Oncology Extra Questions

Option list
A. Stage IA
B. Stage IB
C. Stage IC
D. Stage II
E. Stage IIA
F. Stage IIB
G. Stage IIIA
H. Stage IIIB
I. Stage IIIC1
J. Stage IIIC2
K. Stage IVA
L. Stage IVB
Instructions: For each scenario described below, choose the single most appropriate the International Federation of Gynecology and Obstetrics (FIGO) stage for endometrial cancer from the list of options above. Each option may be used once, more than once, or not at all.

1.A 60-year-old woman presents with postmenopausal bleeding (PMB) tothe gynaecology oncology clinic. An endometrial pipelle biopsy reveals an endometrioid adenocarcinoma. She is further investigated with a magnetic resonance imaging (MRI) scan which reveals uterine myometrial invasion of less than 50% and enlarged pelvic nodes. She subsequently undergoes a total abdominal hysterectomy, bilateral salpingo-oophorectomy and sentinel lymph node biopsy. You review her in the clinic at 2 weeks follow-up with a histology report of endometrial cancer with myometrial invasion of more than 50% and pelvic lymph node involvement.

2. A 44-year-old woman presents to the emergency department with heavy vaginal bleeding and intermenstrual bleeding for the last 6 months. Following a gynaecology review a hysteroscopy and endometrial biopsy were arranged. Two weeks after her hysteroscopy she attends the gynaecology oncology clinic and the histology reveals a papillary serous carcinoma. A computed tomography (CT) scan of the chest is reported as normal while the MRI scan reveals a large uterine tumour infiltrating the serosal surface of the uterus and also involving the pelvic nodes. Subsequently, she undergoes a total abdominal hysterectomy, bilateral salpingo- oophorectomy and pelvic lymphadenectomy in an oncology centre. The final histology confirms the MRI findings.

3. An 82-year-old woman presents to the emergency department with postmenopausal heavy bleeding and her haemoglobin is 7 g/dL. She receives 2 units of blood transfusion and undergoes hysteroscopy and an endometrial biopsy on an emergency basis, as she continued to bleed heavily. An endometrial biopsy reveals clear cell carcinoma. She subsequently undergoes a total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy.
The histology reveals clear cell carcinoma involving the uterine cervix and serosal surface.

4. A 55-year-old woman is referred to a rapid access clinic with PMB. She returns to the clinic for her pipelle biopsy results which reveal endometrial cancer. She then undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The final histology reveals tumour infiltration of less than 50% of the myometrium and involvement of the cervical stroma. Also, peritoneal washings are reported to be positive for malignant cells.

5. A 58-year-old woman attends the rapid access clinic with PMB, following which she has outpatient hysteroscopy and endometrial biopsy. The histology revealed an endometrioid adenocarcinoma. She subsequently undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The final histology is reported as endometrioid adenocarcinoma involving the endometrium and peritoneal washings were positive for malignant cells.

Option list
A. Benign teratoma
B. Choriocarcinoma
C. Dysgerminoma
D. Endodermal sinus tumour
E. Embryonal carcinoma
F. Epithelial ovarian tumour
G. Granulosa cell tumour
H. Gynandroblastoma
I. Gonadoblastoma
J. Leydig cell tumour
K. Malignant teratoma
L. Sertoli cell tumour
Instructions: For each scenario described below, choose the single most appropriate tumour type from the list of options above. Each option may be used once, more than once, or not at all.

6. A 19-year-old girl is referred to the gynaecology clinic with a scan report of a bilateral ovarian mass. An MRI scan confirms a bilateral solid ovarian tumour. The blood test results show an increase in lactate dehydrogenase and placental alkaline phosphatase. She is referred to an oncology centre for further management, following which she undergoes staging for ovarian cancer and bilateral oophorectomy. Her final histology shows marked lymphocytic infiltration in the stroma surrounding the tumour cells.

7. A 20-year-old woman presents to the emergency department with abdominal distention and pain. Clinical examination reveals a palpable abdomino-pelvic mass and an ultrasound scan shows a unilateral solid ovarian mass on the right side. Her tumour marker alpha fetoprotein was 300 U/mL and CA 125 45 U/mL. She was then referred to the gynaecology oncology centre for further management. She had further imaging in the form of MRI and CT scans and underwent staging laparotomy and right-sided oophorectomy. The histology revealed a Schiller–Duval body.

