Lower reproductive tract

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 common complication of radical vulvectomy is surgical wound breakdown

recurrence Very common in the area of the primary surgical resection
The classic symptom is recurrence of pruritus
A 63-year-old patient is seen for routine examination. An
excoriated 2-cm lesion is found on her left labium majus,
which, she states, has been present for at least 3 months.
What is the next best step in the management of this
patient?
(A) prescribe hydrocortisone cream
(B) schedule colposcopy
(C) perform excisional biopsy
(D) prescribe Burow’s solution soaks
(E) paint the area with toluidine blue stain
A 63-year-old patient is seen for routine examination. An
excoriated 2-cm lesion is found on her left labium majus,
which, she states, has been present for at least 3 months.
What is the next best step in the management of this
patient?
(A) prescribe hydrocortisone cream
(B) schedule colposcopy
(C) perform excisional biopsy
(D) prescribe Burow’s solution soaks
(E) paint the area with toluidine blue stain
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 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) stage I verrucous carcinoma

(B) melanoma
(C) stage I squamous cell cancer of vulva
(D) basal cell carcinoma
(E) rhabdomyosarcoma
Which of the following tumors of the vulva has the best
prognosis?

(A) stage I verrucous carcinoma

(B) melanoma
(C) stage I squamous cell cancer of vulva
(D) basal cell carcinoma
(E) rhabdomyosarcoma
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
(C) chronic granulomatous diseases
(D) chronic irritation
(E) unknown
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
(C) chronic granulomatous diseases
(D) chronic irritation
(E) unknown
Which of the following is the most common symptom of
vulvar carcinoma in elderly women?

(A) abnormal bleeding

(B) a foul smell
(C) pruritus
(D) vulvar atrophy
(E) painful intercourse
Which of the following is the most common symptom of
vulvar carcinoma in elderly women?

(A) abnormal bleeding

(B) a foul smell
(C) pruritus
(D) vulvar atrophy
(E) painful intercourse
A 70-year-old woman presents for evaluation of a pruritic lesion on the
vulva. Examination shows a white, friable lesion on the right labia majora
that is 3 cm in diameter. No other suspicious areas are noted. Biopsy of the
lesion confirms squamous cell carcinoma. In this patient, lymphatic drainage
characteristically would be first to which of the following nodes?

a. External iliac lymph nodes

b. Superficial inguinal lymph nodes
c. Deep femoral lymph nodes
d. Periaortic nodes
e. Internal iliac nodes
A 70-year-old woman presents for evaluation of a pruritic lesion on the
vulva. Examination shows a white, friable lesion on the right labia majora
that is 3 cm in diameter. No other suspicious areas are noted. Biopsy of the
lesion confirms squamous cell carcinoma. In this patient, lymphatic drainage
characteristically would be first to which of the following nodes?

a. External iliac lymph nodes

b. Superficial inguinal lymph nodes
c. Deep femoral lymph nodes
d. Periaortic nodes
e. Internal iliac nodes
Unlike the lymphatic drainage from the
rest of the vulva, the drainage from the clitoral
region bypasses the superficial
inguinal nodes and passes directly to the deep
femoral nodes. Thus,
while the superficial nodes usually also have
metastases when the deep
femoral nodes are implicated, it is possible for only
the deep nodes to be
involved if the carcinoma is in the midline near the
clitoris
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. 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
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. 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
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 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

wound breakdown is common

(~50%), but this usually heals
with conservative
management
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
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
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
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.
(C) There is minimal chance of cancer.
(D) There is minimal chance of recurrence.
(E) If there is a recurrence, it will regress spontaneously.
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.
(C) There is minimal chance of cancer.
(D) There is minimal chance of recurrence.
(E) If there is a recurrence, it will regress spontaneously.
A 65-year-old woman presents with complaints of vulvar
redness, pruritus, and occasional weeping from the skin.
Examination reveals erythematous, 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
 Pagets disease of vulva
• Most patients are in their 60s and 70s and Caucasian
• The vulva is one of the most common sites for extramammary
Paget disease
• 12-58% of women experience a local recurrence, which may occur
despite negative surgical margins
• The lesion has an eczematoid appearance; it is well-demarcated
and has slightly raised edges and a red background, often dotted
with small, pale islands. It is usually multifocal and may occur
anywhere on the vulva, mons, perineum/perianal area, or inner
thigh.
• 20-30% of patients will have or will develop an adenocarcinoma
at another non-vulvar location (eg, involving breast, rectum,
bladder, urethra, cervix, or ovary)
• Treatment consists of wide local excision or vulvectomy,
depending upon the extent of disease
A 65-year-old woman presents with complaints of vulvar
redness, pruritus, and occasional weeping from the skin.
Examination reveals erythematous, 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
 Non malignant vulvar pathologies
pathology comments
Bartholin gland cyst Presentation: labial edema and inflammation of the area with a deep fluctuant mass
Management:
• patient <40 years of age: incision and drainage
• Patient >40 years of age: high likelihood for malignancy, excision is most appropriate
Urethral caruncle The most common lesion of the female urethra.
occurring primarily in postmenopausal women
Presentation: Benign fleshy outgrowth at the urethral meatus
Histology: core of blood vessels and loose connective tissue covered by hyperplastic urothelial and
squamous epithelium
Hidradenitis A chronic inflammatory skin condition that is also known as “Acne Inversa” (AI)
suppuritiva Axilla is most common site; the inguinal area, inner thighs, perineal and perianal areas, mammary and
inframammary skin, and buttocks are additional common sites for involvement

