23 yo female p/w 2 day hx of pelvic pain and a 3cm left adnexal mass.

What should be done

next?

a. CT
b. Surgery
c. UPT
d. Observation
e. U/S

c. UPT

(bc shes a premenopausal woman; then, do an ultrasound)

U/S describes a 2.5 cm cystic mass from left ovary suggestive of benign endometrioma. Pain
improves with ibuprofen. Treat with:

a. Immediate surgery
b. Repeat U/S in 4-6 wks
c. Refer to gyn oncologist
d. CT scan

b. Repeat U/S in 4-6 wks

(its a chocolate cyst!)

4 wks later the pain has worsened, UPT is still negative, U/S notes 5 cm left adnexal mass with
free fluid in pelvis. There is rebound and guarding. Treat with:

a. Narcotics
b. Surgery
c. Reassurance and check in 4 wks

b. Surgery
56 yo p/w abdominal bloating and ascites. CT shows omental caking and b/L adnexal masses.
Which tumor marker is most likely elevated?

a. HCG
b. LDH
c. AFP
d. CA125

d. CA125
Surgery confirms Stage 3c ovarian serous cystadenocarcinoma. What screening can be done for
the family?

a. Annual pelvic U/S

b. CA125
c. Both every 2 yrs
d. None, there is no definitive screening test at this time

d. None
Mom had breast cancer at 40 yo and grandma had ovarian cancer at 35 yo. No family hx of
colon cancer. Which test should be done?

a. Serum BRCA
b. MSH/MLH
c. C-kit

a. Serum BRCA
Most common gyn cancer in U.S.?

Endometrial Cancer
Most fatal gyn cancer in U.S.?

Ovarian Cancer
Risk of progressing to endometrial cancer from endometrial hyperplasia:

a. Complex w/atypia

b. Simple w/o atypia

c. Complex w/o atypia

a. 25%

b. 1%

c. 5%

("penny, nickel, dime, quarter")

What are the general screening recommendationsfor endometrial cancer?

a. Transvaginal U/S
b. EMB every 1-2 yrs
c. None
d. Transvaginal U/S + EMB per year

c. None

(if pt has Lynch syndrome, do EMB every 1-2 yrs)

What histologic type has lowest risk of recurrence?

a. Uterine papillary serous carcinoma

b.Carcinosarcoma
c. Grade 3
d. Clear cell
e. Grade 1 endometrioid endometrial carcinoma

e. Grade 1 endometrioid endometrial carcinoma

To determine if adjuvant tx, all of these variables should be considered except:
a. Histology
b. Uterine size
c. Age
d. Depth of invasion
e. Spread of disease

b. Uterine size

(if the pt has any of the rest, it is considered hi risk)

A 32-year-old woman had a firm nodule palpable on her uterus three years ago noted on a
routine physical examination. The nodule has slowly increased in size and is now about twice
the size it was when first discovered. She is asymptomatic. Which of the following does this
patient most likely have?

A. Adenocarcinoma
B. Leiomyosarcoma
C. Rhabdomyosarcoma
D. Leiomyoma

D. Leiomyoma

The nodule grew slowly, and the patient is asymptomatic. Malignant tumors (A - C) would be
more likely to grow quickly and produce nasty symptoms.
A 36-year-old woman finds a lump in her right breast. Her physician notes a 4 cm firm, irregular,
fixed mass in the upper outer quadrant of her right breast. A fine needle aspiration is
performed, and the findings are consistent with infiltrating ductal carcinoma. The mass is
removed, and a sentinel lymph node dissection is performed. Which of the following findings
will best predict a better prognosis for the patient?

A. The patient has concurrent ductal carcinoma in situ in the same breast
B. The sentinel node is negative for tumor
C. The patient has a sister who had a similar type of breast cancer
D. The tumor has a high grade
B. The sentinel node is negative for tumor

Prognosis in breast cancer is determined primarily on the stage of the tumor (how far it has
spread) - so a negative sentinel node is a good prognostic sign. Concurrent ductal carcinoma in
situ (DCIS) would tend to make the prognosis a bit worse - because DCIS is a precursor to
invasive carcinoma. A family history would tend to worsen the prognosis (familial breast cancer
tends to be more aggressive than the sporadic type). The grade of a tumor also has a bearing on
prognosis - higher grade tumors tend to be more aggressive (carry a worse prognosis).
Prognostic factors in invasive breast carcinoma include all of the following EXCEPT:

