Gynaecology Oncology Flashcards

Question 1

Q

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%

Answer

A

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%

Question 2

Q

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%

Answer

A

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%

Question 3

Q

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%

Answer

A

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%

Question 4

Q

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%

Answer

A

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%

Question 5

Q

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

Answer

A

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)

Question 6

Q

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%

Answer

A

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%

Question 7

Q

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%

Answer

A

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%

Question 8

Q

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%

Answer

A

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%

Question 9

Q

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%

Answer

A

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%

Question 10

Q

What is the lifetime risk of breast cancer amongst women in the general population?

a. 3%
b. 8%
c. 12%
d. 15%
e. 20%

Answer

A

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)

Question 11

Q

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%

Answer

A

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

Question 12

Q

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%

Answer

A

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%

Question 13

Q

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%

Answer

A

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%

Question 14

Q

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

Question 15

Q

What is the risk of malignancy amongst women with an RMI of 25-250?

a. 5%
b. 10%
c. 20%
d. 25%
e. 40%

Answer

A

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)

Question 16

Q

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

Answer

A

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.

Question 17

Q

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

Answer

A

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.

Question 18

Q

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

Answer

A

C - HPV 16

Question 19

Q

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

Answer

A

B - HPV 6 and 11

Question 20

Q

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

Answer

A

C - HPV 16 and 18

HPV 16 and 18 cause >70% of cervical cancers.

Question 21

Q

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

Answer

A

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.

Question 22

Q

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

Answer

A

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.

Question 23

Q

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

Answer

A

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.

Question 24

Q

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

Answer

A

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.

Question 25

Q

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

Answer

A

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

Question 26

Q

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

Answer

A

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.

Question 27

Q

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

Answer

A

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.

Question 28

Q

In what percentage of epithelial ovarian tumours will Ca125 be elevated?

a. 50%
b. 60%
c. 75%
d. 80%
e. 90%

Answer

A

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.

Question 29

Q

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

Answer

A

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

Question 30

Q

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

Answer

A

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.

Question 31

Q

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

Answer

A

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.

Question 32

Q

What is the most common gynaecological cancer seen in women in the UK?

a. Ovarian
b. Endometrial
c. Vulval
d. Cervical
e. Vaginal

Answer

A

B - Endometrial

Endometrial cancer is the most common gynaecological malignancy in the Western world and endometrial hyperplasia is its natural precursor

Question 33

Q

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

Answer

A

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.

Question 34

Q

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%

Answer

A

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.

Question 35

Q

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%

Answer

A

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.

Question 36

Q

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

Answer

A

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.

Question 37

Q

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

Answer

A

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

Question 38

Q

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

Answer

A

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.

Question 39

Q

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

Answer

A

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.

Question 40

Q

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%

Question 41

Q

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

Answer

A

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.

Question 42

Q

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

Answer

A

E – TVUSS

Ultrasound is a well established test to assess postmenopausal cysts achieving a sensitivity of 80% and specificity of 73%

Question 43

Q

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%

Answer

A

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%

Question 44

Q

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%

Answer

A

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%

Question 45

Q

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%

Answer

A

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%

Question 46

Q

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%

Answer

A

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%

Question 47

Q

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%

Answer

A

A - >90%

Survival in vulval cancer overall based on lymph node status is:

Node negative: >90%
Groin nodes: ~50%
Pelvic nodes: ~11%

Question 48

Q

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%

Answer

A

B - 50%

Survival in vulval cancer overall based on lymph node status is:

Node negative: >90%
Groin nodes: ~50%
Pelvic nodes: ~11%

Question 49

Q

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%

Answer

A

E - 11%

Survival in vulval cancer overall based on lymph node status is:

Node negative: >90%
Groin nodes: ~50%
Pelvic nodes: ~11%

Question 50

Q

What is the overall 5 year survival for patients with vulval cancer?

a. 90%
b. 82%
c. 64%
d. 47%
e. 33%

Question 51

Q

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

Answer

A

C - 1/3 of cases

HPV (most commonly type 6) is implicated in 35% of vulval cancers and 80% of VIN

Question 52

Q

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

Answer

A

A - 4/5 of cases

HPV (most commonly type 6) is implicated in 35% of vulval cancers and 80% of VIN

Question 53

Q

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

Answer

A

A - 6 and 11

Question 54

Q

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

Answer

A

C - 6, 11, 16 and 18

Gardasil is a quadravalent vaccine effective against HPV strains 6, 11, 16 and 18

Question 55

Q

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

Answer

A

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.

Question 56

Q

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

Answer

A

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.

Question 57

Q

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

Answer

A

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.

Question 58

Q

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

Answer

A

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.

Question 59

Q

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

Answer

A

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.

Question 60

Q

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

Answer

A

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.

Question 61

Q

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

Answer

A

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.

Question 62

Q

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

Answer

A

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.

Question 63

Q

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

Answer

A

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.

Question 64

Q

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

Answer

A

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.

Answer 62

A

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.

Answer 63

A

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.

Answer 64

A

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.

Answer 65

A

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.

Answer 66

A

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.

Answer 67

A

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.

Answer 68

A

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.

Answer 69

A

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.

Answer 70

A

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.

Answer 71

A

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.

Answer 72

A

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.

Answer 73

A

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.

Answer 74

A

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.

Answer 75

A

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.

Answer 76

A

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.

Answer 77

A

D - 79%

5 year survival amongst patients with cervical cancer is as follows:

Overall - 60%