The following is/are true regarding the occurrence of adnexal masses in pregnancy

• a)
  

  The incidence of adnexal masses in pregnancy is 3-5%

  
  
• b)
  

  The incidence of ovarian cancers in pregnancy is between 1:12,000 – 1:32,000

  
  
• c)
  

  The most common type of benign ovarian cyst in pregnancy is a mature teratoma.

  
  
• d)
  

  The most common histopathological subtype for malignant ovarian tumor in pregnancy is epithelial ovarian tumor.

  
  
• e)
  

  The most common histopathological subtype for malignant ovarian tumor in pregnancy is epithelial ovarian tumor.

  
  
• f)
  

  The resolution rate of adnexal masses in the second trimester of pregnancy is 60-70%.

The following is/are true regarding the presentation and imaging of an ovarian cyst during pregnancy.

• a)
  

  The most common mode of presentation of an adnexal mass is pain

  
  
• b)
  

  The sensitivity of detection of ovarian cysts on clinical examination alone is less than 5%.

  
  
• c)
  

  The size of ovarian cyst that should prompt investigation for malignancy is 10 cm

  
  
• d)
  

  The validated sensitivity and specificity of IOTA rules on USS evaluation of an ovarian cyst is sensitivity: 78%, specificity: 87%

  
  
• e)
  

  The sensitivity and specificity of MRI in the diagnosis of a malignancy is 100 and 94% respectively

The following is/are pertinent to surgery in patients with persisting adnexal masses?

• a)
  

  If required, surgery should ideally be scheduled beyond 24 weeks

  
  
• b)
  

  A laparoscopic surgical approach should be adopted in patients with a persisting adnexal mass in pregnancy

  
  
• c)
  

  Poor fetal outcome with surgery is seen beyond 36 weeks

  
  
• d)
  

  Hypertension is a common adverse effect noted with the use of laparoscopy in pregnancy

  
  
• e)
  

  For micro-papillary histopathological subtype of borderline ovarian tumors a completion staging should be considered

The following points is/are true regarding patients receiving chemotherapy for ovarian cancer during pregnancy.

• a)
  

  In a patient with ovarian cancer in pregnancy receiving chemotherapy the delivery should be planned at completion of chemotherapy

  
  
• b)
  

  Chemotherapy use in pregnancy is generally considered safe beyond 20 weeks of gestation

  
  
• c)
  

  CNS and neural tube complications occur during the week 8-12 weeks in pregnancy

  
  
• d)
  

  This percentage of patients receiving chemotherapy in pregnancy who develop major congenital malformations is 30-40 %

  
  
• e)
  

  Cardiovascular defects are common congenital malformations in platin based chemotherapy regimens

Of the following laboratory values and tumor markers, which are significantly impacted by pregnancy?

• a)
  

  White blood cell count

  
  
• b)
  

  Alkaline phosphatase

  
  
• c)
  

  Ovarian cancer antigen 125 (CA-125)

  
  
• d)
  

  Human chorionic gonadotropin (HCG)

  
  
• e)
  

  Carcinoembryonic antigen (CEA)

The following statement(s) is/are true regarding diagnostic imaging performed during pregnancy:

• a)
  

  For any imaging modality, the principle of using it only when clinically indicated, for the shortest amount of time, and with the lowest level of energy compatible with an accurate diagnosis should be employed.

  
  
• b)
  

  Ionizing radiation can result in three harmful fetal effects: cell death (and related teratogenic consequences), carcinogenesis, and genetic effects or mutations in germ cells.

  
  
• c)
  

  The generally accepted safe range of ionizing radiation during pregnancy is less than 20 rad.

  
  
• d)
  

  The use of MRI with or without gadolinium is a safe imaging modality in pregnancy because it utilizes magnets rather than ionizing radiation and gadolinium has not been associated with adverse fetal effects.

  
  
• e)
  

  The fetal thyroid does not concentrate iodine until the third trimester, therefore radiopaque contrast agents can be safely used until that time.

The following statement(s) is/are true regarding chemotherapy during pregnancy?

• a)
  

  The “all or none” in fetal development refers to the third trimester just prior to delivery at which point chemotherapy should not be used.

  
  
• b)
  

  Combination chemotherapy is not associated with an increased risk of congenital anomalies when compared to single-agent chemotherapy.

