Endometrial assessment with Isaacs cell sampler

The Value of Endometrial Cytology in a High Risk Population

Between January 1982 and November 1983, 335 women at risk for endometrial carcinoma, with or without symptoms, were screened on an out-patient basis at the 3rd Department of Obstetrics and Gynecology of the University of Milan for endometrial carcinoma and its precursors. Cytologic diagnosis of material obtained with the Milan-Markley helix (Mi-Mark) was compared, in terms of acceptability and diagnostic accuracy, with histologic diagnosis of material obtained by Vabra curettage. The Mi-Mark was better accepted by the patients and there were almost no complications. Sensitivity was 93 % for adenocarcinoma, 62 % for atypical hyperplasia and 76 % for hyperplasia without atypia. According to epidemiologic data and to our results, we suggest this screening procedure for asymptomatic obese women.

Clinico-cytological study of uterine papillary serous carcinoma

OBJECTIVE

The aim of this study was to determine whether or not we could distinguish uterine papillary serous carcinoma (UPSC) from other types of endometrial cancer by cytology.

METHODS

We examined the cytological findings of the endometrium from five cases with UPSC and compared them with 10 cases with endometrioid adenocarcinoma, grade 1 (G1). A morphometric analysis was performed. Cytological samples from the cervix and ascites of the patients with UPSC were also reviewed.

RESULTS

All five patients had FIGO stage III and IV tumours. Three patients died of the disease and two are still alive with disease. The tumour cells of UPSC tended to be shed in papillary clusters with a tumour diathesis. Psammoma bodies were seen only in UPSC. The frequency of irregular-shaped nuclei, membrane thickness and eccentric nuclei in UPSC was higher than in G1. The chromatin pattern was coarsely granular, and both anisonucleosis and bare nuclei were prominent in UPSC. Cytomorphometrically, the maximum diameter of the nuclei in UPSC was significantly greater than that in G1. The nucleoli were also more often seen in UPSC than in G1. The findings of the nuclei and nucleoli in the cervical and peritoneal fluid cytology closely resembled those in endometrial smears. The features of the cervical smears and peritoneal fluid cytology were different from those of endometrial cytology regarding clear background and small clusters of cells.

CONCLUSION

As the endometrial cytology findings accurately suggested the histological diagnosis of UPSC, the diagnosis of UPSC was confirmed in this study by endometrial cytology. The cytological diagnosis of UPSC should be based on the findings of tumour diathesis, psammoma bodies and papillary clusters composed of tumour cells with enlarged nuclei and numerous nucleoli.

Mucinous metaplasia to neoplastic lesions in endometrial samples with cytohistologic correlation

Seven cases of endometrial mucinous metaplasia and five of well-differentiated mucinous adenocarcinoma of the endometrium were studied. Cytologic specimens were obtained by Isaacs endometrial sampler, avoiding endocervical contamination. The histologic diagnosis between the intermediate type of mucinous metaplasia and the well-differentiated mucinous adenocarcinoma posed no problems. DNA analyses of the histologic samples showed a euploid pattern in benign and intermediate types of metaplasia, while well-differentiated mucinous adenocarcinoma showed a hyperdiploid pattern. The cytologic diagnosis of benign mucinous metaplasia should be suggested in the presence of abundant mucinous cells in endometrial samples in the absence of nuclear abnormalities.

Endometrial cytology: six years of experience

This article deals with a 6-yr mass screening program for the early detection of endometrial cancer, which took place 1978-1983. The diagnostic accuracy of endometrial cytology and the possibility of integrating this technique with the hysteroscopy and endometrial biopsy were studied. The authors analyzed 2,504 outpatients, all over the age of 45. The results of endometrial cytology were compared with those found using hysteroscopy and endometrial biopsy. Endometrial cytology showed high sensitivity in diagnosing endometrial cancer (97.7%) and high specificity in diagnosing true negatives. However, this technique was not adequate in identifying benign endometrial pathology, e.g., endometrial hyperplasia, polyps, or submucous fibromas. Epidemiological and clinical data in our series were fundamental in establishing mass screening for the early detection of endometrial cancer using integrated techniques. These data should be taken into consideration for creating new projects. The significantly high prevalence of endometrial neoplasia even in asymptomatic women over 45 years of age (4 per 1000) and the possibility of improving the accuracy of endometrial diagnosis using hysteroscopy and endometrial biopsy were the cornerstones of this project.