Condyloma Genital warts

acuminatum Appearance: variable, flat papules or raised irregular verrucous exophytic lesions
Related to HPV (6,11) infection
Management:
• Imiquimod is locally applied immunostimulant that leads to sloughing off of the lesion
• Cryotherapy with liquid nitrogen, surgery laser of phdophyllin/trichloroacetic acid
• If bleeding -> excision
An 18-year-old woman consults you for a painful swelling of
her left labium that has progressively worsened over the past
3 days. She has been treating the discomfort with over-the-
counter analgesics and warm sitz baths. On examination, a 6-
cm swollen, red, tender, tense cystic mass is present in the
base of the left labium majus. What is the most appropriate
next step in the care of this patient?
(A) excision of the mass
(B) dry heat
(C) oral antibiotics
(D) intramuscular or intravenous (IV) antibiotics
(E) incision and drainage of the mass
 Bartholin gland cyst/abscess
• Located on the lateral side of the vulva. Secrete mucus and can become
obstructed, leading to cysts or abscess that causes: pain, tenderness and
dysparenuria.
• Physical examination shows edema and inflammation of the area with a
deep fluctuant mass
• In the young patients : Treatment is like any other cyst or abscess: need to
be incised and drained.
• In the adult patient (>40): excision is most appropriate (r/o
adenocarcinoma)
• During drainage, fluid should be cultured for STD’s (Neisseria, chlamydia)
• If refractory, do marsupilization.
An 18-year-old woman consults you for a painful swelling of her left labium
that has progressively worsened over the past 3 days. She has been treating
the discomfort with over-the-counter analgesics and warm sitz baths. On
examination, a 6-cm swollen, red, tender, tense cystic mass is present in the
base of the left labium majus. What is the most appropriate next step in the
care of this patient?
(A) excision of the mass
(B) dry heat
(C) oral antibiotics
(D) intramuscular or intravenous (IV) antibiotics
(E) incision and drainage of the mass
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 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) vaginal trichomoniasis

(B) leukemia
(C) personal hygiene products
(D) secondary syphilis
(E) hidradenitis suppurativa
 Vulvar pruritis
Vaginitis (infectious or atrophic)
Atopic, contact, or seborrheic dermatitis
Psoriasis
Lichen sclerosus, planus, or simplex chronicus
Vulvar intraepithelial neoplasia
Vulvar cancer
Paget's disease
Vulvar infection (bacterial, fungal, viral)
Hidradenitis suppurativa
Scabies
Pediculosis pubis
Systemic diseases with vulvar involvement
Vulvodynia
 Causes of vaginal candidiasis
• Diabetes mellitus
• Antibiotic use
• Increased estrogen levels – oral contraceptives, pregnancy
• Immunosuppression —human immunodeficiency virus (HIV) infection
• Contraceptive devices — Vaginal sponges, diaphragms, and intrauterine
devices have been associated with vulvovaginal candidiasis
• Behavioral factors — Vulvovaginal candidiasis is not traditionally considered a
sexually transmitted disease (STD) since it occurs in celibate women and since
Candida species are considered part of the normal vaginal flora.
• The type of sex may be a factor. Infection may be linked to orogenital and, less
commonly, anogenital sex.
• Evidence of a link between vulvovaginal candidiasis and hygienic habits (eg,
douching, use of tampons/menstrual pads) or wearing tight or synthetic
clothing is weak and conflicting.
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) vaginal trichomoniasis

(B) leukemia
(C) personal hygiene products
(D) secondary syphilis
(E) hidradenitis suppurativa
A 79-year-old woman presents to your office with a 1-cm
fleshy outgrowth from her urethra. It has a slightly infected
appearance and bleeds on contact. You perform a biopsy, and
the report states “transitional and stratified squamous
epithelium with underlying loose connective tissue.” Which of
the following is the most likely diagnosis?