  
  
• c)
  

  Exposure to chemotherapy in the second and third trimesters is associated with fetal growth restriction, preterm delivery, and intrauterine fetal demise, however, long-term complications have not been seen.

  
  
• d)
  

  Biologic agents such as monoclonal antibodies are small molecules that can cross the placenta at any point during pregnancy.

  
  
• e)
  

  Tyrosine kinase inhibitors are small molecule agents that can cross the placenta at any point during pregnancy and therefore should be avoided in the first trimester.

The following statement(s) regarding specific malignancies during pregnancy is/are true?

• a)
  

  Breast cancer in pregnancy is most often axillary lymph node-positive and presents with a larger primary tumor size than outside of pregnancy

  
  
• b)
  

  With a finding of CIN2-3, colposcopy should be performed monthly to evaluate for progression of disease

  
  
• c)
  

  The diagnosis of adnexal masses during pregnancy is a common occurrence and approximately 10% are found to be malignant

  
  
• d)
  

  Acute leukemia adversely impacts a concurrent pregnancy

  
  
• e)
  

  Melanoma is known to metastasize to both the placenta and the fetus

Which of the following is/are true about breaking bad news to cancer patients during pregnancy?

• a)
  

  Questions in relation to diagnosis should be answered in an open and non-defensive way.

  
  
• b)
  

  Family members should not be allowed to participate at the discussion

  
  
• c)
  

  Showing sympathy will build the trust between the patient and the doctor

  
  
• d)
  

  Psychotherapy plays an important role

  
  
• e)
  

  Respecting the patient’s suggestions and decisions is important

Problems encountered during delivery and postpartum period in patients with malignant disease complicating pregnancy include which of the following?

• a)
  

  Psychological distress

  
  
• b)
  

  Increased postpartum haemorrhage

  
  
• c)
  

  The need for more assistance to cope up with raising the child

  
  
• d)
  

  Thromboembolism is more common

  
  
• e)
  

  Malignancy is an indication for Caesarean section

In the management of vulval cancer in pregnancy which of the following is/are true?

• a)
  

  Vulval cancer should be managed after delivery

  
  
• b)
  

  Diagnostic biopsy is safe in pregnancy

  
  
• c)
  

  CT scan is the preferred imaging for staging

  
  
• d)
  

  Chemotherapy is safe in pregnancy

  
  
• e)
  

  Caesarean section is the preferred mode of delivery

Regarding lower genital tract cancers in pregnancy.

• a)
  

  Adenocarcinoma is more common in pregnancy

  
  
• b)
  

  The incidence of vulva cancer in younger women is decreasing

  
  
• c)
  

  Vaginal clear cell cancer is common in pregnancy

  
  
• d)
  

  Squamous carcinoma is the commonest lower genital tract cancer overall in pregnancy

  
  
• e)
  

  Vulval melanoma is more common in pregnancy

Regarding surgical management of lower genital tract cancers which of the following is/are true?

• a)
  

  There is evidence to NOT perform sentinel node sampling in pregnancy

  
  
• b)
  

  It is better to perform inguinal or pelvic lymphadenectomy in the post-partum period

  
  
• c)
  

  Pelvic lymphadenectomy is recommended in lesions in the lower 1/3 of the vagina

  
  
• d)
  

  Wide local excision of vulval lesions is contraindicated in pregnancy

  
  
• e)
  

  Vulvectomy is most commonly performed in the post-partum period

The following is/are true regarding chemotherapy for breast cancer during pregnancy

• a)
  

  It is generally only recommended after delivery

  
  
• b)
  

  It must exclude all Taxanes

  
  
• c)
  

  It is contraindicated only below 14 weeks of gestation

  
  
• d)
  

  It must be given with an increased dose because of changes to maternal pharmacokinetics

  
  
• e)
  

  Altered maternal pharmacodynamics reduce the drug effect for many chemotherapeutic agents

The following is/are true regarding mammography:

• a)
  

  It must not be performed before the end of embryogenesis

  
  
• b)
  

  It should be limited to the affected side only

  
  
• c)
  

  It should be avoided in favor of breast MRI

  
  
• d)
  

  It should be part of routine evaluation of a suspicious mass in pregnancy

  
  
• e)
  

  Shielding will eliminate fetal radiation exposure

The following is/are true regarding termination of pregnancy:

