ONC Flashcards
1
Q
- Pseudomyxoma peritonei
a) can only occur if a primary cyst rupture
b) associated with pleural effusions
c) classically associated with bowel obstruction
d) responds to radiotherapy
e) responds to chemotherapy
A
c) classically associated with bowel obstruction
2
Q
- Acute left heart failure is most likely to occur with which antineoplastic agent
a) vincristine
b) cisplatin
c) bleiomycin
d) doxorubicin
e) cyclophosphamide
A
d) doxorubicin
Vincristine
- cytotoxic, chemotherapy
- use for gestational trophoblastic disease, ovarian germ cell tumours
- main side effects chemotherapy induced peripheral neuropathy, neuropathic pain, , hyponatraemia, constipation and hair loss
Cisplatin
- Use for metastatic ovarian cancer
- main SE – ototoxicity, renal toxicity, anaphylaxis, vesicant ( severe chemical burns ie to eyes, skin and mucosal pain ) in high doses and irritant at lower doses
Bleiomycin
- use for malignant pleural effusion and off label for germ cell tumours
- Main SE – pulmonary toxicity to fibrosis, severe idiosyncratic reaction, hyperpigmentation, stomatitis and mucositis,
Doxorubicin
- Use for Metastatic ovarian ca
- Main SE: Acute and delayed Cardiotoxicity for severe HF, secondary malignancy – AML acute myelogenous leukemia and myelodysplastic syndrome,impaired hepatic function
Cyclophosphamide
- Use for ovarian ca and breast ca
- SE: Reversible alopecia, dose related N+V, leukopenia
3
Q
- A 55 y.0. woman seeks your advice regarding exposure to DES. She used DES during both of her pregnancies. All of the following statements are true except:
a) her daughter has an increased risk of infertility
b) her daughter has an increased risk of developing clear cell CA of the vagina
c) her daughter has an increased risk of cervical dysplasia
d) her son has an increased risk of genital tract abnormalities
e) she has an increased risk of breast cancer
A
All true, see below fro RANZCOG
(DES mothers) are at an increased risk of developing breast cancer.
(DES daughters) are at an increased risk of breast cancer, rare vaginal and cervical clear cell adenocarcinoma (CCA), precancerous changes to the cells in the vagina and cervix, fertility problems and pregnancy problems.
These women also have higher rates of structural abnormalities of the uterus; these are associated with increased perinatal risks of preterm birth and reproductive loss.
(DES sons) an increased risk of testicular abnormalities but not testicular cancers or fertility problems.
4
Q
- A 28 y.o. woman in her first pregnancy presents with a threatened miscarriage at 16/40. On examination a 3cm exophytic lesion is seen on her cervix. Biospy confirms adenocarcinoma. Do you:
a) await maturity
b) arrange EUA, cystoscopy, IVP and CXR
c) irradiate
d) perform radical hysterectomy and PLND
e) reassess after TOP
A
b arrange EUA, cystoscopy, IVP and CXR
Stage 1b1 ( < 4cm )
- Treatment – Radical hysterectomy and PLND or chemoradiation
- Young so radical hysterectomy
- Outcome same for both treatment
- LN involvement 15.9%
- 5 yr survival 60-95%
If desires fertility:
Radical trachelectomy and PLND
- Remove cervix, parametrium and vaginal cuff
- Permanent nylon suture at the base of uterus to replace cervical function
- Future birth via CS
5
Q
Intraoperative findings that are indications for abandoning radical hysterectomy for cervical cancer include all of the following EXCEPT
A. Stage IIA disease with a unilateral 30 mm diameter ovarian cyst.
B. intraperitoneal metastasis.
C. extra-nodal parametrial/pelvic sidewall disease.
D. extensive, unresectable pelvic lymph node disease.
A
A. Stage IIA disease with a unilateral 30 mm diameter ovarian cyst.
CERVICAL CA:
Stage 1a1 ( <3mm stromal invasion and ≤ 7mm diameter ) – cone biopsy if margin clear no need for further treatment, if margin not clear then simple hysterectomy
Stage 1a2 ( 3-5mm stromal invasion and < 7mm diameter ) – modified radical hysterectomy or simple hysterectomy and PLND
Stage 1b1 < 4cm tumour - ( Radical hysterectomy and PLND or chemoradiation )
- Chemo
- Ext beam radiation ( 30min/day x 5/7 x 5/52)
- Weekly cisplatin
- Brachytherapy at end of treatment ( x2 )
-
Stage 1b 2 ( >4cm ) – IV a ( adjacent organs ie bladder and rectum ) – chemoradiation
Stage 2 – Ext beyond cervix
2a – no obvious parametrial involvement and 2/3rd of upper vagina
2b – parametrial involvement
Stage 3 – pelvic sidewall and lower 1/3rd of vagina + hydronephrosis
a- Lower 1/3rd of vagina
b- Side wall and hydronephrosis
Stage IVb – palliative Radiotherapy
6
Q
The primary group of lymph nodes that drain the vulva is the
a. deep inguinal.
b. deep femoral.
c. obturator.
d. superficial inguinal.
A
d. superficial inguinal.
7
Q
A 25 yr old women developed hirsutism, wt gain and deepening of the voice over the last year. Her menstrual cycles are irregular and infrequent. Examination reveals severe facial hair growth and clitoromegaly. The uterus is slightly enlarged. The patient is obese and the ovaries are very difficult to palpate. Investigation shows a testosterone concentration of 17.3 nmol/L (normal range 0.5 - 2.8) and a DHEAS concentration of 9.8 umol/L (normal range 0.9 - 11.7). The MOST APPROPRIATE next step in this patient’s evaluation is
A. measurement of serum androstenedione.
B. measurement of serum 17-hydroxyprogesterone.
C. CT scan of the adrenals.
D. vaginal ultrasound of the ovaries.
A
D. vaginal ultrasound of the ovaries.
`
-Late onset CAH presents at puberty with virulisation.Elevated DHEAS. dx by serum 17 OHP
- this is rapid onset ? pelvic mass, and high testorterone- could be a virilising tumor. ( levels > 6.94nmol/Lor DHEAS > 24nmol/L indicate virilising tumour (eg sex chord tumour: sertoli or legdig cells). Elevated DHEAS would suggest adrenal source of the androgen secreting tumour)
8
Q
A 22-year-old woman has infrequent (three times yearly) heavy menses which last10 to 12 days and increased facial hair growth. She is normotensive and moderately obese. Her last menstrual period started 25 days ago and ended 12 days later. A biopsy specimen from the endometrium would MOST LIKELY show
A.supranuclear vacuoles.
B. stromal oedema with perivascular decidualisation.
c. haemorrhagic stroma and collapsed endometrial glands.
d. crowding of straight tubular glands.
A
d. crowding of straight tubular glands.
9
Q
Which one of the following statements concerning pseudo myxoma peritonei is CORRECT? Pseudo myxoma peritonei;
A. Requires leakage from a parent cyst for the development of the condition.
B responds to treatment with alkylating agents.
C. is characteristically associated with intestinal obstruction.
D. responds to treatment with total abdominal irradiation
A
C. is characteristically associated with intestinal obstruction.
10
Q
- Uterine sarcoma. Risk factors include:
a) family history
b) multiparity
c) previous pelvic irradiation
d) exogenous oestrogen
A
c) previous pelvic irradiation
11
Q
- Ca of one ovary. One lymph node with tumour between renal vein and IVC. Stage is:
a) Ia
b) I
c) II
d) III
e) IV
A
D. STAGE 3
Staging of ovarian Ca
o Stage I – confined to ovary
o Ia – one ovary, capsule intact, no tumour on surface
o Ib – both ovaries, capsule intact, no tumour on surface
o Ic – one or both ovaries, tumour on surface of one or both ovaries: or capsule ruptured; or with ascites present containing malignant or with positive peritoneal washings
o Stage 2 – confined to true pelvis, growth on one or both ovaries
o 2a – growth to the uterus and / or tubes
o 2b – extension to other pelvic tissues
o 2c - stage 2a or 2b (capsule ruptured, ascites, surface tumour, positive pelvic washings)
o Stage 3 – Tumour involving one or both ovaries with peritoneal implants outside the pelvis and /or positive retroperitoneal or inguinal nodes
o 3a – microscopic disease outside the true pelvis negative nodes
o 3b – abdominal deposit < 2cm size, negative nodes
o 3c – abdominal implants > 2cm size or positive nodes
o Stage 4 – growth involving one or both ovaries with distant metastases. If pleural effusion present, there must be positive cytology to allot a case to stage 4. Parenchymal liver metastasis equals stage 4
12
Q
- Lady with Ca Cx on biopsy. EUA extending unilaterally to left pelvic sidewall. Treatment options:
a) Radical hysterectomy and LN dissection
b) Radiotherapy then extended hysterectomy
c) Pelvic exenteration-
d) External beam radiation
e) Palliative irradiation
A
Stage 3b - Answer – chemoradiation therefore d : external beam radiation
Stage 2 a – lower 2/3rd of vagina
2b – parametrium
Stage 3a – lower 1/3rd of vagina
3b – pelvic side wall
Pelvic exenteration is an extensive operation that when used to treat vulvar cancer includes vulvectomy and often removal of the pelvic lymph nodes, as well as removal of one or more of the following structures: the lower colon, rectum, bladder, uterus, cervix, and vagina.
