Cervical Biopsy

Cervical Biopsy: A Diagnostic Test of Cervical Cancer

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Introduction

A cervical biopsy is a minor surgical procedure in which a small amount of cervical tissue is removed for examination to detect abnormal or precancerous conditions or cervical cancer.

  • A cervical biopsy may be performed when cervical abnormalities are found during a pelvic examination or abnormal cells are found during a pap test.
  • Precancerous cells are cells that appear to be abnormal but are not cancerous.
  • The abnormal cells may be the first sign of cancer that may develop later.
  • A colposcopy, also known as a colposcopy-guided cervical biopsy, frequently includes a cervical biopsy.
  • Cervical biopsies are slightly more invasive than Pap tests or colposcopies.

Epidemiology

  • Over 80% of cervical cancer is diagnosed at an advanced clinical stage, which often has a very poor diagnosis.
  • By 2016, the majority of labs (67.2%) in the College of American Pathologists Pap Education Program had implemented the 2014 updated Bethesda System (TBS), and 20.1% had plans to do so.
  • By early 2003, 85.5% of laboratories in the United States had implemented Bethesda 2001 terminology and the adoption of TBS in the international cytopathology community had produced a significant impact.

Indications of Cervical Biopsy

Histopathological examination of tissue through colposcopy-guided biopsy is the standard method for diagnosing cervical precancerous lesions. A cervical biopsy is performed to confirm the diagnosis of cancer when abnormalities are found. In the following situations, a cervical biopsy is necessary:

  • Abnormal Pap smear test
  • Positive Human Papillomavirus (HPV) test
  • Cervical polyps
  • Genital warts
  • Diethylstilbestrol (DES) exposure
  • Post-coital bleeding
  • Abnormal menstrual bleeding
  • Bleeding after menopause
  • Irregular or heavy menstrual bleeding
  • Suspected signs of cancer

Types of Cervical Biopsy

Colposcopic (punch) biopsy

  • A colposcopy, also known as a colposcopy-guided cervical biopsy, frequently includes a cervical biopsy. Colposcope is an instrument that allows visualization of the vagina and cervix.
  • This procedure uses a circular blade, like a paper hole puncher, to remove a sample tissue.
  • Biopsy is taken from the suspected area or a four-quadrant using punch biopsy forceps.
  • It is done on an outpatient basis without anesthesia.

Cone biopsy

  • Conization is another name for a cone biopsy.
  • Both diagnostic and therapeutic applications are possible with it.
  • A large cone-shaped piece of tissue from the cervix is removed during this surgical procedure.
  • Method for removal of a cone may be a cold knife, CO2, laser, or laser diathermy loop.
  • The cone-shaped tissue may contain an entire squamous-columnar junction, stroma with gland, and endocervical mucous membrane.

Indications for a cone biopsy

  • Diagnostic and therapeutic purposes in cervical intraepithelial neoplasia (CIN)
  • Unsatisfactory and inconsistent colposcopic findings
  • Complete removal of precancerous tissues
  • Treatment of early-stage cancer

Endocervical curettage (ECC)

  • This procedure uses a narrow instrument called a curette to scrape the lining of the endocervical canal.
  • The curette is then gently scraped against the walls of the cervical canal, removing some of the tissue.
  • It is done when the transformation zone is not visible with a colposcopy.
  • Endocervical scraping is another name for it.

Wedge biopsy

  • It is done when definite growth is visible.
  • The ideal site for biopsy is an area near the edge.
  • Under this biopsy, after the insertion of a vaginal speculum, the anterior and posterior lip of the cervix is held by alley’s forceps.
  • With a scalpel, a wedge of tissues is cut from the edge of the lesion including the healthy tissue for comparative histological study.

Ring biopsy

  • It is the removal of the whole squamocolumnar junction area of the cervix with a special knife.

Articles required for Cervical Biopsy

  • Kidney tray
  • Bowels 2
  • Vaginal speculum
  • Acetic acid solution
  • Allis forcep
  • Sterile Gloves
  • Lubricant
  • Cystoscope
  • Povidone 10% solution
  • Normal saline
  • Cotton balls/swabs
  • Lidocaine spray/lignocaine gel
  • Endocervical curette
  • Cytobrush
  • Dissolvable suture material
  • Needle drivers
  • Scissors
  • Forceps
  • Labelled specimen jar containing 10% formalin
  • Sanitary pads for the patient after the procedure.

