Oncology Emq Test Part 2

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Oncology EMQ Test Part 2

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1) A 40 year old nulliparous woman had a cervical

smear showing severe dyskaryosis. Colposcopy with

diathermy loop excision has been performed and the

histology shows CIN III which has been completely

excised

A) Routine recall in 3 years

B) Routine recall in 5 years

C) Hysteroscopy + D&C

D) Laser vapourisation

E) Radical trachylectomy

F) Cryotherapy

G) No further cervical smears required

H) Repeat cervical smear in 6 months

2) A 65-year-old woman is referred urgently with weight loss, abdominal bloating

and urinary urgency. An ultrasound scan demonstrates a multicystic mass

with solid areas and ascites. Her serum CA125 is 100 IU/l. A CT scan confirms

a suspicious mass. Which management should be recommended by the

multidisciplinary team?

A) Arrange follow-up scan in 6 months’ time

B) Arrange follow-up scan in 12 months’ time

C) Chemotherapy

D) Combined oral contraceptive pill (COCP) for six cycles

E) Full staging laparotomy

F) Gonadotropin-releasing hormone (GnRH) analogue for 6 months

G) Laparoscopic cyst drainage

H) Laparoscopic bilateral salpingo-oophorectomy

I) Laparoscopic ovarian cystectomy

J) Laparoscopic unilateral oophorectomy

K) Laparotomy, bilateral salpingo-oophorectomy and omental biopsy

L) Measure serum CA125 and calculate risk of malignancy index (RMI)

M) No treatment required

N) Radical hysterectomy including lymph node dissection

O) Radiotherapy

P) Sentinel node biopsy

Q) Total abdominal hysterectomy, bilateral salpingo-oophorectomy and omental biopsy

R) Ultrasound-guided cyst drainage

Explanation

RMI is calculated as: U × M × CA125 (see question 301 for details). This woman’s

RMI is 3 × 3 × 100 = 900.

All ovarian cysts that are suspicious of malignancy in a postmenopausal

woman, as indicated by an RMI of ≥200, CT findings, clinical assessment or

findings at laparoscopy, require a full laparotomy and staging procedure.

3) A 53 year old asymptomatic post menopausal

woman has a cervical smear showing no dyskaryotic

cells but no evidence of transformation zone

sampling. The cervix was well visualised and normal

and she has previously had regular smears which

have all been negative.

A) Routine recall in 3 years

B) Routine recall in 5 years

C) Hysteroscopy + D&C

D) Laser vapourisation

E) Radical trachylectomy

F) Cryotherapy

G) No further cervical smears required

H) Repeat cervical smear in 6 months

4) A compound belonging to the transforming growth factor-β (TGF-β) superfamily,

produced by both the Sertoli cells of the testis and granulosa cell tumours of the

ovary.

A) Cancer antigen 19-9 (CA19-9)

B) Cancer antigen 72-4 (CA72-4)

C) Carcinoembryonic antigen (CEA)

D) Epithelial tumour antigen (ETA)

E) α-Fetoprotein (AFP)

F) Homeobox protein CDX2

G) Human chorionic gonadotropin (hCG)

H) Human epididymis protein 4 (HE4)

I) Inhibin

J) Lactate dehydrogenase (LDH)

K) Oestradiol

L) Oestriol

Explanation

Inhibin supresses follicle-stimulating hormone (FSH) production and secretion by

the anterior pituitary. Inhibin has been used as a tumour marker for granulosa cell

tumours.

5) A 23-year-old woman presents with a two-year history of vulval,

perineal and perianal irritation. The vulva is red, excoriated and

there areas of white, thickened skin. Application of 3% Acetic

acid shows areas of mosaic and coarse punctuation.

A) Oestrogen cream

B) Oral HRT

C) Vaginoplasty

D) Skinning vulvectomy

E) Clobetasol cream

F) Testosterone cream

G) Topical anti-histamines

H) Radical vulvectomy

I) Excision biopsy

J) Topical anti-fungal cream

6) A 37-year-old woman presents to the clinic for her routine smear. The report reads as

follows: CGIN, endocervical cells with changes of CGIN seen.

