Current Health Sciences Journal Vol. 35, No.

3, 2009

Original paper
Cytological Identification of the (Pre)Cancerous
Cervical Lesions within a Clinically
Asymptomatic Female Population
MIHAELA MUNTEAN
Pathology Laboratory, Slatina Emergency County Hospital

ABSTRACT The study was carried out on 1637 clinically asymptomatic women who voluntarily requested the
Babeş - Papanicolaou cytological examination in our laboratory (throughout a two-year period: 2007 - 2008). 1470
smears presented NLIM modifications, 7 presented ASCUS, 3 - ASC-H, 119 - LSIL, 21 - HSIL, 8 SIL borderline, 6
had AGC-NOS and 3 had carcinomatose.

KEY WORDS precancerous lesions, Babeş - Papanicolaou cytological test

Introduction
Throughout the last 20 years numerous
scientific evidence has gathered, that modifies the
traditional approach of cervical cancer prevention,
by means of detecting precancerous lesions
induced HPV, in asymptomatic women, in order
to stop their evolution into invasive cancer. HPV
(human papilloma virus) is the etiologic agent
responsible for most cervical cancers and
precursory lesions (1, 7, 11, 14).
HPV is a universally spread virus and an easily
transmitted one, to such extent that any sexually
active woman is subjected to the risk of contacting
HPV. The risk to develop HPV infection is
initially present on the first sexual contact and
demurs throughout the entire sexually active life
of the woman.
Despite the facility with which cervical cancer
can be determined (clinically, colposcopically and
cytologically), cervical cancer is the second most
frequent malignant neoplasm found in women all
over the world, representing approximately 10%
of all cancers (13). In Europe, it is rated as the
seventh cause of cancer caused deaths (6)
Within international comparative statistics
furnished by WHO, Romania presents the highest
mortality rate by cervical cancer death in Europe
and, throughout the world, it is situated
immediately subsequent to Latin America states.
The Babeş - Papanicolaou cytological test
constitutes a reliable method, swift and
economical of cervical cancer and its precursors’
investigation and detection (7, 9, 16, 17).
The test is composed of sampling a set of cells
from the cervix uteri, which will be examined
under microscope in order to detect the virtual
abnormalities and in order to prevent cancer.
Material and Methods
The study included a number of 1637 clinically
asymptomatic patients selected at our laboratory,
in a two-year time frame, respectively 2007 –
2008. The patients voluntarily requested the Babeş
- Papanicolaou cytological test. We wish to
mention that we excluded from our study the
patients with clinical complaints (abundant
leucorrhea, post-coital bleedings, dyspareunia,
pelvic inflammatory disorder, pelvic neuralgia) or,
the ones with menstrual bleedings.
We collected the sample cells with the cervix-
brush, from the exocervix and the squamous-
cylindrical junction and we placed them in as thin
and uniform layers as possible on two slides
(cleaned and alcohol-degreased) obtaining
conventional smears. The slides were quickly
introduced in fixative solution (absolute ethylic
alcohol) for at least 20 minutes. They were
colored in the Papanicolaou method (nuclear color
agent: Harris hematoxylin; citoplasmatic color
agents: orange G & polychrome mixture EA51).
Result interpretation was carried out descriptively
in Bethesda 2001 nomenclature system.
Regardless all our diligence, we assume the
falsely positive or falsely negative smears, which
emerge from the fact that cervical cytology – as
any other exploration method – retains inherent
limits, discordances, confusions and errors:
unsatisfactory samples for evaluation, screening
neoplastic cells by means of haematids, mucus

Muntean Mihaela, MD, Pathology Laboratory, Slatina Emergency County Hospital 176
Current Health Sciences Journal Vol. 35, No. 3, 2009
and fibrin, especially in the conventional methods
and, even more importantly, the fact that neoplasic
cellular features may sometimes be subtle,
rendering their identification difficult.

Results:
The study included a number of 1637 clinically
asymptomatic patients cytologically tested with
the Babeş - Papanicolaou test. Microscopic
examination of conventional smears and their
interpretation in the Bethesda 2001 algorithm
revealed the following lesion categories: Fig. 2:ASCUS, Ob. x200, Papanicolau stain
1470 negative smears for an intraepithelial
lesion and malignancy (NLIM). We identified
normal, inflammatory or inflammatory-reactive
smears – detecting the presence of various
organisms: Trichomonas vaginalis, candida,
gardnerellla, cocobacillus and IUD reactive,
atrophic ones (fig. 1).

