Gynaecology Oncology Flashcards
A 59 year old nulliparous woman undergoes a hysteroscopy and endometrial biopsy after an episode of post-menopausal bleeding. This demonstrates invasive endometrial malignancy confirmed as stage I on imaging. What is the 5 year survival associated with stage I endometrial cancer?
a. 45%
b. 60%
c. 75%
d. 80%
e. 95%
E - 95%
Five year survival in endometrial cancer by stage is as follows:
- Stage I: 95%
- Stage II: 77%
- Stage III: 39%
- Stage IV: 14%
A 69 year old woman with a body mass index of 42 is referred on the 2-week-wait pathway with post-menopausal bleeding. After investigation, she is diagnosed with stage II endometrial cancer. What is the 5 year survival associated with stage II endometrial cancer?
a. 30%
b. 45%
c. 56%
d. 77%
e. 89%
D - 77%
Five year survival in endometrial cancer by stage is as follows:
- Stage I: 95%
- Stage II: 77%
- Stage III: 39%
- Stage IV: 14%
A patient is admitted for total abdominal hysterectomy following a diagnosis of endometrial cancer. On initial imaging it was believed her cancer was confined to the uterine body, though at laparotomy, serosal breech is identified and there is evidence of spread histologically to the internal iliac lymph nodes. Based on this, her cancer is re-staged to stage III and you are asked to counsel her regarding her prognosis. What is the 5 year survival associated with stage III endometrial cancer?
a. 23%
b. 39%
c. 46%
d. 67%
e. 73%
B - 39%
Five year survival in endometrial cancer by stage is as follows:
- Stage I: 95%
- Stage II: 77%
- Stage III: 39%
- Stage IV: 14%
After originally being referred to the urologists with frank haematuria, a 77 year old patient with known vascular dementia is found to have endometrial cancer with bladder metastasis (Stage IV). What is the 5 year survival associated with stage IV endometrial cancer?
a. 14%
b. 23%
c. 35%
d. 41%
e. 67%
A - 14%
Five year survival in endometrial cancer by stage is as follows:
- Stage I: 95%
- Stage II: 77%
- Stage III: 39%
- Stage IV: 14%
What is the optimum imaging modality to assess depth of myometrial invasion in patients with endometrial cancer?
a. CT
b. PET-CT
c. Ultrasound
d. MRI
e. Hysteroscopy
D - MRI
MRI is the optimum means of assessing myometrial depth of invasion. Stage I tumours are divided into IA (up to 50% myometrial invasion) and IB (50% or greater myometrial invasion)
A patient is referred as a 2 week wait after the incidental discovery of a large ovarian mass on an ultrasound to investigate bloating. A diagnosis of stage I epithelial ovarian cancer is made. What is the 5-year survival of patients with stage I ovarian cancer?
a. 45%
b. 60%
c. 75%
d. 80%
e. 90%
E - 90%
Five year survival in ovarian cancer by stage is as follows:
- Stage I: 90%
- Stage II: 42%
- Stage III: 18%
- Stage IV: 3%
A 78 year old woman is commenced on a course of chemotherapy after she is diagnosed is with stage II ovarian cancer. What is the 5-year survival for patients with stage II ovarian cancer?
a. 42%
b. 58%
c. 65%
d. 75%
e. 85%
A - 42%
Five year survival in ovarian cancer by stage is as follows:
- Stage I: 90%
- Stage II: 42%
- Stage III: 18%
- Stage IV: 3%
A 65 year old with a known BRCA mutation is diagnosed with stage III ovarian cancer. You are asked to counsel her regarding her prognosis. What is the 5-year survival amongst patients with stage III ovarian cancer?
a. 10%
b. 18%
c. 32%
d. 40%
e. 65%
B - 18%
Five year survival in ovarian cancer by stage is as follows:
- Stage I: 90%
- Stage II: 42%
- Stage III: 18%
- Stage IV: 3%
At an emergency laparotomy under the care of the general surgeons, widespread metastatic disease is found – later revealed to be from an ovarian primary and stage IV ovarian cancer is diagnosed. What is the 5-year survival for patients with stage IV ovarian cancer?
a. 3%
b. 12%
c. 24%
d. 36%
e. 45%
A - 3%
Five year survival in ovarian cancer by stage is as follows:
- Stage I: 90%
- Stage II: 42%
- Stage III: 18%
- Stage IV: 3%
What is the lifetime risk of breast cancer amongst women in the general population?
a. 3%
b. 8%
c. 12%
d. 15%
e. 20%
C - 12%
The prevalence of breast cancer in the general population is 12%.
Amongst carriers of the BRCA mutations is is nearer 70% (72% BRCA1; 69% BRCA2)
What is the lifetime prevalence of ovarian cancer in the general population?
a. 0.1%
b. 0.5%
c. 1.3%
d. 3.1%
e. 5.4%
C - 1%
The lifetime risk of ovarian cancer in the general population is 1.3%
Amongst carriers of a BRCA mutation rates are much higher:
- BRCA1: 39%
- BRCA2: 10%
These are the numbers quoted in the RCOG’s own SBA question bank
A woman with a strong family history undergoes genetic counselling regarding her risk of ovarian cancer and is found to carry the BRCA1 mutation. What is her lifetime risk of developing ovarian cancer?
a. 5-10%
b. 20-25%
c. 30-35%
d. 40-45%
e. 60-65%
D - 40-45%
The lifetime risk of ovarian cancer in the general population is 1.3%
Amongst carriers of a BRCA mutation rates are much higher:
- BRCA1: 39%
- BRCA2: 10%
A woman with a strong family history undergoes genetic counselling regarding her risk of ovarian cancer and is found to carry the BRCA2 mutation. What is her lifetime risk of developing ovarian cancer?
a. 10-15%
b. 15-20%
c. 30-35%
d. 40-45%
e. 60-65%
A - 10-15%
The lifetime risk of ovarian cancer in the general population is 1.3%
Amongst carriers of a BRCA mutation rates are much higher:
- BRCA1: 39%
- BRCA2: 10%
Tamoxifen is used in the treatment of patients with known oestrogen-receptor positive breast cancers as it has an anti-oestrogenic effect on breast tissue. It has a weakly oestrogen-agonist effect on the endometrium however. What, if any, is the increased risk of endometrial cancer amongst tamoxifen users?
a. No increased risk
b. 2x
c. 3-6x
d. 8-10x
e. 15-20x
C - 3-6x
What is the risk of malignancy amongst women with an RMI of 25-250?
a. 5%
b. 10%
c. 20%
d. 25%
e. 40%
C - 20%
Patient with an RMI of 25-250 are deemed to have an ‘intermediate’ or moderate risk of ovarian malignancy. In triaging who operates on such patients, it is advised that they be managed by the lead clinician in a cancer unit (i.e. not specifically an gynae-oncologist)
HNPCC – also known as Lynch Syndrome – is known to increase the likelihood of an individual developing numerous malignancies during their lifetime. In respect of risk reduction of gynaecological cancers, what is the recommended management of a 35 year old woman with HNPCC who has completed her family?
a. 6 monthly Ca125 and TVUSS
b. 12 monthly Ca125 and TVUSS
c. Hysterectomy and BSO
d. Laparoscopic BSO
e. Regular use of the combined pill
C - Hysterectomy and BSO
Lynch syndrome/HNPCC is known to increase both endometrial and ovarian cancers. The lifetime risk of ovarian cancer is 3-14% in such individuals.
In the context of ovarian cancer, what is defined as a complete response to chemotherapy?
a. Malignant disease not detectable for 4 weeks
b. Malignant disease not detectable for 8 weeks
c. Malignant disease not detectable for 12 weeks
d. Malignant disease not detectable for 6 months
e. Malignant disease not detectable for 12 months
A - Malignant disease not detectable for 4 weeks
A complete response to chemotherapy is defined as malignant disease not detectable for 4 weeks.
A partial response is a reduction in tumour size of >50% for at least 4 weeks.
Primary vaginal cancer is the least common of all gynaecological malignancies. The most common causes are known to be HPV and irradiation. What is the most common HPV subtype found in vaginal cancer?
a. HPV 6
b. HPV 11
c. HPV 16
d. HPV 18
e. HPV 31
C - HPV 16
What are the most common HPV subtypes found in vulval cancers?
a. HPV 5 and 8
b. HPV 6 and 11
c. HPV 16 and 18
d. HPV 31 and 33
e. HPV 58 and 59
B - HPV 6 and 11
What are the most common HPV subtypes found in cervical cancer?
a. HPV 5 and 8
b. HPV 6 and 11
c. HPV 16 and 18
d. HPV 31 and 33
e. HPV 58 and 59
C - HPV 16 and 18
HPV 16 and 18 cause >70% of cervical cancers.
