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Vulval Cancer:
Best Practice & Research Clinical Obstetrics & Gynaecology Vol. 17, No. 4, pp. A1 –A8, 2003 doi:10.1016/S1521-6934(03)00100-7, www.elsevier.com/locate/jnlabr/ybeog
Vulval Cancer Multiple Choice Questions for Vol. 17, No. 4 Chapter 1: Dhar and Woolas 1.
Historically, in the management of vulval cancer: a. Early concepts in management included en bloc radical resection of the vulva and a bilateral inguinofemoral node dissection. b. Pelvic lymph node dissection was advised. c. Early studies indicated that the draining lymphatics from the vulva crossed the labio-crural folds. d. Prior to 1988, the FIGO staging of vulval cancer was independent of surgicalhistopathological features. e. Lesion size, and perineal location of the cancer are relevant in the current FIGO staging.
2.
Important developments in newer approaches to treatment included: a. Recognition that wound problems following the butterfly incision were related, in part, to compromising basic surgical principles. b. In most vulval cancers spread to the groin nodes was embolic such that a skin bridge between the vulva and groins could be preserved. c. Pelvic node resection should only be performed when the groin nodes contained metastatic disease. d. Squamous cell cancer of the vulva of less than 2 cm diameter rarely had lymph node metastases. e. Vulval cancers that were truly lateral, did not have contralateral node metastases.
3.
In vulval cancer management: a. Imaging of primary vulval cancer and the groin nodes by CT or MRI is an important assessment prior to definitive treatment. b. Compared to lateral vulval cancer, central disease, is more likely to require multi-modal therapy. c. Exenterative surgery continues to have a place in surgical management. d. Multifocal disease is common in younger patients with vulval cancer. e. Centralisation of care with involvement of the multi-disciplinary team (MDT) is standard of care.
1521-6934/$ - see front matter
A2 Appendix
Chapter 2: Sohaib and Moskovic 4.
Regarding high resolution ultrasound of the groin: a. b. c. d. e.
5.
High-resolution ultrasound can identify nodes as small as 5 mm. Malignant nodes are typically round. Reactive lymph nodes typically show peripheral vascularity. Malignant nodes have a low resistive index. Benign lymph may be isoechoic to fat.
Regarding MR imaging: a. MR imaging is essential for the assessment of the primary site of disease. b. Gadolinium enhancement is helpful for the assessment of the primary tumor. c. On MR imaging signal intensity of lymph node has been found to be useful in identify malignant nodes. d. MR imaging lacks sensitivity in detecting involved nodes. e. MR lymphography is more specific than MR imaging in identify involved lymph nodes in pelvic malignancy.
6.
True or false: a. Lymph node cytology is highly sensitive at detecting involved lymph node metastasis. b. Positron emission tomography (PET) is more accurate in detecting groin disease than extranodal metastases. c. Lymphoscintigraphy can only be performed with Tc labelled sulphur colloid. d. If the sentinel is positive for malignancy, then the nodes more distal in the lymphatic chain are not involved. e. Lymphoscintigraphy may also be combined with blue dye technique to identify sentinel nodes.
Chapter 3: Gotlieb 7.
Which of the following statements is not a reason why wide local excision replaced radical surgery for early vulvar cancer? a. Inguinal lymph node involvement occurs by an embolic pattern rather than a contiguous pattern. b. When examined, the skin bridges between the vulva and the groin were found to be free of tumor. c. Local control can be obtained with anatomic clear margins of 1 –2 cm and pathologic clear margins of 1 –2 mm. d. Lymph drainage does not cross the labio-crural fold. e. Radical surgery is associated with more short term morbidity.
Appendix A3
8.
Inguinal lymph nodes: a. should be removed bilaterally for lesions close to the midline. b. are a very important prognostic factor. c. should be removed on the ipsilateral side in the event of a lateral lesion with no suspicious lymph nodes. d. include the node of Cloquet. e. do not have to be removed if the invasion is less than 3 mm.
9.
Sentinel lymph nodes: a. are detected more frequently using the combination of vital blue and radiolabeling. b. are always in the superficial lymph nodes. c. micrometastases can be picked up by serial sectioning and immunohistochemistry. d. can show up in both groins. e. are difficult to detect in infected cancers.
Chapter 4: Hullu and van der Zee 10.
