Addition of dilatation and curettage to conization

106 Correspondence

In our opinion dilatation of the cervix during conization helps to reduce the incidence of postoperative cervical stenosis, which would otherwise occur in higher numbers . We suggest that a prospective study is required to evaluate the incidence of cervical stenosis after conization (without accompanying dilatation and curettage) before this becomes an accepted practice, more so in younger women. Vijay Arora, M.D. John T. Parente, M .D. Department oj Obstetrics and Gynecology Bronx-Lebanon Hospital Center 1650 Grand Concourse Bronx, New York 10457 REFERENCE 1. Larsson, G., Gullber, B.D., and Grundsell, H. : A compari-

son of complications of laser and cold knife conization, Obstet. Gyneco!. 62:213, 1983.

Reply to Arora and Parente

To the Editors: Thank you very much for the opportunity to reply to the letter from Parente and Arora. We agree that cervical stenosis is a significant complication of conization. However, this is more likely related to the technique of cone biopsy and subsequent obstruction of the external os . Patency can be maintained by sounding the endocervical canal following conization! and at the first postoperative visit. We thank Parente and Arora for bringing this problem to the attention of physicians who routinely perform cervical conizations. B. Frederick H elmkamp, M .D. Box 668 601 Elmwood Avenue Rochester, N ew York 14642

REFERENCE 1. Helmkamp, B. F., Krebs, H. B. , and Averette, H. E.: Cone

biopsy of the cervix, Con temp. Ob/Gyn. In press.

Addition of dilatation and curettage to conization

To the Editors: In their article on dilatation and curettage at the time of cervical conization , Helmkamp et a\. (AM . J. OBSTET . GYNECOL. 146:893, 1983) reported 128 cases of dilatation and curettage at the time of conization with no significant pathology found in the curettings . They listed seven criteria for adding a dilatation and curettage to a conization. Ironically, the week of their publication, I encountered the following case which met none of their criteria and in which significant disease was found.

May I , 1984 Am . J. Obstet. Gynecol.

P. D., a 33-year-old, nulligravid woman with regular menses and no abnormal uterine bleeding, underwent conization because of a persistent Class III Papanicolaou smear and a normal colposcopic examination, with the squamocolumnar junction high inside the endocervical cana!' The conization specimen showed moderate dysplasia and the curettings showed a well-differentiated adenocarcinoma of the endometrium. Naturally there was discussion among the pathologists who reviewed this material with some of them designating the lesion a severe atypical adenomatous hyperplasia. Whichever it truly is, from the clinician's point of view vis vis the issue of concomitant curettage, my conclusion has to differ from that of Helmkamp et aI. , i.e., there can be significant pathology found when not expected according to the authors' criteria. If this had been Case 129 in their series, then their conclusion would have been different. The risk of performing dilatation and curettage is minimal and the benefit, although rarely derived, may be very rewarding. A copy of the pathology report and the slides can be made available for review. James Labes, M.D . Willow Oak Professional Mall, Suite 101 25865 West Twelve Mile Road Southfield, Michigan 48034

a

Reply to Labes

To the Editors: Thank you very much for the opportunity to reply to Labes' letter, as he has presented a most interesting case. We are unclear as to what "Class III Papanicolaou smear" implies. Most cytopathologists interpret abnormal cytology as either squamous or glandular (endocervix or endometrium) in origin. Did these Papanicolaou smears include an endocervical aspirate or swab? This technique can aid in the detection of endometrial cancer and its precursors in up to 70% of cases.! A recent article by Crissman et a\.2 addressed the problem of premenopausal endometrial carcinoma. Only 3% of endometrial cancer occurs in women under 40, but 80% of those present with abnormal uterine bleeding. It is likely that Labes' patient would have presented with menstrual abnormalities, and the diagnosis would have been confirmed at dilatation and curettage. If a cervical lesion exists and proper evaluation (cytology, colposcopy, cervical biopsies, and endocervical curettage) has been performed, conization, if indicated , should suffice. B. Frederick Helmkamp, M.D . Box 668 601 Elmwood Avenue Rochester, New York 14642

REFERENCES 1. Ng, A. B. P.: The cellular detection of endometrial carcinoma and its precursors, Gyneco!. Oncol. 2:162,1974.