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28 Cards in this Set
- Front
- Back
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What is the primary lymph node drainage of the female urethral meatus?
A. Inguinal and external iliac B. Obturator and external iliac C. Obturator and internal iliac D. Internal and external iliac |
Correct Answer is A. RATIONALE: The lymphatic drainage of the urethral meatus parallels that of the vulva to the superficial and deep inguinal and external iliac lymph nodes. The primary drainage of the entire urethra is mainly to the obturator and internal and external iliac nodes.
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Which statement about the GOG (Homesley) trial comparing radiation therapy with pelvic lymph node dissection for vulvar cancer is true?
A. Pelvic lymph node dissection provides better local control. B. Inguinal lymph node dissection should be recommended for 5 mm of invasion. C. Both inguinal lymph node dissection and groin irradiation are equally acceptable for control of the disease. D. Pelvic irradiation improves survival in patients with positive lymph nodes in the groin. |
Correct Answer is D. REFERENCES: Kunos C, Simpkins F, Gibbons H, Tian C, Homesley H. Radiation therapy compared with pelvic node resection for node-positive vulvar cancer: a randomized controlled trial. Obstet Gynecol. 2009 Sep;114(3):537-46. Homesley HD, Bundy BN, Sedlis A, Adcock L. Radiation therapy versus pelvic node resection for carcinoma of the vulva with positive groin nodes. Obstet Gynecol. 1986 Dec;68(6):733-40
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Definitive therapy for patients with advanced unresected vulvar cancer should involve:
A. concurrent 5 FU or cisplatin with radiation therapy. B. a curative radiation dose of 70 Gy to the gross tumor. C. chemoradiation therapy for a complete pathologic response rate of 90%. D. chemoradiation therapy not followed by resection. |
Correct Answer is A. RATIONALE: Curative radiation dose to the vulva is usually between 62-65 Gy. Higher doses can cause tissue necrosis. The complete response is usually 50% in most reported series following chemoradiation. Either cisplatin or 5 FU is acceptable for concurrent treatment with radiation.
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Which type of cancer is most likely to be associated with a 65-year-old woman who presents with postmenopausal bleeding?
A. Vaginal B. Cervical C. Endometrial D. Vulvar |
Correct answer is C. RATIONALE: Although all of these conditions can lead to vaginal bleeding in a postmenopausal woman, endometrial cancer is the most common female genital tract malignancy in the United States. There were an estimated 40,000 new cases in 2008 compared to 11,000, 3,500, and 2,000 cases for cervical, vulvar, and vaginal cancers, respectively. REFERENCE: Jemal A, et al. CA Cancer J Clin. 2009;59:225-49.
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What is a valid criticism of the radiation technique used to treat the inguinal lymph nodes in the GOG 88 (Stehman) study of patients who had vulvar cancer with clinically negative lymph nodes?
A. The pelvis was treated with a four-field technique. B. The inguinal lymph nodes were treated with 12 MV photons. C. Patients with surgically positive lymph nodes received adjuvant radiation therapy to both the pelvic and inguinal lymph nodes. D. A midline block was used for treatment of the pelvic field. |
Correct answer is C. RATIONALE: One criticism of the study was that it prescribed 9- to 12-MeV electrons with 4- to 6-MV photons to a depth of 3 cm for radiation treatment of the inguinal lymph nodes in the non-CT era. With modern CT planning, the mean depth of inguinal lymph nodes is 6 cm. This difference meant about 30% less radiation dose was delivered to the inguinal lymph nodes. Another criticism was that patients with positive lymph nodes after surgery received adjuvant radiation therapy to both the pelvic and inguinal lymph nodes, while patients in the radiation arm received radiation to the inguinal lymph nodes only. Midline block causing an increased local failure at the primary site was a criticism of the Dusenberry study.
REFERENCES: Stehman FB, et al. Groin dissection versus groin radiation in carcinoma of the vulva: a Gynecologic Oncology Group study. International Journal of Radiation Oncology, Biology, Physics (Int J Radiat Oncol Biol Phys). 1992;24(2):389-96; Koh WJ, et al. Femoral vessel depth and the implications for groin node radiation. International Journal of Radiation Oncology, Biology, Physics (Int J Radiat Oncol Biol Phys). 1993 Nov 15;27(4):969-74. Dusenbery KE, et al. Radical vulvectomy with postoperative irradiation for vulvar cancer: therapeutic implications of a central block. International Journal of Radiation Oncology, Biology, Physics (Int J Radiat Oncol Biol Phys). 1994 Jul 30;(5):989-98. |
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What is the risk of occult inguinofemoral lymph node metastasis in patients with a 1.5 cm squamous cell carcinoma of the vulva?
