Gynecologic Oncology: Premalignant and Malignant D- 123docz.net

Questions

DIRECTIONS (Questions 1 through 46): For each of the multiple choice questions in this section, select the lettered answer that is the one best response in each case.

1. A 65-year-old woman returns for the results of her vulvar biopsy. Which of the following is the etiologic agent (or immediate precursor lesion) for vulvar cancer?

(A) squamous cell hyperplasia (B) atrophic dystrophy

(E) unknown

2. A 56-year-old woman has a biopsy-proven vulvar intraepithelial neoplasia (VIN III). She undergoes a wide excision and returns 3 months later with vulvar pruritus. What should you advise the patient?

(A) Steroid cream on the vulva will reduce the itching.

(B) She may need a repeat biopsy.

(D) There is minimal chance of recurrence.

(E) If there is a recurrence, it will regress spontaneously.

3. A 65-year-old woman presents with complaints of vulvar redness, pruritus, and occasional weeping from the skin. Examination reveals ery-thematous, eczematoid of the labia minora, and periclitoral area. This is consistent with Paget’s disease of the vulva. Which of the following characterizes Paget’s disease of the vulva?

(A) recurrences are infrequent after treatment

(B) frequent association with other invasive carcinomas (C) appears as a solitary hypopigmented lesion

(D) is treated with laser vaporization

(E) occurs predominantly in premenopausal women

4. Which of the following types of vulvar cancer occurs most commonly?

(A) Paget’s (B) squamous (C) melanoma

(D) adenocarcinoma (E) basal cell

5. A 48-year-old woman presents with a large verrucous lesion of her vulva. It is not particularly painful, but the appearance is worrisome to the patient. Such a lesion is most likely which of the following?

(A) clear cell carcinoma (B) condyloma acuminata (C) adenocarcinoma (D) hidradenoma (E) urethral caruncles

6. Which of the following is the most common symptom of vulvar carcinoma in elderly women?

(A) abnormal bleeding (B) a foul smell

(D) vulvar atrophy (E) painful intercourse

7. A 1-cm vulvar carcinoma with tumor-positive unilateral nodes and no distant spread would be in which FIGO (International Federation of Gynecology and Obstetrics) stage?

(A) I (B) II (C) III (D) IV

(E) cannot be staged without further information Questions 8 through 10 apply to the following patient:

A 58-year-old woman has a 1-cm vulvar ulcer. A biopsy shows invasive squamous cell carcinoma with more than 1 mm of stromal invasion.

8. Which of the following is the preferred treatment?

(A) Burow’s soaks

(B) 5-fluorouracil (5-FU) cream (C) radiotherapy

(D) radical local excision and ipsilateral inguinofemoral lymph node dissection (E) radical hysterectomy and node dissection

9. If the lymph nodes in this case are negative, the 5-year survival should be approximately what percentage?

(A) 12 (B) 25 (C) 52 (D) 78 (E) 90

10. This patient undergoes radical vulvectomy. Which of the following is the most common complication of radical vulvectomy?

(A) debilitating edema of the lower extremities (B) pulmonary embolism

(D) breakdown of the surgical wound

(E) urinary and rectal incontinence

11. A 72-year-old woman has had a radical vulvectomy for stage II squamous cell vulvar cancer. She wants to know the most likely site of recurrence if the tumor comes back. Where would the tumor most likely appear?

(A) at the site of tumor resection (B) in the bladder or rectum (C) in the scalene lymph nodes (D) the chest

(E) the upper leg

12. Which of the following tumors of the vulva has the best prognosis?

(A) stage I verrucous carcinoma (B) melanoma

(E) rhabdomyosarcoma

13. A 56-year-old woman presents with painless mild vaginal spotting. She had a hysterectomy at age 40 for persistent cervical dysplasia. She is otherwise healthy and takes no medications. On further review of symptoms, she has occasional urgency and dysuria. On pelvic examination, a 0.5-cm lesion is felt and visualized in the anterior vagina. What is the next step in the evaluation or treatment of this lesion?

