Oncology Extra Questions

1. The most common cause of death from gynaecological malignancy in the developed world:

2. The risk of endometrial cancer is increased in the following condition:

3. Oral contraceptive pills reduce the risk of endometrial cancer by:

4. The incidence of occult ovarian cancers detected in women with BRCA mutation who undergo risk reducing salpingo-oophorectomy is:

5. The following statements are true regarding borderline ovarian tumours except:

6. Borderline tumours of the ovary are commonly associated with the following genetic mutation:

7. The recommended first line of treatment in Lichen sclerosus is:

8. Lichen sclerosus commonly presents in the following age group:

9. Flat-topped violaceous purpuric plaques on the vulva are characteristic of:

10. A 50-year-old woman presented with 20 mm mass in the left breast associated with skin indentation. Which one of the following is the next most appropriate action?

11. A 72-year-old woman was diagnosed with 10 mm, grade II, oestrogen receptor negative invasive left breast cancer. She had a palpable left axillary lymph node. Which one of the following is the next most appropriate action?

12. Which one of the following correctly describes the NHS breast cancer screening programme?

13. A 34-year-old woman presents with 6 weeks’ history of a lump in the upper outer quadrant of the right breast. She has a family history of breast cancer. Clinical examination of the breast suggests a benign lump (E2 grading on examination). Which one of the following is the next most appropriate action?

14. What percentage of patients in dedicated vulval cancers present with Lichen sclerosus?

15. Untreated VIN (vulva intraepithelial neoplasia) may progress to carcinoma of vulva in:

16. The commonest HPV type to be associated with vulval carcinoma and vulval intraepithelial carcinoma is:

17. In management of invasive vulval cancer, inguinofemoral lymphadenectomy can be avoided in all except:

18. All the following are true about endometrial cancers except:

19. What percentage of endometrial cancers are inherited?

20. In staging of vulvar carcinoma, a tumour of any size, with or without extension to adjacent perineal structures, and with more than three positive inguinofemoral nodes is:

21. The first malignancy that was recognised to be linked to obesity is:

22. The most prevalent cancer affecting pregnancy and puerperium is:

23. The following are recommended by FIGO for staging of cervical cancer except:

24. All of the following about adenocarcinomas of the cervix are true except:

25. Detection rates of endometrial cancer with the Pipelle in postmenopausal women are:

26. Regarding peritoneal cytology in endometrial cancer, the following is true:

27. Regarding lymphatic involvement in endometrial cancer, pick the incorrect statement.

28. The 5-year overall survival for endometrial cancer is:

29. Call–Exner bodies are found in:

30. Ms. XY is 64 years old, postmenopausal. Her recent TV ultrasound scan reveals the presence of a 4 cm right ovarian cyst. The cyst is multiloculated and shows the presence of a solid area. There is no free fluid. The left ovary is normal. Her CA125 is 50 u/ml. She has been explained of her RMI results. What is her RMI score based on the information provided?

31. Ms. XY is 64 years old, postmenopausal. Her recent TV ultrasound scan reveals the presence of a 4 cm right ovarian cyst. The cyst is multiloculated and shows the pres- ence of a solid area. There is no free fluid. The left ovary is normal. Her CA125 is 50 u/ml. She has been explained of her RMI results (450). Which of the following treatment options are best suited to her?

32. Ms. XY is 64 years old, postmenopausal. Her recent TV ultrasound scan reveals the presence of a 4 cm right ovarian cyst. The cyst shows anechoic fluid with no solid areas. There is no free fluid. The left ovary is normal. Her CA125 is 5 u/ml. Which of the following treatment options are best suited to her?

33. Ms. XY is 35 years old and had a LLETZ recently. The histology results confirm the presence of CIN 2, which has been completely excised. How should she be followed up under the NHS cervical screening programme if her subsequent tests are normal?

34. Lifetime increase in risk of breast cancer with CTPA:

35. Ms. XY is 8 weeks’ pregnant. Her last smear result suggested mild dyskaryosis. She is due for a repeat smear. Which of the following treatment options are best suited to her?

