| Abstract|| |
Background: Endometrial cytopathology is a powerful tool for the detection of a wide variety of benign atypias, inflammatory changes, and infectious organisms. It is also helpful for the cytohormonal evaluation of patients and the detection of endometrial malignancies.
Aims: The present study was carried out to assess the sensitivity and specificity of endometrial cytology performed by using an insemination cannula.
Materials and Methods: Endometrial aspiration using an insemination cannula was done in 60 cases who presented with dysuterine bleed, infertility, or postmenopausal bleed. The cytological evaluation of endometrial smears was correlated with histopathological findings with reference to cyclic endometrium, atypical hyperplasia, and endometrial malignancies.
Results: There were 35 patients in the reproductive and 25 in the menopausal age groups. The sample was inadequate in four cases but there was an overall 100% correlation between cytological and histological findings of cyclic endometrium, atypical hyperplasia, and endometrial malignancy. The sensitivity and specificity of endometrial aspiration was 83.3 and 95.4% respectively, with two false negative and false positive cases.
Conclusions: Endometrial aspiration cytology was found to be a safe outpatient procedure in the diagnosis of normal and abnormal endometrium for patients of all ages.The present study emphasizes the need for endometrial screening in postmenopausal patients to enable the detection of endometrial malignancies at an early stage.
Keywords: Endometrial aspiration cytology; endometrial carcinoma; endometrial cytology; insemination cannula.
|How to cite this article:|
Malik R, Agarwal R, Tandon P. Cytological assessment of endometrial washings obtained with an insemination cannula and its histological correlation. J Cytol 2008;25:128-32
|How to cite this URL:|
Malik R, Agarwal R, Tandon P. Cytological assessment of endometrial washings obtained with an insemination cannula and its histological correlation. J Cytol [serial online] 2008 [cited 2020 May 28];25:128-32. Available from: http://www.jcytol.org/text.asp?2008/25/4/128/50797
| Introduction|| |
Endometrial cytopathology is a powerful test for the detection of a wide variety of benign lesions ranging from atypias and inflammatory changes to infectious organisms. It can be used for the cytohormonal evaluation of the endocrine status of patients and for screening for malignancy.
The diagnostic modality for endometrial lesions is mainly endometrial biopsy or curettage, which is an invasive and time-consuming procedure. The routine Pap smear More Details is not adequate for the detection of endometrial cancer as the rate of positivity is only 50%. Papanicolaou and Marchetli described the 'sample aspiration method' in the diagnosis of cancer and other conditions of the uterus, which involved the use of a metal cannula which was developed by Cary in 1943.  Recently, aspiration has been found to be successful for even diagnosing extrauterine malignancies  as well as low-grade endometrial sarcomas.  Subsequent modifications of the endometrial aspiration technique included the endometrial brush, membrane filtration method, endometrial jet machine, Gravlee jet washers, Isaacs endometrial sampler,  Helix lippas loop method, endometrial brush, endocyte, End-pap sampler, and the disposable plastic cannula.
The present study was carried out to assess the sensitivity and specificity of endometrial cytology using an insemination cannula a low cost and easily available device.
| Materials and Methods|| |
The present study included patients of reproductive, menopausal, and postmenopausal age groups who presented with complaints of dysfunctional uterine bleeding, infertility, postmenopausal bleeding, or abnormal cervical cytology, and who had been advised dilatation and curettage (D and C). Thorough general, brief systemic, and detailed local examinations were done for each case. History of drug/oral contraceptive intake and the family history of diabetes, hypertension, and tuberculosis were taken.
Procedure for endometrial aspiration cytology
Taking aseptic precautions, a bivalve speculum was inserted into the vagina and the cervix was grasped with an artery forceps. An insemination cannula of 0.5 mm internal diameter and 1.0 mm external diameter was inserted into the endometrial cavity without anaesthesia or analgesia. Five millilitres of normal saline was pushed with the help of a syringe, followed by suction of uterine cavity material through the cannula.
Aspiration fluid was examined grossly for the presence of tissue fragments and for whether it was hemorrhagic, serous/watery, sticky, mucoid, or purulent in nature. It was centrifuged at 2500 revolutions per minute (rpm) for ten minutes. The sediment obtained after centrifugation was smeared evenly on a nongreasy, albumin-coated glass slide with the help of another glass slide. The slides were fixed in 95% alcohol and stained using Papanicolaou stain.
