Efficacy of random cervical biopsy and routine endocervical curettage in subjects with normal colposcopy

Colposcopy has been shown to reduce morbidity and mortality of cervical cancer, it has some limitations due to the concerns about sensitivity of this tool. Several studies have been shown that, colposcopy has a sensitivity ranging between 30-70 % for the detection of high-grade cervical disease Massad LS, Gynecol Oncol 2003 Massad LS. J Low Genit Tract Dis 2009 Pretorius RG. Am J Obstet Gynecol 2004.

Further data indicated increased sensitivity with additional biopsies. Additionally authors suggested that random biopsies are recommended for special populations like women with low grade cytology Gage JC, Obstet Gynecol 2006;108:264–72. Nakamura, Y., International journal of clinical oncology 2015; 20(3): 579-585.

344 patient 2011 – 2016, in Gynecological oncology clinic of Zeynep Kamil Women and Children’s Health Training and Research Hospital. Indications for colposcopy: High risk HPV types, ASC-US, AGC, ASC-H, LSIL,HSIL. Endocervical curettage (ECC) performed patients included.

Frequency of initial cytology were as follows: AGC:6 (1 Frequency of initial cytology were as follows: AGC:6 (1.7 %), ASC-H:33 (9.6), ASC-US:84 (24.4 %), HGSIL:83 (24.1 %), LGSIL:138 (40.1 %). Bu slaytta herkese neden hpv baktınız derlerse bu hastalar asmlerden hem smear hem hpvleri alınarak referre edilen hastalardı diyeceğim. Çünkü hpv değil 2011’de hala dahi bizde bakılmıyor.

Rate of high grade lesions between groups with and without colposcopy directed biopsy was comparable (33/62 versus 119/282, p < 0.05). Random biopsy was obtained in higher cases with high grade cytology (AGC:0/6, ASC-H:5/33, ASC-US:10/84, HGSIL:26/82, LGSIL:20/137, p < 0.05).

Number of cases with variable histopathological results at cervical directed and random biopsy that corresponds to initial cytology   BR Total NCT CIN 1 CIN 2-3 AGC 1 5 6 0.0% 16.7% 83.3% 100.0% ASC-H 10 22 33 3.0% 30.3% 66.7% ASC-US 4 59 21 84 4.8% 70.2% 25.0% HGSIL 2 17 64 83 2.4% 20.5% 77.1% LGSIL 93 40 138 3.6% 67.4% 29.0% 12 180 152 344 3.5% 52.3% 44.2%

cases underwent directed or random biopsy Comparison result of biopsy and ECC results between cases underwent directed or random biopsy Biopsy Results Total NCT CIN 1 CIN 2-3 Random 2 27 33 62 3.2% 43.5% 53.2% 100.0% Directed 10 153 119 282 3.5% 54.3% 42.2% 12 180 152 344 52.3% 44.2% ECC Result 38 11 13 61.3% 17.7% 21.0% 147 32 50 229 64.2% 14.0% 21.8% 185 43 63 291 63.6% 14.8% 21.6% NCT:Normal cervical tissue

Summary of histopathological results at conization and corresponding cytology and biopsy results Conizations Total NCT CIN 1 CIN 2-3 BR/NCT 1 BR/CIN 1 5 14 8 27 BR/CIN2-3 4 25 116 145 9 40 124 173 AGC ASC-H 2 17 24 ASC-US 11 29 HGSIL 52 67 LGSIL 13 34 49

Number of cases with variable histopathological results that corresponds to initial cytology   ECC Total NCT CIN 1 CIN 2-3 AGC 4 2 6 ASC-H 18 12 32 ASC-US 44 11 8 63 HGSIL 39 9 31 79 LGSIL 80 21 10 111 185 43 291 BR/NCT 3 BR/CIN 1 112 24 145 BR/CIN2-3 73 51 134

Our data showed that random cervical biopsy had significant diagnostic value in cases with normal colposcopy. Further analyses of the data of cases with normal colposcopy without visible lesions revealed that, majority of the cases had HSIL cytology.

Consistent with our result, in study by Pretorius et al, random biopsy was shown to have additional value for the detection of CIN 2 or worse especially in cases with high-grade cytology . In their study authors reported that only 57.1 % of women with CIN 2 or worse was detected by colposcopy directed biopsy, although all the colposcopies were satisfactory. Pretorius RG. Am J Obstet Gynecol 2004.

Similar to our argument, the authors of ATHENA study published in 2014 concluded that a single random biopsy increased the detection of high-grade disease when no lesions were visualized at colposcopy and detection rate was shown to be higher in cases with positive for HPV 16 or 18 screening.

Analyses of HPV data showed that, especially in cases with ASC-US cytology, random biopsies were required for non of the case with HPV positivity (n=7), while 10/77 cases underwent random cervical biopsy procedure negative for HPV test.

Random biopsy was performed in higher number of cases with negative for HPV test (1/23 versus 61/321).