The utility of endocervical curettage: does routine ECC at the time of colposcopy for low-grade cytologic abnormalities improve diagnosis of high-grade disease?

Endocervical curettage for diagnosing high-grade squamous intraepithelial lesions or worse in women with type 3 transformation zone lesions: a retrospective, observational study

BACKGROUND

This study aimed to assess the value of endocervical curettage (ECC) in detecting high-grade squamous intraepithelial lesion or worse (HSIL+) in women with type 3 transformation zone (TZ3) lesions, and to identify the clinical characteristics of patients with TZ3 lesions who benefit most from ECC.

METHODS

This retrospective, multicenter study included 1,905 women with TZ3 lesions who attended cervical screening in one of seven tertiary hospitals in China between January 2020 and November 2021. All participants had received abnormal results and had been referred to colposcopy. Risk factors were identified through univariate and multifactorial logistic analyses.

RESULTS

In total, 20.5% (n = 391) of HSIL+ cases with TZ3 lesions had been diagnosed with biopsy and ECC. ECC detected 0.8% (n = 15) HSIL+ cases otherwise missed by biopsy alone. Multivariate analysis identified four factors which influenced detection performance. The probability of detecting HSIL+ with ECC is 2.653 (95% confidence interval [CI] 1.009-6.977) times greater in women aged 40-49 years and 2.545 (95% CI 0.965-6.716) times greater for those aged 50 years and older compared to those younger than 30 years. The probability of ASC-H (atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion) and HSIL cytologies were respectively 2.415 (95% CI 1.213-4.808) and 2.933 (95% CI 1.648-5.220) times higher than for NILM (negative for intraepithelial lesion or malignancy). Women with human papillomavirus 16/18 infections were 2.299 (95% CI 0.942-5.613) times more likely to be HSIL+. Precancerous lesions were 35.884 (95% CI 12.214-105.426) times more likely in women who had high-grade colposcopic impressions compared to those with normal impressions.

CONCLUSIONS

ECC should be performed for patients with ASC-H or HSIL cytologies, human papillomavirus 16/18 infections, and for those with high-grade colposcopic impressions. This will increase the number of HSIL+ cases identified using biopsy by reducing the number of false negatives.

Diagnostic Utility of Endocervical Curettage During Colposcopy Among Patients of Varying Risk Factors

OBJECTIVE

Endocervical curettage (ECC) during colposcopy is recommended in certain circumstances; however, diagnostic use remains unclear. We evaluate the utility of ECC among patients with non-fully visualized squamocolumnar junction (SCJ) and certain patient socioeconomic factors.

METHODS

Retrospective chart analysis was completed for patients aged older than 21 years who underwent a colposcopy at 2 study sites between 2012 and 2021. Demographics and histopathologic results were analyzed.

RESULTS

A total of 1,516 colposcopies were reviewed; 73.8% (n = 1,119) had an ECC with colposcopy. Of those, 92.1% (n = 1,031) had benign ECC whereas 13.9% (n = 156) had a positive ECC at time of colposcopy. Most patients with benign ECC had benign/low-grade squamous intraepithelial lesion pathology on colposcopy biopsy (82.3%; n = 914; p < .001), and most patients with high-grade squamous intraepithelial lesion (HSIL) on ECC had HSIL on colposcopy biopsy (63.4%; n = 52; p < .001) However, when looking at patients with high-grade pathology on colposcopy biopsy, it was seen that most had benign or low-grade squamous intraepithelial lesion on ECC (79.5%; n = 205; p < .001). Most patients with adequately visualized SCJ on colposcopy were noted to have HSIL on biopsy and negative ECC (73%; n = 81; p < .001). This result was similar in patients with non-fully visualized SCJ, although not statistically significant. When stratified by socioeconomic status, most patients with high-grade lesions had a benign ECC.

CONCLUSIONS

Endocervical curettage has been described to increase the identification of high-grade lesions at time of colposcopy. This descriptive study shows that many high-grade lesions at time of excisional procedure had a benign ECC on colposcopy, with no demonstrated clear additional utility in high-risk groups.