(A) urethral leiomyoma

(B) hidradenitis suppurativa
(C) senile urethritis
(D) urethral caruncle
(E) urethral carcinoma
Urethral caruncle
• A urethral caruncle is a benign fleshy outgrowth at
the urethral meatus.
• It is the most common lesion of the female
urethra.
• occurring primarily in postmenopausal women.
• Histologically, urethral caruncles contain a core of
blood vessels and loose connective tissue covered
by hyperplastic urothelial and squamous
epithelium
A 79-year-old woman presents to your office with a 1-cm fleshy outgrowth
from her urethra. It has a slightly infected appearance and bleeds on
contact. You perform a biopsy, and the report states “transitional and
stratified squamous epithelium with underlying loose connective tissue.”
Which of the following is the most likely diagnosis?

(A) urethral leiomyoma

(B) hidradenitis suppurativa
(C) senile urethritis
(D) urethral caruncle
(E) urethral carcinoma
A patient consults you with complaints of recurrent, painful,
draining vulvar lesions. Examination shows multiple abscesses
and deep scars in the labia. A foul-smelling discharge from the
lesions is noted. During the review of systems, the patient
reports the occasional appearance of similar lesions in the
axilla. Which of the following is the most likely diagnosis?

(A) herpetic vulvitis

(B) hidradenitis suppurativa
(C) lymphogranuloma venereum
(D) granuloma inguinale
(E) secondary syphilis
Hidradenitis suppurativa
• A chronic inflammatory skin condition that
is also known as acne inversa (AI)
• The axilla is the most common site; the
inguinal area, inner thighs, perineal and
perianal areas, mammary and
inframammary skin, and buttocks are
additional common sites for involvement.
• The usual initial presentation of HS/AI is of
recurrent, painful, and inflamed nodules.
The nodules may rupture, discharging
purulent, sometimes malodorous material
A patient consults you with complaints of recurrent, painful,
draining vulvar lesions. Examination shows multiple abscesses
and deep scars in the labia. A foul-smelling discharge from
the lesions is noted. During the review of systems, the patient
reports the occasional appearance of similar lesions in the
axilla. Which of the following is the most likely diagnosis?

(A) herpetic vulvitis

(B) hidradenitis suppurativa
(C) lymphogranuloma venereum
(D) granuloma inguinale
(E) secondary syphilis
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
 Condyloma acuminatum
• From HPV 6, 11
• Diagnosed by appearance
• Imiquimod is locally applied
immunostimulant that leads to
sloughing off of the lesion
• Cryotherapy with liquid nitrogen,
surgery laser of
phdophyllin/trichloroacetic acid
• If bleeding -> excision
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
A 23-year-old woman presents to your office complaining of growths around her
vaginal opening. Recently, the growths have been itching and bleeding. On
physical examination she has several broad-based lesions measuring 2 to 4 cm in
diameter along the posterior fourchette. Although there is no active bleeding,
the largest lesion appears to have been bleeding recently. Which of the following
is the best way to treat this patient?

a. Weekly application of podophyllin in the office

b. Injection of 5-fluorouracil into the lesions
c. Self-application of imiquimod to the lesions by the patient
d. Weekly application of trichloroacetic acid in the office
e. Local excision
A 23-year-old woman presents to your office complaining of growths
around her vaginal opening. Recently, the growths have been itching and
bleeding. On physical examination she has several broad-based lesions
measuring 2 to 4 cm in diameter along the posterior fourchette. Although
there is no active bleeding, the largest lesion appears to have been bleeding
recently. Which of the following is the best way to treat this patient?

a. Weekly application of podophyllin in the office

b. Injection of 5-fluorouracil into the lesions
c. Self-application of imiquimod to the lesions by the patient
d. Weekly application of trichloroacetic acid in the office
e. Local excision
Vaginal malignancy
Vaginal malignancy, the comments
facts
Most common type Squamous cell (85%)
Other types • Adenocarcinoma (9%) - Clear cell adenocar, related to the use of diethylstilbestrol (DES)
• sarcoma (2.5%) – sarcoma botryoides found in the pediatric patient, resembling a mass of grape-
like edematous polyps
• melanoma (2.5%)
• small cell (0.5%)

presentation Symptoms: vaginal spotting/bleeding

Signs: lesion most commonly present on the upper one-third of the vagina
diagnosis • Visible lesion: Punch biopsy
• Non-visible lesion: Papanicolaou screening and vaginoscopy
Staging (and 5 years Stage I: Limited to the vaginal wall – 90%
survival rate) Stage II: Extends to the subvaginal tissue – 60%
Stage III: Reaches to pelvic wall – 35%
Stage IV: Extends beyond the true pelvis or into the mucosa of the bladder or rectum – 15%

management Stage I and II:

• <2 cm - Radical hysterectomy with nodal extirpation and wide removal of the vagina
• >2 cm - radiation therapy
Stage I and II > 4 cm OR Stage III and IV: combined chemotherapy (and radiation)
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 colposcopy 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
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 colposcopy 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
Which of the following is the most likely histology of vaginal
carcinoma?

