Gynecologic Oncology Practice Questions

Q: A woman with postmenopausal bleeding has thickened endometrium. Which approach is most suitable for evaluating malignancy risk?

Endometrial biopsy. ***Endometrial biopsy*** - An **endometrial biopsy** directly obtains tissue samples from the endometrial lining, allowing for histological examination to definitively diagnose or rule out **endometrial hyperplasia** or **carcinoma**. - This is the **most suitable first-line approach** when postmenopausal bleeding is coupled with a thickened endometrium, as it directly assesses for **malignancy at a cellular level**. - It is **cost-effective, minimally invasive, and can be performed in an office setting** without anesthesia. *Transvaginal ultrasound* - While a **transvaginal ultrasound** can measure endometrial thickness and identify structural abnormalities, it cannot definitively differentiate between benign and malignant changes. - It serves as an initial screening tool but requires further investigation like a **biopsy** for definitive diagnosis in cases of thickened endometrium and postmenopausal bleeding. - An endometrial thickness >4-5 mm in postmenopausal women warrants tissue diagnosis. *Pap smear* - A **Pap smear** (Papanicolaou test) is used to screen for **cervical cancer** by collecting cells from the cervix. - It is not effective for detecting **endometrial pathologies** or cancer of the uterine lining. *Hysteroscopy* - **Hysteroscopy** allows for direct visualization of the uterine cavity and directed biopsies under direct vision, which is highly accurate for identifying focal lesions such as polyps or fibroids. - While it provides excellent diagnostic accuracy, it is **more invasive, expensive, and typically requires anesthesia**. - For initial evaluation of postmenopausal bleeding with diffuse endometrial thickening, **endometrial biopsy is preferred** as the first-line approach due to its accessibility, lower cost, and adequate sensitivity (>90% for detecting endometrial cancer).

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: Sentinel lymph node biopsy is most useful for:

Carcinoma vulva. ***Carcinoma vulva*** - **Sentinel lymph node biopsy (SLNB)** is a standard procedure for early-stage vulvar carcinoma to assess nodal involvement with less morbidity than full inguinofemoral lymphadenectomy. - The procedure helps identify metastases in regional lymph nodes, guiding further treatment decisions while minimizing complications like **lymphedema**. *Carcinoma endometrium* - While SLNB can be used in endometrial cancer, its primary utility is in tailoring **lymphadenectomy** rather than being the "most useful" or universally preferred primary staging tool compared to vulvar cancer. - The anatomical spread often involves different lymphatic basins, and **comprehensive pelvic and para-aortic lymphadenectomy** or systematic nodal dissection remains a common approach, though SLNB is gaining traction. *Carcinoma vagina* - The lymphatic drainage of the vagina is complex and variable, making SLNB challenging and less standardized compared to vulvar cancer. - **Radical surgical excision** with **regional lymphadenectomy** remains the mainstay for staging and treatment of invasive vaginal carcinoma. *Carcinoma cervix* - For cervical cancer, SLNB is primarily used in **early-stage disease** to detect micrometastases and guide the extent of lymph node dissection. - However, **imaging** and comprehensive **pelvic lymphadenectomy** are often still crucial components for complete staging and treatment, depending on tumor characteristics.

Q: A 16-year-old girl, not sexually active, came for vaccination against cervical cancer. Which vaccine should be given?

Gardasil. ***Gardasil*** - **Gardasil** is a **quadrivalent HPV vaccine** approved for the prevention of **cervical cancer** caused by HPV types 6, 11, 16, and 18 - It is recommended for adolescents, typically between ages **9-14 years**, ideally before potential exposure to HPV through sexual activity - **For a 16-year-old not sexually active**, Gardasil is the appropriate choice among the given options for cervical cancer prevention - The vaccine provides protection against both high-risk oncogenic HPV types (16, 18) and low-risk types (6, 11) that cause genital warts *Biovac* - **Biovac** is not a recognized or widely used vaccine for cervical cancer prevention - This option serves as a distractor without specific medical vaccine correlation in the context of HPV immunization *Rubavac* - **Rubavac** is a vaccine specifically designed to protect against the **rubella virus** (German measles) - It is part of routine childhood immunization, usually given as part of the **MMR vaccine (measles, mumps, rubella)** - Has no role in cervical cancer prevention *Tdap* - **Tdap** is a combination vaccine that protects against **tetanus, diphtheria, and pertussis (whooping cough)** - Given as a booster for adolescents and adults to maintain immunity against these bacterial infections - Has no role in cervical cancer prevention

Q: Treatment of endometrial hyperplasia with atypia in a 45-year-old female:

Hysterectomy. ***Hysterectomy*** - **Endometrial hyperplasia with atypia** carries a significant risk of progression to **endometrial cancer**, ranging from 20% to 50% over several years, making hysterectomy a definitive treatment option. - For a 45-year-old female, especially if she has completed childbearing or is nearing menopause, a **hysterectomy** eliminates the uterine pathology and prevents future recurrence or malignant transformation. *Progestin* - While progestin therapy can be used for endometrial hyperplasia without atypia or for atypical hyperplasia in women who desire to preserve fertility, its effectiveness for **simple atypical hyperplasia** is 70-80%. - The risk of residual or coexisting carcinoma, and the potential for recurrence if fertility is not a concern, makes progestin a less definitive treatment than hysterectomy in this age group. *Mirena* - The **Mirena IUD** (levonorgestrel-releasing intrauterine system) delivers local progestin, which is effective for **endometrial hyperplasia without atypia** and is sometimes used for atypical hyperplasia when fertility preservation is desired. - However, for **atypical hyperplasia**, which has a notable risk of malignancy, a more definitive treatment like hysterectomy is generally preferred, especially as Mirena's systemic effects are limited and regular follow-up biopsies are needed. *Endometrial ablation* - **Endometrial ablation** destroys the endometrial lining and is typically used for managing **heavy menstrual bleeding (menorrhagia)** when fertility is not desired. - It is **contraindicated in cases of endometrial hyperplasia with atypia** due to the risk of obscuring underlying or developing malignancy and making future surveillance difficult.

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 is the most common complication of molar pregnancy?

Invasive mole. **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.

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: 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.

Question 1

A woman with postmenopausal bleeding has thickened endometrium. Which approach is most suitable for evaluating malignancy risk?

Accepted Answer

Endometrial biopsy

Answer

Transvaginal ultrasound

Answer

Pap smear

Answer

Hysteroscopy

Question 2

Most sensitive marker for early detection of ovarian cancer?

Accepted Answer

HE4

Answer

CA-125

Answer

RMI score

Answer

ROMA score

Question 3

Sentinel lymph node biopsy is most useful for:

Accepted Answer

Carcinoma vulva

Answer

Carcinoma endometrium

Answer

Carcinoma vagina

Answer

Carcinoma cervix

Question 4

A 16-year-old girl, not sexually active, came for vaccination against cervical cancer. Which vaccine should be given?

Accepted Answer

Gardasil

Answer

Biovac

Answer

Rubavac

Answer

Tdap

Question 5

Treatment of endometrial hyperplasia with atypia in a 45-year-old female:

Accepted Answer

Hysterectomy

Answer

Progestin

Answer

Mirena

Answer

Endometrial ablation

Question 6

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 7

Which is the most common complication of molar pregnancy?

Accepted Answer

Invasive mole

Answer

Placenta previa

Answer

Ovarian torsion

Answer

Choriocarcinoma

Question 8

Which condition does NOT increase the risk of cervical cancer?

Accepted Answer

Nulliparity

Answer

Multiple sexual partners

Answer

HPV infection

Answer

Smoking

Question 9

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 10

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

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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