Gynecologic Oncology Practice Questions

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: 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: 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 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.

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: 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: 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: 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.

Question 1

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

Accepted Answer

IIIB

Answer

IIIA

Answer

IIIC

Answer

IVA

Question 2

What is the treatment for stage IB1 cervical cancer?

Accepted Answer

Wertheim's hysterectomy (radical hysterectomy)

Answer

Chemotherapy

Answer

Radiation therapy

Answer

Chemoradiotherapy

Question 3

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 4

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 5

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

Accepted Answer

Renal failure

Answer

Infection

Answer

Haemorrhage

Answer

Metastasis to vital organs

Question 6

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 7

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 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

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 10

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.

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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