13
Q
- 2cm vulval lesion. Wide excision showed invasive Ca to 0.8mm beyond the basement membrane. Therapeutic options include:
a) nothing
b) wider excsion
c) simple vulvectomy
d) radical vulvectomy
e) option d) plus bilateral groin dissection
A
a
Stage 1a is tumour < or = 2 cm with < 1mm stromal invasion and does not require lymph node dissection or any further treatment
14
Q
- During a radical hysterectomy the uterine artery is divided at which of the following:
a) at its origin adjacent to the hypogastric artery
b) adjacent to the ureter
c) where it meets the uterus
d) in the wall of the uterus
A
a) at its origin adjacent to the hypogastric artery
Hypogastric artery ( internal iliac )
Branches – I love going places in my own underwear
Iliolumbar L – lumbosacral G – gluteal ( superior and inferior ) P – pudendal I – uterine M – middle rectal O – obturator U – umbilical
First three posterior divisions of anterior brance
Remainder anterior branches
15
Q
What percentage of women under 35 will have breast cancer?
a) 1/10
b) 1/60
c) 1/400
d) 1/100,000
A
b) 1/60
breast cancer lifetime risk ~12%. This means there is a 1 in 8 chance she will develop breast cancer.
16
Q
In adenocarcinoma of the cervix
a) conservation fo the ovaries is contraindicated
b) exogenous oestrogen is contraindicated
c) exogenous progesterone is contraindicated
d) all of the above
e) none of the above
A
e) none of the above
17
Q
What is the lifetime risk of developing ovarian cancer for a woman whose sister has developed ovarian cancer?
a) 0.1%
b) 1%
c) 5%
d) 20%
e) 50%
A
Answer c 5%
Life time risk 1 in 70
1st degree relative = risk 5%
2x first degree relative = 11%
18
Q
the incidence of lymph node involvement with micro-invasive disease of the cervix is:
a) 1%
b) 5%
c) 10%
d) 20%
e) 30%
A
Answer a – 0.6%
19
Q
Use of vault radiation in endometrial carcinoma aims to treat:
a) pelvic node secondaries
b) vaginal vault secondarises
c) para-aortic secondaries
d) femoral secondaries
A
b) vaginal vault secondarises
Stage 1c to 2 – external beam radiation and brachytherapy
- increased risk of recurrence
Stage 3 – chemoradiation
Stage 4 – palliation
Stage 1 - uterus
Stage 1 a – endometrium – TAH + BSO
B - <50% of myometrium – TAH + BSO
c> 50% of myometrium – radiotherapy
Stage 2 – uterus and cervix
A – inc endocervical glands
B- cervical stroma
stage 3 – outside uterus but remain in pelvis
a- uterine serosa, adnexa + peritoneal fluid
b- vagina mets
c- mets to pelvis and paraaortic ln
Stage 4 -
A – adjacent sites – bladder and rectum
B – distant sites intraabdominal and inguinal LN
20
Q
a 30 yo with abdo hyter for intraepithelial Ca of the cervix. Flushed, temp 39 C, PR 140/min, RR 24, clear chest. Most likely diagnosis?
a) PE – no sx
b) Pelvic sepsis secondary to bacteroides fragilis
c) Beta Strep
d) Pelvic vein thrombosis
e) Reaction to blood
A
b) Pelvic sepsis secondary to bacteroides fragilis
21
Q
All of the following are typical of massive PE except?
a) pulmonary vascular congestion on CXR
b) retrosternal chest pain
c) right ventricular strain on ECG
d) tachypnoea
A
a) pulmonary vascular congestion on CXR
CXR findings: Oligemia ( westermarks sign ), increased size of hilum by thrombus impaction, atelectasis with elevation of hemidiaphragm, pleural effusion consolidation, hamptons hump.
22
Q
- What do you do after TAH/BSO/PLND for endometrial ca with 1 positive LN invasion to inner 2/3 of myometrium
a) external beam MVT
b) progesterone
c) vault Caecium
d) chemotherapy
e) nil
A
a. External beam pelvic radiotherapy then vault brachytherapy
23
Q
- 32 yo PG presented at 12/40 for 1st antenatal visit. Pap smear showed CIN3. Colposcopy and biopsy revealed ?microinvasion. She is currently 16/40. Which of the following is correct?
a) cryotherapy
b) cold knife cone biopsy
c) laser cone
d) TAH
e) Radical hysterectomy
A
b. Knife cone biopsy
Although unless invasive cancer for treatment deferred until after pregnancy
24
Q
- Most common complication of radical vulvectomy.
a) haemorrhage
b) wound infection
A
B wound infection
Some wound breakdown is common, but this usually heals with conservative management. If the wound has been closed with skin flaps and necrosis has occurred, the dead skin should be debrided. Hematomas/seromas, although unusual if adequate drainage is maintained, may require evacuation. Signs of infection should prompt obtaining specimens for culture and instituting antibiotics. Urinary tract infection, thromboembolism, and osteitis pubis are additional potential complications.
Late sequelae include stenosis of the vaginal introitus and pelvic organ prolapse.
25
22. Woman who is 16 weeks pregnant with a breast lump which is confirmed to be carcinoma of the breast. She wants the pregnancy but also wants what is best for her?
a) terminate the pregnancy
b) luscs at 36 weeks
c) IOL at 36 weeks
d) Allow to go to term and deliver spontaneously
e) Deliver at 28 weeks
d) Allow to go to term and deliver spontaneously
Green top guideline
Treatment as per non pregnancy state
Diagnosis in pregnancy has no negative impact on survival
Metaanalysis found that gestational breast cancer was associated with higher risk of death, association primarily associated with diagnosis in the post partum
26
23. Management of stage 2 vulval carcinoma ( > 2cm lesion )
a) wide excision
b) radical vulvectomy
c) radical vulvectomy and ipsilateral XRT to groin
d) radical vulvectomy and deep inguinal and femoral LN dissection
e) wide excision and ipsilateral XRT to goin
Answer d with bilateral LN
Stage 1a – lesion confined to vulva with <1mm stromal invasion. No nodal mets – wide local excision, aim for 1cm clear margins
Stage 1b to Iva – Radical vulvectomy and bilateral groin node dissection
1b - <2cm, >1mm stromal invasion. No nodal mets.
Stage 2 vulval cancer - > 2 cm dimension with no nodal involvement
Stage 3 – adjacent spread to lower urethra , vagina or anus or unilateral node mets
Stage Iva – upper urethra, bladder mucosa, rectal mucosa, pelvic bone or lesions with bilateral groin node mets
4b – distant mets, inc pelvic nodes.
NICE GUIDELINE May 2014 –
- wide local excision and groin node dissection
27
24. In a patient with ovarian carcinoma and negative 2nd look laparotomy the chance of disease recurrence are ?
a) 0-20%
b) 20-40%
c) 40-60%
d) 60-80%
e) 80-100%
.
d)
Overall likelihood of relapse after intial therapy for all stages of disease for women with EOC is 62%
UTD: Taking into account the frequency of each stage of disease and its projected relapse rate, the overall likelihood of relapse after initial therapy for all stages of disease for women with EOC is 62 percent; it is 80 to 85 percent for women who present with stage III or IV disease. The likelihood for recurrence depends on many factors, including distribution of disease at initial presentation, success of initial surgical cytoreduction (ie, the presence of any residual disease), rapidity of CA125 resolution, and treatment response after primary therapy. However, a predictive marker for recurrence has not been prospectively verified
28
25. What percentage of patients with vulval carcinoma have tumours with a depth of invasion less than 1mm?
a) 1%
b) 5%
c) 10%
d) 20%
e) 30%
c) 10%
29
26. What percentage of patients with vulval carcinoma with a depth of invasion less than 1mm have nodal disease?
a) nearly zero
b) 2%
c) 5%
d) 10%
e) 20%
Answer a
Answer a nearly zero
30
27. All of the following constitutes indications for cone biopsy in pregnancy, except:
* a minimally invasive SCC on cervical biopsy
* b smear result suggestive of adenocarcinoma in-situ
* c inadequate colposcopy
* d none of the above
* e all or the above
d none of the above
31
28. The second most common vulval malignancy is:
a) sarcoma
b) verrucous carcinoma
c) melanoma
d) adenocarcinoma
e) basal cell carcinoma
c) melanoma
32
30. What is the country with the highest incidence of cervical cancer?
a) Japan
b) USA
c) India
d) Finland
e) France
c. India
33
31. A 32 yo woman counselling re ovarian cancer. 2 x 2nd degree Ca ovary – grandma and aunt. What would you advise?
a) reassure
b) yearly pelvic examination
c) yearly pelvic examination with Ca 125
d) yearly pelvic examination with Ca 125 + US with Doppler
a) reassure
34
32. 16 yo girl presents with pelvic discomfort and a complex cystic mass was found on US. At laparotomy, an immature teratoma was found in the right ovary. Most appropriate Mx:
* a RSO
* b R ovarian cystectomy
* c R ovarian cystectomy & wedge biopsy of L ovary
* d TAH, BSO omentectomy
* e RSO & wedge biopsy of L ovary
RSO
35
33. What is tumour marker for ovarian embryonal carcinoma?
* **
a) BHCG
b) AlphaFP
c) CEA
d) Ca 125
e) LDH
Answer a) b HCG
| Most of these tumors produce hCG, while some also make AFP
36
34. What is the next management in 40 yo P3 who has had a cone biopsy showing 1mm of invasive cancer and clear margin?
a) nil further
b) simple TAH
c) radical hysterectomy
d) TAH/BSO
a) nil further
37
35. Patient with a past history of Hodgkin’s disease, treated with chemotherapy. Now enquiring if she can get pregnant? Best test?