Procedure of Cervical Biopsy

Before the procedure

  • Refrain from using any vaginal creams, medications, or powders in, or around the vagina for 24 to 48 hours.
  • Avoid vaginal intercourse or tampons for 24-48 hours before and after the procedure.
  • Get informed consent.
  • Explain the procedure to the patient and family members.
  • Allow the patient to empty the bladder.

During the procedure

  • Maintain privacy.
  • Place the patient in a dorsal recumbent position.
  • Perform vaginal examination.
  • Insert vaginal speculum of appropriate size.
  • Clean and soak the cervix with acetic acid.
  • A colposcope is used to visualize the vagina.
  • Allis forcep is used to hold the cervix for biopsy.
  • The type of biopsy depends on the shape, size, and location of the abnormal cells. Depending on the type of cervical biopsy, the process of removal of cervical tissue differs.
  • One or more small samples of tissue will be taken using a special type of forceps called an endocervical curette or an endocervical brush.
  • For a cone biopsy, a loop electrosurgical excision procedure (LEEP) or the cold knife cone procedure may be done.
  • Bleeding from the biopsy site is treated with electrocauterization or suturing.
  • Send the tissue to the lab for testing.
  • Recording and reporting.

After the procedure

  • Collect the sample in a container containing 10% formalin.
  • Proper naming of the specimen should be done.
  • Send the specimen to the lab with proper documentation.
  • Check the vital signs.
  • Check the vaginal bleeding.
  • Put the patient on sanitary pads and check for heavy bleeding.
  • Pain management.
  • Keep the women on bed rest for 24 to 48 hours.

After Discharge from the hospital

  • Do not allow the patient to douche, use tampons, or have sex for 1 week after the biopsy or as per the health care provider’s suggestion.
  • Notify the physician if the woman has any of the following symptoms:
    • Bleeding
    • Foul-smelling discharge from the vagina
    • Fever
    • Severe lower abdominal pain

Side Effects after Cervical Biopsy Procedure

  • Pain
  • Fever/infection
  • Heavy bleeding
  • Foul-smelling vaginal discharge
  • Psychological distress

The Bethesda System

  • The Bethesda System (TBS) is the standardized reporting system in cervicovaginal cytology. TBS reports elements including specimen type, specimen adequacy, general categorization, interpretation, or result.
  • The Bethesda system was first introduced in 1998 and revised in 1991, 2001, and 2014.
  • The World Health Organization (WHO), the American Society for Colposcopy and Cervical Pathology (ASCCP), and the College of American Pathologists now recommend the two-tier classification of the squamous intraepithelial lesion. (the high-grade and low-grade lesions).
  • The Human Papillomavirus (HPV) affects the intraepithelial essentially in two ways: either as a viral infection or viral-associated pre-cancer.

Principles

  • The patient’s health care provider must receive clinically relevant information from the laboratory through terminology.
  • Different pathologists and laboratories should use the same terminology, and it should also be adaptable enough to be used in a wide range of laboratory settings and locations.
  • The terminology must reflect the most recent understanding of cervical neoplasia.

The 2014 Bethesda System (Cervical Biopsy Interpretations)

Specimen Type

  • Indicate conventional smear (Pap smear) vs. Liquid-based preparation vs other

Specimen Adequacy

  • Satisfactory for evaluation (describe the presence or absence of endocervical /transformation zone component and any other quality indicators, e.g., partially obscuring blood, inflammation, etc.)
  • Unsatisfactory for evaluation… (specify reason)
    • Specimen rejected/ not processed (specify reason)
    • Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of…. (specify reason)
  • Samples are smeared directly onto a microscope slide after collection
  • Liquid-based cytology
  • The sample is taken from the transitional zone using an arrow-shaped brush.
  • The cells are collected in a bottle of preservative and transported to the laboratory.

General Categorization (optional)

  • Negative for intraepithelial lesion or malignancy
  • Epithelial cell abnormality
  • Other

Interpretation/Result

Negative for intraepithelial lesion or malignancy

(When there is no cellular evidence of neoplasia, state this in the General Categorization above and/or in the Interpretation/Result section of the report-whether there are organisms or other non-neoplastic findings).

