Suspicion of Cervical or Uterine Pathology in Patients with a Distorted Cervix: Case Series

Abstract

Objective:

The purpose of this study is to present a case series of surgeries performed for patients with distorted cervical anatomy and suspected cervical and/or endometrial pathology. Currently, there are no guidelines for management of these patients.

Design:

This study is a retrospective case series reviewing patients at Moffitt Cancer Center from September 1, 2016, to January 31, 2020.

Materials and Methods:

Patients with distorted cervical anatomy who underwent surgery for suspected cervical or endometrial pathology were identified. Data were collected for each patient including demographics, preoperative clinical examination, intraoperative characteristics, postoperative complications, and final pathology.

Results:

In this study, 21 patients were included and 20 of them were managed with hysterectomy. On final pathology, three patients (14%) were diagnosed with malignancy. Nine patients (43%) were found to have noninvasive disease on final pathology.

Conclusion:

In patients with distorted cervical anatomy and potential pathology, hysterectomy should be considered.

Introduction

Distorted cervical anatomy including stenosis, scarring, or obliteration limits cervical and endometrial evaluation in patients with a history of cervical dysplasia or concern for cervical or endometrial pathology. The distorted anatomy may be secondary to a prior cervical procedure, infection, diethylstilbestrol exposure, or atrophic menopausal changes.^1–6

Anatomic changes may lead to inadequate colposcopy⁷ and/or the inability to perform an endocervical curettage, or endometrial sampling. Given that most cervical neoplasia is located within the transformation zone, cervical scarring, cervical stenosis, and inadequate colposcopy can result in unrecognized lesions.⁸ Cervical stenosis is also a common factor associated with failed endometrial sampling.⁹ The true incidence of cervical stenosis is unknown, but in one series of 31,052 office hysteroscopies, cervical stenosis was found in 32.7% of patients.^1,4 Distorted cervical anatomy poses challenges in the diagnosis of both cervical and endometrial neoplasia as described, and limits options for management of cervical neoplasia. The safety of clinical and cytological surveillance in this specific population of patients is unknown.

Currently, there are no recommendations or guidelines for management of patients with distorted cervical anatomy and potential cervical or endometrial pathology. In the gynecology oncology department at Moffitt Cancer Center, we see patients who have been referred specifically because their cervix and/or endometrium could not be adequately evaluated due to distorted cervical anatomy.

The purpose of this study is to present a case series of surgeries performed for the management of patients with suspected cervical or endometrial neoplasia complicated by a distorted and inevaluable cervix.

Design, Materials, and Methods

This study is a retrospective case series reviewing patients at Moffitt Cancer Center from September 1, 2016, to January 31, 2020. The Institutional Review Board at Moffitt Cancer Center approved this study. Patients were selected if they underwent surgery at Moffitt Cancer Center for a suspicion of cervical or endometrial neoplasia complicated by distorted cervical anatomy. We were unable to identify the cohort of patients referred with a distorted cervix who did not undergo subsequent surgery.

We define severe cervical stenosis as the inability to pass a Cytobrush (Cooper Surgical) beyond the external os. Obliteration of the os was similarly defined but included lack of any visible opening. An otherwise distorted cervix was defined subjectively as complete or almost complete lack of identifiable exocervix.

Data abstracted from electronic chart review included patient demographics and medical history. Prior treatment for cervical dysplasia, surgical history, the results of recent cervical cytology, the results of any imaging of concern (thickened endometrium, etc.), and attempts at diagnosis of cervical or endometrial neoplasia were recorded. Physical examination findings specifically related to the patient's cervical anatomy were noted. Information on the surgery performed, operative time, estimated blood loss (EBL), postoperative complications, and final pathology were included.

Results

There were 21 patients with a distorted cervix who underwent surgical management. Two other such patients planned for surgery were lost to follow-up before operation. Patient demographics are noted in Table 1. The mean age of the patients was 55.8 years (range: 38–69). Eighty-one percent of patients were postmenopausal and 10% were perimenopausal. The mean body mass index (BMI) was 31.7 kg/m² (range: 20–47). The mean parity was 1.52 and 24% of patients were nulliparous. Twenty-nine percent of patients had underlying major medical comorbidities, including coronary artery disease, chronic obstructive sleep apnea, congestive heart failure, diabetes, hypertension, and rheumatoid arthritis.