A. <5% B. 08% C. 20% D. 34% |
Correct answer is C. RATIONALE: The Mayo clinic reviewed over 200 patients and determined that a stage T1 tumor had a 15% risk and a stage T2 tumor had a 30% risk of occult inguinofemoral lymph node metastasis. Based on the tumor size at the primary site, the risk was 7% (<1 cm), 22% (1.1 to 2 cm), 27% (2.1 to 3 cm), and 34% (3.1 to 5 cm).
REFERENCE: Gonzalez Bosquet J, et al. Risk of occult inguinofemoral lymph node metastasis from squamous carcinoma of the vulva. International Journal of Radiation Oncology, Biology, Physics (Int J Radiat Oncol Bio Phys). 2003 Oct 1;57(2):419-24. |
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Which of the following gross surgical resection margins is considered to be the minimum required for a wide local excision of an early squamous cell carcinoma of the vulva?
A. 02 mm B. 05 mm C. 07 mm D. 10 mm |
Correct answer is D. RATIONALE: A 10-mm surgical margin (8 mm if formalin fixed) is associated with a high local control rate and does not need adjuvant radiation therapy, as compared to a 48% local failure rate if the surgical margin is <8 mm (inadequate).
REFERENCE: Heaps JM, et al. Surgical-pathologic variables predictive of local recurrence in squamous cell carcinoma of the vulva. Gynecologic Oncology.(Gynecol Oncol). 1990 Sep;38(3):309-14. |
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The leading cause of gynecological cancer deaths in the United States is:
A. endometrial cancer. B. cervical cancer. C. ovarian cancer. D. vulvar cancer. |
Correct answer is C. RATIONALE: Ovarian cancer is the leading cause of death from gynecological malignancies in the United States. It is the 5th overall cause of cancer death in women, while cervical cancer is the 8th overall cause of cancer death in the United States.
REFERENCE: American Cancer Society (ACS) Cancer Statistics. http://www.cancer.org/downloads/STT/Cancer_Facts_and_Figures_2010.pdf. |
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According to the GOG (Homesley) study, which of the following survival outcomes was demonstrated at 2 years for patients who have vulvar cancer with inguinal lymph node metastases and received pelvic radiation in comparison to pelvic lymphadenectomy?
A. Comparable survival rates B. Better survival rate with radiation C. Worse survival rate with radiation D. Survival was not analyzed. |
Correct answer is B. RATIONALE: In this GOG study, patients with vulvar cancer and positive groin lymph nodes after radical vulvectomy and bilateral groin dissection were randomized to receive pelvic-inguinal irradiation or pelvic lymphadenectomy. Patients who received irradiation had a significantly improved survival compared to patients who had surgery alone (2-year survival = 68% vs. 54%, p = 0.03). REFERENCE: Homesley, et al. Obstetrics & Gynecology. 1986;68:733-40.
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Which of the following lymph nodes is the most common initial site of metastases in patients with vulvar carcinoma?
A. Obturator B. Internal iliac C. External iliac D. Superficial inguinal |
Correct answer is D. RATIONALE: As the primary drainage site for vulvar carcinomas, the superficial inguinal lymph nodes are the most commonly involved lymph node site in these patients. The superficial inguinal lymph nodes subsequently drain into the deep femoral lymph nodes and ultimately to the external iliac lymph nodes. Involvement of these sites without involvement of the superficial inguinal nodes is extremely uncommon.
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Which of the following statements about the HPV vaccination is true?
A. It targets eight HPV serotypes. B. It could reduce up to 70% of cervical cancers worldwide. C. It has been proven to be effective in reducing oropharyngeal cancer. D. It is recommended for all sexually active females. |
Correct answer is B. RATIONALE: HPV has been found to be associated with 70% of cervical cases worldwide. There are currently two different vaccines available: Cevarix, Glaxo Smith Kline, a bivalent vaccine against serotypes 16 and 18 and Gardasil, Merck and Co, a quadrivalent vaccine against serotypes 6, 11, 16, and 18. Current data suggests that it is effective in reducing cervical, vulvar, vaginal, and anogenital cancers with 93% efficacy. The data has not yet proven its efficacy in reducing oropharyngeal cancer. Current recommendations suggest vaccination of sexually inactive females only, though there is evidence to vaccinate sexually active women who are seronegative for HPV.
