Endocervical curettage

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Endocervical curettage
Curette in sterile packaging.jpg
Curette used for Endocervical Curettage
Purposeused to biopsy endocervical canal for abnormalities

Endocervical curettage is a procedure in which the mucous membrane of the cervical canal is scraped using a spoon-shaped instrument called a curette. The procedure is used to test for abnormal, precancerous conditions, or cervical cancer. [1] The procedure is generally performed after an abnormal pap smear to further assess the tissue. Other common indications to perform endocervical curettage include evaluation of persistent human papillomavirus infection infections, workup of unexplained abnormal uterine bleeding, and follow up of inconclusive colposcopy.

Contents

History

Colposcopy was first performed by physician Hans Hinselmann, a German gynecologist, in 1925. He utilized a bright light and low-power microscope to directly visualize atypical cervical cells. [2] However, the first use of endocervical curettage is not clearly delineated in the medical literature. The use of curettage as a method to extract biological tissue dates back to the 19th century. Dr. Ernst Wertheim, an Austrian gynecologist, who pioneered many surgical interventions and techniques in gynecology may have been the first to implement endocervical curettage in its earliest forms. [3]

Use of endocervical curettage became widespread by the mid-20th century as understanding and methods of cervical pathology rapidly advanced. Over the decades endocervical curettage and its inclusion in guidelines have been the subject of debate by medical societies, with some arguing its diagnostic use is limited. [4] However, endocervical curettage has retained its value as a less invasive method to biopsy the endocervical canal. [5]

Medical uses

Endocervical curettage is a medical procedure used to extract cells of the endocervix to visualize under a microscope. Direct cervical visualization, colposcopy, and even endocervical colposcopy are not enough to fully analyze all areas of the endocervical epithelium and thus endocervical curettage is the method of choice in cases where this is necessary.

Indications

Generally the next step in workup of an abnormal pap smear includes a colposcopy which involves the direct visualization of the cervix. However, the cervical epithelium of the endocervix cannot be visualized and endocervical curettage may be used to biopsy the endocervix epithelium. Endocervical curettage is particularly useful in cases of colposcopy where the squamocolumnar junction is not visualized. [6] [7]

The indications to perform endocervical curettage vary by medical society recommendations but some commonly accepted indications include: [4]

  1. Abnormal pap smear with negative findings on colposcopy
  2. Pap smear cytology of atypical glandular cells, high-grade squamous intraepithelial lesions, or carcinoma [6]
  3. Colposcopy findings concerning for endocervical lesion or squamocolumnar junction not visualized [8]
  4. Patient undergoing colposcopy after testing positive for human papillomavirus infection 16 or 18 [6]

Efficacy

The efficacy of endocervical curettage has long been debated with discussions around its value dating back to when its use first became widespread back in the mid-20th century. Numerous studies and meta-analyses have been performed over the centuries to assess the diagnostic value of endocervical curettage in the workup of cervical dysplasia and to determine its sensitivity and specificity. Most recent studies retain its value in the diagnostic workup as an intermediate step between pap smear and cone biopsy. It also maintains value as a less invasive method to analyze the endocervical canal. [5] [9]

Procedure

Speculum Vaginal speculum Collin - easy opening.jpg
Speculum

Endocervical curettage is a type of cervical biopsy that is performed with a curette to scrape cells from endocervical canal. The procedure is generally performed in the outpatient setting and begins with the patient laying flat on their back with feet usually in stirrups. This is the position for most pelvic exams. [9] [10]

Colposcope Colposcope.jpg
Colposcope

The provider will first use a speculum, which is inserted in the vaginal canal, for visualization of the cervix. Anesthetics should be used to ensure that the patient is comfortable during the procedure. A colposcope, a magnifying tool, is used to directly visualize the cervical, vaginal, or vulvar tissue under a low-powered microscope. Once the entire cervix is visualized, an acetic acid solution or lugol's iodine solution may be applied to the cervical canal to identify abnormal lesions. Forceps can be used during the procedure to grasp the cervix. Once these steps of the colposcopy are completed, the provider will proceed with endocervical curettage if the findings indicate that biopsy of the endocervical canal is necessary. [7]

Endocervical curettage is generally the last step of the colposcopy procedure. It is when the curette is inserted and passed through the cervical os, the opening in the cervix that leads into the uterus, and used to scrape cells from the inside of the cervical canal. The curette is firmly held like a pen, and should scrape the endocervical canal in small strokes. [7] The curette should be carefully removed from the canal once the entire area is sampled so the sample is not lost. These biopsied cells should be immediately placed into formalin to ensure their preservation. They are then later viewed under a microscope by a pathologist to assess for any abnormalities. [9] [11]

Risks

Guidelines reveal good evidence that endocervical curettage is contraindicated in pregnancy. [10] There is a risk of damage to fetal membranes or placenta along with an increased risk of cervical perforation due to the softening of the cervix during pregnancy. [6] For these reasons, pregnancy is a well established contraindication to performing endocervical curettage. [10] Other relative contraindications to the procedure include severe cervical stenosis and acute uterine or cervical infections.