a) high FSH
a
38
36. On dermoids
a) 10% are malignant
b) the most common tumour found in pregnancy
c) 20% are bilateral
Answer b)
39
37. Management of stage 3b cervical cancer
a) palliative radiation
b) XRT
c) Exenteration
Answer b)
b) XRT
40
38. 45 yo with 2 family members with ovarian cancer who is booked for elective TAH for menorrhagia. Best option?
a) take out ovaries
b) HRT
a`
41
39. Most common site of primary metastases to the ovary?
a) pancreas
b) liver
c) kidney
d) breast
e) lung
d. breast
42
40. Use of vault radiation in endometrial cancinoma. Aim to treat:
a) pelvic node secondaries
b) vaginal vault recurrences
c) para-aortic node secondaries
d) femoral secondaries
Answer – vaginal vault recurrences
43
41. The most common lymph node involved in ca cervix:
a) femoral
b) obturator
c) external iliac -
d) para-aortic – ovarian
c. external iliac
UTD: The distribution of sites of nodal metastasis were: external iliac (43 percent), obturator (26 percent), parametrial (21 percent), common iliac (7 percent), presacral (1 percent), and paraaortic (1 percent).
Parametrial to internal, external and common ilian and obturator node – paraaortic and presacral late
44
42. What is the increased incidence if 1st degree relative has breast cancer?
a) 10%
b) 30%
c) 50%
d) 100%
e) 200%
d. 100%
- 1.5 x 3 pop average
lifetime risk of breast cancer is 1:8 (12.5%)
in one 1st degree relative with unilateral pre-menopausal breast cancer – 30% lifetime risk
so they put 30/12.5 = 240 – therefore 200% is closest
but is the answer actually b)??
if 1st degree relative with bilateral cancer life-time risk 40-50%
risk no significantly increased if 1st degree relative with post-menopausal breast cancer
45
43. What do you do after rad TAH/BSO/PLA for Ca endometrium with 1 pos pelvic node, invasion to inner 2/3 myometrium, grade 2.
a) external beam MVT
b) vault caesium
c) progesterone
d) chemo
e) nil
a radiation
46
44. A 70 yo lady has metastatic adenocarcinoma of the vagina. The most likely site of the primary is?
a) breast
b) kidney
c) uterus
d) ovary
c) uterus
47
45. A patient who is 28 yo who is at 14 weeks has a 2cm intraductal carcinoma of the breast, has a mastectomy and nodes. The next appropriate management is:
a) termination there and then
b) termination at 16/40
c) CS at 36/40
d) IOL at 36 weeks
e) Leave until term and manage expectantly
e) Leave until term and manage expectantly
48
46. The commonest location of metastatic deposit to the ovary?
a) thyroid
b) breast
c) kidney
d) gallbladder
b) breast
49
47. The treatment of 3cm Paget’s disease on the left labia
a) wide local excision with margin of 5 mm
b) wide local excision with margin of 2 cm
c) vulvectomy
a) wide local excision with margin of 5 mm
Invasive adenocarcinomas may be present within or beneath the surface lesion up to 25% (
Women with Paget disease of the vulva should also be evaluated for the possibility of synchronous neoplasms, as approximately 20 to 30 percent of these patients have a noncontiguous carcinoma (eg, involving breast, rectum, bladder, urethra, cervix, or ovary)
50
48. The ovarian tumour with characteristic signet ring cells is ?
a) endometrioid carcinoma
b) teratoma
c) Krukenberg tumour
d) Brenner tumour
c.
Krukenberg tumour, which can account for 30-40% of metastatic cancers to the ovaries, arises in the ovarian stroma and has characteristic mucin-filled signet-ring cells
Usually bilateral, lesions not usually discovered until the primary disease is advanced
Gastrointestinal cancers and breast cancer are the most common nongenital malignancies that metastasize to the ovary. In studies of 50 or more cases of metastatic neoplasms to the ovary, the sites of primary tumors included: colon cancer (15 to 32 percent); breast (8 to 28 percent); gastric (6 to 22 percent); and appendix (2 to 20 percent
51
49. Ovarian thecoma:
a) predominantly bilateral
b) may produce virilizing symptoms
c) occur predominantly in females less than 14
THECOMA — Thecomas are solid, fibromatous neoplasms and are generally benign. They are composed of theca cells and arise from the ovarian stroma
Thecomas are almost exclusively confined to one ovary and occur predominantly in postmenopausal women (average age 59 years). Thecomas may produce estrogen, and up to 20 percent of patients present with a synchronous endometrial cancer
52
50. Stage 2 ovarina carcinoma had the disease resected down to about 4cm. She had maximal chemotherapy. What is she most likely to die of?
a) uraemia
b) pyelonephritis
c) bowel obstruction
c) bowel obstruction
53
51. A 14 yo lady diagnosed to have adenocarcinoma of the left ovary stage 1a. What is your management?
a) LSO
b) TAH and BSO
c) TAH/BSO and omentectomy
d) TAH/BSO and omentectomy and radiotherapy
e) TAH/BSO and omentectomy and chemotherapy
a) LSO
Stage 1a – limited to one ovary, capsure intact no ascites
If 41 yr old with ovarian cancer – TAH.BSO omentectomy
54
52. Which of the following is correct about carcinoma of the vulva?
a) SCC at the clitoris associates with metastasis of both inguinal nodes at an early stage – No
b) Metastasis to the iliac node with negative inguinal nodes
c) A 3 cm lesion has a 33% chance of positive lymph nodes
d) Stage 3 disease has 40% chance of positive lymph nodes
c) A 3 cm lesion has a 33% chance of positive lymph nodes
```
0-1cm 7.7% LN
1.2-2cm – 23.9% LN
2.1 -3 cm 31%
3.5 36% LN
For all other patients with apparent early stage disease (ie, stage IB to II), inguinofemoral lymphadenectomy is performed because the risk of inguinofemoral lymph node metastases is ≥8 percen
```
90% SCC of vulva, spread by inguinofemoral LN.
Early stage,
Depth of invasion predictive of LN involvement.
< 4cm sentinel nodes were superficial in 85% cases and 15% sentinel nodes laid deep to cribiform fascia
Inguinofemoral lymphadenectomy is the standard approach to evaluation of the lymph nodes in women with vulvar cancer. Historically, pelvic lymph nodes were also removed, but this was found to have no diagnostic or therapeutic benefit.
Assessment for lymph node metastases is essential for staging. Unfortunately inguinofemoral lymphadenectomy is associated with high morbidity rates. This has led to a shift in practice toward unilateral lymphadenectomy whenever possible. Sentinel lymph node biopsy is an active area of investigation, is used in some institutions for women with early stage disease, and is increasingly being utilized in the US.
