SIGNIFICANCE OF PAP SMEAR IN DIAGNOSING ENDOMETRIAL CARCINOMA

Abstract

OBJECTIVE: To explore the role of cervical cytology in the diagnosis of endometrial disease in postmenopausal women in our set up. SETTING: Study was conducted at Department of Pathology and Microbiology of The Aga Khan University, Karachi Pakistan during 2004. METHODS: To assess the correlation between endometrial cells on routine cervical cytology and endometrial carcinoma, 57 Pap smears were taken from postmenopausal women with and without abnormal bleeding. The mean age was 54 ± 7 years. The results of cervical cytology were compared and further confirmed with the endometrial histology. RESULTS: We found a positive association between endometrial cells in Pap smear and carcinoma of the endometrium in six out of 57 patients (11.02%) while remaining 51 patients (88.98%) were benign. However, the presence of atypical endometrial cells in Pap smear and the abnormal vaginal bleeding confirmed the diagnosis. CONCLUSION: The data indicate the importance of further diagnostic evaluation with endometrial sampling in postmenopausal women with endometrial cells seen in Pap smear, especially in abnormal vaginal bleeding.

Full text

SIGNIFICANCE OF PAP SMEAR IN DIAGNOSING
ENDOMETRIAL CARCINOMA
Fauzia Imtiaz, S. Mehmood Hasan, Shabnum Ayub,
Afzal Memon and S. A. H. Zaidi
INTRODUCTION
Cervical cytology has engendered a tremendous
amount of media coverage in recent years. It is
performed by taking Pap smear as screening test for
carcinoma of cervix and the identified cells may
indicate a precancerous or cancerous process in
cervix. However, any abnormal smear must be
followed with a careful clinical examination.
Endometrial carcinomas are the most common
malignancy of the female genital tract and the third
most common cancer worldwide
1
. They make up 97%
of all uterine cancers and arise from the glands within
the endometrium
1
. Endometrial hyperplasia is a
precursor to the most common gynecological cancers
diagnosed in women: endometrial cancer of
endometriod histology. It is most often diagnosed in
postmenopausal women, but women at any age with
unopposed estrogen from any source are at an
increased risk for developing endometrial
hyperplasia. Hyperplasia with cytological atypia and
abnormal uterine bleeding is the most common
presentation of endometrial hyperplasia.
Several studies have found a significant correlation
between endometrial cells detected on Pap smear
and endometrial carcinoma
2
. An association has
been reported with normal and atypical endometrial
cells on cervical cytology primarily in postmenopausal
women. The relationship between these findings on
Pap smear and carcinoma of the uterus has been
shown on range from 1.0% - 11.0%
3-5
. The purpose
of this study was to evaluate the correlation between
endometrial cells found on Pap smear and the
subsequent findings of significant endometrial
pathology in our set up.
MATERIAL AND METHODS
This study was conducted at Department of
Pathology and Microbiology of The Aga Khan
University, Karachi-Pakistan during 2004. A total of
57 Pap smears were obtained from the women with
mean age of 54 ± 7 years. They came to the hospital
with the presenting complaints of postmenopausal
vaginal bleeding. The Pap smear was obtained with
Ayre’s spatula and immediately fixed in absolute
alcohol, stained with Papanicolaou staining
procedure. It was screened for any abnormal
ABSTRACT
OBJECTIVE: To explore the role of cervical cytology in the diagnosis of endometrial disease in
postmenopausal women in our set up.
SETTING: Study was conducted at Department of Pathology and Microbiology of The Aga Khan
University, Karachi Pakistan during 2004.
METHODS: To assess the correlation between endometrial cells on routine cervical cytology and
endometrial carcinoma, 57 Pap smears were taken from postmenopausal women with and
without abnormal bleeding. The mean age was 54 ± 7 years. The results of cervical cytology
were compared and further confirmed with the endometrial histology.
RESULTS: We found a positive association between endometrial cells in Pap smear and
carcinoma of the endometrium in six out of 57 patients (11.02%) while remaining 51 patients
(88.98%) were benign. However, the presence of atypical endometrial cells in Pap smear and the
abnormal vaginal bleeding confirmed the diagnosis.
CONCLUSION: The data indicate the importance of further diagnostic evaluation with
endometrial sampling in postmenopausal women with endometrial cells seen in Pap smear,
especially in abnormal vaginal bleeding.
KEY WORDS: Gynaecology. Endometrium. Cervix. Carcinoma. Pap smear. Diagnosis.
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JLUMHS JANUARY – APRIL 2005
Original Article

