Gynecologic Oncology Practice Questions

Q: Prognosis of Gestational Trophoblastic Disease depends on all, except:

Number of living children. ***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: 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**.

Q: Assuming that the other ovary is grossly normal, what is the likelihood that the contralateral ovary is involved in serous ovarian carcinoma?

33%. ***Correct: 33%*** - Up to **one-third of patients** with serous ovarian carcinoma involving one ovary will have **microscopic involvement** of the contralateral, grossly normal ovary. - This high rate of occult involvement often necessitates **bilateral oophorectomy** in surgical staging for serous ovarian carcinoma. *Incorrect: 5%* - This percentage significantly **underestimates the true incidence** of contralateral involvement in serous ovarian carcinoma. - Serous carcinoma is known for its tendency to be **multifocal** and spread early, even when the presenting lesion appears unilateral. *Incorrect: 15%* - While higher than 5%, 15% still **underestimates the frequent bilateral nature** of serous ovarian carcinoma, even when one ovary appears normal. - Studies consistently show **higher rates of occult contralateral disease**, particularly for serous histologic types. *Incorrect: 45%* - This percentage is **somewhat higher than the generally accepted rate** for contralateral microscopic involvement in grossly normal ovaries affected by serous carcinoma. - While bilateral involvement is common, a 45% rate might be more reflective of **macroscopic or readily apparent involvement** rather than purely occult disease.

Q: At which anatomical site does cervical carcinoma most commonly develop?

Squamo-columnar junction (transformation zone). ***Squamo-columnar junction (transformation zone)*** - The **squamo-columnar junction**, also known as the **transformation zone**, is the site where the columnar epithelium of the endocervix meets the squamous epithelium of the ectocervix. - This area is highly susceptible to oncogenic changes due to its active metaplasia and exposure to risk factors like **human papillomavirus (HPV)**. *Isthmus* - The **isthmus** is the narrow lower portion of the uterus, between the cervix and the body of the uterus. - While it is part of the uterine structure, it is not the primary site for the development of cervical carcinoma. *Cervical lip* - The term **cervical lip** usually refers to the borders of the external os or the everted portion of the cervix. - While it's part of the cervix, it's not specifically identified as the most common origin point for carcinoma compared to the active cellular changes occurring at the squamo-columnar junction. *Internal os* - The **internal os** is the opening between the endocervical canal and the uterine cavity. - While it's a critical anatomical landmark, it does not represent the most common area for the initial development of cervical cancer.

Q: Most common type of cervical cancer is:

Squamous cell carcinoma. ***Squamous cell carcinoma*** - This is by far the **most common type of cervical cancer**, accounting for approximately 70-80% of all cases. - It arises from the **squamous cells** on the exocervix, the outer part of the cervix that projects into the vagina. *Small cell carcinoma* - This is a **rare and highly aggressive** type of cervical cancer, accounting for less than 1% of cases. - It is associated with a **poor prognosis** and often requires intensive treatment. *Adenocarcinoma* - This type of cervical cancer accounts for about 10-20% of cases, making it the **second most common** type after squamous cell carcinoma. - It originates from the **glandular cells** of the endocervix, the inner part of the cervix. *Adenosquamous carcinoma* - This is a **rare mixed tumor** containing both squamous and glandular components, accounting for approximately 3-5% of cervical cancers. - It tends to have a **more aggressive behavior** and worse prognosis compared to pure adenocarcinoma or squamous cell carcinoma.

Q: Carcinosarcoma most commonly arises in which organ?

