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ABOG Gynecologic Oncology study materials
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ABOG Gynecologic Oncology practice questions

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Question 1Screening, Prevention, and Diagnosis of Gynecologic Malignancies

At what age should average-risk cervical cancer screening begin in a woman with no history of abnormal results?

  1. 25 years
  2. 21 years Correct answer.
  3. 18 years or at first intercourse
  4. 30 years

Explanation

Cytology-based screening begins at age 21 regardless of the age of first intercourse, because cervical cancer before 21 is rare and HPV infections in adolescents usually clear spontaneously. Beginning earlier leads to colposcopy and excisional procedures for lesions that would regress. Women aged 21-29 are screened with cytology alone every 3 years.

Question 2Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 62-year-old postmenopausal woman reports a single episode of vaginal bleeding. What is the most appropriate initial diagnostic step?

  1. CT of the abdomen and pelvis
  2. Reassurance and repeat evaluation in 6 months
  3. Serial hCG measurements
  4. Endometrial biopsy Correct answer.

Explanation

Postmenopausal bleeding is endometrial cancer until proven otherwise and requires tissue sampling, usually with office endometrial biopsy, with or without transvaginal ultrasound. Approximately 5-10 percent of women with postmenopausal bleeding have endometrial cancer. Imaging and observation do not substitute for histologic diagnosis.

Question 3Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which approach is recommended for ovarian cancer screening in an asymptomatic woman at average risk?

  1. Annual transvaginal ultrasound alone
  2. Annual serum CA-125 alone
  3. No screening is recommended Correct answer.
  4. Annual pelvic examination combined with CA-125

Explanation

Large randomized trials of CA-125 with or without transvaginal ultrasound have not shown a mortality benefit in average-risk women, and false-positive results lead to surgery with real complications. Therefore no screening test is recommended outside of research for this population. Women with hereditary syndromes or concerning symptoms require a different, individualized approach.

Question 4Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 45-year-old woman has a negative cervical cytology and a negative HPV co-test. When should she next be screened?

  1. 2 years
  2. 1 year
  3. 5 years Correct answer.
  4. 10 years

Explanation

For women aged 30-65 with negative cytology and negative HPV co-testing, the recommended interval is 5 years. A longer interval is safe because a negative HPV test has a very high negative predictive value for subsequent cervical precancer. Screening every 3 years applies to cytology alone regimens.

Question 5Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which woman requires continued vaginal cytology after hysterectomy?

  1. Total hysterectomy for symptomatic fibroids
  2. Hysterectomy performed for CIN 3 Correct answer.
  3. Total hysterectomy for adenomyosis
  4. Total hysterectomy for uterine prolapse

Explanation

Women with a history of CIN 2 or worse who undergo hysterectomy remain at risk for vaginal intraepithelial neoplasia and continue vaginal cuff cytology, typically for at least 20 years after the abnormal result. Women whose hysterectomy was for benign disease with no prior CIN 2 or worse need no further screening. A supracervical hysterectomy leaves the cervix in place and therefore does not end screening.

Question 6Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which symptom reported by a 34-year-old woman most warrants prompt evaluation for cervical cancer?

  1. Postcoital spotting Correct answer.
  2. Discharge that varies with the menstrual cycle
  3. Dysuria with a negative urine culture
  4. Cyclic pelvic pain

Explanation

Postcoital bleeding is the classic presentation of cervical cancer because the tumor friability causes bleeding with contact. Any visible cervical lesion or persistent postcoital bleeding requires visualization and biopsy. Cyclic pain and physiologic discharge are common and nonspecific.

Question 7Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which factor most strongly increases the risk of endometrial cancer?

  1. Combined oral contraceptive use
  2. Obesity Correct answer.
  3. Multiparity
  4. Cigarette smoking

Explanation

Obesity is the strongest modifiable risk factor because peripheral conversion of androgens to estrone produces unopposed estrogen exposure. Parity is protective, combined oral contraceptives are protective, and smoking is associated with lower risk through antiestrogenic effects. Endometrial cancer risk rises steadily with increasing body mass index.

Question 8Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 30-year-old woman has ASC-US on cervical cytology with a negative HPV result. What is the next step?

