Re: Benign Endometrial cells on pap smear in Postmenopausal women.
From: Harrison Sheld (hsheld@anv.net)
Thu Oct 23 16:15:27 2003
There is the statement: "6 of the 10 patients with EH/CA did not have
vaginal bleeding and were referred for evaluation based solely on their
cytological abnormality showing benign endometrial cells (four patients)
or foamy histiocytes (two patients.)" They did exclude 10 patients who
had atypical glandular cells.
It is hard for me to accept that that the sole reason for referral was
the cytology when there is no statement that a complete medical history
and physical examination was performed on all reported patients; we
don't know what confounding factors those patients had.
Neither do we know what in the 34/159 patients' medical histories or
physical examinations that may have been responsible for no followup and
their exclusion from the study.
There are no details about how the specimens were obtained or by whom.
Neither is there indication on who obtained the information about
bleeding and HRT. Could have been done by secretarial help in the office
checking or not checking a box on the Pap requisition. Thanks for your interest.
Terrence.Jones@kp.org wrote:
>
> Thanks Harrison! I hadn't time to hunt down the article, so delayed
> comment. Wonder if there is mention of the cytologic appearance of the
> endometrial cells in the 4 Pts with adenoca? Were they 'benign
> appearing' in every case? Also, any discussion regarding cytobrush, vs
> spatula alone, WRT specificity? tj
>
> Harrison Sheld
> <hsheld@anv.net> To: Multiple recipients
> Sent by: of list OB-GYN-L
> ob-gyn-l@obgyn.net <ob-gyn-l@dns.obgyn.net>
> cc:
> 10/22/2003 04:44 PM Subject: Re: Benign
> Please respond to ob-gyn-l Endometrial cells on pap smear in
> Postmenopausal women.
>
> I have reviewed the article in the JLGTD. I believe there are several
> problems with it.
>
> First, the patients were drawn from the population of a tertiary care
> medical center and may not be representative of the general
> population.
>
> Second, aside from hormone therapy, there are no historical data as to
> reproductive history, previous HRT, current medications including
> those
> considered alternative, concurrent medical conditions, previous
> abnormal
> Paps or previous GYN surgery; all possible confounders in the
> analysis.
>
> Third, the number patients in that hospital's catchment area who did
> not
> have endometrial cells or histiocytes but who had "asymptomatic"
> endometrial carcinoma is not known. Knowing that the sensitivity of
> the
> Pap smear with regard to detecting endometrial pathology is not nearly
> 100%, it may be that the "negative" population also had a 4% or
> greater
> incidence of endometrial cancer. In other words one cannot assume that
> all the patients who did not have endometrial cells or histiocytes on
> their Pap did not have endometrial cancer.
>
> Fourth, 12 patients on followup had insufficient tissue on sampling
> and
> were not included in the analysis. Since a common finding in
> endometrial
> sampling of postmenopausal patients is insufficient tissue commonly
> from
> an atrophic endometrium, these patients could have been included.
> Their
> inclusion would not have substantially changed the findings.
>
> Finally, the Bethesda system as recently revised does not include
> endometrial cells as an epithelial abnormality in women over 40. I
> would
> be hard pressed absent other risks for endometrial cancer to justify
> cell sampling every postmenopausal patient who had one Pap that showed
> histiocytes and/or normal endometrial cells on the basis of this study
> (nor did the authors make that suggestion.)
>
> "Braun, R. Daniel" wrote:
> >
> > They were assymptomatic and there was no relationship to their being
> on
> > estrogen or not according to the study. How many negative samplings
> do
> > you get for every 4 malignancies when you sample 40 yr olds with
> > menomenorrhagia?? I'll bet it is a lot more than 96, still it is the
> > standard of care.
> >
> > Dan
> >
> > -----Original Message-----
> > From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
> > Harrison Sheld
> > Sent: Tuesday, October 21, 2003 12:18 PM
> > To: Multiple recipients of list OB-GYN-L
> > Subject: Re: Benign Endometrial cells on pap smear in Postmenopausal
> > women.
> >
> > I have not read the article in the ASCCP Journal but there are other
> > articles that have a different statistics. I would advise the
> patient of
> > the statistics (some studies report a only 1% malignancy level in
> > asymptomatic patients), and would let her make the decision. That
> said,
> > patients who are on estrogen, symptomatic, or with risk factors for
> > endometrial CA should be sampled. Doing endometrial sampling on
> > menopausal patients is often times difficult and uncomfortable.
> > According to the article cited, and I don't know if the patients
> were at
> > risk for CA, on estrogen, or symptomatic, 96 out of 100 samplings
> would
> > be unnecessary. If the patient chose not to be sampled I would
> inform
> > her to report in a timely fashion symptoms if they should occur and
> > return for a Pap in 4 months. Just my opinion and I could be wrong.
