Endometrial and endocervical secretion: the search for histochemical differentiation

OBJECTIVE: To determine the ideal histochemical stain to differentiate between non-neoplastic and neoplastic endocervix and endometrium. STUDY DESIGN: A total of 90 cases representing nonneoplastic cervix, non-neoplastic endometrium, endocervical adenocarcinoma and endometrial adenocarcinoma were stained with toluidine blue (TB); methylene blue (MB); mucicarmine (MUC); periodic acid-Schiff before and after diastase digestion (PAS, PAS-D); Alcian blue, pH 2.5 (AB); and periodic acid-Schiff after Alcian blue, pH 2.5 (PAB). Cases were blinded and randomly divided between two pathologists for evaluation of the staining and the staining distribution of the glandular epithelium by means of a 36-color scheme. RESULTS: The majority of non-neoplastic endocervix samples stained blue with MB (57%), fuchsia with MUC (70%), magenta with PAS (77%) and PAS-D (73%) and dark turquoise with AB (70%). The majority of non-neoplastic endometrium samples stained slate blue with TB (60%) and pink with PAS-D (53.3%). There is statistical difference (p < 0.05) in the color of the epithelium and secretions between the non-neoplastic cervix and endometrium. The malignant glands of endocervical origin could be differentiated significantly (p = 0.043) from non-neoplastic endocervical epithelium by MUC. The epithelium of the non-neoplastic endometrium is significantly differentiated from malignant endometrium using TB (p = 0.015) and MB (p = 0.038). Endocervical carcinoma could be significantly differentiated from endometrial carcinoma by MB. The staining in endocervical adenocarcinoma and endometrial carcinoma was predominantly present in both apical and cytoplasmic locations compared to their non-neoplastic counterparts (endocervix, p = 0.003; endometrium, p = 0.049). CONCLUSION: This study showed that a panel of histochemical stains could differentiate glandular cells of endocervical epithelium from endometrium.     

Cervicovaginal cytology in uterine adenocarcinoma and adenosquamous carcinoma. Comparison of cytologic and histologic findings

To investigate the diagnostic accuracy and to characterize the findings in false-negative cases, the results of cervicovaginal cytology in 56 adenocarcinomas and 25 adenosquamous carcinomas (42 cervical, 36 endometrial, 2 metastatic and 1 arising synchronously from both cervix and endometrium) were reviewed, including review of the actual slides in 56 cases. Overall, 80% of the initial cytologic diagnoses resulted in diagnostic curettage (i.e., cytology was effectively positive); 84% of the postreview diagnosis were effectively positive. Nine cytology slides showed no malignant cells; eight of these negative smears showed repair, five were atrophic, two showed a high estrogen effect and one had enlarged atypical bare nuclei. These false-negative diagnoses were associated with an endometrial primary site (P less than .01), endometrioid histology (P less than .005), low-grade or intermediate-grade histology (P less than .005), small size of tumor (P less than .05) and absence of cervical involvement (P less than .005) in those cases in which a hysterectomy was performed. False-negative diagnoses were not associated with an absence of endocervical cells or with scanty cellularity. Of 39 cervical and 28 endometrial carcinomas with a positive cytologic diagnosis (initially or after review of the available slides), cytology correctly identified the primary site in 18% and 54% of the cases, respectively. Cytology incorrectly classified the anatomic site of four cervical and three endometrial carcinomas and considered one case arising in both the endometrium and cervix to be endometrial. Routine cervicovaginal cytology does have a role in screening for uterine glandular carcinoma; to maximize its diagnostic sensitivity, we suggest using a recommendation for curettage in the report of positive cases so that all of the varied cytologic diagnoses associated with glandular carcinomas will receive a uniform clinical response. In those cases with preserved cancer cells, a correlation can be made with the histologic type of the carcinoma, rather than with the anatomic site.     