A) two-week referral to colposcopy

B) two-week referral to gynaecology clinic

C) LLETZ under general anaesthesia

D) LLETZ under local anaesthetic block

E) no further Pap smears

F) repeat smear with GP after 6 months

G) routine recall

H) routine referral to colposcopy in 6 weeks

I) see and treat colposcopy in 2 weeks

J) test of cure – High-risk HPV DNA

K) test of triage – High-risk HPV DNA test

Referral to colposcopy in 2 weeks is essential for suspected cervical glandular

intraepithelial neoplasia.

7) A 20 year old woman is admitted with sudden onset left sided

pelvic pain 23 days after her LMP. Her pregnancy test is negative

and her symptoms are improving with simple analgesia. Pelvic

ultrasound scan shows a 5cm left ovarian cyst with internal

echoes consistent with a haemorrhagic cyst.

A) CA-125 assays every 6-12 months

B) Bilateral oophrectomy

C) TAH + BSO

D) Cyst aspiration for cytology

E) Refer to cancer centre

F) Refer to palliative care team

G) Reassure

H) Measure serum CA-125

I) Yearly pelvic ultrasound scans

J) Repeat pelvic ultrasound scan in 4-6 months

8) A 60-year-old woman has an ultrasound scan done for non-specific abdominal pain and

is found to have an ovarian cyst of 28 mm which is fluid filled. The Ca 125 is normal and

the RMI is 100. She is advised a further scan after 4 months. The cyst has not changed

in nature and the size is 22 mm.

A) AFP, LDH and hCG

B) Ca 125

C) combined oral contraceptive pill

D) expectant management

E) further imaging with MRI

F) IOTA scoring

G) laparoscopic removal of cyst

H) laparoscopic removal of ovary

I) laparotomy

J) laparotomy and ovarian cystectomy

K) progesterone only pill

L) repeat ultrasound

M) RMI

N) TAH and BSO

O) ultrasound-guided aspiration

Asymptomatic ovarian cysts that do not increase in size with a normal Ca 125 may be

managed conservatively

9) A 23-year-old woman presents with vulval itching. On examination there is a

well-demarcated symmetrical lesion involving the labia major and minor and

extending to the genitocrural folds. The lesions appear beefy red with scaling.

A biopsy shows papillomatosis, parakeratosis and neutrophil exocytosis.

A) Lichen sclerosus

B) Seborrhoeic dermatitis

C) Atopic vulvitis

D) Lichen simplex

E) Psoriasis

F) Herpes simplex

G) Behcet’s disease

H) Hidradenitis suppurativa

I) Paget’s disease

J) Tinea cruris

Vulval psoriatic lesions are well defi ned, uniform and symmetrical. The appearance

is that of a beefy-red area that may affect any part of the vulva, but not the vaginal mucosa. Characteristic lesions may be present in other locations.

Histologically, there is papillomatosis, parakeratosis with neutrophil exocytosis

and spongiform pustules.

10) A 32 year old teacher has been referred to the

gynaecology clinic because of marked anxiety since

her friend died suddenly from ovarian cancer at the

age of 35 years. She has no family history of ovarian

cancer and enquires about the likelihood of any

woman developing the disease.

A) 85% 5 year survival

B) 60% 5 year survival

C) 25% 5 year survival

D) Almost 100% 5 year survival

E) Overall life-time risk ~2%

F) Overall life-time risk ~3%

G) Overall life-time risk of 0.1%

H) Overall life-time risk _1.5%

I) Overall life-time risk ~1%

J) Virtually 0% 5 year survival

K) 40% 5 year survival

L) 70% 5 year survival

11) A healthy 60-year-old woman with a BMI of 28 kg/m2

presents with lower

abdominal pain and bloating. An ultrasound scan demonstrates a unilocular cyst

of 4 cm diameter with a solid component. There is no ascites. Her serum CA125 is

40 IU/l.

A) Arrange follow-up scan in 6 months’ time

B) Arrange follow-up scan in 12 months’ time

C) Chemotherapy

D) Combined oral contraceptive pill (COCP) for six cycles

E) Full staging laparotomy

F) Gonadotropin-releasing hormone (GnRH) analogue for 6 months

G) Laparoscopic cyst drainage

H) Laparoscopic bilateral salpingo-oophorectomy

I) Laparoscopic ovarian cystectomy

J) Laparoscopic unilateral oophorectomy

K) Laparotomy, bilateral salpingo-oophorectomy and omental biopsy

L) Measure serum CA125 and calculate risk of malignancy index (RMI)

M) No treatment required

N) Radical hysterectomy including lymph node dissection

O) Radiotherapy

P) Sentinel node biopsy

Q) Total abdominal hysterectomy, bilateral salpingo-oophorectomy and omental biopsy

R) Ultrasound-guided cyst drainage

This woman’s RMI is 1 × 3 × 40 = 120 (see question 301 for details).

