Gynecologic Oncology Practice Questions

Q: Which of the following does not meet the criteria for conservative surgery in patients with ovarian carcinoma?

FIGO stage II disease. ***FIGO stage II disease*** - **Conservative surgery** (fertility-sparing surgery) for ovarian carcinoma is generally limited to **early-stage disease**, specifically **FIGO stage IA**. - **FIGO stage II** involves tumor extension beyond the ovaries to other pelvic structures, necessitating more aggressive surgical management, typically including **bilateral salpingo-oophorectomy** and **hysterectomy**. *Young patient with no or few children* - This criterion supports considering conservative surgery as it indicates a desire to preserve **fertility**. - **Fertility preservation** is a primary goal when electing conservative management for ovarian cancer. *Well differentiated serous tumor* - **Well-differentiated tumors** (low grade) are associated with a better prognosis and lower risk of recurrence, making conservative surgery a safer option. - This characteristic suggests a less aggressive tumor biology, further supporting the choice of **fertility-sparing surgery**. *No infiltration of capsule, lymphatics or mesoovarium* - The absence of infiltration into these structures indicates a **confined tumor**, reducing the risk of microscopic spread and recurrence. - This criterion is essential for ensuring that conservative surgery adequately removes all disease and prevents dissemination, thus confirming **early-stage disease**.

Q: What is the next step in investigating a 45 year old female with post coital bleeding and abnormal appearing cervix on speculum examination?

Colposcopy. ***Colposcopy*** - Colposcopy is the appropriate next step to **directly visualize the cervical abnormality under magnification** and identify suspicious areas for targeted biopsy. - This allows for precise, **colposcopy-guided biopsies** of abnormal areas, which is crucial for **histopathological diagnosis** of potential cervical pathology including dysplasia or cancer. - It provides better visualization of the transformation zone and helps determine the extent of any lesion. *Dilatation and curettage* - This procedure involves scraping the uterine lining and is primarily used for diagnosing conditions affecting the **endometrium**, not cervical abnormalities. - It would not provide visualization or targeted biopsy of a cervical lesion. *Conisation* - Conisation is both a diagnostic and therapeutic procedure to remove a cone-shaped piece of cervical tissue. - It is typically performed **after** colposcopy and biopsy have confirmed significant dysplasia or cancer, not as the initial investigative step. - Performing conisation without prior colposcopic assessment risks inadequate margins or unnecessary tissue removal. *Hysteroscopy* - Hysteroscopy is a procedure to visualize the **inside of the uterine cavity** and is used to investigate intrauterine conditions like polyps, fibroids, or endometrial abnormalities. - It does not provide visualization of the cervix and would not help investigate cervical pathology causing post-coital bleeding.

Q: What is the treatment for stage IB1 cervical cancer?

Wertheim's hysterectomy (radical hysterectomy). ***Wertheim's hysterectomy (radical hysterectomy)*** - For **stage IB1** cervical cancer, **radical hysterectomy** (Type III/Wertheim's procedure) with pelvic lymphadenectomy is one of the two standard treatment options. - This procedure removes the uterus, cervix, parametrium, upper vagina, and pelvic lymph nodes to achieve clear margins and assess nodal involvement. - Preferred in **younger women** desiring to preserve ovarian function and sexual function, and in centers with surgical expertise. - Both radical surgery and chemoradiotherapy have **equivalent survival outcomes** for stage IB1. *Chemoradiotherapy* - **Definitive chemoradiotherapy** (concurrent cisplatin-based chemotherapy with external beam radiation plus brachytherapy) is the **other standard first-line treatment** for stage IB1 cervical cancer. - It is preferred in patients who are **poor surgical candidates**, have medical comorbidities, or prefer non-surgical management. - Also the treatment of choice for **locally advanced disease** (stages IB2, IIA2, IIB-IVA). *Radiation therapy* - **Radiation alone** (without concurrent chemotherapy) has inferior outcomes compared to chemoradiotherapy for stages IB1 and above. - May be used only in patients who cannot tolerate chemotherapy. *Chemotherapy* - **Chemotherapy alone** is not curative for localized cervical cancer. - Used for **recurrent or metastatic disease** (stage IVB) in combination with bevacizumab.

Q: Carcinoma endometrium with involvement of the vaginal wall is included in which stage ?

IIIB. ***IIIB*** - **Stage IIIB** for endometrial carcinoma specifically includes tumor involvement of the **vaginal wall** or parametrium, but not the bladder or rectum. - This staging criterion is based on the **FIGO (International Federation of Gynecology and Obstetrics)** staging system, which is used for gynecological cancers. *IIIA* - **Stage IIIA** typically refers to tumor invasion of the **serosa** of the uterus or **adnexa** (ovaries or fallopian tubes). - It does not involve the vaginal wall, differentiating it from IIIB. *IIIC* - **Stage IIIC** indicates regional lymph node metastasis, specifically **pelvic** or **para-aortic lymph nodes**, regardless of the extent of local spread. - While lymph node involvement often co-occurs with advanced local disease, the presence of vaginal wall involvement alone does not automatically classify it as IIIC unless lymph node metastases are confirmed. *IVA* - **Stage IVA** denotes tumor invasion of the **bladder** or **bowel mucosa**. - This stage represents more extensive local spread than vaginal wall involvement, directly invading adjacent pelvic organs.

