Gynecologic Oncology Practice Questions

Q: What is the most appropriate next step in management for a patient with a Stage III ovarian cancer with partial response to platinum-based chemotherapy?

Perform surgery. ***Perform surgery (Interval Debulking Surgery)*** - In **Stage III ovarian cancer**, after an initial partial response to **platinum-based chemotherapy**, **interval debulking surgery** is the standard next step to remove residual disease. - This approach aims to reduce tumor burden to an optimal level (< 1 cm residual disease), which has been shown to improve overall survival in multiple trials (EORTC 55971, GOG-152). - Performed after 3-4 cycles of neoadjuvant chemotherapy when the patient has demonstrated response and is medically fit for surgery. *Bevacizumab* - **Bevacizumab** is an **anti-angiogenic agent** used in ovarian cancer, typically as part of frontline maintenance therapy or for recurrent disease, not as the immediate next step after partial response to primary chemotherapy when surgery is feasible. - While it can be incorporated into maintenance treatment post-surgery, it's not the primary next step after partial response when interval debulking surgery is indicated. *Switch to radiotherapy* - **Radiotherapy** has a limited role in the primary treatment of advanced ovarian cancer due to its widespread peritoneal nature. - It is sometimes used for localized recurrence or symptom palliation, but not as a standard next step after partial response to chemotherapy in Stage III disease. *Continue regimen* - Continuing the same regimen after only a **partial response** is generally not the most effective strategy when further tumor reduction via surgery is possible. - The goal in advanced ovarian cancer is **maximal cytoreduction**, and if residual disease is present after neoadjuvant chemotherapy, interval debulking surgery is preferred over continued chemotherapy alone.

Q: What is the most common etiological factor for cervical cancer worldwide?

Human papillomavirus (HPV). ***Human papillomavirus (HPV)*** - **High-risk HPV types** (e.g., HPV-16 and HPV-18) are responsible for over 99% of all cervical cancer cases globally. - HPV infection is typically sexually transmitted and causes **premalignant lesions** that can progress to invasive cancer over time. *Herpes simplex virus* - While herpes simplex virus (HSV) is a sexually transmitted infection, it has **no direct causal link** to cervical cancer. - HSV primarily causes **genital ulcers** or cold sores, with different cellular mechanisms of infection compared to HPV. *Cigarette smoking* - **Cigarette smoking** is a known risk factor for cervical cancer, but it is considered a **co-factor** that exacerbates HPV-induced carcinogenesis, not a primary etiological factor. - Smoking can impair the immune system and increase the persistence of HPV infection, thereby accelerating progression to cancer. *Long-term use of oral contraceptives* - Long-term use of **oral contraceptives (OCPs)** is a known risk factor for cervical cancer, but it acts primarily as a **co-factor** that enhances the effects of HPV. - OCPs are thought to influence hormonal changes in the cervix that may increase susceptibility to HPV persistence and progression, but they do not directly cause the cancer.

Q: A 50-year-old female presents with abdominal distension and pain. A CT scan of the abdomen shows a large cystic lesion with septations in the left ovary. What is the most likely diagnosis?

Ovarian cancer. ***Ovarian cancer*** - A large **cystic lesion with septations** in the ovary, especially in a 50-year-old female, is highly suspicious for ovarian cancer. - The presence of **septations** suggests a complex cyst, which increases the likelihood of malignancy. *Ovarian cyst* - While an ovarian cyst is a general term, a simple, benign ovarian cyst would typically be **unilocular** and lack septations. - The term **"large cystic lesion with septations"** points to a more complex and potentially malignant etiology rather than a simple cyst. *Endometrioma* - An endometrioma is a type of ovarian cyst formed by **endometrial tissue**, often described as a "chocolate cyst" due to its contents. - It typically presents as a **homogenous cyst** with a ground-glass appearance on imaging, rather than distinct septations. *Tubo-ovarian abscess* - A tubo-ovarian abscess is an **inflammatory mass** involving the fallopian tube and ovary, usually a complication of pelvic inflammatory disease. - It would typically present with signs of **infection** such as fever, elevated white blood cell count, and inflammatory markers, which are not mentioned in this case.

