Questions
DIRECTIONS (Questions 1 through 55): For each of the multiple choice questions in this section, select the lettered answer that is the one best response in each case.
Questions 1 through 3 apply to the following patient:
A 44-year-old multiparous obese woman complains of abnormal vaginal bleeding of 5 months’ duration.
Pelvic examination demonstrates a small, anteverted uterus and a normal-appearing cervix. No adnexal masses are present. A serum pregnancy test is negative, and a cervical Papanicolaou (Pap) smear is normal. Prolactin and thyroid-stimulating hormone (TSH) levels are normal.
1. Which of the following is the most efficient next step in the evaluation of this patient?
(A) dilation and curettage (D&C) (B) endometrial biopsy
(C) endometrial cytology (D) transvaginal sonography (E) hysteroscopy
2. Tissue sampling in this patient reveals endometrial hyperplasia. What is the most common symptom associated with this condition?
(A) vaginal discharge (B) vaginal bleeding (C) amenorrhea (D) pelvic pain
(E) abdominal distention
3. Which of the following factors is protective against endometrial hyperplasias?
(A) obesity (B) tamoxifen
(C) oral contraceptive pills (OCPs).
(D) early menarche or late menopause (E) unopposed exogenous estrogen therapy
4. A 49-year-old woman experiences irregular vaginal bleeding of 3 months’ duration. You perform an endometrial biopsy, which obtains copious tissue with a velvety, lobulated texture. The pathologist report shows proliferation of glandular and stromal elements with dilated endometrial glands,
consistent with simple hyperplasia. Cytologic atypia is absent. Which of the following is the best way to advise the patient?
(A) She should be treated to estrogen and progestin hormone therapy.
(B) The tissue will progress to cancer in approximately 10% of cases.
(C) The tissue may be weakly premalignant and progresses to cancer in approximately 1% of cases.
(D) She requires a hysterectomy.
(E) No further therapy is needed.
5. A 48-year-old woman is referred to you for irregular vaginal bleeding of 6 months’ duration. Her referring physician removed tissue protruding through the cervix 3 months ago. Microscopic examination of the tissue shows a mass with cystic hyperplasia and a central vascular channel
surrounded on three sides by epithelium. The vaginal bleeding has continued. Which of the following is the best way to advise the patient?
(A) Risk of developing endometrial cancer is increased 10-fold.
(B) Bleeding is from an endometrial polyp.
(C) Histology of the tissue may not reflect the source of the bleeding.
(D) Uterus should be probed with a forceps to remove more tissue.
(E) Patient should receive cyclic progestin therapy.
6. A 58-year-old woman on combined estrogen and progesterone hormone replacement has
postmenopausal bleeding. You obtain a pelvic ultrasound that shows an endometrial stripe thickness of 12 mm. Which of the following is most correct?
(A) If the endometrial stripe thickness had been less than 5 mm, you would have told the patient that no further evaluation was needed.
(B) An endometrial stripe thickness of 5 to 10 mm confers no risk of endometrial cancer.
(C) She has a greater than 50% risk of having adenocarcinoma of the endometrium.
(D) The endometrial stripe thickness in premenopausal women is interpreted similar to the endometrial stripe thickness dimensions in postmenopausal women.
(E) Hysterectomy should be performed.
7. An internist calls you for consultation regarding a 55-year-old postmenopausal woman with some vaginal spotting. On examination, a small, round, bright red mass was noted to protrude through the cervical os. It bled during the Pap smear. The Pap smear result was normal. You should advise the internist to do which of the following?
(A) Recheck the mass in 6 months and refer if it enlarges.
(B) Refer the patient for probable polyp removal.
(C) Refer the patient for cone biopsy.
(D) Tell the patient not to worry since the Pap smear is negative.
(E) Tell the patient polyps are never cancerous and refer for removal.
8. A 44-year-old female biochemist has complex hyperplasia without atypia on endometrial biopsy. You prescribe 40-mg megestrol acetate daily. She inquires about the mechanism of action and regression rate. Which of the following explanations is most correct?
(A) The regression of endometrial hyperplasia takes at least 12 months.
(B) Progestins oppose estrogen action in endometrial tissue by reducing the amount of estrogen receptors.
