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

CHAPTER 33
Endometrial Cancer

33–1. What is a woman’s lifetime risk of developing uterine cancer in the United States?

a. 1in8

b. 1in20

c. 1in38

d. 1in77

33–2. Which of the following does not increase a woman’s risk of developing endometrial cancer?

a. Obesity

b. Smoking

c. Tamoxifen

d. Unopposed estrogen

33–3. What is the primary mechanism by which obesity increases the risk of endometrial cancer?

a. Androstenedione is aromatized by adipose tissue to estrone.

b. Androstenedione is aromatized by adipose tissue to estradiol.

c. Higher levels of insulin-like growth factor lead to anovulation, which results in unopposed estrogen.

d. None of the above

33–4. What is the most common genetic syndrome associated with endometrial cancer?

a. Li-Fraumeni syndrome

b. Hereditary nonpolyposis colorectal cancer (HNPCC)

c. Hereditary breast ovarian cancer syndrome (BRCA1/BRCA2)

d. Cowden syndrome (phosphatase and tensin homolog [PTEN] mutation)

33–5. A 60-year-old woman has abnormal uterine bleeding. A transvaginal ultrasound reveals a 15-mm endome-trial stripe and an 8-cm solid right adnexal mass. An office endometrial biopsy shows grade 1 endometrioid adenocarcinoma of the uterus. What is the most likely diagnosis?

a. Endometrial cancer metastatic to the ovary

b. Synchronous ovarian and endometrial cancer

c. Pedunculated leiomyoma and endometrial cancer

d. Ovarian granulosa cell tumor and endometrial cancer

33–6. Which of the following is appropriate treatment of a 35-year-old woman with the diagnosis of complex hyperplasia without atypia?

a. Medroxyprogesterone acetate

b. Combination oral contraceptive pills

c. Levonorgestrel-releasing intrauterine system (IUD)

d. All of the above

33–7. What is the clinical success rate (percent) of the treatment of simple and complex hyperplasia without atypia with progestins?

a. 50

b. 75

c. 90

d. 100

33–8. A 30-year-old nulligravida has a body mass index (BMI) of 35 kg/m2 and desires fertility. An endome-trial biopsy performed for abnormal bleeding reveals complex atypical hyperplasia. What is the most appropriate next step?

a. Magnetic resonance (MR) imaging

b. Dilatation and curettage (D&C)

c. Medroxyprogesterone acetate 10mg orally daily × 10 days monthly

d. Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy

33–9. What is the underlying risk of endometrial cancer (percent) in a woman diagnosed with complex atypical hyperplasia by endometrial biopsy?

a. 29

b. 43

c. 52

d. 61

33–10. Which of the following is the most appropriate surgical approach to a 51-year-old woman with a BMI of 35 kg/m2 and a preoperative diagnosis of complex atypical hyperplasia?

a. Transvaginal hysterectomy, bilateral salpingo-oophorectomy

b. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washings

c. Total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, intraoperative frozen section

d. None of the above

33–11. Which of the following women should undergo annual endometrial biopsy?

a. 36-year-old woman with hereditary nonpolyposis colorectal cancer (HNPCC)

b. 45-year-old woman on tamoxifen for a personal history of breast cancer

c. 40-year-old woman with a BMI of 40 kg/m2, and a family history of colon cancer in her father at age 60, and uterine cancer in her paternal aunt at age 55

d. All of the above

33–12. Which patient below should be referred to genetics for possible hereditary nonpolyposis colon cancer (HNPCC)?

a. 35-year-old with endometrial cancer, and family history of breast cancer in her sister, age 52, and colon cancer in her maternal grandmother at age 60

b. 39-year-old with endometrial cancer, and family history of endometrial cancer in her mother at age 50 and colon cancer in her maternal grandmother at age 55

c. 35-year-old with complex atypical hyperplasia, and family history of colon cancer in her maternal grandmother at age 48 and small bowel cancer in her maternal grandfather at age 70

d. 39-year-old with endometrial cancer, and family history of colon cancer in her maternal grandfather at age 65 and endometrial cancer in her paternal grandmother at age 58

33–13. The histology shown below demonstrates less than 5% solid growth with severe nuclear atypia. What grade endometrioid adenocarcinoma of the uterus does this patient have?

Image

Photograph contributed by Dr. Kelley Carrick.

a. Grade 1

b. Grade 2

c. Grade 3

d. This is not endometrioid adenocarcinoma, but rather papillary serous carcinoma of the uterus

33–14. Which of the following subtypes is NOT a type II endometrial cancer?

a. Clear cell carcinoma

b. Papillary serous carcinoma

c. Endometrioid adenocarcinoma

d. None of the above

33–15. Which of the following is true regarding the type of uterine cancer shown in the photomicrograph below?