Women with an RMI of <200 (i.e. at low risk of malignancy) are suitable

for laparoscopic management. Laparoscopic management of ovarian cysts in

postmenopausal women should comprise bilateral salpingo-oophorectomy rather

than cystectomy.

12) A 50-year-old woman undergoes her routine cervical screening. The results are reported

as high-grade moderate dyskaryosis.

A) two-week referral to colposcopy

B) two-week referral to gynaecology clinic

C) LLETZ under general anaesthesia

D) LLETZ under local anaesthetic block

E) routine recall

F) no further Pap smears

G) repeat smear with GP after 6 months

H) routine referral to colposcopy in 6 weeks

I) see and treat colposcopy in 2 weeks

J) test of cure – High-risk HPV DNA

K) test of triage – High-risk HPV DNA test

High-grade smears both moderate and severe are referred to colposcopy under the

2-week rule.

13) A 34-year-old woman has a routine smear test that has revealed a low-grade dyskaryosis.

She has a test of triage which has been reported to be negative.

A 50-year-old woman undergoes her routine cervical screening. The results are reported

as high-grade moderate dyskaryosis.

A) two-week referral to colposcopy

B) two-week referral to gynaecology clinic

C) LLETZ under general anaesthesia

D) LLETZ under local anaesthetic block

E) routine recall

F) no further Pap smears

G) repeat smear with GP after 6 months

H) routine referral to colposcopy in 6 weeks

I) see and treat colposcopy in 2 weeks

J) test of cure – High-risk HPV DNA

K) test of triage – High-risk HPV DNA test

Low-grade dyskaryosis with negative high-risk DNA test results is reassuring and a

routine recall system may be followed.

14) A steroid that is almost undetectable in the non-pregnant female, but whose levels

rise >1000-fold during pregnancy.

A) Cancer antigen 19-9 (CA19-9)

B) Cancer antigen 72-4 (CA72-4)

C) Carcinoembryonic antigen (CEA)

D) Epithelial tumour antigen (ETA)

E) α-Fetoprotein (AFP)

F) Homeobox protein CDX2

G) Human chorionic gonadotropin (hCG)

H) Human epididymis protein 4 (HE4)

I) Inhibin

J) Lactate dehydrogenase (LDH)

K) Oestradiol

L) Oestriol

Explanation

The key here is to read the question properly. Although most people will

answer G, hCG is not a steroid – it is a glycoprotein. Oestriol is a steroid that

is produced by the placenta, and is one of the components of serum screening.

15) A 43-year-old woman has a routine Pap smear. It is reported negative for cervical cell

dyskaryosis. However, endometrial clusters of cells are noted. Her last menstrual period

was 10 days ago, and she has regular periods.

A) two-week referral to colposcopy

B) two-week referral to gynaecology clinic

C) LLETZ under general anaesthesia

D) LLETZ under local anaesthetic block

E) no further Pap smears

F) repeat smear with GP after 6 months

G) routine recall

H) routine referral to colposcopy in 6 weeks

I) see and treat colposcopy in 2 weeks

J) test of cure – High-risk HPV DNA

K) test of triage – High-risk HPV DNA test

Endometrial pathology must be excluded. An urgent referral to the gynaecology

clinic is recommended.

16) A 35-year-old woman attends her GP surgery for a cervical smear having never

had a smear in the past. A result of high-grade dyskaryosis is returned.

A) No action necessary

B) Perform cervical cytology in 1 year’s time

C) Perform cervical cytology in 3 years’ time

D) Perform colposcopic treatment

E) Perform human papillomavirus (HPV) test of cure

F) Perform HPV triage testing

G) Refer to colposcopy

H) Repeat cervical cytology in 3 months’ time

I) Repeat cervical cytology in 6 months’ time

J) Return to routine recall

17) A 40 year old woman presents with a 12 months history of vague

abdominal discomfort that did not respond to simple analgesia.

