A 79 year old woman presented for what was ostensibly a routine physical examination with pap test. She had not had a pap test prior to this one for many years. Subsequent review of systems did reveal abnormal post menopausal vaginal bleeding.
Examination of the Pap test (SurePrep) slide revealed multiple tight, three-dimensional glandular cell groups (composite figure 1). The nuclear: cytoplasm ratio is high even though some vacuoles can be seen. The nuclei are large, dark and crowded with variably irregular borders and some evident nucleoli.
Benign endometrial cells, hyperplastic endometrial cells, endometrial adenocarcinoma cells, endocervical adenocarcinoma cells. Benign endometrial cells are usually small, dark and degenerating by the time they appear in a Pap sample. Hyperplastic endometrial cells are often not recognizable as such but are usually designated at “atypical glandular cells”. Grade for grade, endocervical carcinoma cells are larger than those of endometrial carcinomas.
Adenocarcinoma of endometrium
Follow-up: An endometrial D&C was obtained which confirmed the presence of papillary serous (“type 2”) adenocarcinoma of the endometrium (figure 2 low power, figure 3 intermediate power, and figure 4 high power).
Comment: One needs to emphasize that the Pap test was never a good means to screen for adenocarcinoma, whether of endometrial or endocervical origin. This case is notable because it is an exception. Even when a vaginal pool sample is included (which has a higher recovery rate of endometrial cells), pap tests have been estimated as showing endometrial cancer cells in as few as 25% of patient who are known subsequently to have endometrial adenocarcinoma. The typical pan-cervical collection will perform less well. Endocervical aspiration has also been tried without good results. Direct endometrial sampling has proven to be the best means of screening for, or of documenting endometrial adenocarcinoma.