Q: A 28-year-old woman has persistent bleeding and elevated β-hCG three months after the evacuation of a molar pregnancy. What is the next step?

Chemotherapy. ***Chemotherapy*** - Persistent bleeding and elevated **β-hCG** three months after molar pregnancy evacuation meets the diagnostic criteria for **gestational trophoblastic neoplasia (GTN)**. - According to **FIGO/WHO criteria**, GTN is diagnosed when β-hCG plateaus or rises after evacuation, indicating progression to **invasive mole** or **choriocarcinoma**. - **Single-agent chemotherapy** (methotrexate or actinomycin D) is the first-line treatment for low-risk GTN and is highly effective with **cure rates >90%** while preserving fertility. - This is the standard of care and must be initiated promptly to prevent complications. *Repeat curettage* - Not recommended for persistent GTN as it carries significant risk of **uterine perforation** (due to myometrial invasion) and does not address potential **metastatic disease**. - Repeat curettage may delay appropriate systemic treatment and worsen outcomes. - The elevated β-hCG indicates need for systemic therapy, not local evacuation. *Hysterectomy* - Reserved for specific scenarios: older patients with completed family, **uncontrolled hemorrhage**, or **chemotherapy-resistant disease** with isolated uterine lesion. - Not first-line in a **28-year-old woman** where fertility preservation is important and chemotherapy is highly effective. - Would not address any occult metastatic disease that may be present. *Radiation therapy* - Used for specific complications such as **brain metastases** or **liver metastases** that are resistant to chemotherapy. - Not the primary treatment for GTN; reserved as adjuvant therapy in high-risk or resistant cases. - Whole-brain radiation may be used for CNS involvement alongside chemotherapy.

Q: A 45-year-old woman presents with irregular vaginal bleeding and an enlarged uterus. A biopsy reveals endometrial hyperplasia with atypia. What is the next best step in management?

Hysterectomy. ***Hysterectomy*** - Endometrial hyperplasia with **atypia** carries a significant risk of progression to **endometrial cancer** (up to 30%), especially in a 45-year-old woman presenting with irregular bleeding. - Given the risk of malignancy and the patient's age (likely completed childbearing), **hysterectomy** is considered the definitive treatment and the next best step for preventing cancer. *Hormonal therapy* - While hormonal therapy (e.g., progestins) can be used for **endometrial hyperplasia without atypia**, or in younger women who wish to preserve fertility, it is less appropriate for hyperplasia with atypia due to the high risk of cancer. - This option would typically be considered if the patient was younger, desired fertility, or had significant contraindications to surgery, and would require close monitoring. *Uterine ablation* - **Uterine ablation** is a procedure to destroy the uterine lining and is primarily used to treat **heavy menstrual bleeding that is not caused by cancer**. - It does not remove the entire uterus and, therefore, is not an appropriate treatment for **atypical endometrial hyperplasia** which has a high malignant potential, as it could mask or prevent further evaluation of precancerous or cancerous changes. *Watchful waiting* - **Watchful waiting** is inappropriate for endometrial hyperplasia with atypia due to the significant risk of progression to **endometrial cancer**. - Delaying definitive treatment can lead to more advanced disease, making outcomes worse.

Q: What is the primary surgical treatment for cervical cancer that has not metastasized beyond the cervix?

