Gynecologic Oncology Practice Questions

Q: What is the most effective method for diagnosing endometrial cancer in a postmenopausal woman with abnormal uterine bleeding?

Endometrial biopsy. ***Endometrial biopsy*** - An **endometrial biopsy** is the most definitive method for diagnosing endometrial cancer as it allows for direct histological examination of endometrial tissue. - It is crucial for confirming the presence of malignancy and determining the specific type and grade of cancer. *Transvaginal ultrasound* - While useful for measuring **endometrial thickness** and identifying abnormalities, it cannot definitively diagnose cancer. - Thickened endometrium on ultrasound in a postmenopausal woman with bleeding warrants further investigation, typically with a biopsy. *Hysteroscopy* - **Hysteroscopy** allows for direct visualization of the uterine cavity and directed biopsies of suspicious areas. - While valuable, it is often performed in conjunction with or after an initial endometrial biopsy, or when biopsy results are inconclusive, rather than as a primary diagnostic tool. *CA-125 blood test* - **CA-125** is a tumor marker primarily used for monitoring ovarian cancer treatment response and recurrence, not for initial diagnosis of endometrial cancer. - Its levels can be elevated in various benign conditions and other cancers, making it non-specific for endometrial cancer diagnosis.

Q: A 65-year-old female presents with postmenopausal bleeding, and an ultrasound reveals a thickened endometrium. What is the most likely diagnosis?

Endometrial carcinoma. ***Endometrial carcinoma*** - **Postmenopausal bleeding** is the classic symptom of endometrial carcinoma, and a **thickened endometrium** on ultrasound is a key indicator. - Endometrial cancer is the most common gynecologic malignancy, particularly in **postmenopausal women**. *Ovarian cyst* - While ovarian cysts are common, they typically present with pelvic pain, pressure, or are asymptomatic, and do not cause **postmenopausal bleeding** or a **thickened endometrium**. - An ultrasound would show a cystic mass in the ovary, not endometrial changes. *Cervical polyp* - Cervical polyps can cause intermenstrual bleeding or postcoital bleeding, but they usually result in **spotting** rather than significant postmenopausal bleeding. - They are typically visualized during a speculum exam and would not explain a diffusely **thickened endometrium** on ultrasound. *Vaginal atrophy* - **Vaginal atrophy** can cause spotting or light bleeding due to thinning and fragility of the vaginal mucosa. - However, it would not lead to a **thickened endometrium** on ultrasound and is usually associated with symptoms like vaginal dryness and dyspareunia.

Q: What is the primary goal of management in a patient with a molar pregnancy?

Complete evacuation of the mole. ***Complete evacuation of the mole*** - The primary goal in managing a molar pregnancy is the complete removal of all **trophoblastic tissue** to prevent persistent gestational trophoblastic disease (GTD) or choriocarcinoma. - This is typically achieved through **suction dilation and curettage (D&C)**, which is the safest and most effective method. *Immediate chemotherapy* - Chemotherapy is not the immediate primary management for a molar pregnancy; it is reserved for patients who develop **persistent GTD** or **choriocarcinoma** after initial evacuation. - The initial approach focuses on removing the abnormal tissue rather than systemic treatment for malignancy unless it develops. *Hysterectomy* - Hysterectomy is generally reserved for patients who have **completed childbearing** and desire definitive treatment to prevent recurrent molar pregnancy or persistent GTD, or in cases of intractable bleeding. - It is not the primary approach for all molar pregnancies, especially in women who desire future fertility. *Preservation of the uterus may be considered in some cases for future fertility.* - While preservation of the uterus is a desirable secondary goal for patients who wish to retain future fertility, it is secondary to the primary goal of **complete mole evacuation**. - The focus is first on safely removing the molar tissue, and then on monitoring to ensure the uterus is healthy for potential future pregnancies.

Q: A 45-year-old woman presents for her annual gynecological exam. Which cytology-based screening test is primarily used for cervical cancer screening?

Pap smear. ***Pap smear*** - A **Pap smear** (Papanicolaou test) is the primary screening tool for **cervical cancer**, detecting **precancerous** and cancerous cells on the cervix. - Given her history of **HPV infection**, which is the main cause of **cervical cancer**, regular Pap smears are crucial for early detection and prevention. *Colonoscopy* - A **colonoscopy** is used to screen for **colorectal cancer** by examining the large intestine for polyps or abnormal tissue. - It is not indicated for cervical cancer screening. *Mammography* - **Mammography** is a screening tool specifically for detecting **breast cancer**. - It uses X-rays to visualize breast tissue and is unrelated to cervical cancer screening. *CA-125* - **CA-125** is a tumor marker primarily used for monitoring treatment response in women with **ovarian cancer**, not as a general screening tool for the general population. - While it can be elevated in some gynecological conditions, it is not a recommended screening test for cervical cancer due to its low specificity and sensitivity for this purpose.

Q: A 45-year-old woman with endometrial cancer exhibits deep myometrial invasion and pelvic lymph node involvement. What is the best treatment?

