Premalignant and Malignant Diseases of the Lower Genital Tract—Vulva, Vagina, and Cervix

1. A 65-year-old woman returns for the results of her vulvar biopsy. Which of the following is the etiologic agent (or immediate precursor lesion) for vulvar cancer?

2. A 56-year-old woman has a biopsy-proven vulvar intraepithelial neoplasia (VIN III). She undergoes a wide excision and returns 3 months later with vulvar pruritus. What should you advise the patient?

3. A 65-year-old woman presents with complaints of vulvar redness, pruritus, and occasional weeping from the skin. Examination reveals ery-thematous, eczematoid of the labia minora, and periclitoral area. This is consistent with Paget’s disease of the vulva. Which of the following characterizes Paget’sdisease of the vulva?

4. Which of the following types of vulvar cancer occurs most commonly?

5. A 48-year-old woman presents with a large verrucous lesion of her vulva. It is not particularly painful, but the appearance is worrisome to the patient. Such a lesion is most likely which of the following?

6. Which of the following is the most common symptom of vulvar carcinoma in elderly women?

7. A 1-cm vulvar carcinoma with tumor-positive unilateral nodes and no distant spread would be in which FIGO (International Federation of Gynecology and Obstetrics) stage?

8. A 58-year-old woman has a 1-cm vulvar ulcer. A biopsy shows invasive squamous cell carcinoma with more than 1 mm of stromal invasion. Which of the following is the preferred treatment?

9. A 58-year-old woman has a 1-cm vulvar ulcer. A biopsy shows invasive squamous cell carcinoma with more than 1 mm of stromal invasion. If the lymph nodes in this case are negative, the 5-year survival should be approximately what percentage?

10. A 58-year-old woman has a 1-cm vulvar ulcer. A biopsy shows invasive squamous cell carcinoma withmore than 1 mm of stromal invasion. This patient undergoes radical vulvectomy. Which of the following is the most common complication of radical vulvectomy?

11. A 72-year-old woman has had a radical vulvectomy for stage II squamous cell vulvar cancer. She wants to know the most likely site of recurrence if the tumor comes back. Where would the tumor most likely appear?

12. Which of the following tumors of the vulva has the best prognosis?

13. A 56-year-old woman presents with painless mild vaginal spotting. She had a hysterectomy at age 40 for persistent cervical dysplasia. She is otherwise healthy and takes no medications. On further review of symptoms, she has occasional urgency and dysuria. On pelvic examination, a 0.5-cm lesion is felt and visualized in the anterior vagina. What is the next step in the evaluation or treatment of this lesion?

14. A 30-year-old woman presents for her annual examination. On history, she reports that her mother was prescribed diethylstilbestrol (DES) during the pregnancy with her. Which of the following conditions is she most at risk for as a result?

15. Which of the following is a malignant tumor of the vagina of young children that appears clinically as a mass of grape-like edematous polyps?

16. A 72-year-old woman complains of vaginal bleeding. On evaluation, a 2-cm vaginal lesion is found in the upper third of the anterior vagina. On bimanual and rectovaginal examination, the mass extends to the lateral pelvic wall. On biopsy, vaginal carcinoma is confirmed.What stage cancer does this patient most likely have?

17. A 72-year-old woman complains of vaginal bleeding. On evaluation, a 2-cm vaginal lesion is found in the upper third of the anterior vagina. On bimanual and rectovaginal examination, the mass extends to the lateral pelvic wall. On biopsy, vaginal carcinoma is confirmed.Which of the following is the most likely histology of vaginal carcinoma in this woman?

18. A 72-year-old woman complains of vaginal bleeding. On evaluation, a 2-cm vaginal lesion is found in the upper third of the anterior vagina. On bimanual and rectovaginal examination, the mass extends to the lateral pelvic wall. On biopsy, vaginal carcinoma is confirmed. Which of the following is the best treatment for her?

19. Which of the following is the most common method used to diagnose cervical intraepithe-lial neoplasia (CIN)?

20. Which of the following reflects the etiology of cervical dysplasia and cervical cancer?

21. Which of the following reflects HPV?

22. A 40-year-old woman is seen for a routine examination. Her menses have been regular, and she has no complaints. Findings, including those on pelvic examination, are normal. Ten days later, her Pap smear is returned as “high-grade squamous intraepithelial lesion.” Which of the following options is the best course of action?

23. A 40-year-old woman is seen for a routine examination. Her menses have been regular, and she has no complaints. Findings, including those on pelvic examination, are normal. Ten days later, her Pap smear is returned as “high-grade squamous intraepithelial lesion.” The colposcope permits one to do which of the following?

24. A 40-year-old woman is seen for a routine examination. Her menses have been regular, and she has no complaints. Findings, including those on pelvic examination, are normal. Ten days later, her Pap smear is returned as “high-grade squamous intraepithelial lesion.” Under colposcopic examination, a distinct area of acetowhite change is noted with associated coarse pattern vessels and punctation. This is consistent with what histologic finding on directed biopsy?

