USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 611:

  A 48-year-old woman had a biopsy of a friable, bleeding lesion on her cervix. She had not had a pelvic examination or Pap smear for about 12 years. The biopsy is reported as invasive squamous cell carcinoma of the cervix. On bimanual examination, there is induration to the side wall of her pelvis.

  Which of the following is the most important prognostic factor for 5-year survival after appropriate treatment of cervical cancer?

  A. presence of high-risk strains of human papilloma virus (HPV)

  B. stage of the cancer

  C. age of the patient

  D. histologic grade of the tumor E. presence of positive regional (pelvic) lymph nodes

  Correct Answer: B

  Stage of the cancer is the most important prognostic factor. Women with stage IA cervical cancer have a 95% 5-year survival. This decreases progressively to 80, 64, 38, and 14% for stages IB, II, III, and IV, respectively. The other choices are prognostic factors but relate to the stage of the cancer. Women with high-risk serotypes (strains) of HPV tend to develop cervical neoplasia at a younger age. More advanced stages of cervical cancer tend to have less differentiated tumors and a greater probability of pelvic and paraaortic lymph node metastasis. Pelvic lymph node metastasis will be found in 5% or fewer of women with stage I cervical cancer, with a progressive increase as the stage advances to 55% of women with stage IV cervical cancer

• Question 612:

  A 48-year-old woman had a biopsy of a friable, bleeding lesion on her cervix. She had not had a pelvic examination or Pap smear for about 12 years. The biopsy is reported as invasive squamous cell carcinoma of the cervix. On bimanual examination, there is induration to the side wall of her pelvis.

  To complete the staging of her cancer according o International Federation of Gynecology and Obstetrics (FIGO) standards, she should have hich of the following?

  A. lymphangiogram

  B. pelvic venogram

  C. cystoscopy

  D. magnetic resonance imaging (MRI) scan f her abdomen

  E. laparoscopy

  Correct Answer: C

  The intent of staging is to judge the results of various treatments and to compare treatment results worldwide. Because advanced procedures such as venography, lymphangiography, MRI or CT scans, and laparoscopy are not universally available, staging of cervical cancer remains primarily clinical. Such tests as cystoscopy, proctosigmoidoscopy, barium enema, IVP, and plain radiographs of the abdomen and chest are permitted. Evidence of mucosal cancer confirmed by biopsy at the time of cystoscopy changes her diagnosis to stage IV cervical cancer.

• Question 613:

  A 48-year-old woman had a biopsy of a friable, bleeding lesion on her cervix. She had not had a pelvic examination or Pap smear for about 12 years. The biopsy is reported as invasive squamous cell carcinoma of the cervix. On bimanual examination, there is induration to the side wall of her pelvis.

  Which of the following is the stage of her cervical cancer?

  A. IA

  B. IB

  C. IIB

  D. IIIB

  E. IV

  Correct Answer: D

  Cancer of the cervix that has not invaded cervical stroma is stage 0 carcinoma in situ. Cancer that has invaded the cervical stroma but has not spread beyond the cervix is stage I. Involvement of the upper vagina or parametria (but not to the pelvic sidewall) is stage II. Stage III is involvement of the lower third of the vagina (IIIA) or parametria to the pelvic sidewall (IIIB). Extension outside the reproductive tract is stage

  IV.

• Question 614:

  A63-year-old woman has a 3-cm pruritic lesion on her right labia majora that she has noted for approximately 9 months. She has been treated with various topical creams and ointments for vulvar candidiasis without resolution of her symptoms or lesion. When you examine this woman, the lesion is still present. Which of the following is the most appropriate intervention?

  A. Papanicolaou (Pap) smear of the lesion

  B. colposcopy of the lesion

  C. biopsy of the lesion

  D. wide local excision of the lesion

  E. vulvectomy

  Correct Answer: C

  Vulvar carcinoma must be considered in any postmenopausal woman with pruritus, especially in the presence of a visible lesion. The appropriate management is to biopsy the lesion after disinfecting the area and infiltrating with 1% Xylocaine. A34 mm dermal punch is useful to obtain the biopsy. Colposcopy alone is less reliable for vulvar lesions compared to cervical abnormalities because the technique requires the topical application of 35% acetic acid, which penetrates a keratinized squamous epithelium (the vulva) less than a nonkeratinized squamous epithelium (the cervix). Multiple biopsies should be obtained for a large, confluent lesion or a multifocal vulvar lesion. Wide local excision may be appropriate for small lesions, but is more difficult in an outpatient setting. Vulvectomy is reserved for women with biopsy-proven vulvar carcinoma.