A. Tumor size
B. Type of carcinoma (ductal, inflammatory, etc.)
C. Location of primary tumor within breast
D. Lymph node involvement by tumor
E. Grade of tumor

C. Location of primary tumor within breast

Staging (which involves the size of the tumor (T), the presence of lymph node metastases (N)
and distant metastases (M)) is very important in prognosis. The grade of the tumor (which is
determined by looking under the microscope and seeing how differentiated the tumor is, and
how mitotically active it is) is also important (but a little less so than staging). Some variants of
breast carcinoma (like inflammatory breast carcinoma) have a particularly bad prognosis - so
this information is important too. It doesn't really matter where the tumor is in the breast.
All of the following are true regarding fibroadenoma EXCEPT:

A. It is the most common benign tumor of the female breast

B. More common in younger women
C. May enlarge late in the menstrual cycle and during pregnancy
D. Is an important risk factor for breast carcinoma
E. Usually presents as a solitary, moveable mass.

D. Is an important risk factor for breast carcinoma

A, B, and E are pretty self-explanatory. C is correct because sometimes fibroadenomas (and

leiomyomas, for that matter) seem to respond to hormonal stimulation. D is incorrect -
fibroadenomas are completely benign and do not turn into (or predispose the patient towards)
carcinoma.
Which of the following neoplasms is derived from all three germ layers?

A. Carcinoma
B. Teratoma
C. Sarcoma
D. Apudoma
B. Teratoma

Teratomas can happen in men or women. Tissues from all three germ layers (endoderm,
mesoderm and ectoderm) must be present in order to call a tumor a teratoma. You remember
what carcinomas and sarcomas are (malignancies of epithelial and mesenchymal origin,
respectively). Apudomas are endocrine tumors that arise in APUD cells (neural crest cells that
make hormones like secretin and cholecystokinin; APUD stands for amine precursor uptake and
decarboxylation). Such tumors can be found in the ampulla of Vater, pancreas and prostate.
All of the following are true of endometrial carcinoma EXCEPT:

A. Most cases occur in postmenopausal women

B. it is caused by prolonged stimulation of the endometrium by progesterone
C. It is preceded by endometrial hyperplasia in most cases
D. It can metastasize via lymphatic and/or hematogenous routes
E. The most important prognostic factor is the stage of the tumor

B. it is caused by prolonged stimulation of the endometrium by progesterone

A and D are pretty self-explanatory. B is incorrect because it is not stimulated by progesterone,

but estrogen (tricky, I know). C is correct; most cases do arise in a background of endometrial
hyperplasia. However, remember that hyperplasia in and of itself is not pre-neoplastic (there
are many, many cases of hyperplasia that never go on to become carcinoma). E is correct; the
depth of invasion (and presence or absence of metastases) - which is basically the stage of the
tumor - is the most important factor in prognosis.
All of the following are true of squamous cell carcinoma of the cervix EXCEPT:

A. It is preceded by squamous cell dysplasia in most cases

B. It is caused by human papillomavirus (HPV)
C. Early age at first intercourse is a risk factor
D. Most cases occur in women over 65
E. The Pap smear is an important screening test

D. Most cases occur in women over 65

HPV is the causative agent of carcinoma of the cervix (or at least, it's the most important
causative agent - there may be additional factors, like smoking, which play a role). So anything
that increases one's risk of acquiring the virus - such as an early age at first intercourse - will
increase the risk of carcinoma. Squamous cell carcinoma is preceded by dysplasia in the cervical
epithelium (high-grade dysplasia carries the greatest risk of turning into invasive carcinoma;
low-grade dysplasia may revert to normal). The Pap smear is great because it can detect these
dysplastic changes well before carcinoma develops, allowing for early intervention and
prevention of carcinoma. D is incorrect; most cases occur in younger women.
Which of the following is true regarding ovarian neoplasms?
A. Most are malignant
B. They usually present while still small (<1 cm)
C. They may interfere with fertility
D. They are very rare
E. Most arise from germ cells