Rare risks of the procedure include cervical perforation though the incidence of perforation is extremely low. Other risks for the procedure include bleeding, infection, and pain. [9] Though sterilization techniques, anesthetics, and hemostasis tools greatly mitigate these risks and the procedure is generally very tolerated aside from discomfort.

Results and follow up

After endocervical curettage, cells are viewed under a high-powered microscope by a pathologist. The pathologist analyzes the cells for any atypical features such as hyperplasia, dysplasia, or neoplasm. [12] Features that are analyzed include nuclear size, evidence of pleomorphism, anisokaryosis, hyperchromasia, and mitotic features.

Grades for cervical dysplasia include low-grade squamous intraepithelial lesion to high-grade squamous intraepithelial lesion. The dysplasia can be rated on the Bethesda System of cervical grades of increasing atypical nature summarized below: [13]

  1. Atypical squamous cell
  2. Low-grade squamous intraepithelial lesion – cervical intraepithelial neoplasia 1
  3. High-grade squamous intraepithelial lesion – cervical intraepithelial neoplasia 2/3
  4. Invasive features
  5. Squamous cell carcinoma

Ratings of cervical intraepithelial neoplasia are also commonly used to grade cytology of cervical epithelium. Cervical intraepithelial neoplasia 1 is the most moderate and are low-grade squamous intraepithelial lesions while cervical intraepithelial neoplasia 2 and 3 are moderate to severe and are high-grade squamous intraepithelial lesions. [14]

Related Research Articles

<span class="mw-page-title-main">Cervix</span> Lower part of the uterus in the female reproductive system

The cervix or cervix uteri is a dynamic fibromuscular sexual organ of the female reproductive system that connects the vagina with the uterine cavity. The human female cervix has been documented anatomically since at least the time of Hippocrates, over 2,000 years ago. The cervix is approximately 4 cm long with a diameter of approximately 3 cm and tends to be described as a cylindrical shape, although the front and back walls of the cervix are contiguous. The size of the cervix changes throughout a woman's life cycle. For example, during the fertile years of a woman's reproductive cycle, females tend to have a larger cervix in comparison to postmenopausal females; likewise, females who have produced offspring have a larger sized cervix than females who have not produced offspring.

<span class="mw-page-title-main">Pap test</span> Cervical screening test to detect potential cancers

The Papanicolaou test is a method of cervical screening used to detect potentially precancerous and cancerous processes in the cervix or, more rarely, anus. Abnormal findings are often followed up by more sensitive diagnostic procedures and, if warranted, interventions that aim to prevent progression to cervical cancer. The test was independently invented in the 1920s by the Greek physician Georgios Papanikolaou and named after him. A simplified version of the test was introduced by the Canadian obstetrician Anna Marion Hilliard in 1957.

<span class="mw-page-title-main">Cervical cancer</span> Cancer arising from the cervix

Cervical cancer is a cancer arising from the cervix or in any layer of the wall of the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal vaginal bleeding, pelvic pain or pain during sexual intercourse. While bleeding after sex may not be serious, it may also indicate the presence of cervical cancer.

<span class="mw-page-title-main">Colposcopy</span> Medical examination of the cervix

Colposcopy is a medical diagnostic procedure to visually examine the cervix as well as the vagina and vulva using a colposcope.

<span class="mw-page-title-main">Anal cancer</span> Medical condition

Anal cancer is a cancer which arises from the anus, the distal opening of the gastrointestinal tract. Symptoms may include bleeding from the anus or a lump near the anus. Other symptoms may include pain, itchiness, or discharge from the anus. A change in bowel movements may also occur.

Carcinoma <i>in situ</i> Pre-cancerous abnormal growth of tissue

Carcinoma in situ (CIS) is a group of abnormal cells. While they are a form of neoplasm, there is disagreement over whether CIS should be classified as cancer. This controversy also depends on the exact CIS in question. Some authors do not classify them as cancer, however, recognizing that they can potentially become cancer. Others classify certain types as a non-invasive form of cancer. The term "pre-cancer" has also been used.