A 65 year old patient is reviewed in the 2WW clinic with bilateral ovarian masses and a raised Ca-125. Calculation of the RMI returns a score of >200. What is the most appropriate next stage in management?
a. Refer to MDT
b. CT abdomen and pelvis
c. MRI abdomen and pelvis
d. List for open TAH+BSO
e. Arrange other tumour markers – CEA, hCG and AFP
B - CT Abdomen and Pelvis
All patients with an RMI >200 should undergo a CT scan of the abdomen and pelvis. While referral to MDT is also prudent, knowledge of the CT scan is required to facilitate that discussion and thus should occur first. MRI is useful in the context of equivocal ultrasound findings though has little role here. Ca125 is the only tumour marker indicated in assessment of the post-menopausal woman. While in all likelihood the patient will require a laparotomy (inclusive of TAH and BSO), further workup is required first.
A 72 year old woman is referred to the 2WW clinic after an ultrasound scan performed in primary care has highlighted the presence of a 6cm cyst on the right ovary. Ca125 is marginally elevated at 42. The USS report is somewhat vague regarding the precise nature of the cyst. What is the next step?
a. Repeat USS
b. CT pelvis
c. MRI pelvis
d. Additional tumour markers – CEA, hCG and AFP
e. MDT discussion
C - MRI Pelvis
Where there is diagnostic uncertainty on ultrasound scanning, an MRI of the pelvis may prove useful in assessment of an indeterminate ovarian mass.
A patient is seen in the GOPD clinic with an ultrasound report from primary care. She is 51 years old and last had a menstrual period over 2 years ago. The ultrasound reports the presence of a 6cm right sided ovarian mass with ‘a heterogeneous appearance, septations and solid components’. The Ca125 is elevated at 45. What is this patient’s RMI score?
a. 90
b. 135
c. 270
d. 405
e. 435
D - 405
Calculation of the RMI is based upon 3 variables:
Menopausal status
o 1 if pre-menopausal
o 3 if post-menopausal
Ca125
Ultrasound findings (where 0 scores 0, 1 scores 1 and 2 or more scores 3): o Bilateral cysts/masses o Ascites o Metastatic disease o Solid components o Multilocular
The score for each should then be multiplied to give the total RMI. In the scenario here, the patient is post-menopasual (3), Ca125 is elevated (45) and she has 2 concerning features on USS, solid and multi-cystic lesion (3) – 3x3x45 = 415. The next step in management is thus to arrange a CT of the abdomen and pelvis and discussion in MDT.
A 62 year old patient is referred to the 2WW clinic after seeing her GP with unexplained weight loss and bloating. A scan in clinic demonstrates a 3cm left ovarian cyst – apparently simple with a larger 9cm cyst on the right which is reported as containing solid components. A transabdominal scan has also been performed which demonstrates suspected ascites. The Ca125 is within normal limits at 16. What is this patient’s RMI score?
a. 48
b. 96
c. 144
d. 288
e. 496
C - 144
In the scenario here, the patient is post-menopausal (3), Ca125 is normal (16) and there are 3 concerning ultrasound features, bilateral lesions, solid components and ascites (3). 3x3x16 = 144.
An alternative to the RMI is the IOTA rules. What is the referral criteria to gynaecology oncology services with the IOTA rules system?
a. Any 3 B rules
b. Any M rule
c. Any 2 M rules
d. One B rule and one M rule
e. Two B rules and one M rule
B - Any M Rule
The IOTA rules form an alternative means of triaging ovarian cysts with similar specificity and sensitivity to the RMI. The suggestion is that use of the IOTA rules may avoid major surgery for more women with benign cysts while appropriately referring more women with a malignant cyst to an oncologist. The simple premise is that a patient with any single ‘M’ rule should be referred:
B Rules: Unilocular cysts Presence of solid components <7mm Presence of acoustic shadowing Smooth multilocular tumour <10cm No blood flow on colour doppler
M Rules: Irregular solid tumour Ascites At least 4 papillary structures Irregular multilocular solid tumour >10cm Prominent blood flow on colour doppler
Which of the following fulfils the ‘M’ rule criteria on the IOTA system?
a. Prominent blood flow on colour doppler
b. Acoustic shadowing
c. Unilocular cyst
d. Solid component of 6mm
e. Multilocular smooth tumour measuring 9cm
A - Prominent blood flow on colour doppler
The M rules on the IOTA system are as follows: irregular solid tumour; ascites; at least 4 papillary structures; irregular multilocular solid tumour >10cm and prominent blood flow on colour doppler. It’s worthwhile remembering the dimensions quoted in the B rules as strictly speaking, rather large multilocular tumours with small solid components could well fall under B rather than M rules using the IOTA system.
A 59 year old patient is referred to the clinic after a pelvic ultrasound performed to investigate post-menopausal bleeding reveals an endometrial thickness of 2mm and a simple 4cm left sided ovarian cyst. Ca125 is normal (12). What is the appropriate management in respect of the ovarian findings in this case?
a. Repeat scan in 4-6 months and discharge from follow up if unchanged in 12 months
b. Repeat scan in 3-4 months and discharge from follow up if unchanged in 24 months
c. Refer to MDT for consideration of BSO
d. CT abdomen and pelvis
e. Discharge
A - Repeat scan in 4-6 months and discharge from follow up if unchanged in 12 months
Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy. In the presence of normal serum Ca125 levels, these cysts can be managed conservatively, with a repeat evaluation in 4–6 months. It is reasonable to discharge these women from follow-up after 1 year if the cyst remains unchanged or reduces in size, with normal Ca125, taking into consideration a woman’s wishes and surgical fitness. The suggestion from the scenario is that this is an incidental finding and the woman is thus not symptomatic though the guideline suggests women who are symptomatic may warrant further surgical evaluation.
In what percentage of epithelial ovarian tumours will Ca125 be elevated?
a. 50%
b. 60%
c. 75%
d. 80%
e. 90%
D - 80%
Ca125 is primary a marker of epithelial cancer and is elevated in around 80% of such tumours and infact is seldom elevated in most primary mucinous tumours. Numerous non-gynaecological and benign conditions are also known to elevate Ca125. The upper limit of normal (35) represents the 99th centile in a study of almost 900 healthy individuals.
At what RMI level is laparotomy advised in lieu of laparoscopic treatment for cysts which appear benign on scan?
a. 150
b. 200
c. 250
d. 300
e. 350
B - 200
Where the RMI is >200, a full staging laparotomy is indicated after a CT abdomen and pelvis. Who performs the surgery and the extent is dependent on the MDT outcome and the anticipated likelihood of malignancy – if high likelihood, a full staging should be done by a trained gynaecological oncologist; if low likelihood, a pelvic clearances (i.e. TAH+BSO, omentectomy and peritoneal cytology) by a ‘suitably trained’ gynaecologist is appropriate
A 60 year old woman is found to have an incidental 5.1 x 5.8cm ovarian cyst on the right side. She reports no symptoms. Her RMI is calculated to be 26. What is the most appropriate treatment?
a. Ovarian cystectomy by a gynae-oncologist
b. Laparoscopic ovarian cystectomy
c. Laparoscopic bilateral oophorectomy
d. Conservative management with serial scans
e. Discharge
C - Laparoscopic bilateral oophorectomy
This question tests a subtle nuance of the guideline. In order to satisfy the criteria for conservative management, the cyst should be: <5cm, asymptomatic, simple, unilocular and unilateral. Those which do not (and indeed at 5.8cm this one doesn’t) should be considered for bilateral salpingoophrectomy. If all criteria are met, a follow up scan and Ca125 in 4-6 months is appropriate.
What is the likelihood of a symptomatic ovarian cyst representing a malignant pathology in a pre-menopausal women?
a. 1 in 5000
b. 1 in 1000
c. 1 in 500
d. 1 in 250
e. 1 in 100
B - 1 in 1000
10% of women will have surgery during their lifetime for the presence of an ovarian mass. In premenopausal women, the likelihood of a symptomatic cyst representing a malignant pathology is 1 in 1000, rising to 3 in 1000 at the age of 50.
What is the most common gynaecological cancer seen in women in the UK?
a. Ovarian
b. Endometrial
c. Vulval
d. Cervical
e. Vaginal
B - Endometrial
Endometrial cancer is the most common gynaecological malignancy in the Western world and endometrial hyperplasia is its natural precursor
A 23 year old woman whose mother died at the age of 56 of cervical cancer comes to see you. She wants to know how to reduce her own risk of cervical cancer. What is the single most important piece of advice you could give her?
a. To attend regularly for cervical screening
b. To avoid sexual promiscuity
c. To stop smoking
d. To use barrier contraception at all times
e. To undergo prophylactic risk-reducing bilateral salpingo-oophorectomy
A - To attend regularly for cervical screening
The incidence of cervical carcinoma has reduced drastically in countries with screening programmes. Only 1% of abnormal smears progresses to malignancy over a long period of time. Most women with cancer have NOT had a smear in the last 5 years and many of them have never had a smear.