Diagnosing endometrial carcinoma with cervical involvement by cervical cytology

OBJECTIVE: To assess the relationship of a cervical cytologic diagnosis based on number, size and degeneration of malignant clusters and necrotic background to cervical involvement of endometrial carcinoma. STUDY DESIGN: Cervical smears of 53 women with endometrial carcinoma were evaluated for cervical involvement. The cytologic diagnosis was compared with actual involvement, and accuracy was calculated. Retrospectively, cytologic features, including number, size and degeneration of malignant clusters and necrotic background, were analyzed in involved and noninvolved cases. RESULTS: Cervical involvement was confirmed in 15 patients (28.3%). The number and size of malignant clusters in the involved cases were significantly larger than those in the noninvolved cases (P < .001 and < .01, respectively). The proportion of degenerated malignant cells and necrotic background in involved cases were significantly higher than those in noninvolved cases (P < .05). Cytologic diagnosis had a sensitivity and specificity of 62.5% and 86.8%, respectively. CONCLUSION: Cervical smears of involved cases revealed a large number and large size of malignant clusters. These findings support cytologic diagnosis based on number, size and degeneration of malignant cells and necrotic background. Cervical cytology is useful to exclude cervical involvement because of its high specificity and can help detect cervical involvement because of its moderately high sensitivity.     

Morphofunctional features of the nucleoli in glandular hyperplasia and endometrial cancer]

The morphofunctional peculiarities of epithelial cells nucleoli in patients with glandular hyperplasia and endometrial cancer has been studied on the cytological smears from endometrium stained with silver nitrate were investigated. The patterns of nucleolonemic nucleoli content and high activity of nucleolar organizers in cancer of corpus uteri are revealed.     

Pemphigus vulgaris and microinvasive squamous-cell carcinoma of the uterine cervix

Although patients with disseminated pemphigus vulgaris may have involvement of the uterine cervix, such involvement is often detected only after vaginal discharge or bleeding. When a cervical smear is obtained, distinctive cytologic abnormalities may be observed; these may be attributed to the changes of pemphigus or to an associated reparative/inflammatory reaction. This study documents the first two cases of microinvasive squamous-cell carcinoma of the uterine cervix developing in association with uterine cervical pemphigus. The gross pathologic, cytologic and histologic features of these lesions are illustrated. The cytologic criteria that may be helpful in distinguishing between cells derived from microinvasive squamous-cell carcinoma and pemphigus of the uterine cervix are described.     

Synthesis and localization of the mucin-associated TFF-peptides in the human uterus

TFF-peptides (formerly P-domain peptides, trefoil factors) are typical secretory products of mucin-producing cells and are thought to influence the rheological properties of mucous gels. Here, the localization of these peptides in the human uterus was investigated. An analysis of TFF-peptides mRNA by the polymerase chain reaction revealed TFF3 mainly in the endocervix and smaller amounts in the endometrium. TFF1 and TFF2 mRNA was detectable occasionally in the endocervix and very rarely in the endometrium. Western blot analysis detected only TFF3 in tissue extracts of the endocervix and as a constituent of human cervical mucus. Immunofluorescence localized TFF3 in the surface epithelium of the endocervix and in gland-like structures of the cervical epithelium.     

Effect of quinestrol-chlormadinone acetate on the endometrium, cervix uteri and vaginal epithelium

The effects of a combination of 4 or 5 mg quinestrol and 10 mg chlormadinone acetate on the female genitalia were studied in 15 women on the 14th, 21st, and 28th days of the cycle. The cervicotropic effect of quinestrol was stronger (studied by cervical mucus, Fern test, and opening of the os uteri) than its endometrial effect. Hormone withdrawal bleeding occurred overwhelmingly from proliferated endometrium. The chlormadinone acetate dose of 10 mg was sufficient to provoke an endometrial secretion in only 4 cases. Cervical, vaginal, and endometrial findings were functionally consistent.     