  1. Endometrial biopsy
  2. Immediate colposcopy
  3. Repeat co-testing in 3 years Correct answer.
  4. Cold knife conization

Explanation

ASC-US with negative HPV testing carries a very low risk of CIN 3 or worse, so repeat co-testing in 3 years is appropriate. Triage by HPV testing is what distinguishes this result from HPV-positive ASC-US, which requires colposcopy. Reflex HPV testing avoids unnecessary colposcopy in most women with ASC-US.

Question 9Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 35-year-old woman has a negative cytology result and tests positive for HPV 16 on co-testing. What is the recommended management?

  1. Repeat HPV testing in 1 year
  2. Repeat co-testing in 3 years
  3. Hysterectomy
  4. Colposcopy Correct answer.

Explanation

HPV 16 carries the highest risk of progression to CIN 3 and cancer, so genotype-specific positivity with concurrent negative cytology warrants immediate colposcopy. Women positive for other high-risk types with negative cytology may be followed at 1 year rather than referred. This risk-based approach is the basis of current management guidelines.

Question 10Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 28-year-old woman has a cytology result of atypical squamous cells, cannot exclude HSIL (ASC-H). What is the appropriate next step?

  1. Repeat cytology in 6 months
  2. Antibiotic treatment followed by repeat cytology
  3. Reflex HPV testing alone with no further action
  4. Colposcopy with directed biopsy Correct answer.

Explanation

ASC-H reflects a substantial risk of underlying CIN 2 or worse, so colposcopy with biopsy is required regardless of the HPV result. HPV testing does not safely triage this category because the prevalence of high-grade disease is too high. Excisional procedures are reserved for cases in which colposcopy is inadequate or invasive disease is suspected.

Question 11Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 40-year-old woman has atypical glandular cells on cervical cytology. Which evaluation is appropriate?

  1. Reflex HPV genotyping with no further testing
  2. Colposcopy with endocervical and endometrial sampling Correct answer.
  3. Repeat cytology in 12 months
  4. Empiric antibiotic therapy followed by repeat cytology in 3 months

Explanation

Atypical glandular cells carry a meaningful risk of both cervical adenocarcinoma in situ and endometrial carcinoma, so evaluation includes colposcopy with endocervical sampling plus endometrial biopsy. Endometrial sampling is required in all women 35 and older and in younger women with risk factors such as abnormal bleeding. HPV testing may be used as an adjunct but does not replace this workup.

Question 12Screening, Prevention, and Diagnosis of Gynecologic Malignancies

An HIV-positive woman has had three consecutive negative annual cervical cytology results. What screening interval is recommended thereafter?

  1. Every year
  2. Every 5 years
  3. Every 10 years
  4. Every 3 years Correct answer.

Explanation

HIV-infected women begin screening within 1 year of sexual activity and no later than age 21, with annual cytology; after three consecutive negative results the interval may be extended to every 3 years. Screening continues throughout life rather than stopping at 65 because of persistent immunocompromise. Co-testing or primary HPV testing may also be used but the interval is not lengthened to 5 years.

Question 13Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 55-year-old asymptomatic woman has benign-appearing endometrial cells reported on cervical cytology. What is the recommended next step?

  1. Hysterectomy
  2. Repeat cytology in 1 year
  3. Endometrial sampling Correct answer.
  4. No further evaluation

Explanation

Exfoliated endometrial cells on cytology in a woman aged 45 or older are associated with endometrial hyperplasia or carcinoma even when the cells appear benign, so endometrial sampling is indicated. In younger women this finding is usually hormonal and requires evaluation only if abnormal bleeding is present. The age threshold exists because anovulation is common below 45.

Question 14Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which test is recommended for essentially all newly diagnosed endometrial carcinomas?

  1. Serum CA-125 measurement
  2. Mismatch repair protein immunohistochemistry or MSI testing Correct answer.
  3. Germline BRCA1 and BRCA2 sequencing
  4. Routine CT of the chest

Explanation

Universal tumor testing for mismatch repair deficiency identifies Lynch syndrome among women with endometrial cancer, which is the most common sentinel cancer in these families. Identification affects the patient's own surveillance and the testing offered to relatives. The finding also carries prognostic and immunotherapy implications.

Question 15Screening, Prevention, and Diagnosis of Gynecologic Malignancies

An asymptomatic woman with breast cancer is taking tamoxifen. What endometrial surveillance is recommended?