You see a 45 year old nulliparous woman in your gynaecology clinic who is a carrier for BRCA2 mutation. She wishes to discuss surgery to reduce her cancer risk. What is the approximate average cumulative risk of her developing ovarian-type cancer by the age of 70?
a. 10%
b. 25%
c. 40%
d. 55%
e. 70%
A - 10%
BRCA 1 and 2 are highly penetrative genes which together account for over 95% of families with both ovarian and breast cancers. The cumulative risk of ovarian is lower in BRCA2 at 10% compared with 39% in BRCA1.
You have informed a 45 year old that she has stage 3C ovarian cancer. She is keen to know about her prognosis. What is the 5 year survival rate in the UK for ovarian cancer?
a. 20-25%
b. 30-35%
c. 40-45%
d. 50-55%
e. 60-65%
C - 40-45%
As with the majority of cancers, ovarian survival is improving. Much of the increase occurred during the 80-90s and appears to be levelling off since the 00’s. The significant increase in 1 year survival is likely to be a product of the use of platinum based chemotherapy.
A 67 year old woman is referred to the rapid access clinic with a 2 day history of postmenopausal bleeding which has since resolved. She is otherwise fit and well. The endometrial thickness is 7mm on TV ultrasound scan, the endometrium appears polypoidal at hysteroscopy and an endometrial sample is reported as showing irregular and tightly packed glands with large and vesicular nuclei containing prominent nucleoli. What is the most appropriate management for this woman?
a. Bilateral oophorectomy
b. Combined oestrogen and progesterone HRT
c. Expectant management
d. Hysterectomy
e. Insertion of a levonorgestrel IUS
D – Hysterectomy
The endometrial sample has features suggestive of complex, atypical hyperplasia. This is a pre-malignant condition and will progress to cancer in 29% of cases. It may co-exist with an invasive carcinoma. Less aggressive abnormalities such as complex hyperplasia will progressive to malignancy in only 4% of cases. Current advice is that these women should be offered a hysterectomy.
You see a 38 year old woman with a 2.5cm malignant tumour on her cervix and no extra-cervical disease on imaging. She is fit and healthy. What is her best treatment option?
a. Radical hysterectomy
b. Radical hysterectomy and bilateral pelvic lymphadenectomy
c. Radical trachelectomy
d. Radical trachelectomy and bilateral pelvic lymphadenectomy
e. Radiotherapy
B – Radical hysterectomy and bilateral salpingo-oophorectomy
Radical surgery is recommended in stage 1B1 if there is no contrainidication to surgery. Radical trachelectomy can only be offered for fertility sparing in tumours <2cm
A 45 year old woman is due to have a total abdominal hysterectomy and bilateral salpingo-oophorectomy for chronic pelvic pain. You receive a letter from her GP informing you that her recent smear has shown borderline changes in endocervical cells. What arrangement will you make, if any, prior to her admission?
a. Endometrial sampling
b. HPV testing
c. No change in management
d. Refer to colposcopy
e. Repeat cytology
D – Referral to colposcopy
All women being considered for hysterectomy who have an uninvestigated abnormal smear test result of symptoms attributable to cancer should have diagnostic colposcopy and appropriate biopsy.
A 30 year old multiparous woman with a suspected left borderline ovarian tumour is awaiting laparotomy, frozen section and conservative or complete staging surgery. She wants to know the accuracy of frozen section. How many cases diagnosed as borderline tumours on frozen section would later be reclassified as invasive tumours?
a. One tenth of cases
b. One fifth of cases
c. One quarter of cases
d. One third of cases
e. One half of cases
D – One third of cases
Approximately 1/3 of cases reported as borderline on frizen section are later reclassified as invasive. If frozen section reports borderline tumour – complete staging should be undertaken as per a cancer.
A 63 year old woman with a history of post-menopausal bleeding returns to the gynaecology clinic. Recent endometrial biopsy shows complex hyperplasia without atypia. She wants to know the risk of these abnormal cells progressing to cancer. What is the risk of her complex hyperplasia progressing to endometrial cancer over 10 years?
a. 4%
b. 8%
c. 12%
d. 16%
e. 20%
A - 4%
A 48 year old woman undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy and omental biopsy for an ovarian tumour. Pathology confirms a serous, borderline ovarian tumour. Which of the following is a feature of borderline tumours?
a. Absence of stromal invasion
b. Complex histological architecture
c. Mitotic figures
d. Peritoneal implants
e. Raised Ca125
A – Absence of stromal invasion
Borderline tumours are often found following primary surgery in younger women. They show higher proliferative activity than benign tumours but no stromal invasion. They constitute 10-15% of ovarian neoplasms. Serous borderline tumours are the most common and are often (30%) bilateral.
A 65 year old woman is referred to the gynaecology outpatient clinic with left-sided lower abdominal discomfort in her left iliac fossa. She is concerned that she may have ovarian cancer. What is the most appropriate radiological investigation for this woman?
a. Colour flow doppler
b. CT
c. MRI
d. PET
e. TV USS
E – TVUSS
Ultrasound is a well established test to assess postmenopausal cysts achieving a sensitivity of 80% and specificity of 73%
A patient is referred to the 2-week-wait clinic with a suspicious lesion on the vulva. This is confirmed as squamous cell carcinoma and following surgical excision graded as Stage I. There is no evidence of disease elsewhere. What is the 5 year survival for patients with Stage I vulval cancer?
a. 98%
b. 90%
c. 85%
d. 79%
e. 62%
A - 98%
Five year survival in vulval cancer by stage is as follows:
- Stage I: 98%
- Stage II: 85%
- Stage III: 74%
- Stage IV: 31%
A patient is referred to the 2-week-wait clinic after she notices a firm mass around the introitus. On examination this is noted to be spreading into the lower third of the vagina and stage II vulval cancer is diagnosed. There is no evidence of nodal metastases on imaging. What is the 5 year survival for patients with stage II vulval cancer?
a. 92%
b. 85%
c. 76%
d. 65%
e. 55%
B - 85%
Five year survival in vulval cancer by stage is as follows:
- Stage I: 98%
- Stage II: 85%
- Stage III: 74%
- Stage IV: 31%
A 69 year old woman is referred to the 2-week-wait clinic with a suspected vulval malignancy. This is confirmed on biopsy and there is evidence of inguinal lymph node involvement on MRI. She is diagnosed with stage III vulval cancer. What is the 5 year survival for patients with stage III vulval malignancy?
a. 74%
b. 65%
c. 55%
d. 42%
e. 29%
A - 74%
Five year survival in vulval cancer by stage is as follows:
- Stage I: 98%
- Stage II: 85%
- Stage III: 74%
- Stage IV: 31%
A 88 year old woman is diagnosed with stage IV vulval cancer. Overall, what is the 5 year survival for patients with stage IV vulval cancer?
a. 65%
b. 42%
c. 31%
d. 23%
e. 15%
C - 31%
Five year survival in vulval cancer by stage is as follows:
- Stage I: 98%
- Stage II: 85%
- Stage III: 74%
- Stage IV: 31%
The presence of lymph node involvement is one of the strongest predictors of outcome in patients with vulval malignancy. What is the overall 5 year survival for patients with lymph-node negative vulval cancers?
a. >90%
b. 85%
c. 70%
d. 65%
e. 50%
A - >90%
Survival in vulval cancer overall based on lymph node status is:
- Node negative: >90%
- Groin nodes: ~50%
- Pelvic nodes: ~11%
The presence of lymph node involvement is one of the strongest predictors of outcome in patients with vulval malignancy. What is the overall 5 year survival for patients with groin lymph-node positive vulval cancers?
a. 60%
b. 50%
c. 30%
d. 25%
e. 11%
B - 50%
Survival in vulval cancer overall based on lymph node status is:
- Node negative: >90%
- Groin nodes: ~50%
- Pelvic nodes: ~11%
The presence of lymph node involvement is one of the strongest predictors of outcome in patients with vulval malignancy. What is the overall 5 year survival for patients with pelvic lymph-node positive vulval cancers?
a. 60%
b. 50%
c. 30%
d. 25%
e. 11%
E - 11%
Survival in vulval cancer overall based on lymph node status is:
- Node negative: >90%
- Groin nodes: ~50%
- Pelvic nodes: ~11%
What is the overall 5 year survival for patients with vulval cancer?
a. 90%
b. 82%
c. 64%
d. 47%
e. 33%
C - 64%
In what proportion of vulval cancers is human papilloma virus implicated?
a. 4/5 of cases
b. 1/2 of cases
c. 1/3 of cases
d. 1/5 of cases
e. 1/10 of cases
C - 1/3 of cases
HPV (most commonly type 6) is implicated in 35% of vulval cancers and 80% of VIN
In what proportion of vulval intra-epithelial neoplasia cases is HPV implicated?
a. 4/5 of cases
b. 1/2 of cases
c. 1/3 of cases
d. 1/5 of cases
e. 1/10 of cases
A - 4/5 of cases
HPV (most commonly type 6) is implicated in 35% of vulval cancers and 80% of VIN
What strains of HPV are the most common cause of genital warts?