A patient presents with a squamous cell carcinoma of the vulva, 2 cm in diameter, on the right labium, with a medial margin of 2 cm from the midline. No suspicious lymph nodes. No other abnormalities are visible on the vulva. a. Standard local treatment is radical vulvectomy. b. Standard regional treatment is unilateral inguinofemoral lymphadenectomy. c. In case of a micrometastasis in the lymph nodes, bilateral inguinofemoral lymphadenectomy is indicated. d. There is low risk on lymph oedema of the legs after inguinofemoral lymphadenectomy. e. Overall prognosis of this patient is good in case of negative lymph nodes. f. In vulvar cancer, there is high risk on hematogenous metastases.
11.
The sentinel lymph node procedure: a. b. c. d. e.
12.
Is a diagnostic procedure for staging. Is introduced as standard treatment for breast cancer and melanoma. Is promising in vulvar cancer, but no standard of care. Its safety still had to be proven in vulvar cancer. Leads to a high rate of lymph oedema.
The following statements are true: a. Depth of invasion of the primary lesion is important in the selection of patients for the sentinel node procedure. b. Patients are eligible for the sentinel node procedure only if it is technically possible to inject around the tumor.
A4 Appendix
c. The occasional patient with a single fixed node in the groin may be suitable for the sentinel node procedure. d. Patients should be warned that the appearance of sentinel lymph nodes on the lymphoscintigram after injection of 99mTc labeled Nanocolloid is indicative of metastasis. e. The sentinel node procedure is now as well as established for vulval cancer as it is for melanoma and breast cancer.
Chapter 5: Allan 13.
A 25 year old woman attends the gynae-oncology clinic having been referred from a Genito-Urinary Medicine clinic. She has obvious skin changes to the vulva and histology indicates VIN III. When taking a history, which of these factors could prove to be most valuable in influencing the patient’s management: a. b. c. d. e.
14.
A 40 year old woman is undergoing radical hysterectomy and bilateral salpingoophrectomy for Stage Ib1 carcinoma of the cervix (Ca Cx). When taking a history which of these issues could prove most important for future psychological support. a. b. c. d. e.
15.
Previous history of HPV. Previous history of other STDs. Multiple sexual partners. Cigarette smoking. Past termination of pregnancies.
Completion of her family. Cessation of ovarian function. Occupation and life style. Body image. Sexual dysfunction.
A 70 year old woman with stage IIIC ovarian carcinoma is about to undergo surgery. What information do you think should be given to this woman preoperatively? a. b. c. d. e.
Additional treatment following surgery. Risk of colostomy formation. Possibility of not being able to remove all disease. Information on HRT. The number of pregnancies the patient has had.
Chapter 6: Finan and Barre 16.
In order to make the diagnosis of Bartholin’s Gland Carcinoma, one must find all of the following except:
Appendix A5
a. b. c. d. e. 17.
Patients with vulvar melanoma treated with surgery, can be placed into prognostic groups based on which of the following factors? a. b. c. d. e.
18.
Anatomic position of tumor located in Bartholin’s gland region. Normal glandular elements present on histology. Areas of apparent transition from normal to neoplastic elements. Overlying skin ulcerated and involved with tumor. No evidence of a concurrent primary tumor elsewhere.
Breslow’s depth of invasion. Metastatic disease involving the inguino-femoral lymph nodes. Size (diameter) of tumor. Tumor thickness. Tumor ulceration.
The following statements are true with regard to vulvar Paget’s disease: a. Generally presents as a crusty, erythematous, dark-pink/red exzematous “glazed” area on the vulva. b. An intraepithelial disease in . 90% of cases. c. Paget’s disease cells occur singly or in small nests within the epithelium as is seen in melanoma. d. Use of intravenous fluorescein dye is of no benefit in identifying free margins during surgery for Paget’s disease. e. 85% of cases of vulvar Paget’s disease are associated with an underlying adenocarcinoma.
Chapter 7: Hoffman 19.
For a patient with locally advanced vulvar cancer, ultraradical surgery: a. b. c. d. e.
20.
Is of greatest benefit for a patient with multiple positive groin nodes. Has included resection of bone in some cases. Results in prolonged disease-free survival in 40 –50% of patients. Is contraindicated in a patient who has undergone prior perineal radiotherapy. May be avoided in some cases by partial resection of the urethra or anus.
Treatment of locally advanced vulvar cancer with preoperative radiotherapy, with or without concomitant chemotherapy: a. Is reserved for patients with unresectable disease. b. May obviate the need for local organ resection. c. Results in a substantially lower survival rate as compared to primary treatment with ultraradical surgery. d. May produce a complete pathologic response. e. Requires implantation of the tumor bed with intersitial iridium.
