Psammoma bodies in routine Pap smears not linked to malignancies. (Asymptomatic Women).
Dr. Howard G. Muntz, a gynecologic oncologist at Virginia Mason Medical Center in Seattle, reviewed 9 years' worth of Pap smears in a computerized cytology registry, finding 25 evaluable samples that contained psammomatous calcifications, for an incidence of 1 in 16,000.
"We worry about psammoma bodies, because they are frequently associated with ovarian serous papillary carcinomas as well as other ... malignancies," he said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society
However, the studies that linked 60% of smears containing psammoma bodies to cancer generally included samples from women with malignant background cytology or abnormal symptoms such as postmenopausal bleeding, he noted.
In asymptomatic women undergoing routine screening in Seattle, psammoma bodies were seen in conjunction with a variety of benign conditions and sometimes seemed to indicate nothing at all, Dr. Muntz said at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.
The average age of a woman with psammoma bodies in the Seattle series was 36, with a range of 22-72. Nine of the 25 were postmenopausal, and 4 in fact had abnormal uterine bleeding, including 2 with menorrhagia, although their Pap smears were performed as part of routine screening examinations. Several had remote histories of abnormal Pap smears unrelated to the index smear that contained psammoma bodies.
Completely normal epithelial components were present in 20 of 25 of the smears in question, while 5 had "a few minor epithelial abnormalities." Ten of 25 smears contained normal endometrial cells.
The women underwent varied and often exhaustive follow-up procedures, ranging from repeat Pap smears to colposcopies, hysteroscopies, biopsies, ultrasounds, blood tests, laparoscopies, and hysterectomies. "Despite all this diagnostic effort, we could only make a clear correlation between the Pap smear and something from the biopsy specimen in four cases, Dr. Muntz said.
None of the 25 patients had cancer at the time of diagnosis, nor have 24 developed cancer during follow-up averaging 3 years and ranging from 6 months to 7 years. One patient was lost to follow-up.
This experience stands in marked contrast to case reports published between 1964 and 2000, in which 21 malignancies were found in 35 women whose cervical cytology revealed psammoma bodies.
Two newer studies, one from Australia and the other from Yale University documented cancer in 5 of 22 patients and 9 of 20 patients, respectively, when Pap smears contained psammoma bodies.
The difference may lie in the context in which psammoma bodies were discovered, Dr. Muntz suggested. Malignant background cytology, palpable adnexal masses, or ominous symptoms were seen in the majority of patients found to have malignancies in the other series.
The Seattle group represented a true screening population, some of whom were later found to have benign conditions that might explain the presence of psammoma bodies: endometrial or endocervical polyps, cervicitis, or pregnancy-related conditions.
In up to half of cases in that series, however, the psammoma bodies seemed to be purely an incidental finding.
"The risk of malignancy is actually very low when you have psammoma bodies present on a Pap smear, assuming the patient is asymptomatic, she has an unremarkable physical examination, and the background cytology is normal," Dr. Muntz said.
A reasonable follow-up in such a patient might include a repeat Pap smear, a pelvic examination, cloposcopy, endocervical curettage, and an endometrial biopsy A transvaginal ultrasound may be necessary in older patients with atrophy in whom some of these tests cannot be performed.
"When the risk of occult cancer is low, surgical interventions such as laparoscopy or exploratory laparotomy are not appropriate," he said.
Dr. Muntz and his associates do recommend an extensive evaluation in any patient in whom cancer is suspected because of malignant background cytology, "worrisome" symptoms, or an abnormal physical examination--particularly in patients of advanced age who are at higher risk of gynecologic malignancies.
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|Publication:||Family Practice News|
|Date:||Dec 1, 2002|
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