a. 6 and 11
b. 16 and 18
c. 31 and 33
d. 42 and 44
e. 51 and 53
A - 6 and 11
What strains of the human papillomavirus (HPV) are covered by Gardasil – the vaccine in use in the UK?
a. 6 and 11
b. 16 and 18
c. 6, 11, 16 and 18
d. 6, 11, 16, 18 and 33
e. 16, 18 and 33
C - 6, 11, 16 and 18
Gardasil is a quadravalent vaccine effective against HPV strains 6, 11, 16 and 18
A 38-year-old woman attends a colposcopy clinic after a smear test shows severe dyskaryosis. On examination a 3.8 cm suspicious looking lesion on her cervix is biopsied. Histology confirms squamous cell cancer. Which next step would be the most appropriate for staging
a. Examination under anaesthesia (EUA) only
b. EUA + TVS + CT chest/ abdomen/pelvis
c. EUA + MRI pelvis +CT chest/ abdomen
d. EUA + CT chest/ abdomen/ pelvis
e. MRI pelvis + CT chest/ abdomen
C - EUA + MRI Pelvis + CT chest/abdomen
FIGO classification is the most widely used staging system for cervical carcinoma. Cervical carcinoma is most prevalent in countries where surgical and diagnostic resources are limited. As such, unlike the staging of other gynaecological cancers, the FIGO staging of cervical carcinoma is clinical and is not dependent on surgico-pathological findings. This strategy therefore allows uniformity of staging for all patients worldwide. The FIGO staging committee nonetheless recognise that clinical staging is limited particularly in the measurement of tumour size, assessment of parametrial and pelvic sidewall invasion, and in the evaluation of lymph node metastases. They therefore recommend the incorporation of cross-sectional imaging (MRI/CT) if these resources are available.
A 57-year-old woman has finished primary treatment with chemo-radiotherapy for stage IIIa cervical cancer 3 years ago. She now presents with lower abdominal pain and loss of appetite. Which imaging modality is most suitable to investigate a potential recurrence?
a. CT
b. MRI
c. PET CT
d. TAS
e. TVS
B - MRI
In the case of tumour recurrence, MRI is superior in distinguishing fibrosis from active disease. In patients with cervical cancer treated with primary chemoradiotherapy, MRI is used to monitor response during and at the completion of treatment.
A fit and healthy 65-year-old women presents with one episode of postmenopausal bleeding. The endometrial thickness on USS is 8 mm and histology of a pipelle biopsy is reported and as grade I endometrial cancer. What is the most appropriate use of MRI imaging in primary endometrial cancer?
a. MRI has no role in primary endometrial cancer
b. Preoperative assessment of disease extent/surgical resectability
c. Post treatment response evaluation
d. Screening
e. Staging
B - preoperative assessment of disease extent/surgical resectability
The correct answer is preoperative assessment of disease extent/surgical resectability. Imaging has no role in screening or staging of endometrial cancer. Full endometrial FIGO staging classification is dependent upon surgico-pathological findings. Imaging is not used routinely after treatment.
A 75-year-old woman who is para two presents with lower abdominal pain, bloating and weight loss. Pelvic examination reveals a 7 cm pelvic mass and a normal size, mobile uterus. What is the most appropriate primary investigation for suspected ovarian cancer in this case?
a. CT
b. CT + MRI
c. MRI
d. Ultrasound
e. Ultrasound + MRI
D - Ultrasound
Ultrasound is usually the primary imaging modality when ovarian cancer is suspected. If ultrasound and/or the risk of malignancy index are highly suggestive of ovarian cancer, then CT is used for staging.
A 32-year-old woman presents as an emergency with vaginal bleeding. She has never had a smear test. Clinical examination reveals a mass replacing the cervix, extending onto the vagina and into the parametria bilaterally. Initial blood tests show acute renal failure with a markedly raised serum urea and creatinine. Imaging shows a 6-cm cervical mass with parametrial spread and bilateral hydronephrosis and hydroureter to the level of the mass. Renal cortical thickness is normal. What is the next most appropriate management step?
a. Chemotherapy
b. Examination under anaesthesia and biopsy
c. Radical hysterectomy with pelvic lymphadenectomy
d. To insert bilateral nephrostomies ± ureteric stents
e. Urgent radiotherapy
D - To insert bilateral nephrostomies ± ureteric stents
The working diagnosis is advanced cervical
cancer. Without diagnostic histology, treatment cannot commence however the more urgent issue is to address the renal impairment. For advanced cervical malignancy, the primary treatment is a combination of chemo and radiotherapy.
An 18-year-old woman presents with a 4-month history of postcoital and intermenstrual bleeding. She has been using the combined oral contraceptive pill for 3 years. Her 26-year-old sister has just completed treatment for a squamous cell cervical cancer. On examination the cervix displays a prominent cervical ectropion. Screening for sexually transmitted infections is negative. What is the most appropriate course of action?
a. A cervical smear test
b. An urgent referral to colposcopy
c. Cautery of the cervical ectropion
d. Cervical biopsy
e. Reassurance that she does not have cancer
E - Reassurance that she does not have cancer
Colposcopy and cytology are not indicated. Cervical ectropion is a normal physiological event and is more common in woman taking hormonal contraception. No good evidence exists to support the effectiveness of cautery in preventing irregular bleeding. Cervical cancer is not familial and in this case, assuming clinical examination was normal, no further action would be necessary.
A 30 year-old woman presents to colposcopy clinics having had a cervical smear showing low-grade dyskaryosis and positivity for high-risk HPV infection. She has no relevant past medical history. She has a family history of her maternal aunt and grandmother both dying from cervical cancer. She smokes ten cigarettes per day and has recently broken up with her partner. Her children are aged 13, 6 and 2 years old. Her BMI is 36. She has regular periods and no postcoital bleeding and no vaginal discharge. She is on depo provera for contraception. What is the most appropriate advice regarding her management?
a. Have a colposcopy and biopsy of any abnormalities revealed
b. Have a colposcopy and if no abnormalities are seen have a repeat cervical smear at that point
c. Have a cervical biopsy only
d. Have a hysterectomy if her family is complete
e. Have an excisional biopsy using LLETZ or other technique
A - Have a colposcopy and biopsy of any abnormalities revealed
The best option for her would be to have a colposcopy and biopsy of any abnormalities revealed. A repeat cervical smear at colposcopy would not add any beneficial information. A cervical biopsy only may not sample the abnormal areas of the cervix. A hysterectomy without confirmed diagnosis is not a viable option. An excisional biopsy may be a viable option if high-grade colposcopic abnormalities are revealed. A colposcopy needs to be performed first.
A 25-year-old woman has multiple biopsies of her cervix at the colposcopy clinic due to high-grade dyskaryosis. The histology shows CIN3 with areas of microinvasion. What is the most appropriate advice regarding her management?
a. Have an excisional biopsy using LLETZ or other technique
b. Have an MRI of the pelvis and a chest x-ray
c. Have an MRI of her pelvis and a CT of her abdomen and thorax
d. Have a radical hysterectomy and pelvic lymphadenectomy
e. Have a cervical smear in 6 months
A - Have an excisional biopsy using LLETZ or other technique
At first instance this woman should have an excisional biopsy to identify the extent of the disease and to excise the abnormality in its entirety. An MRI and a chest x-ray may be recommended in the case of involved margins after excision or suspicion of overt disease. A radical hysterectomy would be overtreatment, especially for this young woman.
A 30-year-old woman has an excisional biopsy of her cervix for high-grade changes on colposcopy for a background of high-grade dyskaryosis. She has no comorbidities and does not want to have children in the future. The histology shows invasive adenocarcinoma extending to 7 mm in depth and 7 mm in lateral dimensions. The excision margins are clear. Radiological investigation reveals no lymphovascular space invasion, no lymphadenopathy and no metastatic disease. What is the most appropriate advice regarding her management?
a. Have a further excisional biopsy using LLETZ or other technique
b. Have a radical hysterectomy, pelvic lymphadenectomy and oopherectomy
c. Have a radical hysterectomy and pelvic lymphadenectomy
d. Have a radical trachelectomy and pelvic lymphadenectomy
e. Have external-beam radiotherapy followed by brachytherapy and chemotherapy
C - Have a radical hysterectomy and pelvic lymphadenectomy
The standard treatment for stage IB1 cervical cancer in the UK is a radical hysterectomy or trachelectomy with pelvic lymphadenectomy. This woman’s does not want children in the future, therefore a trachelectomy is not the best option. As she has no comorbidities radiotherapy and chemotherapy should be reserved in case of future recurrence.