Chemoradiation. ***Correct: Chemoradiation*** - **Deep myometrial invasion + pelvic lymph node involvement** indicates **Stage IIIC1 endometrial cancer** (FIGO staging), which is high-risk disease requiring multimodal therapy - Standard treatment is **surgery** (total hysterectomy with bilateral salpingo-oophorectomy + lymphadenectomy) followed by **adjuvant chemotherapy plus radiation** - **Combined chemoradiation** (concurrent or sequential) is superior to radiation alone for **node-positive disease** as it addresses both local recurrence risk and systemic micrometastases - Evidence from **GOG-122, PORTEC-3, and GOG-258 trials** supports chemotherapy + radiation for advanced/high-risk endometrial cancer *Incorrect: Hysterectomy + radiation* - While surgery followed by radiation was historically used, this approach is **insufficient for Stage IIIC disease** with lymph node involvement - **Radiation alone does not address systemic disease risk** - patients with positive nodes have high risk of distant metastases requiring systemic chemotherapy - Modern guidelines (NCCN, ESMO) recommend **adding chemotherapy** to surgery and radiation for node-positive disease *Incorrect: Hysterectomy only* - Surgery alone is appropriate only for **early-stage, low-risk endometrial cancer** (Stage IA, Grade 1-2) - With deep myometrial invasion and lymph node involvement, surgery alone has **unacceptably high recurrence rates** - Adjuvant therapy is mandatory for disease control *Incorrect: Chemotherapy only* - Chemotherapy alone does not provide adequate **local-regional control** - While chemotherapy addresses systemic disease, **pelvic radiation is needed** to control local disease in the pelvis and reduce pelvic recurrence - The optimal approach combines both modalities after surgical staging

Q: A 55-year-old woman presents with postmenopausal bleeding. An endometrial biopsy reveals atypical endometrial hyperplasia. What is the most appropriate treatment?

Hysterectomy. ***Hysterectomy*** - **Atypical endometrial hyperplasia** carries a significant risk (25-50%) of progression to **endometrial cancer**, especially in postmenopausal women. - **Hysterectomy** (removal of the uterus) is the most appropriate definitive treatment to eliminate the hyperplastic tissue and prevent future malignant transformation. *Observation* - **Observation** is not recommended for atypical hyperplasia due to the high risk of **malignant progression**. - It would be considered only for simple or complex hyperplasia without atypia, or in very specific cases where surgery is contraindicated. *Progesterone therapy* - **Progesterone therapy** can be used to treat simple or complex hyperplasia without atypia, or atypical hyperplasia in women who desire future fertility. - However, for postmenopausal women with **atypical hyperplasia**, the efficacy of medical management is lower, and the risk of progression often warrants surgical intervention. *Endometrial ablation* - **Endometrial ablation** destroys the endometrial lining and is primarily used to treat dysfunctional uterine bleeding. - It is **contraindicated** in cases of atypical hyperplasia or malignancy because it can obscure the diagnosis and prevent adequate sampling if cancer is present.

Q: In a 54-year-old woman presenting with grade 1 endometrial cancer and a strong family history of Lynch syndrome, which genetic test is essential before deciding between a conservative and a radical treatment approach?

MLH1/MSH2/MSH6/PMS2 genetic testing. ***MLH1/MSH2/MSH6/PMS2 genetic testing*** - Given the **strong family history of Lynch syndrome** and endometrial cancer, testing for mutations in the **mismatch repair (MMR) genes (MLH1, MSH2, MSH6, PMS2)** is crucial to confirm the diagnosis of Lynch syndrome. - Identifying Lynch syndrome has significant implications for treatment planning (e.g., risk-reducing surgeries), surveillance for other cancers, and genetic counseling for family members. *BRCA1/2 gene testing* - **BRCA1/2 mutations** are primarily associated with hereditary **breast and ovarian cancer syndrome**, not Lynch syndrome. - While BRCA mutations can increase the risk of some other cancers, they are not the primary genetic drivers for endometrial cancer in the context of Lynch syndrome. *K-ras mutation testing* - **K-ras mutations** are frequently found in various cancers, including colorectal cancer and lung cancer, and can be prognostic or predictive of response to certain targeted therapies, but it is not directly linked to the diagnosis of Lynch syndrome or its management. - It would not help to determine whether to pursue conservative vs. radical treatment specific to the hereditary risk associated with Lynch syndrome. *HER2/neu amplification* - **HER2/neu amplification** is a significant biomarker in **breast and gastric cancers**, guiding the use of anti-HER2 targeted therapies. - It is not a relevant genetic test for diagnosing Lynch syndrome or influencing treatment decisions for endometrial cancer in the context of a suspected hereditary cancer syndrome.

Q: A 30-year-old woman with a recent pregnancy experiences sudden hematuria and uterine bleeding. Histology reveals syncytiotrophoblast and cytotrophoblast cells without chorionic villi. Which malignancy is consistent with this presentation?