<span class="mw-page-title-main">Precancerous condition</span> Condition or cell change indicating increased cancer risk

A precancerous condition is a condition, tumor or lesion involving abnormal cells which are associated with an increased risk of developing into cancer. Clinically, precancerous conditions encompass a variety of abnormal tissues with an increased risk of developing into cancer. Some of the most common precancerous conditions include certain colon polyps, which can progress into colon cancer, monoclonal gammopathy of undetermined significance, which can progress into multiple myeloma or myelodysplastic syndrome. and cervical dysplasia, which can progress into cervical cancer. Bronchial premalignant lesions can progress to squamous cell carcinoma of the lung.

<span class="mw-page-title-main">Cervical intraepithelial neoplasia</span> Medical condition

Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer. More specifically, CIN refers to the potentially precancerous transformation of cells of the cervix.

<span class="mw-page-title-main">Koilocyte</span> Type of cell that has been changed by HPV

A koilocyte is a squamous epithelial cell that has undergone a number of structural changes, which occur as a result of infection of the cell by human papillomavirus (HPV). Identification of these cells by pathologists can be useful in diagnosing various HPV-associated lesions.

<span class="mw-page-title-main">Cervical canal</span> Canal of the uterine cervix

The cervical canal is the spindle-shaped, flattened canal of the cervix which connects the vagina to the main cavity of the uterus in most mammals.

<span class="mw-page-title-main">Cervical ectropion</span> Presence of internal cells of the cervical canal outside the cervix

Cervical ectropion is a condition in which the cells from the 'inside' of the cervical canal, known as glandular cells, are present on the 'outside' of the vaginal portion of the cervix. The cells on the 'outside' of the cervix are typically squamous epithelial cells. Where the two cells meet is called the transformation zone, also known as the stratified squamous epithelium. Cervical ectropion can be grossly indistinguishable from early cervical cancer and must be evaluated by a physician to determine risks and prognosis. It may be found incidentally when a vaginal examination is done. The area may look red because the glandular cells are red. While many women are born with cervical ectropion, it can be caused by a number of reasons, such as:

An anal Pap smear is the anal counterpart of the cervical Pap smear. It is used for the early detection of anal cancer. Some types of human papillomavirus (HPV) can cause anal cancer. Other HPV types cause anogenital warts. Cigarette smokers, men who have sex with men, individuals with a history of immunosuppression and women with a history of cervical, vaginal and vulval cancer are at increased risk of getting anal cancer. Vaccination against HPV before initial sexual exposure can reduce the risk of anal cancer.

The Bethesda system (TBS), officially called The Bethesda System for Reporting Cervical Cytology, is a system for reporting cervical or vaginal cytologic diagnoses, used for reporting Pap smear results. It was introduced in 1988 and revised in 1991, 2001, and 2014. The name comes from the location of the conference, sponsored by the National Institutes of Health, that established the system.

Cervicography is a diagnostic medical procedure in which a non-physician takes pictures of the cervix and submits them to a physician for interpretation. Other related procedures are speculoscopy and colposcopy. The procedure is considered a screening test for cervical cancer and is complementary to Pap smear. The technique was initially developed by Adolf Stafl, MD, of Medical College of Wisconsin in 1981.

Anal dysplasia is a pre-cancerous condition which occurs when the lining of the anal canal undergoes abnormal changes. It can be classified as low grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL). Most cases are not associated with symptoms, but people may notice lumps in and around the anus.

Epithelial dysplasia, a term becoming increasingly referred to as intraepithelial neoplasia, is the sum of various disturbances of epithelial proliferation and differentiation as seen microscopically. Individual cellular features of dysplasia are called epithelial atypia.

<span class="mw-page-title-main">Squamous intraepithelial lesion</span> Abnormal cell growth in the cervix

A squamous intraepithelial lesion (SIL) is an abnormal growth of epithelial cells on the surface of the cervix, commonly called squamous cells. This condition can lead to cervical cancer, but can be diagnosed using a Pap smear or a colposcopy. It can be treated by using methods that remove the abnormal cells, allowing normal cells to grow in their place. In the Bethesda system, the cytology can be graded as LSIL or HSIL.

<span class="mw-page-title-main">Cervical cancer staging</span> Medical condition

Cervical cancer staging is the assessment of cervical cancer to determine the extent of the spread of cancer beyond the cervix. This is important for determining how serious the cancer is and to create the best treatment plan.

<span class="mw-page-title-main">Cervical screening</span> Type of medical screening

Cervical cancer screening is a medical screening test designed to identify risk of cervical cancer. Cervical screening may involve looking for viral DNA, and/or to identify abnormal, potentially precancerous cells within the cervix as well as cells that have progressed to early stages of cervical cancer. One goal of cervical screening is to allow for intervention and treatment so abnormal lesions can be removed prior to progression to cancer. An additional goal is to decrease mortality from cervical cancer by identifying cancerous lesions in their early stages and providing treatment prior to progression to more invasive disease.

