Oncology EMQ Test Part 2
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1) 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.
2) 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.
3) A 28-year-old woman attends her GP surgery for a routine cervical smear. The
examination is difficult and an ‘inadequate’ result is returned.
4) 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.
Asymptomatic ovarian cysts that do not increase in size with a normal Ca 125 may be
5) 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.
6) A 40-year-old woman has her routine smear at the Community Gynaecology clinic.
The smear is reported as borderline dyskaryosis.
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.
7) A 50-year-old woman undergoes her routine cervical screening. The results are reported
as high-grade moderate dyskaryosis.
High-grade smears both moderate and severe are referred to colposcopy under the
8) 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.
This is stage I C1
according to the International Federation of Gynecology and
Obstetrics (FIGO) ovarian cancer staging classification (2014).
9) 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
The lesions described are likely to represent herpes simplex. The differential diagnosis of genital ulcers also includes chancroid and syphilis
10) 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.
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
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
12) 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.
Repeat smear no less than 3 months later is recommended. Three inadequate
samples will trigger a referral to colposcopy.
13) A steroid that is almost undetectable in the non-pregnant female, but whose levels
rise >1000-fold during pregnancy.
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.
14) 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.
Asymptomatic, incidental, fluid-filled ovarian cysts less than 50 mm do not warrant
further imaging or intervention.
15) 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
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.
16) 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.
17) A compound that is elevated in women with an ovarian dysgerminoma.
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
Sanusi FA, Carter P, Barton DPJ. Non-epithelial ovarian cancers. The Obstetrician &
18) 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.
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.
19) 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.
This is stage III B according to the FIGO staging of cervical carcinomas
20) Stage 1 uterine (endometrial) cancer.
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%.
21) Stage 2 carcinoma of the cervix.
The 5-year survival rates for stage 1 to stage 4 cervical cancer are 95.9%, 54.4%,
22) 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
23) 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
Low-grade dyskaryosis with negative high-risk DNA test results is reassuring and a
routine recall system may be followed.
24) 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
A diagnostic colposcopy is recommended.
25) 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.
26) A 90-year-old woman is diagnosed with vulval cancer. Imaging suggests
metastases to both inguinofemoral and pelvic lymph nodes.
This is stage IV B according to the FIGO vulval cancer staging classification (2014)
27) 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.
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.
28) 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
29) 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
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.
30) 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.
31) 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
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.
32) 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.
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.
33) 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
34) 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.
Referral to colposcopy in 2 weeks is essential for suspected cervical glandular
35) Stage 3 ovarian cancer.
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%.
See the Cancer Research UK website at www.cancerresearchuk.org (accessed 25 July 2018).
36) 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
Inhibin supresses follicle-stimulating hormone (FSH) production and secretion by
the anterior pituitary. Inhibin has been used as a tumour marker for granulosa cell
37) 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.
The classical histological features are an atrophic epidermis with overlying hyperkeratosis, an effaced dermoepidermal junction, superfi cial dermal hyalinisation
and lymphocytic infi ltration.
38) 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
39) 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.
Endometrial pathology must be excluded. An urgent referral to the gynaecology
clinic is recommended.
40) A 26-year-old woman undergoes her first cervical routine screening test. Her smear is
reported as borderline squamous cell changes.
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
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