8. An 18-year-old girl presents to her general practitioner with distention of the abdomen. An ultrasound scan reveals a unilateral solid/cystic mass on the left side. An MRI scan confirms that the ovarian tumour is confined to the left ovary and the right ovary looks normal. However, her tumour markers, beta human chorionic gonadotropin (beta hCG) and alpha fetoprotein, were normal. She is then referred to the gynaecology oncology centre for further management, following which she undergoes staging laparotomy and left-sided oophorectomy. One of the components of the histology shows elements of glial tissue.

9. A 55-year-old menopausal woman presents to the emergency department with irregular vaginal bleeding. An abdominal scan shows a large pelvic mass on the right side and a thickened endometrium (20 mm). An MRI scan reveals similar findings. The blood test shows a raised a subunit of inhibin and CA 125 48 U/mL. She gives a family history of breast cancer and is currently on tamoxifen.

10. A 58-year-old woman presents to the emergency department with abdominal bloating and a decreased appetite. She had opened her bowels 2 days ago. Clinical examination reveals a distended abdomen with signs of subacute bowel obstruction. A CT scan of the abdomen and pelvis revealed a large complex pelvic mass (size 15 × 12 × 12 cm) with raised CA 125 (1000 U/mL) and normal carcinoembryonic antigen (CEA) (2 U/mL).

Option list
A. Cervical smear in 6 months
B. Cervical smear in 12 months
C. Cervical smear in 24 months
D. Cervical random punch biopsy
E. Knife cone biopsy
F. Large loop excision of transformation zone (LLETZ)
G. Needs discussion in the multidisciplinary team (MDT) meeting
H. Punch biopsy of the cervical lesion
I. Refer to oncology centre
J. Repeat colposcopy in 3 months
K. Repeat colposcopy in 12 months
L. Repeat colposcopy in 24 months
M. Repeat colposcopy in 2 months
N. Repeat colposcopy in 4 months
O. Repeat colposcopy in 5 years
Instructions: For each scenario described below, choose the single most appropriate management from the list of options above. Each option may be used once, more than once, or not at all.

11. A 28-year-old nulliparous woman is referred to the colposcopy clinic by her general practitioner. She is up to date with smears and never had any previous abnormal smears other than the current cervical smear showing mild dyskaryosis. Colposcopy reveals a mild acetowhite area at the 11 o’clock position and is reported as satisfactory with no abnormal vessels.

12. A 41-year-old woman is referred to the colposcopy clinic with a cervical smear report of moderate dyskaryosis. She also gives a history of two borderline smears in the past. Colposcopy is satisfactory and reveals a severe acetowhite area with coarse mosaicism at the 6 o’clock and 9 o’clock positions. She hates hospitals and did not attend her previous two appointments.

13. A 40-year-old woman is referred to the colposcopy clinic by her general practitioner with a referral cervical smear report of severe dyskaryosis. Colposcopy is unsatisfactory and reveals a severe acetowhite area at the 3 o’clock and 5 o’clock positions with abnormal vessels. She is a chain smoker and gives a family history of stroke.

14. A 30-year-old woman is referred to the colposcopy clinic by her general practitioner with a referral cervical smear report of moderate dyskaryosis. Colposcopy is satisfactory and normal. Medically she suffers from asthma and gives a family history of Huntington disease.

15. A 34-year-old woman is referred to the colposcopy clinic with a smear report of glandular neoplasia. Colposcopy is unsatisfactory and reveals high-grade abnormality intraepithelial neoplasia (CIN3) at the 5 o’clock and 10 o’clock positions and human papillomavirus (HPV) infection at the 6 o’clock position.

Option list
A. Follow-up smear at 6 months
B. Follow-up smear at 8 months
C. Follow-up vault smear at 6 months
D. Follow-up vault smear at 6 and 18 months
E. Follow-up vault smear at 24 months
F. Large loop excision of transformation zone
G. Knife cone biopsy
H. Needs to be seen in a colposcopy clinic within 1 week
I. Needs to be seen in a colposcopy clinic within 2 weeks
J. Needs to be seen in a colposcopy clinic within 3 weeks
K. Needs to be seen in a colposcopy clinic within 4 weeks
L. Needs to be seen in a colposcopy clinic within 8 weeks
M. Needs to be seen in a colposcopy clinic within 10 weeks
N. Needs to be seen in a colposcopy clinic within 14 weeks
O. Needs to be seen in a colposcopy clinic within 18 weeks
Instructions: For each scenario described below, choose the single most appropriate management from the list of options above. Each option may be used once, more than once, or not at all.