Uterus. ***Uterus*** - Carcinosarcoma, also known as **malignant mixed Müllerian tumor**, commonly arises in the uterus, characterized by both **carcinomatous and sarcomatous components** [1]. - It typically presents with **postmenopausal bleeding** and is often diagnosed in older women [1]. *Ovary* - While ovarian tumors can be malignant, **carcinosarcoma is not commonly found** in the ovary; ovarian tumors are more often serous or mucinous in nature. - Ovarian cancer tends to present with **nonspecific abdominal symptoms** rather than the classic features of carcinosarcoma. *Vagina* - Vaginal cancers are rare, and while **sarcoma may occur here**, carcinosarcoma predominantly involves the uterus rather than the vagina. - The types of vaginal malignancies tend to be more commonly **squamous cell carcinomas** or adenocarcinomas. *Cervix* - Cervical cancers are predominantly **squamous cell carcinomas** or adenocarcinomas, and carcinosarcoma is not typically associated with the cervix. - The cervix also has distinctive associated risk factors, such as **HPV infection**, which are not linked to carcinosarcoma. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1022-1024.

Q: Which tumor type is associated with an increased risk of endometrial carcinoma?

Granulosa theca cell. ***Granulosa theca cell*** - Granulosa-theca cell tumors are associated with an increased risk of **endometrial carcinoma** due to their potential to cause **excess estrogen production**. - The **estrogen stimulation** of the endometrium can lead to hyperplasia and subsequently to carcinoma. *Immature teratoma* - Immature teratomas are primarily germ cell tumors and are not typically associated with **endometrial cancer risk**. - Their malignant potential is primarily linked to **germ cell neoplasia** rather than estrogen exposure. *Sertoli Leydig cell* - Sertoli-Leydig cell tumors cause **androgen production** [1], which may have effects on the endometrium but do not significantly raise endometrial carcinoma risk. - These tumors are more associated with **virilization** [1] rather than estrogen-related pathways. *Gonadoblastoma tumor* - Gonadoblastomas are rare and typically found in individuals with **disorders of sexual development**; they are not commonly linked to endometrial cancer. - Their risk is more associated with **germ cell tumor presentation**, without significant impact on endometrial tissue. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1037-1038.

Q: Which of the following screening methods is NOT effective for early detection of cancer in asymptomatic women?

CA-125 for ovarian cancer. ***CA-125 for ovarian cancer*** - **CA-125 lacks sufficient sensitivity and specificity** for screening asymptomatic women, leading to high rates of **false positives** and **false negatives**. - Major randomized trials (**UKCTOCS, PLCO**) demonstrated **no mortality benefit** from CA-125 screening and increased unnecessary invasive procedures. *USG in endometrial cancer* - **Transvaginal ultrasonography** effectively measures **endometrial thickness** and aids in risk stratification for symptomatic women. - While not used for population screening, it serves as a valuable **diagnostic adjunct** in evaluating postmenopausal bleeding and guiding biopsy decisions. *Pap smear for cervical cancer* - The **Pap smear** is the **gold standard** screening method that has dramatically reduced cervical cancer incidence and mortality. - It effectively detects **precancerous lesions** (CIN) and early cervical cancers, allowing for timely intervention and treatment. *Mammography for breast cancer* - **Mammography screening** is proven effective in reducing **breast cancer mortality** by 20-40% in women aged 50-69 years. - It can detect **early-stage breast cancers** and **microcalcifications** before they become palpable, enabling early treatment.

Q: Which of the following is not true for endodermal sinus tumor:

It produces hCG which is a useful tumor marker. **It produces hCG which is a useful tumor marker** - Endodermal sinus tumor (Yolk sac tumor) primarily produces **alpha-fetoprotein (AFP)**, which is the characteristic and highly useful tumor marker for monitoring disease activity and treatment response. - **Human chorionic gonadotropin (hCG)** is typically produced by **choriocarcinoma** and some mixed germ cell tumors, not usually by pure endodermal sinus tumors. *It is the second most common malignant germ cell tumor of the ovary* - **Dysgerminoma** is the most common malignant germ cell tumor of the ovary, accounting for about half of all cases. - **Endodermal sinus tumor** is indeed the second most common, making up approximately 15-20% of malignant ovarian germ cell tumors. *Schiller-Duval body is the characteristic histological feature* - **Schiller-Duval bodies** are pathognomonic histological features of endodermal sinus tumors. - These structures resemble primitive glomeruli with a central capillary surrounded by germ cells within a cystic space. *Surgical staging and unilateral salpingo-oophorectomy is generally the treatment of choice* - For early-stage disease, **unilateral salpingo-oophorectomy** is the standard surgical approach to preserve fertility when possible. - **Surgical staging** is crucial to determine the extent of the disease and guide subsequent management, which typically includes adjuvant chemotherapy.

