1.

A 17-year-old high school student makes her first visit to the gynecologist and
requests a contraception prescription because she is planning to become sexually
active. Her body mass index is 31, she is not physically active, drinks rarely, and
smokes several cigarettes a day. Her mother died of cervical cancer in her early
50s. She inquires how she can minimize cervical cancer risk. You counsel her that
all of the following would decrease her risk of cervical cancer with the exception
of:
(A) Starting an exercise and weight-loss regimen
(B) Obtaining a human papillomavirus vaccine against strains 6, 11, 16, and 18
immediately
(C) Having routine Pap smear examination after age 21 years
(D) Smoking cessation

2. A 29-year-old recently married woman has a preconception counseling visit,

and a speculum examination shows a 1-cm posterior cervical lesion with a friable
surface. A biopsy showed invasive squamous cell carcinoma with no
lymphovascular invasion (LVI). A PET-CT scan does not reveal any distant
metastases, and pelvic MRI shows that the mass is confined to the cervix only.
She would like to have children. The best next step in her treatment plan is:
(A) A cone biopsy and if negative margins, no further Treatment
(B) Simple hysterectomy, pelvic lymph node dissection, and para-aortic lymph
node sampling
(C) Simple trachelectomy
(D) Radical trachelectomy with pelvic lymph node dissection and possible
para-aortic lymph node sampling
3. A 31-year-old woman, married with 1 child, presents to her gynecologist for
postcoital bleeding. Her pelvic examination demonstrates a cervical lesion of 3
cm. A biopsy shows poorly differentiated squamous cell carcinoma. A PET-CT scan
does not show any distant lesions. An MRI of the pelvis confirms that lesion is
confined to the cervix. She undergoes radical hysterectomy with pelvic lymph
node dissection and para-aortic lymph node sampling. The final pathology shows
a 3.5-cm tumor invading the outer two thirds of the cervix with lymphovascular
invasion. All the nodes are negative and margins are uninvolved with tumor. The
most appropriate next step for the patient is the following:
(A) Surveillance with history and physical (H&P) examination every 3 months and
CT scan as clinically indicated
(B) Surveillance with H&P examination every 3 months and CT scan for chest,
abdomen, and pelvis every 6 months for the first 2 years, than annually for 3years
(C) Adjuvant cisplatin-based chemotherapy
(D) Pelvic radiation therapy with or without concurrent cisplatin sensitization
4. A 50-year-old woman, obese, with diabetes mellitustype II, stage III chronic
kidney disease, and well controlled hypertension has a worsening cough of 3
months’ duration. A chest x-ray shows bilateral pulmonary nodules and a
subsequent CT of the chest, abdomen, and pelvis shows an ill-defined cervical
mass extending into parametria bilaterally and reaching the left pelvic sidewall.
There is also retroperitoneal lymphadenopathy, multiple bilateral subcentimeter
lung nodules, and several lytic lesions in the vertebrae. She has never had a Pap
smear. A biopsy of the cervical mass shows poorly differentiated squamous cell
carcinoma. She has lost 10 kg over the last 6 months and is tired, but still able to
work full time as a bus driver. You counsel her about her incurable condition
and offer palliative chemotherapy. She is very determined to try any treatment
offered. The most appropriate first-line chemotherapy regimen for her is:
(A) Cisplatin, paclitaxel, and bevazicumab
(B) Carboplatin, paclitaxel, and bevacizumab
(C) Topotecan and paclitaxel
(D) Carboplatin, gemcitabine, and bevacizumab
5. A 30-year-old woman has her first well-women examination in 10 years. A
speculum examination shows a 2-cm cervical mass with extension into the upper
third of the posterior vaginal wall. On bimanual examination, there was no
evidence of parametrial involvement. A biopsy shows squamous cell carcinoma.
Her Eastern Cooperative Oncology Group performance status is 0 and she has no
other comorbidities. She is scheduled to have surgery in 2 weeks but meanwhile
she is admitted with back pain. CT scan reveals left-sided hydronephrosis
and lower ureteral obstruction due to lateral expansion of the tumor. No stone is
noted. A percutaneous nephrostomy is placed and her symptoms improve. Her
serum creatinine is 1.0. What is the next most appropriate step in her cervical
cancer treatment?
(A) Proceed with radical trachelectomy, pelvic node dissection, and para-aortic
lymph node sampling
(B) Proceed with radical hysterectomy, pelvic node dissection, and para-aortic
lymph node sampling
(C) Cancel surgery and refer her to a radiation oncologist to proceed with
concurrent pelvic radiation therapy with cisplatin sensitization
(D) Proceed with neoadjuvant chemotherapy with cisplatin-containing doublet
prior to radical trachelectomy, pelvic node dissection, and para-aortic lymph node
sampling
6. A 34-year-old woman has an abnormal Pap smear and normal appearing cervix.
Her colposcopy reveals a very small aceto white lesion, and cervical biopsy is
consistent with well-differentiated squamous cell carcinoma with stromal
invasion to a depth of at least 1 mm. She is newly married and desires to have
children. She undergoes a cold knife conization, which reveals a 5-mm tumor with
stromal invasion of 2 mm. What do you offer her regarding further treatment
options?
(A) Adjuvant chemotherapy with cisplatin, paclitaxel, and bevacizumab
(B) R adical trachelectomy with pelvic node dissection and possible para-aortic
lymph node sampling
(C) Close surveillance with routine Pap smears
(D) Radical hysterectomy with pelvic node dissection and possible para-aortic
lymph node sampling
Answers
1. (A) Starting an exercise and weight loss regimen
2. (D) Radical trachelectomy with pelvic lymph node dissection and possible para-
aortic lymph node sampling
3. (D) Pelvic radiation therapy with or without concurrent cisplatin sensitization
4. (B) Carboplatin, paclitaxel, and bevacizumab
5. (C) Cancel surgery and refer her to radiation oncologist to proceed with
concurrent pelvic radiation therapy with cisplatin sensitization
6. (C) Close surveillance with routine Pap smears
1. It is recommended that a human papillomavirus (HPV) vaccine series be
administered to which of the following patient populations:
A. Only males 9 to 21 years old
B. Only females 9 to 26 years old
C. All sexually active women
D. Males 9 to 21 years old and females 9 to 26 years old
E. It is not recommended as routine vaccination for any patients

