We read with interest the article by Gu et al.1 on abnormal peritoneal washings in patients with endometrial carcinoma after hysteroscopy. Patients with preceding hysteroscopy had a higher rate of positive peritoneal cytology than those without hysteroscopy (13.3% vs. 9.6%), but the difference was not significant.1 Gu et al. concluded that diagnostic hysteroscopy does not appear to be associated with a high incidence rate of abnormal peritoneal washings in patients with endometrial carcinoma. The authors cite only one study that looked at peritoneal cytology and outcome after hysteroscopy in patients with endometrial carcinoma, but there are a number of reports that are inconsistent with their conclusions. We have found a slightly but not significantly elevated rate (10.7%) of positive peritoneal cytology after hysteroscopy in 28 patients with endometrial carcinoma confined to the uterus compared to patients in the literature without preceding hysteroscopy.2 Two studies have reported positive peritoneal cytology (in 12.5% and 16.6% of patients) immediately after diagnostic hysteroscopy in patients with negative cytology before hysteroscopy.3, 4 Two other retrospective studies reported significantly elevated positive or suspect peritoneal cytology rates in patients with preceding hysteroscopy.5, 6 In contrast to what Gu et al. concluded, the results of other studies suggest strongly that diagnostic hysteroscopy can cause dispersion of endometrial carcinoma cells into the abdominal cavity.

Although hysteroscopy appears able to disperse tumor cells into the abdomen, the viability and ability of disseminated cells to implant are unknown. Levêque et al.7 found a high (37%) positive peritoneal cytology rate in 19 patients with endometrial carcinoma invading half or less than half of the myometrium, but none of the 7 patients with positive peritoneal cytology developed recurrences after a mean followup of 25 months. We have found no significantly increased risk for early recurrence after at least two years' followup of patients with endometrial carcinoma histologically confined to the uterus with preceding hysteroscopy compared to patients without preceding hysteroscopy.8 Intraabdominal recurrence was not found in either of these series.7, 8 Similarly, Mulvany et al.9 found no significant association between preoperative hysteroscopy and malignant tubal washings and survival.

Whether iatrogenically disseminated malignant cells have the same prognostic implications as positive peritoneal cytology in patients who did not undergo hysteroscopy is unknown. A good answer to this question would require a randomized trial, which in this setting would be unethical. The same issues apply to other uterine manipulations, such as laparoscopically assisted vaginal hysterectomy10 or saline infusion sonography,11 that have also been associated with dispersion of tumor cells into the abdominal cavity.


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  • 1
    Gu M, Shi W, Huang J, Barakat RR, Thaler HT, Saigo PE. Association between initial diagnostic procedure and hysteroscopy and abnormal peritoneal washing in patients with endometrial carcinoma. Cancer (Cancer Cytopathol). 2000; 90: 143-147.
  • 2
    Gücer F, Pieber D, Arikan MG, Lang P, Tamussino K, Winter R. Peritonealzytologie nach Flüssigkeitshysteroskopie bei Patientinnen mit Endometriumkarzinom. Geburtsh Frauenheilk. 1997; 57: 435-439.
  • 3
    Sagawa T, Yamada H, Sakuragi N, Fujimoto S. A comparison between the preoperative and operative findings of peritoneal cytology in patients with endometrial cancer. Asia Oceania J Obstet Gynaecol. 1994; 20: 3947.
  • 4
    Kurz C, Nagele F, Sevelda P. Tumor cell dissemination by fluid hysteroscopy in patients with endometrial carcinoma. In: Proceedings of the Meeting of the Austrian and Bavarian Societies for Obstetrics and Gynecology, Erlangen, Germany, June 14-17, 1995:178-179.
  • 5
    Obermair A, Geramou M, Gücer F, et al. Does hysteroscopy facilitate tumor cell dissemination? Incidence of peritoneal cytology from patients with early stage endometrial carcinoma following dilatation and curettage (D & C) versus hysteroscopy and D & C. Cancer. 2000; 88: 139-143.
  • 6
    Zerbe MJ, Zhang J, Bristow RE, Grumbine FC, Abularach SM, Montz FJ. Retrograde seeding of malignant cells during hysteroscopy in endometrial cancer. Gynecol Oncol. 2000;76;235.
  • 7
    Levêque J, Goyat F, Dugast J, Loeillet L, Grall JY, Le Bars S. Value of peritoneal cytology after hysteroscopy in surgical stage I adenocarcinoma of the endometrium. Oncol Rep. 1998; 5: 713-715.
  • 8
    Gücer F, Tamussino K, Reich O, Moser F, Arıkan G, Winter R. Two-year follow-up of patients with endometrial carcinoma after preoperative fluid hysteroscopy. Int J Gynecol Cancer. 1998; 8: 476-480.
  • 9
    Mulvany NJ, Arnstein MB, Ryan VA. Prognostic significance of fallopian tube cytology: A study of 99 endometrial malignancies. Pathology. 2000; 32: 5-9.
  • 10
    Sonoda Y, Zerbe M, Barakat RR, Brown CL, Chi DS, Poyner EA. High incidence positive peritoneal cytology in low-risk endometrial cancer treated by laparoscopically assisted vaginal hysterectomy (LAVH) [abstract]. Gynecol Oncol. 2000;76;235.
  • 11
    Alcazar JL, Errasti T, Zornoza A. Saline infusion sonohysterography in endometrial cancer: assessment of malignant cells dissemination risk. Acta Obstet Gynecol Scand. 2000; 79: 321-322.