55
53. Which of the following is the best treatment option for carcinoma of the cervix stage 3?
a) rad hyst and bilateral inguinal lymphadenectomy
b) rad hyst and bilateringuinal lymphadenectomy and vault radiotherapy
c) external end extended field radiotherapy
d) extended field radiotherapy and chemotherapy
e) intracavity and extended filed radiotherapy
d) extended field radiotherapy and chemotherapy
Cervical Ca
Stage 1 – cervix
1a – microscopic 0.6% PLND
A1 – stromal invasion ≤ 3mm diameter or ≤ 7mm – 4.8 PLN
A2 – stromal invasion > 3mm -≤ 5mm ≤ 7mm
B > 7mm wide or > 5mm deep or visible ≤ 7mm – 15.9%
B1 < 4cm
B2 > 4cm
2 – beyond cervix but not pelvic side wall or vagina –
IIa – no parametrial but up to upper 2/3rd- 24.5%
IIb – parametrial but not ext to pelvic side wall – 31.4
3 – pelvic side wall, lower 1/3rd of vagina. Or hydronephrosis 44.8%
4 – beyond true pelvis or bladder and rectal mucosa – 55%
A – adj pelvic organs
B – distant mets
```
Treatment
1a1 – cone
1a2- 3-5, <7mm
modified radial or simple TAH with plnd
- if wanting fert then rept cone with lap PLND
1b1 - < 4cm ( 4.8%)
Wertheims hyst and PLDN or Chemorad
- fert sparing – radical trachelectomy then PLND
```
1b2-4a
Chemo rad
4b – palliative + rtx
56
54. Which is not a germ cell tumour?
a) granulosa cell tumour
b) dysgerminoma
c) embryonal cell tumour
d) immature teratoma
a) granulosa cell tumour
| – sex cord tumour / stromal
57
55. A 28 yo presents with threatened miscarriage at 16/40. O/E ecm exophytic lesion on cervix, punch biopsy confirms adenocarcinoma. Do you?
a) arrange EUA/cystoscopy / CXR / IVP
b) await maturity
c) irradiate
d) perform radhyst and PLND
e) reassess after TOP
a) arrange EUA/cystoscopy / CXR / IVP
58
56. 1st AN visit at 10/40. O/E 2 cm Ca cervix confined to cervix. SCC on biopsy. What would you advise patient?
a) rad hyst
b) cone biopsy
c) await fetal maturity
d) radiotherapy
neoadjuvant chemotherapy -> await fetal maturity c.
Stage IB1 (Tumor 2 cm or larger) and higher — For patients with stage IB tumors ≥2 cm or higher (table 1), we offer neoadjuvant chemotherapy if they have no evidence of lymph node involvement on lymphadenectomy. Alternatively, neoadjuvant chemotherapy can be administered without prior staging lymphadenectomy, in which case, surgical staging should be performed after delivery. (See "Management of locally advanced cervical cancer", section on 'Neoadjuvant chemotherapy'.)
In one review of 50 women treated with neoadjuvant chemotherapy, median gestational age at diagnosis was 19 weeks [33]. Chemotherapy was platinum-based and administered at three-week intervals until 33 weeks gestational age on average. The overall response rate was approximately 90 percent (62.5 percent complete response rate). With a median follow-up of two years, survival by stage was reported as (table 1):
●Stage IB1 – 94 percent
●Stage IB2 – 70 percent
●Stage >IB – 70 percent
If neoadjuvant chemotherapy is administered, treatment should continue up to 34 to 35 weeks of gestation with delivery planned three weeks later (ie, term). We would utilize the standard regimen administered to women with metastatic cervical cancer in the nonpregnant patient, which consists of cisplatin plus paclitaxel delivered every three weeks for up to six cycles [47]. However, it should be acknowledged that the literature regarding the use of chemotherapy in pregnancy is based on case reports and small series [48,49]. Still, these series have mostly reported a relatively favorable risk profile for fetal, neonatal, and maternal complications. We agree with the guidance from the Second International Consensus Meeting on Gynecologic Cancers in Pregnancy and suggest not administering gemcitabine, vinorelbine, topotecan, or biologic agents (including antiangiogenesis agents) in the pregnant patient because of the lack of safety data [33].
The majority of studies do not suggest a difference in the oncologic prognosis of women with invasive cervical cancer diagnosed during pregnancy compared with nonpregnant women with invasive cervical cancer when adjusted for stage; however, data are limited [8,9,53,64-66]. As an example, a retrospective study compared 40 women with pregnancy-associated cervical cancer with 89 nonpregnant women with cervical cancer [8]. Maternal survival was not significantly different in both groups after 30 years of follow-up. Another study evaluated 53 women with stage IB disease diagnosed in pregnancy [9]. Five-year survival was similar to that of nonpregnant controls and was not affected by the time of initiation of therapy during the pregnancy. A large, long-term series of pregnant women with invasive cervical cancer reported 5.5 percent developed a second primary, which is similar to the second primary rate in all women under 50 years of age
59
57. 55 yo with Ca cervix. At EUA tumour extends to one pelvic side wall. Best treatment options?
a) rad hyst and nodes
b) exenteration
c) palliative radiotherapy
d) vaginal radiotherapy then extended hysterectomy
e) external beam radiotherapy – full treatment dose
e) external beam radiotherapy – full treatment dose
CHEMORAD
Stage 3 – extend to pelvic sidewall or lower 1/3rd of vaginal or hydroneph
A – no obv parametrial involvement but involvement of lower 1/3d
B- ext to pelvic side wall and hydronephrosis or non functioning kidney
60
58. What is the lifetime risk of ovarian cancer for someone with one first degree relative with Ca ovary?
a) 1%
b) 5%
c) 25%
d) 50%
e) 90%
b. 5%
Lifetime prob of getting ovarian cancer in US population – 2%
The risk of ovarian cancer is increased when the family history suggests a sporadic case but is substantially greater when there is a hereditary cancer syndrome. A meta-analysis of pooled case-control studies calculated an odds ratio of 3.1 for developing ovarian cancer in women with one first- or second-degree relative with the disorder [8]. Based upon these data, it was estimated that a family history of ovarian cancer in one relative increased the lifetime probability of ovarian cancer in a 35-year-old woman from 1.6 to 5.0 percent. In contrast, women with hereditary ovarian cancer syndromes have a lifetime probability of ovarian cancer of 25 to 50 percent
61
59. A 28 yo woman in her first pregnancy presents with a threatened miscarriage at 16/40. O/E a 3 cm exophystic lesion is seen on her cervix. A punch biopsy confirms adenocarcinoma. Do you?
a) await maturity
b) arrange EUA/cystoscopy/CXR/IVP
c) irradiate
d) perform radical hysterectomy/PLND
e) reassess after TOP
b arrange EUA/cystoscopy/CXR/IVP
62
60. For which of the following reasons is radiotherapy given following surgery for endometrial cancer?
a) prevent recurrence in pelvic lymph nodes
b) prevent recurrence at the vault
c) prevent recurrence in para-aortic lymph nodes
b) prevent recurrence at the vault
63
61. What percentage of lymph nodes are involved in microinvasive cancer of the cervix?
a) 1%
b) 5%
c) 10%
d) 30%
e) 50%
a) 1%
64
62. Which of the following is true regarding adencocarcinoma of the cervix?
a. adenocarcinoma iS just as radiosensitive as SCC
b. ovarian conservation is CONTRAINDICATED with adenocarcinoma
c. all of the above
d. none of the above
B
A. – responds differently to radiotherapy, less sensitive
– higher risk of ovarian mets compared to SCC
65
64. What is the best management of a 3 cm vulval carcinoma?
a) wide local excision
b) radical vulvectomy
c) radical vulvectomy and ipsilateral LN
d) radical vulvectomy and bilateral LN
e) radiotherapy
d) radical vulvectomy and bilateral LN
66
66. 65 yo presents with post-menopausal bleeding. D+C – adenocarcinoma grade 3, endometrial. Treatment?
a) vaginal hysterectomy
b) TAH / BSO
c) Radical hysterectomy + BSO
d) TAH / BSO and LN
d) TAH / BSO and LN
TAHBSO + washing then post op – ext beam rtx and
67
67. nts about cervical cancer are proven true except?
a) celibacy protects women for Ca cervix - True
b) having a circumcised male partner is protective for the women – True
c) first intercourse after 27 yrs associated with lower indicence of Ca cx – True
d) divorced women have a greater incidence of Ca cx than married women
e) prostitutes have a higher incidence than a control population - True
d) divorced women have a greater incidence of Ca cx than married women
68
65. Biopsy of cervix confirms invasive squamous cell ca. On EUA extends to pelvic side wall on 1 side. Treatment?
a) radical hysterectomy and LN
b) radiotherapy with external beam
c) intracavity radiotherapy followed by radical hysterectomy
d) pelvic exenteration
Stage 3 - Chemorad
69
68. post menopausal lady with TAH/BSO for fibroids. On sectioning leiomyomatous change found in one fibroid. Subsequent management?
a) radioactive gold
b) watch carefully
c) pelvic lympadenectomy
d) radiotherapy
e) chemotherapy
b) watch carefully
70
69. 32 yo G2P2 with mole. Fundal height 28 weeks. Best method of evacuation?
a) IOL abdominal hysterotomy
b) Suction curettage
c) D&C
d) TAH
b) Suction curettage
71
70. Woman with large pelvic mass. Pre op CXR showed no pleural effusion. At operation ascites nad bilateral multiloculated 8 cm cystic ovaries. Papillary tumour nodules ranging from 0.5-1.5 cm in diam were present on pelvic peritoneum, small bowel mesentery and serosa and liver capsule. Microscopic disease in aortic lymph nodes. Cytology of ascites negative. Stage of ovarian cancer?
a) 2c
b) 3a
c) 3b
d) 3c
e) 4 ( parenchymal mets )
d. 3c
72
71. On routine exam a 70 yo widow is found to have a pap test showing squamous atypia. Colp exam of cervix reveals only normal squamous epithelium on the ectocervix and TZ not visualised. ECC reveals benign squamous and endocervical glandular epithelium. Next?