Microglandular hyperplasia (MGH) of the cervix is an epithelial benign abnormality (lesion) associated with gland proliferation. It can terminate in mature squamous metaplasia, and it is suspected reserve cells are involved in this process, perhaps in the form of reserve cell hyperplasia with glandular differentiation.

References

  1. ↑ Moniak CW, Kutzner S, Adam E, Harden J, Kaufman RH. (2000) Endocervical curettage in evaluating abnormal cervical cytology. Journal of Reproductive Medicine. 45(4):285-92.
  2. ↑ Jafari, Kianoosh; Sansguiri, Ravindranath (May 1978). "Role of endocervical curettage in colposcopy". American Journal of Obstetrics and Gynecology. 131 (1): 83–86. doi:10.1016/0002-9378(78)90479-9. ISSN   0002-9378. PMID   645788.
  3. ↑ Drouin, Emmanuel; Classe, Jean-Marc; Hautecoeur, Patrick (March 2023). "125 years of the Wertheim operation. What next?". Journal of Medicine and Life. 16 (3): 341–343. doi:10.25122/jml-2022-0082. ISSN   1844-3117. PMC   10165519 . PMID   37168301.
  4. 1 2 Bidus, Michael A; Elkas, John C; Rodriguez, Mildred; Maxwell, G Larry; Rose, G Scott (March 2005). "The Clinical Utility of the Diagnostic Endocervical Curettage". Clinical Obstetrics and Gynecology. 48 (1): 202–208. doi:10.1097/01.grf.0000151568.68943.dc. ISSN   0009-9201.
  5. 1 2 Andersen, Willie; Frierson, Henry; Barber, Shannon; Tabbarah, Sana; Taylor, Peyton; Underwood, Paul (September 1988). "Sensitivity and specificity of endocervical curettage and the endocervical brush for the evaluation of the endocervical canal". American Journal of Obstetrics and Gynecology. 159 (3): 702–707. doi:10.1016/s0002-9378(88)80038-3. ISSN   0002-9378.
  6. 1 2 3 4 Massad, L. Stewart; Perkins, Rebecca B.; Naresh, Amber; Nelson, Erin L.; Spiryda, Lisa; Gecsi, Kimberly S.; Mulhem, Elie; Kostas-Polston, Elizabeth; Zou, Tianle; Giles, Tashima Lambert; Wentzensen, Nicolas (2023-01-01). "Colposcopy Standards: Guidelines for Endocervical Curettage at Colposcopy". Journal of Lower Genital Tract Disease. 27 (1): 97–101. doi:10.1097/LGT.0000000000000710. ISSN   1526-0976. PMC   9770112 . PMID   36222824.
  7. 1 2 3 Basu P, Sankaranarayanan R (2017). Atlas of Colposcopy – Principles and Practice IARC CancerBase No. 13 [Internet]. Lyon, France: International Agency for Research on Cancer. accessed on 12/12/2024.
  8. ↑ World Health Organization; World Health Organization, eds. (2014). Comprehensive cervical cancer control: a guide to essential practice (Second ed.). Geneva: World Health Organization. ISBN   978-92-4-154895-3.
  9. 1 2 3 4 "Cervical Biopsy". Archived from the original on 2024-10-01. Retrieved 2024-12-13.
  10. 1 2 3 Cooper, Danielle B.; Dunton, Charles J. (2024), "Colposcopy", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   33232095 , retrieved 2024-12-13
  11. ↑ Comprehensive cervical cancer control: a guide to essential practice (2nd ed.). Geneva: World Health Organization. 2014. ISBN   978-92-4-154895-3.
  12. ↑ "cervical dysplasia". www.cancer.gov. 2011-02-02. Retrieved 2024-12-09.
  13. ↑ Pangarkar, Meena A. (2022). "The Bethesda System for reporting cervical cytology". CytoJournal. 19: 28. doi:10.25259/CMAS_03_07_2021. ISSN   0974-5963. PMC   9168399 . PMID   35673697.
  14. ↑ Alrajjal, Ahmed; Pansare, Vaishali; Choudhury, Moumita Saha Roy; Khan, Mir Yousufuddin Ali; Shidham, Vinod B. (2021). "Squamous intraepithelial lesions (SIL: LSIL, HSIL, ASCUS, ASC-H, LSIL-H) of Uterine Cervix and Bethesda System". CytoJournal. 18: 16. doi:10.25259/Cytojournal_24_2021. ISSN   0974-5963. PMC   8326095 . PMID   34345247.

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