Table 1.

History and Perioperative Outcomes of Patients Undergoing Surgery with Distorted Cervix

Case no.	Age	Parity	BMI	Major medical comorbidities	Prior cervical dysplasia tx	Prior endometrial tx	Other prior surgery	Cervical path since last intervention	Reason for referral	Surgery Performed	Operative time (minutes)	EBL (mL)	Complications	LOS	Final pathology
1	55	2	20	N/A	Cryotherapy CKC Cerclage	N/A	N/A	Bx: CIN 2	CIN, distorted cervix, h/o DES exposure	TVH	45	minutes	None	0	Negative
2	58	2	30	CAD	LEEP x2 CKC	N/A	N/A	Bx: CIN 1	Recent abnormal pap, distorted cervix	TVH with upper vaginectomy	45	50	None	0	Negative
3	57	2	25	N/A	N/A	Supracervical hysterectomy	Cesarean x2	Pap: LGSIL	Persistent abnormal pap, unable to evaluate cervix	RA-trachelectomy, BSO	60	50	None	1	CIN 1
4	59	0	31	N/A	Cryotherapy	N/A	N/A	Pap: HGSIL Bx: CIN 1	Inevaluable cervix	TVH	40	minutes	None	0	negative
5	44	0	40	N/A	LEEP	N/A	N/A	Pap: HGSIL	Abnormal pap unable to find cervix	TVH	70	100	None	0	negative
6	55	2	25	N/A	CKC	N/A	Cesarean x2	Pap: LGSIL, +HRHPV	CIN, distorted/inevaluable cervix	TLH, LSO	90	50	None	0	CIN 1
7	55	1	33	N/A	LEEP	N/A	Cholecystectomy BTL D&C	N/A	PMB, endometrial adenocarcinoma on pap, cervix scarred and distorted	TLH, BSO, PPLND	180	minutes	None	0	Stage 1A, grade 1 endometrial cancer
8	56	2	23	N/A	Cryotherapy x2 Laser	N/A	N/A	Pap: negative, transformation zone not identified	N/A	TVH, BS, uterosacral colpopexy	65	minutes	None	0	Complex endometrial hyperplasia without atypia
9	51	2	39	N/A	N/A	N/A	Cesarean Cholecystectomy	Pap: HGSIL Bx: CIN 1 ECC +	Distorted cervix, inability to do laser excision	TVH, LS	55	minutes	None	0	Negative
10	65	0	33	N/A	N/A	N/A	BTL	Pap: ASCUS, +HRHPV	Unable to see cervix	TVH, RSO	55	minutes	None	0	CIN 2
11	65	2	30	COPD CAD CHF	LEEP	N/A	Cholecystectomy	Cone: CIN 2–3	N/A	TLH, BSO	95	50	None	1	CIN 3
12	53	2	28	N/A	LEEP Cryotherapy CKC	N/A	N/A	N/A	CIN3 + margins	TVH, left salpingectomy, repair incidental of cystotomy	90	50	Cystotomy	1	Negative
13	38	2	34	N/A	LEEP Cryotherapy Cerclage	N/A	Cerclage Cesarean x2	N/A	Persistent abnormal paps, unable to evaluate cervix	TLH, BS, bilateral ovarian suspension	90	min	None	0	Fibroid uterus
14	65	1	34	CAD	N/A	N/A	Cholecystectomy	Pap: LGSIL Bx: CIN 1	Anticipate difficult hysterectomy	TVH	47	minutes	None	0	CIN 1
15	69	2	22	N/A	CKC LEEP	N/A	N/A	Cone: CIN 1	Abnormal pap, unable to visualize cervix	TVH, BS	45	50	None	0	CIN 1
16	64	0	34	DM	N/A	Failed D&C due to severe stenosis	N/A	N/A	Unable to evaluate cervix	TLH, BSO, PLND	120	50	None	1	Stage 1A, grade 2 endometrial cancer
17	49	0	42	DM HTN RA	CKC x2	N/A	N/A	Pap: HRHPV+	Failed D&C due to severe stenosis, inability to clearly identify os	TVH	50	50	Vesicovaginal fistula	0	Negative
18	47	3	35	N/A	CKC	N/A	Cesarean x3	N/A	Distorted cervix, not able to evaluate	RA-TLH, left salpingo-oophorectomy, right oophorectomy	120	50	None	1	CIN 3
19	52	3	38	N/A	Cryotherapy	N/A	Cesarean x3	Bx: CIN 3 ECC +	PMB, stenotic cervix, inability to sample	RA-TLH, BS, left ureteroneocystostomy	180	minutes	L ureteral transection	1	Fibroid uterus
20	47	1	22	N/A	LEEP x2	N/A	N/A	Bx: CIN 1	Scarred cervix, no visible transformation zone	TVH, BS	60	min	None	0	CIN 1
21	68	3	47	DM HTN	N/A	Failed endometrial sampling	Cholecystectomy	N/A	Failed endometrial sampling with persistent endometrial thickness	TVH	75	50	None	0	At least stage 1B FIGO grade 2 endometrial cancer