(A) refer to gynecologic oncologist

(B) perform directed punch biopsy of the lesion

(E) order ultrasound of the pelvis

14. A 30-year-old woman presents for her annual examination. On history, she reports that her mother was prescribed diethylstilbestrol (DES) during the pregnancy with her. Which of the following conditions is she most at risk for as a result?

(A) endometrial adenocarcinoma (B) ovarian adenocarcinoma

(E) fallopian tube adenocarcinoma

15. Which of the following is a malignant tumor of the vagina of young children that appears clinically as a mass of grape-like edematous polyps?

(A) emphysematous vaginitis (B) squamous cell carcinoma (C) sarcoma botryoides (D) adenocarcinoma (E) choriocarcinoma

Questions 16 through 18 apply to the following patient:

A 72-year-old woman complains of vaginal bleeding. On evaluation, a 2-cm vaginal lesion is found in the upper third of the anterior vagina. On bimanual and rectovaginal examination, the mass extends to the lateral pelvic wall. On biopsy, vaginal carcinoma is confirmed.

16. What stage cancer does this patient most likely have?

(A) 0 (B) I (C) II (D) III (E) IV

17. Which of the following is the most likely histology of vaginal carcinoma in this woman?

(A) melanoma (B) verrucous (C) clear cell

(D) adenocarcinoma (E) squamous cell

18. Which of the following is the best treatment for her?

(A) total vaginectomy (B) upper vaginectomy (C) chemotherapy

(D) combination radiation and chemotherapy (E) exenteration

19. Which of the following is the most common method used to diagnose cervical intraepithe-lial neoplasia (CIN)?

(A) complaints of abnormal discharge (B) postcoital bleeding

20. Which of the following reflects the etiology of cervical dysplasia and cervical cancer?

(A) Human papillomavirus (HPV) is the major causal agent.

(B) They are associated with obesity.

(D) There is a strong genetic component to the development of cervical cancer.

(E) They are the direct result of cigarette smoking.

21. Which of the following reflects HPV?

(A) Only 20% of sexually experienced women will be infected with HPV.

(B) The virus is transient for most women.

(D) Other cofactors such as cigarette smoking and altered immune response have not been shown to be related to the development of cervical neoplasia.

(E) There are only 10 subtypes of HPV identified to date.

Questions 22 through 26 apply to the following patient:

A 40-year-old woman is seen for a routine examination. Her menses have been regular, and she has no complaints. Findings, including those on pelvic examination, are normal. Ten days later, her Pap smear is returned as “high-grade squamous intraepithelial lesion.”

22. Which of the following options is the best course of action?

(A) immediate wide-cuff hysterectomy

(B) repeated Pap smears at 3-month intervals (C) fractional dilation and curettage (D&C) (D) punch biopsy of anterior cervical lip (E) colposcopy with biopsy

23. The colposcope permits one to do which of the following?

(A) view the cervix at 1–4 power magnification (B) see the entire transition zone in all patients

(E) make the diagnosis of cancer

24. Under colposcopic examination, a distinct area of acetowhite change is noted with associated coarse pattern vessels and punctation. This is consistent with what histologic finding on directed biopsy?

(A) CIN I (B) atrophy

(E) a nabothian cyst

25. Conization of the cervix would be inappropriate in which of the following instances?

(A) when there is disparity between Pap smear and biopsy results (B) when colposcopy is inadequate

(D) when deeply invasive cancer is shown on a biopsy (E) for treatment of biopsy-proven CIN III

26. This patient has biopsy-proven CIN III. She requests cryotherapy for treatment. Cryotherapy is appropriate to consider in which clinical circumstance?

(A) CIN III

(B) a patient with well-circumscribed, small lesion of mild dysplasia (CIN 1) (C) invasive carcinoma

(D) a patient who wishes to preserve fertility (E) an HIV-positive patient

27. A 25-year-old woman presents with irregular vaginal bleeding. She is otherwise healthy and uses condoms for contraception. She smokes occasionally and takes no medications. Her aunt had cervical cancer and she is worried that she may also have cervical cancer. What is the most common symptom associated with cervical cancer?

(A) no symptom

(B) pain with intercourse (C) vaginal bleeding (D) weight loss (E) vulvar pruritus

28. When sampling the cervix for a Pap smear, it is critical to sample which area since it is the most likely source of cervical cancer. Where do most cervical cancers arise?