36. Ms. XY is 55 years old. She underwent a TAH + BSO, 4 weeks ago. Her preoperative histology following a prior loop excision of the cervix suggested incompletely excised CIN 3. She is at a consultant-led follow-up clinic to discuss her further management. Which of the following treatment options are best suited to her?

37. All of the following statements regarding borderline ovarian tumours are true except:

38. The risk of contralateral lymph node involvement in a laterally placed lesion of vulval carcinoma is:

39. During surgery for ovarian tumour, if the frozen section report is a borderline ovarian tumour, which of the following is not a recommended procedure?

40. The role of the sentinel lymph node mapping is most established in this gynaeco- logical malignancy:

41. Administration of tamoxifen is a cornerstone in the treatment of breast cancer, but it has a weak estrogenic effect on the endometrium.
A woman who is taking Tamoxifen presents with post-menopausal bleeding (PMB).
What is her risk of developing endometrial cancer when compared to the general population?

42. PMB is defined as uterine bleeding occurring after at least one year of amenorrhoea. The main purpose of investigating a woman with PMB is to rule out endometrial cancer.

What is the risk that a woman presenting with PMB will have endometrial cancer?

43. A 60-year-old woman presents with a first episode of PMB. What is the most appropriate first line of investigation?

44. A 55-year-old woman presents with a first episode of PMB. A transvaginal ultrasound scan showed an endometrial thickness of 3.8mm.
What is the most appropriate management plan?

45. A 60 year old undergoes hysterectomy and bilateral salpingo- oophorectomy for grade 1 endometrial cancer. The final histology report confirms tumor invading the uterine serosa.

As per the new FIGO staging of endometrial cancer, what is the stage?

46. Ovarian cysts are common in postmenopausal women, although their prevalence is lower than in premenopausal women. A 59-year-old woman is referred to the clinic with fullness in the lower abdomen and a serum CA125 level of 64iu/l. What is the first line of investigation?

47. It is recommended that ‘risk of malignancy index’ (RMI) should be used to triage post-menopausal women with an ovarian cyst to assess low, moderate or high risk of malignancy.

This is calculated as U (ultrasound score) X M (menopausal status) X CA125.
What is the RMI of a post-menopausal woman with a CA125 of 15, ultrasound showing 6 cm bilateral, multiloculated cyst?

48. It is recommended that RMI should be used to triage post- menopausal women with ovarian cyst to assess low, moderate or high risk of malignancy. This is calculated as U (ultrasound score) × M (menopausal status) × CA125.

What is the risk of ovarian cancer in a woman who has an RMI of 25–250 (moderate risk)?

49. Who should be responsible for the management of women with intermediate risk of malignancy (RMI of 25–250)?

50. Borderline ovarian tumors are a distinct pathological group of neo- plasms typically seen in younger women. They are often diagnosed at an earlier stage resulting in excellent prognosis.

What is the histologic feature that differentiates borderline ovarian tumors from invasive ovarian cancers?

51. A 49-year-old para 3 underwent laparoscopic left salpingo- oophorectomy for a complex left ovarian cyst. Histology shows a serous micro papillary borderline ovarian tumor with the presence of DNA aneuploidy. What is the most appropriate management plan?

52. Borderline ovarian tumors are also known as tumors of low malignant potential. They constitute 10–15% of all epithelial ovarian neoplasms.

What is the 5-year survival rate of stage 1 borderline ovarian tumor?

53. The lifetime risk of ovarian cancer in the general population is 1.4%. However, women with hereditary ovarian cancer syndrome have significantly higher risks of developing ovarian cancer. What is the risk of ovarian cancer in a woman who has a BRCA1 mutation carrier?

54. Lynch syndrome, also called hereditary nonpolyposis colorectal cancer (HNPCC) is associated with the development of multiple types of cancer. What is the suggested management for reduction of risk of developing gynaecological cancers in a 35-year-old woman with HNPCC who has completed her family?

55. NICE recommends not to include systematic retroperitoneal lymphadenectomy as part of standard surgical treatment in women with suspected ovarian cancer whose disease appears to be con- fined to the ovaries (that is, who appears to have stage I disease). What is systematic retroperitoneal lymphadenectomy?

