22 Vulvar, Vaginal, Uterine, and Cervical Cancer

Matthew A. Powell and Laura Divine

QUESTIONS

Each of the numbered items below is followed by lettered answers. Select the ONE lettered answer that is BEST in each case unless instructed otherwise.

Question 22.1 Which of the following feature is most characteristic of type I endometrial cancers?

A. Most of these cancers have serous or clear cell histology.

B. Risk factors include unopposed estrogen, anovulation, and obesity.

C. They are rarely (less than 5% of cases) associated with microsatellite instability.

D. The precursor lesion is preneoplastic atrophic endometrium.

Question 22.2 Type II endometrial cancers have which of the following features?

A. The precursor lesion is atypical hyperplasia.

B. The majority of tumors are slow growing.

C. These cancers are unrelated to estrogen exposure.

D. All of the above.

Question 22.3 Genetic changes commonly seen in type I endometrial cancers include:

A. KRAS mutation

B. PTEN mutation

C. β-Catenin mutation

D. All of the above

Question 22.4 Which of the following genetic change(s) is/are most characteristic of type II endometrial cancers (select three correct answers)?

A. Microsatellite instability (MSI)

B. HER2/neu amplification

C. BCL2 overexpression

D. p53 mutations

Question 22.5 Risk factors for endometrial cancer include: (Select two correct responses)

A. Increasing age.

B. Black race.

C. Family history of endometrial cancer.

D. Combination oral contraceptives (contain estrogen and progestogen).

Question 22.6 The majority of cervical, vaginal, and vulvar cancers appear to have a common cause, which is:

A. Increased exposure to exogenous estrogen.

B. Chronic bacterial and parasitic infections.

C. Multiple prior herpes simplex virus (HSV) infections.

D. Human papillomavirus (HPV) infection with high-risk types.

Question 22.7 In patients with gestational trophoblastic disease (GTD) with a complete mole, molecular features include which of the following?

A. Mutations in p53.

B. Most are diploid with duplication of a haploid maternal genome.

C. Predominance of maternal chromosomes is common.

D. Several genes, including CMYC, ERBB2, CFMS, and BCL2, have been implicated in the pathogenesis of complete moles.

Question 22.8 A 39-year-old married woman is seeing you in the office after recently having a cervical biopsy that demonstrated cervical cancer. She has no prior medical problems other than anemia and one prior uncomplicated child birth. You tell her which of the following epidemiologic factors are TRUE?

A. During the past 80 years, death rates from cervical cancer have decreased primarily because of improved treatment of STDs such as gonorrhea, chlamydia, and syphillis.

B. Delayed childbearing is associated with an increased risk of cervical cancer.

C. HSV is thought to be the causative agent for the majority of patients.

D. The incidence of cervical cancer is 30% and 100% higher in Black and Hispanic women, respectively, compared with Whites in the United States.

Question 22.9 The patient asks about prevention and treatment of HPV infections, and you advise her:

A. The viral infections are rare.

B. Treatments for HPV infections with antiviral therapy are effective if taken within 4 days of exposure.

C. HPV vaccines have been approved by the Food and Drug Administration (FDA) to help prevent infection from the most common HPV types.

D. She should receive the HPV vaccine now to help treat her cancer.

Question 22.10 You counsel her about HPV and human immunodeficiency virus (HIV). After extensive discussion, you decide to proceed with testing for HIV with which of the following justifications? (Select three correct responses)

A. HIV immunosuppression is correlated with an increased risk of cervical HPV infections.

B. Patients with HIV appear to have a faster rate of progression to high-grade dysplasia (cervical intraepithelial neoplasia [CIN]).

C. Antiretroviral therapy to manage HIV has demonstrated direct activity against HPV.

D. Cervical cancers in HIV-positive women may be more aggressive than in HIV-negative women.

Question 22.11 She has done extensive reading about cervical cancer and asks you about factors that are associated with metastatic disease. You advise her that the following are associated with extracervical disease:

A. Tumor size and histologic subtype

B. Presence of microinvasion and lymphovascular space invasion

C. Depth of invasion and presence of microinvasion

D. Presence of lymphovascular space invasion and history of pelvic surgery

Question 22.12 If her initial biopsy returned with invasive squamous cell carcinoma with 2 mm of invasion and no lymphovascular space involvement (LVSI), you recommend:

A. Simple hysterectomy.

B. Radiation therapy with possible chemotherapy.

C. Chemotherapy with cisplatin 40 mg/m² weekly for six cycles.

D. Cervical conization.

Question 22.13 The patient has a 3-cm visible tumor found on her cervix that is biopsied and is frankly invasive squamous cell carcinoma. She has several questions regarding staging of her cancer. You advise the following:

A. If enlarged lymph nodes are seen on her computed tomography (CT) scan, her cancer would be staged appropriately as at least stage III.