a) Cone – ASC-H
b) fractional D&C
c) vaginal oestrogen therapy then repeat colp
d) test for HPV
c) vaginal oestrogen therapy then repeat colp
ASC-H or ASCUS – unsatisfactory colp or cytology review and confirmed ASC-H or HSIL – cone
If ASCUS then HPV if +ve colp
73
72. A 45 yo woman underwent primary cytoreductive surgery for a stage 3 epithelial ovarian cancer. After 6 course of cisplatin and cyclophosphamide a second look operation was positive. She developed progressive abdominal disease during second line treatment with intraperitoneal cisplatin and 5FU. Trials of carboplatin and a new drug failed to control her disease. She is admitted in a severely malnourished condition with a small bowel obstruction. The statement that best reflects the patinet’s current management is?
a) because of her age, she should be urged to undergo a second trial of investigational chemo
b) home TPN sould be instituted as soon as possible –
c) discussion of NFR status should be avoided because emotional trauma may result \
d) relief of pain and vomiting is likely to be this patient’s foremost concern
d) relief of pain and vomiting is likely to be this patient’s foremost concern - T
74
73. A gynaecologist removes a 2 cm ulcerating lesion with sharp rolled edges from the lateral aspect of the right labium majus in an 80 yo patient. The lesion had been present for 15 yrs. Path shows BCC with one surgical margin involved. The best Mx?
a) observation for local recurrence and wide resection if noted
b) application of topical chemotherapy
c) further excision
d) hemivulvectomy with ipsilateral node dissection
c) further excision
Basal cell carcinoma — Two percent of vulvar cancers are basal cell cancers and 2 percent of basal cell cancers occur on the vulva [24]. They usually affect postmenopausal Caucasian women and may be locally invasive, although usually nonmetastasizing [18,25]. The typical appearance is that of a "rodent" ulcer with rolled edges and central ulceration; the lesion may be pigmented or pearly and gray. They are often asymptomatic, but pruritus, bleeding, or pain may occur.
Basal cell carcinomas are associated with a high incidence of antecedent or concomitant malignancy elsewhere in the body [25]. Thus, a thorough search for other primary malignancies should be performed.
4 to 5 mm margins are generally recommended, and five-year cure rates exceeding 95 percent can be expected (
75
74. 21 yo G0P0 comes for contraceptives. Had inutero DES exposure. VE -> small cervix, flush with vaginal fornices, and anterior cervicovaginal ridge. Best Mx of DES exposed patient?
a) patients with adenosis should be treated with CO2 laser -
b) need a pap smear every 6/12
c) the CO2 laser is the most appropriate Rx of high grade CIN in DES exposed patients.
d) DES patients are increased risk of infertility
d) DES patients are increased risk of infertility – subfertility
Vaginal adenosis has been identified in vaginal smears of post-hysterectomy patients, not associated with DES exposure (Eur J Gynaecol Oncol 2000;21:43); may be metaplastic, due to chemotherapy, radiation or Tamoxifen
In a large cohort study of DES-exposed women (the National Cooperative Diethylstilbestrol Adenosis [DESAD] project), one-third of these women had vaginal and cervical adenosis [33]. The prevalence of adenoses in DES daughters has been reported as high as 91 percent in some studies compared with 4 percent in non-DES-exposed controls [22].
Adenosis often regresses over time [34], thus treatment is unnecessary except in rare women who are symptomatic. Although benign, adenosis is considered a precursor of CCA; the factors that promote malignant transformation of adenosis to CCA are not known.
76
75. A 59 yo woman complains of early satiety and distension. Physical exam reveals an irregular pelvic-abdominal cystic mass approx 15 cm in greatest diameter. Physical findings are consistent with ascites. In addition to CXR, preliminary evaluation of this patient prior to exploratory laparotomy should include:
a) paracentesis
b) laparoscopy and US examination of the abdomen and pelvis
c) CA 125 measurement and CT abdomen and pelvis
d) Lymphangiography
e) Liver scan
c) CA 125 measurement and CT abdomen and pelvis
77
76. A patient with stage 3, grade 3, papillary serous ovarian carcinoma was treated with TAH/BSO and omentectomy, followed by 8 courses of ciplatin-based chemotherapy. A second look laparotomy, including pelvic and para-aortic lymph node removal, was negative. 18 months later, an asymptomatic 4 cm pelvic mass at the vaginal apex if found on pelvic exam. The most likely explanation for this finding is?
a) diverticular abscess
b) lymphocyst
c) recurrent ovarian cancer
d) suture granuloma
c) recurrent ovarian cancer
78
77. A 29 yo woman presenting with menometrorrhagia was found to have a 6 cm left adnexal mass, and adenomatous hyperplasia was found on endometrial biopsy. She is interested in preserving her fertility. D&C revealed focal adenomatous hyperplasia. At laparotomy Lso was performed with the removal of a 5x7 cm firm mass. Frozen section – granulosa cell tumour. A staging evaluation (cytology, peritoneal patch biopsies and node biopsies) was compelted. According to the patinet’s wishes, no additional extirpative surgery was performed. The final path confirmed the FS report and the stagin biopsies and cytology showed no tumour. In counselling the patient postoperatively about prognosis and future treatment, you advise her that?
a) this tumour is likely to recur but no for many years
b) she will benefit from adjuvant chemnotherapy –
c) close clinical follow up without additional surgery is acceptable
d) surgery less extensive than hysterectomy and BSO is incomplete treatment – needs TAH BSO once childbearing complete
e) this tumour is not radiosensitive
c) close clinical follow up without additional surgery is acceptable
b. no - n Surgery alone is acceptable treatment for most women with granulosa cell tumors, since the majority are stage IA and confined to one ovary at the time of diagnosis (table 2) [37]. Long-term disease-free survival rates are approximately 90 percent.
Granulosa cell tumors have malignant potential (ie, the ability to metastasize). They are the most common type of potentially malignant ovarian sex cord-stromal tumor; they comprise 2 to 5 percent of all ovarian malignancies [1].
There are two subtypes, adult and juvenile. The adult subtype, which occurs most commonly in middle aged and older women (median age 50 to 54 years), comprises 95 percent of these neoplasms.
The juvenile type comprises 5 percent of all granulosa cell tumors [4]. They typically develop before puberty, and thus, are more common among children and young women. This subtype tends to have a higher proliferative rate than the adult type and a lower risk for late recurrences.
The discussion below relates mainly to the adult subtype.
Granulosa cell tumors appear to be more common in women who are non-white, obese (body mass index >30), and have a family history of breast or ovarian cancer [5]. The risk appears to be decreased in women who are current or past smokers or users of oral contraceptive pills, and in those who are parous.
79
78. a 28 yo nulliparous woman who smokes one pack of cigarettes per day and whose mother has endometrial cancer asks how she can reduce her own risk of the disease. The most effective way to reduce the risk is to ?
a) use a barrier contraceptive
b) take combination oral contraceptives
c) stop smoking
d) maintain ideal weight
d) maintain ideal weight
80
79. You have just made the diagnosis of atypical endometrial hyperplasia in a 32 yo woman with PCO who wants to retain her fertility. She is concerned about developing carcinoma. Which of the following is true about this patient’s condition?
a) her risk of developing cancer approaches 50%
b) if cancer occurs it is likely to be grade 2 or 3
c) if cancer occurs it is likely to be deeply invasive
d) her risk of cancer will be reduced if she becomes ovulatory
d. her risk of cancer will be reduced if she becomes ovulatory
81
81. 14 yo with 3x3 cm breast lump lateral to nipple, no fliud obtained on FNA. Options?
a) RV 6 months
b) Bilateral mammogram
c) Excisional biopsy
d) US localised biopsy
e) Canalise mammary duct adjacent
d) US localised biopsy
82
83. Metastatic carcinoma of the vagina account for > 50% of cases. THe most common primary is from?
a) ovary
b) cervix
c) kidney
d) endometrium
e) fallopian tube
b. cervix
➢ 92% are squamous carcinoma of vagina, commonest type of cervical cancer is SCC 70-80%, only 20% are adenocarcinoma
➢ Endometrial cancer – commonest type is Adenocarcinoma (95%)
83
85. The most appropriate treatment for a patient with poorly differentiated adenocarcinoma of the endometrium is?
a) simple hysterectomy
b) TAH/BSO
c) Radiotherapy
d) Chemotherapy
e) TAH/BSO and pelvic LN dissection
e) TAH/BSO and pelvic LN dissection
84
86. Patients with hyperthyroidism with trophoblastic tumours have?
a) high total T4 +T3
b) high free T4 + T3
c) decrease TSH
d) all of the above
d) all of the above
85
`87. Treatment with wide local excision in all except?
a) Paget’s
b) Melanoma
c) Carcinoma in situ
d) Itch
d. itch
86
88. 36 yo G3 P2 with a 3cm x 3 cm lump at 34 weeks gestation. To investigate for carcinoma which is the best investigation?