A6 Appendix
21.
The following statements are true: a. Squamous cell carcinoma of the anus been shown to be highly resistant to chemoradiotherapy. b. Combination radiotherapy and chemotherapy for cancers of the cervix and head and neck has produced encouraging results, which has stimulated this approach in vulvar cancer. c. The combination of chemotherapy and radiotherapy means that the dose of each treatment modality can be reduced, resulting in reduced local morbidity. d. Neoadjuvant chemotherapy has been shown early promise in cervical cancer, and some have started to take this approach in advanced carcinoma of the vulva. e. Because of proximity and probable similar aetiology, squamous cell cancers of the vulva and anus appear to be equally responsive to the combined chemoradiation therapies.
Chapter 8: Blake 22.
Which of the following are true in the treatment of vulval cancer: a. The chemotherapy itself may have anti-cancer effects. b. The rationale for chemo-radiotherapy is the radiosensitisation of cancer cells by the chemotherapy. c. When used to treat primary disease avoids the need for radical surgery. d. Is characterised by early and late reactions. e. The radiotherapy is best given as orthovoltage as it induces maximum skin reaction.
23.
The chemo-radiotherapy management of vulval cancer: a. Is as successful as the chemo-radiotherapy treatment of squamous cell cancer of the anus (anal canal). b. Is the treatment of choice when the primary cancer is central and has led to a faecal or urinary fistula. c. Despite obvious tumor regression, there may be residual cancer cells in the responsive tissues. d. Can be used in a neo-adjuvant setting in an approach to reduce the radicality of subsequent surgery. e. Clinically uninvolved groin nodes can be effectively treated by radiotherapy alone.
24.
In combination treatments for vulval cancer: a. The optimum management of bulky positive groin nodes is unclear. b. Fixity of groin nodes precludes surgical resection. c. The variation in chemotherapy drugs used and in the radiation therapy protocols has made interpretation of studies difficult.
Appendix A7
d. Problems in administration of radiotherapy include advanced age of patients, location of the cancer, and limited mobility of the hips. e. Brachtherapy techniques may be required to complete the radiotherapy treatment.
Chapter 9: Coulter and Gleeson 25.
Which of the following are true for recurrent cancer of the vulva? a. Local recurrence occurs in about 10% of all cases. b. Groin recurrence has a worse prognosis compared to local recurrence. c. The shorter the disease free interval (DFI)—from primary treatment to recurrence—the worse the prognosis. d. Modified radical surgery, such as a radical hemivulvectomy, is associated with a greater risk of local recurrence compared to a radical total vulvectomy. e. A tumor-free margin of at least 5 mm, is acceptable.
26.
In a patient with suspected local vulval recurrence: a. An examination under anaesthesia is unnecessary if outpatient biopsy confirms recurrence. b. The initial approach should be radical surgery. c. If the recurrence is more than 4 cm in a previously non-irradiated patient, the treatment of choice is radiotherapy, with or without chemotherapy. d. Exenterative surgery with reconstruction may be required. e. Recurrence in a previously irradiated field is best treated by chemotherapy.
27.
In recurrent vulval cancer: a. A major component of management is deciding on whether treatment is with curative or palliative intent. b. The patient’s quality of life can be worsened by treating recurrent disease. c. Most recurrences are unifocal. d. Most patients die from extra pelvic, disseminated disease. e. The palliative care team should be involved soon after treatment of the recurrent disease.
Chapter 10: Barton 28.
Treatment-related morbidity in vulval cancer: a. b. c. d. e.
Is seen only in patients with advanced disease. Has been poorly quantified in the literature. Is more common in patients who receive more than one modality of treatment. Is mainly due to the older age of most patients. Is often chronic and irreversible.
A8 Appendix
29.
Which of the following are true? a. Clinical nurse specialists are best placed to deal with the psychosexual problems faced by patients with vulval cancer. b. Groin wound problems are seen only in patients with groin node metastases. c. Lower limb oedema can develop months after groin node dissection. d. Urinary problems can develop after radical vulval surgery when the urethra has been left intact. e. Vaginal dilators will treat many psychosexual problems after radical vulval surgery.
30.