Q: Most common cause of vulval carcinoma?

HPV infection. ***HPV infection*** - **Human Papillomavirus (HPV)**, particularly high-risk strains like HPV 16 and 18, is the most significant risk factor and cause of most vulvar squamous cell carcinomas. - HPV leads to **dysplastic changes** in the vulvar epithelium (vulvar intraepithelial neoplasia, VIN) that can progress to invasive cancer. *EBV infection* - **Epstein-Barr Virus (EBV)** is primarily associated with lymphomas (e.g., Burkitt lymphoma, Hodgkin lymphoma) and nasopharyngeal carcinoma, not vulvar carcinoma. - While EBV can cause various cancers, there is no direct link establishing it as a common cause of vulvar malignancy. *Herpes genitalis infection* - **Herpes Simplex Virus (HSV)** causes painful genital lesions but is not a recognized cause of vulvar carcinoma. - HSV infection is not associated with the cellular changes that lead to squamous cell cancer development. *Syphilis infection* - **Syphilis**, caused by *Treponema pallidum*, can lead to genital ulcers (chancres) and other systemic manifestations but is not a known cause of vulvar carcinoma. - While chronic inflammation is a risk factor for some cancers, syphilis does not directly induce the genetic mutations typical of vulvar cancer.

Q: What is the most common site of sarcoma botryoides?

Vagina. ***Vagina*** - Sarcoma botryoides is a specific variant of **embryonal rhabdomyosarcoma** that characteristically arises from the **vagina**, specifically the anterior vaginal wall, in young girls (typically under 8 years). - Its presentation as a **grape-like polypoid mass** protruding from the vagina is a classic clinical finding. - This is the **most common site** for sarcoma botryoides, making it the correct answer. *Also called embryonal rhabdomyosarcoma* - While sarcoma botryoides is a **subtype of embryonal rhabdomyosarcoma**, this statement describes the classification, not the anatomical site. - Embryonal rhabdomyosarcoma can occur in various locations (head/neck, genitourinary tract, extremities), but sarcoma botryoides specifically refers to the variant with **mucosal origin**, most commonly in the vagina. *It presents with blood stained watery vaginal discharge* - This is a **clinical presentation/symptom**, not an anatomical site. - Blood-stained discharge occurs due to **ulceration** and **tumor necrosis** of the vaginal mass, and is indeed a common presenting feature. *It can be treated with VAC regime* - The **VAC (Vincristine, Actinomycin D, Cyclophosphamide)** regimen is the standard chemotherapy protocol for rhabdomyosarcoma, including sarcoma botryoides. - This statement describes the **treatment modality**, not the most common site of origin.

Q: Extramammary Paget's disease of the vulva is most commonly associated with which other cancer?

Vulvar cancer. ***Vulvar cancer*** - **Extramammary Paget's disease (EMPD)** frequently presents in the vulvar region and is associated with an underlying **adenocarcinoma** in up to 30% of cases. - The disease involves intraepithelial adenocarcinoma cells that can spread locally and, in some instances, indicates a synchronous or metachronous **internal malignancy**, often of genitourinary or gastrointestinal origin, but primarily vulvar adenocarcinoma in this context. *Vaginal cancer* - While Paget's disease can occur in other anogenital areas, its association with **primary vaginal cancer** is much less common compared to vulvar involvement. - **Vaginal Paget's disease** is rare and usually represents secondary spread from a vulvar primary or an underlying bladder/urethral carcinoma. *Cervical cancer* - **Paget's disease** is not typically associated with **cervical cancer**. Cervical cancers are predominantly squamous cell carcinomas or adenocarcinomas arising from the transformation zone. - While cervical adenocarcinoma can present with similar cells to Paget's, it is a distinct entity and not a common association. *Uterine cancer* - **Uterine cancer**, primarily endometrial carcinoma, has no direct or common association with **Paget's disease**. - Paget's disease primarily affects the skin and can be associated with underlying gland cancers, but these are generally in proximity to the epidermal involvement rather than distant uterine sites.

Q: Which of the following is not a standard treatment option for CIN III?

Wertheim's hysterectomy. ***Wertheim's hysterectomy*** - A **Wertheim's hysterectomy**, also known as a **radical hysterectomy**, involves removal of the uterus, cervix, parametrium, and upper vagina, along with pelvic lymph node dissection. This is typically reserved for **invasive cervical cancer**, not CIN III. - While hysterectomy can be a treatment option for CIN III in specific circumstances (e.g., patient preference, coexisting uterine pathology), a Wertheim's hysterectomy is an **overly aggressive procedure** for precancerous lesions due to its significant morbidity. *LLETZ* - **Large Loop Excision of the Transformation Zone (LLETZ)**, also known as LEEP (Loop Electrosurgical Excision Procedure), is a common and effective outpatient treatment for CIN III. - It involves using a heated wire loop to **excise the abnormal tissue** from the cervix, allowing for histological examination. *Conization* - **Cold knife conization** involves excising a cone-shaped piece of tissue from the cervix using a scalpel. This method is highly effective for CIN III. - It provides **excellent pathological specimens** for evaluation of margins, which is crucial for confirming complete removal of the lesion. *Hysterectomy* - **Hysterectomy** (removal of the uterus, usually simple hysterectomy) can be considered a treatment option for CIN III, particularly in women who have completed childbearing and have other indications for hysterectomy, or when repeated excisional procedures have failed. - While effective, it is a more **invasive procedure** than LLETZ or conization and generally reserved for specific cases where conservative management is not suitable or desired.

