Professional Documents
Culture Documents
oncology
(vulvar, vaginal, cervical and
endometrial neoplasms)
Vulvar malignancy
Vulvar malignancy, the comments
facts
etiology Unknown
Most common type Squamous cell carcinoma – associated with HPV in 40% of cases
Other types Basal cell carcinoma – best prognosis, can be cured by wide excision
Melanoma
Paget’s disease – coexistence of other invasive tumors (cervical, ovarian, bladder, GI, breast)
Bartholin gland adenocarcinoma
Sarcoma – rare yet malignant, found in young patients
Classic presentation Symptoms: labial Pruritus (most common), blood discharge, postmenopausal bleeding
Signs: small ulcerated lesions, large cauliflower-like lesions on the labium
Lymphatic involvement The vulvar area drains first to the superficial inguinal lymph nodes, then to the deep inguinal lymph
nodes and later to the iliac nodes
management 1st step of management: excisional biopsy
• Unilateral and no lymph node involvement and <2cm: modified radical vulvectomy (radical local
excision) and ipsilateral inguinal lymphadenectomy (lymph node dissection)
• Bilateral involvement or > 2cm: radical vulvectomy and bilateral inguinal lymph node dissection
• Lymph node involvement (positive after dissection): deep pelvic lymphadenectomy
(A) Paget’s
(B) squamous
(C) melanoma
(D) adenocarcinoma
(E) basal cell
Which of the following types of vulvar cancer occurs most
commonly?
(A) Paget’s
(B) squamous
(C) melanoma
(D) adenocarcinoma
(E) basal cell
Which of the following tumors of the vulva has the best
prognosis?
a. Chemotherapy
b. Radiation therapy
c. Simple vulvectomy
d. Radical vulvectomy
e. Radical vulvectomy and bilateral inguinal lymphadenectomy
A woman is found to have a unilateral invasive vulvar carcinoma that is
2 cm in diameter but not associated with evidence of lymph node
spread. Initial management should consist of which of the following?
a. Chemotherapy
b. Radiation therapy
c. Simple vulvectomy
d. Radical vulvectomy
e. Radical vulvectomy and bilateral inguinal lymphadenectomy
A 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
(C) necrotizing fasciitis
(D) breakdown of the surgical wound
(E) urinary and rectal incontinence
Radical vulvectomy
a. Marsupialization
b. Administration of antibiotics
c. Surgical excision
d. Incision and drainage
e. Observation
A 58-year-old woman is seen for evaluation of a swelling in
her right vulva. She has also noted pain in this area when
walking and during coitus. At the time of pelvic examination, a
mildly tender, fluctuant mass is noted just outside the
introitus in the right vulva in the region of the Bartholin
gland. Which of the following is the most appropriate
treatment?
a. Marsupialization
b. Administration of antibiotics
c. Surgical excision
d. Incision and drainage
e. Observation
A 21-year-old G0P0 healthy college student presents to
Student Health Center, complaining of severe vulvar puritius.
She has a BMI of 24, uses condoms with coitus, and finished
her last menses 4 days prior. Last month she was diagnosed
with and successfully treated for manila vaginitis. She denies
any other symptoms including vaginal discharge. What is the
most likely diagnosis?
(A) melanoma
(B) verrucous
(C) clear cell
(D) adenocarcinoma
(E) squamous cell
Histologic subtypes of vaginal cancer
(A) melanoma
(B) verrucous
(C) clear cell
(D) adenocarcinoma
(E) squamous cell
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) 0
(B) I
(C) II
(D) III
(E) IV
Vaginal cancer staging
(A) 0
(B) I
(C) II
(D) III
(E) IV
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. Which of the following
is the best treatment for her?
• Stage I and II > 4cm AND stage III and IV -> combination chemo +
RAD
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 (stage
III). On biopsy, vaginal carcinoma is confirmed. Which of the
following is the best treatment for her?
(A) >1
(B) 15
(C) 30
(D) 50
(E) 80
Survival rate of cervical cancer
Number of Overall survival (percent)
FIGO stage
patients One year Two years Five years
IA1 829 99.8 99.5 97.5
IA2 275 98.5 96.9 94.8
IB1 3020 98.2 95.0 89.1
IB2 1090 95.8 88.3 75.7
IIA 1007 96.1 88.3 73.4
IIB 2510 91.7 79.8 65.8
IIIA 211 76.7 59.8 39.7
IIIB 2028 77.9 59.5 41.5
IVA 326 51.9 35.1 22.0
IVB 343 42.2 22.7 9.3
Five-year survival:
I = 80% to 93%
II = 58% to 63%
III = 32% to 35%,
IV = 15% to 16%.
