Staging in Gynaecological Cancers – Multiple Choice Questions for Vol. 29, No. 6

  • 1.

    Which of the following is true regarding the current role of molecular markers in cancer staging?

    • a)

      There is no clear and unanimous consensus on which prognostic biomarkers to include in cancer staging.

    • b)

      Numerous molecular markers are associated with poor clinical outcomes.

    • c)

      Numerous molecular markers are associated with favorable clinical outcomes.

    • d)

      Molecular markers are currently being used to help in staging classification of other cancers but not gynecologic cancers.

    • e)

      Molecular markers are currently being used in staging classification of most cancers, including gynecologic cancers.

  • 2.

    Which one of the following is/are proto-oncogene(s)?

    • a)

      PIK3CA

    • b)

      KRAS

    • c)

      P53

    • d)

      HER2

    • e)

      FGFR2

  • 3.

    Which of the following is/are true regarding molecular markers?

    • a)

      MEK (MAPK pathway) inhibitors are under evaluation in gynaecological cancer

    • b)

      Receptor tyrosine kinase inhibitors are under evaluation in gynaecological cancer

    • c)

      Anti-VEGF monoclonal antibodies are under evaluation in gynaecological cancer

    • d)

      Molecular markers have the potential to improve classification of histologic subtypes

    • e)

      Molecular markers have the potential to predict risk of clinical outcome including progression-free and overall survival

  • 4.

    The new 2009 FIGO Staging for vulvar cancer has meant which of the following?

    • a)

      The definition of micro-invasive vulvar cancer has been changed

    • b)

      A significant number of patients will be down-staged

    • c)

      The number of patients with stage II disease will be increased

    • d)

      Patients with stage III disease will be a more homogeneous group

    • e)

      There is no longer a staging category for patients with bilaterally positive lymph nodes

  • 5.

    Survival of patients with vulvar cancer is worse in the presence of:

    • a)

      Lymph node metastases greater than 15 mm diameter

    • b)

      Bilaterally positive lymph nodes

    • c)

      More than 3 positive lymph nodes

    • d)

      Extra-capsular spread beyond the lymph node

    • e)

      Groin dissections performed through separate groin incisions

  • 6.

    Indications for radiation therapy in patients with vulvar cancer include:

    • a)

      Patients with one microscopically positive groin node (5 mm or less)

    • b)

      Patients with extra-capsular nodal spread

    • c)

      Patients with surgical margins around the primary tumour of less than 5 mm if there is no possibility of further surgical resection (e.g. too close to the anus)

    • d)

      Patients with palpably enlarged positive groin nodes prior to resection of the nodes

    • e)

      Patients with involvement of the anus

  • 7.

    Based on the GOG prospective study, which of the following is/are significant prognostic factors in patients with histologically confirmed stage I cervical cancer?

    • a)

      Age

    • b)

      Tumour size

    • c)

      LVSI

    • d)

      Node positivity

    • e)

      Performance status

  • 8.

    The following statement(s) is/are true with regard to vaginal cancer:

    • a)

      DES associated vaginal cancers are aggressive cancers

    • b)

      Majority of vaginal cancers are seen in the lower 1/3rd of the vagina and metastasize to unilateral pelvic nodes

    • c)

      The vagina has a complex network of lymphatics, therefore bilateral involvement of inguino-femoral lymph nodes may occur

    • d)

      Most vaginal cancers occur in the anterior vaginal wall

    • e)

      Urinary symptoms commonly occur in women with vaginal cancer

  • 9.

    In general, in situ and invasive vaginal cancers are associated with the same risk factors as cervical cancer. Which of the following statements is/are true?

    • a)

      Vaginal cancers occur more often only after surgical treatment of cervical cancer

    • b)

      After the treatment of VAIN vaginal cancers are uncommon and therefore follow-up may be discontinued after 3–5 years

    • c)

      High risk HPV infections are a risk factor in young women with squamous cell carcinoma of vagina

    • d)

      Smoking and alcohol have direct effects on vaginal cancer pathogenesis

    • e)

      DES associated vaginal cancers tend to have better prognosis

  • 10.

