A 62-year-old woman presents to the clinic for postmenopausal bleeding for the past month. She reports that the bleeding often occurs after intercourse with her husband. The patient denies fever, weight loss, chills, chest pain, abdominal pain, or shortness of breath but endorses mild dyspareunia and vaginal discharge. Her past medical history is significant for human papilloma virus and cervical cancer that was treated with surgical resection and radiation 5 years ago. Physical examination is unremarkable except for an irregular mass protruding from the vaginal wall. What is the most likely explanation for this patient’s condition?

Metastasis of cervical cancer via direct extension

Primary malignancy of endometrial cells

Atrophy of vaginal tissues secondary to old age

Metastasis of cervical cancer via hematogenous spread

Primary malignancy of vaginal squamous cells

Patient 1 – A 26-year-old woman presents to her primary care physician for an annual exam. She currently does not have any acute concerns and says her health has been generally well. Medical history is significant for asthma, which is managed with an albuterol inhaler. Her last pap smear was unremarkable. She is currently sexually active with one male and consistently uses condoms. She occasionally smokes marijuana and drinks wine once per week. Her mother recently passed away from advanced ovarian cancer. Her sister is 37-years-old and was recently diagnosed with breast cancer and ovarian cancer. Physical examination is remarkable for a mildly anxious woman. Patient 2 – A 27-year-old woman presents to her primary care physician for an annual exam. She says that she would like to be screened for breast cancer since two of her close friends were recently diagnosed. She noticed she has a small and mobile mass on her left breast, which increases in size and becomes tender around her time of menses. Family history is remarkable for hypertension in the father. The physical exam is significant for a small, well-defined, and mobile mass on her left breast that is not tender to palpation. Which of the following is the best next step in management for patient 1 and 2?

Patient 1 – BRCA testing. Patient 2 – Breast ultrasound

Patient 1 – Breast ultrasound. Patient 2 – Return in 3 months for a clinical breast exam

Patient 1 – Reassurance. Patient 2 – Breast ultrasound

Patient 1 – CA-125 testing. Patient 2 – BRCA testing

Patient 1 – Breast and ovarian ultrasound. Patient 2 – Mammography

A 31-year-old female presents to her gynecologist for a routine Pap smear. Her last Pap smear was three years ago and was normal. On the current Pap smear, she is found to have atypical squamous cells of unknown significance (ASCUS). Reflex HPV testing is positive. What is the best next step?

Repeat Pap smear and HPV testing in 5 years

Loop electrosurgical excision procedure (LEEP)

A 47-year-old woman comes to the physician for a mass in her left breast she noticed 2 days ago during breast self-examination. She has hypothyroidism treated with levothyroxine. There is no family history of breast cancer. Examination shows large, moderately ptotic breasts. The mass in her left breast is small (approximately 1 cm x 0.5 cm), firm, mobile, and painless. It is located 4 cm from her nipple-areolar complex at the 7 o'clock position. There are no changes in the skin or nipple, and there is no palpable axillary adenopathy. No masses are palpable in her right breast. A urine pregnancy test is negative. Mammogram showed a soft tissue mass with poorly defined margins. Core needle biopsy confirms a low-grade infiltrating ductal carcinoma. The pathological specimen is positive for estrogen receptors and negative for progesterone and human epidermal growth factor receptor 2 (HER2) receptors. Staging shows no distant metastatic disease. Which of the following is the most appropriate next step in management?

Lumpectomy with sentinel lymph node biopsy, followed by radiation and hormone therapy

Lumpectomy with sentinel lymph node biopsy followed by hormone therapy

Nipple-sparing mastectomy with axillary lymph node dissection followed by hormone therapy

Nipple-sparing mastectomy with axillary lymph node dissection, followed by radiation and hormone therapy

Radical mastectomy followed by hormone therapy

A 13-year-old boy is brought to the emergency department by his mother because of vomiting and severe testicular pain for 3 hours. The boy has had 4–5 episodes of vomiting during this period. He has never had a similar episode in the past and takes no medications. His father died of testicular cancer at the age of 50. His immunizations are up-to-date. He appears anxious and uncomfortable. His temperature is 37°C (98.6°F), pulse is 90/min, respirations are 14/min, and blood pressure is 100/60 mm Hg. Cardiopulmonary examination shows no abnormalities The abdomen is soft and nondistended. The left scrotum is firm, erythematous, and swollen. There is severe tenderness on palpation of the scrotum that persists on elevation of the testes. Stroking the inner side of the left thigh fails to elicit elevation of the scrotum. Which of the following is the most appropriate next step in management?

Surgical exploration of the scrotum

Ceftriaxone and doxycycline therapy

CT scan of the abdomen and pelvis

A 27-year-old man is brought to the emergency department by ambulance following a motor vehicle accident 1 hour prior. He appears agitated. His blood pressure is 85/60 mm Hg, the pulse is 110/min, and the respiratory rate is 19/min. Physical examination shows bruising of the left flank and fracture of the left lower thoracic bones. Strict bed rest and monitoring with intravenous fluids is initiated. Urinalysis shows numerous RBCs. A contrast-enhanced CT scan shows normal enhancement of the right kidney. The left renal artery is only visible in the proximal section with a small amount of extravasated blood around the left kidney. The left kidney shows no enhancement. Imaging of the spleen shows no abnormalities. Which of the following is the most appropriate next step in management?

