Vulvar and Vaginal Cancer — MCQs
What is the most common histological variety of uterine carcinoma?
Which of the following pre-malignant conditions of the vulva is characterized by well-defined erythematous lesions with a smooth, shiny appearance?
Which condition does NOT increase the risk of cervical cancer?
Sentinel lymph node biopsy is most useful for:
Which of the following statements about carcinoma of the vulva is correct?
Early age at first sexual intercourse is a risk factor for
A lady undergoes radical hysterectomy for suspected stage Ib cancer cervix. Histopathology reveals cancer extension to the lower part of the uterine body with positive surgical margins. What is the next step of management?
A 60-year-old woman is diagnosed with genital malignancy. On physical examination she is found to have the enlargement of superficial inguinal lymph nodes. The most likely organ involved is
Most common presentation of cervical cancer is -
Ball's operation is indicated for which of the following conditions?
Vulvar and Vaginal Cancer Indian Medical PG Practice Questions and MCQs
Question 1: What is the most common histological variety of uterine carcinoma?
- A. Mixed carcinoma
- B. Squamous cell carcinoma
- C. Serous carcinoma
- D. Adenocarcinoma (Correct Answer)
Explanation: ***Adenocarcinoma*** - **Endometrial adenocarcinoma** is by far the most common type of uterine carcinoma, accounting for about 80% of all cases [1]. - It arises from the **glandular epithelial cells** lining the endometrium and is typically associated with **estrogen exposure** [1]. *Squamous cell carcinoma* - **Squamous cell carcinoma** of the uterus is extremely rare and usually occurs in the cervix, not the uterine body. - While it can occur in the endometrium in specific circumstances (e.g., in association with pyometra), it is not the most common type. *Serous carcinoma* - **Uterine serous carcinoma** is a more aggressive, high-grade subtype that accounts for a smaller percentage (5-10%) of uterine cancers. - It is typically seen in older women and often presents at an advanced stage, but it is not the most common overall. *Mixed carcinoma* - **Mixed carcinoma** of the uterus contains elements of more than one histological type, typically adenocarcinoma and another more aggressive component. - These are uncommon and represent a smaller fraction of uterine cancers compared to pure adenocarcinoma. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1016-1018.
Question 2: Which of the following pre-malignant conditions of the vulva is characterized by well-defined erythematous lesions with a smooth, shiny appearance?
- A. Lichen sclerosus
- B. Leukoplakia
- C. Vulval intraepithelial neoplasia
- D. Paget's disease of the vulva (Correct Answer)
Explanation: ***Paget's disease of the vulva*** - This condition presents as **well-defined, erythematous lesions** with a **smooth, shiny appearance** due to the presence of intraepithelial adenocarcinoma cells. - The lesions may also be associated with **pruritus** and can sometimes have a white, macerated, or eczematous appearance. *Vulval intraepithelial neoplasia* - VIN typically presents as **single or multifocal lesions** that can be white, red, or pigmented but are often **raised and warty** rather than smooth and shiny. - The appearance is highly variable and can be subtle, sometimes only detected on colposcopy after application of acetic acid. *Lichen sclerosus* - This is a chronic inflammatory dermatosis causing **thin, white, parchment-like skin** with characteristic **cigarette paper wrinkling** and atrophy, not erythematous and smooth lesions. - It often leads to architectural distortion and severe pruritus, and is associated with an increased risk of vulvar squamous cell carcinoma. *Leukoplakia* - Leukoplakia is a clinical term referring to any **white patch or plaque** on the mucous membrane that cannot be scraped off. - It describes a **gross appearance** rather than a specific diagnosis, and can be seen in various conditions, including lichen sclerosus or VIN, but itself is not characterized by erythema or shininess.
Question 3: Which condition does NOT increase the risk of cervical cancer?
