Gynecologic Oncology Practice Questions

Q: Poor prognostic factor for hydatidiform mole is -

WHO score > 8. ***WHO score > 8*** - A **WHO score > 8** (more specifically, WHO/FIGO score ≥7) indicates **high-risk gestational trophoblastic neoplasia (GTN)**, which is associated with a poor prognosis and requires multi-agent chemotherapy. - The WHO prognostic scoring system incorporates various factors: age, prior pregnancy outcome, antecedent pregnancy type, interval from index pregnancy, pre-treatment hCG level, largest tumor size, site of metastases, and number of metastases. - This is the **strongest poor prognostic indicator** among the options listed. *Prior molar pregnancy* - A **prior molar pregnancy** increases the *risk* of developing another molar pregnancy (recurrence risk ~1-2%), but it is **not a component of the WHO prognostic scoring system** and is not a poor prognostic factor for the outcome of current GTN. - The history affects surveillance requirements but doesn't dictate the difficulty of treating the current episode. *Metastasis to lung* - **Lung metastases** are actually among the **better prognostic sites** for metastatic GTN in the WHO scoring system. - Lung and vaginal metastases score only 1 point, whereas liver and brain metastases (true poor prognostic sites) score 4 points each. - While any metastasis indicates more advanced disease, isolated lung metastases generally have a *good prognosis* with appropriate chemotherapy, with cure rates >90%. *No prior chemotherapy* - The *absence* of **prior chemotherapy** is a **favorable prognostic factor**, not a poor one. - Patients who have *failed* prior chemotherapy or have received ≥2 drugs previously score 2-4 points in the WHO system, indicating worse prognosis. - No prior chemotherapy (scores 0 points) means better treatment response and outcomes.

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: Which of the following precancerous conditions, if treated, has the highest likelihood of not leading to cancer?

Cervical intraepithelial Neoplasia. ***Cervical intraepithelial neoplasia (CIN)*** - CIN has a high success rate with treatment (e.g., **cryotherapy**, **LEEP**), often completely eradicating the dysplastic cells and preventing progression to **invasive cervical cancer**. - The effectiveness of screening via **Pap smears** allows for early detection and intervention, significantly reducing cancer risk. *Ductal carcinoma in situ (DCIS) of breast* - While treatable, DCIS carries a higher risk of recurrence and progression to **invasive breast cancer** in the same or contralateral breast compared to CIN. - Treatment often involves **lumpectomy** with or without radiation, and sometimes **total mastectomy**, reflecting its more serious potential. *Lobular carcinoma in situ (LCIS) of breast* - LCIS is largely considered a **risk indicator** for future invasive cancer in either breast, rather than a direct precursor that inevitably progresses. - Management often involves **close surveillance** or **chemoprevention**, as surgical excision does not prevent cancer development in other areas of the breast. *Vaginal intraepithelial neoplasia (VAIN)* - While treatable, VAIN is less common and often coexists with or follows **cervical or vulvar neoplasia**, indicating a broader field defect due to **HPV**. - Recurrence rates post-treatment can be significant, and patients often require long-term follow-up due to the continued risk of progression.

Q: A patient presents with bilateral ovarian carcinoma, capsule involvement, ascites, and paraaortic lymphadenopathy. What is the appropriate stage of the disease?

Stage 3C. ***Stage 3C*** - **Bilateral ovarian carcinoma** with **capsule involvement**, **ascites**, and especially **paraaortic lymph node metastases** are defining features of Stage IIIC ovarian cancer. - Involvement of **retroperitoneal lymph nodes**, including paraaortic nodes, automatically upstages the disease to Stage III, irrespective of other abdominal spread. *Stage 1C* - This stage refers to ovarian cancer confined to **one or both ovaries**, with evidence of rupture, capsule involvement, or malignant cells in ascites/peritoneal washings, but **without lymph node involvement**. - The presence of **paraaortic lymphadenopathy** in this patient immediately excludes Stage 1C. *Stage 2C* - Stage 2 ovarian cancer involves one or both ovaries with **pelvic extension** beyond the ovaries, but still **without lymph node involvement**. - The patient's involvement of **paraaortic lymph nodes** goes beyond pelvic extension and therefore excludes Stage 2C. *Stage 4C* - Stage 4 ovarian carcinoma involves **distant metastasis** beyond the peritoneal cavity or distant lymph nodes (e.g., pleural effusion with positive cytology, parenchymal liver/spleen metastasis). - While paraaortic lymphadenopathy indicates advanced disease, it falls within the criteria for Stage 3 due to its location, not Stage 4.

Q: In which stage of cervical carcinoma is surgery performed to retain the possibility of conception?