Fig. 3: ASC-H, Ob. x100, Papanicolau stain

119 smears presenting low-grade intraepithelial

lesion (LSIL) with HPV – type S and I koilocytes,
nuclear atypicalities of simple displastic type,
nuclei 4 to 6 times bigger, or less than 2 times
Fig. 1: NLIM, Ob. x200, Papanicolau stain (when viral HPV cytopathic effects are
emphasized), bi-nuclei, hyperchromasia, irregular
7 smears with atypical squamous cells of nuclear envelope, dyskeratosis orangeophilic cells,
undetermined significance (ASCUS) in which with or without inflammations.
abnormal superficial cells are present (S) or
intermediate ones (I), but they are not modified
enough to pronounce a low grade intraepithelial
lesion diagnosis (LSIL); nuclei are two or three
times bigger than normal, round-oval with
irregularities, hyperchrome. The diagnostic was
that of exclusion (outside inflammation and
reactive processes).
3 smears with atypical squamous cells which
cannot exclude a high-grade intraepithelial lesion
(ASC-H): cytological anomalies were revealed,
Fig.4: LSIL, Ob. x200, Papanicolau stain
parabasal (PB) and basal anomalies (B),
suggesting a high-grade intraepithelial lesion 3 smears with high-grade undetermined lesions
(HSIL), but quantitatively insufficient for a final (SIL-borderline), with cytological features running
interpretation. Atypical metaplasmatic cells or of between LSIL and HSIL; I nuclei increased 3
atypical reshuffling, with hyperchrome, irregular times with the uniform or degenerated cromatine
nuclei and non-uniform cromatine. (LSIL); increased nuclei-plasmatic ratio, irregular
nuclear envelope, granular cromatine, evident
cytoplasm or quantitatively reduced cytoplasm –
on PB cells.