Diagnostic usefulness of endometrial aspiration cytology for endometrial cancer cases with normal curettage findings

OBJECTIVE: To determine whether endometrial aspiration cytology is useful for endometrial cancer cases with normal endometrial curettage findings. STUDY DESIGN: Eleven cases in which endometrial cancer could be detected by endometrial aspiration cytology but not endometrial curettage were classified into 2 groups by cancer locus, on the endometrial surface (A) or in the myometrium (B). A clinicopathologic and cytologic analysis was performed to compare the 2 groups. RESULTS: Five cases had cancer lesions localized at the fundus and one at the isthmus (group A). The other 5 had lesions localized in the myometrium (group B). The myometrium invasion was beyond half the myometrium in group B and within half in group A. It required > 2 cytologic examinations for a definitive diagnosis in 33.3% of group A and 80.0% of group B. The endometrial cytology differed clearly between the groups: large clusters of malignant cells with a dirty background (group A) vs. small clusters with a clean background (group B). The log-rank test revealed that group B had significantly poorer prognoses than did group A despite nearly the same rate of stage I/II cases in the 2 groups (p = 0.004). CONCLUSION: Endometrial aspiration cytology was useful for endometrial cancer cases with normal curettage findings as part of early detection. However, the cytologic diagnosis did not indicate good prognoses in the cases of cancer localized in the myometrium.     

The cytologic diagnosis of adenocarcinoma in situ of the cervix uteri and related lesions. III. Pitfalls in diagnosis

Potential pitfalls in the cytologic diagnosis of adenocarcinoma in situ (AIS) of the cervix are illustrated by the presentation of three cases of benign cervical lesions initially diagnosed as AIS: cervical endometriosis, tubal metaplasia of the endocervix and changes due to a previous biopsy. The differential diagnosis of endocervical glandular abnormalities is discussed.     

The cytology of vaginal, cervical and endometrial smears obtained at the time of embryo transfer during in vitro fertilization

Seventy-four women enrolled in an in vitro fertilization (IVF) program had cytologic smears of the vagina, cervix and endometrium obtained at the time of embryo transfer (ET). Of these, 68 vaginal, 46 cervical and 25 endometrial smears were available for cytologic examination. Of the 68 vaginal smears, 4% showed a proliferative pattern, 40% were early secretory and 56% were advanced secretory. The 46 cervical smears demonstrated a delayed hormonal effect, with 70% showing a proliferative pattern, 23% early secretory and 7% advanced secretory cytology. Endometrial cells were obtained only when the Jones catheter, which has a side opening, was used. Twenty-two patients had both vaginal smears and suitable endometrial smears. Of these, 8 of the 9 patients with early secretory vaginal cytology had secretory endometrium while 10 of the 12 patients with mid-secretory vaginal cytology had secretory endometrium. The value of endometrial cytology in predicting conception following IVF-ET is unknown. It seems, however, that a good correlation exists between endometrial and vaginal cytology and that the latter may be of value as an additional, noninvasive tool for the evaluation of endometrial development.     

Cytomorphology and histomorphology after thermal endometrial ablation. Early changes

OBJECTIVE: Endometrial thermal balloon ablation is a recent technique for treatment of dysfunctional uterine bleeding. Although the histologic features of thermal injury to the endometrium have been documented, the cytologic features are not described in the literature. In this study, the cytomorphology of recent thermal injury was studied and correlated with histomorphology. STUDY DESIGN: The study consisted of 29 cases divided into 3 groups: (1) control group, hysterectomies without ablation; (2) specimen (in vitro) group, where ablation was carried out on the uteri in the immediate postoperative period; and (3) in vivo group, with intraoperative endometrial ablation. The cytotoxic effect of thermal injury was assessed by staining the smears for oxidative enzymes. RESULTS: The cytomorphologic features of in vivo thermal ablation were characteristic and composed of fragmented glands, numerous single cells with fuzzy cytoplasm and giant cells. Staining for dehydrogenases was absent from > 90% of endometrial cells in the in vivo cases as against 100% positivity in the control group. CONCLUSION: The cytomorphologic features described for the first time in this study can be applied to endometrial aspirate or brush smears to evaluate the efficacy of the technique and follow-up.     

