What are the next steps if a LEEP (Loop Electrosurgical Excision Procedure) specimen shows endocervical glandular involvement with a benign Top Hat?

Management of LEEP Specimen with Endocervical Glandular Involvement and Benign Top Hat

When a LEEP specimen shows endocervical glandular involvement with a benign Top Hat, a diagnostic excisional procedure (preferably Cold Knife Conization) is recommended to rule out residual disease and potential invasive cancer. 1

Understanding the Clinical Significance

• Endocervical glandular involvement in a LEEP specimen represents a significant finding that requires thorough evaluation, as approximately 45% of patients with atypical glandular cells have clinically significant lesions including CIN, adenocarcinoma in situ (AIS), or invasive cancer 1
• A benign Top Hat (endocervical margin) does not reliably exclude the presence of residual disease in the endocervical canal, as clear margins do not rule out persistent disease 1
• Studies show that approximately 30% of patients with AIS have residual disease on subsequent hysterectomy even with negative margins of excision 1

Recommended Management Algorithm

Immediate Next Steps:

1. Perform Cold Knife Conization (CKC) as the preferred diagnostic procedure 1

   • CKC is superior to repeat LEEP because LEEP has been associated with cautery artifact that may compromise pathologic evaluation 1
   • CKC provides an intact specimen with interpretable margins 1
   • Concomitant endocervical sampling is preferred during the procedure 1

2. Consider referral to a gynecologic oncologist if adenocarcinoma in situ (AIS) is suspected or confirmed 1

   • This is particularly important as glandular lesions can be more difficult to detect and manage than squamous lesions 1

Management Based on CKC Results:

1. If CKC confirms glandular neoplasia with negative margins:

   • For patients desiring fertility: Follow-up with cervical cytology with or without ECC every 6 months 1
   • For patients with completed childbearing: Hysterectomy should be strongly considered 1
   • Counsel patients about the 30% risk of residual disease despite negative margins 1

2. If CKC confirms glandular neoplasia with positive margins:

   • For patients not desiring fertility: Hysterectomy is recommended 1
   • For patients desiring fertility: Repeat CKC to attain negative margins with appropriate counseling about risks 1

3. If CKC reveals invasive adenocarcinoma:

   • Management according to cervical cancer guidelines 1

Important Considerations and Caveats

• Do not rely on colposcopic follow-up alone when endocervical glandular involvement is identified, as glandular lesions affect areas of the cervix that are harder to sample 1
• HPV DNA testing alone is not appropriate for the initial triage of atypical glandular cells 1
• Avoid repeat cervical cytology alone for initial management of glandular abnormalities 1
• Be aware that the depth of the excised specimen does not necessarily correlate with endocervical glandular involvement - a deeper cone biopsy may not necessarily provide more effective treatment 2
• Recognize that residual disease is found in approximately 52% of cases with positive endocervical margins in LEEP specimens, with some cases revealing invasive carcinoma on repeat conization 3

Follow-up After Definitive Management

• For patients who undergo conservative management with CKC (preserving fertility):
  • Continue cervical cytology with or without ECC every 6 months until hysterectomy is performed 1
  • Consider hysterectomy when childbearing is completed 1
  • If follow-up cytology/ECC is positive, manage according to findings 1
  • If follow-up remains negative, continue screening every 6 months 1