European Journal of Cardiovascular Medicine

Cervical cancer remains one of the most common malignancies affecting women worldwide, particularly in low- and middle-income countries, where access to screening and early detection services is limited (1). According to the World Health Organization, cervical cancer ranks as the fourth most frequent cancer among women globally, with an estimated 604,000 new cases and 342,000 deaths in 2020 alone (2). Persistent infection with high-risk human papillomavirus (HPV) types is recognized as the principal etiological factor for cervical intraepithelial neoplasia and invasive cervical cancer (3).

The Papanicolaou (Pap) smear is a simple, cost-effective, and widely used cytological screening method for detecting premalignant and malignant changes in the cervical epithelium. Regular Pap smear screening has been shown to significantly reduce the incidence and mortality associated with cervical cancer through early identification and management of abnormal lesions (4). However, while cytology is valuable for screening, its diagnostic accuracy can be influenced by various factors, including sampling technique, observer variability, and interpretation errors. Therefore, histopathological examination of cervical biopsy specimens remains the definitive standard for confirming cervical epithelial abnormalities (5).

Given the clinical importance of early detection and appropriate management, correlating cytological findings with histopathological diagnoses is essential to validate the effectiveness of the Pap smear and determine the necessity for further interventions. This study aims to evaluate the diagnostic concordance between Pap smear results and histopathological findings in patients presenting with abnormal cervical cytology, thereby contributing to quality assurance in cervical cancer screening programs.

A total of 120 women aged between 25 and 65 years who presented with abnormal cervical cytology reports on Pap smear were included in the study. Women who had a history of cervical cancer, had undergone hysterectomy, or were receiving treatment for any cervical lesion were excluded.

Cervical smears were obtained using an Ayre’s spatula and endocervical brush and fixed immediately in 95% ethanol. The smears were stained using the Papanicolaou technique and interpreted according to the 2014 Bethesda System for reporting cervical cytology. Cytological categories included atypical squamous cells of undetermined significance (ASC-US), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), and squamous cell carcinoma.

All patients with abnormal smears were advised to undergo colposcopic examination followed by guided cervical biopsy. Biopsy samples were fixed in 10% neutral buffered formalin, processed, embedded in paraffin, and stained with hematoxylin and eosin. Histopathological findings were classified as chronic cervicitis, cervical intraepithelial neoplasia (CIN I, CIN II, CIN III), or invasive carcinoma based on WHO classification.

The cytological findings were compared with the corresponding histopathological diagnoses to assess the correlation. Data were analyzed using SPSS version 24. Descriptive statistics were used to summarize findings. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of Pap smear in detecting premalignant and malignant lesions were calculated. Chi-square test was applied to determine statistical significance, with a p-value of <0.05 considered significant.

A total of 120 women with abnormal Pap smear findings were included in the study. The mean age of participants was 39.8 ± 9.3 years. Most participants (60%) were in the 31–45 age group.

Distribution of Cytological Findings
The Pap smear results were categorized based on the Bethesda System. Among the 120 cases, ASC-US was reported in 30 (25%) patients, LSIL in 40 (33.3%), HSIL in 30 (25%), and squamous cell carcinoma in 20 (16.7%) cases (Table 1).

Table 1. Distribution of Pap Smear Findings (n = 120)

(Table 1: Cytological categorization of cervical smears)

Histopathological Findings
On histopathological examination of colposcopic-guided cervical biopsies, 28 (23.3%) showed chronic cervicitis, 36 (30%) showed CIN I, 18 (15%) had CIN II, 16 (13.3%) had CIN III, and 22 (18.3%) were diagnosed as invasive squamous cell carcinoma (Table 2).

Table 2. Histopathological Diagnosis in Abnormal Pap Smear Cases (n = 120)

(Table 2: Histopathological findings of biopsy samples)

Cytology-Histopathology Correlation
Among the 30 ASC-US cases, 20 correlated with chronic cervicitis, while 10 showed CIN I. Of the 40 LSIL cases, 24 had CIN I, 10 had CIN II, and 6 had chronic cervicitis. Out of 30 HSIL cases, 12 had CIN II, 14 had CIN III, and 4 had carcinoma. Among the 20 smears reported as squamous cell carcinoma, 18 were confirmed histologically, and 2 showed CIN III (Table 3).

Table 3. Correlation Between Cytological and Histopathological Findings (n = 120)

(Table 3: Cross-tabulation of Pap smear findings and histopathology)

The overall concordance rate between cytology and histopathology was 81%. The Pap smear demonstrated a sensitivity of 88.2%, specificity of 76.4%, PPV of 84.3%, and NPV of 80.5% for detecting high-grade lesions (CIN II or worse).

The present study aimed to evaluate the diagnostic correlation between Pap smear findings and histopathological diagnoses in women presenting with abnormal cervical cytology. The findings demonstrated an overall concordance rate of 81% between cytological interpretation and biopsy-proven histopathology, which is consistent with other published studies reporting concordance rates ranging from 70% to 85% (1,2).

Pap smear has long been established as an effective screening tool for detecting precancerous lesions and carcinoma of the cervix. However, its reliability can vary based on sample adequacy, interpretation accuracy, and reporting standards (3,4). In this study, ASC-US was the most frequently observed abnormality, followed by LSIL and HSIL, similar to findings reported by Kalita et al. and Sharma et al. (5,6). Among ASC-US cases, the majority showed chronic cervicitis on histopathology, reflecting the possibility of reactive or inflammatory changes being misclassified cytologically (7). This highlights the importance of follow-up and adjunctive testing in borderline cytological interpretations.

The majority of LSIL cases were histologically confirmed as CIN I or II, consistent with previous reports indicating that low-grade cytological lesions correspond well with early dysplastic changes (8). However, a small percentage of LSIL cases in this study turned out to be chronic cervicitis, reinforcing the fact that mild cytological atypia can sometimes be reactive rather than neoplastic in nature (9).

HSIL cases in this study demonstrated good correlation with CIN II, CIN III, and a few cases of invasive carcinoma, suggesting high predictive accuracy of high-grade cytology for significant dysplasia or malignancy. These findings align with those of Goyal et al. and Alakeel et al., who reported high PPVs for HSIL categories (10,11). Cytological diagnosis of squamous cell carcinoma was confirmed histologically in 90% of cases, reflecting the reliability of cytology in identifying invasive disease in advanced cases (12).

The sensitivity and specificity of the Pap smear for detecting high-grade lesions (CIN II or worse) in our study were 88.2% and 76.4%, respectively. These values are in agreement with earlier studies by Kulkarni et al. and Nayar and Wilbur, who reported comparable diagnostic performances of conventional Pap smears (13,14). However, false-negative and false-positive results continue to pose diagnostic challenges. Factors such as obscuring blood or inflammation, sampling errors, and inadequate fixation can compromise cytological interpretation (15).

The results of this study reinforce the necessity of correlating cytological findings with histopathology, especially in cases of HSIL and carcinoma. Colposcopy-directed biopsy should be considered a vital step in the diagnostic algorithm for women with abnormal Pap smears. Moreover, integrating HPV DNA testing and liquid-based cytology could further enhance screening sensitivity and minimize interpretation variability (6,7).

The present study demonstrates a significant correlation between Pap smear findings and histopathological diagnoses in cases of abnormal cervical cytology. While Pap smear remains a reliable and cost-effective screening tool, histopathological examination is essential for definitive diagnosis, especially in high-grade lesions. Strengthening the integration of cytology with biopsy and colposcopy can enhance early detection and improve patient outcomes in cervical cancer prevention programs.

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