Gynecologic Oncology Practice Questions

Q: Which of the following are the vaccines for prevention of cervical cancer? 1. Cervarix 2. Gardasil 3. T-dap 4. Influenza Select the correct answer using the code given below:

1 and 2. ***Option A: 1 and 2 (Cervarix and Gardasil)*** - Both are **HPV vaccines** that prevent cervical cancer by targeting oncogenic human papillomavirus types - **Cervarix**: Bivalent vaccine protecting against HPV-16 and HPV-18 (responsible for ~70% of cervical cancers) - **Gardasil**: Quadrivalent vaccine (Gardasil-4) protecting against HPV-6, 11, 16, and 18; Nonavalent version (Gardasil-9) covers additional high-risk HPV types (31, 33, 45, 52, 58) - **Clinical significance**: Persistent HPV infection is the primary cause of cervical cancer; vaccination is primary prevention *Option B: 1 and 3* - While Cervarix is correct, **T-dap vaccine** (tetanus, diphtheria, acellular pertussis) is a bacterial vaccine with no role in cervical cancer prevention - T-dap targets entirely different pathogens and has no effect on HPV infection *Option C: 2 and 3* - Gardasil is correct for cervical cancer prevention, but **T-dap** is unrelated to HPV or cervical cancer - Mixing a correct HPV vaccine with an unrelated bacterial vaccine makes this option incorrect *Option D: 2 and 4* - Gardasil is correct, but **influenza vaccine** targets influenza virus to prevent seasonal flu, not HPV-related malignancies - Influenza vaccine has no protective effect against cervical cancer

Q: The most common site of cervical cancer is:

Transformation zone. ***Transformation zone*** - The **transformation zone** is where the squamous epithelium of the **ectocervix** meets the columnar epithelium of the **endocervix**. - This area is highly susceptible to **human papillomavirus (HPV) infection**, which is the primary cause of cervical cancer, making it the most common site of origin. *Endocervix* - The **endocervix** is lined by columnar epithelium and primarily gives rise to **adenocarcinoma**, which is less common than squamous cell carcinoma. - While cervical cancer can occur here, it is not the most frequent site of origin for all types of cervical cancer. *Isthmus* - The **isthmus** is the narrow lower part of the uterus, superior to the cervix. - It is not a primary site for the development of cervical cancer; cancerous changes typically originate within the cervical regions proper. *Ectocervix* - The **ectocervix** is the vaginal portion of the cervix, covered by stratified squamous epithelium. - While **squamous cell carcinomas** frequently occur in the cervix, they mostly originate in the transformation zone, not the ectocervix itself.

Q: Tumor marker of epithelial ovarian carcinoma is:

CA-125. ***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.

Q: What is the age group distribution for vulval cancer?

Both age groups (35-55 and 65-85 years). ***Both age groups (35-55 and 65-85 years)*** - Vulval cancer demonstrates a **bimodal age distribution**, meaning it presents with two distinct peaks of incidence. - The first peak occurs in younger women, typically aged **35-55 years**, often associated with **HPV infection** and vulvar intraepithelial neoplasia (VIN). - The second peak is seen in older women, aged **65-85 years**, where the disease is more commonly linked to **chronic inflammatory conditions** such as lichen sclerosus, often without HPV involvement. - This bimodal pattern reflects the **two distinct pathogenic pathways** of vulval cancer: HPV-related and non-HPV-related disease. *65-85 years* - While this age group represents a significant peak of vulval cancer incidence, particularly in cases **unrelated to HPV**, it does not encompass the entire distribution. - Focusing solely on this age range would **miss cases occurring in younger women**, which are increasingly recognized due to HPV-related disease. *35-55 years* - This age group does indeed represent a distinct peak for vulval cancer, especially in cases linked to **Human Papillomavirus (HPV) infection**. - However, ignoring the incidence in older women would provide an **incomplete understanding** of the disease's overall epidemiology. *Not age specific* - Vulval cancer is definitely **age-specific** with distinct age group distributions. - The incidence is **not uniformly distributed** across all ages but rather shows an increased likelihood within specific age ranges, demonstrating clear bimodal peaks.

Q: The following set of instruments are used for which procedure?