(C) Hyperplastic endometrium has few progesterone receptors so a large dose of progestin is needed.
(D) If regression of endometrial hyperplasia occurs within 3 months, it will recur if she stops the medication.
(E) Progestins bind to progesterone receptors in the endometrium and convert the histology to proliferative endometrium.
9. A 45-year-old woman complains of pelvic pressure and abnormal uterine bleeding. Ultrasound reveals an enlarged uterus with an intramural 4 cm mass. Which of the following is the most common uterine neoplasm?
(A) sarcoma
(B) adenocarcinoma (C) adenomyosis (D) choriocarcinoma (E) leiomyoma
10. During a presentation to a group on women’s health a discussion of gynecologic/reproductive cancers including their etiology risk, factors, and normal clinical course is presented. Which of the following types of cancer is the leading cause of gynecologic/reproductive cancer death in women?
(A) cervical (B) uterine (C) ovarian (D) breast (E) vulva
11. A 69-year-old postmenopausal woman is being admitted for surgical treatment of endometrial cancer.
She has no health insurance and would like to know which is the most important preoperative screening test to look for metastasis?
(A) chest X-ray
(B) hysterosalpingogram (C) pelvic ultrasound
(D) intravenous pyelogram (IVP) (E) barium enema
12. A 58-year-old woman develops postmenopausal bleeding. An endometrial biopsy shows
adenocarcinoma. She undergoes a total abdominal hysterectomy with pelvic lymph node sampling. The final pathology shows tumor extending from the uterus into the cervix but no other invasion (see Figure 22–1). Lymph nodes were negative for metastasis. The cancer is classified as which stage?
Figure 22–1. (A) 0
(B) I
(C) II (D) III (E) IV
13. A patient has just been diagnosed with endometrial cancer by endometrial biopsy. During her counseling regarding the disease, staging, management, and prognosis the patient is told that most endometrial cancers are diagnosed as which of the following stages
(A) I (B) II (C) III (D) IV
(E) recurrent
Questions 14 through 16 apply to the following patient:
A healthy 65-year-old woman is seen for postmenopausal bleeding. The pelvic examination is normal. A fractional D&C demonstrates adenocarcinoma of the endometrium. Histologically, endometrial glands are confluent without solid areas of tumor cells. The endocervical curettage shows normal endocervical cells. The cervical Pap smear and other preoperative investigations are normal.
14. Which of the following statements most likely reflects this patient’s endometrial carcinoma stage or treatment.
(A) Invasion of tumor through most of the myometrium will not be found.
(B) Invasion of tumor into pelvic lymph nodes will not occur.
(C) Steroid hormone receptors will not be present in tumor tissue.
(D) Radical hysterectomy and bilateral salpingo-oophorectomy is the primary treatment modality.
(E) Therapy depends on surgical and histologic evaluation of pelvic viscera, peritoneal cavity, and retroperitoneal lymph nodes.
15. Exploratory laparotomy is negative for metastatic disease. The uterus is opened in the operating room and found to have tumor invasion into the myometrium. Histologic examination of the uterus confirms tumor invasion beyond the inner half of the myometrium. Peritoneal washings and pelvic and para- aortic nodes are negative for malignancy. What should you advise this patient?
(A) no further therapy (B) radiation therapy (C) hormonal therapy
(D) single-agent chemotherapy (E) multiple-agent chemotherapy
16. This patient underwent postoperative radiation. During radiation therapy she develops nausea, anorexia, diarrhea, and mild abdominal pain. Which of the following is the most likely diagnosis?
(A) radiation cystitis (B) radiation enteritis (C) radiation proctitis (D) enterovaginal fistula (E) vaginal ulceration
17. A pulmonary nodule is discovered on the chest radiogram of a healthy 82-year-old woman. Four years ago, she was treated for endometrial adenocarcinoma. Excision of the nodule shows moderately
differentiated endometrial adenocarcinoma-containing progesterone receptors. There is no other evidence of metastatic disease. What should you advise this patient?
(A) exploratory laparotomy (B) lobectomy
(C) radiation therapy (D) brachytherapy (E) progestin therapy
18. A 52-year-old patient undergoes a hysterectomy for a rapidly growing uterine mass. At surgery the frozen biopsy is reported as a sarcoma. What is the most common uterine sarcoma?