BS, bilateral salpingectomy; BSO, bilateral salpingo-oophorectomy; BTL, bilateral tubal ligation; Bx, biopsy; CAD, coronary artery disease; CIN, cervical intraepithelial neoplasia; CKC, cold knife conization; D&C, dilation and curettage; EBL, estimated blood loss; ECC, endocervical curettage; HGSIL, high-grade squamous epithelial lesion; LEEP, loop electrosurgical excision procedure; LGSIL, low-grade squamous epithelial lesion; LOS, length of stay; PLND, pelvic lymph node dissection; PMB, postmenopausal bleeding; PPLND, pelvic and para-aortic lymph node dissection; RA, robotic assisted; TLH, total laparoscopic hysterectomy; TVH, total vaginal hysterectomy.

Fifteen of 21 patients underwent prior cervical procedures including cold knife conization, loop electrosurgical excisional procedure, and cervical cryotherapy and 38% of patients underwent more than one prior procedure. Findings on cervical examination are noted in Table 2, and included severe cervical stenosis, obliterated or nonvisible cervical os, small or absent exocervix, and fornices flush with the vagina.

Table 2.

Cervical Examination Findings

Case no.	Cervical os	Exocervix	Fornices	Inadequate colposcopy	Inability to undergo ECC
1	Patent	Minimal	Almost flush
2	Not visible	Absent	Scarred upper vagina, no cervix	x	x
3	Very close to anterior vaginal wall with scarring	Minimal	Minimal	x
4	Stenotic, obliterated, unable to identify	Normal	Normal	x	x
5	Unable to identify	Small	Flush	x	x
6	stenotic, unable to pass brush, transformation zone not visible	Small	Almost flush	x	x
7	Not identifiable	Minimal	Almost flush	x	x
8	Severely stenotic, unable to pass brush	Flush	Minimal	x	x
9	Scarred to L vaginal wall	Scarred to L fornix	Scarred
10	Stenotic unable to pass brush, no transformation zone visible	Small	Almost flush	x	x
11	Not identifiable	Not identifiable	Flush	x	x
12	Severely stenotic, a dimple	None	Flush	x	x
13	Very stenotic, unable to pass cytobrush, small scarred cervix high in pelvis	Minimal	Minimal	x	x
14	Obliterated	Small	Almost flush	x	x
15	Small, obliterated dimple	Not identifiable	Completely flush	x	x
16	Not visible	Not visible	Obliterated	x	x
17	Dimple	Small	Flush	x	x
18	Brush would not pass	Small	Fairly normal	x	x
19	Not clearly identifiable, scarred	Small, scarred, fixed Anterior	Anterior gone	x
20	Patent	Small	Flush
21	Stenotic	Normal	Normal		x

In this study, 20 of the 21 patients were managed with hysterectomy. One patient previously underwent supracervical hysterectomy, and a robotically assisted trachelectomy was performed. Routes of hysterectomy were vaginal (13), laparoscopic (5), and robotic (2). Intra-operative and post-operative findings are noted in Table 3. The mean operative time for the 13 vaginal hysterectomies was 57.1 minutes (range: 40–90 minutes) and that for laparoscopic hysterectomy was 125 minutes (range: 90–180 minutes). EBL for all cases ranged from minimal to 100 mL. The complication rate was 14% (3 out of 21 patients). Two patients had intraoperative urinary tract injuries (one cystotomy and one left ureteral transection), both of which were detected and repaired at the time of the initial surgery. One patient subsequently developed a vesicovaginal fistula. Average length of stay was 0.29 days. Fifteen out of 21 patients were discharged home on the day of surgery.