Q: Which of the following is the PRIMARY risk factor for cervical carcinoma?

Human papilloma virus. ***Human papilloma virus*** - **High-risk HPV types**, particularly **HPV 16 and 18**, are the primary causative agent of cervical carcinoma, responsible for over 90% of cases. - HPV infection is the **most significant and essential risk factor**, leading to persistent changes in cervical cells that can progress to **dysplasia** and eventually **invasive cancer**. - Cervical cancer is considered an **HPV-associated malignancy**, making HPV the central etiological factor. *Smoking* - **Smoking** is an important cofactor that increases the risk of cervical carcinoma in women with HPV infection, but it is not the primary cause. - Smoking impairs the immune system's ability to clear HPV infections and promotes progression of HPV-induced lesions. - Without HPV infection, smoking alone does not cause cervical cancer. *Low socioeconomic status* - **Low socioeconomic status** is an indirect risk factor associated with reduced access to healthcare and **cervical cancer screening** (Pap smears). - It does not directly cause cervical cancer but leads to delayed diagnosis and treatment, resulting in poorer outcomes. *All of the options* - While all listed factors influence cervical carcinoma risk, **Human papillomavirus (HPV)** is the primary and essential causative agent. - The other factors are cofactors or indirect associations, not primary causes.

Q: What is the most common cause of death in cervical cancer?

Renal failure. ***Renal failure*** - As cervical cancer progresses, it can invade surrounding structures, including the **ureters**. - **Ureteral obstruction** leads to **hydronephrosis** and ultimately **renal failure**, which is a common cause of death. *Infection* - While infections can occur due to immunosuppression or compromised tissue integrity in advanced cancer, they are generally **not the most common direct cause of death**. - Infections are often secondary complications rather than the primary mode of mortality. *Haemorrhage* - Local invasion of blood vessels by advanced cervical cancer can cause **significant bleeding** (haemorrhage). - While potentially life-threatening, it is **less frequent** as a direct cause of death compared to renal failure. *Metastasis to vital organs* - Cervical cancer can metastasize to distant organs like the lungs, liver, or bone; however, direct organ failure solely due to metastases is **less common than renal complications** from local tumor spread. - The impact of metastases often contributes to overall decline but is not the most frequent immediate cause of death.

Question 1

Which of the following does not meet the criteria for conservative surgery in patients with ovarian carcinoma?

Accepted Answer

FIGO stage II disease

Answer

No infiltration of capsule, lymphatics or mesoovarium

Answer

Well differentiated serous tumor

Answer

Young patient with no or few children

Question 2

What is the next step in investigating a 45 year old female with post coital bleeding and abnormal appearing cervix on speculum examination?

Accepted Answer

Colposcopy

Answer

Dilatation and curettage

Answer

Conisation

Answer

Hysteroscopy

Question 3

What is the treatment for stage IB1 cervical cancer?

Accepted Answer

Wertheim's hysterectomy (radical hysterectomy)

Answer

Chemotherapy

Answer

Radiation therapy

Answer

Chemoradiotherapy

Question 4

Carcinoma endometrium with involvement of the vaginal wall is included in which stage ?

Accepted Answer

IIIB

Answer

IIIA

Answer

IIIC

Answer

IVA

Question 5

Most common cause of vulval carcinoma?

Accepted Answer

HPV infection

Answer

EBV infection

Answer

Herpes genitalis infection

Answer

Syphilis infection

Question 6

What is the most common site of sarcoma botryoides?

Accepted Answer

Vagina

Answer

It presents with blood stained watery vaginal discharge

Answer

It can be treated with VAC regime

Answer

Also called embryonal rhabdomyosarcoma

Question 7

Extramammary Paget's disease of the vulva is most commonly associated with which other cancer?

Accepted Answer

Vulvar cancer

Answer

Vaginal cancer

Answer

Cervical cancer

Answer

Uterine cancer

Question 8

Which of the following is not a standard treatment option for CIN III?

Accepted Answer

Wertheim's hysterectomy

Answer

LLETZ

Answer

Conization

Answer

Hysterectomy

Question 9

Which of the following is the PRIMARY risk factor for cervical carcinoma?

Accepted Answer

Human papilloma virus

Answer

Smoking

Answer

Low socioeconomic status

Answer

All of the options

Question 10

What is the most common cause of death in cervical cancer?

Accepted Answer

Renal failure

Answer

Infection

Answer

Haemorrhage

Answer

Metastasis to vital organs

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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