REFERENCE: International Journal of Gynecological Cancer. October 2009;19(7):1166-76. |
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A vulvar cancer arising on the labia minora with involvement of the upper urethra is classified as stage:
A. T1. B. T2. C. T3. D. T4. |
Correct answer is D. RATIONALE: According to the 1997 AJCC staging manual, vulvar tumors involving the lower urethra and/or vagina and anus are classified as T3. Upper urethral involvement is classified as T4.
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What is the most common anatomical location for a melanoma involving the vulva?
A. Clitoris B. Mons pubis C. Labia majora D. Vaginal vestibule |
Correct answer is C. RATIONALE: Most vulvar cancers (including melanomas) arise on the labia majora or minora.
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What is the most common histology of vulvar cancer?
A. Melanoma B. Adenocarcinoma C. Clear cell carcinoma D. Squamous cell carcinoma |
Correct answer is D. RATIONALE: The most common tumor histology for vulvar cancers is squamous cell carcinoma (85%). The second most common histology is melanoma, comprising about 10% of all cases. Other histologies are significantly less common (<5%).
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What is the probability of occult metastasis to the inguinofemoral lymph nodes of a 2.5-cm squamous cell carcinoma of the vulva classified as clinical stage T2N0M0?
A. 10% B. 20% C. 30% D. 40% |
Correct answer is C. RATIONALE: Clinical tumor size correlates with occult metastases in patients with clinically negative lymph node involvement as follows: 0 to 1 cm = 7.7%; 1.1 to 2 cm = 23.9%; 2.1 to 3 cm = 31%; 3.1 to 5 cm = 36.4%.
REFERENCE: Adapted from Gonzalez, et al. International Journal of Radiation Oncology, Biology, Physics (IJROBP). 2003;57:419-424. |
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What is the expected incidence of inguinal lymph node metastasis in a patient with a 2-cm squamous cell carcinoma of the vulva with a depth of invasion of 5.5 mm?
A. 06% B. 08% C. 22% D. 37% |
Correct answer is D. RATIONALE: Pooled data from vulvar series notes the following correlation of incidence of groin lymph node metastases in patients with primary tumors of 2 cm or less and the following depths of invasion: 1 mm or less = 0%; 1.1 to 2 mm = 6.6%; 2.1 to 3 mm = 8.2%; 3.1 to 4 mm = 22.0%; 4.1 to 5 mm = 25.0; and >5 mm = 37.5%.
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Which of the following AJCC stage groups is associated with a 2.5-cm squamous cell carcinoma of the vulva with bilateral inguinal lymph node metastases and no evidence of metastatic disease?
A. IIIA B. IIIB C. IVA D. IVB |
Correct answer is C. RATIONALE: T2N2M0 is Stage IVA. IVB represents distant metastatic disease.
REFERENCE: AJCC Cancer Staging Manual, 6th edition. |
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What is the most common gynecologic malignancy in the United States?
A. Vulvar cancer B. Ovarian cancer C. Cervical cancer D. Endometrial cancer |
Correct answer is D. RATIONALE: The most common gynecologic malignancy diagnosed each year in this country is endometrial cancer with approximately 40,000 cases per year. Worldwide, however, the most common gynecologic cancer is cervical cancer.
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According to the GOG trial (Stehman) for vulvar cancers with clinically negative groin nodes, patients who underwent groin dissection versus groin irradiation experienced which of the following progression-free interval and overall survival results?
Progression-Free Interval Overall Survival A. Improved Improved B. Worse Worse C. Improved No difference D. No difference No difference |
Correct answer is A. RATIONALE: In the study referenced, patients in the groin dissection arm had significantly better progression-free interval and overall survival compared to the groin irradiation arm, but the radiation techniques were deemed to be inadequate (by prescribing to a depth of 3 cm for all patients, most patients would have received an underdose).
Reference: Stehman FB, Bundy BN, Thomas G, et al. Groin dissection versus groin irradiation in carcinoma of vulva: a gynecologic oncology group study. International Journal of Radiation Oncology, Biology, Physics. 1992;24:39. |
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What is the minimum tumor-free pathologic margin in fixed tissue required to minimize the risk of local recurrence for patients who have undergone surgery for vulvar cancer?
A. 2 to 4 mm B. 5 to 7 mm C. >8 mm D. >10 mm |
Correct answer is C. RATIONALE: This was a large UCLA surgicopathologic retrospective review showing that surgical margins of 1 cm (>8 mm in fixed tissue, pathological margins) were associated with lower local recurrences.