- A. Multiple sexual partners
- B. HPV infection
- C. Nulliparity (Correct Answer)
- D. Smoking
Explanation: ***Nulliparity*** - **Nulliparity** (never having given birth) is generally associated with a *reduced* risk of cervical cancer, or it has no significant impact. - Increased parity (multiple full-term pregnancies) is a risk factor, possibly due to hormonal changes or chronic inflammation. *Multiple sexual partners* - Having multiple sexual partners increases the risk of exposure to **Human Papillomavirus (HPV)**, the primary cause of cervical cancer. - Greater exposure to various HPV strains elevates the likelihood of persistent viral infection and subsequent cellular changes. *HPV infection* - **High-risk HPV strains** (e.g., HPV 16, 18) are the leading cause of cervical cancer, responsible for almost all cases. - Persistent infection with these oncogenic HPV types leads to progressive cervical dysplasia and, eventually, invasive cancer. *Smoking* - Smoking is an independent risk factor for cervical cancer, even after accounting for HPV infection. - Chemicals in tobacco smoke can reach the cervical mucus and damage DNA, impairing the immune system's ability to clear HPV infections.
Question 4: Sentinel lymph node biopsy is most useful for:
- A. Carcinoma vulva (Correct Answer)
- B. Carcinoma endometrium
- C. Carcinoma vagina
- D. Carcinoma cervix
Explanation: ***Carcinoma vulva*** - **Sentinel lymph node biopsy (SLNB)** is a standard procedure for early-stage vulvar carcinoma to assess nodal involvement with less morbidity than full inguinofemoral lymphadenectomy. - The procedure helps identify metastases in regional lymph nodes, guiding further treatment decisions while minimizing complications like **lymphedema**. *Carcinoma endometrium* - While SLNB can be used in endometrial cancer, its primary utility is in tailoring **lymphadenectomy** rather than being the "most useful" or universally preferred primary staging tool compared to vulvar cancer. - The anatomical spread often involves different lymphatic basins, and **comprehensive pelvic and para-aortic lymphadenectomy** or systematic nodal dissection remains a common approach, though SLNB is gaining traction. *Carcinoma vagina* - The lymphatic drainage of the vagina is complex and variable, making SLNB challenging and less standardized compared to vulvar cancer. - **Radical surgical excision** with **regional lymphadenectomy** remains the mainstay for staging and treatment of invasive vaginal carcinoma. *Carcinoma cervix* - For cervical cancer, SLNB is primarily used in **early-stage disease** to detect micrometastases and guide the extent of lymph node dissection. - However, **imaging** and comprehensive **pelvic lymphadenectomy** are often still crucial components for complete staging and treatment, depending on tumor characteristics.
Question 5: Which of the following statements about carcinoma of the vulva is correct?
- A. Commonly seen after menopause and associated with viral predisposition. (Correct Answer)
- B. Spreads to iliac nodes.
- C. Spreads to superficial inguinal nodes and is treated with radiotherapy.
- D. All of the options.
Explanation: ***Commonly seen after menopause and associated with viral predisposition.*** - **Vulvar carcinoma** is primarily a disease of **postmenopausal women**, with the average age at diagnosis being in the 60s. - A significant subset of vulvar squamous cell carcinomas (SCCs), particularly in younger women, is associated with **human papillomavirus (HPV) infection**, especially types 16 and 18. *Spreads to iliac nodes.* - The initial lymphatic spread of vulvar carcinoma is typically to the **superficial inguinal lymph nodes**, then to the deep inguinal nodes, and finally to the **femoral lymph nodes**. - Spread to the **iliac nodes** usually occurs at a later stage or in cases where the deep inguinal and femoral nodes are already involved. *Spreads to superficial inguinal nodes and is treated with radiotherapy.* - While vulvar carcinoma does primarily spread to the **superficial inguinal nodes**, **surgical excision** (radical vulvectomy and lymphadenectomy) is the primary treatment modality for invasive disease. - **Radiotherapy** is often used as adjuvant treatment for patients with positive surgical margins, advanced disease, or nodal involvement, but it is not the sole or primary treatment. *All of the options.* - This option is incorrect because the statement regarding iliac node spread as the initial pathway and radiotherapy as the primary treatment are not entirely accurate in all contexts of vulvar carcinoma management.
