Gestational Trophoblastic Disease — MCQs
What are the potential complications in subsequent pregnancies for a woman with a history of gestational trophoblastic disease?
A case of gestational trophoblastic neoplasia with lung metastasis should be staged as:
Snow storm appearance on an ultrasound is seen in:
Prognosis of Gestational Trophoblastic Disease depends on all, except:
A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
Risk of recurrence of hydatidiform mole in future pregnancy is:
A 32-year-old woman with a history of molar pregnancy presents with heavy vaginal bleeding. Which of the following is a serious malignant complication of molar pregnancy?
Tumor marker of epithelial ovarian carcinoma is:
Which is the most common complication of molar pregnancy?
Hysterectomy specimen from a 40-year-old lady is shown along with histology slide. The diagnosis is:
Gestational Trophoblastic Disease Indian Medical PG Practice Questions and MCQs
Question 1: What are the potential complications in subsequent pregnancies for a woman with a history of gestational trophoblastic disease?
- A. Neural tube defects
- B. Skeletal defects
- C. Cardiac defects
- D. Increased risk of recurrent GTD and pregnancy complications (Correct Answer)
Explanation: ***Increased risk of recurrent GTD and pregnancy complications*** - A history of **gestational trophoblastic disease (GTD)** significantly increases the risk of recurrence in subsequent pregnancies, emphasizing the need for close monitoring. - There is also an elevated risk of other **adverse pregnancy outcomes**, including **preterm birth** and **preeclampsia**, following a GTD history. *Neural tube defects* - **Neural tube defects** are congenital anomalies primarily associated with **folate deficiency** and genetic factors, not a prior history of GTD. - They involve incomplete closure of the neural tube during embryonic development, unrelated to trophoblastic tissue. *Cardiac defects* - **Congenital cardiac defects** are multifactorial, linked to genetic predisposition, maternal conditions like **diabetes**, and certain exposures, but not a history of GTD. - They result from abnormal heart development in the early stages of pregnancy. *Skeletal defects* - **Skeletal defects** can be hereditary or related to maternal infections (e.g., rubella), drug exposure (e.g., thalidomide), or specific genetic syndromes, not GTD. - These malformations occur during fetal bone and limb development.
Question 2: A case of gestational trophoblastic neoplasia with lung metastasis should be staged as:
- A. Stage-I
- B. Stage-II
- C. Stage-III (Correct Answer)
- D. Stage-IV
Explanation: ***Stage-III*** - **Stage III** Gestational Trophoblastic Neoplasia (GTN) is defined by the presence of disease that has spread to the **lungs**, with or without genital tract involvement. - The presence of **lung metastasis** immediately classifies the GTN as Stage III, regardless of the primary tumor site. *Stage-I* - **Stage I** GTN is characterized by disease strictly confined to the **uterus**. - There is no evidence of local or distant metastasis in Stage I disease. *Stage-II* - **Stage II** GTN involves disease extension to the **genital structures** (e.g., vagina, ovary, broad ligament) but without distant metastasis. - Lung metastases would automatically preclude a Stage II classification. *Stage-IV* - **Stage IV** GTN indicates the presence of **distant metastases** beyond the lungs, such as to the brain, liver, or kidneys. - While lung metastasis is present in this case, there is no mention of spread to other distant sites that would classify it as Stage IV.
Question 3: Snow storm appearance on an ultrasound is seen in:
- A. Vesicular mole (Correct Answer)
- B. Chronic ectopic pregnancy
- C. Hydatid cyst
- D. Dermoid cyst
Explanation: ***Vesicular mole*** - The classic ultrasound finding in a **complete hydatidiform mole** is a **"snowstorm" appearance**, characterized by a uterine cavity filled with echogenic, vesicular tissue and no fetal parts. - This appearance is due to the **swollen chorionic villi** and **trophoblastic proliferation**. *Chronic ectopic pregnancy* - While an ectopic pregnancy involves an implantation outside the uterus, it typically presents with an **adnexal mass**, sometimes with a **"ring of fire" sign** on Doppler, but not a snowstorm pattern within the uterine cavity. - Chronic ectopic pregnancies may show a more complex adnexal mass with varying echogenicity due to hemorrhage and organization, but this is distinct from the diffuse uterine changes in a hydatidiform mole. *Hydatid cyst* - A **hydatid cyst**, caused by *Echinococcus granulosus*, is typically found in the liver or lungs and appears as a **well-defined, anechoic lesion** with possible internal septations or daughter cysts (often called a "water lily" sign if ruptured) but not a diffuse snowstorm pattern within the uterus. - This condition is a parasitic infection, entirely unrelated to pregnancy. *Dermoid cyst* - A **dermoid cyst** (mature cystic teratoma) is an ovarian tumor that typically appears as a **complex adnexal mass** with characteristic features like a **"Rokitansky nodule"**, fat-fluid levels, and highly echogenic components (e.g., hair, teeth). - Its appearance is localized to the ovary and does not mimic the widespread uterine findings of a vesicular mole.