Non-neoplastic Findings

  • Non-neoplastic cellular variations
    • Squamous metaplasia
    • Keratotic changes
    • Tubal metaplasia
    • Atrophy
    • Pregnancy-associated changes
  • Reactive cellular changes associated with
    • Inflammation (includes typical repair)
    • Radiation
    • Intrauterine contraceptive device
  • Glandular cells status post hysterectomy

Organisms

  • Trichomonas vaginalis
  • Fungal organisms morphologically consistent with Candida species
  • Shift in flora suggestive of bacterial vaginosis
  • Bacteria morphologically consistent with Actinomyces sp.
  • Cellular changes consistent with herpes simplex virus
  • Cellular changes consistent with cytomegalovirus

Other non-neoplastic findings

  • Endometrial cells (in a woman ≥ 45 years age)

Specify if negative for squamous intraepithelial lesion)

Epithelial cell abnormalities

Squamous cell abnormalities

  • Atypical squamous cells
    • Of undetermined significance
    • Cannot include High-grade squamous intraepithelial lesion (HSIL)
  • Low-grade squamous intraepithelial lesion (LSIL): Encompassing: HPV/mild dysplasia/CIN1
  • High-grade squamous intraepithelial lesion (HSIL): Encompassing moderate and severe dysplasia, CIS; CIN 2 and CIN 3
    • with features suspicious for invasion
  • Squamous cell carcinoma

Glandular cell

  • Atypical
    • Endocervical cells
    • Endometrial cells
    • Glandular cells
  • Atypical
    • Endocervical cells, favor neoplastic
    • Glandular cells, favor neoplastic
  • Endocervical adenocarcinoma in situ
  • Adenocarcinoma
    • Endocervical
    • Endometrial
    • Extrauterine
    • No otherwise specified

Other malignant neoplasms (specify)

Adjunctive testing

  • Report the test’s outcome with a brief explanation that the clinician can easily understand.

Computer-assisted interpretation of cervical cytology

  • If an automated device examines a case, specify the device and the result.

Educational notes and comments appended to cytology reports (optional)

  • Suggestions should be concise and consistent with clinical follow-up guidelines published by professional organizations (references to relevant publications may be included).

Benefits

  • It leads to the early detection and treatment of intraepithelial lesions.
  • It provides effective communication among cytopathologists and referring physicians.
  • It facilitates cytologic-histopathological correlation.
  • It provides reliable data for national and international statistical analysis comparisons.

Contraindications of Cervical Biopsy

  • Active cervical and vaginal infection
  • Incompetent cervix
  • Pelvic pain
  • Heavy vaginal bleeding
  • Injury to cervical tissue
  • Cervical stenosis
  • Late pregnancy or active labor
  • If a patient does not consent to a cervical biopsy

Complications of Cervical Biopsy

  • Secondary hemorrhage
  • Cervical stenosis
  • Infertility
  • Cervical incompetence
  • Mid-trimester abortion or preterm labor

Summary

  • A cervical biopsy is a surgical procedure in which a small amount of tissue is removed from the cervix, often using a colposcope.
  • Indications of a cervical biopsy are abnormal pap smear tests, cervical polyps, genital warts, positive HPV test, post-coital bleeding, etc.
  • Depending on the location, extent, and severity of the cervical lesion, a variety of cervical biopsy options are available.
  • Furthermore, special patient preparation is necessary before, during, and after the cervical biopsy.
  • The interpretations of cervical biopsy are based on the Bethesda system that classifies the cervical lesions based on the specimen type, adequacy, general category, interpretation, and adjunctive testing.

References

  1. Robson, J., Merwe, C., Walters, L., Noack, L., Giles, S.M. (2022). The occasional cervical biopsy. Can J Rural Med, 27 (2),72-76. https://www.cjrm.ca/text.asp?2022/27/2/72/341022
  2. Nayar, R., & WILBUR, C.D. (2015, March – April). The Pap Test and Bethesda 2014. Acta Cytologica, 59 (2), 121-132. https://doi.org/10.1159/000381842
  3. Reyes, M. C., Cooper, K. (2014, August). Cervical Cancer Biopsy Reporting. A Review. Indian J Pathol Microbiol. 57, 364-8. https://www.ijpmonline.org/text.asp?2014/57/3/364/138713
  4. Wang, Y,. Wang, J,. & Mei, H. (2022). Diagnosis of Cervical Intraepithelial Neoplasia and Invasive Cervical Carcinoma by Cervical Biopsy under colposcopy and Analysis of Factors Influencing. Emergency Medical International, 2022, 9621893. Doi: 10.1155/2022/9621893
  5. https://www.hopkinsmedicine.org
  6. https://www.healthline.com
  7. https://www.cancercenter.com
  8. https://www.uptodate.com

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