16. A 36-year-old woman, para 2, is referred to the colposcopy clinic after a routine smear showing mild dyskaryosis. She is up to date with her smears and gives a history of mild dyskaryosis on cytology 6 months ago. She is currently in a relationship and is using the progesterone only pill for contraception. She smokes 12 cigarettes per day.

17. A 38-year-old woman, para 4, is referred to the colposcopy clinic with a smear result of moderate dyskaryosis. She is generally up to date with her smears with no previous abnormal smears. She had a copper coil fitted 6 months ago for contraception. She now suffers from heavy periods but does not have intermenstrual or postcoital bleeding. She is a social drinker and smokes five cigarettes per day. She also gives a strong family history of ovarian cancer

18. A 26-year-old woman is referred to the colposcopy clinic following a routine smear showing borderline abnormality in the endocervical cells. She is terrified that she has cancer. She has been on ethinylestradiol with drospirenone (Yasmin) for the last 2 years and complains of some headache and tiredness. She also smokes 10 cigarettes per day.

19. A 48-year-old woman, para 10, is referred to the colposcopy services with a clinical impression of suspicious cervix. She is up to date with her smears and has never had an abnormal smear. She has never had surgery before and is needle-phobic. She is social drinker and smokes 20 cigarettes per day. Recently, her mother died of breast cancer and her father has pancreatic cancer.

20. A 35-year-old woman is referred to the colposcopy clinic with a smear report of glandular neoplasia. Medically, she suffers from contact dermatitis and is allergic to peanut oil. She does not have any support at home.

Option list
A. Follow-up cervical smears in 6 months
B. Follow-up cervical smear in10 months
C. Follow-up cervical smear in 12 months
D. Follow-up cervical smear in 14 months
E. Follow-up cervical smear in 6 months  and colposcopy
F. May need hysteroscopy and endometrial biopsy
G. May need a knife cone biosy
H. No need for repeat cervical smear
I. Vault smear in 6 months
J. Vault smear in 6 and 18 months
K. Vault smears and colposcopy as per protocols for follow-up of grade III cervical intraepithelial neoplasia (CIN3)
L. Vault smears and colposcopy as per protocol for follow-up for grade I cervical intraepithelial neoplasia (CIN 1)
M. Vault smears at 1 year and 2 years N Vault smears at 1 year and 5 years O Vault smear not indicated
N. Vault smear at 1 and 2 years
O. Vault smear at 1 and 5 year
P. Vault smear not indicated

21. A 36-year-old woman, para 3, presents to her general practitioner with an excessive white vaginal discharge. She has had three partners in the last year and is currently in a new relationship. She gives a history of an intrauterine copper device (IUCD) fitted 4 years ago. She drinks socially and smokes 20 cigarettes per day. Her cervical cytology a year ago was reported normal.

22. A26-year-old woman had her first cervical smear recently which is reported as negative with some wart virus changes. She gives a history of childbirth 6 months ago.

23. A 25-year-old woman underwent a medical termination of pregnancy 3 months ago. She comes to the general practitioner centre today and has her first cervical smear, which is reported as borderline in squamous cells.

24. A 36-year-old woman presents to her general practitioner with vulval itching. Clinical examination reveals contact dermatitis. Her periods are generally regular and she is currently on her period. Her recent smear is normal but shows candida infection.

Option list
A. CA 125
B. Chemotherapy
C. Computed tomography (CT)
D. Magnetic resonance imaging (MRI)
E. Ovarian cyst aspiration
F. Ovarian cystectomy
G. Oophorectomy
H. Ovarian transposition
I. Repeat scan not necessary
J. Repeat the transabdominal ultrasound scan
K. Repeat the transvaginal scan (TVS)
L. Refer to the colposcopy clinic
M. Refer to the cancer centre
N. Refer to the gynaecology clinic
O. Staging laparotomy
Instructions: For each scenario described below, choose the single most appropriate management from the list of options above. Each option may be used once, more than once, or not at all.

25. A 20-year-old woman attends the emergency department with acute abdominal pain. The surgeon suspects appendicitis and performs a diagnostic laparoscopy. You are the on-call registrar for that night and the surgeon calls you to give an opinion on an incidentally found large solid ovarian mass in the right adnexa with papillary projections on the surface. There is some free fluid in the pelvis and the other ovary appears normal.

