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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 191-193

The importance of endocervical curettage in an old post-loop electrosurgical excision procedure woman with abnormal cervical cytology and a normal punch biopsy histology: A case report and literature review


1 Medical Center of Diagnosis and Treatment for Cervical Diseases, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200011, China
2 Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200011, China
3 Medical Center of Diagnosis and Treatment for Cervical Diseases, Obstetrics and Gynecology Hospital of Fudan University; Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Fudan University, Shanghai 200011, China

Date of Submission08-Apr-2019
Date of Web Publication27-Sep-2019

Correspondence Address:
Long Sui
Medical Center of Diagnosis and Treatment for Cervical Diseases, Obstetrics and Gynecology Hospital of Fudan University, No. 419 Fangxie Road, Shanghai 200011
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2096-2924.268156

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  Abstract 


Endocervical curettage (ECC) is an optional practice during colposcopy, and the indication for endocervical curettage (ECC) is controversial between Europe and the USA. Here, we explored the value of ECC in a specific situation. An elderly post-loop electrosurgical excision procedure woman, who had undergone a colposcopy 4 months before, went for her follow-up and abnormal cytology was found, and both the ECC and punch biopsy showed negative results. Then, a second ECC was performed, which led to the diagnosis of a high-grade squamous intraepithelial lesion. This case report shows that ECC is useful for diagnosing elderly women with Type 3 squamocolumnar junction.

Keywords: Endocervical Curettage; High-Grade Squamous Intraepithelial Lesion; Loop Electrosurgical Excision Procedure


How to cite this article:
Guo LP, Cong Q, Zhang H, Sui L. The importance of endocervical curettage in an old post-loop electrosurgical excision procedure woman with abnormal cervical cytology and a normal punch biopsy histology: A case report and literature review. Reprod Dev Med 2019;3:191-3

How to cite this URL:
Guo LP, Cong Q, Zhang H, Sui L. The importance of endocervical curettage in an old post-loop electrosurgical excision procedure woman with abnormal cervical cytology and a normal punch biopsy histology: A case report and literature review. Reprod Dev Med [serial online] 2019 [cited 2019 Nov 18];3:191-3. Available from: http://www.repdevmed.org/text.asp?2019/3/3/191/268156




  Introduction Top


Cervical cancer screening with cervical cytology, such as Papanicolaou smear, ThinPrep cytologic test or liquid-based cytology test, and human papillomavirus (HPV) test is the most successful cancer prevention program. Women with abnormal results are referred to colposcopy. The American Society for Colposcopy and Cervical Pathology guidelines recommended colposcopists to perform endocervical curettage (ECC) besides a punch biopsy in women with high-grade squamous intraepithelial lesion (HSIL), atypical squamous cells (ASCs) of undetermined significance, or low-grade squamous intraepithelial lesion (LSIL) cytologies. The European guidelines regard ECC as ineffective in the diagnosis of endocervical lesions and the identification of glandular disease, and the specific indications for ECC remain controversial.[1] Whether and when ECC should be performed remains debated. Here, we report a post-loop electrosurgical excision procedure (LEEP) patient who had a negative result of cervical punch biopsy but was diagnosed with residual cervical HSIL by ECC.


  Case Report Top


A 69-year-old postmenopausal woman was referred to the colposcopy Department of Obstetrics and Gynecology Hospital of Fudan University in May 2018, and was cytologically diagnosed with HSIL and had cervical HPV 16 infection. She had neither a history of postmenopausal vaginal bleeding nor any other diseases. The patient underwent a colposcopy-directed biopsy and ECC [Figure 1]a and [Figure 1]b. The colposcopic impression was unsatisfactory because of Type 3 squamocolumnar junction (SCJ). Therefore, the punch biopsy was performed and showed high-grade cervical intraepithelial neoplasia (CIN2+) with glands involved and mild dysplasia in the right wall of the vagina; the ECC showed HSIL [Figure 1]c and [Figure 1]d. Preoperative preparation was achieved, and the ultrasound reported the length of the cervix was 23 mm. Then, the LEEP was performed for the patient. The specimen's square, thickness, and length were 1 cm 2, 0.8 cm, and 0.6 cm, respectively, and the histopathological findings revealed chronic cervicitis [Figure 1]e.
Figure 1: (a and b) Colposcopy view of the 69-year-old postmenopausal woman. (c) Endocervical curettage reported as high-grade squamous intraepithelial lesion. (d) Ectocervical biopsies reported as high-grade squamous intraepithelial lesion. (e) The specimen of the cervical loop electrosurgical excision procedure. “→” represents where lesions are located.

