Gynecologic Oncology

Match each clinical vignette describing a characteristic gynecologic neoplasm with the serum tumor marker most likely to be elevated in that patient.

A 57-year-old woman is evaluated in the clinic for three weeks of intermittent vaginal spotting. She experienced menopause seven years ago and had no vaginal bleeding until this recent episode. She denies abdominal pain, weight loss, or changes in bowel and bladder habits. Her past medical history is significant only for hypertension, which is well controlled with amlodipine. Her body mass index is 24 kg/m². Vital signs are within normal limits. On pelvic examination, the vulva and vagina appear atrophic. The cervix has no visible lesions, but blood is noted at the external os. Bimanual examination reveals a firm, mobile, non-tender, 8-cm mass in the right adnexa. A transvaginal ultrasound demonstrates an 8.5-cm right ovarian mass with both solid and cystic components. The endometrial stripe thickness is measured at 13 mm. Which of the following is the most appropriate next step in the management of this patient?

Evaluated in the emergency department for severe nausea, vomiting, and vaginal bleeding, a 22-year-old primigravida reports her last menstrual period occurred $10$ weeks ago. Her blood pressure is $155/95$ mm Hg, and her pulse is $110$/min. Physical examination reveals a uterus that is palpable midway between the pubic symphysis and the umbilicus. Fetal heart tones cannot be auscultated by Doppler. Quantitative serum $\beta$-hCG is $250,000$ mIU/mL. Pelvic ultrasonography demonstrates a heterogeneous, echogenic intrauterine mass containing multiple small cystic spaces, with no fetal pole identified. Which of the following is the most appropriate next step in the management of this patient?

Review the clinical scenarios detailing specific presentations and histopathologic findings of various gynecologic neoplasms. Match each patient vignette with the most appropriate primary serum tumor marker used for disease surveillance.

A 34-year-old nulliparous woman is evaluated in the clinic after a routine Papanicolaou (Pap) smear demonstrates a high-grade squamous intraepithelial lesion (HSIL). She has no significant past medical history, and her previous Pap smears were normal. She wishes to preserve her fertility. Arrange the following clinical steps in the most appropriate chronological sequence for the diagnosis, definitive management, and surveillance of this patient according to standard clinical guidelines.

A $63$-year-old G2P2 woman presents to the clinic reporting vaginal dryness, dyspareunia, and two episodes of light vaginal spotting over the last month. She attained menopause at age $51$. Medical history is significant for hypertension and osteoarthritis. Vital signs are within normal limits. Pelvic examination reveals thin, pale, and friable vaginal mucosa with diminished rugae. No cervical or vulvar lesions are visualized. Bimanual examination reveals a small, mobile uterus and no adnexal masses. A transvaginal ultrasound performed in the office shows a homogeneous endometrial stripe with a thickness of $7\text{ mm}$ and normal bilateral ovaries. Which of the following is the most appropriate next step in the management of this patient?

A 58-year-old female presents to the clinic to discuss the results of recent imaging. Two weeks prior, she reported a single episode of blood-tinged vaginal discharge. She underwent menopause at age 50 and takes no medications. A transvaginal ultrasound was subsequently ordered, which demonstrates an endometrial stripe thickness of $9$ mm. Today, her vital signs are within normal limits. Speculum examination reveals a normal-appearing cervix with no active bleeding. Which of the following is the most appropriate next step in the management of this patient?

A 59-year-old postmenopausal woman with a family history of breast cancer and a recently confirmed BRCA1 pathogenic variant presents to her physician with early satiety, bloating, and increasing abdominal girth for the past month. Physical examination reveals a palpable, fixed, irregular left adnexal mass and a clinically detectable fluid wave indicating ascites. Arrange the following steps in the most appropriate chronological order for the diagnostic workup and standard management of this patient, from initial evaluation to post-remission therapy.

During a health maintenance visit, a $54$-year-old woman (G2P2) returns to the clinic to discuss the results of her recent cervical cancer screening. Two weeks prior, she underwent a routine Pap test and reported a self-resolving episode of brownish vaginal spotting. She reached menopause at age $50$ and does not take hormone replacement therapy. Her past medical history is notable for obesity with a body mass index of $32$ and well-controlled hypertension. The cytology report indicates atypical glandular cells (AGC), and high-risk human papillomavirus (HPV) co-testing is negative. Pelvic examination demonstrates a parous, normal-appearing cervix without visible lesions, and bimanual examination reveals a mobile, non-tender uterus of normal size. Which of the following is the most appropriate next step in the diagnostic workup for this patient?

Match each patient's clinical presentation with the characteristic histopathological finding expected on biopsy or surgical excision of their adnexal mass.

Review the following patient vignettes detailing specific clinical histories and gynecologic neoplasms. Pair each patient presentation with its most likely underlying germline genetic abnormality.

A 68-year-old woman is evaluated in the clinic for a follow-up appointment. Three days ago, she presented to the emergency department with acute left lower quadrant abdominal pain and was diagnosed with uncomplicated diverticulitis based on a computed tomography (CT) scan of the abdomen and pelvis. She was prescribed a course of oral antibiotics, and her abdominal pain is now significantly improving. The CT scan report, however, also noted an incidental finding of an enlarged uterus with a $15\text{ mm}$ thickened endometrial stripe. During the current visit, the patient admits to having experienced two episodes of light vaginal spotting over the past month, which she had initially dismissed. She reached menopause at age 52 and has never used hormone replacement therapy. Her body mass index is $24\text{ kg/m}^2$. Abdominal examination shows resolving mild left lower quadrant tenderness. Pelvic examination reveals a normal-appearing cervix, pale and thinned vaginal mucosa, and no palpable adnexal masses. Which of the following is the most appropriate next step in the management of this patient's gynecologic findings?