(A) melanoma
(B) verrucous
(C) clear cell
(D) adenocarcinoma
(E) squamous cell
 Histologic subtypes of vaginal cancer

Histology Number of patients Incidence

Squamous cell 627 83.4
Adenocarcinoma 70 9.3
Sarcoma 20 2.6
Melanoma 2 2.6
Undifferentiated 8 1.0
Small cell 5 0.7
Lymphoma 2 0.3
Carcinoid 1 0.1
Total 753 100.0
Which of the following is the most likely histology of vaginal
carcinoma?

(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) refer to gynecologic oncologist

(B) perform directed punch biopsy of the lesion
(C) perform Papanicolaou (Pap) smear of the vagina and vaginoscopy
(D) perform laser ablation therapy
(E) order ultrasound of the pelvis
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
(C) perform Papanicolaou (Pap) smear of the vagina and vaginoscopy
(D) perform laser ablation therapy
(E) order ultrasound of the pelvis
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
(C) clear cell adenocarcinoma of the vagina
(D) ovarian cysts
(E) fallopian tube adenocarcinoma
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
(C) clear cell adenocarcinoma of the vagina
(D) ovarian cysts
(E) fallopian tube adenocarcinoma
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
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
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. What stage cancer
does this patient most likely have?

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

• Stage I: Limited to the vaginal wall

• Stage II: Extends to the subvaginal tissue
• Stage III: Reaches to pelvic wall
• Stage IV: Extends beyond the true pelvis or into the mucosa of the
bladder or rectum
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. What
stage cancer does this patient most likely have?

(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?

(A) total vaginectomy

(B) upper vaginectomy
(C) chemotherapy
(D) combination radiation and chemotherapy
(E) exenteration
 Approach to vaginal cancer
• Stage I and II tumors (no extension to the pelvic wall and no
metastasis)
• <2 cm in size may be removed surgically (Radical hysterectomy with
nodal extirpation and wide removal of the vagina)
• If > 2cm in size -> treat with radiation therapy.

• 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) total vaginectomy

(B) upper vaginectomy
(C) chemotherapy
(D) combination radiation and chemotherapy
(E) exenteration
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
 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?

(A) intravaginal 5-FU

(B) upper vaginectomy
(C) simple hysterectomy and upper vaginectomy
(D) radical hysterectomy, bilateral pelvic lymphadenectomy, and upper
vaginectomy
(E) anterior exenteration
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
(C) simple hysterectomy and upper vaginectomy
(D) radical hysterectomy, bilateral pelvic lymphadenectomy, and upper
vaginectomy
(E) anterior exenteration
Cervical cancer
Cervical carcinoma, the facts comments
Epidemiology Least common gynecologic cancer (Due to early detection with Pap smear)
Classically present in young females (<40 years of age)
Risk factors Early onset of sexual activity, multiple sexual partners, pregnancy, STD’s (genital warts), smoking, oral contraceptives,
immunodeficiency
Histology Mainly arise from the squamocolumnar junction(upper 1/3)
Types: Squamous cell carcinoma (most common - 80% ), small cell, adenocarcinoma.
Cervical intraepithelial CIN I (LGSIL in Pap smear) – mild dysplasia/atypia involving the upper third of the epithelium
neoplasia (a biopsy result - CIN II (HGSIL on Pap smear) – moderate dysplasia/atypia involving the lower 2/3 of the epithelium
colposcopy) CIN III (HGSIL on Pap smear) – severe dysplasia to Carcinoma in situ (CIS) involving the full thickness of the epithelium
Notes:
- majority of CIN cases are associated with HPV 16,18
- ASCUS is a pap smear result standing for cellular abnormalities not suggestive of intraepithelial lesions (the risk of invasive
cervical cancer is 0.1%)
- AGC - atypical glandular cells on Pap smear – high risk for malignancy
Clinical presentation The most common symptom is: NO SYMPTOMS! Other findings may include: Malodorous discharge, poscoital bleeding
Diagnosis • Routine Pap smear screening
• ASCUS & LSIL <21 - should be managed by repeated Pap 12 months
• ASCUS & LSIL >21 – perform HPV testing; if positive -> colposcopy; if negative-> repeat the Pap smear at 6 months
• if colposcopy/biopsy is normal but suspicious repeat Pap smear(=discrepancy) - cone biopsy for a higher position of the
malignancy (remember: if you already have a diagnosis of invasive cancer, there’s no need for this biopsy)
• HSIL - Colposcopy plus punch b iopsy
• AGC - endocervical curettage; if >35 perform endometrial BX too