• Question 615:

  A23-year-old woman develops painful vulvar vesicles that contain intranuclear inclusions on cytologic examination. She is 22 weeks' pregnant. Which of the following statements about genital herpes is correct?

  A. Acyclovir should be prescribed from 36 gestational weeks until after delivery in women with primary herpes anytime during pregnancy.

  B. Herpes cultures from the cervix should be obtained weekly beginning at 36 weeks' gestation.

  C. An active genital herpetic lesion any time after 20 weeks' gestation requires a cesarean section.

  D. Intrauterine infection with herpes is common after 20 weeks in women with primary herpes.

  E. Pitocin induction of labor should be started within 4 hours after ruptured amniotic membranes in a woman at term with active genital herpes.

  Correct Answer: A

  Acyclovir prescribed from 36 gestational weeks until after delivery reduces the probability of a cesarean section, although in one study of a small number of patients there were no cases of neonatal herpes in either the treatment or control group. Nonetheless, acyclovir (a class C drug) and newer antiviral drugs (valacyclovir, famciclovir, both class B) should be given to women with either a primary outbreak or a recurrence during pregnancy. Weekly cultures are unreliable to exclude active herpes lesions in pregnancy and are not recommended for basing a decision to perform a cesarean section. A cesarean section should be performed if a woman develops an active cervical or vaginal lesion at term. However, genital herpetic lesions before 36 weeks do not necessitate a cesarean section, because there is no evidence that vertical transmission to the fetus is increased until the pregnancy is within 24 weeks of delivery. Intrauterine infections via transplacental or transmembrane transmission of the herpesvirus are rare. Most infections of the infant occur after passage through an infected birth canal. A cesarean section should be performed at term if the amniotic membranes rupture in a woman with an active herpetic lesion in the genital area, regardless of the duration of membrane rupture.

• Question 616:

  After an appropriate diagnostic evaluation, a 59-year-old woman with postmenopausal bleeding had a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). The pathologic diagnosis is adenocarcinoma of the endometrium. An endometrial adenocarcinoma that is confined to the uterus and extends more than 50% through the myometrium is at which stage?

  A. IC

  B. IIA

  C. IIB

  D. IIIA

  E. IVA

  Correct Answer: A

  In general, gynecologic cancers confined to the organ of origin are stage I. Thus, this patient has a stage I cancer. In 1988, FIGO revised the staging of endometrial cancer from a clinical staging to surgical staging. Cancer limited to the endometrium is stage IA. Myometrial invasion less than 50% is stage IB, and myometrial invasion more than 50%, but not involving the serosa, is stage IC.

• Question 617:

  A 39-year-old woman at 16 weeks' gestation complains of headaches, blurred vision, and epigastric pain.

  Her blood pressure is now 56/104 mmHg. Her uterine fundus is palpable 2 cm above her symphysis pubis.

  Fetal heart tones could not be heard with a handheld Doppler. She has 3+ proteinuria.

  Which of the following is the most likely diagnosis?

  A. anencephaly

  B. twin gestation

  C. maternal renal disease

  D. hydatidiform mole

  E. gestational diabetes mellitus

  Correct Answer: D

  The onset of preeclampsia before the 20th week of pregnancy is clinically seen only with a hydatidiform mole. Advanced maternal age, uterine size greater than gestational weeks, and the absence of a fetal heartbeat are added features to suggest gestational trophoblastic disease. Hydramnios, which can be associated with anencephaly and other fetal developmental abnormalities, also predisposes to preeclampsia, but its onset does not occur before 24 weeks. Renal disease, diabetes mellitus, and chronic hypertension also increase the likelihood of preeclampsia, but not before 24 weeks of pregnancy. The incidence of preeclampsia is increased in twin gestation, but again, its onset is not before 24 weeks

• Question 618:

  The mother of a 3-year-old girl brings her daughter to see you because the girl developed breasts 6 months ago. The girl has had no vaginal bleeding, and there is no pubic hair. She takes no medication

  Which of the following is the most appropriate management of this girl?