Ultrasound scan shows bilateral complex ovarian cysts with right

sided hydronephrosis and ascites. Her CA-125 is 1500iu

A) CA-125 assays every 6-12 months

B) Bilateral oophrectomy

C) TAH + BSO

D) Cyst aspiration for cytology

E) Refer to cancer centre

F) Refer to palliative care team

G) Reassure

H) Measure serum CA-125

I) Yearly pelvic ultrasound scans

J) Repeat pelvic ultrasound scan in 4-6 months

18) A 54-year-old woman presents with abdominal pain and has had an ultrasound scan

done. It showed an ovarian cyst which triggered a transvaginal scan. Pain has resolved

now. A 46-mm cyst with a thin wall within with normal CA 125 is noted. She has a

repeat scan after 2 months that shows a 58 mm cyst with similar features and normal

tumour markers. No new symptoms are noted.

A) AFP, LDH and hCG

B) Ca 125

C) combined oral contraceptive pill

D) expectant management

E) further imaging with MRI

F) IOTA scoring

G) laparoscopic removal of cyst

H) laparoscopic removal of ovary

I) laparotomy

J) laparotomy and ovarian cystectomy

K) progesterone only pill

L) repeat ultrasound

M) RMI

N) TAH and BSO

O) ultrasound-guided aspiration

While it is safe to manage an ovarian cyst conservatively when fluid-filled, the

increasing size of the cyst needs to be given due concern. It is unlikely to be

functional and a laparoscopic cystectomy should be considered.

19) A 65-year-old woman has an incidental finding of an ovarian cyst during an MRI

scan to evaluate her spine. A follow-up ultrasound confirms this to be a simple

cyst with a maximum diameter of 4.5 cm. Her serum CA125 is 5 IU/l. The woman

is asymptomatic.

A) Arrange follow-up scan in 6 months’ time

B) Arrange follow-up scan in 12 months’ time

C) Chemotherapy

D) Combined oral contraceptive pill (COCP) for six cycles

E) Full staging laparotomy

F) Gonadotropin-releasing hormone (GnRH) analogue for 6 months

G) Laparoscopic cyst drainage

H) Laparoscopic bilateral salpingo-oophorectomy

I) Laparoscopic ovarian cystectomy

J) Laparoscopic unilateral oophorectomy

K) Laparotomy, bilateral salpingo-oophorectomy and omental biopsy

L) Measure serum CA125 and calculate risk of malignancy index (RMI)

M) No treatment required

N) Radical hysterectomy including lymph node dissection

O) Radiotherapy

P) Sentinel node biopsy

Q) Total abdominal hysterectomy, bilateral salpingo-oophorectomy and omental biopsy

R) Ultrasound-guided cyst drainage

Asymptomatic, simple, unilateral, unilocular ovarian cysts of <5 cm in diameter

have a low risk of malignancy. In the presence of normal serum CA125 levels,

these cysts can be managed conservatively, with a repeat evaluation in 4–6

months. It is reasonable to discharge these women from follow-up after 1 year if

the cyst remains unchanged or reduces in size, with normal serum CA125, taking

into consideration the woman’s wishes and surgical fitness.

20) A 31-year-old woman attends her GP surgery for a cervical smear. This is reported

as low-grade dyskaryosis and an HPV test is organised. Unfortunately, the HPV

test is inadequate.

A) No action necessary

B) Perform cervical cytology in 1 year’s time

C) Perform cervical cytology in 3 years’ time

D) Perform colposcopic treatment

E) Perform human papillomavirus (HPV) test of cure

F) Perform HPV triage testing

G) Refer to colposcopy

H) Repeat cervical cytology in 3 months’ time

I) Repeat cervical cytology in 6 months’ time

J) Return to routine recall

21) A frail 90-year-old woman presents with abdominal discomfort and bloating. She

has mitral stenosis and atrial fibrillation. She has urinary frequency and nocturia.

An ultrasound scan reveals a 10 cm simple ovarian cyst. Her serum CA125 is

2 IU/l.

A) Arrange follow-up scan in 6 months’ time

B) Arrange follow-up scan in 12 months’ time

C) Chemotherapy

D) Combined oral contraceptive pill (COCP) for six cycles

E) Full staging laparotomy

F) Gonadotropin-releasing hormone (GnRH) analogue for 6 months

G) Laparoscopic cyst drainage

H) Laparoscopic bilateral salpingo-oophorectomy

I) Laparoscopic ovarian cystectomy

J) Laparoscopic unilateral oophorectomy

K) Laparotomy, bilateral salpingo-oophorectomy and omental biopsy

L) Measure serum CA125 and calculate risk of malignancy index (RMI)

M) No treatment required

N) Radical hysterectomy including lymph node dissection

O) Radiotherapy

P) Sentinel node biopsy

Q) Total abdominal hysterectomy, bilateral salpingo-oophorectomy and omental biopsy

R) Ultrasound-guided cyst drainage

Explanation

This woman’s RMI is 1 × 3 × 2 = 6 (see question 301 for details).