• 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. Young age at initiation of sexual activity

b. Multiple sexual partners
c. History of genital warts
d. Use of Depo-Provera
e. Smoking
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. Young age at initiation of sexual activity

b. Multiple sexual partners
c. History of genital warts
d. Use of Depo-Provera
e. Smoking
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 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) 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.
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.
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 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. Common iliac nodes

b. Parametrial nodes
c. External iliac nodes
d. Paracervical or ureteral nodes
e. Para-aortic nodes
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. Common iliac nodes

b. Parametrial nodes
c. External iliac nodes
d. Paracervical or ureteral nodes
e. Para-aortic nodes
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
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) It is an invasive cancer.

(B) It includes carcinoma in situ (CIS).
(C) It requires no further treatment.
(D) It is due to a bacterial infection.
(E) It corresponds to the LGSIL shown on her prior Pap smear.
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) It is an invasive cancer.

(B) It includes carcinoma in situ (CIS).
(C) It requires no further treatment.
(D) It is due to a bacterial infection.
(E) It corresponds to the LGSIL shown on her prior Pap smear.
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
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) Human papillomavirus (HPV) is the major causal agent.

(B) They are associated with obesity.
(C) They are associated with nulliparity.
(D) There is a strong genetic component to the development of cervical
cancer.
(E) They are the direct result of cigarette smoking
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.
(C) They are associated with nulliparity.
(D) There is a strong genetic component to the development of cervical
cancer.
(E) They are the direct result of cigarette smoking
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
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?

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

with HPV.
(B) The virus is transient for most women.
(C) Most women with HPV will go on to develop warts, CIN, or
cancer.
(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.
 Human Papillomavirus
• A papovaviridae (double stranded circular DNA virus), the second
smallest DNA virus
• Up to 80% of sexually experienced women will be positive for HPV
during their reproductive lifetime
• Most infections are asymptomatic and transient
• HPV 6,11 – low risk (but risk for condyloma acuminatum)
• HPV 16,18 – high risk for cervical cancer
• Currently the HPV vaccine is approved for girls and women aged 9 to
26 years; protects 6, 11, 16, and 18
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.
(C) Most women with HPV will go on to develop warts, CIN, or
cancer.
(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.
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
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
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%
(C) represent a minority of abnormal Pap smears per year in U.S. women
(D) requires immediate colposcopy
(E) is not associated with high-risk HPV subtypes
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%
(C) represent a minority of abnormal Pap smears per year in U.S. women
(D) requires immediate colposcopy
(E) is not associated with high-risk HPV subtypes
If a nonhealing ulcer is seen on the cervix, it is best
evaluated by which of the following?

(A) repeat examination

(B) Pap smear
(C) punch biopsy
(D) cone biopsy
(E) vaginal steroid cream
If a nonhealing ulcer is seen on the cervix, it is best
evaluated by which of the following?

(A) repeat examination

(B) Pap smear
(C) punch biopsy
(D) cone biopsy
(E) vaginal steroid cream
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
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
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.” 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
 DX cervical cancer
• Routine Pap smear screening
• ASCUS & LSIL <21 - should be managed by repeated Pap 12 months
• ASCUS & LSIL >21 – perform HPV testing; if positive -> colposcopy; if
negative-> repeat the Pap smear at 6 months
• if colposcopy/biopsy is normal but suspicious repeat Pap
smear(=discrepancy) - cone biopsy for a higher position of the
malignancy (remember: if you already have a diagnosis of invasive
cancer, there’s no need for this biopsy)
• HSIL - Colposcopy plus punch b iopsy
• AGC - endocervical curettage; if >35 perform endometrial BX too
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.” 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
A 22-year-old woman presents for her first Pap smear. She has
been sexually active with only one boyfriend since age 19. Her
physical examination is completely normal. However, 2 weeks
later her Pap smear results return showing HGSIL. There were
no endocervical cells seen on the smear. Which of the
following is the most appropriate next step in the
management of this patient?

a. Perform a cone biopsy of the cervix

b. Repeat the Pap smear to obtain endocervical cells
c. Order HPV typing on the initial Pap smear
d. Perform random cervical biopsies
e. Perform colposcopy and directed cervical biopsies
A 22-year-old woman presents for her first Pap smear. She has been
sexually active with only one boyfriend since age 19. Her physical
examination is completely normal. However, 2 weeks later her Pap smear
results return showing HGSIL. There were no endocervical cells seen on the
smear. Which of the following is the most appropriate next step in the
management of this patient?

