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Endocervical curettage

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Endocervical curettage
Curette used for Endocervical Curettage
Curette used for Endocervical Curettage
Purposeused to biopsy endocervical canal for abnormalities

Endocervical curettage (ECC) 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 ECC include evaluation of persistent HPV infections, workup of unexplained abnormal uterine bleeding, and follow up of inconclusive colposcopy.

History

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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 ECC 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.

Medical Uses

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ECC 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 ECC is the method of choice in cases where this is necessary.

Indications

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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 ECC may be used to biopsy the endocervix epithelium. ECC is particularly useful in cases of colposcopy where the squamocolumnar junction (SCJ) is not visualized.[4]

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

  1. Abnormal pap smear with negative findings on colposcopy
  2. Pap smear cytology of atypical glandular cells, high-grade squamous intraepithelial lesions (HSIL), or carcinoma[4]
  3. Colposcopy findings concerning for endocervical lesion or SCJ not visualized[5]
  4. Patient undergoing colposcopy after testing positive for HPV 16 or 18[4]

Efficacy

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The efficacy of ECC 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 ECC 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.[6]

Procedure

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Speculum

Endocervical curettage is type of cervical biopsy that is performed with a curette which is used 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 which is the position for most pelvic exams.[7][8]

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 cervical canal to identify abnormal lesions. Forceps can also be used during the procedure to grasp the cervix. Once these steps of the colposcopy are completed, the provider will proceed with ECC if the findings indicate that biopsy of the endocervical canal is necessary.[9]

ECC is generally should be the last step of the colposcopy procedure. It is when the curette is inserted and passed through the cervical os (opening in the cervix that leads into the uterus) and used to scrap cells from the inside of the cervical canal. The curette is advised to be firmly held like a pen, and should scrape the endocervical canal in small strokes.[9] 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. They are then later viewed under a microscope by a pathologist to assess for any abnormalities.[7][10]

Risks

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Guidelines reveal good evidence that ECC is contraindicated in pregnancy. 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.[4] For these reasons, pregnancy is a well established contraindication to performing ECC.[8] 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.[11] 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

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After ECC, endocervical epithelial 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 analzyed include nuclear size, evidence of pleomorphism, anisokaryosis, hyperchromasia, and miotitic features.

Grades for cervical dysplasia include low-grade squamous intraepithelial lesion (LSIL) to high-grade squamous intraepithelial lesion (HSIL). 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 (LSIL) - CIN 1
  3. High-grade squamous intraepithelial lesion (HSIL) - CIN 2/3
  4. Invasive features
  5. Squamous Cell Carcinoma

Ratings of cervical intraepithelial neoplasia (CIN) are also commonly used to grade cytology of cervical epithelium. CIN1 is the most moderate and are LSIL while CIN2 and CIN3 are modern to serve and are HSIL.[14]

References

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  1. ^ Moniak CW, Kutzner S, Adam E, Harden J, Kaufman RH. (2000) Endocervical curettage in evaluating abnormal cervical cytology. J Reprod Med. 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. ^ a b c d 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.
  5. ^ 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.
  6. ^ 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. PMID 15725872.
  7. ^ a b "Cervical Biopsy". Archived from the original on 2024-10-01. Retrieved 2024-12-13.
  8. ^ a b Cooper, Danielle B.; Dunton, Charles J. (2024), "Colposcopy", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 33232095, retrieved 2024-12-13
  9. ^ a b Basu P, Sankaranarayanan R (2017). Atlas of Colposcopy – Principles and Practice: IARC CancerBase No. 13 [Internet]. Lyon, France: International Agency for Research on Cancer. Available from: https://screening.iarc.fr/atlascolpo.php, accessed on 12/12/2024.
  10. ^ World Health Organization (2014). Comprehensive cervical cancer control: a guide to essential practice (2nd ed.). Geneva: World Health Organization. ISBN 978-92-4-154895-3.
  11. ^ "Cervical Biopsy". Archived from the original on 2024-10-01. Retrieved 2024-12-13.
  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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Public Domain This article incorporates public domain material from Dictionary of Cancer Terms. U.S. National Cancer Institute.

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