56. NICE recommends that women with suspected stage 1 ovarian cancer should undergo optimal surgical staging.

What is optimal surgical staging?

57. A 70-year-old woman underwent optimal surgical staging for suspected early stage ovarian cancer. Her final histology showed stage 1a grade 3 epithelial ovarian cancers. What is the preferred plan of care after discussion in MDT?

59. It is estimated that 75% of women with ovarian cancer currently receive a paclitaxel/platinum combination as first-line therap. Although most patients (70–80%) initially respond to first-line chemotherapy, most responders eventually relapse (55–75% within 2 years).What is the definition of ‘Complete response’ to chemotherapy?

59. A 70-year-old woman has undergone laparotomy for suspected ovarian cancer. At laparotomy, the cancer is found to involve the left ovary and uterus and she has positive peritoneal washings. As per the FIGO classification for staging of ovarian cancer, what is her staging?

60. A 65-year-old woman complaining of severe itching is diagnosed with Vulval intraepithelial neoplasia (VIN) 3 on biopsy.

What is the first line of management?

61. A 65-year-old woman presents with a history of vulval discomfort and soreness for 6 months. On examination, there is 2.5 cm raised ulcerated area on the left labia majora which looks highly suspicious of vulval cancer. What is the first line of investigation?

62. In vulval cancer, the depth of invasion directly correlates with lymph node involvement, thus affecting prognosis and the management plan. What is the rate of lymph node involvement in women with stage 1a (<1mm invasion) vulval cancer?

63. Vulval cancers are relatively rare cancers with surgery as the mainstay of treatment. In recent years, a lot of emphasis has been given to sentinel node biopsy to decide management.

What is the role of sentinel node biopsy in the management of early vulval cancer?

64. Vulval cancers account for 6% of gynaecological cancers in the United Kingdom. In 2009, a new FIGO staging was introduced with greater emphasis on the inguino-femoral lymph node status to understand prognosis.

What is the FIGO stage for a woman who has a 3cm vulval cancer involving the anus with metastases in 2 lymph nodes <5 mm?

65. Primary vaginal cancer is rare. There were 281 cases of vaginal cancer in the United Kingdom in 2010. The most common causes of squamous cell vaginal cancer are HPV and irradiation.

What is the most common HPV type found in vaginal cancers?

66. Recently, the prevalence of HPV-related VIN has increased significantly and consequently the incidence of vulval cancer in young women is rising.

What are the most common HPV serotypes found in vulval cancers?

67. A 45-year-old woman complains of intermenstrual bleeding for the past 6 months. Past history includes 6 normal vaginal deliveries and hypertension and last smear was over 5 years ago. On speculum examination, there is a raised 2 cm friable area on the cervix.

What is the most likely diagnosis?

68. A 40-year-old woman with severe dyskariosis on smear under- went colposcopy and large loop excision of transformation zone (LLETZ). Histology confirmed a moderately differentiated squamous cell carcinoma 4mm deep and 6 mm wide. Clinical and radiological examination confirmed organ confined disease. What stage of cervical cancer is this?

69. A 53-year-old woman is diagnosed with stage IA1 cervical squamous cell carcinoma after histological, clinical and radiological assessment.

What is the most appropriate management plan?

70. A 35-year-old woman is diagnosed with stage IB1 cervical squamous cell carcinoma of the cervix on histological and clinical assessment.

What is the most appropriate radiological investigation for this patient?

71. A 55-year-old patient has had a colposcopic examination or a suspicious well-circumscribed vulval lesion and vulvar intraepithelial neoplasia 3 is identified at histopathology.

What is the most appropriate next step in management?

72. A 65-year-old patient undergoes a TAH+BSO or a suspicious 8-cm right ovarian mass and normal CA-125. She had originally presented with postmenopausal bleeding. Frozen section examination demonstrates Call–Exner bodies.

It is likely that the pathology specimen will also demonstrate which of the following?