人滋养细胞表面抗原（Trop-2）在病变子宫内膜中表达的研究

摘要 目的：探讨人滋养细胞表面抗原（trophoblast cell-surface antigens2,Trop-2）在病变子宫内膜中的表达及其临床相关性。方法：采用免疫组化法检测100例正常子宫内膜或病变子宫内膜组织中Trop-2蛋白的表达,其中单纯增生子宫内膜患者26例,复杂或不典型增生子宫内膜患者34例,子宫内膜腺癌患者20例,对照组为20例增生期子宫内膜患者。结果：免疫组织化学法研究结果显示,Trop-2蛋白在正常增生子宫内膜和单纯性增生子宫内膜中几乎不表达,在复杂或不典型增生子宫内膜组织中以及子宫内膜腺癌呈阳性表达。主要分布在细胞膜上,阳性率分别为35.29 %和65.00 %,经过对比子宫内膜癌组的阳性表达率显著高于复杂型或伴不典型增生子宫内膜组的阳性表达率（P<0.05）,且复杂型或伴不典型增生子宫内膜组的阳性表达率显著高于单纯性增生子宫内膜组（P<0.05）,其表达水平随内膜病变程度的加重而升高,呈正相关关系（P＜0.05）。结论：Trop-2蛋白在子宫内膜病变中的表达与其严重程度一致,可反映子宫内膜病变的发生发展,或可作为判断其严重程度的指标。     

Hormonal regulation of lysosomal hydrolases in the reproductive tract of the rabbit

The total protein content and the activities of lysosomal hydrolases (arylsulphatase, alkaline and acid phosphatases, beta-glucuronidase, beta-N-acetylhexosaminidase, alpha-L-fucosidase and beta-galactosidase) in the uteri of ovariectomized rabbits treated with different concentrations of progesterone, oestradiol-17 beta and a combination of progesterone and oestradiol were determined. The enzyme activities were also measured in the reproductive organs of rabbits induced to superovulate by PMSG and hCG. In superovulated and steroid-treated rabbits, the changes in lysosomal hydrolases were more obvious in the endometrium than the myometrium. Except for the myometrial alkaline phosphatase and beta-galactosidase and the endometrial alkaline phosphatase, there were no significant changes in the solubilities of hydrolases after treatment with steroids. beta-Galactosidase levels were significantly higher in the ovariectomized rabbits treated with progesterone. An antagonistic effect of oestradiol and progesterone was observed with respect to uterine weight, protein content and enzyme activities in the ovariectomized rabbits treated simultaneously with oestradiol and progesterone.     

Potential of the learning vector quantizer in the cell classification of endometrial lesions in postmenopausal women

OBJECTIVE: To investigate the potential of artificial neural networks for cell identification in endometrial lesions from postmenopausal women. STUDY DESIGN: The study was performed on cytologic material obtained by the Gynoscann endometrial cell samplerfrom 12 cases of atrophic endometrium, 48 cases of hyperplasia without cytologic atypia (18 cases of simple hyperplasia and 30 cases of complex hyperplasia), 12 cases of hyperplasia with cytologic atypia (complex atypical hyperplasia) and 48 cases of adenocarcinoma (30 cases of well-differentiated, 12 cases of moderately differentiated and 6 cases of poorly differentiated carcinoma). From each case approximately 100 cells were examined using a custom image analysis system. A learning vector quantizer (LVQ) identified the collected data. RESULTS: Investigation of cells from Endometrial Alterations with LVQ proved that according to the nuclear characteristics, as expressed by morphometric and textural measures, the endometrial cells from postmenopausal women may be identified as belonging to one of thefollowing three groups: atrophy, hyperplasia without cytologic atypia (simple and complex hyperplasia) and malignant neoplastic lesions (atypical complex and adenocarcinoma). CONCLUSION: The role of nuclear morphologic features in the cytologic diagnosis of endometrial alterations was confirmed. The overlap in thefeature space observed indicates that cell characteristics do not form strictly separate clusters. Thatfact explains the difficulty that morphologists have with the reproducible identification of cells from endometrial lesions in postmenopausal women. Application of LVQ offers a good classification at the cell level and promises to be a powerful toolfor classification on the individual patient level andfor the clarification of the natural history of endometrial pathology.     