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
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?
• On colposcopy: an “acetowhite” appearance with punctate vessels strongly suggest moderate to severe dysplasia (CIN II or III)
if biopsy proves invasive neoplasm, do a metastatic workup (CXR, IV pyelogram, Sigmoidoscopy etc. – the main cause of death is
local spread to ureter thus causing renal failure)
Malignancy characteristics Lymphatic Spreading route (by order): paracervical, parametrial, obturator, hypogastric, external iliac, and sacral nodes
A 22-year-old G3P0030 obese female comes to your office for a routine gynecologic
examination. She is single, but is currently sexually active. She has a history of five sexual
partners in the past, and became sexually active at age 15. She has had three first-
trimester voluntary pregnancy terminations. She uses Depo-Provera for birth control, and
reports occasionally using condoms as well. She has a history of genital warts, but denies
any prior history of abnormal Pap smears. The patient denies use of any illicit drugs, but
admits to smoking about one pack of cigarettes a day. Her physical examination is
normal. However, 3 weeks later you receive the results of her Pap smear, which shows a
high-grade squamous intraepithelial lesion (HGSIL). Which of the following factors in this
patient’s history does not increase her risk for cervical dysplasia?
a. Cervix
b. Ovary
c. Breast
d. Vagina
e. Colon
A pregnant 35-year-old patient is at highest risk for the concurrent development of
which of the following malignancies?
a. Cervix
b. Ovary
c. Breast
d. Vagina
e. Colon
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
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
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) no symptom
(B) pain with intercourse
(C) vaginal bleeding
(D) weight loss
(E) vulvar pruritus
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
A 50-year-old woman is diagnosed with cervical cancer. Which lymph node group
would be the first involved in metastatic spread of this disease beyond the cervix
and uterus?
(A) exophytic
(B) endophytic
(C) nodular
(D) ulcerating
(E) edematous
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
A patient wishes you to explain the concept of cervical intraepithelial neoplasia
(CIN) III, which has been diagnosed from her cervical biopsy after a low-grade
squamous intraepithelial lesion (LGSIL) was found on a Pap smear. What can you
correctly tell her about CIN III?
(A) adenocarcinoma
(B) microglandular hyperplasia
(C) moderate dysplasia (CIN II)
(D) CIS
(E) invasive squamous cell carcinoma
While viewing a cervical biopsy, squamous cell atypia is noted. It extends from the basal
layer to a little more than one-half the thickness of the epithelium. Beyond that level,
maturation is evident. There is no invasion of stroma. Which of the following is the
correct diagnosis based on these biopsy findings?
(A) adenocarcinoma
(B) microglandular hyperplasia
(C) moderate dysplasia (CIN II)
(D) CIS
(E) invasive squamous cell carcinoma
Which of the following reflects the etiology of cervical dysplasia and
cervical cancer?
a. HPV type 6
b. HPV type 11
c. HPV type 16
d. HPV type 42
e. HPV type 44
A 21-year-old woman returns to your office for evaluation of
an abnormal Pap smear. The Pap smear showed a squamous
abnormality suggestive of a high-grade squamous
intraepithelial lesion (HGSIL). Colposcopy confirms the
presence of a cervical lesion consistent with severe cervical
dysplasia (CIN III). Which of the following human papilloma
virus (HPV) types is most often associated with this type of
lesion?
a. HPV type 6
b. HPV type 11
c. HPV type 16
d. HPV type 42
e. HPV type 44
Which of the following reflects HPV?
or (4) cells seen on cervical biopsy that do not adequately explain the cells
a. IIa
b. IIb
c. IIIa
d. IIIb
e. IV
FIGO classification cervical CC–
must know!