(A) on the portio vaginalis (B) at the internal os

(D) at the squamocolumnar junction (E) at the external os

29. What percentage of clinical stage I carcinomas of the cervix will have lymphatic spread?

(A) 0–1 (B) up to 7 (C) 15 (D) 25 (E) 40

30. If a nonhealing ulcer is seen on the cervix, it is best evaluated by which of the following?

(A) repeat examination (B) Pap smear

(E) vaginal steroid cream

Questions 31 and 32 apply to the following patient:

A 48-year-old woman presents for her routine annual examination. Her last Pap smear was more than 10 years ago. She has had occasional abnormal Pap smear during her lifetime, but no treatments were recommended. Otherwise, she has mild hypertension and is on a beta-blocker. On examination, she has a normal pelvic examination, but her Pap smear reveals high-grade squamous intraepithelial lesion (SIL). A colposcopically directed biopsy reveals invasive squamous cell carcinoma.

31. Which of the following should be the most appropriate next step in the care of the patient?

(A) metastatic evaluation (B) conization

(E) both irradiation and radical hysterectomy

32. The woman had a negative metastatic workup. Her clinical examination shows cancer growth shown in Figure 21–1. Her preliminary clinical stage is which of the following?

Figure 21–1. (A) IA

(B) IB (C) IIA (D) IIB (E) III

33. The majority of deaths from cervical carcinoma are due to which of the following?

(A) local spread obstructing the ureters, causing renal failure (B) brain metastasis with resultant cerebral hemorrhage

(C) hemorrhage into the pelvis from erosion of vessels by the tumor (D) pulmonary failure secondary to metastatic disease filling the lungs (E) bone metastasis causing crush injuries to the central nervous system

34. The 5-year survival rate for stage IV invasive cervical cancer is approximately what percentage?

(A) >1 (B) 15 (C) 30 (D) 50 (E) 80

35. Which of the following is the best term for a bulky, friable, papillary tumor mass growing from the cervix?

(A) exophytic (B) endophytic (C) nodular (D) ulcerating (E) edematous

36. A 34-year-old woman G1 is 16 weeks pregnant and has a Pap smear suspicious for cancer. How do you advise her?

(A) have colposcopy with biopsy

(B) have colposcopy, but biopsy is too risky in pregnancy

(D) undergo a termination of pregnancy and then undergo complete evaluation (E) have cervical conization

37. A 65-year-old woman presents with vaginal discharge and rare mild bleeding. She had a cone of the cervix for CIN III 20 years ago. She has since had a complete hysterectomy for uterine fibroids. You perform a pelvic examination and see an irregular area in the vagina. Vaginal col-poscopy and directed biopsy reveal vaginal intraepithelial neoplasia (VAIN). VAIN is most commonly found in which part of the vagina?

(A) the upper one-third (B) the mid-vagina (C) the distal vagina (D) at the hymenal ring (E) the posterior fourchette

38. The preferred treatment for a 1.5-cm stage I vaginal carcinoma confined to the upper one-third of the lateral vagina in a 29-year-old woman would be which of the following?

(A) intravaginal 5-FU (B) upper vaginectomy

(D) radical hysterectomy, bilateral pelvic lymphadenectomy, and upper vaginectomy (E) anterior exenteration

39. A 42-year-old presents with a history of post-coital spotting. Examination of the cervix reveals a raised/reddened well-circumscribed lesion next to the os. Which of the following is the most likely diagnosis?

(A) carcinoma (B) condyloma lata (C) ectropion (D) cervical polyp (E) nabothian cyst

40. The treatment of carcinoma of the cervix during pregnancy should depend on all except which of the following?

(A) the recommendation of the oncologist

(B) the religious and moral beliefs of the patient (C) the trimester of the pregnancy

(D) the stage of the lesion (E) the length of the cervix

41. A 42-year-old woman with cervical cancer undergoes a radical hysterectomy and requires postoperative radiation. During the radiation therapy she returns complaining of watery vaginal discharge and recurrent urinary tract infections. Which of the following would be the first test to perform to evaluate the most likely cause of the discharge?