The smears were later screened for adequacy using criteria suggested by Bistoletti and Hjerpe.  They suggested that the yield of 10-20 endometrial fragments be considered adequate. Adequate smears were divided into four groups: 1) Cyclic endometrium (proliferative and secretory phase), 2) Endometrial hyperplasia (simple hyperplasia, complex hyperplasia and atypical hyperplasia), 3) Endometrial carcinoma, 4) Extrauterine (metastatic) malignancy.
The cytological assessment and criteria used for the diagnosis of endometrium were as given by An-Foraker et al.  and Bistoletti and Hjerpe: 
Glandular cells in tight cohesion, exhibiting uniform, round, or oval nuclei with scanty cytoplasm, lacking secretory activity, but with evenly distributed nuclear chromatin. Endometrial cell sheets have a honeycomb appearance [Figure 1].
Sheets of single layered cells with round or oval nuclei, finely granular chromatin, with cytoplasm showing vacuolations, and well defined borders [Figure 1].
Little increase in cellularity, with cells arranged in small and large groups, and in sheets and coin-like configuration with cell cohesion. There is tendency for cystic dilatation in tissue fragments. Nuclei show mild to moderate anisonucleosis, fine granulation, even chromatin, and scant cytoplasm [Figure 2].
Increased cellularity, piling up of cells, increase in the size of cells, enlargement of nuclei, fine granular chromatin, and macronucleation with mild variation of nuclear size [Figure 2].
Atypical endometrial hyperplasia
Hypercellularity of smears, three dimensional structures, glandular and papillary formation of cells, increased nuclear cytoplasmic (N:C) ratio, granular chromatin, presence of nucleoli, nuclear crowding, and disturbed nuclear polarity [Figure 3].
Disorganisation of cells in sheets and three dimensional clusters with extreme variation in shape and size of cells, disturbed nuclear polarity, hyperchromasia, increased nuclear chromatin granularity, increased number of macronucleoli, loss of cohesiveness, and abnormal mitotic figures [Figure 3].
Metastatic squamous cell carcinoma
Large number of discohesive single cells and spindle-shaped keratinised cells, hyperchromatic nuclei with considerable variation in size and shape with granular necrotic background.
In all the cases, simultaneous histopathological examination was done of tissue obtained by dilatation and curettage, and from hysterectomy specimens.
| Results|| |
Endometrial aspiration was done in 60 cases: 35 females (58.3%) belonged to the reproductive age group and 25 females (41.6%) were in the menopausal and postmenopausal age groups. Out of the 35 females in the reproductive age group, 15 (42.8%) presented with complaints of menstrual disturbance and 20 (57.1%) presented with infertility. Out of the 25 patients in the menopausal and postmenopausal groups, 22 patients (88%) complained of menstrual disturbance, two (8%) patients had postmenopausal bleeding, and one (4%) came with blood-mixed discharge.
Out of 60 patients, endometrial aspirate was satisfactory in 56 patients whereas aspiration could not yield any material in two patients because of senile endometrial atrophy and technical failure. Although inadequate sample was obtained on aspiration from two patients, endometrial yield was sufficient on curettage. Thus, the problem with aspiration may be attributable to technical difficulties due to flushing of the cavity by insufficient quantities of saline.
On gross examination, 50 aspirated fluids were found to be hemorrhagic, five were hemorrhagic with flakes, three were watery/serous, and two were mucoid and purulent. The cytological and histological findings of the Papanicolaou-stained smears and hematoxylin and eosin (H and E) stained sections are shown in [Table 1].
Cytological examination of 35 cases in the reproductive age group showed that 32 (91.4%) were reported as cyclic endometrium and 14/32 (43.7%) were reported as proliferative phase (PP) and 18/32 (56.2%) as secretory phase (SP). Two (5.7%) cases were reported as simple hyperplasia (SH) and one (2.8%) was inadequate.
When histological correlation was done [Table 1], it was found that endometrial cytology was not useful to diagnose three cases of simple hyperplasia in the reproductive age group. Two were diagnosed as proliferative phase and one case which was inadequate on aspiration, was reported as simple hyperplasia on histological examination.
In the menopausal group, out of three inadequate aspirates, one case was reported as complex hyperplasia (CH) and two as proliferative phase on histological examination. Overall, there was 100% correlation of cytological and histological findings in secretory phase, atypical hyperplasia (AH), primary endometrial carcinoma, and metastatic squamous cell carcinoma [Table 2].