    Which of the following is/are true regarding lymph node metastasis in endometrial cancer?

    • a)

      It occurs in the majority of cases

    • b)

      It is one of the major prognostic factors in EC, regardless of the number of metastatic LNs

    • c)

      It is included in FIGO staging

    • d)

      It is rarely observed in the para-aortic area when the pelvic area is involved

    • e)

      Probability can accurately be predicted using dedicated scores

  • 11.

    Detection of metastatic lymph nodes:

    • a)

      Is mandatory before surgery for endometrial cancer

    • b)

      In the para aortic area does not require dissection above the inferior mesenteric artery since this location is infrequent

    • c)

      Can use sentinel lymph node biopsy in all risk groups to reduce complications associated with lymphadenectomy

    • d)

      Is accurate using 18F-FDG PET

    • e)

      Is accurate using MRI

  • 12.

    Removal of metastatic lymph nodes

    • a)

      Requires complete pelvic and para aortic lymphadenectomy as well as resection of deep inguinal nodes not to miss any of them

    • b)

      Is not mandatory in at least half of patients with presumed early stage EC

    • c)

      Should be performed systematically since LN status improves survival prediction

    • d)

      Could improve survival in intermediate and high risk groups

    • e)

      Is mandatory since this information is a determinant for the decision to deliver adjuvant chemotherapy

  • 13.

    Which of the following statement(s) is/are true about endometrial carcinoma?

    • a)

      It is not necessary to assess the status of pelvic and para-aortic lymph node in endometrial cancer

    • b)

      Lymph node dissection is considered as an important aspect of the management of endometrial cancer

    • c)

      Extensive lymph node dissection prolongs overall survival (OS) compared to fewer nodes removed

    • d)

      Incidence of lymph node metastasis are correlated with tumour size in endometrial cancer

    • e)

      Pelvic and para-aortic lymph node dissection does not lead to better OS

  • 14.

    Which of the following statement(s) is/are true about lymph node metastases?

    • a)

      Systematic lymphadenectomy is the standard technique used for resection of bulky lymph nodes

    • b)

      Pelvic and para-aortic lymph node dissection have become an important part of the surgical treatment of gynaecological cancers

    • c)

      Lymph node metastases either start there itself or cancer cells can spread to lymph nodes through the normal circulation of body fluid

    • d)

      As per FIGO, lymphatic spread has not been reported as a common feature of gynaecological cancers

    • e)

      Surgical debulking of enlarged lymph nodes would not be effective in chemo-radiation resistant lymph nodes

  • 15.

    The following features on de-bulking of lymph nodes can be interpreted as follows:

    • a)

      Resection of the bulky lymph nodes is not reported to be beneficial if the patients had clear cell histology, myometrial invasion (>50%) and large tumor (>2 cm in diameter)

    • b)

      The success rates with de-bulking depend on compliance, morbidity and survival rates in cancer patients

    • c)

      One of the most important prognostic factors for survival in women with cervical cancer are the status of lymph nodes

    • d)

      There are two basic approaches for de-bulking retroperitoneal nodes in cervical cancer

    • e)

      Pelvic and para-aortic lymph node dissection can help treatments like radiation or chemotherapy work better for gynaecological cancer

  • 16.

    The following features on involvement of lymph nodes can be interpreted as follows:

    • a)

      In patients with advanced ovarian cancer, retroperitoneal lymph node involvement is reported in 50–75% of patients

    • b)

      In early stage uterine leiomyosarcoma, the incidence of lymph node metastases has been shown to be approximately 3%

    • c)

      Pelvic disease control may reduce the risk of distant metastatic spread by 60–75%

    • d)

      Incidence of nodal metastases decreases with the increase in FIGO stage

    • e)

      Removal of positive bulky node along with cyto-reductive surgery does not offer survival benefits

  • 17.

    The following statement(s) is are true/false about stage I carcinoma of the ovary or fallopian tube:

    • a)

      “Surgical spill” (IC1) refers to a macroscopically recognizable intraoperative rupture of a tumour and requires a positive peritoneal cytology for malignant cells.