2. A 32-year-old woman presents with stage IVB squamous cell carcinoma of the
cervix. Preferred first-line treatment is:
A. Chemotherapy with cisplatin, paclitaxel, and bevacizumab
B. Surgery with radical hysterectomy (uterus, cervix, parametrium, and upper
vagina)
C. Pelvic radiation with chemosensitization
D. Surgery with simple hysterectomy (uterus and cervix only)

4. The majority of cervical cancer worldwide is believed to be secondary to

infection with which strains of the human papillomavirus (HPV)?
A. HPV 6 and 11
B. HPV 16 and 18
C. HPV 34 and 36
D. HPV 56 and 62
ANSWERS
1. D. Males 9 to 21 years old and females 9 to 26 years old. The Centers for
Disease Control and Prevention recommends that an HPV vaccine series
(consisting of three shots) be administered to males aged 9 to 21 and females
aged 9 to 26 years. The preferred age for vaccination is 11 or 12 years old. Males
who are at high risk for HPV infection (homosexual, immunosuppressed) should
receive a vaccination series up to age 26 if they have not been previously
vaccinated.

2. A. Chemotherapy with cisplatin, paclitaxel, and bevacizumab. Systemic

chemotherapy with cisplatin, paclitaxel, and bevacizumab has been shown to
result in improved overall survival, progression-free survival, and overall response
rate when compared to cisplatin and paclitaxel alone in patients with metastatic
or recurrent cervical cancer. Patients with microinvasive cervical squamous cell
cancer (stage IA1) are recommended to undergo a simple hysterectomy.

4. B. HPV 16 and 18. While HPV 6 and 11 are responsible for the majority of
genital and anal warts, HPV 16 and 18 are believed to be associated with ~70% of
cases of cervical cancer. In addition to cervical cancer, HPV infection is believed to
be responsible for 90% of anal cancers; 71% of vulvar, vaginal, or penile cancers;
and 72% of oropharyngeal cancers.