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Understanding the significance of the presence of normal-appearing
endometrial cells in the Pap test presents an ongoing challenge, as reported
in a May 2006 "Recommended Reading" in CAP TODAY (Related article: Significance
of benign endometrial cells in cervicovaginal smears). In the previous
report, it was noted that one of the most recent and comprehensive reviews
of the topic published by Fadare, et al (Adv
Anat Pathol. 2005;12:274-287) still concluded that the recommendations
in the Bethesda System 2001 for reporting endometrial cells was appropriate
but worthy of continued evaluation. The authors indicated that, particularly
for premenopausal women 40 years of age or older, the issue is essentially
one of sensitivity versus specificity. A more recent publication appears
to provide a thorough examination of the problem by assessing the cost-effectiveness
of endometrial sampling in women of this age group found to have normal
endometrial cells in their Pap tests (Kapali M, Agaram NP, Dabbs D, et
al. Cancer
Cytopathol. 2007;111:26-33).
The authors studied a cohort of 499 women 40 years
of age and older reported to have normal endometrial cells in their Pap
tests who also underwent endometrial sampling. In this cohort, the population
was divided into two age groups, 40-45 years and older than 45 years;
day of the menstrual cycle, before day 12 or after day 12; and menopausal
or postmenopausal status. The type of sampling and the results were obtained
from the surgical pathology reports, and the cutoff for significant endometrial
disease was set at atypical complex hyperplasia or endometrial adenocarcinoma.
The cost of the sampling, including the pathology and gynecology components,
was estimated based on Medicare reimbursement for the type of procedure
used.
Of the 499 patients included in the study, only six
patients were found to have significant pathology, and of these six patients,
four were postmenopausal, including the three asymptomatic patients. No
asymptomatic premenopausal women presenting with normal endometrial cells
in their Pap smears were found to have significant disease. The total
cost of sampling the 350 asymptomatic women was $107,272.
The authors conclude that endometrial sampling of asymptomatic
premenopausal women in their 40s presenting with normal endometrial cells
in their Pap tests is not cost-effective. Furthermore, they indicate that
reporting normal endometrial cells in postmenopausal women produces the
highest yield of women with significant endometrial pathology confirmed
on biopsy. Of note, the authors also report that the distinction between
normal and abnormal endometrial cells may not be a simple problem, and
it may be significantly affected by the type of sample processing. They
recommend a conservative approach to identifying endometrial glandular
cell atypia in conjunction with implementing the reduction of unproductive
endometrial sampling.
Dr. Tench, a member of the CAP Cytopathology Committee, is chief of cytopathology and associate director of the laboratory at Palomar Medical Center, Escondido, Calif.
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