Richard Hopley, M.D. | 02/20/2023Gynecologic cancers account for a significant proportion of deaths and disease in the United States. These include cervical, endometrial/uterine, ovarian, vaginal, and vulvar cancers.
Cervical cancer used to be both the most common gynecologic malignancy as well as the leading cause of death in women. However, it currently has not only a well-established screening program (the Pap test) but also a preventative vaccine (HPV.) Instead, ovarian cancer is currently the cause of most gynecologic cancer related deaths, due to symptoms which are usually hidden until late in the disease process.
Uterine, or endometrial cancer is now the most common gynecologic malignancy. Despite this, there is no routine screening program. However, unlike ovarian cancer, it may be symptomatic, which usually takes the form of abnormal uterine/vaginal bleeding. Therefore, patients can be evaluated when symptomatic, which may (hopefully) be early in the disease process.
The “standard” method for endometrial biopsy is the D&C, which stands for ‘dilatation and curettage’ of the uterus. This is performed under anesthesia, is costly and must be performed in a surgical setting. Therefore, it is usually preceded by less invasive or aggressive biopsy methods which may be accomplished as an outpatient, in a clinician office. The main screening devices for endometrial cancer include the pipelle, the endometrial brush, endometrial aspiration devices, or the SAP-1 device.
The SAP-1 sampler may be a reliable method and it is patented for use in China but there have not been enough clinical trials to support its feasibility. Aspiration technology is a safe, simple, and reliable technique for screening endometrial lesions, although this is less commonly used than the pipelle as the latter can obtain more tissue than aspiration and cause less pain. Aspiration is also unable to allow diagnosis of certain common uterine lesions.
The pipelle is the most studied device in the literature and perhaps the most frequently used biopsy sampler. However, it suffers from similar limitations as curettage in that it may only sample a small proportion of the endometrial surface and demonstrates variable pathological accuracy. Surprisingly, some studies described the pipelle as being more costly than the D&C.
Endometrial Brushing
Endometrial brushing has been commercially available for approximately 30 years, may be used without anesthesia in an outpatient setting and may be the most well tolerated device among women. A large review article described specimen volume satisfaction to range from 90-100% (compared to 74-100% for the pipelle) while pathologic accuracy varied from 91 to 96%, which is much less variable than the pipelle (62 to 97%.) While insertion of the brush into the endometrial cavity was unsuccessful in one study in as many as 20% of nulliparous patients, the pipelle was similarly unsuccessful in 22% of the same population. Diagnostic limitations of the endometrial brush include described difficulties in distinguishing simple hyperplasia from disordered proliferative mucosa and difficulty in identifying endometrial polyps.
This review article, which examined different endometrial biopsy sampling devices, concluded that endometrial brushing provided more accurate diagnoses, greater specimen volume satisfaction and more pathological accuracy in detecting endometrial lesions.
At PathAdvantage, we examine all types of endometrial biopsy specimens but are the only laboratory in the United States to offer the MatrixBrush. The MatrixBrush, designed by PathAdvantage’s founder and Medical Director, Alexandra Gillespie M.D., is an endometrial sampling brush which offers high sensitivity, diagnostic accuracy, and reduced discomfort. The described challenges (for example, discerning simple hyperplasia from disordered proliferative endometria) have not been an issue for our specialized and experience gynecologic pathologists.
References:
Du J, et al. Endometrial sampling devices for early diagnosis of endometrial lesions. J Cancer Res Clin Oncol. 2016 Dec;142(12):2515-2522. doi: 10.1007/s00432-016-2215-3.
https://www.cdc.gov/cancer/gynecologic/index.htm