Diagnosis of endometrial carcinoma by histopathological examination of the endometrial aspirate by the Curity-Isaacs sampler

The Curity-Isaacs Endometrial Cell (CIEC) sampler was used for endometrial tissue and cell sampling in 230 patients before dilatation and curettage to determine the efficacy of its use as an outpatient endometrial sampler. Its use was found to be safe and without complication. It could be easily inserted into the uterine cavity in 92.0% of patients and did not cause undue discomfort in 88.9% of them. Using histopathological diagnostic techniques, there was 100% accuracy in the diagnosis of endometrial carcinoma. However, it was found that diagnostic accuracy of endometrial hyperplasia was only 33.3%. It is suggested that the CIEC sampler could be used as a first-line diagnostic procedure to exclude endometrial carcinoma in patients with abnormal vaginal bleeding.

The cytology of the normal cyclic endometrium

Endometrial cytologic samples obtained with Cohen's endocyte from 501 normally menstruating women were studied and correlated with histologic sections from cell blocks. In this article, the cytologic diagnostic criteria for normal cyclic endometrium are pointed out. The diagnostic accuracy of normal cyclic endometrium has been 92%. A possibility of a cytologic dating is discussed. The diagnostic accuracy was 71.8% for early proliferative endometria, 82% for late proliferative, 93% for early secretory, 81% for midsecretory, and 60% for late secretory endometria.

Routine outpatient diagnostic uterine curettage using a flexible plastic aspiration curette

Diagnostic curettage using a flexible aspiration curette was possible in 97% of 246 women with abnormal uterine bleeding or discharge. Altogether 15 women with pelvic malignancy were detected or suspected by histological examination of the tissue obtained; no uterine malignancy was missed. The technique appears simple, safe, reliable and cheap and acceptable to patients. Delays in diagnosis and treatment are reduced and formal curettage under general anaesthetsia is avoided in the majority of women requiring investigation.

Nuclear size and shape of epithelial cells from the endometrium: lack of value as a criterion for differentiation between normal, hyperplastic, and malignant conditions

Nuclear area and shape of epithelial cells were measured in cytological specimens from 10 patients with cystic hyperplasia of the endometrium and four patients with adenomatous hyperplasia. Only specimens from patients with histologically confirmed widespread disease of the endometrium were accepted in the study. The mean nuclear area in cystic hyperplasia was significantly lower than in adenomatous hyperplasia. Results from previous measurements with the same method in normal and malignant conditions were compared with those from hyperplastic conditions. Both cystic and adenomatous hyperplasia differed from normal endometrium but not from malignant conditions. The scatter in values in the different conditions overlapped to such a degree as to make nuclear size of little importance as a diagnostic criterion. There were no differences in nuclear shape between normal, hyperplastic, and malignant conditions.

An alternative to the diagnostic dilatation and curettage--endometrial cytology

Endometrial aspiration cytology has been shown by multicentre prospective studies to be an acceptable and valuable method of assessing the endometrium. A retrospective study was undertaken over three years' routine use of the Isaacs cell sampler. In 86% of the cases suitable endometrium was obtained, with experience of the technique being the important factor. When compared with histological findings, all 11 cases of malignancy were confirmed, including one ovarian adenocarcinoma. Of the cytological reports of endometrial hyperplasia, 78% were confirmed by the histological findings, with the remainder showing minor degrees of cystic hyperplasia or normal endometrium. In no case was a more abnormal lesion present on histological examination than had been suggested by cytological findings. The use of progestogens in reversing hyperplasia is seen to be effective, though the long term benefit remains uncertain. It is concluded that with an experienced cytologist, Isaacs endometrial aspiration should be used routinely for the primary investigation of dysfunctional uterine bleeding and postmenopausal bleeding.

A controlled trial of naproxen sodium for relief of pain associated with Vabra suction curettage

In a double-blind study naproxen sodium (550 mg), or placebo was administered 1 h before Vabra curettage and pain associated with the procedure was assessed immediately after operation and 30, 60 and 120 min later by visual analogue and verbal rating scales, and the McGill pain questionnaire. The pre-curettage anxiety of the patients was assessed by the Spielberger state anxiety inventory. Of the 58 patients, 51 (87.9%) reported pain during the procedure; there was no relation between the level of pain experienced and the pre-curettage anxiety score. Compared with the placebo group, the pain experienced by the naproxen group was significantly less as measured by the McGill pain questionnaire immediately after curettage, and by visual analogue scales 30 and 60 min after the procedure. The verbal rating scales showed that naproxen significantly reduced backache 30 min after curettage, and cramp immediately after the procedure and 30 and 60 min later but did not reduce the severity of the pain associated with the procedure.