  1. Annual endometrial biopsy
  2. Hysteroscopy every 2 years
  3. Annual transvaginal ultrasound
  4. No routine surveillance; evaluate any bleeding Correct answer.

Explanation

Tamoxifen raises the risk of endometrial hyperplasia and carcinoma, but routine ultrasonography or biopsy in asymptomatic users produces false-positive findings and unnecessary procedures without improving outcomes. Surveillance is symptom-driven, and any postmenopausal bleeding or abnormal premenopausal bleeding is evaluated with endometrial sampling. Ultrasound findings such as cystic lucencies are common on tamoxifen and are not diagnostic.

Question 16Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 24-year-old woman has an incidental, asymptomatic, simple ovarian cyst measuring 3 cm. What is the appropriate management?

  1. No intervention; routine follow-up imaging is not required Correct answer.
  2. Laparoscopic cystectomy
  3. Repeat ultrasound in 6 weeks
  4. Serum CA-125 with gynecologic oncology referral

Explanation

Simple cysts 5 cm or smaller in premenopausal women are physiologic and carry negligible malignant potential, so no follow-up imaging or surgery is needed. Intervention is reserved for cysts that are complex, symptomatic, enlarging, or persist beyond the expected physiologic window. Counseling the patient about expected resolution avoids unnecessary anxiety.

Question 17Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which statement best describes serum CA-125 in the diagnostic evaluation of a premenopausal woman with an adnexal mass?

  1. A normal value excludes ovarian cancer
  2. It is reliably elevated in stage I ovarian cancer
  3. It is commonly elevated by endometriosis and leiomyomas Correct answer.
  4. It is highly specific for ovarian malignancy

Explanation

CA-125 is a marker of coelomic epithelium and rises with many benign conditions, including endometriosis, leiomyomas, pelvic inflammatory disease, and pregnancy, which limits specificity in premenopausal women. It is also normal in roughly half of stage I ovarian cancers, limiting sensitivity for early disease. It is therefore used adjunctively with imaging and menopausal status rather than as a stand-alone diagnostic test.

Question 18Screening, Prevention, and Diagnosis of Gynecologic Malignancies

After evacuation of a molar pregnancy, which finding meets the FIGO criteria for gestational trophoblastic neoplasia?

  1. A single hCG value that rises once
  2. A plateau in hCG lasting 1 week
  3. An hCG plateau lasting 3 weeks Correct answer.
  4. A 50 percent fall in hCG during the first week

Explanation

FIGO defines postmolar gestational trophoblastic neoplasia as a plateau of hCG over at least 3 weeks (four values across days 1, 7, 14, and 21) or a rise lasting at least 2 weeks (three values across days 1, 7, and 14). These criteria distinguish true neoplasia from the normal slow decline after evacuation. hCG surveillance after molar evacuation is continued until levels are undetectable.

Question 19Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 45-year-old woman has a visible, friable, exophytic cervical lesion. What is the most appropriate next step to establish the diagnosis?

  1. Punch biopsy of the lesion Correct answer.
  2. Repeat cervical cytology
  3. PET-CT of the pelvis
  4. Cervical conization

Explanation

A clinically suspicious cervical lesion is biopsied directly, because directed punch biopsy provides histologic diagnosis quickly and safely even when the lesion is exophytic. Conization is avoided when gross invasive cancer is suspected because of bleeding risk and because it does not change management. Staging imaging follows only after tissue confirmation.

Question 20Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A woman with a known BRCA1 mutation has completed childbearing. At what age is risk-reducing salpingo-oophorectomy recommended?

  1. 25-30 years
  2. 35-40 years Correct answer.
  3. 45-50 years
  4. 50-55 years

Explanation

Risk-reducing salpingo-oophorectomy is recommended at 35-40 years for BRCA1 carriers and 40-45 years for BRCA2 carriers, timed to precede the steep rise in ovarian cancer incidence while balancing surgical menopause effects. Salpingectomy at the time of other pelvic surgery may be offered to carriers who have not completed risk-reducing surgery. Bilateral mastectomy decisions are managed separately.

Question 21Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 33-year-old woman who wishes to preserve fertility has adenocarcinoma in situ on cervical biopsy. What is the most appropriate next step?