(A) intravenous pyelogram (IVP) (B) cystoscopy

(D) sigmoidoscopy

(E) inject diluted methylene blue in sterile water into the bladder and examine the vagina

42. A 35-year-old woman with stage IIB squamous cell carcinoma of the cervix will receive radiation.

Regarding reproductive changes, how should you advise her?

(A) Ovaries are radioresistant.

(B) Fertility is maintained.

(D) Younger patients are more susceptible to radiation-induced castration.

(E) There is no change in vaginal function.

43. A 46-year-old obese woman smokes two packs of cigarettes a day. She had a radical hysterectomy with a para-aortic and pelvic lym-phadenectomy for stage IB squamous cell carcinoma of the cervix.

At surgery she was found to have dense pelvic small-bowel adhesions from a prior ruptured appendix and appendectomy. Lymph nodes were positive for cancer cells. In discussing postoperative radiation, you counsel her that she has an increased rate of radiation-related complication because of which of the following?

(A) obesity

(B) excision of lymph nodes

(E) stage of the cancer

44. A 24-year-old healthy woman has her routine examination and Pap smear. Her Pap smear is atypical squamous cells of undetermined significance (ASCUS). Which of the following reflects our current knowledge about ASCUS?

(A) the risk of CIN II or III on biopsy is 1%

(B) the risk of invasive cervical cancer is 0.1%

(E) is not associated with high-risk HPV subtypes

45. A 48-year-old postmenopausal woman presents for routine gynecologic examination. The examination is normal; however, the Pap smear returns atypical glandular cells (AGCs). What would be the most appropriate management for this patient?

(A) repeat Pap smear in 4 to 6 months

(B) treat with intravaginal estrogen and repeat Pap smear (C) perform cone biopsy of the cervix

(D) perform colposcopy, cervical and endometrial biopsies (E) refer to Gynecologic Oncology

46. A 30-year-old woman presents for her annual examination. She inquires whether she should receive the HPV vaccine. For which patient population is the HPV vaccine FDA approved?

(A) women of all ages

(B) only women who are virginal and have never had an abnormal Pap smear (C) men, for the prevention of female cervical dysplasias and cancer

(D) girls and women aged 9 to 26 years

(E) for pregnant or lactating women

Answers and Explanations

1. (E) The etiologic agent for vulvar carcinoma is unknown. Vulvar diseases (squamous cell hyperplasia, previously known as hyperplastic dystrophy, sexually transmitted diseases, gran-ulomatosis diseases) are all associated with an increased incidence of vulvar cancer, but none are considered the cause. The majority arise within squamous epithelium. For squamous cell carcinoma, high-risk HPV infection is found in 40% of cases.

2. (B) VIN can certainly recur, although it has a much longer transition time than CIN. Some VINs may regress spontaneously, but this is not guaranteed. VIN can be multifocal, and approximately 20% of patients with an initial biopsy of VIN III have been reported to have microinvasive cancer in the resected specimen. Steroid cream is the treatment of choice for pruritus from vulvar dystrophies, but this woman needs a vulvar examination and possible biopsy to rule out recurrence.

3. (B) Paget’s disease may be identified by the typical vacuolated, large, pale, mucin-containing cells infiltrating the epidermis, often in a serpig-inous manner (Paget cells). It presents typically with pruritus and appears as diffuse erythema-tous eczematous change of the vulva. The gynecologist must be vigilant to evaluate the rest of the vulva and cervix, as well as the breast and GI track as frequently other carcinomas coexist. Treatment consists of full-thickness wide excision with a 1-cm margin

around the visible lesion. Recurrences are common and require regular surveillance examinations. This disease typically affects women aged 60–70 years.

4. (B) Cancer of the vulva makes up approximately 5% of all gynecologic malignancies, and

approximately 90% of vulvar cancer is squamous cell. Paget’s disease is an intraepithelial lesion derived from an undifferentiated glandular cell. Extramammary Paget’s disease is most often an intraepithelial lesion that may spread over the perineum. Adenocarcinoma probably arises from glandular structures of the vulva and comprises <1% of all vulvar carcinomas. Malignant melanoma can occur over any skin area but is relatively rare in the vulva (approximately 5% of cases).