Pap smear. ***Pap smear*** - The image displays a complete set of instruments used for a **Pap smear**, including **glass slides** for sample collection, a **cervical brush**, a **spatula** (cytobrush and Ayre spatula), and a **speculum** to visualize the cervix. - These tools are specifically designed for collecting cervical cells to screen for **cervical cancer** and **precancerous changes**. *Biopsy* - A biopsy typically involves specialized instruments like **punch biopsy tools**, **forceps**, or needles to extract tissue samples, which are not depicted here. - While glass slides might be used for processing biopsy samples, the primary collection tools are absent. *Dilatation and curettage* - This procedure requires instruments such as **dilators** to open the cervix and **curetters** to scrape the uterine lining, which are not shown in the image. - The instruments shown are for surface cell collection, not for uterine cavity procedures. *Hysteroscopy* - Hysteroscopy uses a **hysteroscope**—a thin, lighted tube with a camera—to visualize the inside of the uterus. - The instruments in the image are for external examination and cervical cell collection, not for direct visualization of the uterine cavity.

Q: Arrange the following in sequential order with regards to the steps of collection of samples for pap smear testing: Use posterior vaginal wall retractor Take the sample Make smear on a slide Fix the smear

1,2,3,4. ***1,2,3,4*** - The correct sequence for collecting a Pap smear involves first **visualizing the cervix** using a posterior vaginal wall retractor, then **taking the sample** (e.g., using a broom or spatula and brush), followed by **making a smear on a slide** and finally **fixing the smear** to preserve the cells. - This sequential order ensures proper cell collection and preservation for accurate cytological examination. *1,2,4,3* - This option incorrectly places **fixing the smear** before **making the smear on the slide**. Cells must first be spread onto the slide before they can be fixed. - Fixing an un-smeared sample or attempting to smear after fixing would lead to an inadequate or damaged specimen. *3,1,2,4* - This sequence incorrectly starts with **making a smear on a slide** before any sample has been collected or the cervix visualized. - One cannot make a smear without first taking a sample and accessing the cervix via a retractor. *2,1,3,4* - This option incorrectly states that **taking the sample** occurs before **using a posterior vaginal wall retractor**. The retractor is essential for proper visualization and access to the cervix to obtain a quality sample. - Attempting to take a sample without proper visualization would lead to an inadequate or incorrect specimen collection.

Q: A 32-year-old HIV-positive woman with CD4 count 180/µL presents with extensive genital warts resistant to conventional therapy. Recent Pap smear shows HSIL. Which management approach is most appropriate?

Immediate colposcopy and surgical excision. ***Immediate colposcopy and surgical excision*** - Given the patient's **HIV-positive status**, **low CD4 count**, extensive and resistant **genital warts**, and **HSIL on Pap smear**, there is a high likelihood of advanced or rapidly progressing cervical intraepithelial neoplasia or early invasive carcinoma. - **Colposcopy** allows for direct visualization and targeted biopsies, while **surgical excision** (e.g., LEEP or cold knife conization) can effectively remove both the HSIL and resistant warts, which is crucial in immunocompromised patients. *Observation and repeat Pap in 6 months* - This approach is inappropriate due to the patient's **immunocompromised state** (low CD4 count), which predisposes her to more aggressive and rapidly progressive **HPV-related disease**. - **HSIL** in an HIV-positive patient warrants immediate investigation and intervention, not delayed follow-up, as the risk of progression to **invasive cancer** is significantly higher. *Topical imiquimod alone* - **Imiquimod** is an immune-response modifier used for external genital warts, but it is unlikely to be sufficient for extensive, resistant warts, especially in an **immunocompromised host**. - It does not directly address the underlying **HSIL**, which requires histological evaluation and potential excisional treatment to prevent progression to cancer. *Podophyllin application weekly* - **Podophyllin** is a cytotoxic agent used for external genital warts, but it is generally reserved for smaller lesions and requires careful application due to its potential toxicity. - It is **contraindicated in pregnancy** and not recommended for internal lesions or for treating or preventing the progression of **HSIL**, which requires a more definitive management.