25. A 40-year-old woman is seen for a routine examination. Her menses have been regular, and she has no complaints. Findings, including those on pelvic examination, are normal. Ten days later, her Pap smear is returned as “high-grade squamous intraepithelial lesion.”Conization of the cervix would be inappropriate in which of the following instances?

26. A 40-year-old woman is seen for a routine examination. Her menses have been regular, and she has no complaints. Findings, including those on pelvic examination, are normal. Ten days later, her Pap smear is returned as “high-grade squamous intraepithelial lesion.” This patient has biopsy-proven CIN III. She requests cryotherapy for treatment. Cryotherapy is appropriate to consider in which clinical circumstance?

27. A 25-year-old woman presents with irregular vaginal bleeding. She is otherwise healthy and uses condoms for contraception. She smokes occasionally and takes no medications. Her aunt had cervical cancer and she is worried that she may also have cervical cancer. What is the most common symptom associated with cervical cancer?

28. When sampling the cervix for a Pap smear, it is critical to sample which area since it is the most likely source of cervical cancer. Where do most cervical cancers arise?

29. What percentage of clinical stage I carcinomas of the cervix will have lymphatic spread?

30. If a nonhealing ulcer is seen on the cervix, it is best evaluated by which of the following?

31. A 48-year-old woman presents for her routine annual examination. Her last Pap smear was more than 10 years ago. She has had occasional abnormal Pap smear during her lifetime, but no treatments were recommended. Otherwise, she has mild hypertension and is on a beta-blocker. On examination, she has a normal pelvic examination, but her Pap smear reveals high-grade squamous intraepithelial lesion (SIL). A colposcopically directed biopsy reveals invasive squamous cell carcinoma. Which of the following should be the most appropriate next step in the care of the patient?

32. A 48-year-old woman presents for her routine annual examination. Her last Pap smear was more than 10 years ago. She has had occasional abnormal Pap smear during her lifetime, but no treatments were recommended. Otherwise, she has mild hypertension and is on a beta-blocker. On examination, she has a normal pelvic examination, but her Pap smear reveals high-grade squamous intraepithelial lesion (SIL). A colposcopically directed biopsy reveals invasive squamous cell carcinoma. The woman had a negative metastatic workup. Her clinical examination shows cancer growth shown in Figure 21–1. Her preliminary clinical stage is which of the following?

33. The majority of deaths from cervical carcinoma are due to which of the following?

34. The 5-year survival rate for stage IV invasive cervical cancer is approximately what percentage?

35. Which of the following is the best term for a bulky, friable, papillary tumor mass growing from the cervix?

36. A 34-year-old woman G1 is 16 weeks pregnant and has a Pap smear suspicious for cancer. How do you advise her?

37. A 65-year-old woman presents with vaginal discharge and rare mild bleeding. She had a cone of the cervix for CIN III 20 years ago. She has since had a complete hysterectomy for uterine fibroids. You perform a pelvic examination and see an irregular area in the vagina. Vaginal col-poscopy and directed biopsy reveal vaginal intraepithelial neoplasia (VAIN). VAIN is most commonly found in which part of the vagina?

38. The preferred treatment for a 1.5-cm stage I vaginal carcinoma confined to the upper one-third of the lateral vagina in a 29-year-old woman would be which of the following?

39.  A 42-year-old presents with a history of post-coital spotting. Examination of the cervix reveals a raised/reddened well-circumscribed lesion next to the os. Which of the following is the most likely diagnosis?

40. The treatment of carcinoma of the cervix during pregnancy should depend on all except which of the following?

41. A 42-year-old woman with cervical cancer undergoes a radical hysterectomy and requires postoperative radiation. During the radiation therapy she returns complaining of watery vaginal discharge and recurrent urinary tract infections. Which of the following would be the first test to perform to evaluate the most likely cause of the discharge?

42. A 35-year-old woman with stage IIB squamous cell carcinoma of the cervix will receive radiation. Regarding reproductive changes, how should you advise her?

43. A 46-year-old obese woman smokes two packs of cigarettes a day. She had a radical hysterectomy with a para-aortic and pelvic lym-phadenectomy for stage IB squamous cell carcinoma of the cervix. At surgery she was found to have dense pelvic small-bowel adhesions from a prior ruptured appendix and appendectomy. Lymph nodes were positive for cancer cells. In discussing postoperative radiation, you counsel her that she has an increased rate of radiation-related complication because of which of the following?

44. A 24-year-old healthy woman has her routine examination and Pap smear. Her Pap smear is atypical squamous cells of undetermined significance (ASCUS). Which of the following reflects our current knowledge about ASCUS?

45. A 48-year-old postmenopausal woman presents for routine gynecologic examination. The examination is normal; however, the Pap smear returns atypical glandular cells (AGCs). What would be the most appropriate management for this patient?

46. A 30-year-old woman presents for her annual examination. She inquires whether she should receive the HPV vaccine. For which patient population is the HPV vaccine FDA approved?