A 17-year-old girl without a significant past medical history has been diagnosed and treated for a yolk-sac tumour. Which tumour marker would be most appropriate to use for follow up?
a. α-fetoprotein
b. CA125
c. hCG
d. Lactate dehydrogenase
e. Placental alkaline phosphatase
A - α-fetoprotein
Tumour markers can be used for pre-operative assessment and post-operative follow up in germ cell tumours. Trophoblast-derived tumours produce hCG; yolk sac tumours α-FP +/- LDH. Dysgerminomas are undifferentiated tumours and can produce hCG, PLAP and LDH, but not α-FP.
A 19-year-old woman undergoes surgery for a unilateral pelvic mass. Intraoperative findings show implants on the fallopian tube and cytology confirms malignant peritoneal washings. Histology confirms a granulosa cell tumour. CT imaging excludes nodal involvement or distant metastasis What is the correct FIGO staging for this woman?
a. IIA
b. IIB
c. IIIA2
d. IIIB
e. IIIC
A - IIA
The presence of positive peritoneal cytology without disease extensions or implants outside the ovaries has been classified as stage IC3 according to the latest FIGO staging guidelines.
An 18-year-old nulliparous woman with a right ovarian mass has been diagnosed with a stage IA choriocarcinoma. Which is the most appropriate surgical treatment option?
a. Laparoscopy + USO + omental/peritoneal biopsies + biopsy of the contralateral ovary + washings
b. Laparoscopy + BSO + omental/peritoneal biopsies and washings
c. Laparotomy + USO + omental/ peritoneal biopsies and washings
d. Laparotomy + USO + omental/ peritoneal biopsies + biopsy of the contralateral ovary + washings
e. Laparotomy + BSO + omental/ peritoneal biopsies and washings
C - Laparotomy + USO + omental/ peritoneal biopsies and washings
Primary surgery is the standard of care for apparently early-stage (suspected stage IA) MOGCTs. Fertility-preserving surgery via a mid-line incision with unilateral salpingo-ophorectomy alongside careful surgical staging with omental and multiple peritoneal biopsies, peritoneal washings and biopsy of any suspicious lymph nodes has become the accepted standard of care. Biopsies from a seemingly health contralateral ovary are not recommended due to potential impairment of fertility. Advanced disease will require multi-modal treatment.
A 25-year-old woman who is para 2 was treated with surgery + chemotherapy for stage IC dysgerminoma. She is anxious about the future and during a follow up consultation enquires about the “chance of seeing her children grow up”. In this case, what is the most likely percentage for her estimated five-year survival?
a. 50%
b. 60%
c. 70%
d. 80%
e. 90%
E - 90%
For patients with germ cell tumours requiring chemotherapy (stage IC or greater), published reports have shown a long-term survival of approximately 90%. The overall aim in treatment of germ cell tumours overall is cure, not palliation.
A 20-year-old nulliparous woman received surgical treatment and chemotherapy for a stage IA yolk sac tumour. She is keen to start a family in the near future. What are her chances of a successful pregnancy?
a. 15%
b. 25%
c. 35%
d. 55%
e. 70%
E - 70%
Publications have reported a successful pregnancy rate of 69–75% in those wishing to conceive following chemotherapy for GCTs. Treatment with surgery alone or surgery and chemotherapy does not appear to materially alter the chances of conception. Equally importantly, there are no reports of an increased congenital abnormality rate following chemotherapy.
A 24-year-old woman was seen for a rapidly growing abdominal mass and abdominal pain. Further radiological investigations and the tumour marker panel suggest an endodermal sinus tumour. Her case is being discussed by at the gynaecological oncology mutidisciplinary team panel. Which of the following is the best management in this case?
a. Radiotherapy
b. Surgical exploration, total abdominal hysterectomy and bilateral salpingo- oophorectomy
c. Surgical exploration, unilateral salpingo-oophorectomy
d. Surgical exploration, unilateral salpingo-oophorectomy with either adjuvant or therapeutic combination chemotherapy
e. Surgical staging
D - Surgical exploration, unilateral salpingo-oophorectomy with either adjuvant or therapeutic combination chemotherapy
The surgical treatment of endodermal sinus tumour is surgical exploration, unilateral salpingo-oophorectomy. The addition of hysterectomy and contralateral salpingo-oophorectomy does not alter the outcome. Any gross metastases should be removed, if possible, but thorough surgical staging is not indicated because all women need chemotherapy. Routine combination chemotherapy has significantly improved the 2-year survival to 70%. Loss of fertility is a problem with radiation therapy therefore it is not used as first line treatment.
A 17-year-old girl has recently been found to have a quickly growing large unilateral ovarian mass. During the operation, the surgical team decides to incise the tumour capsule to drain 5 litres of its content with a suction prior to removal, in order to avoid making a large midline laparotomy. Some of the cyst liquid is spilled into the abdominal cavity during the process. After removal of the mass, no disease was apparent elsewhere. Histology confirms a granulosa cell tumour. Staging CT imaging shows no evidence of secondary malignancy. What FIGO stage best descibes this woman?
a. Stage IA
b. Stage IC1
c. Stage IC2
d. Stage IC3
e. Stage IIIA2
B - Stage IC1
Surgical spill, whether during deliberate incision of the capsule or accidental during dissection has been classified as FIGO stage IC1 in the latest FIGO staging guideline.
A 75-year-old woman presents via an urgent referral with a 4-month history of vulval pain. On examination she has a 4-cm irregular exophytic tumour replacing the clitoris and extending to within 15 mm of the urethra. Enlarged lymph nodes are palpable in both groins. What is the next most appropriate action?
a. Perform CT scan of the abdomen and pelvis
b. Simple vulvectomy
c. Urgent radiotherapy
c. Vulvectomy and bilateral inguinofemoral lymphadenectomy
d. Wedge biopsy of the lesion
D - Wedge biopsy of the lesion
Although the clinical picture is strongly suggestive of vulval malignancy, a diagnostic biopsy is essential. A wedge biopsy will provide information regarding the type, grade and depth of invasion of the tumour. This information, in combination with imaging and MDT discussion, will facilitate appropriate treatment. In some cases, for instance basal cell carcinomas and verrucous carcinomas, lymphadenectomy is not necessary.
A 75-year-old woman is seen in a urogynaecology clinic complaining of pelvic organ prolapse. Of note there is a history of intermittent steroid cream use for a sore and itching vulva. On examination there is a warty lesion on the vulva that is 1 x 1 cm on the left inferior aspect of the labia majora. What would be the most appropriate action?
a. Arrange excision biopsy of the entire lesion under local anaesthesia
b. Prescribe topical imiquimod on the lesion
c. Reassure the woman that vulval condyloma are common in postmenopausal women and concentrate on the reason for the referral, the pelvic organ prolapse
d. Refer to a dedicated gynaecological onclogy/vulva clinic for an opinion
e. Try a course of topical steroid and review the lesion in 6 months
D - Refer to a dedicated gynaecological onclogy/vulva clinic for an opinion
Suspected vulval malignancies should be managed by a dedicated vulval clinic or gynaecological oncologist and newly acquired condylomas are unusual in this age group. In addition, if biopsy were performed, the lesion should be identifiable post biopsy (i.e. a wedge biopsy rather than excisional procedure).
The other options are incorrect because if the lesion is removed and the excision is done locally, the woman may need repeat surgery/will not remain suitable for sentinel node biopsies, which can have impact on her overall treatment. An incisional biopsy can be taken, but it is not an option that has been listed.
A 77-year-old woman is seen by the GP for routine recall of her lichen sclerosus. She mentions the itching has become gradually worse over the year with no relief after using different creams as suggested by the pharmacist. She also mentions she has some swelling down below that feels like the size of a 10 pence coin. She is referred to the hospital and on examination, you note a raised ulcer with rolled edges. Her general examination is normal with no groin nodes palpable. A biopsy is taken under local anaesthetic in clinic. In anticipation, a pre-op is arranged. Which of the following test is the most suitable for her?
a. FBC
b. FBC, serum biochemistry
c. FBC, serum biochemistry, CXR
d. FBC, serum biochemistry, CXR, ECG
e. FBC, serum biochemistry, CXR, ECG, CT pelvis
D - FBC, serum biochemistry, CXR, ECG
This woman is very likely to have vulval carcinoma. 30% of cancers develop in women with lichen sclerosus with a lifetime risk of developing cancer within lichen sclerosus is 3–5%. In lesions that are 2 cm or less, a wide local excision biopsy is appropriate but should include a surrounding 1 cm zone of normal tissue. This can be performed under general anaesthetic. Vulval cancer patients are generally elderly and often have comorbidity so a preoperative anaesthetic assessment can be invaluable. Preoperative investigations should include FBC, serum biochemistry, CXR and ECG. Women with advanced disease should have a CT scan of the pelvis to exclude pelvic nodal involvement, which does not appear to be the case in this woman.