Q: Risk of endometrial cancer is least in:

Multipara. ***Multipara*** - **Multiparity** (having multiple successful pregnancies) is associated with a reduced risk of **endometrial cancer**. Each pregnancy provides a period of reduced estrogen exposure and increased progesterone, which is protective against endometrial hyperplasia. - The protective effect is thought to be cumulative, with **higher parity** correlating with a lower risk. *Late menopause* - **Late menopause** prolongs the duration of lifetime exposure to endogenous unopposed estrogen, which significantly increases the risk of **endometrial cancer**. - Estrogen stimulates **endometrial proliferation**, and continued exposure without the counter-regulatory effects of progesterone (as seen in later menopause) can lead to atypical hyperplasia and malignancy. *A positive family history* - A **positive family history** of endometrial cancer suggests a genetic predisposition, which is a significant **risk factor**. - Conditions like **Lynch syndrome** (hereditary non-polyposis colorectal cancer or HNPCC) are strongly associated with an increased risk of endometrial cancer. *Obesity* - **Obesity** is a major risk factor for **endometrial cancer** due to increased peripheral conversion of androgens to estrogens in adipose tissue. - This leads to higher levels of **unopposed estrogen**, promoting endometrial proliferation and increasing cancer risk.

Question 1

Which of the following are the vaccines for prevention of cervical cancer?

1. Cervarix
2. Gardasil
3. T-dap
4. Influenza

Select the correct answer using the code given below:

Accepted Answer

1 and 2

Answer

1 and 3

Answer

2 and 3

Answer

2 and 4

Question 2

The most common site of cervical cancer is:

Accepted Answer

Transformation zone

Answer

Endocervix

Answer

Isthmus

Answer

Ectocervix

Question 3

Tumor marker of epithelial ovarian carcinoma is:

Accepted Answer

CA-125

Answer

Alpha feto protein

Answer

Beta HCG

Answer

LDH

Question 4

What is the age group distribution for vulval cancer?

Accepted Answer

Both age groups (35-55 and 65-85 years)

Answer

65-85 years

Answer

35-55 years

Answer

Not age specific

Question 5

A 37-year-old unmarried nulliparous woman, having regular intercourse, is on oral contraceptive pills. Her mother was diagnosed with carcinoma breast at 60 years of age, and her elder sister was diagnosed with carcinoma ovary at 40 years of age. What is the next line of management?

Accepted Answer

Genetic counseling and screening for BRCA

Answer

Prophylactic surgery

Answer

Stop taking oral contraceptive pills

Answer

Routine mammography

Question 6

The following set of instruments are used for which procedure?

Accepted Answer

Pap smear

Answer

Biopsy

Answer

Dilatation and curettage

Answer

Hysteroscopy

Question 7

Arrange the following in sequential order with regards to the steps of collection of samples for pap smear testing:
Use posterior vaginal wall retractor
Take the sample
Make smear on a slide
Fix the smear

Accepted Answer

1,2,3,4

Answer

1,2,4,3

Answer

3,1,2,4

Answer

2,1,3,4

Question 8

A 32-year-old HIV-positive woman with CD4 count 180/µL presents with extensive genital warts resistant to conventional therapy. Recent Pap smear shows HSIL. Which management approach is most appropriate?

Accepted Answer

Immediate colposcopy and surgical excision

Answer

Observation and repeat Pap in 6 months

Answer

Topical imiquimod alone

Answer

Podophyllin application weekly

Question 9

A 56-year-old woman makes an appointment with her physician to discuss the results of her cervical cancer screening. She has been menopausal for  2 years and does not take hormone replacement therapy. Her previous Pap smear showed low-grade squamous intraepithelial lesion (LSIL); no HPV testing was performed. Her gynecologic examination is unremarkable. The results of her current Pap smear is as follows:
Specimen adequacy satisfactory for evaluation
Interpretation low-grade squamous intraepithelial lesion
Notes atrophic pattern
Which option is the next best step in the management of this patient?

Accepted Answer

Colposcopy

Answer

Reflex HPV testing

Answer

Repeat HPV testing in 6 months

Answer

Immediate loop excision

Answer

Intravaginal estrogen therapy followed by repeat Pap smear in 1 week

Question 10

Risk of endometrial cancer is least in:

Accepted Answer

Multipara

Answer

Late menopause

Answer

A positive family history

Answer

Obesity

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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