Clinical significance of a cytologic diagnosis of atypical glandular cells, favor endometrial origin, in Pap smears

OBJECTIVE: To evaluate the significance of a diagnosis of atypical glandular cells, favor endometrial origin (AGC-EM), using cytohistologic correlation. STUDY DESIGN: A retrospective search identified 90 cervicovaginal smears (vaginal pool) with a diagnosis of AGC-EM, in 2 tertiary care medical centers between January 1998 and December 2002. RESULTS: Forty-six (51%) were conventional preparations and 44 (49%) were liquid-based monolayers (SurePath, TriPath Imaging Inc., Burlington, North Carolina, U.S.A.). Follow-up biopsies were available in 55 of 90 (61%) cases, 15 of 90 (17%) cases had cytology follow-up, and 20 of 90 (22%) were lost to follow-up. The patients ranged in age from 30 to 86 years (mean, 56); 56 of 90 (62%) were > 50 years. Among the patients who underwent biopsy, 22 (40%) had a clinically significant lesion, including 10 (18%) endometrial adenocarcinomas, 8 (15%) endometrial hyperplasias and 4 (7%) high grade squamous intraepithelial lesion/squamous cell carcinoma, nonkeratinizing type. The remaining 33 patients had benign histology, including benign endometrium, endometrial polyp, tubal metaplasia, cystic endometrial atrophy and cervical microglandular hyperplasia. Of the patients with cytologic follow-up, 2 had Pap smears showing atypical squamous cells of undetermined significance, while the remainder had negative results. CONCLUSION: In our study population, 40% (22 of 55) of women who underwent biopsy following a diagnosis of AGC-EM had significant uterine lesions, with the majority of the lesions endometrial in origin. Patients with a diagnosis of AGC-EM, especially those > 50, should be followed closely, and endometrial sampling should be included in their initial workup.     

Clinical significance of atypical glandular cells by the 2001 Bethesda System in cytohistologic correlation

OBJECTIVE: To evaluate incidence, cytology findings and pathology outcome of atypical glandular cells (AGC) in Pap smears according to the 2001 Bethesda criteria. STUDY DESIGN: From 103,073 consecutive Pap smears, 113 (0.1%) AGC cases were identified. Of these, 91 (80%) had adequate histologic evaluation included in this study. RESULTS: Abnormal histology findings were seen in 38 patients (42%). Final pathology results revealed 14 endometrial adenocarcinomas, 5 endocervical adenocarcinomas, 1 cervical squamous cell carcinoma, 1 endometrial stromal sarcoma, 6 other malignancies, 4 endocervical adenocarcinomas in situ, 4 cases ofendometrial complex byperplasia, 1 case of endocervical glandular dysplasia and 2 cases of cervical intraepithelial neoplasia 3 with glandular involvement. Women with AGC, favor neoplasia, were more likely to have significant pathology than those with AGC, not otherwise specified, 74% vs. 33% (p = 0.002). Some characteristic background cytologic findings were also noticed in most cases of endometrial, fallopian tube and endocervical adenocarcinoma. CONCLUSION: A diagnosis of AGC is more clinically significant by the 2001 Bethesda System, especially the "AGC, favor neoplastic" category. Some background cytologic features are important because they are indicators of malignancy.     

