Gynecologic Oncology Practice Questions

Q: Which of the following is NOT an indication for postoperative radiotherapy in a case of carcinoma endometrium?

Tumor positive for estrogen receptors. ***Tumor positive for estrogen receptors*** - A tumor being **positive for estrogen receptors** indicates a potential responsiveness to **hormonal therapy**, rather than an indication for postoperative radiotherapy. - While it guides treatment decisions, it does not suggest a need for radiation to reduce local recurrence risk, unlike other high-risk features. *Myometrial invasion >1/2 thickness* - **Deep myometrial invasion (>1/2 thickness)** is a significant **risk factor for recurrence** and metastases in endometrial carcinoma. - Radiotherapy is often indicated in such cases to improve **local control** and reduce recurrence. *Positive lymph nodes* - The presence of **positive lymph nodes** signifies regional spread of the cancer. - This is a strong indication for **adjuvant therapy**, including radiotherapy, to target residual disease and prevent recurrence. *Endocervical involvement* - **Endocervical stromal invasion** indicates a more aggressive tumor that has extended beyond the endometrium. - This finding is associated with a higher risk of **locoregional recurrence**, making postoperative radiotherapy a crucial component of treatment to improve outcomes.

Q: What is the current treatment of choice for choriocarcinoma?

Chemotherapy with Methotrexate. ***Chemotherapy with Methotrexate*** - **Chemotherapy** is the cornerstone of treatment for choriocarcinoma due to its **high chemosensitivity**. - **Single-agent chemotherapy** with **methotrexate** or actinomycin D is highly effective for **low-risk disease**, while **multi-agent regimens** (EMA-CO protocol) are used for high-risk cases. - This systemic approach effectively targets the rapidly dividing **trophoblastic cells**, often achieving **cure rates exceeding 90%**. - Chemotherapy is preferred over surgery because choriocarcinoma typically has **widespread metastatic potential** even when the primary tumor appears localized. *Hysterectomy* - While hysterectomy may be considered in specific situations (intractable bleeding, isolated uterine disease in patients with completed fertility), it is **not the primary treatment of choice**. - The **high metastatic potential** of choriocarcinoma necessitates a **systemic treatment** approach rather than local surgical intervention alone. - Surgery alone would not address micrometastases commonly present at diagnosis. *Radiotherapy* - **Radiotherapy** is not a primary treatment for choriocarcinoma due to its **excellent chemosensitivity**. - It may be used adjunctively in special circumstances such as **brain metastases** for local control, but chemotherapy remains the definitive treatment. - The systemic nature of the disease makes local radiation therapy insufficient as sole treatment. *Observation* - **Choriocarcinoma** is an aggressive, rapidly progressive malignancy with **high metastatic potential**; therefore, **observation alone is inappropriate**. - Delaying active treatment could lead to widespread dissemination and significantly worsen prognosis. - Unlike some gestational trophoblastic diseases (e.g., complete mole), choriocarcinoma requires immediate chemotherapy.

Q: In a suspected case of ovarian cancer, imaging work-up is required for all of the following EXCEPT:

Staging. ***Staging*** - **Clinical staging** for ovarian cancer is primarily surgical, meaning the definitive stage is determined during exploratory laparotomy rather than pre-operative imaging. - While imaging helps assess the extent of disease, the final **FIGO stage** relies on direct visualization and biopsy or resection of suspicious lesions during surgery. *Characterization of lesion* - Imaging modalities like **ultrasound**, **CT**, or **MRI** are crucial for determining features such as **cyst vs. solid**, size, septations, and presence of ascites, helping to differentiate benign from malignant masses. - This characterization guides the initial management plan, including the need for surgery or further investigations. *Assess resectability* - Imaging is essential to evaluate the **extent of tumor spread**, particularly to assess for widespread peritoneal carcinomatosis, bowel involvement, or distant metastases. - This information helps surgeons plan for optimal **cytoreductive surgery** and determine if a complete resection is feasible. *Detection of adnexal lesion* - The initial detection of an adnexal mass often occurs via imaging, typically **transvaginal ultrasound**, when a patient presents with symptoms or during a routine examination. - Imaging confirms the presence and location of the lesion, which is the first step in the diagnostic work-up for suspected ovarian cancer.