  1. Repeat colposcopy and cytology in 6 months
  2. Simple hysterectomy
  3. Cold knife conization to assess margins Correct answer.
  4. Cryotherapy of the transformation zone

Explanation

Adenocarcinoma in situ is a glandular lesion that frequently extends into the endocervical canal, so cold knife conization is required to exclude invasive adenocarcinoma and to determine margin status. Margin status then determines whether a second excision is needed before fertility-sparing management. Ablative therapy is contraindicated because it leaves the endocervical canal unevaluated.

Question 22Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 70-year-old woman has an erythematous vulvar plaque that has not responded to topical corticosteroids. Biopsy shows intraepithelial adenocarcinoma of the epidermis. Which is the most important next step?

  1. Reassurance and observation
  2. Topical imiquimod therapy
  3. Radical vulvectomy
  4. Evaluation for an underlying adenocarcinoma Correct answer.

Explanation

This is extramammary Paget disease, which may be primary or may overlie an underlying adenocarcinoma of the vulvar apocrine glands, anus, rectum, or urinary tract. Because of this association, examination and imaging of the anogenital and gastrointestinal tracts are essential, and recurrence is common even after clear-margin excision. The lesion also requires excision or another definitive local therapy.

Question 23Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 68-year-old woman has recurrent postmenopausal bleeding. Transvaginal ultrasound shows an endometrial thickness of 3 mm. What is the most appropriate next step?

  1. Reassurance without further testing
  2. Repeat transvaginal ultrasound in 12 months
  3. Hysterectomy
  4. Endometrial sampling Correct answer.

Explanation

A thin endometrial echo lowers but does not eliminate the risk of endometrial cancer, and recurrent or persistent bleeding in a postmenopausal woman still warrants tissue sampling. Up to a small percentage of endometrial cancers occur with an endometrial thickness of 4 mm or less. Visible focal lesions at hysteroscopy should also be biopsied regardless of thickness.

Question 24Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which molecular subtype of endometrial carcinoma carries the most favorable prognosis?

  1. POLE ultramutated Correct answer.
  2. Non-specific molecular profile
  3. Mismatch repair deficient
  4. p53 abnormal

Explanation

The POLE ultramutated subgroup has an excellent prognosis driven by high immunogenicity from its enormous mutation burden, even among tumors that are histologically high grade. p53 abnormal tumors, which include most uterine serous carcinomas, have the worst outcomes. Mismatch repair deficient and non-specific profiles fall in between.

Question 25Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A healthy 13-year-old girl presents for routine care and has not received HPV vaccination. According to CDC recommendations, which vaccination schedule is appropriate?

  1. Three doses administered at 0, 1 to 2, and 6 months
  2. Four doses administered at 0, 2, 6, and 12 months
  3. A single dose followed by a booster at age 18 years
  4. Two doses administered 6 to 12 months apart Correct answer.

Explanation

For immunocompetent individuals who begin HPV vaccination before age 15, a two-dose series is recommended, with the second dose given 6 to 12 months after the first. A three-dose series is reserved for those who start at age 15 or older or who are immunocompromised.

Question 26Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 25-year-old woman with no history of abnormal cervical cytology or HPV infection requests cervical cancer screening. She is asymptomatic and immunocompetent. Which screening strategy is recommended?

  1. Co-testing with cytology and HPV every 5 years
  2. Primary high-risk HPV testing every 5 years
  3. No screening until age 30 years
  4. Cervical cytology alone every 3 years Correct answer.

Explanation

For average-risk women aged 21 to 29 years, cervical cytology alone every 3 years is recommended; HPV-based screening is generally reserved for women aged 30 years and older. Screening should not be deferred until age 30 in a woman who is already 25.

Question 27Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 58-year-old postmenopausal woman reports three episodes of vaginal bleeding over the past 2 months. She is hemodynamically stable. What is the most appropriate initial diagnostic test to evaluate for endometrial carcinoma?

  1. Magnetic resonance imaging of the pelvis
  2. Serum CA-125 measurement
  3. Transvaginal ultrasonography alone
  4. Office endometrial biopsy Correct answer.

Explanation

Office endometrial biopsy is the initial diagnostic test for suspected endometrial carcinoma because it is minimally invasive and highly sensitive. Transvaginal ultrasonography may help triage bleeding, but it is not definitive, and imaging does not replace tissue diagnosis.