You are about to see a 60-year-old woman at the vulva clinic. She initially presented 2 weeks ago complaining of soreness and irritation of the vulva. On examination there was is a 4.5-cm ulcerated lesion of the left anterior vulva, involving the clitoris. A punch biopsy was taken and the histology reveals a squamous cell carcinoma. In addition to radical excision of the primary lesion, how will you counsel her regarding lymph node management?
a. Bilateral inguino-femoral lymphadenectomy is recommended
b. Lymphadenectomy is not required for this lesion
c. Sentinel node biopsy is recommended
d. Unilateral (left) inguino-femoral lymphadenectomy is recommended
e. Unilateral (right) inguino-femoral lymphadenectomy is recommended
A - Bilateral inguino-femoral lymphadenectomy is recommended
The RCOG/BGCS guidance recommends bilateral groin node investigation in lesions within 1 cm of the midline. The diameter of this lesion is above that recommended as safe (4 cm) for sentinel node assessment only.
A 65-year-old lady was referred with soreness of the vulva. On examination, there is a raised irregular lesion with a erosive appearance measuring 1cm in diameter. What would you do next?
a. Refer to a cancer centre
b. Obtain a representative incisional biopsy
c. Request MRI
d. Perform a wide local excision
e. Request a groin ultrasound scan.
B - Obtain a representative incisional biopsy
Any change in the vulval epithelium in postmenopausal women warrants a biopsy. Lesions should be biopsied rather than excised in order to allow for the identification and removal of sentinel nodes. A representative biopsy which includes the transition from abnormal to normal epithelium should be obtained for diagnosis.
A 70-year-old lady presents with a 3.5 cm x 4.5cm raised irregular fungating mass on the left labia extending to the clitoris. A representative biopsy of this lesion has confirmed a moderately differentiated squamous cell carcinoma of the vulva with a depth of invasion of 8 mm. What is the most optimal management plan for this lady?
a. Radical wide local excision alone
b. Radical wide local excision and left groin sentinel node biopsy
c. Radical wide local excision and left groin lymphadenectomy
d. Radical wide local excision and bilateral groin sentinel node biopsy
e. Radical wide local excision and bilateral groin lymphadenectomy.
E - Radical wide local excision and bilateral groin lymphadenectomy.
Excision of the primary tumour should be radical enough to obtain a 15 mm margin on all sides in a fresh surgical specimen. Dissection of groin nodes should be performed when the lesion has a depth of invasion greater than 1 mm or the maximum tumour size is more than 2 cms. Identification and removal of sentinel lymph nodes is safe only in patients with unifocal tumours less than 4 cms in maximum dimension. In patients with lesions greater than 4 cms, groin lymphadenectomy should be performed. As this tumour involves the midline (clitoris), bilateral groin lymphadenectomy should be performed.
A 62-year-old woman with a past history of breast cancer presents with a 5-month history of dyspepsia, early satiety and bloating. A CT scan shows a complex pelvic mass, ascites, omental cake, peritoneal and serosal deposits and multiple parenchymal liver metastases. What is the next most appropriate management step?
a. Laparotomy and debulking of tumour
b. Mammogram
c. Paracentesis and omental biopsy
d. Referral to an oncologist for palliative chemotherapy
e. Upper gastrointestinal endoscopy
C - Paracentesis and Omental Biopsy
A diagnostic biopsy is needed before commencing the appropriate treatment. If tissue is unobtainable then diagnostic cytology may suffice. In view of her past history of breast cancer, exclusion of recurrence is essential. In view of the widespread disease and liver metastases, optimal debulking is unlikely and therefore neoadjuvant chemotherapy is preferable.
A 56-year-old woman presents with symptoms of an ovarian mass that has been confirmed on ultrasound scan. It is a theca cell tumour. What is the most appropriate advice regarding prognosis?
a. She should be told that they are characteristically bilateral
b. She should be counselled that Meig syndrome is a recognised complication
c. That up to 10% of them are androgenic
d. Then there is no need to screen her for endometrial hyperplasia
e. She should be advised that they are usually malignant
C - That up to 10% of them are androgenic
Theca cell tumours are benign ovarian tumours of sex cord/stromal (mesenchymal) origin. The tumour belongs to the same histopathologic spectrum as a fibroma/fibrothecoma and can be divided into two main types: typical and luteinised.
Luteinised thecomas occur in a younger age group than typical thecoma. Approximately 50% are estrogenic, approximately 40% are non-functioning and approximately 10% are androgenic.
A 56-year-old woman is referred to the gynaecological oncology MDT (multidisciplinary team) because of a suspicious pelvic tumour. The woman complains of occasional abdominal pain, and is thought to have gained some weight recently unintentionally. Her overall WHO performance index is 0. A pelvic ultrasound revealed a complex ovarian mass of 9 cm with central blood flow on power Doppler. The Ca125 level was 522 U/ml. A staging CT showed a 10 cm pelvic tumour with solid and cystic elements, moderate amount of ascitis, a thickened omentum and otherwise normal upper abdominal organs. Biopsy from pelvic mass confirms adenocarcinoma cells. What is the most appropriate management for this woman?
a. Total abdominal hysterectomy, bilateral salpingoophorectomy, infracolic omentectomy
b. Neoadjuvant chemotherapy followed by interval debulking surgery
c. Primary debulking surgery followed by adjuvant chemotherapy
d. Either primary debulking surgery or neoadjuvant chemotherapy
e. Laparoscopic debulking surgery
D - Either primary debulking surgery or neoadjuvant chemotherapy
In women with stage III or IV ovarian cancer, survival with primary chemotherapy is non-inferior to primary surgery. In a study population, giving primary chemotherapy before surgery is an acceptable standard of care for women with advanced ovarian cancer.
A patient is referred to colposcopy after detection of high grade changes on a routine smear. A microscopic invasive tumour measuring 4mm diameter with 2mm invasion is excised with clear margins at LLETZ. What is the 5-year survival for patients with Stage I cervical cancer?
a. 98%
b. 91%
c. 86%
d. 79%
e. 72%
D - 79%
5 year survival amongst patients with cervical cancer is as follows:
Overall - 60%
Stage I: 79%
Stage II: 47%
Stage III: 22%
Stage IV: 7%
A 39 year old woman who has never had a smear presents with post-coital bleeding. On examination a large 4cm tumour is seen on the cervix with extension into the upper third of the vagina and a suggestion of parametrial invasion on bimanual. What is the 5-year survival for patients diagnosed with Stage II cervical cancer?
a. 92%
b. 85%
c. 79%
d. 56%
e. 47%
E - 47%
5 year survival amongst patients with cervical cancer is as follows:
Overall - 60%
Stage I: 79%
Stage II: 47%
Stage III: 22%
Stage IV: 7%
A 44 year old woman who has never had a smear is referred with loin pain and irregular vaginal bleeding. On CT there is a large tumour causing ureteric obstruction and bilateral hydronephrosis. What is the 5 year survival for patients diagnosed with Stage III cervical cancer?
a. 76%
b. 64%
c. 48%
d. 37%
e. 22%
E - 22%
5 year survival amongst patients with cervical cancer is as follows:
Overall - 60%
Stage I: 79%
Stage II: 47%
Stage III: 22%
Stage IV: 7%
A 55 year old woman undergoes a CT to investigate haematuria and rectal bleeding. A large tumour filling much of the pelvis with invasion to both bowel and bladder is seen and a diagnosis of Stage IV cervical cancer made. What is the 5 year survival amongst patients with Stage IV cervical cancer?
a. 54%
b. 32%
c. 22%
d. 7%
e. 3%
D - 7%
5 year survival amongst patients with cervical cancer is as follows:
Overall - 60%
Stage I: 79%
Stage II: 47%
Stage III: 22%
Stage IV: 7%
What is the overall 5 year survival amongst women with cervical cancer?
a. 90%
b. 85%
c. 70%
d. 60%
e. 45%
D - 60%
5 year survival amongst patients with cervical cancer is as follows:
Overall - 60%
Stage I: 79%
Stage II: 47%
Stage III: 22%
Stage IV: 7%
A patient undergoes a laparotomy to remove a suspect ovarian mass with an elevated Ca125 - it is noted that there is breach of the ovarian capsule and perinteonal washings are positive for malignant cells. Her tumour is staged at 1C. What is the 5 year survival associated with stage IC ovarian tumours?
a. 90%
b. 80%
c. 65%
d. 40%
e. 30%
B - 80%
While the 5 year survival for stage I ovarian cancer is quoted as 90%, this is reduced to 80% for stage IC where there is either surgical spill (IC1); pre-operative rupture/ tumour on the ovarian surface (IC2) or malignant cells in ascites/washings (IC3)
A 54 year old woman attends the vulval clinic with itching and pain. Appearances on examination are highly suggestive of vulval lichen sclerosis which is confirmed on biopsy. Her associated risks of this condition include all but which of the following:
a. A personal history of autoimmune disorders
b. A family history of autoimmune disorders
c. Associated thyroid disease
d. Associated pernicious anaemia
e. Vesiculobullous autoimmune disease of the anogenital site
E - Vesiculobullous autoimmune disease of the anogenital site
Evidence suggests ~40% of women with vulval lichen sclerosis have an associated autoimmune condition including thyroid disease, type 1 diabetes mellitus and pernicious anaemia. Prevalence in first-degree relatives is around 30%
Source: GT Book
A patient who has been on long term steroid therapy for biopsy-proven lichen sclerosis is referred to the gynaecology clinic with a deterioration in her symptom control over the preceding 3-4 months. A vulval biopsy is taken which confirmed vulval squamous cell carcinoma. What is the risk of progression to cancer in patients with lichen sclerosis?
a. <1%
b. 2-4%
c. 5-7%
d. 8-9%
e. 10-15%
B - 2-4%
A patient with biopsy-proven VIN is anxious about undergoing surgical excision. You explain that this is a pre-malignant condition. What is the risk of progression to malignancy with untreated VIN?
a. 2-4%
b. 8-10%
c. 20-40%
d. 60-80%
e. >90%
C - 20-40%
Furthermore, as many as 12-17% of patients with suspected VIN are found to have unrecognised invasive disease at the time of excision.