73. In counselling a patient who had recently tested positive or BRCA1 mutation, risk-reducing bilateral salpingo-oophorectomy (RRBSO) decreases ovarian cancer risk by:

74. A 25-year-old para 0, who wished to preserve future fertility, underwent a cervical conization after an unsatisfactory colposcopy. The conization specimen demonstrated an invasive carcinoma of the cervix infiltrating 2.5 mm below the basement membrane. There was no evidence of lymphovascular space involvement, and the margins of the cone were free of dysplasia or carcinoma.

What would be the best strategy of management for this patient?

75. A 45-year-old patient is found to have a large cervical cancer infiltrating into the right parametrium. Rectovaginal examination suggests parametrial involvement, although not reaching the pelvic sidewall. A chest x-ray and cystoscopy were both clear. A computed tomography o the abdomen and pelvis, however, shows an enlarged, suspicious le paraaortic lymph node.

What stage of disease is this?

76. A 29-year-old patient is found to have high-grade squamous dyskaryosis at routine cervical smear at 7 weeks’ gestation. Colposcopic biopsies show early invasive disease. A subsequent cold-kni e conization at 17 weeks shows microinvasive carcinoma o the cervix with clear surgical margins.

What would be the most appropriate plan of action?

77. A 60-year-old patient who had previously had a TAH+BSO or benign disease is found to have an exophytic 1-cm nodule in the upper part of the vagina. Biopsies obtained demonstrate an adenocarcinoma.

What is the most likely diagnosis?

78. In cases of cervical cancer, radical hysterectomy with bilateral pelvic lymphadenectomy can potentially be used to treat all of the following stages of cervical cancer except

79. A 47-year-old patient with a history of severe endometriosis is found to have a left-sided, 10-cm unilocular cystic mass with a solid component arising from its wall. A computed tomography scan supports this finding and the CA-125 is 300 U/ml.

These  findings raise suspicion of:

80. A 55-year-old patient who has a BMI o 39 is scheduled to have a TAH+BSO and pelvic lymphadenectomy or endometrial cancer.

What is the best method to reduce her venous thromboembolic risk?

81. A 40-year-old patient has had a cervical smear showing moderate/ severe dyskaryosis. Colposcopic examination and biopsy conf rm CIN II, and she opts or TAH as her family is complete. Histopathology conf rms completely excised CIN.

What is the most appropriate follow-up?

82. In counselling a 45-year-old woman has recently been diagnosed with Stage II cervical squamous carcinoma. It is reasonable to quote a 5-year survival rate of around:

83. A 66-year-old patient presented with vulval pruritus. On examination there was a 1.5-cm lesion on her right labia majora with an irregular border; the lesion was tender to touch. An excision biopsy was obtained which showed squamous cell carcinoma with positive margins and invasive disease to 0.8 mm.

What is the most appropriate next step in management?

84. A 60-year-old patient presents with a 3-month history of intermittent vaginal bleeding. She has been menopausal since the age of 55 and is otherwise fit and well. The vaginal bleeding was sudden in onset and heavy, with the passage of blood clots and intermittent lower abdominal pain. She has no history of postcoital or contact bleeding, weight loss or anorexia and she was not on HRT. A transvaginal ultrasound scan shows an endometrial thickness of 15 mm and Pipelle biopsy confirms endometrial adenocarcinoma. At TAH+BSO, the left ovary was noted to contain solid tumour.

What is the most likely diagnosis?

85. A 15-year-old patient presents with le lower abdominal pain. Transvaginal and transabdominal ultrasound scans show a 10-cm solid ovarian mass. The lactate dehydrogenase is elevated with a normal alphaetoprotein and human chorionic gonadotropin.

What is the most likely diagnosis?

86. An endometrial Pipelle biopsy result that you have performed a week ago has shown endometrial hyperplasia with atypia. The patient is a 55-year-old para 0 who has a previous history of breast cancer. When counselling the patient, what would be the chance of her also having an endometrial cancer, if a hysterectomy is performed in the next few weeks?

87. A 56-year-old patient has had an ultrasound scan, which shows a right adnexal unilocular cystic mass, and subsequent computed tomography scan which has confirmed the same findings but with evidence of peritoneal deposits. Her CA-125 is 10 and the RMI is 30.

Where should she receive her treatment?