I: Cervical carcinoma confined to the cervix
• Ia - preclinical (microscopic <3mm deep),
• Ib - macroscopic disease
II: involves the vagina, but upper 2/3, or infiltrates the parametrium, but not out to
the pelvic side wall
• IIa- vaginal upper 2/3extension
• IIb - parametrial extension
III - involves the lower 1/3 vagina or extends to the pelvic side wall
• IIIa - Tumor involves lower 1/3of vagina, no extension to pelvic wall
• IIIb - Tumor extends to pelvic wall and/or causes hydronephrosis or
nonfunctional kidney
IV - Tumor invades mucosa of bladder or rectum and/or extends beyond true
pelvis
A 51-year-old woman is diagnosed with invasive cervical
carcinoma by cone biopsy. Pelvic examination and rectal-
vaginal examination reveal the parametrium to be free of
disease, but the upper portion of the vagina is involved with
tumor. Intravenous pyelography (IVP) and sigmoidoscopy are
negative, but a computed tomography (CT) scan of the
abdomen and pelvis shows grossly enlarged pelvic and
periaortic nodes. This patient is classified at which of the
following stages?
a. IIa
b. IIb
c. IIIa
d. IIIb
e. IV
An intravenous pyelogram (IVP) shows hydronephrosis in the workup of
a patient with cervical cancer otherwise confined to a cervix of normal
size. This indicates which one of the following stages?
a. Microinvasive stage
b. I
c. II
d. III
An intravenous pyelogram (IVP) shows hydronephrosis in the workup
of a patient with cervical cancer otherwise confined to a cervix of
normal size. This indicates which one of the following stages?
a. Microinvasive stage
b. I
c. II
d. III
A 35-year-old G3P3 with a Pap smear showing high-grade
squamous intraepithelial lesion of the cervix (CIN III) has an
inadequate colposcopy. Cone biopsy of the cervix shows squamous
cell cancer that has invaded only 1 mm beyond the basement
membrane. There are no confluent tongues of tumor, and there is
no evidence of lymphatic or vascular invasion. The margins of the
cone biopsy specimen are free of disease. How should you classify
or stage this patient’s disease?
(A) CIN I
(B) atrophy
(C) squamous cell cancer
(D) CIN II-III
(E) a nabothian cyst
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
(C) squamous cell cancer
(D) CIN II-III
(E) a nabothian cyst
Cryotherapy is appropriate to consider in which clinical
circumstance?
Women younger than age 20 have a high prevalence of HPV infection and minimally abnormal cytology tests (ASC-US, LSIL).
The spontaneous resolution rate of these abnormalities is 90 percent and the risk of invasive cancer is very low. Therefore,
colposcopy during pregnancy can be omitted, but cytology should be repeated postpartum.
ASC-US and LSIL in pregnant women over the age of 20 years may be managed as in the non-pregnant patient, with the
exception that it is acceptable to defer colposcopy to at least six weeks postpartum.
Colposcopy is recommended for all adolescent and non-adolescent women with ASC-H, HSIL, and AGC.
If colposcopy reveals no CIN 2,3 or suspicion for cancer, additional cytologic and colposcopic evaluation should be performed
postpartum, but no sooner than six weeks after delivery.
A 34-year-old woman G1 is 16 weeks pregnant and has a
Pap smear suspicious for cancer. How do you advise her?
Uterine sarcoma • Consist of malignant mesenchymal (sarcomatous) components arising from endometrial stroma, myometrium, or
uterine connective tissue
• The most common sarcoma is the malignant mixed Müllerian tumor (up to 43%), followed by leiomyosarcoma (up
to 33%).
• Mainly seen in females > 40 year of age
• Risk factors: previous pelvic irradiation
• abdominal pain (from a rapidly enlarging uterus), vaginal discharge, vaginal bleeding
postmenopausal women with endometrial hyperplasia should consider hysterectomy with bilateral salpingo-
oophorectomy, since uterine or ovarian disease may coexist.
An 80-year-old woman who has never taken estrogen develops a pink vaginal
discharge. An endometrial biopsy shows adenocarcinoma of the endometrium.
Papanicolaou smear is negative. Which of the following is the most important
prognostic indicator?
(A) sarcoma
(B) adenocarcinoma
(C) adenomyosis
(D) choriocarcinoma
(E) leiomyoma
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
In which of the following patients is uterine sarcoma most likely to be
found?
(A) leiomyosarcoma
(B) endometrial stromal sarcoma
(C) endolymphatic stromal myosis
(D) malignant mixed müllerian tumor
(E) lymphoma
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
Which of the following is a factor predisposing to the development of malignant
mixed müllerian tumors?
(A) obesity
(B) tamoxifen
(C) oral contraceptive pills (OCPs).
(D) early menarche or late menopause
(E) unopposed exogenous estrogen therapy
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
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) 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.
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.
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) I
(B) II
(C) III
(D) IV
(E) recurrent
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
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?