Gynecologic Oncology Practice Questions

Q: In a case of molar pregnancy, the most important marker for monitoring response to treatment is:

Serum hCG. ***Serum hCG*** - **Human chorionic gonadotropin (hCG)** is produced by the trophoblastic tissue, which is overproliferated in molar pregnancies. - Monitoring **serial hCG levels** post-evacuation is the **gold standard** for detecting persistent trophoblastic disease or malignant transformation. - A rise or plateau in hCG levels indicates inadequate treatment or recurrence, requiring chemotherapy. - **Clinical protocol**: Weekly hCG monitoring until three consecutive negative results, then monthly for 6 months (FIGO guidelines). *Serum CA-125* - **CA-125** is primarily a marker for ovarian cancer and certain benign gynecologic conditions like endometriosis. - It is not a reliable marker for monitoring the response to treatment in **molar pregnancies**. *Serum estriol* - **Estriol** is a hormone produced by the placenta and fetal adrenal gland, primarily used to monitor fetal well-being during pregnancy. - It has no role in the diagnosis or monitoring of **molar pregnancies**. *Serum AFP* - **Alpha-fetoprotein (AFP)** is a tumor marker for certain germ cell tumors, liver cancer, and is also used in prenatal screening for neural tube defects. - It is not associated with the pathogenesis or monitoring of **molar pregnancies**.

Q: Most sensitive marker for early detection of ovarian cancer?

HE4. ***HE4*** - **HE4 (Human Epididymis Protein 4)** demonstrates **higher specificity** than CA-125 in distinguishing **malignant from benign pelvic masses**, particularly in premenopausal women where CA-125 has many false positives. - It is less frequently elevated in **benign gynecological conditions** (endometriosis, fibroids) compared to CA-125. - While sensitivity is comparable to CA-125, HE4's advantage lies in its **superior specificity**, making it useful for risk assessment when an ovarian mass is detected. - **Important limitation**: Neither HE4 nor CA-125 alone is sufficiently sensitive or specific for population-based screening for early ovarian cancer. *CA-125* - **CA-125** remains the most widely used biomarker and has **high sensitivity** for epithelial ovarian cancer, especially in postmenopausal women. - Major limitation is **low specificity** - elevated in numerous **benign conditions** including endometriosis, uterine fibroids, menstruation, pregnancy, and pelvic inflammatory disease. - Its primary utility is in **monitoring treatment response** and **detecting recurrence**, rather than initial screening. *RMI score* - The **Risk of Malignancy Index (RMI)** combines CA-125 levels, menopausal status, and ultrasound findings to assess the risk of malignancy in women with adnexal masses. - Used for **risk stratification** and determining appropriate referral to gynecologic oncology. - It is a composite scoring system, not a single biomarker. *ROMA score* - The **Risk of Ovarian Malignancy Algorithm (ROMA)** combines **CA-125 and HE4 levels** with menopausal status to estimate the probability of epithelial ovarian cancer. - Provides **better diagnostic accuracy** than either CA-125 or HE4 alone for distinguishing benign from malignant pelvic masses. - It is a **predictive algorithm** utilizing multiple parameters rather than a single marker.

Q: A 76-year-old female presented with non-healing ulcer on labia majora for 6 months measuring 2 x 3 cm with no palpable lymphadenopathy. Biopsy shows Squamous cell carcinoma. Management of this patient includes?

Radical vulvectomy with sentinel LN biopsy. ***Radical vulvectomy with sentinel LN biopsy*** - Due to the **size and invasive nature** of the squamous cell carcinoma (2x3 cm), a **radical vulvectomy** is necessary to achieve clear margins and prevent recurrence. - Absence of palpable **lymphadenopathy** makes **sentinel lymph node biopsy** appropriate for staging and determining the need for further groin dissection. *Chemoradiation with resection* - While chemoradiation is used for advanced or inoperable vulvar cancer, **primary surgical resection** is the preferred treatment for localized, resectable lesions. - This approach might be considered as **adjuvant therapy** or for locally advanced disease, but not as the initial definitive management for a resectable lesion. *Simple vulvectomy* - A **simple vulvectomy** involves removing only the vulvar skin and superficial tissue, which is **insufficient for invasive squamous cell carcinoma** of this size. - This procedure would likely result in **positive margins** and a high risk of local recurrence. *Wide excision* - A **wide local excision** provides wider margins than simple excision but may still be inadequate for an invasive lesion measuring 2x3 cm, especially in an area with a high risk of local spread. - It does not address the crucial aspect of **lymphatic staging**, which is essential for determining prognosis and further treatment.

Q: Which condition does NOT increase the risk of cervical cancer?

Nulliparity. ***Nulliparity*** - **Nulliparity** (never having given birth) is generally associated with a *reduced* risk of cervical cancer, or it has no significant impact. - Increased parity (multiple full-term pregnancies) is a risk factor, possibly due to hormonal changes or chronic inflammation. *Multiple sexual partners* - Having multiple sexual partners increases the risk of exposure to **Human Papillomavirus (HPV)**, the primary cause of cervical cancer. - Greater exposure to various HPV strains elevates the likelihood of persistent viral infection and subsequent cellular changes. *HPV infection* - **High-risk HPV strains** (e.g., HPV 16, 18) are the leading cause of cervical cancer, responsible for almost all cases. - Persistent infection with these oncogenic HPV types leads to progressive cervical dysplasia and, eventually, invasive cancer. *Smoking* - Smoking is an independent risk factor for cervical cancer, even after accounting for HPV infection. - Chemicals in tobacco smoke can reach the cervical mucus and damage DNA, impairing the immune system's ability to clear HPV infections.

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: 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.

Question 1

In a case of molar pregnancy, the most important marker for monitoring response to treatment is:

Accepted Answer

Serum hCG

Answer

Serum CA-125

Answer

Serum estriol

Answer

Serum AFP

Question 2

Which drug is most appropriate for reducing risk of ovarian cancer in a BRCA1 positive woman not planning for children?

Accepted Answer

Oral contraceptive pills

Answer

Gonadotropin-releasing hormone

Answer

Tamoxifen

Answer

Progesterone IUD

Question 3

Most sensitive marker for early detection of ovarian cancer?

Accepted Answer

HE4

Answer

CA-125

Answer

RMI score

Answer

ROMA score

Question 4

A 76-year-old female presented with non-healing ulcer on labia majora for 6 months measuring 2 x 3 cm with no palpable lymphadenopathy. Biopsy shows Squamous cell carcinoma. Management of this patient includes?

Accepted Answer

Radical vulvectomy with sentinel LN biopsy

Answer

Chemoradiation with resection

Answer

Simple vulvectomy

Answer

Wide excision

Question 5

Which condition does NOT increase the risk of cervical cancer?

Accepted Answer

Nulliparity

Answer

Multiple sexual partners

Answer

HPV infection

Answer

Smoking

Question 6

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 7

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 8

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 9

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 10

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

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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