cytology. Suspected cases were confirmed by
histological study after taking biopsy.
RESULTS
The observations were taken on total 57 Pap smears.
The mean age of women was 54 ± 7 years. Among
these 57 Pap smears, 29 (50.9%) were normal
superficial cells pattern (Figure I), 22 (38.6 %)
showed infection on cytology (Figure II) while 6 (10.5
%) showed atypical abnormal cells on Pap smear
which were suspected of endometrial origin
(Figure III). The biopsy samples of these six women
were taken to confirm the diagnosis of endometrial
carcinoma on histology (Figure IV). The
postmenopausal vaginal bleeding was present in 39
(68%) women while it was absent in 17 (32%)
women. The mean duration of bleeding was 2
weeks. A positive correlation between presence of
atypical cells on Pap smear and carcinoma of
endometrium was observed at p<0.05 (Table I).
These atypical cells were confirmed on histology and
the distribution is shown in Graph I.
TABLE I: CORRELATION BETWEEN PAP SMEAR
AND POSTMENOPAUSAL BLEEDING
PMB = Postmenopausal bleeding
*Significance at p< 0.05
GRAPH I: DISTRIBUTION OF PAP SMEAR
FINDINGS
FIGURE I: PAP SMEAR SHOWS NORMAL
SUPERFICIAL SQUAMOUS CELLS
FIGURE II: PAP SMEAR SHOWS INFECTION
FIGURE III: PAP SMEAR SHOWS ATYPICAL
ABNORMAL CELLS
FIGURE IV: HISTOLOGY SHOWS ENDOMETRIAL
ADENOCARCINOMA
Significance of pap smear
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JLUMHS JANUARY – APRIL 2005
Pap Smear PMB
Pap Smear 1.000 0.041 *
PMB 1.000
Distribution of Pap smear Findings
38.6
10.5
50.9
0
10
20
30
40
50
60
Normal Infection
Findings
atypical
Percentage

DISCUSSION
The Pap smear test was introduced by George
Papanicolaou about 80 years back and it is now
proved to be one of the best procedures for cervical
cancer prevention. Most cervical cancers start from
an area of dysplastic epithelium which can be
detected well by taking good Pap smear
6
.
Endometrial cells reported on a Pap smear are a
annoying finding in the postmenopausal patients. A
study conducted on 227 postmenopausal women
especially older than 59 years have showed that
benign endometrial cells on a Pap smear may
warrant direct endometrial sampling to rule out
malignancy
7
.
There is importance of further diagnostic evaluation
with endometrial sampling in postmenopausal
patients with endometrial cells seen in Pap smear,
especially those with abnormal bleeding
2
. Our results
also show the correlation between presence of
atypical cells on Pap smear and postmenopausal
vaginal bleeding. The presence of atypical glandular
cells of undetermined significance in cervical smear
from women over 50 years was highly predictive of
abnormal lesions detected by histological
examination. Recently, Obenson and coworker
reported that three cancers were detected on
histology follow up and the most common lesions
were endometrial polyps
8
. Cytohistological correlation
of abnormal cervico-vaginal smears indicates that
endometrial metaplasia may be associated with the
presence of atypical glandular cells
9
. We also
confirmed our results on the basis of histological
findings.
A prompt and aggressive work up is recommended
for those patients who show the atypical glandular
cells of undetermined significance on Pap smears.
The diagnostic sensitivity of the Pap smear is highest
for invasive endocervical adenocarcinoma and lowest
for endometrial carcinoma
10
. Presence of adenocar-
cinoma of endometrium (1.4% of all Pap smears) has
also been reported in Saudi population
11
. Abnormal
Pap smears are significantly associated with the high
grade of tumor and stage II – IV endometrial
carcinoma. However, they are not associated with
patient’s age and depth of myometrial invasion or
vascular invasion
12
.
The presence of Pap smear abnormalities correlates
positively with known indicators of poor prognosis in
endometrial carcinoma of high grade at presentation.
This information is most useful in the management of
patients of endometrial carcinoma with adjuvant
therapy.
CONCLUSION
The data indicates the importance of further
diagnostic evaluation with endometrial sampling in
postmenopausal women with endometrial cells seen
in Pap smear, especially in abnormal vaginal
bleeding. There is no test in medicine which is 100 %
accurate. Even, if all the proper collection
techniques, specimen handling and screening
procedure are utilized, there will still be a false
negative (missed lesion) rate of at least 4%. Hence,
postmenopausal women need to be educated in our
set up as well about the importance of seeking
attention if any vaginal bleeding occurs.
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Fauzia Imtiaz, S. Mehmood Hasan, Shabnum Ayub et al.
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10. Raab SS. Can glandular lesions be diagnosed in
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Significance of pap smear
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AUTHOR AFFILIATION:
Dr. Fauzia Imtiaz (Corresponding Author)
Senior Instructor, Department of Pathology and Microbiology
The Aga Khan University, Karachi - Pakistan.
Dr. S. Mehmood Hasan
Department of Pathology
Hamdard College of Medicine and Dentistry, Hamdard University, Karachi.
Dr. Shabnum Ayub
Department of Gynaecology and Obstetrics
Abbasi Shaheed Hospital, Karachi.
Dr. Afzal Memon
Department of Forensic Medicine
Liaquat University of Medical and Health Sciences, Jamshoro, Sindh
Dr. S. A. H. Zaidi
Department of Pathology
Hamdard College of Medicine and Dentistry, Hamdard University, Karachi.