This is very unlikely to be a malignant cyst, but the woman is symptomatic.

She is frail with co-morbidities.

Aspiration has no role in the management of asymptomatic ovarian cysts in

postmenopausal women. An exception exists for those symptomatic women who

are medically unfit to undergo surgery or further intervention. In these women,

aspiration will provide relief of their symptoms, albeit temporarily.

22) A 60-year-old woman has a laparoscopic bilateral oophorectomy for a persistent

ovarian cyst. Her serum CA125 is 50 IU/ml. The ovarian capsule is noted to

be intact, but during the course of the operation, the cyst ruptures. Peritoneal

washings prior to the rupture are clear. The contralateral ovary is normal.

Histology confirms an ovarian carcinoma.

A) I A

B) I B

C) I C1

D) I C2

E) I C3

F) II

G) III A1

H) III A2

I) I III B

J) III C1

K) III C2

L) IV A

M) IV B

This is stage I C1

according to the International Federation of Gynecology and

Obstetrics (FIGO) ovarian cancer staging classification (2014).

23) A 26-year-old woman undergoes her first cervical routine screening test. Her smear is

reported as borderline squamous cell changes.

A) two-week referral to colposcopy

B) two-week referral to gynaecology clinic

C) LLETZ under general anaesthesia

D) LLETZ under local anaesthetic block

E) routine recall

F) no further Pap smears

G) repeat smear with GP after 6 months

H) routine referral to colposcopy in 6 weeks

I) see and treat colposcopy in 2 weeks

J) test of cure – High-risk HPV DNA

K) test of triage – High-risk HPV DNA test

A high-risk HPV DNA test is recommended to triage a referral to the colposcopy

unit. If negative, she is discharged to routine recall; if positive, she is invited to

colposcopy.

24) Stage 1 uterine (endometrial) cancer.

A) 1%

B) 2%

C) 5%

D) 10%

E) 20%

F) 40%

G) 55%

H) 60%

I) 70%

J) 80%

K) 90%

L) 95%

M) 100%

The 5-year survival rates for stage 1 to stage 4 uterine (endometrial ) cancer are

95.3%, 77%, 39% and 13.6%,respectively. For all stages taken together, the overall

5-year survival rate is 84.4%. Where the stage is not known, the 5-year survival

rate is 54.4%.

25) Stage 3 ovarian cancer.

A) 1%

B) 2%

C) 5%

D) 10%

E) 20%

F) 40%

G) 55%

H) 60%

I) 70%

J) 80%

K) 90%

L) 95%

M) 100%

The 5-year survival rates for stage 1 to stage 4 ovarian cancer are 90%, 42.8%, 18.6%

and 3.5%, respectively. For all stages taken together, the overall 5-year survival rate

is 39.3%. Where the stage is not known, the 5-year survival rate is 12.5%.

Reference

See the Cancer Research UK website at www.cancerresearchuk.org (accessed 25 July 2018).

26) A 34-year-old woman presents with a burning sensation in the vulval region.

On examination the vulva is erythematous with marked oedema and numerous

small superfi cial ulcerations. The inguinal lymph nodes are enlarged and

tender.

A) Lichen sclerosus

B) Seborrhoeic dermatitis

C) Atopic vulvitis

D) Lichen simplex

E) Psoriasis

F) Herpes simplex

G) Behcet’s disease

H) Hidradenitis suppurativa

I) Paget’s disease

J) Tinea cruris

The lesions described are likely to represent herpes simplex. The differential diagnosis of genital ulcers also includes chancroid and syphilis

27) Stage 2 carcinoma of the cervix.

A) 1%

B) 2%

C) 5%

D) 10%

E) 20%

F) 40%

G) 55%

H) 60%

I) 70%

J) 80%

K) 90%

L) 95%

M) 100%

The 5-year survival rates for stage 1 to stage 4 cervical cancer are 95.9%, 54.4%,

28) A compound that is elevated in women with an ovarian dysgerminoma.

