Is Endocervical Curettage (ECC) Necessary for All HPV16/18-Positive Patients? A Stratified Analysis of 670 Cases

Background: High-risk HPV16/18 subtypes account for over 70% of cervical cancers, but should all HPV16/18-positive patients routinely undergo endocervical curettage (ECC)? Methods: A retrospective cohort study was conducted on 670 HPV16/18-positive patients who underwent colposcopy at Peking University People’s Hospital from 2021 to 2024. Stratified analysis was performed based on prior HPV infection history, current cervical cytology and HPV test results, transformation zone (TZ) type, and colposcopic impression. Primary outcome was the detection rate of cervical intraepithelial neoplasia above (CIN2)+ on final pathology and the additional diagnostic yield of ECC in the ECC subgroup. Results: Among the 670 HPV16/18-positive women, CIN2+ was identified in 32.5% (218/670); the CIN2+ group was significantly younger than the < CIN2 group (median 36.5 vs. 41.0 years, p < 0.001). A high-grade colposcopic impression (G2) steeply elevated the observed CIN2+ proportion to 100%, especially combined with high-grade cytology. In contrast, a Normal/G1 colposcopic finding effectively downgraded the risk to 4.8% in the presence of prior HPV negativity + low-grade cytology + visible TZ. Among the 523 ECC specimens, it is noteworthy that even when the final pathology was diagnosed as CIN2+, a considerably high proportion of patients (44.4–64.7%) remained free of lesions in the endocervical canal; in the colposcopy impression (G2) population, 68.1% of the ECC was normal. The incremental yield of ECC over directed biopsy was only 2.7% (14/523), and all 14 incremental cases occurred in TZ3 (100%). Among the 146 women meeting the composite low-risk profile (TZ1/2 combined with a Normal/G1 colposcopic impression), none had an incremental CIN2+ detection. Conclusion: Women with HPV16/18-positive CIN2+ lesions presented at a younger age. Approximately one-third were diagnosed with CIN2+, and more than half of these had normal ECC histology. With a low additional diagnostic rate observed, ECC provided incremental diagnostic benefit in only 2.7% of HPV16/18-positive women undergoing colposcopy, almost exclusively among patients with a Type 3 transformation zone. The composite low-risk profile identified a subgroup with an extremely low additional diagnostic yield of ECC; however, prospective validation is required before the omission of ECC in this subgroup can be recommended as a change in clinical practice.