Select patients may be treated medically with laser ablation or topical imiquimod though surgical excision should be considered first line.
Women diagnosed with VIN require regular (annual) follow up with clinical assessment and vulvoscopy as even after surgical excision a risk of cancer and recurrence remains.
A 25 year old woman is referred to the gynaecology oncology clinic following detection of a large abdomino-pelvic mass on ultrasound. Tumour markers are taken and a significant elevation in LDH levels noted. Surgical histology demonstrates “nests of tumour cells (vesicular with clear cytoplasm and central nuclei) separated by fibrous stroma with evidence of T-cell infiltration. What is the most likely type of ovarian tumour here?
a. Brenner tumour
b. Immature teratoma
c. Endodermal sinus tumour
d. Dysgermioma
e. Embryonal carcinoma
D - Dysgermioma
Germ cells account for 10% of all ovarian tumour and usually arise in younger women in their 20s. The main challenge is preserving fertility without compromising cure.
The corresponding tumour marker elevation helps is making a diagnosis of the subtype:
- AFP: endodermal sinus tumour
- AFP and hCG: embryonal carcinoma
- hCG: choriocarcinoma/non-gestational choriocarcinoma
- LDH (+ALP/hcg): dysgermioma
Dysgermioma (equivalent of seminoma in a male) is most common subtype. They are bilateral in 10% of cases
Source: GT books
A 68 year old woman is seen in the two-week wait clinic with vulval soreness and itching. The vulva is erythematous with excoriation and lichenification on examination. Vulval biopsy shows large pleomorphic cells with granular cytoplasm and prominent nucleus focused in the lower epidermis. Based on this information what is the most likely diagnosis?
a. Plasma cell vulvitis
b. Vulval Crohn’s disease
c. Malignant melanoma
d. Bowen’s disease
e. Paget’s disease of the vulva
E - Paget’s disease of the vulva
The histological features described are classical of Paget’s disease.
A 39 year old patient with a known BRCA1 mutation has completed her family and undergoes a prophylactic bilateral salpingo-oophorectomy. What is her risk of developing primary peritoneal cancer over the following 20 years?
a. Up to 2%
b. Up to 6%
c. Up to 12%
d. Up to 16%
e. Up to 20%
B - Up to 6%
Women with BRCA mutations retain a small risk (2-6%) of primary peritoneal carcinoma for 20 years following risk-reducing ovarian surgery.
Women with BRCA1 have the highest risk of ovarian cancer from 40 years onwards, therefore RRS is advised aged 35-40.
Women with BRCA2 have the highest risk from their mid-40s, thus RRS may be deferred until age 45 onwards
A 52 year old woman is referred to the 2 week wait clinic with an ultrasound scan which has demonstrated a thickened endometrium and a right-sided solid ovarian tumour. Pipelle biopsy in clinic returns a result of Grade I endometroid cancer. Ca-125 is elevated at 150 and Inhibin B levels are also noted to be raised. She undergoes a full staging laparotomy and TAH/BSO. What is the most likely histological diagnosis of the ovarian tumour in this case?
a. Polyembryoma
b. Granulosa cell tumour
c. Sertoli-stromal cell tumour
d. Gynandroblastoma
e. Serous cystadenocarcinoma
B - Granulosa cell tumour
Granulosa - sex-cord stromal - tumours occur at both extremes of age (average 52). Older women tend to present with PMB while younger women present with menstrual dysfunction or precocious puberty as the tumours typically produce oestrogen in high doses so as to cause endometrial cancer in 10%.
They tend to be unilateral, stage I at presentation and thus treatment is usually confined to surgery. Risk of recurrence is high, even several years after cure thus long term follow up is required.
Inhibin A/B levels are measured for follow up (normal 5/15ng/L)
A 21 year old woman presents to the 2WW clinic after an ultrasound, performed to investigate abdominal distension, reveals a large left-sided ovarian mass. Her Ca125 is elevated at 100 though other tumour markers are normal. She undergoes surgical management and histology from the tumour reveals ‘grade 2 neural tissue’. What is the most likely histological diagnosis?
a. Struma Ovarii
b. Mature teratoma
c. Glioblastoma
d. Neuroblastoma
e. Immature teratoma
E - Immature teratoma
Teratomas are germ-cell tumours of the ovary and classified thus:
Mature teratomas are benign and arise from 2-3 germ cell layers. There is a small 1-2% risk of malignant transformation.
Immature teratomas are malignant. They are almost always unilateral and occur most commonly in the first 2 decades of life. They arise from endo-, ecto- and mesoderm and contain both mature and immature elements - most commonly immature neural tissue.
Management is surgery and chemotherapy - they are generally not radiosensitive. Prognosis depends on yolk sac components.
A patient has removal of bilateral ovarian tumours. The histology report notes the presence of ‘signet ring’ morphology and suggests that the tumours are more likely to represent a metastatic rather than primary malignant process. What is the most likely site of origin of the primary?
a. Cervix
b. Thyroid
c. Pancrease
d. Stomach
e. Lung
D - Stomach
Krukenberg tumours represent a metastatic adenocarcinoma of the ovary, usually arising secondary to a GI tract primary (76% from the stomach though can also arise from the pancreas). They are usually bilateral and symmetrical in both ovaries. Mucin-secreting ‘signet ring’ cells are the key histological finding.
An 82 year old woman is referred to the 2-week wait clinic with a 2cm mass on the right labia, away from the midline which is revealed to be a squamous cell carcinoma on biopsy with <1mm depth of invasion. MRI of the pelvis reveals no other abnormality. What would management of this patient involve?
a. Radical vulvectomy
b. Radical vulvectomy with bilateral groin lymphadenectomy
c. Radical vulvectomy with ipsilateral groin lymphadenectomy
d. Wide local excision of the vulval lesion
e. Wide local excision of the vulval lesion with ipsilateral lymphadenectomy
D - Wide local excision of the vulval lesion
Management of vulval tumours is individualised.
Stage IA tumours (=2cm diameter with stromal invasion =1mm) can generally be managed by simple wide local excision without the need for groin nodes. Margins should be at least 1cm wide and to the level of the inferior fascia of the urogenital diaphargm.
All patients with tumours >2cm or >1mm invasion should at least have ipsilateral node dissection.
Bilateral node dissection is indicated in patients with central tumour or those involving the clitoris.
What proportion of endometrial cancer in the UK is attributable to obesity?
a. 10%
b. 25%
c. 33%
d. 50%
e. 75%
D - 50%
Radio-isotopes of which element is typically used for modern brachytherapy in gynaecological malignancy?
a. Radium
b. Caesium
c. Cobalt
d. Curium
e. Boron
C - Cobalt
TOG 2017
In which gynaecological malignancy is radiotherapy used most frequently?
a. Ovarian
b. Endometrial
c. Vaginal
d. Vulval
e. Cervical
E - Cervical
TOG 2017
In which gynaecological malignancy is bowel obstruction most commonly seen?
a. Cervical
b. Ovarian
c. Endometrial
d. Vaginal
e. Vulval
B - Ovarian
TOG 2017
A 58-year-old woman has been diagnosed with endometrial cancer following investigations that included histology on an endometrial biopsy. She had surgery and has come back for review two weeks after the surgery. What will be the most important factor in providing a guide to prognosis?
a. Depth of myometrial invasion
b. Histological type of the malignancy
c. Lymphovascular space invasion
d. Stage of the disease
e. Volume of the tumour
C - LVSI
TOG 2017
A 50-year-old woman who had surgical treatment for cervical cancer three years ago now presents with clinical features of relapsed disease. This has been confirmed. What investigation will help determine whether she will have a chance of local control and cure from chemoradiation?
a. Computed tomography scan
b. Examination under anaesthesia
c. Magnetic resonance imaging
d. Positron emission tomography
e. Ultrasound of the pelvis and abdomen
D - Positron emission tomography
TOG 2017
A woman who has had treatment for a gynaecological cancer is admitted with bowel obstruction. What type of gynaecological cancer is most associated with bowel obstruction?