Q: Most useful investigation in a 55-year-old postmenopausal woman with diabetes mellitus and hypertension who has presented with postmenopausal bleeding is:

Endometrial biopsy. ***Endometrial biopsy*** - This is the **most crucial investigation** for postmenopausal bleeding to rule out **endometrial cancer** or **hyperplasia**, especially in a patient with risk factors like diabetes and hypertension. - An endometrial biopsy directly samples the **uterine lining** for histological examination, providing a definitive diagnosis of any abnormal tissue changes. *Pap test* - A Pap test, or **Papanicolaou test**, primarily screens for **cervical cancer** by examining cells from the cervix. - It is **not effective** for detecting uterine (endometrial) abnormalities or cancer, which is the main concern with postmenopausal bleeding. *Transvaginal ultrasound examination* - While useful for assessing **endometrial thickness** and identifying structural abnormalities like polyps or fibroids, it is **not diagnostic** on its own. - An abnormal ultrasound finding, such as a thickened endometrium (usually >4-5mm in postmenopausal women), would typically prompt an endometrial biopsy for definitive diagnosis. *CA-125 blood test* - **CA-125** is a tumor marker primarily used for monitoring the response to treatment in **ovarian cancer** and can be elevated in other conditions like endometriosis or fibroids. - It is **not a screening tool** for endometrial cancer and is **not specific or sensitive enough** to be the primary investigation for postmenopausal bleeding.

Question 1

Prognosis of Gestational Trophoblastic Disease depends on all, except:

Accepted Answer

Number of living children

Answer

Age

Answer

Previous HCG titre

Answer

Site of metastases

Question 2

Assuming that the other ovary is grossly normal, what is the likelihood that the contralateral ovary is involved in serous ovarian carcinoma?

Accepted Answer

33%

Answer

5%

Answer

15%

Answer

45%

Question 3

At which anatomical site does cervical carcinoma most commonly develop?

Accepted Answer

Squamo-columnar junction (transformation zone)

Answer

Cervical lip

Answer

Isthmus

Answer

Internal os

Question 4

Most common type of cervical cancer is:

Accepted Answer

Squamous cell carcinoma

Answer

Small cell carcinoma

Answer

Adenocarcinoma

Answer

Adenosquamous carcinoma

Question 5

Carcinosarcoma most commonly arises in which organ?

Accepted Answer

Uterus

Answer

Cervix

Answer

Vagina

Answer

Ovary

Question 6

In which of the following conditions is serial monitoring of β-HCG post-treatment most useful?

Accepted Answer

Hydatidiform mole

Answer

Choriocarcinoma

Answer

Ectopic pregnancy

Answer

None of the options

Question 7

Which tumor type is associated with an increased risk of endometrial carcinoma?

Accepted Answer

Granulosa theca cell

Answer

Sertoli Leydig cell

Answer

Immature teratoma

Answer

Gonadoblastoma tumor

Question 8

Which of the following screening methods is NOT effective for early detection of cancer in asymptomatic women?

Accepted Answer

CA-125 for ovarian cancer

Answer

USG in endometrial cancer

Answer

Pap smear for cervical cancer

Answer

Mammography for breast cancer

Question 9

Which of the following is not true for endodermal sinus tumor:

Accepted Answer

It produces hCG which is a useful tumor marker

Answer

It is the second most common malignant germ cell tumor of the ovary

Answer

Schiller-Duval body is the characteristic histological feature

Answer

Surgical staging and unilateral salpingo-oophorectomy is generally the treatment of choice

Question 10

Most useful investigation in a 55-year-old postmenopausal woman with diabetes mellitus and hypertension who has presented with postmenopausal bleeding is:

Accepted Answer

Endometrial biopsy

Answer

Pap test

Answer

Transvaginal ultrasound examination

Answer

CA-125 blood test

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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