a) mammogram
b) thermogram
c) FNAB
d) Excision biopsy
d) Excision biopsy
Excision core incision – secondary to high risk inadeq tissue
87
89. 60 yo woman with PMB and D&C revealed poorly differentiated endometrial ademocarcinoma. Mx?
a) Pfannenstiel & TAH/BSO
b) Vertical incision & TAH/BSO
c) Vertical incision & Wertheim’s radical hysterectomy
d) Vertical incision, TAH/BSO, PLND
d) Vertical incision, TAH/BSO, PLND
88
90. Highest incidence of vaginal malignancy is?
a) VAIN
b) Metastatic carcinoma of the cervix
c) Clear cell adenocarcinoma with exposure to DES
d) Primary SCC of the vagina
e) Vaginal metastases from adenocarcinoma of the endometrium
b) Metastatic carcinoma of the cervix
Primary Vaginal cancer rare < 1% of all malignancy, UTD
Uterine most common gynae malignancy
Cervix 2nd most common cancer – 18/100 000
89
91. Regarding Ca cervix in young < 35 yo cf older age groups which is true?
a) more aggressive tumour
b) even if node neg 1b or 2a high chance of recurrence
c) no difference in course of disease
c) no difference in course of disease
90
92. What is next management in 40 yo P3 who has had a cone biopsy showing 1 mm of invasive ca and clear margins?
a) nil further
b) simple TAH
c) rad hyst
d) TAH/BSO
a) nil further
91
93. Detection rate of FNA in benign and malignant breast tumour?
a) 50%
b) 70%
c) 90%
d) 99%
e) 100%
c) 90%
92
94. Which is most malignant?
a) granulosa cell tumour
b) thecoma – bening sex cord stromal tumour
c) luteoma – benign assoc wti preg, inc p and Estrogen. Resolve post delivery.
d) hilus cell tumour – Leydig cell tumours
e) Sertoli tumou
a) granulosa cell tumour
93
95. Ovarian cancer assoc with Peutz-Jegher syndrome?
a) papillary serous cancer
b) mucinous
c) endometrial ca
d) clear cell ca
e) sex cord stromal
e) sex cord stromal
Hereditary cancer syndrome, assoc with gynae tumours
Tumour phenotype – GI hamarthomatous polyps, tumours of stomach, duodenum, colon, ovarian sex cord tumour with annular tubules
94
96. PMB – D&C with undifferentiated adenocarcinoma. Mx?
a) TAH & BSO
b) Irradiation
c) Radical hyst
d) TAH/BSO and pelvic nodes
d) TAH/BSO and pelvic nodes
95
97. Patient presents 4 months after a term delivery with daily pv bleeding. Serum bhCG 104,000IU. CXR shows multiple opacities. CT head and abdo normal. LFTs normal. Management:
a) Methotrexate – only for low risk score less than = 6
b) hysterectomy to debulk disease
c) suction curette – role in GTN limited unless persistent bleeding, to determine rpoc or GTN, biopsy not needed as tumour are very vascular and increase risk of haemorrhage
d) combined chemotherapy
e) lumbar puncture
d) combined chemotherapy
Choriocarcinoma, most common type of GTN
WHO prognostic scoring system. Risk assessment Score 2 ( term ), 1 ( interval months from preg ), 4 ( serum hcg >10x5), = score 7 therefore high risk patients with high risk of resistance to single agent chemo
Overall cure close to 85%
96
98. 3cm lesion on left lateral labium. Biopsy shows Paget’s disease. Management:
a) excision with 5mm margin
b) excision with 2cm margin
c) simple vulvectomy
d) radical vulvectomy
e) radical vulvectomy and lymph node dissection
b) excision with 2cm margin
97
99. 60y woman with 8cm pelvic mass on examination. Best investigation to give a differential diagnosis?
a) upper GI series
b) cholecystogram
c) IVP
d) Barium enema
e) Plain AXR
d) Barium enema
98
100. Treatment of non metastatic gestational trophoblastic tumour in a 21yo who had D&C 8 weeks earlier is:
a) single agent chemotherapy
b) multi agent chemotherapy
c) radiotherapy
d) hysterectomy
e) D&C
) single agent chemotherapy
99
101. Which of the following organs is most resistant to radiation?
a) liver
b) kidney
c) ovaries
d) spleen
e) bladder
b) kidney
100
102. 60 yo woman presented with a 3cm lesion in the posterolateral part of the right labium. Punch biopsy suggested changes consistent with Paget’s disease of the vulva. No inguinal node palpable. What is the most appropriate treatment?
a) local excision with 5mm extra surgical margin
b) local excision with 2cm extra surgical margin
c) skinning vulvectomy
d) simple vulvectomy
e) radical vulvectomy
b) local excision with 2cm extra surgical margin
101
103. Which of the following are correct about vulvar carcinoma except:
a) radical vulvectomy and bilateral lymphadenectomy for stage 2 disease is adequate – incorrect now but true = treatment
b) 3cm SCC on the right vulva, radical vulvectomy showed clear surgical margins and bilateral inguinal lymphadenectomy showed one positive node. Additional pelvic and groin irradiation is needed – stage 3 therefore wide local excision and radiotherapy
c) Pelvic exenteration combined with radical vulvectomy and bilateral groin dissection performed for stage 3 disease only for a younger and psychologically fit woman – False
d) Chronic leg oedema is found in 60-70% of patients after a bilateral inguinal lymphadenectomy ( - 21% for lymphadenopathy ) 20-40% wound breakdown and 30-70% lymphoedema, no comparative data from unilat and bilat Lymphadenopathy )
e) Wound breakdown and infection reported in up to 85% of patients having en bloc operation -
e) Wound breakdown and infection reported in up to 85% of patients having en bloc operation -
102
104. When you are doing a radical hysterectomy you make a hole in the external iliac vein. What is you immediate management?
a) put a finger over the hole
b) put a sponge over the hole
c) put a Kelly clamp over the hole
d) put a Kelly clamp distal to the hole
e) put a Kelly clamp proximal and distal to the hole.
a) put a finger over the hole
103
106. ovarian thecomas are associated with
a) Brenner tumour
b) Kruckenberg tumour
c) Granulosa cell tumour
d) Endometrioid tumour
e) Mucinous cystadenoma
d) Endometrioid tumour
104
107. Which of the following is the commonest tumour of the round ligament?
a) paramesonephric tumour
b) mesonephric tumour
c) leiomyoma
d) Gartner’s duct tumour
e) Metastatic carcinoma
c) leiomyoma
105
108. Patient presents at 16w. Examination revels a 3cm diameter cancer of the cervix. Management:
a) EUA, CXR, IVP, cystoscopy
b) Suction TOP and XRT
c) Rad hyst and PLND
a) EUA, CXR, IVP, cystoscopy
106
109. Which of the following is divided in performing an omentectomy?
a) omental branch of the abdominal aortic artery
b) middle colic artery
c) epigastric artery –
d) gastroepiploic artery –
e) median sacral artery -
d) gastroepiploic artery –
The right and left gastroepiploic arteries provide the sole blood supply to the greater omentum. Both are branches of the celiac trunk. The right gastroepiploic artery is a branch of the gastroduodenal artery, which is a branch of the common hepatic artery, which is a branch of the celiac trunk. The left gastroepiploic artery is the largest branch of the splenic artery, which is a branch of the celiac trunk. The right and left gastroepiploic arteries anastomose within the two layers of the anterior greater omentum along the greater curvature of the stomach.
107
114. Regarding Meigs syndrome
a) it is associated with fibromas > 10 cm
b) pleural effusions are composed of peritoneal fluid
c) pleural effusions are more common on the left side
a) it is associated with fibromas > 10 cm
Meigs' syndrome, also Meigs syndrome, is the triad of ascites, pleural effusion and benign ovarian tumor (fibroma,Brenner tumour and occasionally granulosa cell tumour).[1][2][3] It resolves after the resection of the tumor. Because the transdiaphragmatic lymphatic channels are larger in diameter on the right, the pleural effusion is classically on the right side. The etiologies of the ascites and pleural effusion are poorly understood.[1] Atypical Meigs' syndrome, characterized by a benign pelvic mass with right-sided pleural effusion but without ascites, can also occur. As in Meigs syndrome, pleural effusion resolves after removal of the pelvic mass.[1]
108
115. During a TAH for severe endometriosis a 1cm longitudinal incision is accidentally made in sigmoid colon with the scalpel. Mx.