Choriocarcinoma. ***Choriocarcinoma*** - The presence of **syncytiotrophoblast** and **cytotrophoblast cells** without **chorionic villi** in the context of recent pregnancy, uterine bleeding, and hematuria is characteristic of choriocarcinoma. - This highly aggressive tumor often develops after a molar pregnancy, abortion, or normal pregnancy and is associated with very high **beta-hCG levels**. *Complete hydatidiform mole* - Characterized by **swollen chorionic villi** and **trophoblastic proliferation**, which are explicitly stated as absent in the provided histology. - While it can present with uterine bleeding and high hCG, the histological findings differentiate it from choriocarcinoma. *Placental site trophoblastic tumor* - Composed predominantly of **intermediate trophoblast cells** and lacks the prominent syncytiotrophoblast and cytotrophoblast differentiation seen in choriocarcinoma. - Though it also follows pregnancy, its microscopic features and clinical behavior, including hCG levels, differ from choriocarcinoma. *Partial hydatidiform mole* - Involves the presence of **fetal tissue** and **some normal chorionic villi** alongside hydropic villi, which are not described in the patient's histology. - It also has a lower risk of malignant transformation compared to complete moles or choriocarcinoma.

Q: Extramammary Paget's disease most commonly affects which anatomical site?

Vulva. **Vulva** - **Extramammary Paget's disease (EMPD)** primarily occurs in areas rich in **apocrine glands**. - The **vulva** is the most common site for EMPD, followed by the perianal region and groin. *Vagina* - The vagina is lined by **squamous epithelium** and lacks the abundance of apocrine glands typically associated with EMPD. - While extremely rare, primary vaginal Paget's disease is uncharacteristic compared to vulvar involvement. *Cervix* - The cervix is composed of **squamous and glandular epithelium** but is not a typical site for EMPD. - Cervical lesions are more commonly associated with human papillomavirus (HPV) infection. *Uterus* - The uterus is an internal organ lined by **endometrial tissue** and is not a site where EMPD typically develops. - Uterine pathologies usually involve endometrial or myometrial cells, unrelated to Paget's disease.

Question 1

What is the most effective method for diagnosing endometrial cancer in a postmenopausal woman with abnormal uterine bleeding?

Accepted Answer

Endometrial biopsy

Answer

Transvaginal ultrasound

Answer

Hysteroscopy

Answer

CA-125 blood test

Question 2

A 65-year-old female presents with postmenopausal bleeding, and an ultrasound reveals a thickened endometrium. What is the most likely diagnosis?

Accepted Answer

Endometrial carcinoma

Answer

Ovarian cyst

Answer

Cervical polyp

Answer

Vaginal atrophy

Question 3

What is the primary goal of management in a patient with a molar pregnancy?

Accepted Answer

Complete evacuation of the mole

Answer

Immediate chemotherapy

Answer

Hysterectomy

Answer

Uterine preservation for future fertility

Question 4

A 22-year-old woman presents for a routine check-up. The Pap smear shows LSIL. What is the appropriate follow-up?

Accepted Answer

Repeat Pap smear in 6 months

Answer

Immediate colposcopy

Answer

HPV testing

Answer

Cone biopsy

Question 5

A 45-year-old woman presents for her annual gynecological exam. Which cytology-based screening test is primarily used for cervical cancer screening?

Accepted Answer

Pap smear

Answer

Colonoscopy

Answer

Mammography

Answer

CA-125

Question 6

A 45-year-old woman with endometrial cancer exhibits deep myometrial invasion and pelvic lymph node involvement. What is the best treatment?

Accepted Answer

Chemoradiation

Answer

Hysterectomy + radiation

Answer

Hysterectomy only

Answer

Chemotherapy only

Question 7

A 55-year-old woman presents with postmenopausal bleeding. An endometrial biopsy reveals atypical endometrial hyperplasia. What is the most appropriate treatment?

Accepted Answer

Hysterectomy

Answer

Observation

Answer

Progesterone therapy

Answer

Endometrial ablation

Question 8

In a 54-year-old woman presenting with grade 1 endometrial cancer and a strong family history of Lynch syndrome, which genetic test is essential before deciding between a conservative and a radical treatment approach?

Accepted Answer

MLH1/MSH2/MSH6/PMS2 genetic testing

Answer

BRCA1/2 gene testing

Answer

K-ras mutation testing

Answer

HER2/neu amplification

Question 9

A 30-year-old woman with a recent pregnancy experiences sudden hematuria and uterine bleeding. Histology reveals syncytiotrophoblast and cytotrophoblast cells without chorionic villi. Which malignancy is consistent with this presentation?

Accepted Answer

Choriocarcinoma

Answer

Placental site trophoblastic tumor

Answer

Complete hydatidiform mole

Answer

Partial hydatidiform mole

Question 10

Extramammary Paget's disease most commonly affects which anatomical site?

Accepted Answer

Vulva

Answer

Vagina

Answer

Cervix

Answer

Uterus

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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