Radical hysterectomy. ***Radical hysterectomy*** - This is the **primary surgical treatment** for early-stage invasive cervical cancer (stages IB1-IIA) that has not metastasized beyond the cervix. - It involves removal of the **uterus, cervix, parametria, uterosacral ligaments**, and the **upper 1-2 cm of vagina**, along with **pelvic lymphadenectomy**. - Provides adequate surgical margins and removes tissue at risk for microscopic disease spread. - This is the **standard of care** for operable cervical cancer confined to the cervix when fertility preservation is not required. *Pelvic exenteration* - This is a much more extensive surgery, involving removal of the uterus, cervix, vagina, bladder, and/or rectum. - Reserved for **recurrent or advanced cervical cancer** that has spread to nearby pelvic organs. - Not the primary treatment for non-metastatic disease confined to the cervix due to its significant morbidity and impact on quality of life. *Total hysterectomy* - A total hysterectomy (removal of the uterus and cervix only) is **insufficient** for invasive cervical cancer. - It does not remove the **parametria** or adequate vaginal margins, which are necessary to ensure complete tumor excision. - May be appropriate for **adenocarcinoma in situ (AIS)** or certain cases of **stage IA1 without lymphovascular invasion**, but not for most invasive cancers. *Conization* - **Conization** (cone biopsy) involves removal of a cone-shaped piece of tissue from the cervix. - Primarily a **diagnostic and treatment procedure** for **cervical intraepithelial neoplasia (CIN)** or **stage IA1 microinvasive cancer** without lymphovascular invasion. - Insufficient as primary treatment for invasive cervical cancer that has not metastasized, which requires more extensive surgery like **radical hysterectomy** or, in select cases, **radical trachelectomy** for fertility preservation.

Q: A 34-year-old woman presents with persistent irregular uterine bleeding six months after a molar pregnancy evacuation. Serum β-hCG levels are elevated, and imaging shows multiple lung nodules. Given these findings, what is the most appropriate management approach?

Multi-agent chemotherapy using the EMA-CO protocol. ***Multi-agent chemotherapy using the EMA-CO protocol*** - The combination of **persistent irregular uterine bleeding**, **elevated serum β-hCG**, and **multiple lung nodules** six months after a molar pregnancy evacuation is highly suggestive of **high-risk gestational trophoblastic neoplasia (GTN)**, specifically **choriocarcinoma with metastatic disease**. - **EMA-CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine)** is the gold-standard multi-agent chemotherapy regimen for high-risk GTN due to its high efficacy in achieving remission and cure. *Surgical removal of the uterus (hysterectomy)* - While hysterectomy can be considered in some cases of **low-risk GTN** or for patients desiring definitive contraception, it is not the primary treatment for **metastatic disease** like lung nodules. - Hysterectomy alone would not address the **systemic spread** of the trophoblastic disease. *Single-agent chemotherapy with methotrexate* - **Single-agent chemotherapy**, often with **methotrexate** or **actinomycin D**, is appropriate for **low-risk GTN (non-metastatic or good prognosis metastatic disease)**. - Given the presence of **multiple lung nodules**, this patient is categorized as **high-risk GTN**, for which single-agent therapy is insufficient and would likely lead to treatment failure. *Monitoring with regular follow-up and imaging* - This approach is only appropriate for patients with declining or normalizing β-hCG levels after molar evacuation who are in follow-up for **remission**, or for those with **low-risk GTN** after initial treatment. - The elevated β-hCG and metastatic lung nodules indicate **active and aggressive disease** requiring immediate and aggressive treatment, not just monitoring.

Q: In a postmenopausal woman with vaginal bleeding, what is the first-line investigation to rule out endometrial cancer?

Transvaginal ultrasound. ***Transvaginal ultrasound*** - **Transvaginal ultrasound (TVUS)** is the recommended first-line investigation in postmenopausal women with vaginal bleeding to assess the **endometrial thickness**. - An **endometrial thickness of 4 mm) or if TVUS is inconclusive. - It is an **invasive procedure** and not the initial screening tool for all postmenopausal bleeding. *Hysteroscopy* - **Hysteroscopy** involves direct visualization of the uterine cavity and is often combined with targeted biopsy. It is usually performed if TVUS or blind endometrial biopsy is inconclusive or to evaluate focal lesions. - It is a **more invasive** and resource-intensive procedure, not suitable as a first-line screening tool. *Pap smear* - A **Pap smear** screens for **cervical cellular abnormalities** and cervical cancer, not endometrial cancer. - It is **not effective** in detecting endometrial pathology, and a normal result does not rule out endometrial cancer in a woman with postmenopausal bleeding.

Q: What is the recommended initial treatment for a woman diagnosed with gestational trophoblastic neoplasia?