177
Mihaela Muntean: Cytological identification of the (pre)cancerous cervical lesions within a clinically ...
Fig. 5: SIL - borderline, Ob. x200, Papanicolau stain
21 high-grade intraepithelial lesion (HSIL)
smears with atypical type PB and B cells, isolated,
grouped or syncytial cells with or without
koilocytotic atypicality, increased nuclei,
hyperchromasis, emphasized increased in nucleus
– cytoplasm ration, indistinct or immature
cytoplasm, nuclear contour irregularities.
Frequent isolated dysplastic cells.
Fig. 6: HSIL, Ob. x200, Papanicolau stain
6 smears with atypical glandular cells, not
otherwise specified (AGC-NOS), with glandular
cells of nuclear supraposition, great anisocaria
nuclei, rougher cromatine, unequally distributed,
granular or vacuolized cytoplasm.
Fig. 7: AGC-NOS, Ob. x200, Papanicolau stain
3 carcinomatose smears, with tumor cells
presenting marked pleomorphism, eerie nuclear
forms, budded aspect with irregularly engrossed
nuclear membrane, marginal cromatine or piled
cromatine, atypical mytoses, inflammatory smears
178
with haematids and cytonecrosis detrituses (fig.
8).
Fig. 8: Carcinomatous smear, Ob. x100,
Papanicolau stain
Discussion
The study included a number of 1637 clinically
asymptomatic patients who voluntarily requested
the Babeş - Papanicolaou cytological test. No
clinical complaints were registered (at most, a
‘normal’ secretion), i.e. patients having a firm
conviction that they were under no abnormal
smear risk. However, smear evaluation within the
Bethesda 2001 system identified 167
(approximately 10%) abnormal cytology smears: 7
ASCUS, 3 ASCH, 119 LSIL, 21 HSIL, 8 SIL
borderline, 6 AGC-NOS, and 3 carcinomatose
smears.
The psychological impact on learning of an
unwanted diagnostic was invariably negative
(uneasiness, depression, fear, anxiety or shock).
For this reason, encouraging and motivating
women to take the Babeş - Papanicolaou
cytological test, which is both professional
accuracy within method limits and also a risk as
regards falsely positive and falsely negative
results, is the only procedure by which they may
understand what happens when requesting a
cytological examination and also what may
happen if they choose not to take this test.
Generally, the evolution modality of SIL
lesions is difficult to predict, but it is believed that
LSILs have a greater tendency to regress, while
HSILs persist or progress (10). There are solid
molecular and epidemiologic proofs that
demonstrate the close relationship between
persistent HPV infections with certain types of
high-risk HPVs and the development and
progression of cervical cancerous disorders (7).
HPV 16 and 18 presence increases the relative risk
of developing HSIL by approximately 200 times,
it a timeframe of merely two years from detection
(12). In this context, immunocytochemical
identification of HPV HR (high-rish HPV),
suggested in a combined screening, seems to be a
Current Health Sciences Journal
promising tool in anticipating SIL behavior
associated with HPV, offering the certainty of
identifying preinvasive cervical lesions caused by
HPV HR infection, thus avoiding aggressive
treatment in patients with low-grade lesions (4, 5,
8, 18).
Conclusion:
Few women request the Babeş - Papanicolaou
test and too few doctors recommend it to their
patients. Gynecologists’ statistics show that every
year in Romania 2,500-3,000 new cancer
instances appear, in advanced stages, 1,400-1,500
deaths are recorded annually and there are more
than 15,000 cervical cancer patients registered and
monitored (2,3,13). In these circumstances, the
vital message that must reach women is that,
although the Babeş - Papanicolaou test is not
perfect-proof, voluntary testing remains the best
method of preventing cervical cancer, as in this
case, prevention ratio is of 80 – 90% (1, 7).
References
1. Mihaela Badea, Petrache Vartej –2003, Sinopsis de
patologie cervicala preinvaziva Editura “Medica”
Bucuresti, 9,10: 209-211, 213-247;
2. Bosch FX, Lörincz A, Munoz N, Meijer CJ, Shah -
2002,The cansal relation Between human
papillomavirus and cervical cancer, J Clin Pathol, 55
: 244 – 265;
3. FX Bosch et al.-2008, HPV and Cervical Cancer:
Screening or Vaccination?, B.J.C. ( British Journal
of Cancer ), 98(1): 15-21;
4. Dehn D, Torkko KC, Shroyer KR- 2000, Human
papillomavirus testing and molecular markers of
cervical dysplasia and carcinoma, Cancer.,
111(1):1-14;
5. Friedrich T, Kunz J.- 2007, Nachweis von humanen
Papillomaviren, Gynakologie, 4 : 5-8;
6. Grce M, Davies P. - 2008, Human papillomavirus
testing for primary cervical cancer screening, Expert
Rev Mol Diagn., 8(5):599-60;
Corresponding Adress: Dr. Muntean Mihaela, Pathology Laboratory, Slatina Emergency County Hospital,
mihaela.muntean69@yahoo.com
Vol. 35, No. 3, 2009
7. Zur Hausen H. - 2001, Papillomaviruses causing
cancer: evasion from host-cell control in early events
in carcinogenesis, J Natl Cancer Inst, 92: 690-8;
8. Hilfrich R, Hariri J. -2008, Prognostic relevance of
human papillomavirus L1 capsid protein detection
within mild and moderate dysplastic lesions of the
cervix uteri in combination with p16 biomarker,Anal
Quant Cytol Histol Apr, 30(2):78-82;
9. Rana S. Hoda, Syed A. Hoda – 2006,
Fundamentals of Pap Test Cytology – Humana
Press;
10. Kurman JR, Norris HJ, Wilkinson EJ - 1992, Atlas
of the tumor pathology. Tumors of the cervix, vagina
and vulva, third series, fasc 4, AFIP, Ed J
R.Rosai:37-141;
11. Robert J. Kurman -2003, Blaunstein’s Pathology of
the Female Genital Tract ,Springer 2002, 7: 299-
314;
12. Muñoz N et al.- 2003, Epidemiologic Classification
of Human Papillomavirus Types Associated with
Cervical Cancer, The New England Joutnal of
Medicine, 348: 518-527;
13. Parkin DM, Bray F, Ferlay J, Pisani P- 2005, Global
cancer statisticis, 2002, Cancer J Clin, 55:74-108;
14. Maria Sajin - 2003, Colul uterin – Citohistopatologia
leziunilor epiteliale Editura Universitară “Carol
Davila” 8-9-10: 75-173;
15. Smith JH. - 2002, Bethesda 2001 - Review,
Citopathology, 13 : 4 - 10;
16. Diane Solomon, Ritu Nayar - 2004 ,The Bethesda
System for Reporting Cervical Cytology Second
Edition 6,7: 125-133;
17. Simona Spineanu - 2002, Prevenirea cancerului de
col uterin, Ed.Corint, 1,2,4: 5-23;
18. Toro M, Llombart-Bosch - 2005, A Detección
inmunohistoquímica de la proteína L1 de Virus
Papiloma Humano (HPV) de alto riesgo en
citologías y biopsias de cuello uterino, Revista
española de patologia, 38(1);
Abbreviations
NLIM = negative for intraepithelial lesion and malignancy;
ASC-US = atypical squamous cells of undetermined
significance; LSIL = low-grade squamous intraepithelial lesion;
ASC-H = atypical squamous cells, cannot exclude an HSIL;
HSIL = high-grade squamous intraepithelial lesion; AGC-NOS
= atypical glandular cells, not otherwise specified.
179