BACKGROUND: A lack of standardized assays and consensus of cell definition has lead to a wide variation in the reported range of circulating endothelial cells (CECs). METHODS: An automated rare cell analysis system was used to enumerate nucleated, CD146+/CD105+/CD45- CECs in 4 mL of blood. RESULTS: Recoveries of spiked HUVECs were linear over a range of 0-1,241 cells (R2>or=0.99) with recoveries of >or=70% at each spike level. Correlation coefficient values for interoperator variability and duplicate sample variation were (R2=0.99 and 0.90), respectively. Correlation of CEC counts between tubes 1-2 and 2-3 drawn from the same subject in sequence differed (R2=0.48 and 0.63, respectively). The normal CEC reference range established in 249 healthy donors was 1-20 CECs/mL blood. CEC counts were significantly higher in the 206 metastatic carcinoma patients (P<0.0001). CONCLUSION: CECs can be accurately and reproducibly enumerated in blood and are elevated in metastatic carcinomas compared with healthy donors. Phlebotomy procedures can affect endothelial cell counts.