Regarding first line therapy for advanced stage EOC which of the following is/are true?

• a)
  

  Adding gemcitabine to carboplatin and paclitaxel improves overall survival.

  
  
• b)
  

  Intra-peritoneal chemotherapy is a well-tolerated treatment option that improves overall survival.

  
  
• c)
  

  Platinum and taxane combination therapy improves survival compared to platinum mono-therapy or a platinum/non-taxane combination.

  
  
• d)
  

  Neo-adjuvant chemotherapy is indicated for patients presenting with advanced ovarian cancer with ascites, poor performance status and medical co-morbidities.

  
  
• e)
  

  The optimal scheduling of carboplatin and paclitaxel is unknown.

Regarding the impact of histology on treatment selection which of the following is/are true?

• a)
  

  Women with early stage high grade serous cancers should receive 6 cycles of platinum-based chemotherapy

  
  
• b)
  

  Clear cell cancers have poor response rates to platinum-taxane chemotherapy and should be treated with alternative agents such as irinotecan with cisplatin

  
  
• c)
  

  Mucinous ovarian cancers may represent metastases from a gastrointestinal primary cancer

  
  
• d)
  

  Mucinous ovarian cancers have been shown in trials to respond better to capecitabine and oxaliplatin

  
  
• e)
  

  Low grade and high grade serous tumours have similar response rates to chemotherapy

Regarding platinum-resistant ovarian cancer

• a)
  

  Quality of life is a key determinant in recommending therapy

  
  
• b)
  

  Oral etoposide is a well-tolerated option with low rates of myelosuppression

  
  
• c)
  

  Gemcitabine, pegylated liposomal doxorubicin (PLD) and weekly paclitaxel are commonly used alternatives

  
  
• d)
  

  Response rates to chemotherapy are typically 10-15%

  
  
• e)
  

  Median PFS is typically 13-14 months

In women who develop relapsed EOC more than 6 months since their last platinum-based chemotherapy:

• a)
  

  Re-treatment with platinum and taxane is the treatment of choice for most women.

  
  
• b)
  

  Treatment should commence when relapsed disease is confirmed on the basis of a rising CA125 tumour marker.

  
  
• c)
  

  Platinum hypersensitivity reactions are common.

  
  
• d)
  

  Carboplatin hypersensitivity precludes the use of cisplatin.

  
  
• e)
  

  Carboplatin and pegylated liposomal doxorubicin is an active therapy with advantages of 4-weekly scheduling and low rates of alopecia or neurotoxicity.

The following factor(s) is/are prognostic for borderline ovarian tumours?

• a)
  

  Fertility-sparing surgery

  
  
• b)
  

  Lymph node involvement

  
  
• c)
  

  Smoking

  
  
• d)
  

  Peritoneal implants

  
  
• e)
  

  Preoperative serum CA 125 level

The following statement(s) regarding the surgical management of borderline ovarian tumours is/are true?

• a)
  

  Approximately 60% of mucinous borderline tumours are stage I

  
  
• b)
  

  Routine pelvic lymphadenectomy is recommended for serous borderline tumours but not mucinous borderline tumours

  
  
• c)
  

  Following ovarian cystectomy in the management of borderline ovarian tumours, the recurrence rate in the ipsilateral or contralateral ovary is < 10%

  
  
• d)
  

  Factors to be considered in performing minimally invasive surgery for an adnexal mass should include size of the mass, body habitus, and number and type of previous surgical procedures

  
  
• e)
  

  Frozen section examination is more accurate for serous than mucinous borderline ovarian tumours

A patient has a strong family history of breast and ovarian cancer and was tested 10 years ago for a BRCA1 or BRCA 2 mutation with negative results. Now she presents with an ovarian cancer. Which of the following is/are appropriate with respect to counselling and testing?

• a)
  

  She cannot have hereditary disease because she tested negative so no further testing should be done.

  
  
• b)
  

  She should be offered re-testing because the new testing may identify mutations in cancer predisposition genes which were not known a decade ago.

  
  
• c)
  

  She should be re-tested because the new sequencing technology can pick up mutations in BRCA1 and BRCA2that we were not able to identify 10 years ago.

  
  
• d)
  

  She should be reassured that she does not have a familial disease.

  
  
• e)
  

  Re-testing can be offered but would need to be funded by the patient as she has previously tested negative.

Which of the following is/are true regarding founder mutations?

