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Difficulty: MediumGynecologic Oncology

Routine cervical cancer screening is performed on a 44-year-old patient during her annual health maintenance visit. The patient has a medical history significant for type 2 diabetes mellitus and a body mass index of 33 kg/m233 \text{ kg/m}^2. She reports that her menstrual cycles occur every 28 days and last for 5 days with moderate flow. She has two children delivered vaginally at term. The laboratory reports the cytology results as atypical glandular cells. Speculum examination reveals a parous cervix with no visible lesions. Bimanual examination demonstrates a normal-sized, mobile uterus and no adnexal tenderness. Which of the following is the most appropriate next step in the management of this patient?

  1. Colposcopy, endocervical sampling, and endometrial samplingAnswer
  2. B
    Colposcopy and targeted ectocervical biopsy only
  3. C
    High-risk human papillomavirus DNA testing
  4. D
    Repeat cervical cytology in 12 months
  5. E
    Transvaginal ultrasonography

Answer

Colposcopy, endocervical sampling, and endometrial sampling
The most appropriate next step in management is colposcopy, endocervical sampling, and endometrial sampling. Atypical glandular cells (AGC) on cervical cytology present a high risk of significant underlying pathology, including cervical adenocarcinoma in situ, invasive cervical adenocarcinoma, and endometrial adenocarcinoma. Because of this risk, all women age 35 and older with AGC must undergo a thorough evaluation of both the cervix and the endometrium. Furthermore, this patient's history of obesity and type 2 diabetes mellitus places her at even higher baseline risk for endometrial neoplasia.

Step-by-Step Solution

1
Interpret the cervical cytology result.
The cytology shows atypical glandular cells (AGC), which carry a higher risk of significant underlying pathology (cervical or endometrial) compared to atypical squamous cells.
AGC can originate from the endocervix or the endometrium, and differentiating the source is critical for appropriate management.
2
Assess the patient's demographic and clinical risk factors.
The patient is 44 years old, which is above the threshold of 35 years. She also has additional risk factors for endometrial cancer, including obesity and type 2 diabetes mellitus.
Age and specific risk factors dictate whether an endometrial evaluation must be added to the standard cervical evaluation.
3
Determine the guideline-concordant next step in management.
The standard of care is to perform colposcopy with endocervical sampling and endometrial sampling.
Current guidelines require this comprehensive tissue sampling for all women age 35 and older with AGC to adequately evaluate for both cervical and endometrial neoplasia.

Key Concept

Management of Atypical Glandular Cells (AGC) on cervical cytology
Estimated Time:1m 0s
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Topics

Gynecologic Oncology

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