Stage 1B1. ***Stage 1B1*** - In **Stage 1B1 cervical carcinoma** (FIGO 2018), the tumor size is **≤2 cm** and confined to the cervix, making it amenable to **fertility-sparing surgery** like radical trachelectomy. - This stage allows for removal of the cervix and parametrium while preserving the **uterine body** and ovaries, thus retaining the possibility of conception. - Strict selection criteria must be met including tumor size ≤2 cm, no lymphovascular space invasion, negative lymph nodes, and adequate follow-up compliance. *Stage 1B2* - **Stage 1B2** (FIGO 2018) involves tumors **>2 cm to ≤4 cm** but still confined to the cervix, which generally have a higher risk of recurrence and lymph node metastasis. - While fertility-sparing surgery might be considered in highly selective cases with tumors 2-3 cm, it is much less commonly performed than in Stage 1B1 due to the increased tumor burden and higher oncological risk. *Stage 2A* - In **Stage 2A cervical carcinoma**, the tumor has spread beyond the cervix to involve the upper two-thirds of the vagina (2A1: ≤4 cm, 2A2: >4 cm) but not the parametrium. - The disease extent typically necessitates more aggressive treatment such as radical hysterectomy or **chemoradiation**, precluding preservation of fertility in most cases. *Stage 2B* - **Stage 2B** involves tumor invasion into the **parametrium**, making fertility-sparing surgery contraindicated and typically requiring **definitive chemoradiation**. - The spread of cancer to the parametrium indicates a more advanced disease that cannot be adequately treated by methods that preserve fertility.

Q: Which of the following statements about radical hysterectomy in stage Ib cervical cancer compared to radiotherapy is false?

It is less complicated than radiotherapy.. ***It is less complicated than radiotherapy.*** - Radical hysterectomy is a **major surgical procedure** with potential complications like **hemorrhage**, infection, **ureteral injury**, and **lymphedema**, which can be significant and life-altering. - Radiotherapy, while having its own set of side effects (e.g., **vaginal stenosis**, bladder/rectal irritation), typically avoids the acute surgical risks and recovery period associated with extensive surgery. *Chance of recurrence is lower with radical hysterectomy.* - For early-stage cervical cancer (Ib1/Ib2), both **radical hysterectomy** and **radiotherapy** provide **comparable outcomes** in terms of recurrence rates. - The choice between therapies often depends on patient factors, surgeon expertise, and pathological findings, but neither consistently demonstrates a significantly lower recurrence rate over the other in large cohorts. *Ovarian function can be preserved.* - In younger patients undergoing **radical hysterectomy**, it is often possible to **preserve the ovaries** by transplanting them or avoiding their removal if not directly involved, thus maintaining **endocrine function**. - **Pelvic radiotherapy**, in contrast, invariably leads to **ovarian radiation** and subsequent **ovarian failure** and menopause. *Chance of survival is higher with radical hysterectomy.* - For early-stage cervical cancer (Ib), **overall survival rates** are generally **equivalent** between radical hysterectomy and primary radiotherapy. - Meta-analyses and large retrospective studies have shown **similar 5-year survival rates** for both treatment modalities when applied appropriately to well-selected patients.

Q: Magnification obtained by colposcopy is?

10-20 times. ***10-20 times*** - Colposcopes typically provide magnification in the range of **10 to 20 times** to allow for detailed examination of the cervix, vagina, and vulva. - This magnification level is sufficient to identify changes in the **epithelium**, such as those associated with dysplasia or cancer. *1-2 times* - A magnification of 1-2 times is very low and would not be adequate for **detailed visualization** of the cervix and its microscopic changes. - This range is more akin to **naked eye** observation or a simple magnifying glass, insufficient for colposcopic purposes. *5-6 times* - While 5-6 times magnification offers some detail, it is generally **insufficient** for the precise identification of subtle epithelial changes or abnormal vascular patterns characteristic of dysplasia. - Most colposcopes are designed to provide higher magnification to enhance diagnostic accuracy. *15-25 times* - While some advanced colposcopes might offer magnification up to 25 times, the standard and most commonly used range is **10-20 times**. - Magnification significantly beyond 20 times can sometimes lead to a **smaller field of view** and increased difficulty in focusing, making it less practical for routine examination.

Q: Most common presentation of cervical cancer is -

Abnormal vaginal bleeding. ***Abnormal vaginal bleeding*** - **Abnormal vaginal bleeding** is the most frequent presenting symptom of cervical cancer, often manifesting as **postcoital bleeding**, intermenstrual bleeding, or heavier, longer menstrual periods. - This symptom arises as the tumor on the cervix ulcerates and bleeds due to its friable nature and rich vascularization. *Pelvic pain* - **Pelvic pain** is typically a symptom of more **advanced cervical cancer**, indicating tumor invasion into surrounding tissues or nerves. - It is not usually an early or the most common presenting symptom, unlike abnormal bleeding. *Pain during intercourse* - **Pain during intercourse (dyspareunia)** can be a symptom of cervical cancer, particularly with larger lesions or those causing inflammation. - However, it is less common than abnormal bleeding and often occurs concurrently with or after the onset of bleeding symptoms. *Unusual vaginal discharge* - An **unusual vaginal discharge**, which may be watery, foul-smelling, or blood-tinged, can occur with cervical cancer. - While a common symptom, it is generally considered less frequent than abnormal vaginal bleeding as the primary presenting complaint.

Q: What is the stage of endometrial carcinoma when it involves the cervix?