26. A 58-year-old woman presents to her general practitioner with gradual distension of the abdomen for the last 6 months. She is then referred to the gynaecology clinic for suspected ovarian cancer. An ultrasound scan of the pelvis reveals a large multilocular ovarian cyst on the right side. Her tumour markers are reported as: (a) CA 125 2000 U/mL, (b) CEA 1.2 ng/mL, and (c) CA 19.9 1 U/mL.

27. A 39-year-old woman is reviewed in the gynaecology clinic with symptoms of pelvic pain for the last 2 years. She was treated for endometriosis 5 years ago with laparoscopic laser ablation. Her ultrasound scan 2 months ago revealed a left-sided ovarian cyst (5.8 cm) with diffuse low-level internal echoes with one thin internal septae. Her CA 125 level is raised (61 U/mL).

28. A 28-year-old woman is referred to the gynaecology clinic with symptomsof enorrhagia with no intermenstrual and postcoital bleeding. Her pelvic examination is normal. However, an ultrasound scan of the pelvis shows an incidental finding of a simple ovarian cyst (size 3 × 3 × 3 cm) on the right side. A serum CA 125 level is 15 U/mL. Her recent cervical smear was normal.

29. A 50-year-old woman is referred to the gynaecology clinic with two ultrasound scan reports: (a) a current one showing a simple left ovarian cyst of 3 × 4 cm in size, and (b) the previous one performed 4 months ago showing a simple left ovarian cyst of 5 × 4 cm in size. Her CA 125 is 6 U/mL. She is otherwise asymptomatic and well.

Option list
A. Arrhenoblastoma
B. Brenner tumour
C. Borderline serous ovarian tumour
D. Clear cell carcinoma
E. Endometrioid carcinoma
F. Dermoid cyst
G. Granulosa cell tumour
H. Krukenberg tumour
I. Mucinous cystadenoma
J. Mucinous cystadenocarcinoma
K. Papillary serous carcinoma
L. Serous cystadenoma
M. Serous cystadenocarcinoma
N. Struma ovarii
O. Thecoma
Instructions: For each of the pathological findings described below, choose the single most appropriate tumour diagnosis from the list of options above. Each option may be used once, more than once, or not at all.

30. Signet ring cells on histology.

31. Low malignant potential with no stroma invasion.

32. Low malignant potential with no stroma invasion.

33. Müllerian origin with poor prognosis.

34. Usually seen in postmenopausal women and is associated with fibroma (Meigs syndrome).

Option list
A. Cervical biopsy
B. Cervical smear
C. Computed tomography (CT) scan
D. Hysteroscopy and endometrial biopsy
E. Diagnostic laparoscopy and proceed
F. Magnetic resonance imaging (MRI) scan
G. No further tests required
H. Transvaginal scan (TVS) for endometrial thickness
I. Thyroid function tests
J. Pregnancy test
K. Pelvic examination
L. Rectal examination
M. Renal function tests
N. Saline hysterosonography
O. Speculum examination of cervix
Instructions: For each case described below, choose the single most appropriate investigation in women with postmenopausal bleeding (PMB) from the above list of options. Each option may be used once, more than once, or not at all.

35. A 48-year-old Caucasian woman is referred to the rapid access gynaecology oncology clinic with PMB. Speculum examination reveals stenosed cervical os and two failed attempts at endometrial pipelle biopsy. A transvaginal ultrasound shows an endometrial thickness of 6 mm. She claims to be fit and well.

36. A 48-year-old Asian woman presents to her general practitioner with PMB. She had a left mastectomy and axillary node dissection for breast cancer 4 years ago. She is currently on two medications: tamoxifen and anastrozole. She has been up to date with her smears and all her previous smears including the current one are normal. A TVS performed in the clinic reveals 5 mm endometrial thickness and normal ovaries. A recent breast appointment shows no clinical evidence of recurrence of breast cancer.

37. A 48-year-old Caucasian woman visits the UK to see her daughter-in-law and her grandson. She is newly registered with a general practitioner and presents with PMB for the last 2 weeks. She is up to date with her smears and has never had any abnormal smears. Pelvic examination is normal.

38. A 48-year-old Asian woman is referred to the gynaecology oncology clinic for PMB which occurred 2 weeks ago. She did not have any further bleeding following that one episode. She is up to date with her smears which are normal, and a TVS reveals 3 mm endometrial thickness. Clinical examination reveals an atrophic cervix and vagina.

39. A 48-year-old Caucasian woman is referred to the gynaecology oncology clinic for ongoing PMB for the last 3 weeks. So far all her previous smears have been normal and her endometrial thickness measures 4 mm on recent TVS. Clinical examination is normal.