C. They may interfere with fertility

Ovarian neoplasms are pretty common (so D is wrong). Most are benign (so A is wrong) and
arise from the surface epithelium of the ovary (so E is wrong). They often grow to great
proportions before presenting with symptoms (because the ovary is really just a tiny thing
floating out there in the peritoneal space - so a tumor of the ovary can get pretty big before
you'd notice that anything was wrong). C is correct - any time you mess with the ovary
(whether it's a benign tumor, a malignant tumor, or endometriosis), you can impact fertility.
Mrs. B comes to your office complaining of progressively painful menstrual periods. She has
had 2 previous pregnancies, one of which delivered at term, and the other at 34-weeks
gestation, but otherwise has no medical or surgical issues. Her menses last for 6 days with the
heaviest flow on Day 1. The LEAST likely explanation for Mrs. B's complaints is:

a. Fibroids
b. Endometriosis
c. Uterine septum
d. Adenomyosis

c. Uterine septum
The term "dysfunctional uterine bleeding" implies the presence of:

a. Menstrual outflow obstruction

b. Endometrial hyperplasia
c. Endometrial polyps
d. Fibroids
e. No anatomic abnormality

e. No anatomic abnormality
In the treatment of anovulation/failure to ovulate, often medications are used that are
primarily used in the treatment of:

a. Hyperthyroidism
b. Osteoporosis
c. Hypercalcemia
d. Diabetes
e. Migraine Headaches
d. Diabetes
Ovulation predictor kits work by measuring what substance or metabolite in the
urine?

a. Estriol
b. LH
c. FSH
d. Progesterone

b. LH
The main reason screening asymptomatic women for endometrial cancer is NOT cost-effective
is that:

a. No effective treatment is available

b. Endometrial biopsy requires hospitalization
c. There is low prevalence of disease
d. Most patients are symptomatic with early stage of disease
e. High false-positive rate of histologic interpretation

d. Most patients are symptomatic with early stage of disease

Which of the following is a risk factor for endometrial carcinoma?

a. Smoking
b. Obesity
c. Long term use of oral contraceptives
d. IUD usage for 7 years
e. Early menopause

b. Obesity
Which of the following physical or sonographic characteristics is associated with an
increased risk of malignancy in an ovarian neoplasm?

a. Unilateral
b. Cystic
c. Intraluminal nodularity
d. Smooth contour
e. Mobile

c. Intraluminal nodularity
What is the primary site of the deadliest form of gynecologic cancer in the U.S.?

a. Cervix
b. Uterus
c. Ovary
d. Vulva tube

c. Ovary
34 year old female presents for her well women exam. She has a pap smear which shows
ASCUS. Which of the following is an appropriate next step in care?

a. Do nothing
b. Proceed with colposcopy
c. Schedule her for a LEEP (excisional biopsy)
d. Schedule her for hysterectomy

b. Proceed with colposcopy

The highest risk of developing squamous cell carcinoma of the cervix is associated with which of
the following Pap results:

a. ASCUS
b. LSIL
c. HSIL
d. Positive for HPV Type 16, but negative cytology
e. Negative for HPV Type 16, with negative cytology

c. HSIL
The most common site of distant metastases from breast carcinoma is:

a. Abdominal viscera
b. Uterus
c. Lungs
d. Brain
e. Bone

e. Bone
Which of the following forms of breast cancer has the overall best prognosis for long-term
survival?

a. Infiltrating ductal carcinoma

b. Infiltrating lobular carcinoma
c. Inflammatory carcinoma
d. Medullary carcinoma
e. Tubular carcinoma

e. Tubular carcinoma
Which of the following is NOT a typical side effect for injectable medroxyprogesterone acetate?

a. Breakthrough bleeding
b. Delayed return of ovulation when drug is stopped
c. Decreased bone density
d. Increased risk of endometrial hyperplasia
e. Bloating sensation

d. Increased risk of endometrial hyperplasia

A 23-year-old dental assistant seeks contraception. She reports moderate acne and irregular
periods for the past 3 years. She is a long distance runner with a small skeletal frame. She has
normal vital signs and her pelvic exam is normal. The best contraceptive option for her is:

a. Diaphragm
b. Oral contraceptive pills
c. Tubal ligation
d. Injectable medroxyprogesterone acetate (Depo-Provera)
e. Rhythm method

b. Oral contraceptive pills

What is the typical effect of menopause on Estrogen?

a. Serum levels increase

b. Serum levels decrease
c. No significant change in serum levels

b. Serum levels decrease

Mrs. Valenzuela is an 51 year female who was recently diagnosed with breast cancer. She has
not had a menstrual cycle in 1 year and has recently begun to experience severe hot flashes.
Which of the following medications is not appropriate for the treatment of Mrs. Valenzuela's
hot flashes?

a. Paroxetine
b. Oral estrogen/progesterone hormone replacement
c. Clonidine
d. Gabapentin
e. Vitamin B6

b. Oral estrogen/progesterone hormone replacement