Question 6: Early age at first sexual intercourse is a risk factor for
- A. Carcinoma vagina
- B. Carcinoma ovary
- C. Carcinoma cervix (Correct Answer)
- D. Carcinoma vulva
Explanation: ***Carcinoma cervix*** - **Early age of sexual debut** is a significant risk factor for cervical cancer due to increased exposure time to **human papillomavirus (HPV)**, the primary cause. - The immature transformation zone of the cervix in younger individuals is more vulnerable to HPV infection and subsequent dysplastic changes. *Carcinoma vagina* - While HPV can cause vaginal cancer, the association with **early sexual debut** is less direct and less prominent compared to cervical cancer. - Risk factors often include a history of **cervical cancer** or **cervical intraepithelial neoplasia (CIN)**. *Carcinoma ovary* - Ovarian cancer is primarily linked to **genetic factors** (e.g., BRCA mutations), **nulliparity**, and **endometriosis**. - There is no established link between **age of sexual debut** and the risk of ovarian cancer. *Carcinoma vulva* - Vulvar cancer is also associated with **HPV infection**, but its primary risk factors often include **lichen sclerosus**, **chronic irritation**, and **immunodeficiency**. - The link to **early sexual debut** is less strong compared to cervical cancer, which is almost exclusively HPV-driven and highly sensitive to infection duration.
Question 7: A lady undergoes radical hysterectomy for suspected stage Ib cancer cervix. Histopathology reveals cancer extension to the lower part of the uterine body with positive surgical margins. What is the next step of management?
- A. Chemoradiation (Correct Answer)
- B. Chemotherapy
- C. Radiotherapy
- D. Follow-up
Explanation: ***Correct Option: Chemoradiation*** - **Positive surgical margins** after radical hysterectomy represent a **high-risk feature** requiring adjuvant concurrent chemoradiation. - According to **GOG 109 trial** and **NCCN/ESGO guidelines**, high-risk features (positive surgical margins, parametrial involvement, or positive pelvic lymph nodes) mandate **concurrent chemoradiation** (external beam radiotherapy + cisplatin-based chemotherapy). - **Cisplatin-based chemoradiation** improves local control and overall survival compared to radiotherapy alone in high-risk post-operative cervical cancer. - The combination provides both local control (radiation) and systemic treatment (chemotherapy) to address micrometastatic disease. *Incorrect Option: Radiotherapy* - Radiotherapy alone is used for **intermediate-risk features** (large tumor size >4 cm, deep stromal invasion, lymphovascular space invasion) without positive margins or nodal involvement. - In this case with **positive surgical margins**, radiotherapy alone is insufficient and would miss the survival benefit provided by concurrent chemotherapy. - The presence of positive margins elevates this to high-risk category requiring combined modality treatment. *Incorrect Option: Chemotherapy* - Chemotherapy alone (without radiation) is not standard adjuvant treatment after radical hysterectomy. - Systemic chemotherapy as a single modality is reserved for recurrent or metastatic disease. - The standard in high-risk post-operative cases is **concurrent** chemoradiation, not sequential therapy. *Incorrect Option: Follow-up* - Follow-up alone is contraindicated with **positive surgical margins**, which indicate residual microscopic disease. - Without adjuvant treatment, the risk of local recurrence and distant metastasis is unacceptably high. - Active intervention with chemoradiation is essential to improve disease-free and overall survival.
