Gynaecological oncology: vulval Paget disease: practice question

A OBG question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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OBG · Gynaecological oncology: vulval Paget disease

Sample item

A 68-year-old woman has a long-standing pruritic, red, well-demarcated eczematous plaque with white islands on the vulva that has not responded to steroid creams. Biopsy shows large pale cells with mucin in the epidermis. What is the next step?

AWide local excision and evaluation for an associated underlying adenocarcinomaBAntifungal therapyCReassurance and continued topical steroidsDImiquimod only

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

A. Wide local excision and evaluation for an associated underlying adenocarcinoma

Extramammary Paget disease of the vulva is an intraepidermal adenocarcinoma that appears as an eczematoid plaque and is confirmed by Paget cells staining for mucin and CK7. It is associated with an underlying adnexal or distant adenocarcinoma in a proportion of cases, so evaluation of the breast, cervix, bowel and urinary tract is required. Treatment is wide local excision, and recurrence is common.

Option by option

A. Wide local excision and evaluation for an associated underlying adenocarcinoma (correct)
Correct. Excision and a search for associated carcinoma are required.
B. Antifungal therapy
Fungal infection would not show Paget cells.
C. Reassurance and continued topical steroids
Persistent eczema unresponsive to steroids needs biopsy and, when malignant, excision.
D. Imiquimod only
Imiquimod is used in selected cases but does not replace evaluation for invasive disease.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

Questions about this OBG question

What is the answer to this OBG question?

The best answer is A, Wide local excision and evaluation for an associated underlying adenocarcinoma. Extramammary Paget disease of the vulva is an intraepidermal adenocarcinoma that appears as an eczematoid plaque and is confirmed by Paget cells staining for mucin and CK7.

Why is "Antifungal therapy" not the answer?

Fungal infection would not show Paget cells.

Why is "Reassurance and continued topical steroids" not the answer?

Persistent eczema unresponsive to steroids needs biopsy and, when malignant, excision.

Why is "Imiquimod only" not the answer?

Imiquimod is used in selected cases but does not replace evaluation for invasive disease.

What concept does this question test?

It tests Gynaecological oncology: vulval Paget disease in OBG. It is associated with an underlying adnexal or distant adenocarcinoma in a proportion of cases, so evaluation of the breast, cervix, bowel and urinary tract is required. Treatment is wide local excision, and recurrence is common.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Gynaecological oncology: vulval Paget disease?

Learn management algorithms as steps: PPH, eclampsia, ectopic pregnancy. Then use the flashcards and the other OBG questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.