(A) leiomyosarcoma
(B) endometrial stromal sarcoma (C) endolymphatic stromal myosis (D) malignant mixed müllerian tumor (E) lymphoma
19. A 55-year-old woman undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a rapidly enlarging pelvic mass. A frozen section is sent, although the pathologist tells you he
cannot distinguish leiomyosarcomas very well on frozen section. Nonetheless, the specimen looks very suspicious. You still have her abdomen open in the operating room. Which of the following statements describes the optimal next step in the evaluation and management for this patient?
(A) Radical parametrectomy should be performed.
(B) Lymphadenectomy should be performed.
(C) Radiation to the pelvis has no effect on pelvic recurrence of sarcoma.
(D) There are no additional benefits from intraoperative radiation, radical surgery, or optimal cytoreduction.
(E) Intraperitoneal radioactive phosphorus (32P) should be considered for treatment.
20. A 40-year-old woman is found on pelvic examination to have an enlarged uterus. Ultrasound reveals a well-circumscribed intramural mass consistent with the leiomyoma. The patient asks: what is the
incidence of sarcomatous degeneration in a uterine leiomyoma?
(A) <1%
(B) 3%
(C) 10%
(D) 15%
(E) 30%
21. Which of the following is a factor predisposing to the development of malignant mixed müllerian tumors?
(A) prenatal exposure to diethylstilbestrol (DES) (B) exposure to mumps virus
(C) family history of ovarian cancer (D) previous pelvic irradiation (E) perineal use of talc
22. A 38-year-old nulliparous woman presents requesting a bilateral salpingo-oophorectomy. Her mother died of ovarian cancer at the age 64, and her sister at the age 48. There is no family history of other cancers. You advise her that her risk of developing ovarian cancer is what percentage?
(A) 1–2%
(B) 7%
(C) 20%
(D) 30–40%
(E) >50%
23. The same patient gets on the Internet and returns asking about the hereditary types of epithelial ovarian cancer. Which of the following statements is true?
(A) A site-specific defect transmitting the trait for only ovarian carcinoma is common.
(B) A BRCA1 gene mutation increases her lifetime risk of ovarian cancer to 10%.
(C) Lynch type II cancer syndrome includes ovarian malignancy.
(D) Fifty percent of ovarian cancer is hereditary.
(E) A BRCA2 mutation increases the risk of ovarian cancer by 70%.
24. A 56-year-old healthy woman develops vague complaints and presents to her primary care physician.
Which of the following accurately describes symptoms that could be associated with a diagnosis of ovarian cancer?
(A) there are no identifiable symptoms in women with ovarian cancer (B) symptoms are usually present for years prior to a diagnosis
(C) shortness of breath and cough (D) diarrhea
(E) urinary urgency and bloating
25. Which of the following is a cornerstone for detection of ovarian neoplasia?
(A) CA-125
(B) human chorionic gonadotropin (hCG) (C) pelvic examination
(D) pelvic ultrasound (E) alpha-fetoprotein
26. Ovarian neoplasms most commonly arise from which of the following cell lines?
(A) ovarian epithelium (B) ovarian stroma (C) ovarian germ cells (D) ovarian sex cords (E) metastatic disease
27. Which of the following postmenopausal women is most protected from ovarian epithelial carcinoma?
(A) a married woman using perineal talc powder
(B) an unmarried woman with a history of breast cancer (C) a nun with a history of late menopause
(D) a nulliparous woman with a history of regular menses
(E) a multiparous woman who used OCPs and now postmenopausal
28. Which of the following statements accurately reflects the natural history of ovarian epithelial carcinoma?
(A) The incidence of ovarian carcinoma increases with age until the seventh decade of life.
(B) Elderly women are less likely than younger women to have disease diagnosed at an advanced stage.
(C) Most women with ovarian cancer do not have any symptoms prior to dissemination of disease.
(D) Seventy-five percent of all ovarian tumors in women older than 50 years are malignant.
(E) Twenty-five percent of all ovarian tumors in women between 20 and 40 years of age are malignant.