Question 8: A 60-year-old woman is diagnosed with genital malignancy. On physical examination she is found to have the enlargement of superficial inguinal lymph nodes. The most likely organ involved is
- A. Adnexa
- B. Vulva (Correct Answer)
- C. Cervix
- D. Uterus
Explanation: ***Vulva (Correct Answer)*** - The **vulva** drains primarily to the **superficial inguinal lymph nodes**, making its malignancy the most likely cause of their enlargement. - Unlike deeper pelvic organs, vulvar cancer metastases travel directly to these easily palpable nodes. - This is a key anatomical principle: **external genitalia → superficial inguinal nodes**. *Adnexa (Incorrect)* - Malignancies of the **adnexa** (ovaries, fallopian tubes) typically metastasize via the **para-aortic or pelvic lymph nodes**, not the superficial inguinal nodes. - These follow the ovarian vessels along the infundibulopelvic ligament. - Distant inguinal node involvement would indicate advanced disease, but initial spread is not to these nodes. *Cervix (Incorrect)* - Cervical cancer primarily metastasizes to the **pelvic lymph nodes** (e.g., obturator, internal iliac, external iliac), with superficial inguinal nodes rarely involved unless there is extensive local spread. - The lymphatic drainage of the cervix is distinct from that of the external genitalia. *Uterus (Incorrect)* - Uterine cancer (endometrial or uterine body) typically spreads to the **pelvic** and **para-aortic lymph nodes**, following the ovarian and uterine vessels. - Like cervical cancer, superficial inguinal lymph node involvement is uncommon and usually a sign of very advanced or unusual spread.
Question 9: Most common presentation of cervical cancer is -
- A. Abnormal vaginal bleeding (Correct Answer)
- B. Pelvic pain
- C. Pain during intercourse
- D. Unusual vaginal discharge
Explanation: ***Abnormal vaginal bleeding*** - **Abnormal vaginal bleeding** is the most frequent presenting symptom of cervical cancer, often manifesting as **postcoital bleeding**, intermenstrual bleeding, or heavier, longer menstrual periods. - This symptom arises as the tumor on the cervix ulcerates and bleeds due to its friable nature and rich vascularization. *Pelvic pain* - **Pelvic pain** is typically a symptom of more **advanced cervical cancer**, indicating tumor invasion into surrounding tissues or nerves. - It is not usually an early or the most common presenting symptom, unlike abnormal bleeding. *Pain during intercourse* - **Pain during intercourse (dyspareunia)** can be a symptom of cervical cancer, particularly with larger lesions or those causing inflammation. - However, it is less common than abnormal bleeding and often occurs concurrently with or after the onset of bleeding symptoms. *Unusual vaginal discharge* - An **unusual vaginal discharge**, which may be watery, foul-smelling, or blood-tinged, can occur with cervical cancer. - While a common symptom, it is generally considered less frequent than abnormal vaginal bleeding as the primary presenting complaint.
Question 10: Ball's operation is indicated for which of the following conditions?
- A. Cervical cancer (Ca. Cx)
- B. Ovarian cancer (Ca. Ovary)
- C. Fallopian tube cancer (Ca. Fallopian tube)
- D. Vulvar cancer (Ca. Vulva) (Correct Answer)
Explanation: ***Vulvar cancer (Ca. Vulva)*** - **Ball's operation** (radical vulvectomy) is a surgical procedure specifically designed for the treatment of **vulvar cancer**. - It involves the **wide excision of the vulva** along with lymphadenectomy to remove cancerous tissue and prevent spread. *Cervical cancer (Ca. Cx)* - Treatment for cervical cancer typically involves procedures like **cone biopsy**, **hysterectomy**, or **radical trachelectomy**, often combined with radiation and chemotherapy. - Ball's operation is not indicated for cervical cancer, as it targets the external genitalia. *Ovarian cancer (Ca. Ovary)* - Ovarian cancer is primarily managed through **surgical debulking**, which includes **hysterectomy**, **bilateral salpingo-oophorectomy**, and omentectomy. - This type of cancer requires intra-abdominal surgery, distinct from procedures for external genital cancers. *Fallopian tube cancer (Ca. Fallopian tube)* - Treatment for fallopian tube cancer also involves intra-abdominal surgery, typically **salpingectomy** (removal of the fallopian tube) and often **hysterectomy** and **oophorectomy**. - Ball's operation is not relevant for this internal gynecologic malignancy.
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