A) Cancer antigen 19-9 (CA19-9)

B) Cancer antigen 72-4 (CA72-4)

C) Carcinoembryonic antigen (CEA)

D) Epithelial tumour antigen (ETA)

E) α-Fetoprotein (AFP)

F) Homeobox protein CDX2

G) Human chorionic gonadotropin (hCG)

H) Human epididymis protein 4 (HE4)

I) Inhibin

J) Lactate dehydrogenase (LDH)

K) Oestradiol

L) Oestriol

Explanation

LDH is found throughout the body, and levels are elevated in a number of cancers.

From a gynaecological perspective, it has been used as a tumour marker in

ovarian dysgerminoma.

Reference

Sanusi FA, Carter P, Barton DPJ. Non-epithelial ovarian cancers. The Obstetrician &

Gynaecologist 2000;2:37–9.

29) A 52-year-old woman presents to her GP surgery for a repeat smear as her previous

routine smear 6 months ago was inadequate. The second sample now has been reported

as inadequate too.

A) two-week referral to colposcopy

B) two-week referral to gynaecology clinic

C) LLETZ under general anaesthesia

D) LLETZ under local anaesthetic block

E) no further Pap smears

F) repeat smear with GP after 6 months

G) routine recall

H) routine referral to colposcopy in 6 weeks

I) see and treat colposcopy in 2 weeks

J) test of cure – High-risk HPV DNA

K) test of triage – High-risk HPV DNA test

Repeat smear no less than 3 months later is recommended. Three inadequate

samples will trigger a referral to colposcopy.

30) A 30-year-old woman undergoes colposcopic treatment for cervical intraepithelial

neoplasia (CIN) 3. Histology shows incomplete excision at the ectocervical

margin but complete excision at the endocervical margin

A) No action necessary

B) Perform cervical cytology in 1 year’s time

C) Perform cervical cytology in 3 years’ time

D) Perform colposcopic treatment

E) Perform human papillomavirus (HPV) test of cure

F) Perform HPV triage testing

G) Refer to colposcopy

H) Repeat cervical cytology in 3 months’ time

I) Repeat cervical cytology in 6 months’ time

J) Return to routine recall

31) A 40-year-old woman has her routine smear at the Community Gynaecology clinic.

The smear is reported as borderline dyskaryosis.

A) two-week referral to colposcopy

B) two-week referral to gynaecology clinic

C) LLETZ under general anaesthesia

D) LLETZ under local anaesthetic block

E) no further Pap smears

F) repeat smear with GP after 6 months

G) routine recall

H) routine referral to colposcopy in 6 weeks

I) see and treat colposcopy in 2 weeks

J) test of cure – High-risk HPV DNA

K) test of triage – High-risk HPV DNA test

A borderline smear should be triaged by the presence of high-risk HPV DNA.

A positive test should trigger a referral to colposcopy within 6 weeks.

32) A 90-year-old woman is diagnosed with vulval cancer. Imaging suggests

metastases to both inguinofemoral and pelvic lymph nodes.

A) I A

B) I B

C) I C1

D) I C2

E) I C3

F) II

G) III A1

H) III A2

I) III B

J) III C1

K) III C2

L) IV A

M) IV B

This is stage IV B according to the FIGO vulval cancer staging classification (2014)

33) A 5-year-old girl presents with burning on micturition and vulva I scratching.

On examination the vulva is noted to have a well-demarcated white area around

the introitus. The overlying skin appears thin with extensive fi ssuring. The perianal area is not involved.

A) Lichen sclerosus

B) Seborrhoeic dermatitis

C) Atopic vulvitis

D) Lichen simplex

E) Psoriasis

F) Herpes simplex

G) Behcet’s disease

H) Hidradenitis suppurativa

I) Paget’s disease

J) Tinea cruris

Lichen sclerosus can occur in any age group. Skin in the whole genital region may

be affected, including the perianal area and genitocrural folds. The skin has welldemarcated whitening that does not extend to the vaginal mucosa. Pruritus is a

common associated symptom.

34) A 70-year-old postmenopausal woman presents with vulval itching. On examination, she has a narrow introitus. The skin over the labia, the perineal area and

the genitocrural folds is thin and dry, with white discoloration and superfi cial

excoriations. A skin biopsy reveals atrophic epidermis with hyperkeratosis and

superfi cial dermal hyalinisation with lymphocytic infi ltrates.

