Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

CHAPTER 29
Preinvasive Lesions of the Lower Genital Tract

29–1. The location of the cervical squamocolumnar junction (SCJ) varies with age and hormonal status. The SCJ tends to move outward onto the ectocervix, as in the example below, with which of the following conditions?

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Reproduced, with permission, from Cunningham FG, Leveno KL, Bloom SL et al (eds): Williams Obstetrics, 23rd ed. New York, McGraw-Hill, 2010, Figure 5-1.

a. Menopause

b. Pregnancy

c. Prolonged lactation

d. Use of progestin-only contraceptives

29–2. All EXCEPT which of the following are true statements regarding the cervical transformation zone (TZ)?

a. Squamous metaplasia occurring within the TZ is abnormal.

b. Most cervical neoplasia arises within the TZ.

c. The TZ lies between the original squamous epithelium and columnar epithelium of the cervix.

d. The location and size of the TZ changes through the process of squamous metaplasia.

29–3L1 and L2, which are the two late genes of the human papillomavirus (HPV), encode proteins responsible for which of the following?

a. Capsid construction

b. Regulatory functions

c. DNA synthesis and replication

d. Conformational changes aiding entry into the host cell

29–4. More than 100 human papillomavirus (HPV) types have been identified to date. Clinically, HPV types are classified as high risk (HR) or low risk based upon their oncogenic potential. Which two HR HPV types together account for approximately 70 percent of cervical cancers worldwide?

a. 6 and 11

b. 11 and 45

c. 16 and 18

d. 18 and 31

29–5. Which of the following is the LEAST common outcome of cervical human papillomavirus (HPV) infection?

a. Condylomata

b. Latent infection

c. Subclinical infection

d. Neoplasia (dysplasia or cancer)

29–6. A 40-year-old woman has been in a mutually monogamous relationship for 25 years. She is upset that her recent Pap test result is low-grade squamous intraepithelial neoplasia (LSIL), consistent with human papillomavirus (HPV) changes. HPV infection is reliably diagnosed by which of the following clinical tests?

a. Cytology

b. Histology

c. Colposcopy

d. HPV DNA testing

29–7. Which of the following is true of the two prophylactic human papillomavirus (HPV) vaccines currently available?

a. They require one initial dose followed by a booster dose 2 years later.

b. Both use HPV type-specific virus-like particles to induce immunity.

c. They are theoretically protective against the HPV types that account for 90% of cervical cancers.

d. They are Food and Drug Administration (FDA) approved for the prevention of cervical, vulvar, and vaginal neoplasia.

29–8. What approximate percentage of women in the United States who undergo cervical cancer screening will have an abnormal cervical cytology result?

a. 1

b. 7

c. 11

d. 17

29–9. The natural history of cervical intraepithelial neoplasia (CIN) lesions is better known than in the past. Respectively, what percentages of CIN 1 lesions are expected to spontaneously regress and progress to invasive malignancy without treatment?

a. 60, 1

b. 50, 5

c. 40, 10

d. 20, 15

29–10. A 22-year-old woman with a low-grade squamous intraepithelial neoplasia (LSIL) Pap result is subsequently diagnosed with cervical intraepithelial neoplasia (CIN) 2 by colposcopy (as shown) and directed biopsy. Colposcopy is satisfactory, and the endocervical curettage is negative for dysplasia or cancer. She is given the option of undergoing treatment or observation. She should be counseled that CIN 2 may spontaneously regress without treatment. Approximately what percentage of CIN 2 shows spontaneous regression?

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a. 20

b. 40

c. 60

d. 80

29–11. A 42-year-old multipara has negative screening Pap test and positive human papillomavirus (HPV) DNA test results. These were repeated 1 year later with the same results. She is a long-time cigarette smoker and has had six lifetime sexual partners. She has not had a new sexual partner for 7 years. What is her strongest risk factor for cervical cancer?

a. Parity

b. Tobacco use

c. Persistent HPV infection

d. Multiple lifetime sexual partners

29–12. Cervical cytology screening is one of modern medicine’s success stories. Although the sensitivity of an individual Pap test is imperfect, organized screening programs have generally decreased the incidence of cervical cancer by what percentage?

a. 20 to 30

b. 40 to 50

c. 60 to 70

d. 80 to 90

29–13. Clinical studies have conclusively shown which of the following to be increased by liquid-based Pap tests compared with conventional (glass slide) Pap testing?

a. Cost

b. Sensitivity

c. Specificity

d. Cervical cancers prevented

29–14. Which of the following patients should be offered initiation of cervical cancer screening according to 2009 American College of Obstetricians and Gynecologists (ACOG) guidelines?

a. 19-year-old female who has never been sexually active

b. 17-year-old female with multiple sexual partners since age 14 years

c. 18-year-old female who has one lifetime partner and who has recently been diagnosed with human immunodeficiency virus (HIV) infection

d. 20-year-old primigravida who present for her first prenatal examination and who has been sexually active with her first partner for 1 year

29–15. Based on 2009 American College of Obstetricians and Gynecologists (ACOG) guidelines, at what interval should a 52-year-old woman undergo cervical cancer cytologic screening if she has an average risk for this cancer and if her three previous, consecutive Pap test results are negative?

a. Annually

b. Every 2 years

c. Every 3 years

d. Every 5 years

29–16. For which of the following women would discontinuation of cervical cancer screening be acceptable? All of their Pap tests to date have been negative and performed at intervals adherent to current screening guidelines.

a. 42-year-old woman with past hysterectomy for leiomyomas

b. 72-year-old woman in good health with one longstanding sexual partner

c. 55-year-old woman with metastatic breast cancer refusing further therapeutic cancer interventions

d. All of the above are reasonable candidates for discontinuation of cervical cancer screening.