Observation with delayed repair

Renal artery embolization with delayed nephrectomy

A 67-year-old woman with endometrial cancer undergoes robotic-assisted staging surgery. Final pathology reveals grade 2 endometrioid adenocarcinoma with 60% myometrial invasion, positive pelvic lymph nodes (2/15), negative para-aortic nodes (0/8), and lymphovascular space invasion. No cervical or adnexal involvement. The tumor care team debates adjuvant treatment. Evaluate which combination of pathologic features most significantly impacts treatment recommendations?

Positive pelvic nodes and negative para-aortic nodes

Grade 2 histology and depth of myometrial invasion

Number of positive nodes and total nodes removed

Lymphovascular space invasion and myometrial invasion depth

Absence of cervical involvement and patient age

Gynecologic cancer staging procedures for USMLE Step 2 CK: High-Yield Surgery Lessons

🧭 The Cancer Compass

Purpose: Staging determines prognosis and dictates the therapeutic plan (surgery, chemotherapy, radiation).
Method: Most gynecologic cancers use the FIGO surgical staging system, based on findings at laparotomy or laparoscopy.
- Surgically Staged: Ovarian, Endometrial, Fallopian Tube, Vulvar, Vaginal.
Key Procedures: Total hysterectomy, bilateral salpingo-oophorectomy (BSO), lymphadenectomy, peritoneal washings, and biopsies.

⭐ Cervical cancer is the major exception, staged clinically (physical exam, biopsy, basic imaging). Surgical findings post-treatment do not alter the initial stage.

⚖️ Diagnosis - FIGO's Firm Rules

Staging for gynecologic malignancies primarily follows the FIGO system. The method-surgical versus clinical-is cancer-specific and dictates the diagnostic workup.

Surgically Staged (Pathology is King):
- Cancers: Endometrial, Ovarian, Fallopian Tube, Peritoneal.
- Procedure: Stage is determined by findings at surgical exploration (laparotomy/laparoscopy) and the final pathology report. Includes hysterectomy, oophorectomy, lymph node sampling, and peritoneal washings.
Clinically Staged (Exam is Key):
- Cancers: Vaginal, Vulvar.
- Procedure: Based on physical exam, biopsies, colposcopy, cystoscopy, proctoscopy, and imaging. The stage is set pre-treatment and is not altered by later surgical findings.

⭐ Cervical Cancer Shift: Traditionally clinical, the 2018 FIGO update for cervical cancer now incorporates findings from advanced imaging (MRI, PET/CT) and surgical pathology (if available) to assign the stage.

Endometrial Cancer Staging: Stages IA and IB

🔪 Gynecologic Cancer Staging Procedures

Goal: Comprehensive surgical exploration to pathologically define disease extent, which guides adjuvant therapy decisions. Essential for ovarian, endometrial, and fallopian tube cancers.
Staging Laparotomy/Laparoscopy: A systematic approach is critical for accuracy. The procedure is both diagnostic (staging) and often therapeutic (debulking/cytoreduction).

Key Components & Samples:
- Cytology: Peritoneal fluid/washings are the first step after entry.
- Biopsies: Multiple random and targeted biopsies of peritoneum, diaphragm, and any suspicious lesions.
- Resection: TAH-BSO, omentectomy (standard for ovarian), and lymph node dissection.

⭐ Crucial Exception: Cervical cancer is staged clinically (physical exam, imaging, limited biopsy). Surgical findings (e.g., positive nodes) inform treatment but do not upstage the official FIGO stage.

⚠️ Complications - Procedural Pitfalls

Intraoperative Risks:
- Hemorrhage
- Damage to adjacent structures: Ureter, bladder, bowel
- ⚠️ Tumor Spillage: Can iatrogenically upstage ovarian cancer (e.g., Stage IA → IC).
Postoperative & Long-Term:
- Lymphadenectomy-Specific:
  - Lymphedema (chronic, debilitating)
  - Lymphocele formation
  - Nerve injury (obturator, genitofemoral)
- Infection, VTE, vaginal cuff dehiscence.

⭐ Chronic lower extremity lymphedema is a major long-term morbidity of pelvic/para-aortic lymphadenectomy, significantly impacting quality of life.

Lymphedema: Normal vs. Obstructed Lymphatic Flow

⚡ Biggest Takeaways

Cervical cancer is uniquely staged clinically (physical exam, biopsy, colposcopy); advanced imaging (CT/PET) is for treatment planning, not official staging.

Ovarian and endometrial cancers are staged surgically, requiring comprehensive exploration.

Surgical staging includes total hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO), peritoneal washings, omentectomy, and lymph node sampling.

Sentinel lymph node (SLN) biopsy is an alternative for early-stage endometrial and vulvar cancers.

CA-125 monitors ovarian cancer response, but is not used for staging.

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Gynecologic cancer staging procedures