B. Staging for cervical cancer is clinical, involving pelvic examination.

C. If hydronephrosis is demonstrated on her CT scan, her cancer would be staged appropriately as at least stage II.

D. Positron emission tomography (PET) scanning is used in staging to determine nodal involvement.

Question 22.14 The patient’s 3-cm visible tumor appears confined to the cervix and is staged as IB1. Which of the following therapies is most appropriate?

A. Radiation and chemotherapy with weekly cisplatin dosed at 40 mg/m²

B. Simple hysterectomy with removal of fallopian tubes and ovaries

C. Radiation therapy or radical hysterectomy with lymphadenectomy

D. Brachytherapy radiation with a dose of 75 Gy

Question 22.15 A 40-year-old woman is diagnosed with invasive cervical cancer. She has a 5-cm cervical tumor with parametrial involvement, and evidence of hydronephrosis on imaging. Her cancer is stage IIIB. You elect to treat her with combined chemotherapy and radiation. Which of the following applies to the treatment of locoregionally advanced cervical cancer?

A. Randomized trials involving patients with locally advanced cervical cancer have failed to demonstrate a benefit of chemotherapy in addition to standard radiation therapy.

B. Carboplatin appears to be the most appropriate agent to combine with radiation therapy for cervical cancer and this should be followed by hysterectomy.

C. Paclitaxel with cisplatin is an acceptable regimen to combine with radiation therapy and has demonstrated improved survival.

D. Weekly cisplatin with radiation therapy appears as active as other regimen with manageable toxicity.

Question 22.16 After receiving definitive concurrent chemoradiotherapy for her stage IIIB cervical cancer, the patient develops a recurrence in the cervix, 18 months from the completion of therapy. Imaging studies suggest no extrapelvic disease. You recommend the following:

A. Referral back to the radiation oncologist for consideration of further radiation

B. Chemotherapy with combined cisplatin and topotecan

C. Chemotherapy with combined cisplatin and paclitaxel

D. Referral for consideration of further surgery

Question 22.17 A 67-year-old woman presents for evaluation of a cancer found in the vagina. Before any examination or evaluation, you review with her that which of the following are TRUE? (Select two correct responses)

A. Prior in utero exposure to the synthetic estrogen diethylstilbestrol (DES) places a woman at an increased risk for development of vaginal clear cell adenocarcinoma.

B. Most cancers found in the vagina are actually metastases or direct extensions from other gynecologic tumors.

C. Vaginal squamous cell carcinoma is thought to be unrelated to the HPV.

D. Staging for primary vaginal cancers includes surgical exploration.

Question 22.18 The patient is found to have had a prior hysterectomy for mild dysplasia. Her apparent primary vaginal cancer extends to the subvaginal tissues and is appropriately staged as a stage II cancer. You recommend:

A. Referral for total radical vaginectomy

B. Chemotherapy with a cisplatin-based regimen

C. Referral for radiation therapy

D. Local excision followed by close observation

Question 22.19 Which of the following statement(s) applies to invasive vulvar cancer? (Select two correct responses)

A. There are three distinct types of invasive squamous vulvar cancer.

B. HPV-associated vulvar cancer tends to occur in younger women (age <55 years) and is associated with prior cervical precancerous abnormalities.

C. Melanoma of the vulva is caused by exposure to HPV.

D. Non–HPV-associated invasive squamous vulvar cancer is associated with lichen sclerosis.

Question 22.20 A 55-year-old patient with a history of abnormal Pap smears presents for evaluation of a 3-cm vulvar mass. The mass is located 1 cm lateral to the clitoris on the right and has an ulcerated appearance. She states she noticed it 2 years ago and has tried many different ointments to help control the itching and irritation. This was recently biopsied to reveal invasive squamous cell carcinoma. What treatment would you recommend?

A. Neoadjuvant chemoradiation followed by local resection

B. Concurrent chemoradiation

C. Radical vulvectomy with bilateral inguinal lymphadenectomy

D. Local resection followed by radiation and/or chemotherapy

Question 22.21 Which of the following histologic feature(s) is/are most significant in predicting the outcome for a patient with vulvar cancer? (Select two correct responses)

A. Presence of lymphovascular invasion

B. Tumor grade

C. Depth of invasion and tumor diameter

D. Presence and number of positive lymph nodes

Question 22.22 The final pathology reveals a 3.3-cm invasive squamous cell carcinoma with 2 involved (positive) lymph nodes larger than 1.0 cm, without extracapsular spread, in the right inguinal/femoral lymph node dissection out of 12 removed. The contralateral node dissection was negative. Margins around the primary tumor were negative and greater than 1 cm. Her appropriate International Federation of Gynecology and Obstetrics (FIGO) and TNM stage are:

A. II and T2N2M0.

B. IIIA and T3N1M0.

C. IIIB and T2N1M0.

D. IVA and T2N1M0.

Question 22.23 The most appropriate therapy for this patient after she recovers from surgery is:

A. Close observation.

B. Chemotherapy with cisplatin plus 5FU.

C. Referral for consideration of radiation therapy.

D. Exploration with dissection of the pelvic lymph nodes.

Question 22.24 Unfortunately, despite the use of adjuvant therapy, this patient’s cancer recurs locally on the vulva with a 2-cm lesion. Which of the following would you advise?