• a)
  

  It can improve maternal outcome when performed during the 1st trimester for concurrent breast cancer

  
  
• b)
  

  Overall it has no effect on oncologic survival

  
  
• c)
  

  It is indicated for all patients receiving chemotherapy

  
  
• d)
  

  It actually worsens maternal prognosis as shown in prospective trials

  
  
• e)
  

  The reduction in oestrogen levels following TOP reduce the need for adjuvant anti-oestrogen therapy

The following is/are true regarding surgery for breast cancer during pregnancy:

• a)
  

  It should be mastectomy because the most straightforward technique should be used

  
  
• b)
  

  It should be breast conservation because reconstruction during pregnancy is not possible

  
  
• c)
  

  It should be delayed until after neoadjuvant chemotherapy to minimize anaesthesia exposure of the fetus

  
  
• d)
  

  It should follow the same guidelines as for non-pregnant patients

  
  
• e)
  

  The physiological changes to the breast make the surgery more challenging

A 35yo lady G3P2, 18 weeks pregnant, is found to have a large cancer on the cervix replacing the substance of the cervix and infiltrating the left parametrium. Rectovaginal examination shows parametrial involvement which has not reached the pelvic side wall. Pelvic MRI did not detect any suspicious nodes. The chest X-ray was negative. Which of the following is/are true?

• a)
  

  Laparoscopic pelvic lymph node dissection is contraindicated because at that gestational age there is a low chance of harvesting a good number of lymph nodes

  
  
• b)
  

  Careful discussion on pros/cons on pregnancy preserving management should be taken in the presence of CNS nurse

  
  
• c)
  

  Trachelectomy followed by cervical cerclage should be advised as a treatment option in pregnancy preserving treatment

  
  
• d)
  

  Chemotherapy should not be offered because lymph nodes are not suspicious on MRI

  
  
• e)
  

  TOP followed by chemo/radiotherapy should be offered in pregnancy non-preserving treatment

With regard to cervical cancer in pregnancy:

• a)
  

  Cervical cancer is the most common malignancy detected in pregnancy

  
  
• b)
  

  TOP and radical hysterectomy followed by PLND is mandatory in stage 1B1 disease diagnosed during the second trimester

  
  
• c)
  

  Cervical cancer is an indication for a classical caesarean section

  
  
• d)
  

  In micro invasive tumors (Stages 1A1/1A2) diagnosed during the early second trimester, pregnancy preserving management is not indicated and TOP should be performed asap

  
  
• e)
  

  Fetal viability is one of the most important aspects to be considered in the management of cervical cancer in pregnancy

A 40 yo G4P3, 18 weeks pregnant, has had post coital bleeding for the last month. Speculum examination showed a vaginal discharge and a 1 cm exophytic lesion on the anterior cervical lip. She does not remember when she last time had a smear test. Which of the following statements is true regarding her further management?

• a)
  

  She should have a pap smear test performed

  
  
• b)
  

  Punch biopsy of the lesion is indicated

  
  
• c)
  

  Prescribe a dose of antibiotics and reassess the cervix when the vaginal discharge has settled down

  
  
• d)
  

  In view of the findings and the gestational age a cone biopsy should be offered as treatment of the lesion

  
  
• e)
  

  Assuming that the lesion has been biopsied and histology results showed cancer cells, MRI without contrast should be considered as next step

A 26 year old primigravida presents in the antenatal clinic with post coital bleeding. Clinical examination reveals a 5 cm tumour in the cervix. Biopsy shows the presence of moderately differentiated squamous cell carcinoma. In managing the patient, the following considerations is/are important:

• a)
  

  Gestational age of the patient

  
  
• b)
  

  Stage of the disease

  
  
• c)
  

  Mode of delivery

  
  
• d)
  

  Multidisciplinary management

  
  
• e)
  

  The patient’s wishes

Regarding chemotherapy in pregnancy:

• a)
  

  The most important risk of using chemotherapy in the first trimester of pregnancy is the occurrence of intrauterine growth restriction and low birth weight

  
  
• b)
  

  The most important risk of using chemotherapy in second trimester of pregnancy, is the occurrence of teratogenesis

  
  
• c)
  

  Chemotherapeutic drugs cross freely into the fetal circulation

  
  
• d)
  

  Cisplatin is the most commonly used drug in pregnancy

  
  
• e)
  

  Neoadjuvant chemotherapy makes it possible for fertility preservation in selected patients

The following statement(s) is/are true regarding pre-malignant disease of the lower genital tract in pregnancy:

• a)
  

  CIN complicates 2-8% of pregnancies.