29–17. Your patient is a healthy 38-year-old woman with a history of total hysterectomy 1 year ago for uterine leiomyomas and menorrhagia. She has no prior history of abnormal Pap test results or lower genital tract neoplasia. She smokes cigarettes and has a new sexual partner. Her physical examination is without abnormalities. Which of the following strategies for prevention of lower genital tract neoplasia is indicated?

a. Vaginal cytology every 3 years

b. Vaginal cytology and human papillomavirus (HPV) DNA testing every 3 years

c. Vaccination against high-risk HPV infection (types 16 and 18)

d. Discontinue screening for neoplasia with Pap tests or HPV DNA testing

29–18. Which of the following is an appropriate clinical use of human papillomavirus (HPV) DNA testing according to current evidence-based guidelines?

a. Determine eligibility for HPV vaccination in females aged 9 to 26 years

b. Cervical cancer screening of women aged 30 years and older in conjunction with cervical cytology

c. Reflex testing of atypical glandular cell Pap results to determine triage for further evaluation

d. Cervical testing for posttreatment surveillance 4 to 6 weeks after ablation or excision with negative margins

29–19. A 42-year-old patient with normal, cyclic menses is referred for colposcopy for an “AGC (atypical glandular cells), not otherwise specified” Pap result. Your evaluation of her should include which of the following?

a. Colposcopy

b. Human papillomavirus (HPV) DNA test

c. Endometrial biopsy

d. All of the above

29–20. Deferral of colposcopy should be considered for which of the following conditions?

a. Mucopurulent cervicitis

b. Anticoagulation for a mechanical heart valve

c. Unscheduled, intermenstrual bleeding on the day of examination

d. Last menstrual period began 20 days ago; negative urine pregnancy test; condoms for contraception

29–21. A 32-year-old presents for evaluation of an abnormal Pap test result. This is a colpophotograph of her cervix before and after application of 5-percent acetic acid. It does NOT demonstrate which of the following?

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a. Acetowhite change

b. Columnar epithelium

c. Squamous epithelium

d. Unsatisfactory colposcopy

29–22. Your patient is a 45-year-old with a Pap test result of high-grade squamous intraepithelial lesion (HSIL). Subsequent colposcopy is unsatisfactory due to incomplete visualization of the squamocolumnar junction. Cervical biopsy confirms a CIN 3 lesion; there is also histologic CIN 2 present in the endocervical curettage specimen. Which of the following is the most appropriate procedure for further diagnosis and / or treatment?

a. Cryosurgery

b. Hysterectomy

c. Loop excision

d. Laser ablation

29–23. A 27-year-old nulligravida is referred to you for evaluation of a Pap test result indicating low-grade squamous intraepithelial neoplasia (LSIL). Colposcopy is negative for lesions, but vaginal lesions (shown here) are observed in numerous locations along the vaginal walls after application of 5-percent acetic acid. A biopsy of a representative lesion shows features characteristic of human papillomavirus (HPV) infection and low-grade vaginal intraepithelial neoplasia (VaIN 1). The patient is asymptomatic. Which of the following is the best option for management of these vaginal lesions?

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a. Observation

b. Laser ablation

c. HPV vaccination

d. Intravaginal fluorouracil (5-FU) cream

29–24. A 48-year-old multiparous woman presents with a vulvar lesion and itching and burning. She estimates that it has been present and growing in size and number for the past 2 years. She has no medical problems but is a heavy cigarette smoker. She was treated for cervical intraepithelial neoplasia (CIN) 3 in the past. Her lesion (shown here) is most likely histologically to show which of the following?

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Photograph contributed by Dr. David Miller.

a. Paget disease

b. Condyloma acuminata

c. Squamous cell hyperplasia

d. Vulvar intraepithelial neoplasia (VIN) 3

29–25. Which of the following are risk factors for anal intraepithelial neoplasia, seen here with high-resolution anoscopy?

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Photography contributed by Naomi Jay, RN, NP, PhD. Reproduced, with permission, from Werner CL, Griffith WF: Preinvasive lesions of the lower genital tract. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 29-17.

a. Human immunodeficiency virus (HIV) infection

b. Tobacco smoking

c. Anal receptive intercourse

d. All of the above

Reference:

American College of Obstetricians and Gynecologists: Cervical cytology screening. Practice Bulletin No. 109, December 2009.

Chapter 29 ANSWER KEY

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