Changing spectrum of squamous cell abnormalities observed on papanicolaou smears in Mubarak Al-Kabeer Hospital, Kuwait, over a 13-year period. Med Princ Pract 2006; 15:253–9. doi: 10.1159/000092986. 10. el-All HS, Refaat A, Dandash K. Prevalence of cervical neoplastic lesions and human papilloma virus infection in Egypt: National Cervical Cancer Screening Project. Infect Agent Cancer 2007; 2:12. doi: 10.1186/1750-9378-2-12. 11. Musmar GS. Pattern and factors affecting pap smear test in Nablus: A retrospective study. Middle East J Family Med 2004; 2:7–12. 12. Solomon D, Davey D, Kurman R, Moriarty A, O’Connor D, Prey M, et al. The 2001 Bethesda system: Terminology for reporting results of cervical cytology. JAMA 2002; 287:2114– 19. doi: 10.1001/jama.287.16.2114. 13. Akamatsu S, Kodama S, Himeji Y, Ikuta N, Shimagaki N. A comparison of liquid-based cytology with conventional cytology in cervical cancer screening. Acta Cytol 2012; 56:370– 4. doi: 10.1159/000337641 14. Siebers AG, Klinkhamer PJ, Grefte JM, Massuger LF, Vedder JE, Beijers-Broos A, et al. Comparison of liquid-based cytology with conventional cytology for detection of cervical cancer precursors: A randomized controlled trial. JAMA 2009; 302:1757–64. doi: 10.1001/jama.2009.1569. 15. Arbyn M, Bergeron C, Klinkhamer P, Martin-Hirsch P, Siebers AG, Bulten J. Liquid compared with conventional cervical cytology: A systematic review and meta-analysis. Obstet Gynecol 2008; 111:167–77. doi: 10.1097/01.AOG.0000296 488.85807.b3. 16. Schiffman M, Solomon D. Screening and prevention methods for cervical cancer. JAMA 2009; 302:1809–10. doi: 10.1001/ jama.2009.1573.