A. Repeat resection

B. Chemotherapy with bleomycin

C. Best supportive care

D. Chemotherapy with cisplatin plus 5FU

Question 22.25 A 62-year-old woman has been diagnosed with a uterine corpus (body) cancer. You have not received her records for review, but she is seen in your office for consultation and asks many general questions. Which of the following would you tell her?

A. Approximately 90% of these cancers arise from the endometrial lining and are typically managed with hysterectomy and staging.

B. Most of these cancers are caused by exogenous estrogen use.

C. Uterine sarcomas are more common than endometrial cancers and represent approximately 90% of corpus cancers.

D. Endometrial cancer typically presents at late stage with patients having abnormal uterine bleeding.

Question 22.26 This patient’s records arrive in the office, and the pathology verifies the diagnosis of a grade 2 endometrioid-type endometrial cancer from an office endometrial biopsy. She asks what has caused her cancer to develop. Which of the following are considered to be independent risk factors for the development of endometrial cancer? (Select three correct responses)

A. Obesity

B. Diabetes mellitus

C. Premature ovarian failure with early menopause

D. Presence of an estrogen-producing tumor

Question 22.27 For this patient with an office biopsy demonstrating grade 2 endometrioid endometrial cancer who is of apparent good heath with no other medical comorbidities, you recommend:

A. Further evaluation with CT scan and PET scan to evaluate for metastatic disease.

B. A formal dilation and curettage (D&C) to obtain a more accurate pathologic diagnosis.

C. Hysterectomy with removal of the tubes and ovaries with consideration of pelvic and para-aortic lymphadenectomy.

D. Referral for radiation therapy with possible chemoradiation.

Question 22.28 During the patient’s initial visit, she reports that her mother was diagnosed with endometrial cancer at age 42, her maternal aunt with colon cancer at age 51, and her sister with endometrial cancer at age 38. You are concerned her cancer may be hereditary. You advise that:

A. She undergoes colon assessment if she is not up to date with age-appropriate screening and considers counseling and possible testing for hereditary nonpolyposis colorectal cancer (Lynch II syndrome).

B. She undergo breast MRI and be tested for BRCA1 and BRCA2.

C. Colon and endometrial cancers are common, and no further evaluation is necessary at this time.

D. The maternal side of her family very likely has familial adenomatous polyposis and should be further evaluated.

Question 22.29 The patient undergoes hysterectomy with full staging, including pelvic washing for cytology, removal of both tubes and ovaries as well as pelvic and para-aortic lymph nodes. She is noted to have cancer involving three pelvic lymph nodes, but not the para-aortic lymph nodes. Her stage is designated:

A. IIIB.

B. IIIC1.

C. IIIC2.

D. IVA.

Question 22.30 For this patient with three positive pelvic lymph nodes and a grade 2 endometrioid endometrial cancer, you recognize adjuvant therapy is controversial but ultimately recommend:

A. Hormone therapy with a progestational agent

B. Referral for pelvic radiation therapy

C. Chemotherapy with combined paclitaxel, cisplatin, and doxorubicin

D. Combination of radiation and chemotherapy

Question 22.31 The most active (improved disease-free and overall survival) chemotherapy regimen as determined in randomized clinical trials in women with advanced or recurrent endometrial cancer with measurable disease is:

A. Doxorubicin plus paclitaxel

B. Cisplatin/doxorubicin

C. Cisplatin/doxorubicin/paclitaxel

D. Ifosfamide plus paclitaxel

Question 22.32 A 17-year-old female patient presents to your office with pelvic ultrasound suggesting intrauterine gestational trophoblastic neoplasia (GTN). The most common of the distinct clinicopathologic entities of GTN is:

A. Complete hydatidiform mole.

B. Partial hydatidiform mole.

C. Choriocarcinoma.

D. Placental site trophoblastic tumor.

Question 22.33 This patient has a beta-human chorionic gonadotropin (hCG) of 122,300 and undergoes therapy with a suction D&C. Final pathology confirms the diagnosis of complete hydatidiform mole. The patient is followed with the following:

A. CT scan every 3 months.

B. Ultrasound of the pelvis every 3 months.

C. Pelvic examination with Pap smear every 6 weeks.

D. Beta-hCG weekly.

Question 22.34 After a complete metastatic workup, the patient is determined to have low-risk disease. You recommend the following chemotherapy:

A. Etoposide

B. Vincristine

C. Methotrexate

D. Cyclophosphamide

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