5. (B) At age 48, this lesion is most likely condy-loma acuminate or genital wart. These are due to HPV and typically range from flat papules to raised irregular verrucous exophytic lesions. However, it could be verrucous carcinoma, which is a locally invasive tumor that does not tend to metastasize via the lymphatics. Clear cell carcinoma and adenocarcinoma are much less likely and carcinoma in general presents with erythema, pruritus. If any doubt exists, adequate biopsy should be done. Hidradenomas typically start as a nodule and can form an abscess. They are often uncomfortable and can be found within intertriginous areas. Urethral caruncles originate from the urethral meatus, not on the vulva 6. (C) Pruritus is the presenting complaint in over one-half of patients. Twenty percent are asymptomatic,

and the remainder may have pain, bleeding, or a foul smell from tumor necrosis. Atrophy is not usually a complaint.

7. (C) The tumor could be of any size, but the positive unilateral nodes place the lesion in stage III. In the Tumor, Node, Metastasis (TNM) staging, T1N1M0. The TNM system seems to be more prognostic than the FIGO system.

8. (D) This patient has a stage IB vulvar carcinoma (if the invasion is >1 mm, the stage is IB instead of IA). In IB, there is an 8% incidence of positive ipsilateral nodes. Deep pelvic nodes are excised only if the others are positive, and there is little salvage demonstrated by removing these deep pelvic lymph nodes. If the lesion was central in the vulva or crossed the midline, bilateral lymph node dissection would be warranted.

9. (E) If multiple inguinal nodes are positive, the cure rate drops to less than 15%, and if the deep nodes are involved, the cure rate is very low. This illustrates the importance of the lymphatic route of spread in this disease and the importance of extirpative surgery in treating the disease. Before radical surgery, almost no one survived this disease. Survival for stage II is 67%, stage III is 40%, and stage IV is 22%.

10. (D) While all of the choices may be complications of radical vulvectomy, approximately 50% of the patients experience significant problems with wound healing. This is because of the large amount of tissue removed and the poor blood supply of the remaining tissues. Patients often spend 2 or more weeks in the hospital just for the postoperative care of their wounds. Leg edema is also common, and incontinence of urine is not unusual (likely due to resection of the distal third of the urethra), but neither is as frequent as wound problems.

11. (A) The most common site of recurrence is the site of the primary surgical resection or the groin area where nodes were positive (if not previously resected). The tumor occurs centrally and seldom as distant metastases.

12. (D) Pure basal cell tumors can be cured by wide excision. The other tumors are all treated as invasive carcinomas with radical surgery. Rhabdomyosarcomas are found in young patients, are extremely

malignant, and, fortunately, are very rare.

13. (B) Vaginal bleeding is the most common complaint in women diagnosed with vaginal cancer however, most vaginal cancers are asymptomatic and not visible to the unaided eye on routine examination nor palpable to the average examiner. If a lesion is seen or palpated on examination, immediate directed biopsy is indicated to make a diagnosis. If no lesion is apparent, Papanicolaou screening and vaginoscopy are useful for further evaluation of the vagina. Ablative therapy, like laser, would not be appropriate until a diagnosis is established and no malignancy is found. A referral to Gynecologic Oncology would follow once a diagnosis of cancer is made.

14. (C) Epithelial endometrial, ovarian, and fallopian tube cancers are not linked to DES exposure.

Vaginal clear cell or adenocarcinoma is quite rare, but it is increased in the offspring of women who took DES (incidence estimated at 1 per 1,000 exposed female fetuses). In addition, cervical SILs and squamous cell cancer are also increased in DES-exposed women. Other reproductive tract

abnormalities associated with DES include adenosis (columnar irregular cells in the vagina), T-shaped uterus, endometrial adhesions, and transverse vaginal septum.

15. (C) This highly malignant tumor of the vagina is fortunately rare but must be thought of whenever vaginal bleeding or discharge occurs in a young female patient. A small scope or examination under anesthesia may be used for diagnostic purposes. Sarcoma botryoides, so called because of its

sometimes grape-like gross appearance. This is a highly aggressive tumor but multimodal therapy with surgery, chemotherapy, and radiation has increased survival to 75%.

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