Question 4: Prognosis of Gestational Trophoblastic Disease depends on all, except:
- A. Age
- B. Number of living children (Correct Answer)
- C. Previous HCG titre
- D. Site of metastases
Explanation: ***Number of living children*** - The number of living children is **not included** in the prognostic scoring systems for Gestational Trophoblastic Disease (GTD), such as the **FIGO scoring system**. - This is a personal/social factor unrelated to disease characteristics or tumor burden. - Therefore, it does **not** affect the prognosis of GTD. *Age* - **Age ≥40 years** is assigned 1 point in the FIGO prognostic scoring system. - Advanced maternal age is associated with **worse prognosis** in GTD. - This is a well-established prognostic factor. *Previous HCG titre* - The **pre-treatment serum hCG level** is a critical prognostic factor in the FIGO scoring system. - hCG levels are scored: <10³ (0 points), 10³-10⁴ (1 point), 10⁴-10⁵ (2 points), >10⁵ (4 points). - Higher initial hCG levels indicate greater **tumor burden** and correlate with worse prognosis. *Site of metastases* - The **anatomic location of metastases** is a key prognostic factor in FIGO scoring. - Lung/vaginal metastases score lower (1-2 points) while spleen/kidney and GI/liver/brain metastases score higher (2-4 points). - Brain and liver metastases confer the **worst prognosis**.
Question 5: A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
- A. 48%
- B. 12%
- C. 24%
- D. 3% (Correct Answer)
Explanation: ***3%*** - **Purely cystic thyroid nodules** (as described in this case with "isolated cystic swelling") have a **very low risk of malignancy**, typically **2-3%** or less. - According to **ATA guidelines** and **TIRADS classification**, purely cystic nodules are considered **low suspicion** lesions. - The cystic nature suggests a **benign process** such as a degenerated adenoma, colloid cyst, or simple cyst. - **Fine needle aspiration (FNA)** may still be considered if the nodule is >2 cm or has any suspicious solid components, but is often not required for purely cystic lesions. *48%* - This percentage is **significantly higher** than the actual malignancy risk for a purely cystic thyroid swelling. - Such a **high risk** would typically be associated with **solid nodules** exhibiting highly suspicious ultrasound features such as: - Microcalcifications - Irregular or spiculated margins - Taller-than-wide shape - Marked hypoechogenicity - Extrathyroidal extension *24%* - This percentage represents a **moderate to high risk** of malignancy, which is **not characteristic** of an isolated purely cystic thyroid swelling. - A risk in this range might be seen with: - **Mixed solid-cystic nodules** with predominantly solid components - Solid nodules with **intermediate suspicious features** on ultrasound *12%* - While lower than 24% or 48%, 12% is still **considerably higher** than the generally accepted malignancy risk for purely cystic thyroid nodules. - This risk level could be plausible for: - **Predominantly cystic nodules** with some eccentric solid components - Solid nodules with **mildly suspicious** features on ultrasound
Question 6: Risk of recurrence of hydatidiform mole in future pregnancy is:
- A. 8-10%
- B. 1-4% (Correct Answer)
- C. 4-8%
- D. 10-12%
Explanation: ***1-4%*** - The risk of a **recurrent hydatidiform mole** in a subsequent pregnancy is generally cited to be between **1-2%**, with some sources extending it up to 4%. - This risk is significantly higher than that of the general population for a first mole (0.1%), but still relatively low. *8-10%* - This percentage represents a **significantly higher recurrence risk** than what is typically observed for hydatidiform moles. - Such a high risk would be more concerning for **persistent trophoblastic disease** or choriocarcinoma development after an initial mole, rather than for recurrence in a future pregnancy. *4-8%* - While higher than the typical 1-2%, a 4-8% recurrence risk is still considered **elevated** compared to the established data. - This range might be considered if there are **additional risk factors** or a history of multiple previous molar pregnancies, which are not specified in the question. *10-12%* - A 10-12% risk for recurrence of hydatidiform mole is **exceptionally high** and not consistent with current understanding. - Such a high figure would suggest almost certain recurrence, which is not the case for most patients.
Question 7: A 32-year-old woman with a history of molar pregnancy presents with heavy vaginal bleeding. Which of the following is a serious malignant complication of molar pregnancy?
- A. Choriocarcinoma (Correct Answer)
- B. Endometrial carcinoma
- C. Cervical cancer
- D. Benign ovarian cysts
Explanation: **Choriocarcinoma** - **Choriocarcinoma** is a highly malignant form of trophoblastic neoplasia that can arise after a **molar pregnancy**, especially a complete hydatidiform mole. - The persistent elevation of **human chorionic gonadotropin (hCG)** following a molar pregnancy is a key indicator for the development of choriocarcinoma. *Endometrial carcinoma* - **Endometrial carcinoma** is a cancer of the lining of the uterus and is typically associated with hormonal imbalances or genetic predispositions, not directly with molar pregnancy. - While both affect the uterus, they originate from different cell types: molar pregnancy complications arise from **trophoblasts**, whereas endometrial cancer arises from **endometrial glandular cells**. *Benign ovarian cysts* - **Benign ovarian cysts**, particularly **theca-lutein cysts**, can be associated with molar pregnancies due to excessive hCG stimulation of the ovaries. - However, these cysts are typically **benign** and resolve spontaneously after the molar pregnancy is treated, and are not a malignant complication like choriocarcinoma. *Cervical cancer* - **Cervical cancer** is caused primarily by persistent infection with **human papillomavirus (HPV)** and is not a direct complication of molar pregnancy. - The pathology and risk factors for **cervical cancer** are distinct from those associated with gestational trophoblastic disease.