Endometrial monitoring of high-risk women

The outpatient monitoring of the endometrium is mandatory in a defined high-risk population. Countless reports support this thesis. The authors' candidates for screening include initial samples of all patients over 40 years of age, with annual evaluation of a high risk group. This included patients with a family history of endometrial cancer, where the endometrium is subjected to continue estrogen stimulation either exogenous or endogenous, abnormal perimenopausal or postmenopausal bleeding, low fertility, and the medical triad of obesity, diabetes and/or hypertension. The methodology of monitoring is outlined and assessed. The ease of performance, inexpensiveness, and accuracy of 94% had led the authors to support cytology. Combined cytology, histology and hysteroscopy are needed in selected cases.

Aspiration cytology versus histology in the assessment of the endometrium of women attending a menopause clinic

The endometrium of 100 women attending a menopause clinic was assessed cytologically, using the Isaacs cell sampler, and then histologically, using the Vabra suction curette. Satisfactory specimens for diagnosis were obtained in 96 per cent of cases with the Isaacs cell sampler and in 62 per cent of cases with the Vabra suction curette. There were eight discrepancies between the diagnoses obtained by the cytological and histological methods and these are analysed. Thirty patients were asked to grade the discomfort experienced during the procedures, and of these 26 found the Vabra method more painful than the Isaacs method.

Detection of endometrial cancer and its precursors

Any approach to the control of endometrial cancer must include a consideration of the individual at high risk; this will include the obese, the infertile, those with failure of ovulation and dysfunctional bleeding; and those postmenopausal women who ae chronic estrogen users. The detection of adenomatous hyperplasia offers us the opportunity to recognize the developmental phase of the disease before invasion is established. The cytologic method of Papanicolaou, used in the conventional way, is inefficient for the detection of endometrial cancer. Cell studies taken by cannula from the endometrial cavity can be more accurate for the diagnosis of invasive cancer but fail in the hands of most pathologists to detect adenomatous hyperplasia. We have found the highest rate of accuracy in the aspiration curettage histologic method, both for endometrial cancer and adenomatous hyperplasia. It is quick, relatively painless in most, and an outpatient procedure that does not require anesthetic. It offers the pathologist a sample that is readily interpreted. Our public education effort must include the warning that a negative Pap smear does not rule out endometrial carcinoma.

Out-patient curettage: a comparison of Vabra and Gravlee methods

A prospective survey was carried out on 64 patients comparing the the use of the Gravlee and Vabra methods of out-patient curettage. The Gravlee jet was more difficult to use and had a higher rate of failure of introduction. Provided it is technically possible, however, the Gravlee has similar results to the Vabra in terms of patient acceptance and diagnostic reliability.

The Isaacs cell sampler: an alternative to curettage

The Isaacs cell sampler was tested in 150 women (102 of them postmenopausal) referred for curettage. The results of cytological testing of material obtained with the sampler were compared with histological findings from curettage performed immediately afterwards. Satisfactory aspirates for cytological diagnoses were obtained in 141 patients and satisfactory material for histological diagnosis in 124. In the 102 postmenopausal patients the cytological method yielded 94 satisfactory specimens, while curettage yielded only 76. All the 17 carcinomas were diagnosed cytologically. Of the 12 cases of premalignant change, nine were diagnosed cytologically; two cytologically diagnosed premalignant cases did not, however, yield satisfactory material by curettage. The Isaacs cell sampler is a simple and reliable way of diagnosing malignancies. Further investigation is needed to define the cytological criteria for diagnosing premalignant cases, but as the material is well preserved accuracy should improve with increasing experience. The method should be valuable in screening women having oestrogen substitution therapy.

An assessment of the Mi-Mark endoemtrial sampling technique

One hundred and twenty cytological smears and 106 histological specimens were obtained from 115 patients using a new technique of endometrial sampling. It proved an atraumatic procedure and was well accepted by the patients. Some problems were encountered in the preparation of satisfactory cytological specimens and in their interpretation. The method was not completely reliable for detecting endometrial pathology and is therefore considered unsuitable for monitoring patients on hormone replacement therapy. It was found to be useful as a gynaecological outpatient technique for sampling the endometrium when formal curettage was unsuccessful, in avoiding the necessity for a preoperative curettage to confirm suspected carcinoma, and in the investigation of infertility.

Relation between the karyopyknotic index and plasma oestrogen concentrations after the menopause

The karyopyknotic index correlated significantly (p less than 0.001) with the plasma oestradiol but not plasma oestrone concentration in 38 postmenopausal women. This ties with previous findings that postmenopausal women with superficial dyspareunia have a more severe degree of vaginal atrophy than asymptomatic women, and that oestradiol is probably more important biologically than oestrone.