Section 2: Cervical, Prostrate, Ovarian and Testicular Cancers

Question 1

Cervical cancer:

What is the next line of action after an abnormal pap smears with low-grade or high-grade dysplasia?

Answer 1

Colposcopy and biopsy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8431-8442). Kaplan Publishing. Kindle Edition.

Question 2

Cervical cancer:

What is the next line of action after an abnormal pap smears shows atypical squamous cells of undetermined significance (ASCUS)?

Answer 2

Do HPV testing

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8431-8442). Kaplan Publishing. Kindle Edition.

Question 3

Cervical cancer:

What is the next line of action after an abnormal pap smears shows atypical squamous cells of undetermined significance (ASCUS) and the HPV test is

1. Positive?
2. Negative?

Answer 3

1. Colposcopy
2. Repeat the Pap smear in 6– 12 months

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8431-8442). Kaplan Publishing. Kindle Edition.

Question 4

Cervical cancer:

An abnormal pap smears shows atypical squamous cells of undetermined significance (ASCUS) and the HPV test is negative. A repeat Smear 6 months later is normal. What is the next line of action?

Answer 4

Return to routine screening

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8431-8442). Kaplan Publishing. Kindle Edition.

Question 5

Cervical Cancer

Pap smears lower mortality in screen populations but not as much as mammography, because the incidence of cervical cancer is much less than that of breast cancer

Age to start Pap Smear?

Frequency of Pap Smear?

Age to stop Pap Smear?

When should HPV vaccine be administered?

Answer 5

• Start Pap smears at age 21 regardless of the onset of sexual activity
• Frequency should be every 2– 3 years until age 65.
• Stop at age 65, unless there has been no previous screening.
• Between the ages of 13 and 26 to all women. It is a quadrivalent vaccine (Gardasil)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8431-8442). Kaplan Publishing. Kindle Edition.

Question 6

True or False:

There is no proven screening method that lowers mortality for prostrate cancer

Answer 6

True

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8431-8442). Kaplan Publishing. Kindle Edition.

Question 7

A 65-year-old man comes to you requesting screening for prostate cancer. What should you do?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8446-8451). Kaplan Publishing. Kindle Edition.

Answer 7

Patients requesting screening for prostate cancer should undergo PSA and digital rectal exam. Though seemingly self-contradictory, the recommendation is that the physician should not “routinely offer” screening but, if requested, should perform it if the age < 75.

No PSA testing over age 75.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8446-8451). Kaplan Publishing. Kindle Edition.

Question 8

True or False:

There is no proven screening method that lowers mortality for prostate cancer

Answer 8

True

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8455-8464). Kaplan Publishing. Kindle Edition.

Question 9

List the prognostic factors for prostrate cancer

Answer 9

• Presence of metastasis
• Gleason score. The Gleason score is a measure of the level of differentiation of the histology. The higher the score, the more aggressive the cancer

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8455-8464). Kaplan Publishing. Kindle Edition.

Question 10

Rx of localized prostrate cancer

Answer 10

• Surgery and external radiation

or

• Surgery and implanted radioactive pellets

Both are nearly equal in efficacy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8455-8464). Kaplan Publishing. Kindle Edition.

Question 11

Rx of metastatic prostrate cancer

Answer 11

Androgen blockade is the standard of care

• Flutamide (testosterone receptor blocker) and leuprolide

OR

• Flutamide and goserelin

Both leuprolide and goserelin are gonadotropin-releaseing hormone (GNRH) agonist

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8455-8464). Kaplan Publishing. Kindle Edition.

Question 12

Finasteride is a 5 alpha-reductase inhibitor.

List the indications for the use of finasteride

Answer 12

• Benign prostatic hyperplasia
• Male pattern hair loss

Question 13

What is the fastest way to lower androgen/ testosterone levels?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8470-8482). Kaplan Publishing. Kindle Edition.

Answer 13

Orchiectomy. We did not say to do it, but this is the fastest way.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8470-8482). Kaplan Publishing. Kindle Edition.

Question 14

A man with prostate cancer presents with severe, sudden back pain. His MRI shows cord compression, and he is started on steroids. What is the next best step in management?

a. Flutamide
b. Flutamide and leuprolide simultaneously
c. Leuprolide followed by flutamide
d. Ketoconazole

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8470-8482). Kaplan Publishing. Kindle Edition.

Answer 14

A. Flutamide should be started first to block the temporary flare up in androgen levels that accompanies GnRH agonist treatments. When cord compression is described, GnRH agonists, if used too soon, can worsen the compression. Ketoconazole, at a high dose, blocks the production of androgens, but it is not as effective as the other therapies.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8470-8482). Kaplan Publishing. Kindle Edition.

Question 15

Ovarian cancer:

Look for a woman > 50 with increasing abdominal girth at the same time as weight loss

1. List the diagnostic test for screening for ovarian cancer
2. Name the diagnostic marker for ovarian cancer

Answer 15

1. There is no routine screening test for ovarian cancer
2. CA125 is a marker of progression and response to therapy for ovarian cancer, not a diagnostic test.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8483-8492). Kaplan Publishing. Kindle Edition.

Question 16

Rx of ovarian cancer

Answer 16

Surgical debulking followed by chemotherapy

Even in cases of extensive local metastatic disease. Ovarian cancer is unique in that surgical resection is beneficial even when there is a large volume of tumor spread through the pelvis and abdomen. Removing all visible tumor still helps.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8483-8492). Kaplan Publishing. Kindle Edition.

Question 17

Testicular cancer:

Presents with a painless scrotal lump in a man under 35

Diagnostic tests in testicular cancer

Answer 17

Most accurate test: Inguinal orchiectomy of the affected testicle

Serum levels of α-fetoprotein (AFP), LDH, and β-hCG should be measured.

Scrotal ultrasound is also a useful means of differentiating cancer from nonneoplastic lesions (eg, hydrocele, spermatocele, infection)

Do not do a scrotal biopsy to diagnose testicular cancer, as this may result in seeding of the biopsy tract

95% of testicular cancers are germ cell tumors (seminoma and nonseminoma)

Le, Tao; Bhushan, Vikas; Herman Bagga (2010-09-21). First Aid for the USMLE Step 3, Third Edition (First Aid USMLE) (Kindle Locations 5229-5233). McGraw-Hill. Kindle Edition.

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Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8492-8507). Kaplan Publishing. Kindle Edition.

Question 18

True or False:

Only nonseminomas produce alpha-fetoprotein

Answer 18

True: Alpha fetoprotein (AFP) is secreted only by nonseminomas

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8492-8507). Kaplan Publishing. Kindle Edition.

Question 19

Rx of testicular cancer

Answer 19

Local disease: Radiation

Widespread disease: Chemotherapy

Chemotherapy can cure even metastatic disease. Testicular cancer is extremely curable with a 90– 95 percent 5-year survival rate. It is not diagnosed by biopsy of the testicle

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 8492-8507). Kaplan Publishing. Kindle Edition.