Question 28Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which asymptomatic woman should be offered endometrial cancer surveillance because of a substantially increased lifetime risk?

  1. A 45-year-old woman with obesity and polycystic ovary syndrome
  2. A 55-year-old woman with long-standing hypertension
  3. A 42-year-old woman with a germline Lynch syndrome mutation Correct answer.
  4. A 50-year-old woman with type 2 diabetes

Explanation

Women with Lynch syndrome have a markedly elevated lifetime risk of endometrial cancer, and expert groups recommend surveillance, typically with endometrial biopsy and transvaginal ultrasound, beginning around age 30 to 35. Obesity, diabetes, and hypertension increase risk but do not by themselves warrant routine surveillance.

Question 29Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 34-year-old woman undergoes loop electrosurgical excision for cervical intraepithelial neoplasia grade 3 with negative margins. What surveillance is recommended after treatment?

  1. Colposcopy every 6 months for 2 years, then no further screening
  2. No further screening if the 3-month cytology is negative
  3. High-risk HPV testing at 6 and 12 months Correct answer.
  4. Annual cervical cytology for 20 years

Explanation

After excisional treatment for CIN 2 or 3, HPV-based testing is recommended at 6 and 12 months; if both results are negative, routine screening can resume. Cytology alone or colposcopy alone is less sensitive for residual or recurrent disease.

Question 30Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 48-year-old average-risk woman is scheduled for hysterectomy for symptomatic uterine fibroids. She has no family history of ovarian cancer and wishes to retain ovarian hormone production. Which additional procedure most appropriately reduces her risk of ovarian cancer?

  1. Omental biopsy
  2. Bilateral oophorectomy
  3. Peritoneal washings for cytology
  4. Opportunistic bilateral salpingectomy Correct answer.

Explanation

Opportunistic salpingectomy at the time of benign hysterectomy reduces ovarian cancer risk while preserving ovarian function, because many high-grade serous carcinomas arise in the fallopian tube. Oophorectomy would reduce risk further but is not indicated solely for prevention in an average-risk woman who wishes to retain hormones.

Question 31Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which statement about ovarian cancer screening in asymptomatic average-risk women is correct?

  1. Combined CA-125 and transvaginal ultrasound screening is recommended annually
  2. Transvaginal ultrasound screening is recommended starting at age 50
  3. Annual CA-125 measurement reduces ovarian cancer mortality
  4. No screening strategy has been shown to reduce ovarian cancer mortality Correct answer.

Explanation

In average-risk asymptomatic women, neither CA-125 nor transvaginal ultrasound, alone or combined, has been shown to reduce ovarian cancer mortality, and screening can cause false-positive results and unnecessary surgery. Screening is therefore not recommended outside high-risk populations or research settings.

Question 32Screening, Prevention, and Diagnosis of Gynecologic Malignancies

A 52-year-old woman has an endometrial biopsy showing atypical endometrial hyperplasia. She undergoes hysterectomy. Approximately what proportion of women with this diagnosis have concurrent endometrial carcinoma at hysterectomy?

  1. 40% Correct answer.
  2. Less than 5%
  3. 20%
  4. 10%

Explanation

Atypical endometrial hyperplasia carries a substantial risk of coexisting endometrial carcinoma, reported in roughly 40% of women at hysterectomy, which is why hysterectomy is recommended when fertility is not desired. Intraoperative frozen section cannot reliably exclude concurrent carcinoma.

Question 33Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which transvaginal ultrasound finding is most characteristic of a complete hydatidiform mole?

  1. A simple ovarian cyst with a normal endometrial stripe
  2. A uniformly thin endometrium with no adnexal masses
  3. Multiple cystic spaces without fetal parts Correct answer.
  4. A single fetus with a thickened, cystic placenta

Explanation

A complete mole typically produces a diffuse vesicular pattern, often described as a snowstorm, with no fetal tissue because the pregnancy is androgenetic and lacks a maternal chromosome complement. A fetus with a thickened cystic placenta is more consistent with a partial mole.

Question 34Screening, Prevention, and Diagnosis of Gynecologic Malignancies

Which vulvar dermatosis is most strongly associated with an increased risk of differentiated vulvar intraepithelial neoplasia and vulvar squamous cell carcinoma?