Reference: Heaps JM, Fu YS, Montz, FJ, et al. Surgical-pathologic variables predictive of local recurrence in squamous cell carcinoma of the vulva. Gynecological Oncology. 1990;38:309-314. |
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CA-125 is most commonly used in monitoring the response to treatment in which of the following gynecologic cancers?
A. Vulvar B. Vaginal C. Endometrial D. Ovarian |
Correct answer is D. RATIONALE: CA-125 (an abbreviation for cancer antigen-125) is a tumor marker or biomarker that is most commonly used in the monitoring of patients with ovarian cancer after treatment. It is less commonly used in patients with endometrial cancer.
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According to the GOG trial (Homesley), what is the 2-year survival rate for patients with positive inguinofemoral lymph nodes treated with radiation therapy to the pelvis and groin versus those treated with pelvic lymph node dissection?
Radiation Therapy Group Pelvic Lymph Node Dissection Group A. 54% 68% B. 68% 54% C. 73% 82% D. 82% 73% |
Correct answer is B. RATIONALE: This landmark trial (GOG 37 trial, Homesley) closed early because an interim analysis showed that the patients in the radiation therapy arm had a statistically significant advantage in 2-year overall survival. Thus, radiation therapy was established as the standard adjuvant therapy for positive groin lymph node disease.
Reference: Homesley HD, Bundy BN, Sedlis A, et al. Radiation therapy versus pelvic lymph node resection for carcinoma of the vulva with positive nodes. Gynecological Oncology. 1986;68:733. |
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Which of the following gynecologic cancers is most similar to fallopian tube carcinoma in terms of patterns of failure and treatment protocols?
A. Vulvar B. Vaginal C. Endometrial D. Ovarian |
Correct answer is D. RATIONALE: Fallopian tube cancer behaves most like ovarian cancer, particularly in terms of patterns of failure. In fact, ovarian and fallopian carcinomas are commonly grouped together in treatment protocols.
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According to the GOG 88 (Stehman) trial for vulvar cancer, which of the following outcomes is associated with patients who undergo definitive groin irradiation compared to groin dissection alone, each in conjunction with a radical vulvectomy?
A. Worse local control and worse survival rates B. Similar local control and similar survival rates C. Improved local control and improved survival rates D. Improved local control and similar survival rates |
Correct answer is A. RATIONALE: In the GOG 88 trial, the irradiated patients had a significantly worse local (inguinal) control and worse overall survival than patients treated with surgery alone. This trial has been criticized, however, due to the fact that the groin irradiation was prescribed only to 3 cm below the anterior skin surface significantly underdosing many women's inguinal lymph nodes.
Reference: Stehman, et al. International Journal of Radiation Oncology, Biology, Physics. 1992;24:380-96. |
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Which of the following tumor stages is associated with a patient who has vulvar cancer arising on the labia minora with involvement of the lower urethra?
A. T1 B. T2 C. T3 D. T4 |
Correct answer is C. RATIONALE: According to the AJCC Cancer Staging Manual, vulvar tumors involving the lower urethra and/or vagina and anus are classified as stage T3. Upper-urethral involvement is classified as stage T4.
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According to GOG 37 (Homesley), the 2-year survival rate of patients who have vulvar cancer with positive inguinal lymph nodes and undergo adjuvant pelvic-inguinal irradiation compared to pelvic lymphadenectomy alone is:
A. 44% versus 50%. B. 54% versus 68%. C. 68% versus 54%. D. 73% versus 72%. |
Correct answer is C. RATIONALE: In GOG 37, patients with vulvar cancer and positive groin lymph nodes after radical vulvectomy and bilateral groin dissection were randomized to pelvic-inguinal irradiation or pelvic lymphadenectomy. Patients undergoing irradiation had a significantly improved survival compared to patients undergoing surgery alone (2-year survival of 68% vs. 54%, p = 0.03).
Reference: Homesley, et al. Obstetrics Gynecology. 1986;68:733-40. |
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Where is vulvar carcinoma most commonly located?
A. Clitoris B. Mons pubis C. Vaginal vestibule D. Labia |
Correct answer is D. RATIONALE: Most vulvar cancers arise on the labia majora or minora. The second most common site is the clitoris. The mons pubis and vaginal vestibule are uncommon sites.
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What is the second most common histology associated with vulvar cancers?
A. Adenocarcinoma B. Adenosquamous carcinoma C. Squamous cell carcinoma D. Melanoma |
Correct answer is D. RATIONALE: The most common tumor histology for vulvar cancers is squamous cell (85%). The second most common histology is melanoma, comprising about 10% of all cases. Other histologies are significantly less common (<5%).
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