A 27-year-old white female sees you for the first time for a routine evaluation. A Papanicolaou test reveals atypical glandular cells of undetermined significance (AGUS). Of the following, which one is most commonly found in this situation?
Correct Answer A: Clinical practice guidelines recommend that all patients with atypical glandular cells of undetermined significance (AGUS) be evaluated by colposcopy and endocervical curettage; endometrial sampling is recommended in women 35 years of age or older, and in those with AGUS favouring neoplasia or suggesting an endometrial source. Cervical intraepithelial neoplasia is the most common histologic diagnosis found in patients evaluated for AGUS.
A 56-year-old female presents for a health maintenance examination. She has a history of a total hysterectomy for benign disease 4 years ago. You are able to document that the hysterectomy pathology was benign and that she has had normal Papanicolaou (Pap) tests for 10 years. The patient asks about regular Pap smears.
Which one of the following would be the most appropriate recommendation?
Correct Answer C: After a hysterectomy for documented benign disease, cytologic screening may be discontinued. Papanicolaou (Pap) smears in this population are low yield and may cause unnecessary testing due to false positives. Pap smears may be continued if the reason for the hysterectomy is uncertain. If there is a history of invasive cervical cancer or DES exposure, screening should be continued, although there is not a great deal of data to support this practice.
Which one of the following Papanicolaou test results is most likely to indicate a cancerous lesion?
Correct Answer C: Papanicolaou (Pap) tests are intended to screen for cervical cancer, but abnormal Pap tests are associated with precancerous lesions or with no abnormality. The category of atypical glandular cells not otherwise specified (AGC-NOS) has a benign sound to it, although it is associated with a 17% rate of cancer (8% carcinoma in situ, and 9% invasive carcinoma). High-grade squamous intraepithelial lesion (HSIL), which would seem worse intuitively, has only a 3% associated cancer rate. AGC-NOS is associated with higher rates of cancer than the other choices listed.
A 39-year-old female with no past history of abnormal Papanicolaou (Pap) test receives a report indicating the presence of “atypical glandular cells.”
Appropriate management would include:
Correct Answer B: Atypical glandular cells (AGC) on a Papanicolaou (Pap) test refers to tissue of endocervical or endometrial origin and not the typical squamous cells of the ectocervix. A Pap test demonstrating AGC is an indication for colposcopy with endometrial sampling. If the patient is over 35 years of age, when the risk of endometrial adenocarcinoma increases, an endometrial biopsy is also mandatory. AGC has not been associated with HPV infection.
A 45-year-old woman is referred to your office for a Pap smear that is suspicious for malignancy. The cervix appears grossly normal on speculum exam.
The next most appropriate procedure is:
Correct Answer E: The Pap smear is a screening test. Although the cervix appears normal to the naked eye, once acetic acid is applied and the magnification of the colposcope added, vascular abnormalities will often be seen. The most concerning colposcopic finding is the presence of abnormal vessels. These suggest carcinoma in situ or invasive carcinoma. If the colposcopic exam is negative, a cone biopsy is performed to find the source of the suspicious cells.
A. This is the therapy for early stage cervical carcinoma. The diagnosis of cancer has not yet been made. A biopsy is necessary.
B. Simple hysterectomy is not the proper cure for invasive cervical carcinoma. Also, the diagnosis of cancer has not yet been made. A biopsy is necessary.
C. It is still likely that a cone biopsy will be necessary if a colposcopic exam is unsatisfactory. The first step, however, in the workup, is a colposcopy with directed biopsy. If invasive cancer is then found, appropriate therapy can be started.
D. Cryotherapy is only indicated for low-grade dysplastic lesions of the cervix, after adequate colposcopic exam to rule out malignancy
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