Measure to reduce the morbidity of treatment of vulval cancer include: a. b. c. d. e.
vertical groin incision. vulval and vaginal douches. continuous peri-operative antibiotics. compression dressing to the groin. preservation of the short saphenous vein.
Vulval Cancer Multiple Choice Questions for Vol. 17, No. 4 Chapter 1: Dhar and Woolas 1.
Historically, in the management of vulval cancer: a. Early concepts in management included en bloc radical resection of the vulva and a bilateral inguinofemoral node dissection. b. Pelvic lymph node dissection was advised. c. Early studies indicated that the draining lymphatics from the vulva crossed the labio-crural folds. d. Prior to 1988, the FIGO staging of vulval cancer was independent of surgicalhistopathological features. e. Lesion size, and perineal location of the cancer are relevant in the current FIGO staging.
2.
Important developments in newer approaches to treatment included: a. Recognition that wound problems following the butterfly incision were related, in part, to compromising basic surgical principles. b. In most vulval cancers spread to the groin nodes was embolic such that a skin bridge between the vulva and groins could be preserved. c. Pelvic node resection should only be performed when the groin nodes contained metastatic disease. d. Squamous cell cancer of the vulva of less than 2 cm diameter rarely had lymph node metastases. e. Vulval cancers that were truly lateral, did not have contralateral node metastases.
3.
In vulval cancer management: a. Imaging of primary vulval cancer and the groin nodes by CT or MRI is an important assessment prior to definitive treatment. b. Compared to lateral vulval cancer, central disease, is more likely to require multi-modal therapy. c. Exenterative surgery continues to have a place in surgical management. d. Multifocal disease is common in younger patients with vulval cancer. e. Centralisation of care with involvement of the multi-disciplinary team (MDT) is standard of care.
1521-6934/$ - see front matter
A2 Appendix
Chapter 2: Sohaib and Moskovic 4.
Regarding high resolution ultrasound of the groin: a. b. c. d. e.
5.
High-resolution ultrasound can identify nodes as small as 5 mm. Malignant nodes are typically round. Reactive lymph nodes typically show peripheral vascularity. Malignant nodes have a low resistive index. Benign lymph may be isoechoic to fat.
Regarding MR imaging: a. MR imaging is essential for the assessment of the primary site of disease. b. Gadolinium enhancement is helpful for the assessment of the primary tumor. c. On MR imaging signal intensity of lymph node has been found to be useful in identify malignant nodes. d. MR imaging lacks sensitivity in detecting involved nodes. e. MR lymphography is more specific than MR imaging in identify involved lymph nodes in pelvic malignancy.
6.
True or false: a. Lymph node cytology is highly sensitive at detecting involved lymph node metastasis. b. Positron emission tomography (PET) is more accurate in detecting groin disease than extranodal metastases. c. Lymphoscintigraphy can only be performed with Tc labelled sulphur colloid. d. If the sentinel is positive for malignancy, then the nodes more distal in the lymphatic chain are not involved. e. Lymphoscintigraphy may also be combined with blue dye technique to identify sentinel nodes.
Chapter 3: Gotlieb 7.
Which of the following statements is not a reason why wide local excision replaced radical surgery for early vulvar cancer? a. Inguinal lymph node involvement occurs by an embolic pattern rather than a contiguous pattern. b. When examined, the skin bridges between the vulva and the groin were found to be free of tumor. c. Local control can be obtained with anatomic clear margins of 1 –2 cm and pathologic clear margins of 1 –2 mm. d. Lymph drainage does not cross the labio-crural fold. e. Radical surgery is associated with more short term morbidity.
Appendix A3
8.
Inguinal lymph nodes: a. should be removed bilaterally for lesions close to the midline. b. are a very important prognostic factor. c. should be removed on the ipsilateral side in the event of a lateral lesion with no suspicious lymph nodes. d. include the node of Cloquet. e. do not have to be removed if the invasion is less than 3 mm.
9.
Sentinel lymph nodes: a. are detected more frequently using the combination of vital blue and radiolabeling. b. are always in the superficial lymph nodes. c. micrometastases can be picked up by serial sectioning and immunohistochemistry. d. can show up in both groins. e. are difficult to detect in infected cancers.
Chapter 4: Hullu and van der Zee 10.