Question 8: Tumor marker of epithelial ovarian carcinoma is:
- A. Alpha feto protein
- B. CA-125 (Correct Answer)
- C. Beta HCG
- D. LDH
Explanation: ***CA-125*** - **CA-125 (Cancer Antigen 125)** is the most widely used and validated tumor marker for detecting and monitoring **epithelial ovarian carcinoma**. - Elevated levels are found in approximately 80% of women with epithelial ovarian cancer, making it useful in guiding treatment decisions and assessing recurrence. *Alpha feto protein* - **Alpha-fetoprotein (AFP)** is primarily elevated in **germ cell tumors** of the ovary (e.g., endodermal sinus tumor) or in hepatocellular carcinoma and some testicular cancers, not epithelial ovarian carcinoma. - Its presence usually indicates a different histological subtype of ovarian malignancy. *Beta HCG* - **Beta-human chorionic gonadotropin (β-hCG)** is a tumor marker utilized for detecting **germ cell tumors**, particularly **choriocarcinoma** and some embryonal carcinomas, as well as pregnancy. - It is not typically elevated in epithelial ovarian carcinoma. *LDH* - **Lactate dehydrogenase (LDH)** is a general marker of **tissue damage or high cell turnover**, elevated in many cancers, including dysgerminoma (an ovarian germ cell tumor), but it is not specific for epithelial ovarian carcinoma. - Due to its lack of specificity, LDH alone is not considered the primary tumor marker for epithelial ovarian cancer.
Question 9: Which is the most common complication of molar pregnancy?
- A. Placenta previa
- B. Ovarian torsion
- C. Choriocarcinoma
- D. Invasive mole (Correct Answer)
Explanation: **Invasive mole** - An **invasive mole** is the most common complication of molar pregnancy, occurring in about 10-15% of complete hydatidiform moles and 1-5% of partial moles. - It involves the trophoblastic tissue invading the myometrium, which can lead to continued **human chorionic gonadotropin (hCG) elevation** and persistent vaginal bleeding. *Placenta previa* - **Placenta previa** is a condition where the placenta partially or totally covers the cervix, which is unrelated to the abnormal trophoblastic proliferation seen in molar pregnancies. - Its primary risk factors differ from those for molar pregnancy complications and include prior C-sections or uterine surgery. *Ovarian torsion* - **Ovarian torsion** is the twisting of the ovary and/or fallopian tube, cutting off blood supply, and although it can occur in pregnancy, it is not a direct complication of molar pregnancy. - It is often associated with ovarian cysts or masses, and while **theca lutein cysts** can be seen with molar pregnancy, torsion of these cysts is less common than invasive mole. *Choriocarcinoma* - While a serious neoplastic complication of molar pregnancy, **choriocarcinoma** is much rarer than an invasive mole, occurring in only 2-3% of complete hydatidiform moles. - It represents a **malignant transformation** of trophoblastic tissue with metastatic potential, distinguishing it from the localized invasion of an invasive mole.
Question 10: Hysterectomy specimen from a 40-year-old lady is shown along with histology slide. The diagnosis is:
- A. Carcinoma endometrium
- B. Leiomyoma (Correct Answer)
- C. Leiomyosarcoma
- D. Endometriosis
Explanation: ***Leiomyoma*** - Leiomyomas are **benign smooth muscle tumors** of the uterus, characterized by well-demarcated, whorled, and firm cut surfaces [1]. - Histologically, they show bundles of **smooth muscle cells** arranged in fascicles, with minimal atypia and low mitotic activity [1]. *Carcinoma endometrium* - Endometrial carcinoma typically presents as an **irregular, friable mass** originating from the endometrial lining, often with areas of necrosis or hemorrhage. - Histologically, it shows **glandular proliferation** with architectural complexity, nuclear atypia, and often invasion into the myometrium [2]. *Leiomyosarcoma* - Leiomyosarcomas are **malignant smooth muscle tumors** that are often poorly circumscribed, with areas of hemorrhage and necrosis [1]. - Histologically, they exhibit significant **nuclear atypia**, high mitotic activity (often >10 mitoses/10 HPF), and atypical mitoses [1]. *Endometriosis* - Endometriosis involves the presence of **endometrial glands and stroma outside the uterus**, often forming "chocolate cysts" in the ovaries or implants on peritoneal surfaces. - Histology would reveal **endometrial glands and stroma** surrounded by hemosiderin-laden macrophages, not a smooth muscle tumor. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1024-1025. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1020-1021.
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