Authors, year
Definition of postmenopausal
Cases with biopsy, n
Hyperplasia, n (%)
Cancer, n (%)
Hyperplasia or cancer, n (%)
Cherkis et al. (1988) [1]
≥40
179
23 (13)
20 (11)
43 (24)
Gomez-Fernandez et al. (1999) [2]
Unknown
84
6 (7)
6 (7)
12 (14)
Gondos and King (1977) [3]
≥40
147
23 (16)
2 (1)
25 (17)
Ng et al. (1974) [4]
≥40
501
52 (10)
23 (5)
75 (15)
Sarode et al. (2001) [5]
>55
81
4 (5)
4 (5)
8 (10)
Yancey et al. (1990) [6]
Unknown
74
9 (12)
0
9 (12)
Zucker et al. (1985) [7]
Unknown
23
10 (43)
6 (26)
16 (70)
Total
1,089
127 (12 %)
61 (6 %)
188 (17 %)
Table 3.2
Benign-appearing endometrial cells in women over 40: predictive value for endometrial hyperplasia and carcinoma (Data post-2001)
Authors, year | Cases with biopsy, n | Hyperplasia, n (%) | Cancers, n (%) | Hyperplasia or cancer, n (%) |
|---|---|---|---|---|
Browne et al. (2005) [11] | 211 | 1 (0.5) | 6 (2.8) | 7 (3.3) |
Thrall et al. (2005) [12] | 159 | 9 (5.7) | 0 | 9 (5.7) |
Bean et al. (2006) [13] | 140 | 2 (1.4) | 0 | 2 (1.4) |
Kapali et al. (2007) [14] | 499 | 4 (0.8) | 4 (0.8) | 8 (1.6) |
Moroney et al. (2007) [15] | 370 | 9 (2.4) | 6 (1.6) | 15 (4.0) |
Li et al. (2012) [16] | 739 | 13 (1.8) | 7 (0.9) | 20 (2.7) |
Moatamed et al. (2013) [18] | 186 | 10 (5.4) | 4 (2.1) | 14 (7.5) |
Total | 2,394 | 48 (2.0) | 27 (1.1) | 75 (3.1) |
The clinical management proved to be a source of confusion to healthcare providers, especially non-gynecologists. To clarify this, if a woman aged 40 years or older has endometrial cells on a cervical cytology test, the American Society for Colposcopy and Cervical Pathology (ASCCP) specifically recommended in the 2012 management guidelines that histologic endometrial assessment only be performed if the woman is postmenopausal [20].
Studies in the 2001 Bethesda System era found little evidence to support the role of cervical cytology in uncovering endometrial cancer in women under the age of 45 [10, 11, 17, 21]. To improve the predictive value of exfoliated endometrial cells, it is now recommended that benign–appearing endometrial cells be reported in women 45 years of age or older. This revised recommendation is made with the understanding that it is not feasible for a screening test to detect every malignancy. Moreover, it bears emphasis that cervical cytology is primarily a screening test for squamous lesions; it is not intended to screen for endometrial lesions and should not be used to evaluate suspected endometrial abnormalities.
Atypical endometrial cells should still be reported under the general category “epithelial cell abnormality” and managed as such.
3.3 Exfoliated Endometrial Cells (Figs. 3.1–3.4)
Fig. 3.1
Exfoliated endometrial cells (conventional preparation, CP). Cells are arranged in three-dimensional clusters. Nuclei are small and similar in size to an intermediate squamous cell nucleus. Nucleoli are inconspicuous. Cytoplasm is scant, and cell borders are indistinct
Fig. 3.2
Exfoliated endometrial cells (liquid-based preparation (LBP), ThinPrep)
Fig. 3.3
Double-contoured cluster of exfoliated endometrial cells (LBP, ThinPrep). Endometrial glandular cells surround a dark core of stromal cells. Note the cleaner background typical of LBP menstrual specimens
Fig. 3.4
Exfoliated endometrial cells (LBP, SurePath). Single cell necrosis (apoptosis) can be seen in exfoliated endometrial cell clusters (arrow)
3.3.1 Criteria
Cells are small and often arranged in tight, ball-like clusters, rarely as isolated cells (Figs. 3.1 and 3.2).
Nuclei are small, similar in area to a normal intermediate squamous cell nucleus.
Some nuclei around the edge of clusters may have a cup-shaped appearance (Fig. 3.1, arrow).
Nuclei are dark, but the chromatin pattern is often difficult to discern because of overlapping cells.
Nucleoli are inconspicuous.
Karyorrhexis is often present.
Mitoses are absent.
Cytoplasm is scant, occasionally vacuolated.
Cell borders are ill defined.
Double-contoured clusters of endometrial cells may be seen (Fig. 3.3).
Preparation-Specific Criteria
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