Q: Which of the following pre-malignant conditions of the vulva is characterized by well-defined erythematous lesions with a smooth, shiny appearance?

Paget's disease of the vulva. ***Paget's disease of the vulva*** - This condition presents as **well-defined, erythematous lesions** with a **smooth, shiny appearance** due to the presence of intraepithelial adenocarcinoma cells. - The lesions may also be associated with **pruritus** and can sometimes have a white, macerated, or eczematous appearance. *Vulval intraepithelial neoplasia* - VIN typically presents as **single or multifocal lesions** that can be white, red, or pigmented but are often **raised and warty** rather than smooth and shiny. - The appearance is highly variable and can be subtle, sometimes only detected on colposcopy after application of acetic acid. *Lichen sclerosus* - This is a chronic inflammatory dermatosis causing **thin, white, parchment-like skin** with characteristic **cigarette paper wrinkling** and atrophy, not erythematous and smooth lesions. - It often leads to architectural distortion and severe pruritus, and is associated with an increased risk of vulvar squamous cell carcinoma. *Leukoplakia* - Leukoplakia is a clinical term referring to any **white patch or plaque** on the mucous membrane that cannot be scraped off. - It describes a **gross appearance** rather than a specific diagnosis, and can be seen in various conditions, including lichen sclerosus or VIN, but itself is not characterized by erythema or shininess.

Q: Which of the following is the MOST significant risk factor for carcinoma of the cervix?

None of the options. ***None of the options*** - The **MOST significant risk factor** for cervical carcinoma is **persistent infection with high-risk HPV types** (especially HPV 16 and 18), which is found in >99% of cervical cancers and is considered the **necessary cause**. - Since **HPV infection** is not listed among the options, none of the given choices represents the most significant risk factor. - While HIV, smoking, and multiparity are all associated with increased cervical cancer risk, they are **secondary factors** that work primarily by affecting HPV persistence or acting as co-factors. *HIV infection* - **HIV infection** is an important risk factor as it compromises immune surveillance and reduces the ability to clear **HPV infections**, leading to persistent high-risk HPV and progression to CIN and invasive cancer. - However, HIV increases risk **through its effect on HPV persistence**, not as an independent primary cause. - Without HPV, HIV alone does not cause cervical cancer. *Smoking* - **Smoking** is an independent co-factor that increases cervical cancer risk, with tobacco carcinogens found in cervical mucus acting synergistically with **HPV**. - It is a secondary risk factor, not the primary cause. *Multiparity* - **Multiparity** shows a weak association with cervical cancer risk, possibly related to hormonal changes or increased HPV exposure. - It is the least significant among the listed factors and is not a primary driver of cervical carcinogenesis.

Q: In which stage of cervical cancer is brachytherapy primarily utilized?

Stage II-III cervical cancer. ***Stage II-III cervical cancer*** - **Brachytherapy** is a crucial component of definitive chemoradiation in locally advanced cervical cancer, targeting the uterus and cervix. - This stage often involves **regional spread** to parametrial tissues or lower vagina, requiring combined external beam radiation therapy (EBRT) and brachytherapy for optimal local control. - **Chemoradiation with brachytherapy is the PRIMARY treatment modality** for Stage II-III, making this the stage where brachytherapy is most prominently utilized. *Stage IVB cervical cancer* - This stage involves **distant metastases**, where the primary treatment strategy shifts towards **palliative systemic therapy** (chemotherapy or immunotherapy). - While localized radiation might be used for symptom control, **brachytherapy** alone is not curative and not the primary treatment modality. *Stage IA cervical cancer* - This stage represents very **early-stage disease** confined to the cervix, typically treated with **surgical excision** (e.g., cone biopsy or hysterectomy). - Radiotherapy, including brachytherapy, is generally reserved for patients who are not surgical candidates or for those with high-risk features post-surgery. *Stage Ib1 cervical cancer* - This stage involves a **tumor confined to the cervix** (visible lesion ≤2 cm), with **two equal treatment options**: **radical hysterectomy** OR **definitive chemoradiation** with brachytherapy. - While brachytherapy is used when radiation is chosen for Ib1, it serves as an ALTERNATIVE to surgery rather than the PRIMARY modality, unlike in Stage II-III where radiation is the standard first-line treatment.

