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Difficulty: MediumGynecologic Oncology

A 64-year-old female presents to the gynecology clinic evaluating intermittent vaginal bleeding that has been ongoing for the past two months. She notes that the bleeding is particularly noticeable after intercourse. She reached menopause at age 52 and takes no medications. Her last gynecologic examination and cervical cancer screening were over two decades ago. Vital signs are within normal limits. Speculum examination reveals a 3.5-cm friable, ulcerated mass on the anterior lip of the cervix that bleeds on contact. Bimanual examination demonstrates a normal-sized, mobile uterus with no adnexal masses. A transvaginal ultrasound shows an endometrial stripe of 2.5 mm. Which of the following is the most appropriate next step in the management of this patient?

  1. Biopsy of the visible cervical lesionAnswer
  2. B
    Endometrial tissue sampling
  3. C
    Cervical cytology with human papillomavirus cotesting
  4. D
    Total extrafascial hysterectomy
  5. E
    Topical vaginal estrogen therapy

Answer

Biopsy of the visible cervical lesion
The correct response is to biopsy the visible cervical lesion. This patient's presentation of postcoital and postmenopausal bleeding, combined with a lack of regular screening and a 3.5-cm friable, ulcerated cervical mass, is highly suspicious for invasive cervical carcinoma. Any gross, exophytic, or ulcerated cervical lesion must be biopsied directly to establish a histologic diagnosis. Once the diagnosis of cervical cancer is confirmed, the patient will undergo staging (often clinical or with advanced imaging like PET/CT) to determine if she is a candidate for radical surgery (e.g., radical hysterectomy) or primary chemoradiation.

Step-by-Step Solution

1
Analyze the patient's presentation and demographics.
A 64-year-old postmenopausal woman without recent screening presents with postcoital bleeding.
Establishing the patient's risk profile for gynecologic malignancies.
2
Evaluate the physical examination and imaging findings.
A 3.5-cm friable, ulcerated cervical mass is present. Ultrasound shows a normal, thin endometrium (2.5 mm).
To localize the source of the bleeding and identify the primary pathology.
3
Determine the most appropriate next step in management.
The correct action is to obtain a tissue biopsy directly from the cervical mass.
A macroscopic, suspicious lesion requires direct histologic diagnosis to guide further staging and treatment.

Key Concept

Patients presenting with postmenopausal or postcoital bleeding and a gross, clinically suspicious cervical lesion require direct biopsy of the lesion rather than screening cytology or endometrial evaluation.
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Topics

Gynecologic Oncology

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