A) Lichen sclerosus

B) Seborrhoeic dermatitis

C) Atopic vulvitis

D) Lichen simplex

E) Psoriasis

F) Herpes simplex

G) Behcet’s disease

H) Hidradenitis suppurativa

I) Paget’s disease

J) Tinea cruris

The classical histological features are an atrophic epidermis with overlying hyperkeratosis, an effaced dermoepidermal junction, superfi cial dermal hyalinisation

and lymphocytic infi ltration.

35) A 26-year-old woman presents to the gynaecology OPD with an ultrasound scan of her

pelvis for menorrhagia. It reports an anechoic ovarian cyst of 28 mm × 37 mm on the

right side. No other abnormal findings are reported.

A) AFP, LDH and hCG

B) Ca 125

C) combined oral contraceptive pill

D) expectant management

E) further imaging with MRI

F) IOTA scoring

G) laparoscopic removal of cyst

H) laparoscopic removal of ovary

I) laparotomy

J) laparotomy and ovarian cystectomy

K) progesterone only pill

L) repeat ultrasound

M) RMI

N) TAH and BSO

O) ultrasound-guided aspiration

Asymptomatic, incidental, fluid-filled ovarian cysts less than 50 mm do not warrant

further imaging or intervention.

36) A 26-year-old patient has had a routine smear which revealed borderline squamous cell

changes on cytology. She has had a high-risk HPV DNA test that has been reported to

be positive.

A) two-week referral to colposcopy

B) two-week referral to gynaecology clinic

C) LLETZ under general anaesthesia

D) LLETZ under local anaesthetic block

E) routine recall

F) no further Pap smears

G) repeat smear with GP after 6 months

H) routine referral to colposcopy in 6 weeks

I) see and treat colposcopy in 2 weeks

J) test of cure – High-risk HPV DNA

K) test of triage – High-risk HPV DNA test

A diagnostic colposcopy is recommended.

37) A woman is diagnosed with cervical cancer. The carcinoma has extended into the

pelvic sidewall. On rectal examination, there is no cancer-free space between the

tumour and the pelvic sidewall. The tumour involves the lower third of the vagina.

There is unilateral hydronephrosis.

A) I A

B) I B

C) I C1

D) I C2

E) I C3

F) II

G) III A1

H) III A2

I) III B

J) III C1

K) III C2

L) IV A

M) IV B

This is stage III B according to the FIGO staging of cervical carcinomas

classification (2006).

38) A 28-year-old woman attends her GP surgery for a routine cervical smear. The

examination is difficult and an ‘inadequate’ result is returned.

A) No action necessary

B) Perform cervical cytology in 1 year’s time

C) Perform cervical cytology in 3 years’ time

D) Perform colposcopic treatment

E) Perform human papillomavirus (HPV) test of cure

F) Perform HPV triage testing

G) Refer to colposcopy

H) Repeat cervical cytology in 3 months’ time

I) Repeat cervical cytology in 6 months’ time

J) Return to routine recall

39) A 68 year old woman attends the gynaecology clinic

4 weeks after TAH + BSO for endometrial carcinoma.

The histology shows that the tumour had extended to

involve the cervix and she has been advised to have

radiotherapy. She enquires about the survival rate for

women with similar tumours.

A) 85% 5 year survival

B) 60% 5 year survival

C) 25% 5 year survival

D) Almost 100% 5 year survival

E) Overall life-time risk ~2%

F) Overall life-time risk ~3%

G) Overall life-time risk of 0.1%

H) Overall life-time risk _1.5%

I) Overall life-time risk ~1%

J) Virtually 0% 5 year survival

K) 40% 5 year survival

L) 70% 5 year survival

40) A 47 year old woman complains of a 3 months history of vulval

irritation and superficial dyapareunia. The vulval skin is thin and

white with fissures and narrowing of the introitus and fusion of

the labia minora over the clitoris

A) Oestrogen cream

B) Oral HRT

C) Vaginoplasty

D) Skinning vulvectomy

E) Clobetasol cream

F) Testosterone cream

G) Topical anti-histamines

H) Radical vulvectomy

I) Excision biopsy

J) Topical anti-fungal cream

Your score is