Q: All of the following investigations are used in FIGO staging of carcinoma cervix except:

CECT. ***CECT*** - While CECT (Contrast-Enhanced Computed Tomography) is a valuable tool for assessing **tumor size** and **metastasis** in cervical cancer, the traditional FIGO (International Federation of Gynecology and Obstetrics) staging system relies primarily on **clinical examination** and specific imaging/procedural findings, not routine CECT. - FIGO staging is largely **clinical** and does not formally require CECT for staging decisions, though it may be used for treatment planning. - **Note:** The 2018 FIGO revision allows advanced imaging (CT/MRI/PET) to be incorporated if available, but the traditional investigations (IVP, cystoscopy, proctoscopy) remain the standard baseline for staging. *Intravenous pyelography* - **Hydronephrosis** due to ureteral obstruction (indicating advanced disease) is a criterion for Stage IIIB in FIGO staging. - IVP (Intravenous Pyelography) is used to detect hydronephrosis, which helps in differentiating between Stage IIB and Stage IIIB disease. - This is a **traditional FIGO staging investigation**. *Cystoscopy* - **Bladder involvement** with bullous edema or tumor infiltration directly into the bladder mucosa is a criterion for Stage IVA. - Cystoscopy is performed to visually inspect the bladder for such involvement. - This is a **traditional FIGO staging investigation**. *Proctoscopy* - **Rectal involvement** with bullous edema or tumor infiltration directly into the rectal mucosa is also a criterion for Stage IVA. - Proctoscopy is used to visually examine the rectum for signs of tumor extension. - This is a **traditional FIGO staging investigation**.

Q: 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?

Choriocarcinoma. **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 1

Which of the following is NOT an indication for postoperative radiotherapy in a case of carcinoma endometrium?

Accepted Answer

Tumor positive for estrogen receptors

Answer

Positive lymph nodes

Answer

Endocervical involvement

Answer

Myometrial invasion >1/2 thickness

Question 2

What is the current treatment of choice for choriocarcinoma?

Accepted Answer

Chemotherapy with Methotrexate

Answer

Hysterectomy

Answer

Radiotherapy

Answer

Observation

Question 3

In a suspected case of ovarian cancer, imaging work-up is required for all of the following EXCEPT:

Accepted Answer

Staging

Answer

Characterization of lesion

Answer

Assess resectability

Answer

Detection of adnexal lesion

Question 4

Which of the following pre-malignant conditions of the vulva is characterized by well-defined erythematous lesions with a smooth, shiny appearance?

Accepted Answer

Paget's disease of the vulva

Answer

Lichen sclerosus

Answer

Leukoplakia

Answer

Vulval intraepithelial neoplasia

Question 5

Which of the following is the MOST significant risk factor for carcinoma of the cervix?

Accepted Answer

None of the options

Answer

Multiparity

Answer

HIV infection

Answer

Smoking

Question 6

In which stage of cervical cancer is brachytherapy primarily utilized?

Accepted Answer

Stage II-III cervical cancer

Answer

Stage IVB cervical cancer

Answer

Stage IA cervical cancer

Answer

Stage Ib1 cervical cancer

Question 7

All of the following investigations are used in FIGO staging of carcinoma cervix except:

Accepted Answer

CECT

Answer

Cystoscopy

Answer

Proctoscopy

Answer

Intravenous pyelography

Question 8

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?

Accepted Answer

Choriocarcinoma

Answer

Endometrial carcinoma

Answer

Cervical cancer

Answer

Benign ovarian cysts

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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