Missed Diagnosis of Invasive Cervical Cancer Leads to Fatal Metastasis

This case involves a fifty-nine-year-old female patient who presented to her gynecologist complaining of abnormal vaginal bleeding that usually occurred after sexual intercourse. The patient also reported some vaginal discomfort, malodorous discharge, and painful urination. The physician said that her symptoms were likely due to vaginal atrophy and suggested that she use water-based lubricants before intercourse to prevent tearing and the associated bleeding. The patient did not receive a vaginal exam, ultrasound, or any other diagnostic testing during the visit. Four months later, the patient was admitted to the hospital for severe leg edema, pelvic pain, and acute kidney failure. The physician on her case suggested that the triad of symptoms pointed to a possible malignancy, with pelvic wall involvement. Upon further workup, it was revealed that the patient had invasive cervical cancer with distant metastasis, which included positive extra, pelvic lymph nodes that spread to the liver, lung, and bone. Her prognosis was considered to be very poor and she was referred for palliative measures.

Question(s) For Expert Witness

1. What is the accepted workup when a patient presents with abnormal vaginal bleeding?

Expert Witness Response E-006303

Complete evaluation starts with Papanicolaou (Pap) testing and this patient should have had this performed on her original visit to attempt to discover the cancer, sooner. Positive results should prompt colposcopy and biopsies with further workup of cervical intraepithelial neoplasia (CIN), including excisional procedures. If pathologic evaluation after loop electrosurgical excision or conization suggests invasive cancer with positive margins, the patient should be referred to a gynecologic oncologist. Patients with suspicious or grossly abnormal cervical lesions on physical examination should undergo biopsy regardless of the cytologic findings.