Cone biopsy: has endocervical sampling a role?

European guidelines for clinical management of abnormal cervical cytology, part 2

The current paper presents the second part of chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. The first part of the same chapter was published in a previous issue (Cytopathology 2008;19:342-54). This part provides guidance on how to manage and treat women with histologically confirmed cervical intraepithelial neoplasia. The paper describes the characteristics, indications and possible complications of excisional and ablative treatment methods. The three options to monitor the outcome after treatment (repeat cytology, HPV testing and colposcopy) are discussed. Specific recommendations for particular clinical situations are provided: pregnancy, immuno-suppression, HIV infection, post-menopause, adolescence and cyto-colpo-histological disparity. The paper ends with recommendations for quality assurance in patient management and some general advice on how to communicate screening, diagnosis and treatment results to the woman concerned. Finally, a data collection form is attached.

Endocervical curettage at the time of colposcopic assessment of the uterine cervix

Colposcopic examination of the uterine cervix remains the gold standard in the evaluation of patients with abnormal cervical cytology. Endocervical curettage (ECC) still forms a limited part of the overall assessment of women with abnormal cervical smears (Pap test) in the United States and in certain other parts of the world. To date, there are no properly randomized trials on the place of ECC in the overall care of women with abnormal Pap test. This review critically appraises the available evidence to look at the possible role of ECC in the complete evaluation of abnormal cervical smears.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to list the proposed indications for endocervical curettage (ECC), to summarize the data in support of the routine use of ECC at the time of colposcopy, and to outline the evidence against the use of routine ECC at colposcopy.

Prediction of disease persistence after conization for microinvasive cervical carcinoma and cervical intraepithelial neoplasia grade 3

We attempted to determine the significant variables and to predict the probability of disease persistence after conization for microinvasive cervical carcinoma and cervical intraepithelial neoplasia grade 3 (CIN3). We analyzed 133 patients from 2001 to 2002 who had a subsequent hysterectomy after conization. The histological findings of the cone specimens, together with the clinical parameters, were correlated with the presence of residual dysplasia in the hysterectomy specimen. The probability of having residual dysplasia was calculated based on the function of the significant variables obtained by logistic regression analysis. Of the 133 patients, 42 (31.6%) had residual disease in their hysterectomy specimens. Using multivariate analysis only for the postmenopausal state, positive endocervical curettage, positive margin, and microinvasive carcinoma were predictive of residual dysplasia. The probabilities of having residual dysplasia were about 0.99, 0.84, 0.4, 0.07, and 0.01 in patients with a presence of all four, any three, any two, any one, and no risk factors, respectively. The best cutoff probability determined by the receiver operating characteristic curve was 0.32, yielding a sensitivity of 81% and a specificity of 88%. Based on these results, patients with the presence of any two or more of the risk factors mentioned above should be considered as a high-risk group for having disease persistence after conization for the treatment of CIN3 and microinvasive carcinoma.

Endocervical sampling by Kevorkian curette or Pipelle aspiration device: a randomized comparison

OBJECTIVE

Our purpose was to compare two means of endocervical sampling-the Kevorkian curette and the Pipelle aspiration device (Unimar Co., Wilton, Conn.)-with respect to patient discomfort, tissue volume, and specimen adequacy for diagnosis.

STUDY DESIGN

Fifty-two women undergoing investigation of abnormal cervical cytologic results were assigned randomly to endocervical sampling by Kevorkian or Pipelle instruments. Pain associated with the procedure was assessed by having each subject indicate her pain level on a visual analog scale. Tissue volume was graded by examination of the microscopic slides by two investigators blinded to assignment. Adequacy for diagnosis was evaluated by reviewing pathology reports.

RESULTS

Subjects having Pipelle endocervical aspiration (n = 24) had significantly lower mean (+/- SEM) pain scores (27 +/- 5 vs 48.5 +/- 7, p = 0.02) than those in whom the Kevorkian instrument was used (n = 28). However, there were no significant differences in tissue volume obtained or in proportions considered adequate for diagnosis.

CONCLUSIONS

Use of the Pipelle instrument was associated with less patient discomfort than Kevorkian curettage for endocervical sampling while providing similar tissue volume and adequacy for diagnosis.

The incomplete cone biopsy: a comparison of conservative and surgical management

OBJECTIVE

to determine the reliability of conservative management of cone biopsies showing apparently incomplete excision of cervical intraepithelial neoplasia (CIN) by comparing surgical and conservative management.

DESIGN

a retrospective study.

SUBJECTS

74 consecutive cone biopsies with a histology report of apparently incomplete excision of CIN 2 or CIN 3 from a series of 738 cone biopsies.

MAIN OUTCOME MEASURES

the presence of CIN at hysterectomy against the pick up rate in conservatively managed patients.

RESULTS

where excision appeared incomplete at the ectocervix this was confirmed in 1 of 6 (16.7%) of patients managed surgically and 2 of 17 (11.8%) of patients managed conservatively (P = 0.40). Where excision appeared incomplete at both endo- and ectocervix, 5 of 6 (83.3%) were confirmed to have incomplete excision in the surgical group, and 3 of 5 (60%) had further proven CIN in the conservative group (P = 0.34). Where excision appeared incomplete at the endocervix only, this was confirmed in 7 of 22 (32%) of cases managed surgically, but only 2 of 18 (11.1%) of cases managed conservatively had further proven CIN (P = 0.14). Combining all patients with incomplete excision at the endocervix irrespective of the ectocervix status revealed confirmation of residual CIN in 12 of 28 (42.9%) patients managed surgically and in 5 of 23 (21.7%) patients managed conservatively (P = 0.097).

CONCLUSIONS

management should depend on the site of the apparent incomplete excision. Where excision appears incomplete at the ectocervix only, cytological follow up should be employed. If the endocervix is involved, further excisional surgery may be more appropriate.