Utility of Endocervical Sampling at Time of Colposcopy when Referral Cytology Is Low Grade or Better

The utility of endocervical sampling at the time of colposcopic examination after less than high-grade screening Papanicolaou smear is unknown. To address this question, we performed a retrospective review using a colposcopy patient care database maintained at our urban academic medical center. We examined the prevalence of high-grade dysplasia in endocervical samples, the prevalence of high-grade dysplasia in directed cervical biopsies, and the correlations between high-grade endocervical dysplasia and patient factors of age and time to colposcopy. A total of 3026 patient records met inclusion criteria. Mean age at the time of colposcopy was 30 ± 9 years with a range of 21-75 years. The mean time to colposcopy was 96 ± 90 days with a range of 4-1207 days. There was no difference in mean age or days to colposcopy in women who had grade 2 or greater cervical intraepithelial neoplasia on endocervical sampling compared to those who did not. The overall prevalence of high-grade dysplasia in endocervical samples in women with less than high-grade screening Pap results was 5.3%. For all entries, 4.2% (126/3026) had grade 2 or greater cervical intraepithelial neoplasia on endocervical sampling that would not otherwise have been identified. This study demonstrates that endocervical sampling has diagnostic utility in the setting of less than high-grade referral Pap smears. No benefit was demonstrated in patients with normal cytology and high-risk strains of human papillomavirus identified on referral Pap.

A retrospective analysis of the utility of endocervical curettage in screening population

The performance of endocervical curettage (ECC) is a dispute in population screening programs. Data of 3,460 women referred to colposcopy examination and had completed pathological results in the Shanxi Province Cervical Cancer Screening Study I and II were reviewed. Among them, 0.6% and 2.7% women were identified as the histopathological confirmed high-grade squamous intraepithelial lesion or worse (HSIL+) by ECC alone or both ECC and quadrants biopsy respectively. Age, cytology, and colposcopy impression are the impact factors for the HSIL+ yield of ECC (P<0.05). The age-adjusted odds ratio for cytology and colposcopic impression were 5.283 (95%CI: 3.989-6.997) and 3.609 (95%CI: 2.910-4.476) respectively. In low-grade squamous intraepithelial lesion cytology and abnormal colposcopy, no additional HSIL+ was found by ECC. In low-grade squamous intraepithelial lesion cytology but normal colposcopy, the additional yield was 0.6%, 0.8% and 1.1% for the three age groups respectively. In high-grade squamous intraepithelial lesion or worse cytology, the additional HSIL+ yield by ECC ranged between 1.4% and 6.6%. We conclude that the performance of ECC increases with age, the severity of cytology, and colposcopic impression. For women 35 years and older, ECC should be performed if the cytological finding is high-grade or worse in cervical cancer screening program.

Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

OBJECTIVE

To evaluate the performance of routine endocervical curettage (ECC) for diagnosing high-grade cervical intraepithelial neoplasia (CIN) 2 or worse and additional precancers not otherwise detected by ectocervical biopsies.

METHODS

In a secondary analysis of the Biopsy Study, a cross-sectional study conducted between 2009 and 2012 at the University of Oklahoma Health and Sciences Center that found an incremental increase in detection of cervical precancers by multiple biopsies at colposcopy, ECC was performed in most women aged 30 years or older. Cervical intraepithelial neoplasia 2 or worse yield by ECC alone was evaluated in analyses stratified by cervical cytology (atypical squamous cells of undetermined significance [ASC-US] or low-grade squamous intraepithelial lesions [LSIL] compared with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions [ASC-H] or high-grade squamous intraepithelial lesions [HSIL] or worse), colposcopic impression (less than high-grade compared with high-grade), human papillomavirus (HPV)-16 infection status, whether the examination was satisfactory, and by ECC indications per the current guidelines for cervical cancer screening. The diagnostic value of ECC for detecting additional disease was evaluated by the number of lesion-directed ectocervical biopsies.

RESULTS

Of the 204 women aged 30 years or older, 181 (88.7%) underwent ECC. Overall ECC detected 14.4% CIN 2 or worse (95% CI 10.0-20.2%). Endocervical curettage was more likely to find disease in the endocervix among women with high-grade cytology, positive HPV-16 infection, or high-grade colposcopic impressions (respective P values <.05). Among women with ASC-US or LSIL cytology, those with an unsatisfactory examination had a 13.0% CIN 2 or worse yield on ECC (95% CI 6.1-25.7); when colposcopic examination was normal or satisfactory with visible abnormal lesions, ECC detected less than 5% CIN 2 or worse in the endocervix. An ASC-H or HSIL or worse cytology was associated with a CIN 2 or worse yield of 25.8% by ECC (95% CI 16.6-37.9%). However, ECC found only 3.9% (95% CI 1.9-7.8%) additional CIN 2 or worse beyond the cumulative disease detected by up to four biopsies of visible acetowhite ectocervical lesions. Additional CIN 2 or worse yield by ECC increased when fewer lesion-directed biopsies were taken (P<.05).