Image

Reproduced, with permission, from Miller DS, Schorge JO: Endometrial cancer. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 33-6C.

a. It is the most common cell type of uterine cancer.

b. It is the least common cell type of uterine cancer.

c. Most patients with this cell type are cured with surgery alone.

d. This is an aggressive type II uterine cancer, managed by a combination of surgery and chemotherapy, with or without radiation therapy.

33–16. What is the most common way endometrioid adeno-carcinoma of the uterus spreads?

a. Lymphatic

b. Hematogenous

c. Intraperitoneal

d. Direct extension

33–17. A 60-year-old woman undergoes a robotic assisted hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic and paraaortic lymph node dissection. Her pathology reveals a grade 2 endometrioid adenocarcinoma with greater than 50% myometrial invasion, lymphovascular space invasion (LVSI), and positive washings. All the other pathology is benign. What stage is she assigned according 2009 International Federation of Gynecology and Obstetrics (FIGO) criteria?

a. Stage IB

b. Stage IC

c. Stage IIIA

d. Stage IIIC

33–18. A 52-year-old woman undergoes a robotic hysterectomy and bilateral salpingo-oophorectomy for grade 1 endometrioid adenocarcinoma of the uterus. The uterus is opened (shown below). On frozen section, there is no myometrial invasion and no lymphovascular space invasion (LVSI). Which of the following is FALSE?

Image

Reproduced, with permission, from Miller DS, Schorge JO: Endometrial cancer. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 33-13.

a. There is an approximately 20% chance that the frozen section is inaccurate.

b. Many experts recommend a complete pelvic and paraaortic lymphadenectomy in this patient, although this is controversial.

c. If the final pathology concurs with the frozen section, she will need postoperative radiation if a lymph node dissection is not done.

d. None of the above

33–19. For the endometrial cancer shown here, which International Federation of Gynecology and Obstetrics (FIGO) 2009 stage is represented?

Image

Reproduced, with permission, from Miller DS, Schorge JO: Endometrial cancer. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 33-12.

a. IIIA

b. IIIB

c. IIIC1

d. IIIC2

33–20. Which of the following is NOT an advantage of laparoscopy compared with laparotomy for the surgical management of uterine cancer?

a. Shorter hospital stay

b. Improved quality of life

c. Lower rate of intraoperative injuries

d. Fewer moderate to severe complications

33–21. Which of the following women needs continued Pap smears after a hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic and paraaortic lymph node dissection for a stage IB grade 1 endometrioid adenocarcinoma of the uterus?

a. A 50-year-old woman with no history of abnormal Pap smears

b. A 50-year-old woman with a history of CIN 2 in the past 3 years, whose most recent Pap smear was normal

c. A 50-year-old woman with a remote history of cervical intraepithelial neoplasia (CIN) 2 treated with a loop electrosurgical excision procedure (LEEP) and no abnormal Pap smears in the last 10 years

d. All of the above

33–22. A 60-year-old woman is diagnosed with a grade 1 endometrioid adenocarcinoma of the uterus by office endometrial biopsy. She has a BMI of 45 kg/m2, uncontrolled type 2 diabetes mellitus, and a myocardial infarction within the past 3 months. She has undergone placement of two drug-eluting stents in her coronary arteries and takes clopidogrel (Plavix). What is the most appropriate management?

a. Tamoxifen

b. Progesterone

c. Vaginal hysterectomy

d. Robotic hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and paraaortic lymph node dissection, pelvic washings

33–23. A 65-year-old otherwise healthy woman has an episode of postmenopausal bleeding. You perform an endometrial biopsy, which reveals papillary serous carcinoma. At exploration, she has carcinomatosis and an omental cake (shown here). What is the most appropriate management of this patient?

Image

Photograph contributed by Dr. David Miller.

a. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, adjuvant chemotherapy

b. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, omental biopsy, adjuvant chemotherapy

c. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, maximal effort at tumor debulking, adjuvant chemotherapy

d. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, maximal effort at tumor debulking, adjuvant hormonal therapy

33–24. A 34-year-old nulligravida with polycystic ovarian syndrome (PCOS) who desires fertility has undergone a hysteroscopy, dilatation and curettage (D&C), and placement of a levonorgestrel-releasing intrauterine system (IUD) for grade 1 endometrioid adenocarcinoma of the uterus. Findings at the time of surgery are depicted below. How should she be followed?

Image

Photograph contributed by Dr. Mayra Thompson.

a. Remove IUD in 3 months and perform an office biopsy

b. Repeat endometrial biopsy in 3 months with IUD in place

c. Remove IUD in 3 months and perform a hysteroscopy, D&C

d. None of the above

33–25. What is the most important prognostic factor for a woman with endometrioid adenocarcinoma of the uterus?

a. Age

b. Grade

c. Stage

d. Positive peritoneal washings

Chapter 33 ANSWER KEY

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