a) Hartmanns procedure and colostomy
b) End to end reanastomosis
c) Simple closure
d) Simple closure and caecotomy
e) Repair and transverse colostomy
c. simple closure
If serosa only then watch
If serosa and muscle cut then repair in 2 layers
• 2 layer closure perpendicular to the lumen of the bowel
• use interrupted delayed absorbable stitches for the mucosa layer 3-0
• use interrupted isld for the second layer
if multiple defects then better to resect bowel and do a primary closure
if major (>5cm) defect in large bower and bowel not prepped, then do a loop closure and put back in 4-6 months
Incidence of intestinal perforation is 0.7%
• 37% during entry to the abdomen, 35% dissecting adhesions, 10% laparoscopy, 9% at vaginal surgery
• 75% small bowel, 25% large bowel
109
116. Difficult TAH for endometriosis, with difficultly with haemostasis. Finally haemostasis secured but stitch uncomfortably close to left ureter at top of vaginal vault.
a) do nothing, observe closely post-op
b) Ureterotomy at level of pelvic brim and insert ureteric stent
c) Cystotomy and insert stent into left ureter
d) Injection of indigo carmine IV and follow dye flow through ureter
e) Remove suture
Cystoscopy and IV Carmine indigo
| To assess ureter flow
110
119. A woman in her 30’s with postcoital and IMB attends her LMO. She is referred to you with a Pap smear showing CIN2 and many inflammatory cells. On speculum examination she has an exophytic lesion on the posterior lip; the remainder of the examination is unremarkable. Your next step in management is:
a) colposcopy
b) punch biopsy
c) cone biopsy
d) antibiotics
b) punch biopsy
111
122. A 47 y.o. woman with irregular heavy bleeding has a curette. Pathology shows atypical adenomatous hyperplasia. What is the best treatment?
a) MPA 100mg IM monthly
b) TAH
c) NSAIDs
d) Hysteroscopy to rule out cancer, then rollerball diathermy
e) Nd-YAG laser endometrial ablation
b) TAH
112
123. Regarding thecoma, which is incorrect?
a) usually benign
b) commonly unilateral
c) associated with virilisation
d) may be associated with endometrial hyperplasia
e) usually occurs in prepubertal girls
e) usually occurs in prepubertal girls
113
124. Which of the following is not an indication for abandoning a radical hysterectomy for cervical cancer?
a) Stage 2A disease – beyond cervix and upper 2/3rd of vagina = chemoradiation
b) Involvement of the para-aortic lymph nodes – Not part of staging
c) Parametrial extension to the pelvic side wall on one side – stage 2b = chemoradiation
d) Involvement of one ovary =
a) Stage 2A disease
114
125. Uterine sarcoma. Risk factors include:
a) family history
b) multiparity – not conclusive
c) previous pelvic irradiation
d) exogenous oestrogen
c) previous pelvic irradiation – definite risk factor
115
125. Uterine sarcoma. Risk factors include:
a) family history
b) multiparity – not conclusive
c) previous pelvic irradiation
d) exogenous oestrogen
c) previous pelvic irradiation – definite risk factor
116
126. Ca of one ovary. One lymph node with tumour between renal vein and IVC. Stage is:
a) Ia
b) I
c) II
d) III
e) IV
d. 3
117
1. Lady with Ca Cx on biopsy. EUA extending unilaterally to left pelvic sidewall. Treatment options:
a) Radical hysterectomy and LN dissection
b) Radiotherapy then extended hysterectomy
c) Pelvic exenteration
d) External beam radiation
e) Palliative irradiation
d) External beam radiation
| Stage 3
118
129. 34 yo pelvic clearance for ovarian Ca develops hot flushes at 6 weeks visit. Previously on OCP. Mother has past history of Colles fracture, sister of breast Ca. Normal breast examination. Therapeutic options include:
a) initiate clonidine
b) oestrogen alone
c) oestrogen after bone densitometry
d) oestrogen and progesterone after mammography
e) recommence OCP
b) oestrogen alone
119
130. What percentage of women under 35 will have breast cancer?
a) 1/10
b) 1/60
c) 1/400
d) 1/100,000
c. 1/400'
1 in 453
2.4% diagnosed before age 35, and 1% diagnosed before age 30Table 1
Risk of Breast Cancer as Function of Age Estimated From Women Diagnosed in the US SEER17 Registries, 2004
```
Age (yr) Risk: 1 in ×
15 571,429
20 75,188
25 8,684
30 1,523
35 453
40 173
45 82
50 45
55 30
60 21
65 15
70 12
75 9
80 8
85 7
UTD Risk of breast cancer - Birth to age 39 – 0.49 (1 in 203 women)
```
120
133. In adenocarcinoma of the cervix
a) conservation of the ovaries is contraindicated
b) exogenous oestrogen is contraindicated
c) exogenous progesterone is contraindicated
d) all of the above
e) none of the above
e) none of the above
Treatment guideline as SCC but observational studies show worse prognosis compared to SCC
When adjusted for stage, some series support the prognostic equivalence of cervical adenocarcinoma versus SCC, but most have shown that adenocarcinoma carries a worse prognosis
One of the largest studies included 24,562 patients with cervical cancer from the Surveillance, Epidemiology and End Results database, of whom 77, 17, and 6 percent had squamous cell, adenocarcinoma, and adenosquamous carcinoma, respectively [31]. The main findings were:
●An increased risk of death for women with adenocarcinoma compared with SCC (odds ratio [OR] 1.39, 95% CI 1.23-1.56) who presented with early-stage cervical cancer (stage IB1 to IIA) (table 3).
●An increased risk of death for women with adenocarcinoma who presented with higher-stage disease (stage IIB to IVA) (OR 1.21, 95% CI 1.10-1.32).
The worse outcomes reported in many series have been attributed to several factors, including:
●A higher rate of distant metastases with adenocarcinomas (particularly those >4 cm) compared with SCC [4,30,32,33].
●Higher rates of human papillomavirus (HPV)-18 infection [34,35].
●A higher incidence of nodal metastases (32 versus 15 percent with SCC in one series [36]) and a significantly worse overall survival among those who have lymphatic metastases [29,36,37].
Indications for adjuvant therapy after hysterectomy — As with cervical SCC, women with one or more of the following findings are considered to be at high riskfor recurrent disease and should receive adjuvant chemoradiotherapy following hysterectomy:
●Positive or close resection margins
●Positive lymph nodes
●Microscopic parametrial involvement
121
135. What is the lifetime risk of developing ovarian cancer for a woman whose sister has developed ovarian cancer?
a) 0.1%
b) 1%
c) 5%
d) 20%
e) 50%
c) 5%
122
137. The most common presenting symptom for molar pregnancy is:
a) abnormal bleeding
b) hyperemesis
c) fundus larger than dates
d) thyrotoxicosis
e) pre-eclampsia
a) abnormal bleeding (84%)
b) hyperemesis ( 8%)
c) fundus larger than dates ( 28%)
123
138. What degree of cervical dysplasia must be treated in pregnancy?
a) HPV
b) CIN2
c) CIN3
d) All of the above
e) None of the above
e) None of the above
124
144. Lichen planus, incorrect option
a) purple scaly patches
b) white mucosal lesions
c) flexor surfaces
d) erosive vaginitis
e) saw tooth rete pegs - true
f) corticosteroids effective
All correct??
Hypertrophic lichen planus – Hypertrophic lichen planus is characterized by the development of intensely pruritic, flat-topped plaques (picture 6). The typical site of involvement is the anterior lower legs. Of note, the occasional development of cutaneous squamous cell carcinoma has been reported in patients with longstanding hypertrophic lichen planus lesions [25].
●Annular lichen planus – Annular lichen planus is characterized by the development of violaceous plaques with central clearing (picture 7A-C). Although the penis, scrotum, and intertriginous areas are common sites of involvement, annular lesions may occur in other areas [26]. Central atrophy may be present.
●Bullous lichen planus – Patients with bullous lichen planus develop vesicles or bullae within the sites of existing cutaneous lichen planus lesions. The legs are a common site of lesion development [2].
●Actinic lichen planus – Actinic lichen planus (also known as lichen planus tropicus) presents with a photodistributed eruption of hyperpigmented macules, annular papules, or plaques [2]. This variant is most commonly seen in the Middle East, India, and east Africa [4].
●Lichen planus pigmentosus – Lichen planus pigmentosus presents with gray-brown or dark brown macules or patches that are most commonly found in sun-exposed or flexural areas [27]. Pruritus is minimal or absent. The term “lichen planus pigmentosus-inversus” is used to describe patients with primarily flexural involvement [28].
●Inverse lichen planus – Inverse lichen planus is characterized by erythematous to violaceous papules and plaques in intertriginous sites, such as the axillae, inguinal creases, inframammary area, or limb flexures (picture 8) [2]. Associated hyperpigmentation is common. Scale and erosions may be present.
●Atrophic lichen planus – Atrophic lichen planus presents with violaceous, round or oval, atrophic plaques. The legs are a common site of involvement [2], and lesions often clinically resemble extragenital lichen sclerosus. A rare annular atrophic variant of lichen planus characterized by violaceous papules that enlarge peripherally leaving an atrophic center that demonstrates complete loss of elastic fibers on pathology has also been reported [29-31].