a. Perform a cone biopsy of the cervix

b. Repeat the Pap smear to obtain endocervical cells
c. Order HPV typing on the initial Pap smear
d. Perform random cervical biopsies
e. Perform colposcopy and directed cervical biopsies
55-year-old postmenopausal female presents to her gynecologist for a
routine examination. She denies any use of hormone replacement
therapy and does not report any menopausal symptoms. She denies the
occurrence of any abnormal vaginal bleeding. She has no history of any
abnormal Pap smears and has been married for 30 years to the same
partner. She is currently sexually active with her husband on a regular
basis. Two weeks after her examination, her Pap smear comes back as
atypical glandular cells of undetermined significance (AGUS). Which of the
following is the most appropriate next step in the management of this
patient?

a. Repeat the Pap in 4 to 6 months

b. HPV testing
c. Hysterectomy
d. Cone biopsy
e. Colposcopy, endometrial biopsy, endocervical curettage
55-year-old postmenopausal female presents to her gynecologist for a routine
examination. She denies any use of hormone replacement therapy and does
not report any menopausal symptoms. She denies the occurrence of any
abnormal vaginal bleeding. She has no history of any abnormal Pap smears
and has been married for 30 years to the same partner. She is currently
sexually active with her husband on a regular basis. Two weeks after her
examination, her Pap smear comes back as atypical glandular cells of
undetermined significance (AGUS). Which of the following is the most
appropriate next step in the management of this patient?

a. Repeat the Pap in 4 to 6 months

b. HPV testing
c. Hysterectomy
d. Cone biopsy
e. Colposcopy, endometrial biopsy, endocervical curettage
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
(C) choose the most suspicious areas on the cervical
portion to biopsy
(D) treat invasive cancer with a biopsy
(E) make the diagnosis of cancer
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
(C) choose the most suspicious areas on the cervical
portion to biopsy
(D) treat invasive cancer with a biopsy
(E) make the diagnosis of cancer
A 32-year-old woman consults with you for evaluation of an abnormal Pap smear done by
a nurse practitioner at a family planning clinic. The Pap smear shows evidence of a high-
grade squamous intraepithelial lesion (HGSIL). You perform colposcopy in the office. Your
colposcopic impression is of acetowhite changes suggestive of human papilloma virus
infection (HPV). Your biopsies show chronic cervicitis but no evidence of dysplasia. Which
of the following is the most appropriate next step in the management of this patient?

a. Cryotherapy of the cervix

b. Laser ablation of the cervix
c. Conization of the cervix
d. Hysterectomy
e. Repeat the Pap smear in 3 to 6 months
conization
The indications for a cone biopsy :

(1) unsatisfactory colposcopic examination (ie, the entire transformation

zone cannot be seen);

(2) a colposcopically directed cervical biopsy that

indicates the possibility of invasive disease;

(3) neoplasm in the endocervix;

or (4) cells seen on cervical biopsy that do not adequately explain the cells

seen on cytologic examination (ie, the Pap).

A 32-year-old woman consults with you for evaluation of an abnormal Pap smear done by
a nurse practitioner at a family planning clinic. The Pap smear shows evidence of a high-
grade squamous intraepithelial lesion (HGSIL). You perform colposcopy in the office. Your
colposcopic impression is of acetowhite changes suggestive of human papilloma virus
infection (HPV). Your biopsies show chronic cervicitis but no evidence of dysplasia. Which
of the following is the most appropriate next step in the management of this patient?

a. Cryotherapy of the cervix

b. Laser ablation of the cervix
c. Conization of the cervix
d. Hysterectomy
e. Repeat the Pap smear in 3 to 6 months
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
(C) when microinvasion is diagnosed by biopsy
(D) when deeply invasive cancer is shown on a biopsy
(E) for treatment of biopsy-proven CIN III
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
(C) when microinvasion is diagnosed by biopsy
(D) when deeply invasive cancer is shown on a biopsy
(E) for treatment of biopsy-proven CIN III
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
(C) in the endocervix
(D) at the squamocolumnar junction
(E) at the external os
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
(C) in the endocervix
(D) at the squamocolumnar junction
(E) at the external os
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
 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. Carcinoma of low malignant potential

b. Microinvasive cancer, stage Ia1
c. Atypical squamous cells of undetermined significance
d. Carcinoma in situ
e. Invasive cancer, stage IIa
Staging Cervical Cancer

 Stage I- Confined to Cervix

 Ia1 <3 mm deep, < 7 mm wide
 Ia2 >3 <5 mm deep
 Ib1 < 4cm
 Ib2 > 4 cm
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. Carcinoma of low malignant potential

b. Microinvasive cancer, stage Ia1
c. Atypical squamous cells of undetermined significance
d. Carcinoma in situ
e. Invasive cancer, stage IIa
The diagnosis of carcinoma of the cervix, International
Federation of Gynecology and Obstetrics (FIGO) stage III,
is assigned when which of the following occurs?

