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Difficulty: HardGynecologic Oncology

A 33-year-old nulligravid woman comes to the clinic for a routine wellness examination. She states that her menstrual cycles have always been irregular, occurring every 4545 to 6060 days, with menses lasting 77 to 88 days and accompanied by heavy flow. Her medical history includes type 2 diabetes mellitus, chronic hypertension, and obesity. Her body mass index is 3838 kg/m 2^2. Pelvic examination shows a normal-appearing cervix with no visible lesions. A Pap test is performed, and the cytology report reveals atypical glandular cells. High-risk human papillomavirus testing is negative. Which of the following is the most appropriate next step in the management of this patient?

  1. Colposcopy, endocervical curettage, and endometrial biopsyAnswer
  2. B
    Colposcopy and endocervical curettage
  3. C
    Endometrial biopsy only
  4. D
    Pelvic ultrasound and continuous oral contraceptives
  5. E
    Repeat Pap test and human papillomavirus co-testing in 1 year

Answer

Colposcopy, endocervical curettage, and endometrial biopsy
The correct answer is colposcopy, endocervical curettage, and endometrial biopsy. Atypical glandular cells (AGC) on a Pap test indicate a risk of cervical, endocervical, or endometrial adenocarcinoma. The standard initial evaluation for AGC in all patients involves colposcopy and endocervical sampling (curettage) to assess the cervix and endocervical canal. Furthermore, because AGC can also originate from the endometrium, endometrial sampling is indicated in women age 3535 years and older, as well as in women younger than 3535 years who have risk factors for endometrial neoplasia. This patient is 3333 years old but has a history of chronic anovulation (irregular, infrequent menses) and obesity, which expose her endometrium to unopposed estrogen, significantly increasing her risk for endometrial hyperplasia and cancer. Therefore, an endometrial biopsy must be included in her initial diagnostic workup.

Step-by-Step Solution

1
Identify the primary finding on the cervical cancer screening test.
The Pap test shows atypical glandular cells (AGC).
AGC is a significant finding that carries a higher risk of underlying severe pathology (cervical, endocervical, or endometrial adenocarcinoma) compared to squamous cell abnormalities.
2
Determine the baseline diagnostic requirement for all patients with AGC.
All women with AGC must undergo colposcopy and endocervical curettage (ECC).
This evaluates the exocervix and endocervical canal for pre-malignant or malignant glandular lesions.
3
Evaluate if the patient meets criteria for concurrent endometrial sampling.
The patient requires an endometrial biopsy (EMB).
Guidelines mandate adding EMB for women with AGC if they are age ≥35\geq 35 years, OR if they are <35< 35 years but have risk factors for endometrial cancer. This 33-year-old patient has significant risk factors, including obesity and chronic anovulation (irregular menses).

Key Concept

Workup of atypical glandular cells (AGC) on Pap testing
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Topics

Gynecologic Oncology

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