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Three months later, the patient returned for a follow-up. The follow-up examination reported cervical HPV 16 infection and cervical cytological abnormality, which was ASC and could not rule out HSIL (ASC-H) [Figure 2]a. The patient underwent another colposcopy-directed biopsy and ECC. The colposcopic impression was still unsatisfactory because of Type 3 SCJ. The biopsy histopathology revealed (1) no lesion on the ectocervix, and (2) low-grade vaginal intraepithelial neoplasia. The ECC revealed few squamous epithelial cells in the cervical canal [Figure 2]b. Concerning the abnormal ASC-H cytology and the potential ECC insufficiency due to cervical adhesion and atrophy, another ECC was suggested. The patient understood the possibility of ECC risk and failures due to cervical adhesion and atrophy after conization. With the sufficiently informed consent of the patient, an ECC was performed. The whole endocervical canal was successfully curetted twice, and mucous tissue was obtained. The histopathology indicated HSIL [Figure 2]c. Considering atrophic cervix, a laparoscopic hysterectomy and bilateral salpingo-oophorectomy were performed. An intraoperative frozen section of the cervical specimen at 6 o'clock of the cervix showed no lesion. Four days later, the postoperative histopathology demonstrated a circle of cervical HSIL that involved glands with negative margins [Figure 2]d. The patient was discharged uneventfully on the 2nd postoperative day.
Figure 2: (a) Abnormal cytology of ASC-H. (b) During follow-up, ECC and ectocervical biopsies reported negative results. (c) The second ECC follow-up revealed an HSIL. (d) The histopathology after hysterectomy revealed high-grade intraepithelial neoplasia (HSIL). “→” represents where lesions are located. HSIL: High-grade squamous intraepithelial lesion; ECC: Endocervical curettage; ASC-H: Atypical squamous cells could not exclude HSIL.

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  Discussion Top


Colposcopy plays an important role in cervical precancer diagnosis. Taking multiple lesion-directed biopsies have been proposed during colposcopies for women with high-risk factors, such as cytology HSIL, AGC (atypical glandular cells), or HPV 16/18 positive.[2] However, ECC is still controversial, and some scholars agree that ECC is meaningful in elderly women and those with Type 3 SCJ. The ECC yield increases with age, since the SCJ recedes into the endocervix, with less visualized lesions. While there are disagreements among gynecologists, some of whom think that elderly women with unsatisfactory colposcopy and CIN2+ often have positive ECCs, and all of such patients are treated with diagnostic excisional procedures. Therefore ECC can be avoided, as it does not change the management.[3] Several studies have demonstrated that ECCs can discover additional CIN 2+ that are missed by ectocervical biopsies, but the rates of identification have varied from 3.9% to 11.9%. Wentzensen's study put forward that ECC should be performed for women older than 45 years of age, especially those with HPV 16 infections.[4] In our case, the SCJ was located in the endocervical canal, and no lesions were identified during the follow-up. If ECC had not been performed, the HSIL would have been missed, because secondary LEEP could not be performed in the atrophic cervix. Furthermore, a total hysterectomy would not have been carried out, based on ASC-H and the histology of cervicitis. From our perspective, ECC is indispensable in detecting cervical HSIL, especially for postmenopausal women.

In this case, the first follow-up ECC only found a few squamous cells. It was the review of the ASC-H cytology that led to the next ECC. Thereafter, the pathologists found HSIL. Our experience proved that the former ECC provided a false-negative result. For the pathologists, the ECC could be difficult to interpret because of fragmented, deficient specimens.[5] For gynecologists, we should suspect the possibility of insufficient sampling if no glandular cells were found. A sufficient ECC should include the whole endocervical canal, since a shallow ECC may fail to sample squamous cell and glandular cell lesions. Even among old postmenopausal women, a sufficient specimen can be obtained with careful curettage, and the detection of glandular cells can be the sign of a successful ECC. However, the sensitivity of ECC is suboptimal due to limited epithelial tissue. One study reported that the false-negative rate of ECC in CIN patients reached 45%.[6] Therefore, we should realize the limitations of ECC and develop new methods to perform sufficient ECCs.