(A) The carcinoma has infiltrated the bladder base.

(B) The carcinoma involves the distal vaginal mucosa.
(C) The carcinoma has extended into the parametria, but
not to the pelvic sidewall.
(D) X-ray reveals tumor.
(E) Adenocarcinoma is present.
The diagnosis of carcinoma of the cervix, International
Federation of Gynecology and Obstetrics (FIGO) stage III,
is assigned when which of the following occurs?

(A) The carcinoma has infiltrated the bladder base.

(B) The carcinoma involves the distal vaginal mucosa.
(C) The carcinoma has extended into the parametria, but
not to the pelvic sidewall.
(D) X-ray reveals tumor.
(E) Adenocarcinoma is present.
The criteria for FIGO staging of carcinoma of
the cervix should be memorized !!
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
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?

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

(A) metastatic evaluation

(B) conization
(C) radical hysterectomy
(D) radiation therapy
(E) both irradiation and radical hysterectomy
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 (HSIL). A colposcopically directed
biopsy reveals invasive squamous cell carcinoma. Which of the
following should be the most appropriate next step in the care of
the patient?

(A) metastatic evaluation

(B) conization
(C) radical hysterectomy
(D) radiation therapy
(E) both irradiation and radical hysterectomy
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
(C) have a repeat Pap smear in 3 months
(D) undergo a termination of pregnancy and then undergo
complete evaluation
(E) have cervical conization
 Diagnosis of cervical cancer in pregnancy
Management of an abnormal screening cervical cytology in pregnancy should follow the 2006 Bethesda consensus guidelines:

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.

Lesions suspicious for CIN 2,3 or cancer should be biopsied.

It is recommended that endocervical curettage not be performed in pregnancy.

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?

(A) have colposcopy with biopsy

(B) have colposcopy, but biopsy is too risky in pregnancy
(C) have a repeat Pap smear in 3 months
(D) undergo a termination of pregnancy and then undergo
complete evaluation
(E) have cervical conization
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
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
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
(C) wet mount
(D) sigmoidoscopy
(E) inject diluted methylene blue in sterile water into the bladder and examine the
vagina
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
(C) wet mount
(D) sigmoidoscopy
(E) inject diluted methylene blue in sterile water into the bladder and examine
the vagina
A patient has stage III cancer of the cervix and will be treated with
radiation. Which of the following is of greatest concern while delivering
this therapy?

(A) harming small bowel

(B) inducing sarcoma of the uterus
(C) destroying the bladder or rectum
(D) causing infection or necrosis
(E) destroying surrounding pelvic muscles
A patient has stage III cancer of the cervix and will be treated with
radiation. Which of the following is of greatest concern while delivering
this therapy?

(A) harming small bowel

(B) inducing sarcoma of the uterus
(C) destroying the bladder or rectum
(D) causing infection or necrosis
(E) destroying surrounding pelvic muscles
Endometrial cancer
Endometrial cancer, the facts comments
Epidemiology Most common gynecologic cancer
pathogenesis Prolonged estrogen (without progesterone) exposure:
• early menarche, late menopause
• Nulliparity
• obesity (increased aromatization of androgens to estrogen)
• PCOS
Note: combination of progestins to estrogen (i.e. OCP’s) decrease the risk for endometrial ca. by
reducing the amounts of estrogen receptors on the tissue
Classic findings Postmenopausal bleeding
types Well differentiated Adenocarcinoma - most common malignant type
Adenoacanthoma – contains foci of benign squamous tissue
Adenosquamous carcinoma – contain foci of malignant squamous cancer (worst prognosis)
Papillary adenocarconima – highly aggressive
Diagnosis • Best initial step - look for atypia on histology biopsy (“the tissue is the issue” )
• Altenative way (If a patient for some reason refuses for biopsy) transvaginal US to measure
endometrial thickness – (wall thickness of less the 5 mm is of minimal risk for malignancy)

metastasis Lung is most common target organ (always perform Chest-X-Ray)

 Other uterine disorders
disorder comments
Leiomyoma (fibroids) • A benign estrogen sensitive, smooth muscle tumor
• Commonly undergoes: degeneration, dystrophic calcification, hyalinization
• Do not transform to leiomyosarcoma
• Patient classically present with pelvic pressure, menorrhagia, obstructive delivery during labor