Origin of adenocarcinoma cells observed on cervical cytology

OBJECTIVE: To clarify the ratio of diseases suspected when malignant glandular cells are observed on cervical cytology. STUDY DESIGN: Seventy cases of cervical adenocarcinoma/adenosquamous carcinoma, 207 cases of endometrial adenocarcinoma, 7 cases of tubal adenocarcinoma and 83 cases of ovarian adenocarcinoma were reviewed. The positive rate in cervical cytology performed 3 months before surgery was calculated. Based on the positive rate for each entity and the number of cases treated in the previous 10 years, we estimated the incidence of disease responsible for malignant glandular cells on cytology. RESULTS: The positive rate was 93% in cervical adenocarcinoma/adenosquamous carcinoma, 45% in endometrial adenocarcinoma, 14% in tubal adenocarcinoma and 6% in ovarian adenocarcinoma. These positive rates and case numbers at our institute indicated the percentage of suspicious diseases to be 38% for cervical aaenocarcinoma/adenosquamous carcinoma, 53% for endometrial adenocarcinoma, 1% for tubal adenocarcinoma and 8% for ovarian adenocarcinoma. CONCLUSION: When a cytologic specimen suggested the existence of adenocarcinoma, the most probable disease was endometrial adenocarcinoma, and the second was cervical adenocarcinoma/adenosquamous carcinoma. Adnexal malignancies were responsible in 9% of cases. In the case of positive cervical cytology suggesting adenocarcinoma, the ratio of suspicious diseases is as valuable as the cytologic findings for the differential diagnosis.     

Diagnostic accuracy of liquid‐based endometrial cytology in the evaluation of endometrial pathology in postmenopausal women

C. Remondi, F. Sesti, E. Bonanno, A. Pietropolli and E. Piccione
Diagnostic accuracy of liquid‐based endometrial cytology cytology in the evaluation of endometrial pathology in postmenopausal women Objective: The aim of this study was to compare liquid‐based endometrial cytology with hysteroscopy and endometrial biopsy regarding its diagnostic accuracy in a series of postmenopausal women with abnormal uterine bleeding (AUB) or asymptomatic women with thickened endometrium assessed by transvaginal ultrasound as a screening procedure. Methods: Inclusion criteria were: menopausal status; the presence of AUB and/or thickened endometrium assessed by ultrasound (cut‐off 4 mm); a normal Papanicolaou (Pap) smear; and no adnexal pathology at ultrasound. Exclusion criteria were: previous endometrial pathology; and previous operative hysteroscopy. Of 768 postmenopausal women referred to our general gynaecology clinics, 121 fulfilled the inclusion criteria and were recruited to the trial. Twenty‐one refused to participate. Cytological sampling was carried out by brushing the uterine cavity using the Endoflower device with no cervical dilation and the vial was processed using a ThinPrep® 2000 automated slide processor. The slides were stained using a Pap method. Results: In 98 cases with histological biopsies, endometrial cytology detected five cases of endometrial carcinoma, 10 of atypical hyperplasia and 47 of non‐atypical hyperplasia; 36 cases were negative. In two cases cytology was inadequate because of uterine cervical stenosis. Taking atypical hyperplasia or worse as a positive test and outcome, the diagnostic accuracy of the endometrial cytology was 93.5%, with a sensitivity of 92% and specificity of 95%, a positive predictive value of 73% and a negative predictive value of 99%. All the carcinomas were detected by cytology. Only 42% of women with a positive diagnosis were symptomatic. The cytological sampling was well tolerated by all patients. No complication was registered. Conclusions: Liquid‐based endometrial cytology can be considered an useful diagnostic method in the detection of endometrial pathology as a first‐line approach, particularly if associated with transvaginal ultrasound.     

Endometrium estradiol receptors type I and type II during early pregnancy of rat

By centrifugation in a sucrose density gradient we studied the citosol 17beta-estradiol binding sites of blastocyst receptive and non-receptive endometrial zones, as well as uterine horn endometrium whose ovary was extirpated three weeks before pregnancy. The cytosol was prelabelled with [3H]-17beta-estradiol 2 and 25 nM. In this work two incubation temperatures were studied. On the other hand, at 4 degrees C unoccupied receptors were identified as different from the classic receptor 8S type I. At the same time, we found that 25 degrees C is the optimal temperature for the assay of total receptors to achieve complete exchange of [3H]-17beta-estradiol by 17beta-estradiol in the binding sites. In these conditions, the major component was the 4S type II receptor, mainly in the endometrium from ovariectomized uteri. Furthermore, 17beta-estradiol content was determined in the total homogenized by radioimmunoassay and the results were: 1.42+/-0.16, 1.22+/-0.15 and 1.75+/-0.27 pmol/g wet tissue for receptive, non-receptive and ovariectomized uteri, respectively.