This case also raised a question of skip lesions. The nomenclature of “skip lesion” refers to lesion lying deep in the cervical canal, which is discontiguous with other lesions in the transformation zone. We used to believe that HSIL is persistent precancerous lesions. However, lesion persistence and recurrence after LEEP procedure present around 15% of patients. Since residual lesion is less likely to exist with a negative surgical margin. In other words, skip lesions may be left in cervical canal undetected after LEEP, which leads to recurrence. When the patient initially visited our department, both the cytology and colposcopy results indicated HSIL. However, the histology of the LEEP specimen revealed negative results. We attribute this phenomenon to several factors. First, there is a likelihood of thermal artifact with LEEP that can interfere with the histopathological assessment.[7] Second, excised atrophic cervix tissue tends to be smaller in premenopausal women; therefore, it is possible that the lesion was missed. ECC exactly at the time of LEEP helps detect deep lesions.[8] Third, cervical squamous intraepithelial lesions may show features of skip lesions. Based on the latest study, about 9.4% of patients with CIN 3 had skip lesions, among 2260 patients who were treated with LEEP.[9] Thus, ECC has played an essential role in this case.

The necessity of ECC is well-known, but in which situation, we should perform ECC remains controversial. According to this case, we have demonstrated the importance of ECC for elderly postmenopausal women whose cytology reports are HSIL/ASC-H/AGC, or HPV 16/18 positive.[10]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank the patient for her kind cooperation during the treatment and follow-up.

Financial support and sponsorship

Shanghai Medical Center of Key Programs for Female Reproductive Diseases (No. 2017ZZ01016).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Massad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis 2013;17:S1-27. doi: 10.1097/LGT.0b013e318287d329.  Back to cited text no. 1
    
2.
Hu SY, Zhang WH, Li SM, Li N, Huang MN, Pan QJ, et al. Pooled analysis on the necessity of random 4-quadrant cervical biopsies and endocervical curettage in women with positive screening but negative colposcopy. Medicine (Baltimore) 2017;96:e6689. doi: 10.1097/md.0000000000006689.  Back to cited text no. 2
    
3.
Massad LS. Selecting patients for endocervical curettage. J Low Genit Tract Dis 2015;19:271-2. doi: 10.1097/lgt.0000000000000130.  Back to cited text no. 3
    
4.
Liu AH, Walker J, Gage JC, Gold MA, Zuna R, Dunn ST, et al. Diagnosis of cervical precancers by endocervical curettage at colposcopy of women with abnormal cervical cytology. Obstet Gynecol 2017;130:1218-25. doi: 10.1097/aog.0000000000002330.  Back to cited text no. 4
    
5.
Gage JC, Duggan MA, Nation JG, Gao S, Castle PE. Detection of cervical cancer and its precursors by endocervical curettage in 13,115 colposcopically guided biopsy examinations. Am J Obstet Gynecol 2010;203:481.e1-9. doi: 10.1016/j.ajog.2010.06.048.  Back to cited text no. 5
    
6.
Lastra RR, Meykler SE, Baloch ZW, Barroeta JE. Increasing the sensitivity of endocervical curettings by performing ThinPrep® pap on transport container fluid: Is diagnostic material going down the drain? Cytopathology 2015;26:368-72. doi: 10.1111/cyt.12177.  Back to cited text no. 6
    
7.
Cohen PA, Brand A, Sykes P, Wrede DC, McNally O, Eva L, et al. Excisional treatment in women with cervical adenocarcinoma in situ (AIS): A prospective randomised controlled non-inferiority trial to compare AIS persistence/recurrence after loop electrosurgical excision procedure with cold knife cone biopsy: Protocol for a pilot study. BMJ Open 2017;7:e017576. doi: 10.1136/bmjopen-2017-017576.  Back to cited text no. 7
    
8.
Cuello MA, Espinosa ME, Orlandini EJ, Hwang DY. The value of endocervical curettage during loop electrosurgical excision procedures in predicting persistent/recurrent preinvasive cervical disease. Int J Gynaecol Obstet 2018;141:337-43. doi: 10.1002/ijgo.12480.  Back to cited text no. 8
    
9.
Leng F, Jiang L, Nong L, Ren X, Xie T, Dong Y, et al. Value of top-hat procedure in management of squamous intraepithelial lesion. J Obstet Gynaecol Res 2019;45:182-8. doi: 10.1111/jog.13781.  Back to cited text no. 9
    
10.
Shepherd JP, Guido R, Lowder JL. Should endocervical curettage routinely be performed at the time of colposcopy? A cost-effectiveness analysis. J Low Genit Tract Dis 2014;18:101-8. doi: 10.1097/LGT.0b013e3182a0b572.  Back to cited text no. 10
    


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