●Lichen planopilaris (follicular lichen planus) – The scalp is the classic site for lichen planopilaris. However, follicular involvement manifesting as follicular papules may be observed in other body sites, particularly in patients with the Graham-Little-Piccardi-Lasseur syndrome. (
125
145. What is reason not to abandon surgery for cervical cancer?
a) stage 2a
b) positive paraaortic lymph node
c) intraperitoneal tumour
d) pelvic side wall involvement
a) stage 2a
126
146. What do you do after TAH/BSO/PLND for endometrial ca with 1 positive LN invasion to inner 2/3 of myometrium
a) external beam MVT
b) progesterone
c) vault Caecium
d) chemotherapy
e) nil
a.
Stage 3 – Chemo then radiotherapy
127
147. 32 yo PG presented at 12/40 for 1st antenatal visit. Pap smear showed CIN3. Colposcopy and biopsy revealed ?microinvasion. She is currently 16/40. Which of the following is correct?
a) cryotherapy
b) coldknife cone biopsy
c) laser cone
d) TAH
e) Radical hysterectomy
b) coldknife cone biopsy
Invasive conisation only if invasive disease suspected, UTD recommends
For pregnant women with CIN 2,3, if invasive disease is not suspected, there are two options for follow-up [2,38-40]:
●Repeat evaluation with cytology and colposcopy during the pregnancy, but not more often than every 12 weeks. A biopsy may be repeated only if the appearance of the lesion worsens or if cytology suggests invasive disease. Endocervical sampling with a curette and endometrial sampling should NOT be performed, as there is a risk of disturbing the pregnancy.
●Alternatively, reevaluation may be deferred until six weeks postpartum.
A diagnostic excisional procedure is performed only if invasive disease is suspected (see "Cervical cancer in pregnancy"). High-grade lesions discovered during pregnancy have a high rate of regression in the postpartum period. As an example, in one study, 70 percent of 153 women with CIN 3 had regression, and none progressed to invasive carcinoma [38]. This underscores the role for conservative antepartum management followed by careful postpartum evaluation. Furthermore, the morbidity associated with cervical conization during pregnancy is substantial.
128
148. Which of the following combinations is correct?
a) Struma Ovari – carcinoid tumour
-
b) Lymphocytic infiltration and large vacuolated cells – dysgerminoma
c) Leiomyosarcoma – 7 mitotic figures/10 HPF
d) Cystic Endometrial hyperplasia – endometrial cancer
e) Sarcoma botryoides – mesonephric duct
b. Lymphocytic infiltration and large vacuolated cells – dysgerminoma
Struma ovarii is a rare ovarian tumor defined by the presence of thyroid tissue comprising more than 50% of the overall mass. Rare carcinoid tumour.
b.-
Dysgerminoma young 20’s, 20% bilateral, common malignant in young. Dysgerminomas often occur bilaterally (approximately 10-20% of cases).
129
150. Which of the following is a type of epithelial tumour of the ovary?
a) embryonal cancer
b) dysgerminoma
c) endometrioid carcinoma
d) endometrioma
e) endodermal sinus tumour
c) endometrioid carcinoma
====
a) embryonal cancer – uncommon germ cell tumour, bhcg and AFP
b) dysgerminoma – germ cell tumour
e) endodermal sinus tumour – yolk sac tumour of germ cell tumour
130
152. In a patient with ovarian carcinoma and negative 2nd look laparotomy the chances of disease recurrence are?
a) 0-20%
b) 20-40%
c) 40-60%
d) 60-80%
e) 80-100%
d/ 60-80%
UTD 62%
131
154. CO2 laser vaporisation. Energy is derived from vaporisation of?
a) mitochondria
b) DNA
c) Intracellular water
d) Intracellular protein
e) Intracellular lipids
c) Intracellular water
132
155. What percentage of patients with vulval carcinoma have tumours with a depth of invasion less than 1mm?
a) 1%
b) 5%
c) 10%
d) 20%
e) 30%
c) 10%
133
156. What percentage of patients with vulval carcinoma with a depth of invasion less than 1mm have nodal disease?
a) nearly zero
b) 2%
c) 5%
d) 10%
e) 20%
a) nearly zero
134
157. What degree of cervical dysplasia must be treated in pregnancy?
a) HPV
b) CIN 2
c) CIN 3
d) None of the above
e) All of the above
d) None of the above
135
158. All of the following constitutes indications for cone biopsy in pregnancy, except:
a) minimally invasive SCC on cervical biopsy
b) smear result suggestive of adenocarcinoma in-situ
c) inadequate colposcopy
d) none of the above
e) all or the above
c) inadequate colposcopy
136
he second most common vulval malignancy is:
a) sarcoma
b) verrucous carcinoma
c) melanoma
d) adenocarcinoma
e) basal cell carcinoma
d) adenocarcinoma
```
most common SCC
then adenocarcinoma (8/100 vulva cancers)
then melanoma (6/100 vulva cancers)
then sarcoma (2/100 vulval cancers)
then BCC (rare)
verrucous carcinoma is a rare variant of SCC
```
137
32 yo woman counselling re ovarian cancer. 2 x 2nd degree Ca ovary – grandma and aunt. What would you advise?
a) reassure
b) yearly pelvic examination
c) yearly pelvic examination with Ca 125
d) yearly pelvic examination with Ca 125 + US with Doppler
a) reassure
138
164. What is tumour marker for ovarian embryonal carcinoma?
a) BHCG
b) AlphaFP
c) CEA
d) Ca 125
e) LDH
a) BHCG
139
165. What structures would you not meet when repairing a 3rd degree tear?
a) bulbocavernosus
b) ischiocavernosus
c) external anal sphincter
d) superficial transverse perinei
e) deep transverse perinei
b) ischiocavernosus
140
166. What is the next management in 40 yo P3 who has had a cone biopsy showing 1mm of invasive cancer and clear margin?
a) nil further
b) simple TAH
c) radical hysterectomy
d) TAH/BSO
a) nil further
141
168. 45 yo with 2 family members with ovarian cancer who is booked for elective TAH for menorrhagia. Best option?
a) take out ovaries
b) HRT
a) take out ovaries
142
171. The most common lymph node involved in ca cervix:
a) femoral
b) obturator
c) external iliac
d) para-aortic
c) external iliac
143
what is the increased incidence if 1st degree relative has breast cancer?
a) 10%
b) 30%
c) 50%
d) 100%
e) 200%
d) 100%
144
173. 47 yo who has irregular heavy vaginal bleeding. D&C shows atypical adenomatous hyperplasia. Mx
a) MPA 100mg IM monthly
b) TAH
c) NSAIDS
d) Microhysteroscopy to rule out CA then roller ball ablation
e) YAG laser endometrial ablation
b) TAH
145
175. What do you do after rad TAH/BSO/PLA for Ca endometrium with 1 pos pelvic node, invasion to inner 2/3 myometrium, grade 2.
a) external beam MVT
b) vault caesium
c) progesterone
d) chemorad
e) nil
d) chemorad
146
177. Regarding Meigs syndrome
a) it is associated with fibromas > 10 cm
b) pleural effusions are composed of peritoneal fluid
c) pleural effusions are more common on the left side
a) it is associated with fibromas > 10 cm
147
179. The treatment of 3cm Paget’s disease on the left labium
a) wide local excision with margin of 5 mm
b) wide local excision with margin of 2 cm
c) vulvectomy
b) wide local excision with margin of 2 cm
148
180. The ovarian tumour with characteristic signet ring cells is?
a) endometrioid carcinoma
b) teratoma
c) Krukenberg tumour
d) Brenner tumour
c) Krukenberg tumour
149
181. Ovarian thecoma:
a) predominantly bilateral
b) may produce virilizing symptoms
c) occur predominantly in females less than 14
b) may produce virilizing symptoms
150
182. Stage 2 ovarian carcinoma had the disease resected down to about 4cm. She had maximal chemotherapy. What is she most likely to die of?
a) uraemia
b) pyelonephritis
c) bowel obstruction
c) bowel obstruction
151
184. Which of the following is correct about carcinoma of the vulva?
a) SCC at the clitoris associated with metastasis of both inguinal nodes at an early stage
b) Metastasis to the iliac node with negative inguinal nodes
c) A 3 cm lesion has a 33% chance of positive lymph nodes
d) Stage 3 disease has 40% chance of positive lymph nodes
c) A 3 cm lesion has a 33% chance of positive lymph nodes
152
185. Which of the following is the best treatment option for carcinoma of the cervix stage 3?
a) rad hyst and bilateral inguinal lymphadenectomy
b) rad hyst and bilateral inguinal lymphadenectomy and vault radiotherapy
c) external end extended field radiotherapy
d) extended field radiotherapy and chemotherapy
e) intracavity and extended field radiotherapy
d) extended field radiotherapy and chemotherapy
153
186. Which is not a germ cell tumour?
a) granulosa cell tumour
b) dysgerminoma
c) embryonal cell tumour
d) immature teratoma
a) granulosa cell tumour