a. Cervical cancer post radiotherapy
b. Endometrial cancer post radiotherapy
c. Epithelial ovarian cancer
d. Germ cell ovarian cancer
e. Stroma ovarian cancer
C - Epithelial ovarian cancer
TOG 2017
A woman who had treatment for ovarian cancer a few years ago presents with symptoms of bowel obstruction. Which symptom will make you suspect that the obstruction is in the proximal intestines?
a. Absolute constipation
b. Intermittent diarrhoea alternating with constipation
c. Nausea and vomiting
d. Spasmodic pain and vomiting
e. Spurious diarrhoea and then obstruction
C - Nausea and vomiting
TOG 2017
In which of the following situations may be exenterative surgery considered for women with gynaecological cancer?
a. As the primary procedure in 29 year old BRCA carrier who presents with stage III ovarian malignancy
b. A 35 year old with a history of cervical cancer treated with trachelectomy now presents with local recurrence
c. A 55 year old with a history of cervical cancer in the past which was treated with both radical hysterectomy and adjuvant radiotherapy presents with recurrence
d. 63 year old with Stage III endometrial cancer
e. 72 year old with locally advanced vulval cancer and large ulcerated groin nodes
C - A 55 year old with a history of cervical cancer in the past which was treated with both radical hysterectomy and adjuvant radiotherapy presents with recurrence
TOG 2017
What is the incidence of malignancy (any origin) in pregnancy?
a. 1 in 500
b. 1 in 1000
c. 1 in 5000
d. 1 in 10,000
e. 1 in 50,000
B - 1 in 1000
TOG 2017
A 32 year old who has never had a cervical smear presents with post-coital bleeding at 25 weeks of gestation in her first pregnancy and is referred to colposcopy. A directed biopsy reveals invasive cervical carcinoma, clinically graded stage IA1. What treatment option is most appropriate?
a. LLETZ
b. Trachelectomy
c. Caesarean delivery followed by radical hysterectomy now
d. Caesarean delivery followed by radical hysterectomy at 30 weeks of gestation
e. Vaginal brachytherapy
A - LLETZ
TOG 2017
What is the most common ovarian malignancy seen in pregnancy?
a. Germ cell
b. Borderline
c. Epithelial
d. Fibroma
e. Sex cord
A - Germ Cell
TOG 2017
Until what gestation can laparoscopic management of an ovarian mass in pregnancy be considered?
a. 10-12/40
b. 14-16/40
c. 20-22/40
d. 26-28/40
e. 30-32/40
C - 20-22/40
TOG 2017
A 60 year old woman has just been diagnosed with recurrent cervical cancer, which had previously been treated with radiotherapy. She is offered a pelvic exenteration. This surgery would be considered palliative rather than curative when she has which of the following features present?
a. Central disease involving the bladder
b. Central disease involving the rectum
c. Disease involving the vagina and side wall
d. Disease that has spread to the bladder, urethra and side wall
e. Involvement of the pelvic and para-aortic nodes
E - Involvement of the pelvic and para-aortic nodes
TOG 2017
What is the best investigation to identify extra-pelvic disease in patients being considered for pelvic exenteration for recurrent gynaecological cancer?
a. Abdominal x-ray
b. CT scan
c. MRI abdomen and pelvis
d. PET-CT scan
e. Ultrasound abdomen and pelvis
D - PET-CT scan
TOG 2017
A 37 year old woman who presented with vaginal bleeding at 19 weeks of gestation was investigated and found to have an invasive squamous cell carcinoma. What would be the best test to assess local and regional spread of her cancer at this stage in pregnancy?
a. CT
b. EUA + cystoscopy + proctosigmoidoscopy
c. MRI
d. PET
e. USS pelvis
C - MRI
TOG 2017
Human papillovirus (HPV) is implicated in a majority of cervical cancers worldwide. What sort of virus is HPV?
a. Single stranded RNA
b. Double stranded RNA
c. Single stranded DNA
d. Double stranded DNA
e. DNA-RNA virus
D - Double-stranded DNA virus
TOG 2016
HPV subtypes 16 and 18 are the two strains most commonly associated with cervical cancer. What proportion of cervical cancer diagnoses are attributable to HPV 16 and 18?
a. 30%
b. 40%
c. 50%
d. 70%
e. 95%
D - 70%
Worldwide, 70% of cervical cancers are thought to be due to HPV-16 and 18.
After 16 and 18, 31 and 33 are implicated next.
TOG 2016
A 28 year old patient who’s previous cervical smear was negative for HPV on testing has now tested HPV positive 3 years later on recall. What is believed to be the minimum time period between infection with high-risk HPV and the development of a lesion with true malignant potential?
a. 2 years
b. 3 years
c. 5 years
d. 6 years
e. 7 years
E - 7 years
7 years is believed to be the minimum time span between infection with HPV and the development of a pre-malignant lesion with true malignant potential
TOG 2016
What has been the reduction of cervical cancer mortality in the UK associated with the widespread implantation of the cervical screening programme?
a. 25-30%
b. 40-50%
c. 60-70%
d. 80-90%
e. 90-95%
C - 60-70%
Since its introduction, cervical screening in the UK has seen a 60-70% drop in mortality associated with cervical cancers.
TOG 2016
A 25 year old woman attends for her first cervical screening test which is reported as ‘high-grade dyskaryosis’. What is the next step in her management?
a. Refer to colposcopy
b. HPV test
c. Refer to gynaecological-oncologist
d. Repeat cervical smear in 6 months
e. Repeat cervical smear in 12 months
A - Refer to colposcopy
Unlike patients with borderline or low-grade dyskaryosis on cytology who have a reflex HPV test, those with high-grade changes should be referred promptly to colposcopy
TOG 2016
What proportion of cervical smear tests undertaken each year in the UK result in a referral to colposcopy?
a. <1%
b. 2%
c. 4%
d. 8%
e. 12%
C - 4%
TOG 2016
What HPV subtypes are implicated in the development of CGIN?
a. 6 and 11
b. 16 and 18
c. 16 and 31
d. 18 and 45
e. 31 and 33
D - 18 and 45
CGIN - endocervical glandular lesions which are known precursors to cervical adenocarcinoma - are associated with HPV subtypes 18 and 45.
Women who undergo excision of CGIN have considerably higher recurrence rates than women with CIN (18% v. 5%) owing to the presence of ‘skip lesions’ - areas of pathological tissue separated by normal tissue - in CGIN
TOG 2016
At what age are girls in the UK offered vaccination against HPV?
a. 7-8 years
b. 9-10 years
c. 12-13 years
d. 14-15 years
e. 16-17 years
C - 12-13 years
Girls in the UK are offered vaccination against HPV with the quadrivalent Gardasil vaccine (against HPV 6, 11, 16 and 18) at 12-13 years of age.
TOG 2016
Which are the most pathogenic human papillomavirus (HPV) subtypes that are responsible for most cancers?
a. 12 and 16
b. 14 and 15
c. 16 and 18
d. 31 and 33
e. 36 and 45
C - 16 and 18
Subtypes 16 and 18 (HPV-16 and HPV-18) have been found to be the most pathogenic of the high-risk HPV subtypes. Indeed, together they account for 70−80% of cervical cancers, 40−50% of vulval and oropharyngeal cancers and 70−80% of anal cancers in women.
TOG StratOG Resource
A 30-year-old had a routine recall cervical smear, which was reported as high-grade dyskaryosis. She attends for a colposcopy and a large loop excision of the transformation zone is performed. What follow-up should be arranged for her?
a. Cervical cytology alone at 6 months
b. Cervical cytology and colposcopy at 6 months
c. Cervical cytology and if negative, HPV test at 6 months
d. Cervical cytology at 6 and 12 months and then yearly for 9 years
e. Cervical cytology, colposcopy and, if negative, HPV test at 6 months
C - Cervical cytology and if negative, HPV test at 6 months
Following treatment for abnormal cervical cytology that was reported as high-grade moderate-to-severe dyskaryosis, a follow-up visit should be arranged at 6 months. At this visit, a repeat cytology and HPV testing should be done. Further management will depend on the cytology and the HPV test result. If the cytology is negative or borderline/low-grade and the HPV test is negative, she should be referred for routine 3-yearly recall cytology. If the HPV is positive, or high-grade moderate/severe dyskaryosis, referral to colposcopy should be arranged. Where the HPV test in inadequate and the cytology is low grade, refer to colposcopy but if it is borderline, repeat at 3 months.
TOG StratOG Resource
A 29 year old nuliparous patient diagnosed with cervical adenocarcinoma wishes to know if she is suitable for fertility sparing sugery. What is the upper limit of tumour size at which trachelectomy may be considered?
a. 5mm
b. 7mm
c. 15mm
d. 20mm
e. 25mm
D - 20mm
