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Difficulty: HardGynecologic Oncology

A 54-year-old woman comes to the clinic for a routine wellness examination. She went through menopause 33 years ago and reports no vaginal bleeding, discharge, or pelvic pain. Her past medical history is notable for type 2 diabetes mellitus and hypertension. Her BMI is 32 kg/m232 \text{ kg/m}^2. A speculum examination reveals a normal-appearing cervix with no visible lesions. A Pap test is performed and the cytology report indicates atypical glandular cells (AGC). A subsequent human papillomavirus (HPV) test is negative. Which of the following is the most appropriate next step in management?

  1. Colposcopy, endocervical curettage, and endometrial biopsyAnswer
  2. B
    Colposcopy and endocervical curettage only
  3. C
    Pelvic ultrasound to evaluate for endometrial thickening
  4. D
    Endometrial biopsy alone
  5. E
    Repeat cervical cytology and HPV co-testing in 1 year

Answer

Colposcopy, endocervical curettage, and endometrial biopsy
Atypical glandular cells (AGC) on cervical cytology is a significant finding associated with a higher risk of underlying malignancy compared to atypical squamous cells. AGC can originate from cervical adenocarcinoma in situ, invasive cervical adenocarcinoma, or endometrial adenocarcinoma. Consequently, clinical guidelines mandate an aggressive diagnostic approach. For all women with AGC, colposcopy and endocervical curettage (ECC) are required to evaluate the cervix and endocervical canal. Furthermore, because the risk of endometrial pathology increases with age, endometrial biopsy must be added to the diagnostic evaluation for all women aged 35 years and older, as well as for younger women with risk factors for endometrial cancer (e.g., obesity, chronic anovulation). Because this patient is 54 years old, she requires all three procedures: colposcopy, ECC, and endometrial biopsy. A negative HPV test does not alter this management, as endometrial malignancies are not caused by HPV.

Step-by-Step Solution

1
Interpret the cervical cytology and HPV results.
The patient has atypical glandular cells (AGC) with a negative HPV test.
AGC indicates a higher risk for underlying severe dysplasia or malignancy (cervical or endometrial) compared to squamous cell abnormalities, and a negative HPV test does not negate this risk because endometrial cancers are not HPV-mediated.
2
Identify the patient's age and clinical risk profile.
The patient is 54 years old and has additional risk factors for endometrial cancer, including obesity and type 2 diabetes.
Management guidelines for AGC are stratified by age (cutoff of 35 years) and the presence of endometrial cancer risk factors.
3
Determine the indicated diagnostic interventions.
The standard of care requires colposcopy, endocervical curettage (ECC), and endometrial biopsy.
Because AGC can originate from the cervix, endocervical canal, or the endometrium, all three anatomic sites must be sampled in women age 35 and older.

Key Concept

The finding of atypical glandular cells (AGC) on a Pap test requires evaluation with colposcopy and endocervical curettage for all women, plus an endometrial biopsy for women age 35 and older or those with risk factors for endometrial cancer.
Estimated Time:1m 30s
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Topics

Gynecologic Oncology

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