  1. Lichen simplex chronicus
  2. Lichen sclerosus Correct answer.
  3. Lichen planus
  4. Psoriasis

Explanation

Lichen sclerosus is associated with a small but important increased risk of vulvar squamous cell carcinoma, often arising through differentiated vulvar intraepithelial neoplasia in older women. Long-standing lichen sclerosus should be treated and monitored, with biopsy of any new or persistent lesion.

Question 35Surgical Management of Gynecologic Cancer

A patient undergoes laparotomy for an adnexal mass that proves to be stage IA grade 2 endometrioid ovarian cancer. Which additional procedure completes comprehensive surgical staging?

  1. Appendectomy alone
  2. Routine splenectomy with distal pancreatectomy and partial gastrectomy
  3. Omentectomy with pelvic and para-aortic lymph node dissection Correct answer.
  4. Pelvic exenteration

Explanation

Comprehensive staging for early epithelial ovarian cancer combines hysterectomy and bilateral salpingo-oophorectomy with total omentectomy, pelvic and para-aortic lymphadenectomy, and multiple peritoneal biopsies from the diaphragm, paracolic gutters, and pelvic peritoneum. Upper abdominal organ resections such as splenectomy or partial pancreatectomy belong to cytoreduction, not staging. Appendectomy is not a required staging step for endometrioid histology.

Question 36Surgical Management of Gynecologic Cancer

A type III (Piver) radical hysterectomy differs from a simple extrafascial hysterectomy mainly because it includes removal of:

  1. The common iliac vessels
  2. The ovaries and both fallopian tubes
  3. The parametrium and upper vagina Correct answer.
  4. The entire vagina together with the bladder and rectum

Explanation

Radical hysterectomy removes the parametria, comprising the cardinal and uterosacral ligaments, together with a cuff of upper vagina, and this wider soft-tissue envelope is what defines its radicality. Simple extrafascial hysterectomy removes only the uterus and cervix. Ovaries may be removed at either operation depending on the indication.

Question 37Surgical Management of Gynecologic Cancer

A 55-year-old has a 2.5 cm unifocal squamous carcinoma of the left labium majus with clinically and radiologically negative groins. What is the most appropriate groin management?

  1. External beam radiation to both groins
  2. Observation with clinical groin examination every six months only
  3. Bilateral complete inguinofemoral lymphadenectomy
  4. Sentinel lymph node biopsy of the groin Correct answer.

Explanation

Sentinel lymph node biopsy is standard for unifocal vulvar tumors under 4 cm with clinically negative groins because it detects occult metastasis while avoiding the morbidity of full lymphadenectomy. A lateralized lesion drains predominantly to the ipsilateral groin, so unilateral mapping is acceptable when the tumor lies more than 1 cm from the midline. Observation alone risks missing occult nodal disease, and prophylactic groin irradiation is not indicated in node-negative disease.

Question 38Surgical Management of Gynecologic Cancer

What is the surgical objective of primary cytoreduction for advanced epithelial ovarian cancer?

  1. No visible residual disease Correct answer.
  2. Residual disease less than 10 cm in diameter
  3. Completion of surgery within two hours regardless of residual tumor
  4. Removal of the uterus and both adnexa only

Explanation

Maximal cytoreduction aims for complete resection with no macroscopic residual disease, which is the strongest surgical prognostic factor in advanced ovarian cancer. A residual threshold of 1 cm is historical and clearly inferior to complete resection. The extent of the operation should be dictated by the goal of complete resection rather than by operative time.

Question 39Surgical Management of Gynecologic Cancer

A 26-year-old nulliparous woman has a 6 cm mass that frozen section confirms as stage IA grade 1 endometrioid carcinoma of the right ovary. Which operation is appropriate?

  1. Bilateral ovarian cystectomy without staging
  2. Bilateral salpingo-oophorectomy with total hysterectomy
  3. Unilateral salpingo-oophorectomy with full staging Correct answer.
  4. Hysterectomy with preservation of both ovaries and omentectomy only

Explanation

Fertility-sparing surgery for stage IA grade 1 endometrioid ovarian cancer consists of unilateral salpingo-oophorectomy with complete staging, including peritoneal biopsies, omentectomy, and nodal assessment, while preserving the uterus and contralateral ovary. Bilateral oophorectomy with hysterectomy is not required for stage IA disease in a patient who wishes to preserve fertility. Cystectomy alone is inadequate because it risks incomplete resection and leaves the stage unknown.