Table 3.

Intraoperative and Postoperative Findings

Mean OR time all cases	79.9 minutes
Mean OR time for TVH	57.1 minutes
Mean OR time for TLH	125 minutes
Percentage of patients with complications	14%
Average length of stay	0.29 days

OR, operating room; TLH, total laparoscopic hysterectomy; TVH, total vaginal hysterectomy.

Before definitive surgical management, 43% of patients had biopsy-proven neoplasia (of these, 81% had an unsatisfactory colposcopy and 71% were unable to undergo endocervical curettage due to stenosis). On final pathology, three patients (14%) were diagnosed with malignancy (Fig. 1). Three patients had endometrial cancer (stage 1A, FIGO grade 1, stage 1A, FIGO grade 2, and one patient had at least stage 1B, FIGO grade 2). Nine patients (43%) were found to have noninvasive disease on final pathology (Fig. 2). Five patients had CIN 1, three patients had CIN 2/3, and one patient had complex endometrial hyperplasia without atypia. Nine patients (43%) had no evidence of neoplasia (Table 4). Figures 3 –5 are intra-operative photos from one case included in this case series.

FIG. 1.

Final pathology in patients undergoing hysterectomy with distorted cervical anatomy.

FIG. 2.

Percentage of patients with precancerous, cancerous, and benign pathology.

FIG. 3.

Exocervix with cervical stenosis.

FIG. 4.

Uterus and distorted cervix status posthysterectomy.

FIG. 5.

External cervical os.

Table 4.

Final Pathology

Final pathology	Percentage of patients
Negative	33.3% (7/21)
Fibroids	9.5% (2/21)
CIN 1	23.8% (5/21)
CIN 2	4.8% (1/21)
CIN 3	9.5% 2 (21)
Endometrial hyperplasia	4.8% (5/21)
Endometrial cancer	14.3% (3/21)

CIN, cervical intraepithelial neoplasia.

Conclusion

The vast majority of women who fall within the guidelines for routine cervical screening are adequately sampled with an Ayer's spatula and endocervical brush (or similar devices). However, in the presence of marked cervical distortion and, especially, severe stenosis or obliteration of the canal, sampling error is a distinct possibility. This is of particular concern in women with a history or even current evidence of cervical neoplasia. Further attempts at sampling or even resolving stenosis have been described, but they are not definitive and may be impractical or limited by anatomy.^1,2 Our management of choice in such patients who are fit for surgery is, therefore, hysterectomy. The pathological findings in this study support this approach. Concerns with proceeding directly to hysterectomy included the possibility of occult invasive cervical cancer and complications of surgery. Surgical challenges in these women include loss of some anatomic landmarks when proceeding vaginally and placement of a uterine manipulator. The high rate of urinary tract injury in the present series is likely a consequence, and raises a note of caution when proceeding to hysterectomy in such patients.

The vast majority of women who have findings suspicious for endometrial neoplasia (postmenopausal bleeding and thickened endometrium) will be adequately evaluated with office or operating room endometrial sampling. Cervical stenosis in such patients is generally easily surmounted in the operating room (if not the office).^1,4 However, if sampling is not anatomically possible for the reasons described, hysterectomy is a reasonable consideration for operable women. The current series supports this contention. The vaginal route was deemed appropriate given a combination of factors, including a less invasive procedure relative to the lack of a definitive diagnosis and comorbidities (including BMI).¹⁰

In conclusion, for women with suspected cervical or endometrial neoplasia and the inability to undergo adequate evaluation due to cervical distortion as described, hysterectomy should be considered. Such cases may be associated with an elevated operative risk of urinary tract injury.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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