Chemotherapy. ***Chemotherapy*** - **Chemotherapy** is the cornerstone of treatment for gestational trophoblastic neoplasia (GTN), especially for **high-risk disease** or persistent low-risk disease after suction curettage. - **Methotrexate** or **actinomycin D** are common first-line agents, with multi-agent regimens like EMA-CO reserved for high-risk cases. *Hysterectomy* - **Hysterectomy** may be considered in cases of GTN where future fertility is not desired or in specific scenarios like **chemotherapy-resistant disease** confined to the uterus. - It is not the initial treatment strategy, particularly for patients who wish to preserve fertility. *Radiation therapy* - **Radiation therapy** is generally reserved for GTN cases with **brain metastases** or other specific sites of resistant disease, often in conjunction with chemotherapy. - It is not a standard initial treatment for uncomplicated GTN. *Biologic therapy* - **Biologic therapy** is an emerging area of research for GTN, but it is not currently an established initial treatment modality. - Treatment guidelines primarily recommend **chemotherapy** due to its proven efficacy.

Question 1

What is the most appropriate next step in management for a patient with a Stage III ovarian cancer with partial response to platinum-based chemotherapy?

Accepted Answer

Perform surgery

Answer

Bevacizumab

Answer

Switch to radiotherapy

Answer

Continue regimen

Question 2

What is the most common etiological factor for cervical cancer worldwide?

Accepted Answer

Human papillomavirus (HPV)

Answer

Herpes simplex virus

Answer

Cigarette smoking

Answer

Long-term use of oral contraceptives

Question 3

A 50-year-old female presents with abdominal distension and pain. A CT scan of the abdomen shows a large cystic lesion with septations in the left ovary. What is the most likely diagnosis?

Accepted Answer

Ovarian cancer

Answer

Ovarian cyst

Answer

Endometrioma

Answer

Tubo-ovarian abscess

Question 4

A 28-year-old woman has persistent bleeding and elevated β-hCG three months after the evacuation of a molar pregnancy. What is the next step?

Accepted Answer

Chemotherapy

Answer

Repeat curettage

Answer

Hysterectomy

Answer

Radiation therapy

Question 5

A 45-year-old woman presents with irregular vaginal bleeding and an enlarged uterus. A biopsy reveals endometrial hyperplasia with atypia. What is the next best step in management?

Accepted Answer

Hysterectomy

Answer

Hormonal therapy

Answer

Uterine ablation

Answer

Watchful waiting

Question 6

What is the primary surgical treatment for cervical cancer that has not metastasized beyond the cervix?

Accepted Answer

Radical hysterectomy

Answer

Pelvic exenteration

Answer

Total hysterectomy

Answer

Conization

Question 7

A 34-year-old woman presents with persistent irregular uterine bleeding six months after a molar pregnancy evacuation. Serum β-hCG levels are elevated, and imaging shows multiple lung nodules. Given these findings, what is the most appropriate management approach?

Accepted Answer

Multi-agent chemotherapy using the EMA-CO protocol

Answer

Surgical removal of the uterus (hysterectomy)

Answer

Single-agent chemotherapy with methotrexate

Answer

Monitoring with regular follow-up and imaging

Question 8

In a postmenopausal woman with vaginal bleeding, what is the first-line investigation to rule out endometrial cancer?

Accepted Answer

Transvaginal ultrasound

Answer

Endometrial biopsy

Answer

Hysteroscopy

Answer

Pap smear

Question 9

What is the recommended initial treatment for a woman diagnosed with gestational trophoblastic neoplasia?

Accepted Answer

Chemotherapy

Answer

Hysterectomy

Answer

Radiation therapy

Answer

Biologic therapy

Question 10

A 30-year-old woman presents with a rapidly enlarging, firm mass in the lower abdomen. What is the initial diagnostic test to evaluate for leiomyosarcoma?

Accepted Answer

Transvaginal ultrasound

Answer

MRI of the pelvis

Answer

CT scan of the abdomen

Answer

Biopsy of the mass

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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