Question 40Surgical Management of Gynecologic Cancer

During hysterectomy for endometrial cancer, which intraoperative finding most strongly supports performing pelvic and para-aortic lymphadenectomy?

  1. Multiple small leiomyomas in the fundus
  2. A polypoid exophytic tumor growth pattern
  3. Deep myometrial invasion Correct answer.
  4. Coexisting adenomyosis in the myometrium

Explanation

Deep myometrial invasion on frozen section, particularly when combined with high-grade histology or a non-endometrioid subtype, raises the risk of nodal metastasis enough to justify lymphadenectomy. Adenomyosis and leiomyomas are common benign findings that do not influence nodal risk. Growth pattern alone is not a validated predictor of lymphatic spread.

Question 41Surgical Management of Gynecologic Cancer

To which nodal group does the vulva primarily drain?

  1. External iliac nodes directly
  2. Superficial inguinal nodes Correct answer.
  3. Deep femoral and obturator nodes
  4. Para-aortic nodes

Explanation

Lymph from the vulva drains first to the superficial inguinal nodes and from there through the femoral canal to the deep inguinal and pelvic nodes. Direct spread to pelvic or para-aortic nodes without inguinal involvement is uncommon. This stepwise drainage is why groin assessment is the cornerstone of vulvar cancer staging.

Question 42Surgical Management of Gynecologic Cancer

Which macroscopic surgical margin is recommended for wide local excision of a vulvar squamous carcinoma?

  1. 5 mm of clinically normal skin
  2. 2 cm of clinically normal skin
  3. 1 cm of clinically normal skin Correct answer.
  4. 3 cm of clinically normal skin

Explanation

A gross margin of about 1 cm allows the pathologist to confirm a clear microscopic margin while limiting removal of normal vulvar tissue and preserving sexual and urinary function. Margins wider than 1 cm have not improved local control and increase morbidity. A 5 mm gross margin risks an inadequate final pathologic margin after fixation and shrinkage.

Question 43Surgical Management of Gynecologic Cancer

A patient with apparent stage I endometrial cancer undergoes sentinel lymph node mapping. Which technique gives the highest bilateral detection rate?

  1. Systemic intravenous injection of technetium-99m radiocolloid on the day of surgery
  2. Cervical injection of indocyanine green with near-infrared imaging Correct answer.
  3. Preoperative subcutaneous injection of radiocolloid into the vulva
  4. Intraoperative injection of blue dye into the uterine fundus

Explanation

Cervical injection of indocyanine green with near-infrared fluorescence gives the highest bilateral sentinel node detection rates in endometrial cancer because the cervix is accessible and the dye travels through the same lymphatic channels that drain the uterus. Blue dye alone has lower detection and requires direct visual identification. Systemic intravenous injection does not map lymphatics adequately, and vulvar injection maps the groin rather than the pelvis.

Question 44Surgical Management of Gynecologic Cancer

Which patient with cervical cancer is the best candidate for radical trachelectomy?

  1. A 29-year-old with a 1 cm tumor extending to the lower uterine segment
  2. A 45-year-old with a 5 cm FIGO IB2 adenocarcinoma
  3. A 38-year-old with a 3 cm tumor and pelvic nodal metastasis
  4. A 32-year-old with a 2 cm FIGO IB1 squamous tumor Correct answer.

Explanation

Radical trachelectomy is offered to young patients with early cervical cancer who wish to preserve fertility, ideally with tumors 2 cm or smaller and no nodal or uterine corpus involvement. Tumors larger than 2 cm have higher recurrence rates after trachelectomy and are usually treated with radical hysterectomy or chemoradiation. Nodal metastasis and extension to the lower uterine segment are contraindications.

Question 45Surgical Management of Gynecologic Cancer

A woman with stage IIIC ovarian cancer has miliary peritoneal carcinomatosis and a computed tomography scan showing no feasible complete resection. What is the preferred management?

  1. Neoadjuvant chemotherapy followed by interval cytoreduction Correct answer.
  2. Immediate second-look laparotomy
  3. Palliative chemotherapy alone without any surgery
  4. Primary cytoreductive surgery with resection of all visible disease

Explanation

When upfront complete cytoreduction is not achievable or would require excessive morbidity, neoadjuvant platinum-based chemotherapy followed by interval cytoreduction yields similar survival with less perioperative morbidity. Interval surgery is usually performed after three to four cycles in patients who respond or remain stable. Palliative chemotherapy without any planned surgery is reserved for patients who are not surgical candidates at all.