  
  
• b)
  

  CIN progresses due to the relative immune-suppression of pregnancy.

  
  
• c)
  

  CIN3 should be treated during pregnancy to prevent progression to cancer.

  
  
• d)
  

  It is ideal to use pregnancy care as an opportunity to perform cervical cytology.

  
  
• e)
  

  Suspicious vulval lesions noted during pregnancy, should be biopsied.

The following statement(s) is/are true regarding colposcopy in pregnancy:

• a)
  

  It increases the risk of preterm delivery and should ideally be avoided in pregnancy

  
  
• b)
  

  It does not increase the risk of early miscarriage

  
  
• c)
  

  An abnormal cytology result in pregnancy requires referral for colposcopy

  
  
• d)
  

  It is only indicated if the woman previously had treatment for CGIN or treatment for CIN2/3 with involved or uncertain margin

  
  
• e)
  

  It can be undertaken by any colposcopist

The following statement(s) is/are true regarding pregnancy-related outcomes:

• a)
  

  HPV vaccination in pregnancy is not associated with an increase in stillbirth or spontaneous miscarriage

  
  
• b)
  

  Cold-knife and laser conisation are associated with an increased risk of preterm delivery

  
  
• c)
  

  Ablative treatments are associated with an increased risk of serious adverse pregnancy outcomes

  
  
• d)
  

  The risk of preterm delivery increases after multiple conisations

  
  
• e)
  

  Most of the studies on adverse pregnancy outcomes after treatment for CIN are large prospective studies

The following statement(s) is/are true regarding the management of CIN in pregnancy:

• a)
  

  Colposcopic directed biopsies are mandatory in the management of CIN in pregnancy

  
  
• b)
  

  Punch biopsies are adequate to safely confirm or exclude invasive disease

  
  
• c)
  

  Standard practice in the UK involves deferring definitive treatment until 3-4 months post-partum if invasive cancer has been excluded

  
  
• d)
  

  Colposcopy should be repeated at 3-monthly intervals during pregnancy if CIN2/3 is suspected

  
  
• e)
  

  Haemorrhage is more likely to occur if biopsies are taken in pregnancy

The following is/are true regarding radiotherapy in pregnancy:

• a)
  

  Deterministic effects have a cause and effect relationship

  
  
• b)
  

  Deterministic effects are radiation effects that occur by chance, for example, induction of cancer

  
  
• c)
  

  Deterministic effects mean that once a threshold dose has been exceeded the severity of the effect will increase in a linear fashion with increasing dose

  
  
• d)
  

  Stochastic effects have shown that risk increases in a linear quadratic relationship with dose

  
  
• e)
  

  The threshold dose a fetus can be exposed to is 0.1Gy

Radiotherapy has been given safely to a pregnant woman with which of the following?

• a)
  

  Breast cancer

  
  
• b)
  

  Non-Hodgkin’s lymphoma

  
  
• c)
  

  Cervical cancer

  
  
• d)
  

  Endometrial cancer

  
  
• e)
  

  Naso-phyaryngeal cancer

Which of the following tumour markers is/are increased by pregnancy itself and are therefore less accurate in diagnosis and follow-up of pregnant cancer patients?

• a)
  

  Squamous cell carcinoma antigen (SCC)

  
  
• b)
  

  Human epididymis protein 4 (HE4)

  
  
• c)
  

  Cancer antigen 125 (CA 125)

  
  
• d)
  

  Carbohydrate antigen 15-3 (CA 15-3)

  
  
• e)
  

  Anti-Müllerian hormone (AMH)

Which of the following issues should be taken into account when choosing appropriate imaging techniques in pregnant women?

• a)
  

  Safety of the imaging technique for the fetus

  
  
• b)
  

  The expected mode of delivery

  
  
• c)
  

  The time until the imaging can take place for logistic reasons

  
  
• d)
  

  Physiological body alterations secondary to pregnancy

  
  
• e)
  

  The risk of metastatic disease