A new diagnostic test for endometrial cancer?: Cytology analysis of sonohysterography distention media.

Investigation of endometrial pathology is indicated in women with heavy or interval bleeding during the reproductive years, postmenopausal bleeding, and/or identification of thickened endometrium according to age. The management algorithm for such patients includes a combination of 1 or more of the following (depending on clinical suspicion): pipelle curettage, ultrasonography, saline-infused sonohysterography (SIS), dilatation and curettage (D&C), and hysteroscopy (with guided biopsy). Although pipelle curettage is quick, inexpensive, and less invasive, a smaller portion of the total endometrial cavity is sampled compared with hysteroscopic-guided biopsy and D&C. Therefore, the diagnostic capacity is lower. Unfortunately, many women still require additional, often invasive, procedures to further evaluate abnormal bleeding, because of a significant number of missed lesions with pipelle sampling.1,2 Saline-infused sonohysterography has an important role in evaluating the endometrium in women with perimenopausal/postmenopausal bleeding or space-occupying lesions in endometrial cavity. This procedure is relatively less complicated than hysteroscopy and has a reported sensitivity of 96%, specificity of 97% to 100%, positive predictive value of 96%, and negative predictive value of 97% in the diagnosis of endometrial lesions3,4 compared with hysteroscopy. The idea of cytologic examination in endometrial washings goes back to 1972. Abate et al5 suggested a technique called “jet washing,” and Henderson et al6 suggested that endometrial samples obtained with the intrauterine jet washer provide information about the endometrium, which is comparable to that obtained by conventional curettage. Several authors evaluated this technique7–10 and concluded that the method was simple and might be of special value in postmenopausal patients. Moreover, tubal adenocarcinomas that had not been detected by curettage were suggested to be detected by intrauterine washing cytology.11 A small number of studies have looked at cytology analysis of the distension media at the time of hysteroscopy as a predictor of endometrial pathology.12–16 Although the results are somewhat conflicting, Gerbaldo et al17 found endometrial cytology to be adequate in 94% of 243 patients. All cases of atypical cells on cytology represented either atypical complex hyperplasia or endometrial cancer at final histologic diagnosis. Actual cases of cancer were rare in these studies, and therefore sensitivity could not be precisely determined. At the time of SIS, the distension fluid is typically aspirated to reduce postprocedure cramping and then discarded. However, if cytology analysis could identify those patients with endometrial cancer, many women would be spared from further invasive and uncomfortable procedures. In this study, we aimed to evaluate SIS distension fluid for cytologic examination and assess the sensitivity of the SIS as a diagnostic test utilizing patients with a known diagnosis of endometrial cancer.