Questions 29 and 30 apply to the following patient:
A 35-year-old woman desiring fertility undergoes exploratory laparotomy for a 12-cm pelvic mass. At surgery, a large, lobulated, right ovarian mass is observed. It has a smooth external capsule and a bluish- gray appearance. The uterus, fallopian tubes, and left ovary appear normal. Abdominal exploration is negative for metastatic disease. A right salpingo-oophorectomy is performed. The tumor is opened intraoperatively and found to be divided by septa into lobules. Frozen section of the tumor shows a mucinous cystadenoma of low malignant potential.
29. One would base the remainder of the surgical intervention at this time on which of the following statements regarding mucinous cystadenoma of low malignant potential?
(A) Spread of the tumor outside the ovary occurs 30–40% of the time in the form of intraperitoneal growth of mucin-producing cells.
(B) It has 1–2% incidence of bilaterality.
(C) It has a 5-year survival rate of 60%.
(D) It typically occurs in postmenopausal women.
(E) It comprises atypical epithelial proliferation without stromal invasion.
30. Two days after surgery, you receive the pathology report of the ovarian tumor. It is a mucinous cystadenoma of low malignant potential mixed with well-differentiated carcinoma. The tumor has not invaded the ovarian capsule, lymphatics, or mesovarium. Omental and retroperitoneal lymph node biopsies and peritoneal washings are negative for tumor cells. How do you advise this patient?
(A) biopsy of the contralateral ovary
(B) removal of the uterus and contralateral adnexum (C) postoperative chemotherapy
(D) postoperative radiation therapy (E) no further therapy
31. A 54-year-old healthy woman comes for an annual examination. Her last menstrual period (LMP) was 4 years ago. The physical examination is normal. Pelvic examination shows vaginal atrophy and a small, mobile uterus. The right ovary is 2.5 x 4.5 cm in diameter. The left ovary is nonpalpable.
Vaginal ultrasonography shows that the right ovary is similar in size to that of a premenopausal ovary.
What should you advise this patient?
(A) The ovaries of a postmenopausal woman are usually palpable.
(B) The right ovary of a postmenopausal woman is usually palpable by right-handed examiners.
(C) A palpable ovary in a postmenopausal woman is suspicious for malignancy.
(D) The right ovary is still producing significant amounts of estrogen.
(E) The vaginal ultrasound is an unnecessary diagnostic test.
Questions 32 through 41 apply to the following patient:
A 65-year-old woman has abdominal distention of 3 months’ duration. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination shows a right ad-nexal mass. It is 8 cm in size, nodular, and fixed in the pelvis. The left ovary is nonpalpable. Blood chemistries, urinalysis, cervical Pap smear, mammography, and chest X-ray are normal. Stool gua-iac examination and gastrointestinal studies are also normal. A serum CA-125 level is 250 U/mL (normal, <35 U/mL).
32. Which of the following statements reflects CA-125?
(A) It is a circulating antigenic marker for germ cell ovarian carcinoma.
(B) It is found in normal fetal and adult ovaries.
(C) It is secreted by mesothelial cells of the pleura, pericardium, and peritoneum.
(D) It is not useful in monitoring tumor progression.
(E) It is never elevated in the sera of women with benign diseases.
33. Which of the following is the most likely diagnosis?
(A) gonadoblastoma (B) Meigs’ syndrome (C) Krukenberg’s tumors
(D) serous cystadenocarcinoma (E) endodermal sinus tumor
34. Her surgical treatment should do which of the following?
(A) remove all gross disease if the risk of fatal complications is minimal (B) avoid resection of bowel
(C) be done through a Pfannenstiel incision (D) be done laparoscopically
(E) be done without a bowel preparation
35. Exploratory laparotomy shows a tumor involving the right ovary. The left ovary appears normal.
Several tumor implants are present on the peritoneal surfaces of small bowel and omentum. Biopsies of the peritoneal implants and ovarian tumor show moderately differentiated serous cystadenocarcinoma.
There are no distant metastases, and the liver appears normal (see Figure 22–2). What is the initial intraoperative assessment of stage of the tumor?
Figure 22–2. (A) 0
(B) I (C) II (D) III (E) IV
36. The primary tumor and all metastases are surgically removed. You meet with the patient postoperatively to discuss her prognosis. How do you advise this patient?