Endometrial cytology was unable to diagnose three cases of simple hyperplasia, two of which were reported as proliferative phase whereas one was inadequate. One case of complex hyperplasia was missed as the aspirated material was inadequate. One case of simple hyperplasia was underdiagnosed as being proliferative phase. The procedure had a sensitivity of 83.3% and a specificity of 95.4%.
| Discussion|| |
Cytology is an important tool that complements histopathology. The main purpose of the present study is to suggest and establish cytology of the endometrium as a routine diagnostic modality's it is a safe outpatient procedure without any complications. Studies have also revealed that, at times, even when curettage findings have been normal, endometrial aspiration cytology has been found to be useful for diagnosing endometrial cancers.  Inadequacy rates reported in the literature varied from 1.6 to 27% depending on the technique used. In the present study, the inadequacy rate was 6.6%.
Various techniques have been employed to increase the cellular yield of endometrial aspiration cytology (EAC). The cellularity in our study using an insemination cannula was 93.3%.
The processing of endometrial cytological samples and their staining was mainly aimed to increase the cell yield and to achieve uniform staining patterns to aid the comparison of results.
Samples of endometrial aspiration were judged for adequacy on the basis of endometrial cells or tissue. Bistoletti and Hjerpe  suggested the yield of 10-50 endometrial cell fragments to be taken as being adequate. Using the above criteria, 56 (93.3%) out of 60 cases in the present study were found to be adequate whereas four (6.6%) were found to be inadequate for opinion.
The various causes of inadequacy of cellular yield in EAC ,,,, have been summarized in [Table 3]. These include atrophic endometrium, stenosis of cervical canal, difficulty in insertion, drying artifact, and poor technique. In the present study, atrophic endometrium and poor technique were probably the major factors. [Table 3] also compares the inadequacy rates and the causes reported by various authors with those of the present study. The inadequacy rates obtained by using the Gravlee Jet Washer have been reported by Dowling et al. ,  Afonso et al. ,  and Richart et al. ,  to be 27, 1.66, and 9.6% respectively. Using the Isaac endosampler  gave a 2.5% inadequacy rate which was very close to the rates given by Liza et al.  (2.8%) and the present study (6.6%).
Using a menstrual regulation (MR) syringe with 4 mm Karman cannula, Hemlatha et al .  also compared histopathological and cytological findings in cases of dysfunctional uterine bleeding. They also found 95% correlation in cytological and histological findings with a diagnostic accuracy that was higher with aspiration than with D and C.
The present study found adequate and reportable endometrial cell yields by using the technique of disposable sterile plastic cannula aspiration by irrigation with normal saline. The fluid was centrifuged at 2500 rpm for 10-15 minutes and the resulting sediments contained adequate endometrial material (93.3%). Papanicolaou stain was found to be excellent at highlighting endometrial cell features.
The sensitivity and specificity reported in the present study by using the insemination cannula when compared to methods used by other authors ,,,, for intrauterine washing is summarized in [Table 4].
Liza et al .  used the insemination cannula for intrauterine aspiration with a sensitivity of 81.6% and a specificity of 83.3%. In the present study too, the insemination cannula was used which gave a sensitivity of 83.3% and a specificity of 95.4%. Similar studies were also done by An-Foraker et al. ,  Favre et al. ,  Byrne  and Bistoletti and Hjerpe  by using different devices such as the Isaac cell sampler,  Gravlee jet washer,  Endocyte,  and Endopap. 
Thus, it was observed that the methods used did not influence sensitivity or specificity as the sensitivity and specificity obtained by all methods were 68.2-97% and 79-100% respectively.
Gross examination of aspirated fluids was also significant. The endometrial aspirates were divided into red and colourless specimens. Red specimens had a higher adequacy rate as compared to colourless, watery, serous specimens that were reported as being inadequate specimens. Out of 50 hemorrhagic aspirates, 48 (96%) were reported as cyclic endometrium, one as hyperplasia, and one was inadequate. All five aspirates that were hemorrhagic with flakes, were reported as hyperplasia. The three watery and serous aspirates were considered inadequate. On the other hand, mucoid and purulent aspirates turned out to be endometrial adenocarcinoma and metastatic squamous cell carcinoma respectively.
| Conclusions|| |
Endometrial aspiration cytology was found to be a safe, well tolerated outpatient procedure in the diagnosis of abnormal and normal endometrium for patients of all ages. The study emphasizes the need of endometrial screening in postmenopausal patients so that uterine as well as extrauterine metastatic malignancies can be detected at an early stage.
The insemination cannula method used in this study was a very cheap and effective alternative to other expensive methods such as the Isaac cell sampler, Gravlee Jet Washer, Endocyte, and Endopap. The insemination cannula can be conveniently used in developing countries like India, for endometrial screening programmes. Its sensitivity and specificity were found to be equally good and the inadequacy rate was also very low.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]