• a)
  

  Mutations are specific to an ethnic group

  
  
• b)
  

  They are the result of a contraction and then expansion of a population containing those mutations

  
  
• c)
  

  There are 3 founder BRCA1/2 mutations in the Ashkenazi population

  
  
• d)
  

  Many ethnic groups have founder mutations

  
  
• e)
  

  There is a founder mutation found in over 10% of the Jewish population

The histology most commonly associated with an inherited BRCA1 mutation is?

• a)
  

  Clear cell

  
  
• b)
  

  Serous

  
  
• c)
  

  Mucinous

  
  
• d)
  

  Endometrioid

  
  
• e)
  

  Borderline

BRCA1 mutations differ from BRCA2 mutations in which of the following ways?

• a)
  

  There is a lower cancer penetrance (i.e. incidence of cancer)

  
  
• b)
  

  There is usually an earlier age of onset of the index cancer

  
  
• c)
  

  They produce a more aggressive histologic type

  
  
• d)
  

  They produce mucinous histology

  
  
• e)
  

  They are inherited in an autosomal recessive way rather than autosomal dominant

The following statement(s) is/ are true about borderline tumors of the ovary:

• a)
  

  Approximately 90% of serous borderline tumors (SBT) are confined to one or both ovaries (stage I) at the time of diagnosis.

  
  
• b)
  

  SBTs with exophytic growth are associated more frequently with peritoneal implants than intracystic tumors.

  
  
• c)
  

  Most peritoneal implants associated with SBTs infiltrate the underlying normal tissue (invasive implants).

  
  
• d)
  

  The recurrence rate of SBT is approximately 50% and most tumors recur as low-grade serous carcinoma.

  
  
• e)
  

  Mucinous borderline tumours (MBT) of intestinal-type exhibiting focal epithelial cell stratification, foci of cribriform architecture, and severe nuclear atypia (grade 3 nuclei) have been designated MBT with “intraepithelial carcinoma” and are associated with poor prognosis.

The following statements is/are true about high-grade serous carcinoma of the ovary:

• a)
  

  Women with germline mutations in BRCA1 or BRCA2 have a 10% to 15% risk of developing HGSC of the ovary by the age of 70.

  
  
• b)
  

  p53 signatures probably represent early clonal expansion short of neoplastic proliferation and are found more frequently in the fimbria of women with BRCA1 or BRCA2 mutations.

  
  
• c)
  

  Almost all “ovarian” HGSC originate in the fimbriated end of the fallopian tube.

  
  
• d)
  

  The most characteristic microscopic features of HGSC are variation in nuclear size (more than 3-fold) and high mitotic activity.

  
  
• e)
  

  HGSC is confined to the ovary at diagnosis in approximately 60% of cases.

Which of the following increase a woman’s risk of developing clear cell ovarian cancer?

• a)
  

  Smoking

  
  
• b)
  

  Endometriosis

  
  
• c)
  

  Use of menopausal hormone therapy

  
  
• d)
  

  Obesity

  
  
• e)
  

  Tubal ligation

The following statement(s) is/are true about endometrioid and clear cell carcinomas of the ovary:

• a)
  

  Endometrioid carcinoma of the ovary is thought to arise from ovarian endometriosis.

  
  
• b)
  

  Simultaneous carcinomas of the uterine corpus and ovary occur in 5% of ovarian endometrioid carcinomas.

  
  
• c)
  

  Most endometrioid carcinomas of the ovary immunoreact for p53, BRCA1 and WT1.

  
  
• d)
  

  Clear cell carcinoma (CCC) of the ovary is found in advanced stage at diagnosis in approximately 80% of cases.

  
  
• e)
  

  ARID1A (AT-rich interactive domain 1A gene) mutations occur exclusively in ovarian clear cell carcinomas.

Which of the following statements relating to surgical staging of early ovarian cancer is/are true?

• a)
  

  The main purpose of staging is to detect subclinical residual tumour spread.

  
  
• b)
  

  Without complete surgical staging early ovarian carcinoma cannot be established.

  
  
• c)
  

  The upstaging potential of a proper surgical staging procedure is around 16%.

  
  
• d)
  

  The staging procedure in itself does not change the survival of patients.

  
  
• e)
  

  Apparent early stage disease can harbour subclinical or microscopic tumour seeding in the upper abdomen or retroperitoneal area.

Which of the following is/are true regarding adjuvant chemotherapy following surgical treatment and staging for early stage ovarian carcinoma?

• a)
  

  It carries a fourfold increased risk of leukaemia in long term survivors.

  
  
• b)
  

  It is indicated in patients following complete and optimal surgical staging.