A physician is evaluating a menopausal patient who reports a recent onset of unprovoked vaginal spotting. The patient's last menstrual cycle occurred $4$ years ago. Her past medical history is significant for a localized, hormone-receptor-positive invasive ductal carcinoma of the breast, which was treated with a lumpectomy and radiation therapy $3$ years ago. Since completing radiation, she has been maintained on daily tamoxifen therapy. She denies pelvic pain, dyspareunia, and weight loss. Vital signs are within normal limits. On speculum examination, the vaginal mucosa appears pale and thin, and the cervix is grossly normal without visible lesions. A trace amount of dark blood is noted in the vaginal vault. Transvaginal ultrasonography demonstrates a symmetrically thickened endometrial stripe measuring $8$ mm, with scattered subendometrial cystic spaces. Which of the following is the most appropriate next step in the management of this patient?

During a routine wellness check, a patient reports noticing small amounts of dark blood on her toilet tissue over the past week. Review of her medical record confirms she is nulliparous, has a body mass index of $34 \text{ kg/m}^2$, and experienced her final menstrual period eight years ago. A pelvic examination reveals a small amount of blood in the vaginal vault with a visually normal cervix and no vaginal lacerations. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old woman presents to the clinic reporting recurrent, light vaginal bleeding for the past 4 months. Three months ago, she was evaluated at an outside facility for the initial onset of this symptom. At that time, a transvaginal ultrasound was performed, demonstrating a homogeneous endometrial stripe of 2.6 mm and normal-appearing ovaries. A Pap test was negative for intraepithelial lesion or malignancy. She was diagnosed with genitourinary syndrome of menopause and prescribed vaginal estrogen therapy. The patient has been using the estrogen cream twice weekly as directed, but reports that the intermittent spotting has persisted. She takes no other medications and has no history of abnormal Pap smears. Vital signs are within normal limits. Pelvic examination reveals a well-rugated, moist vaginal mucosa. The cervix appears nulliparous and grossly normal, with a small amount of dark blood noted at the external os. The uterus is small, mobile, and non-tender, with no palpable adnexal masses. Which of the following is the most appropriate next step in management?

During a routine health maintenance visit, a 54-year-old G2P2 patient reports experiencing two days of light vaginal spotting the previous week. She underwent natural menopause at age 51. Her past medical history is significant for estrogen receptor-positive, node-negative breast cancer, for which she was treated with a lumpectomy and radiation therapy three years ago. Since completing her primary surgical and radiation treatment, she has been maintained on tamoxifen. Her body mass index is 26 kg/m^2. Vital signs are within normal limits. Pelvic examination demonstrates normal external genitalia, a small and mobile uterus, and no palpable adnexal masses. Speculum examination shows a small amount of dark red blood in the vaginal vault, but no active bleeding or visible cervical lesions. Which of the following is the most appropriate next step in management?

A 64-year-old female presents to the gynecology clinic evaluating intermittent vaginal bleeding that has been ongoing for the past two months. She notes that the bleeding is particularly noticeable after intercourse. She reached menopause at age 52 and takes no medications. Her last gynecologic examination and cervical cancer screening were over two decades ago. Vital signs are within normal limits. Speculum examination reveals a 3.5-cm friable, ulcerated mass on the anterior lip of the cervix that bleeds on contact. Bimanual examination demonstrates a normal-sized, mobile uterus with no adnexal masses. A transvaginal ultrasound shows an endometrial stripe of 2.5 mm. Which of the following is the most appropriate next step in the management of this patient?

An oncologist refers a 58-year-old patient to the gynecology clinic after she reports a recent episode of dark red vaginal spotting. She underwent breast-conserving surgery and radiation for early-stage hormone receptor-positive breast cancer three years ago. Since her surgery, she has been maintained on adjuvant tamoxifen therapy. The patient's last menstrual period occurred naturally at age 52. She denies pelvic pain, dysuria, or systemic symptoms. Her body mass index is $26 \text{ kg/m}^2$. Speculum examination demonstrates pale, thinned vaginal walls with a small amount of blood in the vaginal vault. The cervix appears grossly normal without lesions. Which of the following is the most appropriate next step in management?

Arrange the following clinical events in the correct chronological sequence for the standard screening, diagnosis, and definitive management of a 34-year-old patient who is found to have high-grade cervical dysplasia.

A 62-year-old woman comes to the clinic reporting intermittent vaginal spotting for the past month. She went through menopause at age 50. Her medical history is notable for estrogen receptor-positive breast cancer diagnosed three years ago, which was treated with lumpectomy, radiation therapy, and ongoing tamoxifen therapy. Vital signs are within normal limits. Pelvic examination demonstrates a normal-appearing vulva, thin vaginal mucosa, and a small amount of dark red blood in the vaginal vault. The cervix has no visible lesions. A transvaginal ultrasound reveals a heterogeneous endometrial stripe of 14 mm. Which of the following is the most appropriate next step in management?