A patient presents with a squamous cell carcinoma of the vulva, 2 cm in diameter, on the right labium, with a medial margin of 2 cm from the midline. No suspicious lymph nodes. No other abnormalities are visible on the vulva. a. Standard local treatment is radical vulvectomy. b. Standard regional treatment is unilateral inguinofemoral lymphadenectomy. c. In case of a micrometastasis in the lymph nodes, bilateral inguinofemoral lymphadenectomy is indicated. d. There is low risk on lymph oedema of the legs after inguinofemoral lymphadenectomy. e. Overall prognosis of this patient is good in case of negative lymph nodes. f. In vulvar cancer, there is high risk on hematogenous metastases.
11.
The sentinel lymph node procedure: a. b. c. d. e.
12.
Is a diagnostic procedure for staging. Is introduced as standard treatment for breast cancer and melanoma. Is promising in vulvar cancer, but no standard of care. Its safety still had to be proven in vulvar cancer. Leads to a high rate of lymph oedema.
The following statements are true: a. Depth of invasion of the primary lesion is important in the selection of patients for the sentinel node procedure. b. Patients are eligible for the sentinel node procedure only if it is technically possible to inject around the tumor.
A4 Appendix
c. The occasional patient with a single fixed node in the groin may be suitable for the sentinel node procedure. d. Patients should be warned that the appearance of sentinel lymph nodes on the lymphoscintigram after injection of 99mTc labeled Nanocolloid is indicative of metastasis. e. The sentinel node procedure is now as well as established for vulval cancer as it is for melanoma and breast cancer.
Chapter 5: Allan 13.
A 25 year old woman attends the gynae-oncology clinic having been referred from a Genito-Urinary Medicine clinic. She has obvious skin changes to the vulva and histology indicates VIN III. When taking a history, which of these factors could prove to be most valuable in influencing the patient’s management: a. b. c. d. e.
14.
A 40 year old woman is undergoing radical hysterectomy and bilateral salpingoophrectomy for Stage Ib1 carcinoma of the cervix (Ca Cx). When taking a history which of these issues could prove most important for future psychological support. a. b. c. d. e.
15.
Previous history of HPV. Previous history of other STDs. Multiple sexual partners. Cigarette smoking. Past termination of pregnancies.
Completion of her family. Cessation of ovarian function. Occupation and life style. Body image. Sexual dysfunction.
A 70 year old woman with stage IIIC ovarian carcinoma is about to undergo surgery. What information do you think should be given to this woman preoperatively? a. b. c. d. e.
Additional treatment following surgery. Risk of colostomy formation. Possibility of not being able to remove all disease. Information on HRT. The number of pregnancies the patient has had.
Chapter 6: Finan and Barre 16.
In order to make the diagnosis of Bartholin’s Gland Carcinoma, one must find all of the following except:
Appendix A5
a. b. c. d. e. 17.
Patients with vulvar melanoma treated with surgery, can be placed into prognostic groups based on which of the following factors? a. b. c. d. e.
18.
Anatomic position of tumor located in Bartholin’s gland region. Normal glandular elements present on histology. Areas of apparent transition from normal to neoplastic elements. Overlying skin ulcerated and involved with tumor. No evidence of a concurrent primary tumor elsewhere.
Breslow’s depth of invasion. Metastatic disease involving the inguino-femoral lymph nodes. Size (diameter) of tumor. Tumor thickness. Tumor ulceration.
The following statements are true with regard to vulvar Paget’s disease: a. Generally presents as a crusty, erythematous, dark-pink/red exzematous “glazed” area on the vulva. b. An intraepithelial disease in . 90% of cases. c. Paget’s disease cells occur singly or in small nests within the epithelium as is seen in melanoma. d. Use of intravenous fluorescein dye is of no benefit in identifying free margins during surgery for Paget’s disease. e. 85% of cases of vulvar Paget’s disease are associated with an underlying adenocarcinoma.
Chapter 7: Hoffman 19.
For a patient with locally advanced vulvar cancer, ultraradical surgery: a. b. c. d. e.
20.
Is of greatest benefit for a patient with multiple positive groin nodes. Has included resection of bone in some cases. Results in prolonged disease-free survival in 40 –50% of patients. Is contraindicated in a patient who has undergone prior perineal radiotherapy. May be avoided in some cases by partial resection of the urethra or anus.
Treatment of locally advanced vulvar cancer with preoperative radiotherapy, with or without concomitant chemotherapy: a. Is reserved for patients with unresectable disease. b. May obviate the need for local organ resection. c. Results in a substantially lower survival rate as compared to primary treatment with ultraradical surgery. d. May produce a complete pathologic response. e. Requires implantation of the tumor bed with intersitial iridium.