  
  
• c)
  

  It has the theoretical potential to cure at least 20 out of a 100 patients with early ovarian carcinoma.

  
  
• d)
  

  It seems to diminish the efficacy of salvage chemotherapy at the time of possible tumour recurrence.

  
  
• e)
  

  There is a good argument for postponing chemotherapy to the time of recurrence and not giving it in an adjuvant setting.

Early stage ovarian cancer is primarily treated by surgical removal of the affected adnexum together with the contralateral adnexum, the uterus and a complete surgical staging to rule out residual disease. Which of the following is/are true?

• a)
  

  In young patients with a future pregnancy wish it is permitted to leave the uterus and contralateral adnexum in situ and omit the staging procedure to prevent infertility.

  
  
• b)
  

  In mucinous grade I early ovarian carcinoma lymph node dissection can safely be omitted.

  
  
• c)
  

  It is generally accepted that a proper staging lymph node dissection in early stage ovarian cancer requires a minimum of at least 30 nodes.

  
  
• d)
  

  Lymph node dissection in the surgical staging of early ovarian carcinoma should be performed from a number of strictly defined high risk sites for retroperitoneal metastases including the para-aortic area.

  
  
• e)
  

  Lymph node dissection in the surgical staging of early ovarian carcinoma should be performed from a number of strictly defined high risk sites for retroperitoneal metastases including the para-caval area.

Regarding primary cytoreductive (debulking) surgery for patients with advanced epithelial ovarian cancer:

• a)
  

  The prognosis does not depend on the extent of metastatic disease if there is no macroscopic residual disease

  
  
• b)
  

  The prognosis does depend on the histologic type of tumour if there is no macroscopic residual disease

  
  
• c)
  

  There is no survival advantage for the patient if residual nodules up to 10mm diameter are left

  
  
• d)
  

  The American Society of Anaesthesiology (ASA) grade is an independent predictor of the rate of optimal cytoreduction

  
  
• e)
  

  Systematic pelvic and para-aortic lymphadenectomy should be performed in all patients

Regarding primary cytoreductive surgery for patients with stage IV disease:

• a)
  

  These patients should always be considered candidates for neoadjuvant chemotherapy

  
  
• b)
  

  Survival is still dependent on the known residual disease

  
  
• c)
  

  Splenic metastases are always due to haematogenous spread so splenectomy is not indicated

  
  
• d)
  

  Liver metastases are always due to haematogenous spread so partial hepatectomy is not appropriate

  
  
• e)
  

  Video Assisted Thoracic Surgery (VATS) may be used to evaluate the operability of intrathoracic disease

With respect to neoadjuvant chemotherapy (NACT) and interval debulking surgery:

• a)
  

  In randomized trials, survival is equivalent to patients having primary cytoreduction

  
  
• b)
  

  Survival is equivalent for patients having primary and interval debulking if both are left with no macroscopic residual disease

  
  
• c)
  

  Post-operative morbidity and mortality are better after NACT

  
  
• d)
  

  There is no surgical disadvantage to NACT

  
  
• e)
  

  NACT should always be performed on patients older than 70 years

With respect to patient selection for primary surgery, and post-operative morbidity and mortality:

• a)
  

  Age is a predictor of outcome

  
  
• b)
  

  There are no validated predictive scoring systems for selecting patients for surgery with advanced epithelial ovarian cancer

  
  
• c)
  

  Morbidity increases with increased number of cytoreductive procedures undertaken for a given patient

  
  
• d)
  

  Obesity increases morbidity in patients undergoing cytoreductive surgery

  
  
• e)
  

  Delay in chemotherapy due to morbidity from cytoreductive surgery does not affect survival

Which factor(s) in recurrent ovarian cancer setting were showed to have a good prognostic predictive value in the evaluation of the likelihood of complete secondary cytoreduction?

• a)
  

  Ascites >500mL at the recurrent setting,

  
  
• b)
  

  Residual disease <1cm after primary cytoreduction

  
  
• c)
  

  Good performance status

  
  
• d)
  

  A platinum-free interval

  
  
• e)
  

  A score positive AGO score

When ovarian cancer is grossly confined to the pelvis, which are the main indicators of quality promoted by EORTC?

• a)
  

  The number of patients with a suspicious ovarian mass undergoing staging laparotomy within 1 month after decision to treat or documented clinical or patient-related reason for delay.