CONCLUSION

The additional yield of CIN 2 or worse by ECC in a colposcopy with up to four ectocervical biopsies was low. Based on our findings, we recommend routine ECC be performed in women aged 45 years old or older with HPV-16 infection and in any woman aged 30 years or older with HSIL or worse or ASC-H cytology, high-grade colposcopic impression, or ASC-US or LSIL cytology and an unsatisfactory examination.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT00339989.

Accuracy of Colposcopically Guided Diagnostic Methods for the Detection of Cervical Intraepithelial Neoplasia

Introduction: Many factors can affect the accuracy of colposcopically guided biopsy, endocervical curettage (ECC) and differential cytology, all of which are standard, minimally invasive procedures used to detect cervical intraepithelial neoplasia. Method: All conizations carried out between 2007 and 2013 in the gynecological department of Hannover Medical School were retrospectively reviewed. The agreement between colposcopic diagnosis and histology was evaluated retrospectively. The analysis included 593 complete datasets out of a total of 717 cases treated. Results: The overall agreement was 85.5 %; the accuracy was significantly higher (p = 0.029) when three biopsy specimens were taken rather than just one. The agreement between diagnosis and histological findings from conization was highest for women < 30 years (90.7 %) and lowest for women > 50 years (72.1 %; p = 0.008). The agreement between preoperative differential cytology and histology results after conization was 86.7 % and improved as patient age increased (p = 0.035). The agreement between ECC findings and the results of conization was only 49.1 % irrespective of patient age, transformation zone or the patient's menopausal status. Conclusion: The accuracy of colposcopically guided biopsy appears to increase when three biopsy specimens are taken and is particularly high for younger patients. Differential cytology was also found to be highly accurate and is particularly useful for patients aged more than 50 years. The accuracy of ECC was significantly lower; however ECC can provide important additional information in selected cases.

Adjunct p16(INK4a) immunohistochemistry aids the detection of high-grade squamous intraepithelial lesions in endocervical curettage specimens

OBJECTIVES

We questioned whether the use of p16(INK4a) immunohistochemistry in endocervical curettage (ECC) specimens would improve the detection of high-grade squamous intraepithelial lesions (HSIL) in a high-risk patient population.

METHODS

Papanicolaou test results were retrieved in 58 consecutive ECC specimens that were previously diagnosed as no histopathologic abnormality in patients with antecedent HSIL or atypical squamous cells, cannot exclude HSIL. An H&E recut and immunohistochemistry for p16(INK4a) were performed on all cases.

RESULTS

HSIL were found in 18 (31%) ECC specimens originally interpreted as negative. Of these 18 cases, three had moderate-sized fragments of ectocervical epithelium with HSIL seen on the recut H&E with concurrent positivity for p16(INK4a). Fourteen cases had rare to occasional clusters of atypical cells with strong immunoreactivity for p16(INK4a). A single case showed a medium-sized fragment of HSIL on the p16(INK4a)-stained section.

CONCLUSIONS

The use of recuts and adjunct p16(INK4a) should be considered when evaluating ECC specimens in high-risk patient populations.

[Reliability of endocervical curettage after conservative treatment of intraepithelial neoplasia of the cervix]

OBJECTIVE

To evaluate the reliability of endocervical curettage (ECC) in patients previously treated for CIN.

PATIENTS AND METHODS

Retrospective analysis of data from 85 patients between January 1985 and December 2011 who received an ECC during monitoring after treatment of CIN. The reliability of the ECC was evaluated by comparison with the final histological analysis of the surgical specimen or the data for subsequent cyto-colpo-histological follow-up.

RESULTS

Patients were referred to colposcopy either within the immediate post-treatment monitoring (n=42), meanly 9.7±5.3 months after treatment, or if cytological abnormalities were detected during long-term monitoring, meanly 78.6±52.4 months after treatment. Colposcopy was unsatisfactory in 75.3% of patients and normal colposcopic findings were found in 80% of patients. A perfect agreement between the ECC and the endocervical final diagnosis was noted in 68 patients (80%). For the diagnosis of severe cervical lesions (CIN 2+) ECC had a sensitivity of 86.2% (68.3-96.1), a specificity of 94.6% (85.1-98.9) and positive and negative predictive values of 61.4% (47.6-74.0) and 93% (83.0-98.1), respectively.

CONCLUSION

The high sensitivity and negative predictive value of ECC for the diagnosis of severe post-therapeutic endocervical lesions avoid iterative treatment without increasing the risk of progression of a lesion to cancer.