(A) The 5-year survival rate with no postoperative chemotherapy is approximately 70%.
(B) The response to chemotherapy is related to the amount of residual disease after surgery.
(C) Older patients achieve results from postoperative chemotherapy superior to those of younger patients.
(D) A second-look operation is performed in patients with incomplete response to chemotherapy.
(E) Few women thought to be free of disease after therapy have disease present at second-look operation.
37. You are called to the operating room by the general surgeons at a local children’s hospital. A 4-year- old girl with acute abdominal pain was thought to have appendicitis; instead, she has a large right ovary. What is the most likely diagnosis?
(A) germ cell tumor
(B) epithelial stromal tumor (C) sex cord-stromal tumor
(D) nonneoplastic follicle or theca lutein cyst (E) metastatic tumor
38. An 18-year-old woman with a history of pelvic inflammatory disease (PID) undergoes a laparoscopic ovarian cystectomy for a 5-cm ovarian mass containing a tooth. The contents of the cyst spill during removal and contain thick sebaceous material and hair. Copious irrigation was used to remove this material. She is noted to have marked bowel adhesions in the pelvis, which require dissection to reach the ovarian cyst. Four days postoperatively she returns to the emergency department with a temperature of 101.1°F, abdominal pain, nausea, and vomiting. White blood cell (WBC) count is 15.0. What is the most likely diagnosis?
(A) ileus
(B) narcotic-induced constipation (C) chemical peritonitis
(D) influenza
(E) bowel perforation
39. An 11-year-old girl presents with abdominal pain, and a right 5-cm solid ovarian mass is found. The alpha-fetoprotein level is elevated. In which of the following ways should you counsel the girl and parents?
(A) Seventy percent of cases are stage I.
(B) The tumor is common and accounts for half of all germ cell tumors.
(C) Bilateral salpingo-oophorectomy is indicated since bilateral tumors are common.
(D) No surgery is indicated until after puberty.
(E) If the tumor is stage I, no further therapy is needed.
40. A 10-year-old girl presents with abdominal pain. During the emergency department workup, an adnexal mass is found. You suspect a germ cell tumor. In preoperative discussion, her parents are told that the most common germ cell tumor is which of the following?
(A) dysgerminoma
(B) endodermal sinus tumor (C) embryonal carcinoma (D) choriocarcinoma (E) mature teratoma
41. A 19-year-old woman with an ovarian mass is thought to have a dermoid or teratoma based on ultrasound findings and gross examination at removal by laparoscopy. At her postoperative visit the pathology returns with the finding of an immature teratoma. Which of the following statements reflects current knowledge about immature teratomas?
(A) They are the most common malignant germ cell tumor.
(B) They are commonly bilateral.
(C) They produce alpha-fetoprotein.
(D) They commonly occur during the first two decades of life.
(E) They contain malignant squamous cell elements.
Questions 42 and 43 apply to the following patient:
A 26-year-old nulliparous woman is seen in the emergency department for acute abdominal pain. Her vital signs are blood pressure, 90/50 mm Hg; pulse, 120 bpm; and temperature, afebrile. Abdominal examination shows right lower quadrant tenderness with rebound. Pelvic examination demonstrates a painful 10-cm right adnexal mass. A serum pregnancy test is negative. A hematocrit is 24% (normal, 35–
45%). Exploratory laparotomy confirms a hemoperitoneum. A smooth right ovarian tumor is bleeding from its ruptured capsule. Inspection of the uterus, fallopian tubes, and left ovary is normal. A right salpingo-oophorectomy is performed. Frozen section of the tumor shows primitive germ cells with intervening connective tissue infiltrated by lymphocytes.
42. The tumor is most likely which of the following?
(A) dysgerminoma
(B) endodermal sinus tumor (C) choriocarcinoma
(D) embryonal carcinoma (E) mature teratoma
43. Which of the following statements reflects current understanding about the above tumor?
(A) It occurs in women of all ages with equal frequency.
(B) It has a bilaterality rate of less than 1%.
(C) It is usually resistant to radiotherapy.
(D) It can occur in combination with other germ cell elements.
(E) It has a poor survival rate following unilateral adnexectomy for stage I disease.