A6 Appendix
21.
The following statements are true: a. Squamous cell carcinoma of the anus been shown to be highly resistant to chemoradiotherapy. b. Combination radiotherapy and chemotherapy for cancers of the cervix and head and neck has produced encouraging results, which has stimulated this approach in vulvar cancer. c. The combination of chemotherapy and radiotherapy means that the dose of each treatment modality can be reduced, resulting in reduced local morbidity. d. Neoadjuvant chemotherapy has been shown early promise in cervical cancer, and some have started to take this approach in advanced carcinoma of the vulva. e. Because of proximity and probable similar aetiology, squamous cell cancers of the vulva and anus appear to be equally responsive to the combined chemoradiation therapies.
Chapter 8: Blake 22.
Which of the following are true in the treatment of vulval cancer: a. The chemotherapy itself may have anti-cancer effects. b. The rationale for chemo-radiotherapy is the radiosensitisation of cancer cells by the chemotherapy. c. When used to treat primary disease avoids the need for radical surgery. d. Is characterised by early and late reactions. e. The radiotherapy is best given as orthovoltage as it induces maximum skin reaction.
23.
The chemo-radiotherapy management of vulval cancer: a. Is as successful as the chemo-radiotherapy treatment of squamous cell cancer of the anus (anal canal). b. Is the treatment of choice when the primary cancer is central and has led to a faecal or urinary fistula. c. Despite obvious tumor regression, there may be residual cancer cells in the responsive tissues. d. Can be used in a neo-adjuvant setting in an approach to reduce the radicality of subsequent surgery. e. Clinically uninvolved groin nodes can be effectively treated by radiotherapy alone.
24.
In combination treatments for vulval cancer: a. The optimum management of bulky positive groin nodes is unclear. b. Fixity of groin nodes precludes surgical resection. c. The variation in chemotherapy drugs used and in the radiation therapy protocols has made interpretation of studies difficult.
Appendix A7
d. Problems in administration of radiotherapy include advanced age of patients, location of the cancer, and limited mobility of the hips. e. Brachtherapy techniques may be required to complete the radiotherapy treatment.
Chapter 9: Coulter and Gleeson 25.
Which of the following are true for recurrent cancer of the vulva? a. Local recurrence occurs in about 10% of all cases. b. Groin recurrence has a worse prognosis compared to local recurrence. c. The shorter the disease free interval (DFI)—from primary treatment to recurrence—the worse the prognosis. d. Modified radical surgery, such as a radical hemivulvectomy, is associated with a greater risk of local recurrence compared to a radical total vulvectomy. e. A tumor-free margin of at least 5 mm, is acceptable.
26.
In a patient with suspected local vulval recurrence: a. An examination under anaesthesia is unnecessary if outpatient biopsy confirms recurrence. b. The initial approach should be radical surgery. c. If the recurrence is more than 4 cm in a previously non-irradiated patient, the treatment of choice is radiotherapy, with or without chemotherapy. d. Exenterative surgery with reconstruction may be required. e. Recurrence in a previously irradiated field is best treated by chemotherapy.
27.
In recurrent vulval cancer: a. A major component of management is deciding on whether treatment is with curative or palliative intent. b. The patient’s quality of life can be worsened by treating recurrent disease. c. Most recurrences are unifocal. d. Most patients die from extra pelvic, disseminated disease. e. The palliative care team should be involved soon after treatment of the recurrent disease.
Chapter 10: Barton 28.
Treatment-related morbidity in vulval cancer: a. b. c. d. e.
Is seen only in patients with advanced disease. Has been poorly quantified in the literature. Is more common in patients who receive more than one modality of treatment. Is mainly due to the older age of most patients. Is often chronic and irreversible.
A8 Appendix
29.
Which of the following are true? a. Clinical nurse specialists are best placed to deal with the psychosexual problems faced by patients with vulval cancer. b. Groin wound problems are seen only in patients with groin node metastases. c. Lower limb oedema can develop months after groin node dissection. d. Urinary problems can develop after radical vulval surgery when the urethra has been left intact. e. Vaginal dilators will treat many psychosexual problems after radical vulval surgery.
30.
Measure to reduce the morbidity of treatment of vulval cancer include: a. b. c. d. e.
vertical groin incision. vulval and vaginal douches. continuous peri-operative antibiotics. compression dressing to the groin. preservation of the short saphenous vein.