Stage 2: Cancer has spread to the cervix.. ***Stage 2: Cancer has spread to the cervix*** - According to the **FIGO 2009 staging system** for endometrial carcinoma (applicable at the time of this exam), involvement of the cervix with **stromal invasion** without extending beyond the uterus into the parametrium is classified as **Stage II**. - This stage indicates that the cancer remains within the confines of the uterus but has spread from the uterine corpus to the **cervical stroma**. - **Note:** FIGO staging was updated in 2023, but this question reflects the 2009 criteria used at the time. *Stage 1: Cancer confined to the uterus* - This stage indicates that the cancer is **limited to the uterine corpus (body of the uterus)**, with no spread to the cervix or beyond. - Stage 1 is further subdivided based on the **depth of myometrial invasion**, but the cervix is not involved at this stage. *Stage 3: Cancer has spread beyond the uterus but not beyond the pelvis* - Stage 3 involves spread **beyond the uterus but is still confined to the pelvis**, including parametrial involvement, vaginal or serosal invasion, or pelvic/paraaortic lymph node involvement. - This stage represents more extensive local or regional spread than simply cervical involvement. *Stage 4: Cancer has spread to distant sites* - This is the most advanced stage, indicating that the cancer has spread to **distant organs** (e.g., lungs, bone) or involves the **bladder or bowel mucosa**. - Stage 4 represents a systemic disease rather than localized pelvic spread.

Q: What is the initial drug of choice for ovarian cancer?

Cisplatin. ***Cisplatin*** - **Cisplatin** is a platinum-based chemotherapy drug that forms DNA adducts, leading to apoptosis and is a **first-line agent** for ovarian cancer. - Historically, it was the platinum agent of choice and is typically used in combination with a taxane (e.g., **paclitaxel**) for initial treatment of advanced disease. - **Note:** In current practice, **carboplatin** has largely replaced cisplatin as the preferred platinum agent due to better tolerability, less nephrotoxicity and neurotoxicity, and easier administration, while maintaining equivalent efficacy. - Among the options listed, **cisplatin remains the correct answer** as it is the only platinum-based first-line agent. *Doxorubicin* - **Doxorubicin** is an **anthracycline antibiotic** used in various cancers but is **not a first-line drug** for ovarian cancer. - It may be used in recurrent or platinum-resistant disease. - Its use is limited due to potential **cardiotoxicity**. *Ifosfamide* - **Ifosfamide** is an **alkylating agent** that is generally reserved for **recurrent** or refractory ovarian cancer. - It is associated with **hemorrhagic cystitis** (preventable with mesna) and neurotoxicity. - Not part of standard first-line treatment. *Methotrexate* - **Methotrexate** is an **antimetabolite** primarily used in other cancers like choriocarcinoma and is **not a standard treatment** for epithelial ovarian cancer. - It works by inhibiting dihydrofolate reductase, disrupting DNA synthesis. - Has no role in first-line ovarian cancer treatment.

Question 1

Poor prognostic factor for hydatidiform mole is -

Accepted Answer

WHO score > 8

Answer

Prior molar pregnancy

Answer

Metastasis to lung

Answer

No prior chemotherapy

Question 2

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 3

Which of the following precancerous conditions, if treated, has the highest likelihood of not leading to cancer?

Accepted Answer

Cervical intraepithelial Neoplasia

Answer

Ductal carcinoma in situ of breast

Answer

Lobular carcinoma in situ of breast

Answer

Vaginal intraepithelial neoplasia

Question 4

A patient presents with bilateral ovarian carcinoma, capsule involvement, ascites, and paraaortic lymphadenopathy. What is the appropriate stage of the disease?

Accepted Answer

Stage 3C

Answer

Stage 1C

Answer

Stage 2C

Answer

Stage 4C

Question 5

In which stage of cervical carcinoma is surgery performed to retain the possibility of conception?

Accepted Answer

Stage 1B1

Answer

Stage 1B2

Answer

Stage 2A

Answer

Stage 2B

Question 6

Which of the following statements about radical hysterectomy in stage Ib cervical cancer compared to radiotherapy is false?

Accepted Answer

It is less complicated than radiotherapy.

Answer

Chance of recurrence is lower with radical hysterectomy.

Answer

Ovarian function can be preserved.

Answer

Chance of survival is higher with radical hysterectomy.

Question 7

Magnification obtained by colposcopy is?

Accepted Answer

10-20 times

Answer

1-2 times

Answer

5-6 times

Answer

15-25 times

Question 8

Most common presentation of cervical cancer is -

Accepted Answer

Abnormal vaginal bleeding

Answer

Pelvic pain

Answer

Pain during intercourse

Answer

Unusual vaginal discharge

Question 9

What is the stage of endometrial carcinoma when it involves the cervix?

Accepted Answer

Stage 2: Cancer has spread to the cervix.

Answer

Stage 1: Cancer confined to the uterus.

Answer

Stage 3: Cancer has spread beyond the uterus but not beyond the pelvis.

Answer

Stage 4: Cancer has spread to distant sites.

Question 10

What is the initial drug of choice for ovarian cancer?

Accepted Answer

Cisplatin

Answer

Doxorubicin

Answer

Ifosfamide

Answer

Methotrexate

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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