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Diagnosis of Cervical

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

Introduction

To address selection bias related to


cytology and colposcopic findings,
Endocervical curettage (ECC) has
colposcopic biopsy can fail to detect we designed an ancillary analysis of
been increasingly incorporated in the
30–50% of prevalent high-grade the Biopsy Study to evaluate
colposcopy–biopsy examination for
cervical precancers detection of cervical precancers by
abnormal screening cytology
routine endocervical sampling in
women 30 years or older
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.
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Methods
2,270 women The diagnostic
Women were
referred to the value of ECC for
referred with one
colposcopy clinic 690 of 1,373 detecting
of the following
at the University (50.3%) eligible additional disease
diagnoses: ASC-
of Oklahoma women agreed to was evaluated by
US, LSIL, ASC-H,
Health Sciences participate in the the number of
HSIL, AGC, AIS,
Center February study lesion-directed
and squamous
2009 - September ectocervical
cell carcinoma
2012 biopsies.
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Data Collection

All women aged 30 years or older enrolled in


the Biopsy were supposed to undergo
women aged 30 years or older underwent endocervical sampling Cervical samples were collected using a
routine endocervical sampling in the Biopsy Wallach broom and transferred to PreservCyt
Study for abnormal cervical screening results Women younger than 30 years old received solution for cytology and human
or treatment of previously diagnosed disease ECC for the following indications: discrepancy papillomavirus (HPV) testing.
between colposcopic findings and HSIL
referral cytology, AGC or AIS cytology.
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Results in brief in brief

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 highgrade colposcopic
impressions (respective P values ,.05).
Endocervical curettage was more likely to find disease in the
endocervix among women with high-grade cytology, positive
HPV-16 infection, or highgrade colposcopic impressions
(respective P values ,.05).
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Results in brief in brief

Those with an unsatisfactory examination had


a 13.0% CIN 2 or worse yield on ECC (95% CI
An ASC-H or HSIL or worse cytology was
6.1–25.7); when colposcopic examination was
associated with a CIN 2 or worse yield of
normal or satisfactory with visible abnormal
25.8% by ECC (95% CI 16.6–37.9%)
lesions, ECC detected less than 5% CIN 2 or
worse in the endocervix.
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Results in brief in brief


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).
Tabel 1.
Table 2.
Tabel 3.
Tabel 4.
Tabel 5.
Tabel 6.
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Discussion
our finding of 10.1% CIN 2 or worse yield on ECC in women 20–29 years old implicates that AGC
or AIS cytology, unsatisfactory examination as well as discrepancy between HSIL cytology and
normal examination remain important considerations for performing ECC in young women

In the Biopsy Study, selecting for the ECC procedure by age alone affirmed previously reported
associations between diagnosing cervical precancers on routine ECC and high-grade colposcopic
impression and ASC-H or HSIL or worse cytology.

For the first time, we described an association between HPV-16 infection and positive ECC
among women 45 years old or older (Tables 3 and 4).
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Discussion
Given acetowhitening is highly sensitive for the detection of cervical precancers, the
additional yield of CIN 2 or worse by ECC was less than 10% in our study even when
the worst-appearing colposcopic lesion was the only ectocervical biopsy taken.

Our results showed that an unsatisfactory examination in women with lowgrade or


equivocal cytology warrants endocervical sampling, which may indicate excision
rather than ablation therapy in approximately one of every seven or eight women
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

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.
CRITICAL APPRAISAL
POPULATION • women referred to the colposcopy clinic at the for
abnormal cervical screening results or treatment of
previously diagnosed disease

• Endocervical Curettage
INTERVENTION

• Did Not receive ECC


COMPARISON

OUTCOME • detection of cervical precancers, additional


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

Is the aim clearly stated?

To evaluate the performance of


routine endocervical curettage (ECC)
Yes, the authors for diagnosing high-grade cervical
elaborated the intraepithelial neoplasia (CIN) 2 or
objective clearly worse and additional precancers not
otherwise detected by ectocervical
biopsies.
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Were the basic data adequately


described?

No, it is not clearly described

690 of 1,373 (50.3%) eligible women agreed to participate


in the study.
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Was the sample size justified?


Yes, There is sample justification
The remaining 897 women were excluded by a history of
previous surgery, chemotherapy, or radiation treatment for
cervical disease or neoplasia; pregnancy; or known human
immunodeficiency virus infection
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Was the statistical significance


assessed?

Yes, the authors mention it explicitly

Endocervical curettage was more likely to find disease in the endocervix among women with high-grade
cytology, positive HPV-16 infection, or highgrade colposcopic impressions (respective P values <,.05).
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).
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Are the statistical methods described?

all analyses were performed with the


statistical programming language R-
3.1.2 in the open-source integrated
development environment of RStudio
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Where are the biases?


Selection bias  No All women aged 30 years or older
enrolled in the Biopsy Study (age range 18–76 years, median age
26 years) were supposed to undergo endocervical sampling

Information bias  No
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

Did untoward events occur during the study?

Concern for persistent oncogenic


infection and trigger endocervical
sampling at colposcopy
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

How do the results compare with previous


reports? (1)

In the Biopsy Study, selecting for the ECC procedure by age alone affirmed
previously reported associations between diagnosing cervical precancers on
routine ECC and high-grade colposcopic impression and ASC-H or HSIL or worse
cytology.

Our findings support the following ECC indications in the current cervical cancer
screening guidelines: 1) ASC-H or HSIL or worse cytology and 2) ASC-US or LSIL
cytology with unsatisfactory colposcopy. Using a multiple-biopsy colposcopy
protocol, we showed that detection of additional CIN 2 or worse by ECC
substantially decreases with increasing number of ectocervical biopsies
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

How do the results compare with previous


reports? (2)

In contrast to previous research, we showed that ECC did not yield significantly
more disease in unsatisfactory examinations in women 30–44 years old

The current U.S. management guideline recommends against ablation in women


with significant endocervical disease.12 Our results showed that an unsatisfactory
examination in women with lowgrade or equivocal cytology warrants endocervical
sampling, which may indicate excision rather than ablation therapy in
approximately one of every seven or eight women
Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology

What implications does the study have for your


practice?

By refining the selection of women for ECC, young women with


unsatisfactory examination may be spared a painful procedure, high-risk
women with positive ECC will receive appropriate excision treatment to
confirm the margin status and minimize missed disease or recurrence, and
obstetric complication can be avoided in women with low-grade cytology
and intermediate risk of precancers in the endocervix
Thank you

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