  
  
• b)
  

  The rate of performed staging laparotomies for an ovarian mass suspected to be malignant performed through a vertical incision;

  
  
• c)
  

  The rate of patients that complete adjuvant chemotherapy;

  
  
• d)
  

  The rate of surgical reports with documented presence or absence of cyst rupture before or during surgery;

  
  
• e)
  

  The rate of surgical reports with documented presence or absence of dense adhesions, and rate of dense adhesions biopsied.

Recently, the ESGO committee has developed ten quality indicators for the management of advanced ovarian cancer. What is the optimal target for the rates of complete surgical resection and the number of cytoreductive surgeries performed per centre?

• a)
  

  An optimal target of >65% of optimal debulking surgeries.

  
  
• b)
  

  A minimum target of 50% of optimal debulking surgeries.

  
  
• c)
  

  The proportion of primary debulking surgeries / patients referred with stage III/IV patients should be more than 65%.

  
  
• d)
  

  More than 100 cytoreductive surgeries per surgeon a year.

  
  
• e)
  

  A minimum target of 35 new cases per surgeon a year.

Which of the following is/are true regarding the diagnosis of ovarian cancer during pregnancy?

• a)
  

  It is challenging because only 15% of ovarian masses during pregnancy are malignant.

  
  
• b)
  

  It is challenging because tumour markers are useless, as CA 125 levels are elevated during normal gestation.

  
  
• c)
  

  It is challenging because CT scan cannot be performed during pregnancy.

  
  
• d)
  

  It is challenging because functional cysts during pregnancy, like the corpus luteum, can mimic malignancy on imaging.

  
  
• e)
  

  It is challenging since, similar to non-pregnant women, the diagnosis is made in the majority of cases when the disease has already spread to the abdomen.

Which of the following is/are true regarding surgery for adnexal masses during pregnancy?

• a)
  

  It should be always performed.

  
  
• b)
  

  It can be safely performed during the second and third trimester.

  
  
• c)
  

  It should preferably be by laparotomy.

  
  
• d)
  

  It requires measures to prevent fetal hypoxia.

  
  
• e)
  

  It can be scheduled after delivery in cases of malignancy.

Which of the following is/are true regarding chemotherapy for epithelial ovarian cancer during pregnancy?

• a)
  

  It can be safely administered only in the third trimester.

  
  
• b)
  

  Cisplatin should be preferred to carboplatin.

  
  
• c)
  

  Bevacizumab increases the progression-free survival of women treated during pregnancy.

  
  
• d)
  

  It should be administered not later than two weeks before the planned delivery.

  
  
• e)
  

  It can be administered as neoadjuvant treatment.

Which of the following statements about bevacizumab is/are true?

• a)
  

  It is a fusion protein that binds to VEGF.

  
  
• b)
  

  It has been shown to improve progression free survival in women with high risk disease when given in combination with first line chemotherapy followed by 12 months maintenance therapy

  
  
• c)
  

  Trials failed to show benefit in ‘platinum-resistant’ recurrent ovarian cancer.

  
  
• d)
  

  Toxicities of bevacizumab include increased risk of bowel perforation, fistulae formation, impaired wound healing, increased risk of thromboembolism and hypertension.

  
  
• e)
  

  Measurement of predictive markers allow the selection of patients who will benefit.

Which of the following statements related to homologous recombination deficiency (HRD) in ovarian cancer is/are true?

• a)
  

  Single strand DNA breaks are the most lethal insult to the genome

  
  
• b)
  

  Germline BRCA mutations are present in 50% of high grade serous ovarian cancer

  
  
• c)
  

  Olaparib only improves PFS in BRCA mutated ovarian cancer, but has no activity in BRCA ^wt cancer

  
  
• d)
  

  PARP inhibitors are well tolerated, with the most common toxicities being nausea, vomiting, fatigue and anaemia

  
  
• e)
  

  The most evidence for the use of PARP inhibitors is in the ‘platinum- sensitive’ setting

In relation to the association between ovarian cancer and oral contraceptive (OC) use, which of the following is/are true?

• a)
  

  The risk of ovarian cancer decreases with longer duration of use of combined OCs.

  
  
• b)
  

  The risk reduction associated with combined OCs wanes rapidly, lasting less than 10 years after last use.

  
  
• c)
  

  The reduction in risk associated with combined OC use does not appear to have changed with reductions in oestrogen dose over time.

  
  
• d)
  

  Use of the combined OC does not reduce risk for women carrying a BRCA mutation.

  
  
• e)
  

  Oral progestin-only pills (POP contraceptives) have clearly been shown to reduce ovarian cancer risk.