Question 46Surgical Management of Gynecologic Cancer

During cytoreduction a segment of sigmoid colon is densely infiltrated by tumor, but the rectum is spared. What is the most appropriate approach?

  1. Leave the tumor in place to avoid anastomotic complications
  2. Total proctocolectomy with permanent end ileostomy
  3. Diverting colostomy without resecting the tumor
  4. En bloc segmental colectomy with primary anastomosis Correct answer.

Explanation

Segmental bowel resection is appropriate when tumor infiltrates the bowel wall, provided complete resection can be achieved, and a primary anastomosis is safe in the absence of gross contamination, ischemia, or extensive prior radiation. Leaving visible tumor defeats the purpose of cytoreduction. A diverting stoma without resection does not remove disease, and total proctocolectomy is excessive when the rectum is spared.

Question 47Surgical Management of Gynecologic Cancer

Which finding is an absolute contraindication to pelvic exenteration for recurrent cervical cancer?

  1. Extensive pelvic sidewall involvement with sciatic nerve pain Correct answer.
  2. Unilateral hydronephrosis with a normal contralateral kidney and preserved renal function
  3. A vesicovaginal fistula within the radiation field
  4. Central pelvic recurrence after primary radiotherapy

Explanation

Exenteration is offered for central pelvic recurrence without extrapelvic spread, and sidewall involvement with sciatic pain indicates unresectable lumbosacral plexus disease. Hydronephrosis alone is not a contraindication when renal function can be preserved, and a fistula within the radiation field may itself be part of the indication for exenteration. Distant metastasis, peritoneal carcinomatosis, and tumor fixed to the pelvic sidewall at the sciatic notch are the classic absolute contraindications.

Question 48Surgical Management of Gynecologic Cancer

A 16-week pregnant woman has a 10 cm complex adnexal mass with solid components and ascites. What is the most appropriate management?

  1. Observation until delivery with serial ultrasound
  2. Chemotherapy with carboplatin and paclitaxel started in the second trimester
  3. Immediate cesarean delivery followed by surgery
  4. Exploratory laparotomy with staging and frozen section Correct answer.

Explanation

A complex mass with solid components and ascites is suspicious for malignancy and warrants surgical exploration, ideally in the second trimester when the risk of miscarriage is lower and the uterus is less obstructive. Frozen section guides the extent of surgery, and staging can often be completed at the same operation with ovarian preservation when disease is confined. Cytotoxic chemotherapy is not given empirically for an undiagnosed mass.

Question 49Surgical Management of Gynecologic Cancer

A simple hysterectomy performed for presumed benign disease reveals a 2 cm squamous cervical carcinoma with 4 mm stromal invasion and negative margins. What is the next step?

  1. Observation with vaginal cytology alone
  2. Immediate pelvic exenteration
  3. Whole-pelvis external beam radiation without any nodal staging
  4. Completion radical parametrectomy with pelvic lymphadenectomy Correct answer.

Explanation

Occult cervical cancer found after simple hysterectomy with invasion deeper than 3 mm and no prior nodal assessment is managed with completion radical parametrectomy and pelvic lymphadenectomy, which offers survival comparable to primary radical surgery. Observation alone undertreats the parametrial and nodal risk. Exenteration is reserved for central recurrence after radiation.

Question 50Surgical Management of Gynecologic Cancer

A mucinous ovarian carcinoma is found at surgery. Which additional procedure should be performed to exclude a metastatic origin?

  1. Liver wedge resection
  2. Appendectomy Correct answer.
  3. Splenectomy with distal pancreatectomy
  4. Total gastrectomy with esophagectomy

Explanation

Primary mucinous ovarian cancer is uncommon, and many mucinous tumors in the ovary are metastases from the appendix or other gastrointestinal sites. Appendectomy with careful inspection of the gastrointestinal tract, together with immunohistochemistry, helps distinguish a primary ovarian mucinous tumor from a metastasis. Solid organ resections of the spleen, pancreas, or liver are not part of this evaluation.