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

Endometrial Prolonged estrogen (without progesterone) exposure:

hyperplasia • early menarche, late menopause
• Nulliparity
• obesity (increased aromatization of androgens to estrogen)
• PCOS
Note: combination of estrogen and progesterone decrease the risk for endometrial ca. (e.g. OCP)
Classification:
• simple hyperplasia (1% chance of malignant transformation,
• complex hyperplasia (1-22% chance of malignant transformation)
• atypical hyperplasia ( 22% increased risk for cancer)
A 40-year-old nulligravida female pediatrician comes to see you for irregular
vaginal bleeding of 1- year duration. She has not been using birth control and had
hoped to conceive. Endometrial biopsy revealed endometrial hyperplasia. She
would like medical treatment and wants to know which factor is most important in
determining premalignant potential. Which of the following is the best way to
advise your patient?

(A) age of the patient

(B) degree of cystic atrophy
(C) persistence of bleeding
(D) thickness of endometrial hyperplasia
(E) degree of cytologic atypia
A 40-year-old nulligravida female pediatrician comes to see you for irregular
vaginal bleeding of 1- year duration. She has not been using birth control and had
hoped to conceive. Endometrial biopsy revealed endometrial hyperplasia. She
would like medical treatment and wants to know which factor is most important in
determining premalignant potential. Which of the following is the best way to
advise your patient?

(A) age of the patient

(B) degree of cystic atrophy
(C) persistence of bleeding
(D) thickness of endometrial hyperplasia
(E) degree of cytologic atypia
 ENDOMETRIAL HYPERPLASIA - THX
In women of child-bearing age desiring fertility, endometrial hyperplasia with or without cytologic atypia may be
treated with progestins (e.g., OCs, medroxyprogesterone acetate, and megestrol acetate). An
endometrial biopsy should be repeated in 3 to 6 months. If repeat endometrial sampling shows normal
endometrium, progestins may be continued or the patient may be observed without hormone therapy for
evidence of ovulation. Persistent symptomatology despite adequate therapy requires hysteroscopy combined
with D&C

Perimenopausal women may be treated by progestins or hysterectomy, depending on severity of

hyperplasia, desire for sterilization, or persistence of symptoms. Patients with moderate-to-severe
atypical hyperplasia should consider hysterectomy. Individuals with lesser disease may receive
progestin therapy but require hysterectomy

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) body habitus

(B) level of CA-125
(C) nutritional status
(D) histologic type of tumor
(E) presence of peptide hormone receptors
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) body habitus

(B) level of CA-125
(C) nutritional status
(D) histologic type of tumor
(E) presence of peptide hormone receptors
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
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) 10-year-old girl with recent onset vaginal bleeding

(B) 9-year-old girl with a rapidly enlarging pelvic mass
(C) 55-year-old woman with a rapidly enlarging uterus
(D) 40-year-old woman with a slowly enlarging uterus
(E) 25-year-old woman with a rapidly enlarging uterus
In which of the following patients is uterine sarcoma most likely to be
found?

(A) 10-year-old girl with recent onset vaginal bleeding

(B) 9-year-old girl with a rapidly enlarging pelvic mass
(C) 55-year-old woman with a rapidly enlarging uterus
(D) 40-year-old woman with a slowly enlarging uterus
(E) 25-year-old woman with a rapidly enlarging uterus
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
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) 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
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
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
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) 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.
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.
A 53-year-old woman who has not menstruated for 1 year is started on cyclic hormonal
replacement therapy. She has scant vaginal bleeding of 2 days’ duration as she starts her
second cycle of replacement. She is healthy, body mass index (BMI) 21, normal blood
pressure, and used OCs until age 42. She refuses an endometrial sampling. Of the
following, which is the most appropriate next step in the management of her bleeding?

(A) begin a menstrual (bleeding) calendar

(B) take a Pap smear, including endocervical sampling
(C) insist on an endometrial sample
(D) perform colposcopy
(E) perform a transvaginal ultrasonography to measure endometrial thickness
A 53-year-old woman who has not menstruated for 1 year is started on cyclic hormonal
replacement therapy. She has scant vaginal bleeding of 2 days’ duration as she starts her
second cycle of replacement. She is healthy, body mass index (BMI) 21, normal blood
pressure, and used OCs until age 42. She refuses an endometrial sampling. Of the
following, which is the most appropriate next step in the management of her bleeding?

(A) begin a menstrual (bleeding) calendar

(B) take a Pap smear, including endocervical sampling
(C) insist on an endometrial sample
(D) perform colposcopy
(E) perform a transvaginal ultrasonography to measure endometrial thickness
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 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) 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.
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.
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
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
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 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?

(A) exploratory laparotomy

(B) lobectomy
(C) radiation therapy
(D) brachytherapy
(E) progestin therapy
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