  A. pituitary suppression with a gonadotropin-releasing hormone (GnRH) agonist

  B. laparoscopy

  C. assurance that the condition is benign and self-limiting

  D. corticosteroid suppression of adrenal function

  E. breast biopsy

  Correct Answer: C

  Premature thelarche is a benign, self-limited disorder that does not progress. Breast development may actually regress, though the regression may not be complete. The girl and her parents should be assured that the events of puberty will be normal at a normal age. Examination of the girl should be repeated at 3to 6-month intervals for about 1 year to be certain that additional pubertal events do not occur (such as growth of pubic hair, accelerated linear growth, and vaginal bleeding). Because pituitary and adrenal functions are normal for a prepubertal girl, therapy with a GnRH agonist (Lupron, Synarel, and so forth) or a corticosteroid is ineffective and inappropriate. Although breast cancer is a rare possibility in prepubertal girls, the presence of bilateral breast buds effectively excludes this diagnosis. A breast biopsy may destroy breast analge, and these girls will not have breast development at puberty.

• Question 619:

  The mother of a 3-year-old girl brings her daughter to see you because the girl developed breasts 6 months ago. The girl has had no vaginal bleeding, and there is no pubic hair. She takes no medication

  The tests you ordered are normal for a prepubertal girl. Which of the following is the most likely diagnosis?

  A. ingestion of the mother's OC pills

  B. a granulosa cell tumor

  C. 21-hydroxylase deficiency

  D. polycystic ovary syndrome

  E. premature thelarche

  Correct Answer: E

  Premature thelarche is a disorder that probably occurs as a consequence of increased sensitivity of breast tissue to the low levels of circulating estradiol in prepubertal girls. The disorder occurs most commonly before the age of 3 years. The estradiol concentration may be normal in young girls ingesting estrogen if the serum estrogen concentration is not obtained at the time the estrogen is ingested. A negative medication history is helpful to exclude this possibility. The absence of a palpable lower abdominal mass and a prepubertal concentration of estradiol exclude a granulosa cell tumor. Adrenal 21-hydroxylase deficiency and polycystic ovary syndrome are function disorders that require the stimulation of adrenocorticotropic hormone (ACTH) and pituitary gonadotropins (FSH and LH), respectively, to become clinically apparent. Neither disorder appears until after the onset of puberty. Moreover, both are associated with androgen excess and masculinization, not estrogen excess and precocious breast development.

• Question 620:

  The mother of a 3-year-old girl brings her daughter to see you because the girl developed breasts 6 months ago. The girl has had no vaginal bleeding, and there is no pubic hair. She takes no medication.

  Which of the following is the most appropriate next diagnostic step?

  A. an ultrasound of the pelvis

  B. a pelvic examination under general anesthesia

  C. computed tomography (CT) scan of her head

  D. a serum estradiol concentration

  E. a serum follicle-stimulating hormone (FSH) concentration

  Correct Answer: D

  Breast development in an infant or young child is the consequence of increased estrogen secretion, exposure to exogenous estrogens, or increased response of breast tissue to normal, prepubertal amounts of estrogen. After excluding exposure to exogenous estrogens (e.g., OCs, estrogen creams), increased response to estrogen is more common than increased estrogen secretion from the ovaries or adrenal glands when breast development is the only sign of precocious puberty. The uterus and adnexa can be palpated abdominally in prepubertal girls if they are pathologically enlarged. For this reason, an estrogen-secreting ovarian tumor (granulosa cell is the most common type) is usually palpable, and an ultrasound examination is unnecessary. For the same reason, a pelvic examination under anesthesia is not necessary, especially if the serum estradiol concentration is normal. CT scan of the head and a serum FSH concentration are unnecessary if breast development is the only sign of precocious puberty, and the serum estradiol concentration is normal in the prepubertal range.