    • b)

      FIGO recommends performing peritoneal washing and cytological evaluation only when rupture of the tumour is noted.

    • c)

      This recommendation applies only to a rupture that occurred before the operation.

    • d)

      Positive peritoneal fluid is stage IC3 regardless of rupture.

    • e)

      Negative cytology in the initial peritoneal washing in a case of ruptured capsule before surgery can only be understood in the sense of failure to identify the presence of rare tumour cells.

  • 18.

    The following statement(s) is/are true/false about stage II carcinoma of the ovary or fallopian tube:

    • a)

      A tumor confined to one ovary showing dense fibrous adhesions with histologically proven tumour cells should be upgraded from stage I to stage II.

    • b)

      Stage II comprises approximately 30% of ovarian cancers.

    • c)

      Biologically, stage II carcinomas behave similar to stage III disease and it is only because of their anatomic location in the pelvis that they are designated stage II.

    • d)

      All stage II disease is treated with adjuvant chemotherapy.

    • e)

      Extension and/or implants on the uterus and/or fallopian tubes/and/or ovaries with ascites or positive peritoneal washings is designated stage IIC

  • 19.

    Ovarian carcinomas extending beyond the pelvis with exclusively retroperitoneal lymph node involvement are currently classified as stage:

    • a)

      IIB

    • b)

      IIIA1

    • c)

      IIIA2

    • d)

      IIIB

    • e)

      IIIC

  • 20.

    The sentinel lymph node procedure is only recommended in well selected patients. Selection criteria include:

    • a)

      Primary squamous cell vulvar cancer with a depth of invasion > 1mm

    • b)

      Local recurrences < 4cm with previously a negative sentinel node

    • c)

      Uni-focal tumors

    • d)

      No clinically suspicious groin nodes

    • e)

      Enlarged lymph nodes excluded by preoperative imaging

  • 21.

    A patient with histologically proven squamous cell cancer of the vulva, 5cm in diameter and 5mm from the midline is best treated with:

    • a)

      Wide local excision only

    • b)

      Wide local excision with unilateral SN procedure

    • c)

      Wide local excision with bilateral SN procedure

    • d)

      Wide local excision with unilateral inguino-femoral lymphadenectomy

    • e)

      Wide local excision with bilateral inguino-femoral lymphadenectomy

  • 22.

    Which of the following is/are seen as a result of ultra-staging?

    • a)

      More metastases are diagnosed.

    • b)

      Smaller metastases are diagnosed.

    • c)

      More patients will be in stage III, from stage I

    • d)

      The prognosis of stage III increases

    • e)

      The prognosis of stage I decreases

  • 23.

    A 61 year old patient was treated with wide local excision and SN procedure in the left groin (tumor was lateralized, 2cm from midline). Pathology shows a squamous cell tumor of 19mm with a depth of invasion of 3mm. The removed sentinel node shows a metastases of 0.7mm, without extra-nodal tumor growth. What is the most appropriate advice on treatment?

    • a)

      Radiotherapy on left groin

    • b)

      Radiotherapy on both groins

    • c)

      Radiotherapy and on both groins and brachytherapy

    • d)

      Left inguino-femoral lymphadenectomy

    • e)

      Bilateral inguino-femoral lymphadenectomy

  • 24.

    In cervical cancer,

    • a)

      Lymphadenectomy is not necessary in stage 1a1 disease as the risk of lymph node metastasis is low.

    • b)

      There is high accuracy in CT, MRI and PET-CT for diagnosing lymph node metastasis.

    • c)

      Laparoscopic lymphadenectomy has proven to have a therapeutic value in late-stage cervical cancer.

    • d)

      The risk of isolated para-aortic lymph node metastasis is low and so routine para-aortic lymphadenectomy is not recommended.

    • e)

      Laparoscopic lymphadenectomy is important because if lymph node metastasis is found, the disease will be upstaged and systematic chemotherapy or extended radiotherapy may be needed.

  • 25.

    In endometrial cancer,

    • a)

      Systematic pelvic and para-aortic lymphadenectomy should only be performed in those with high-risk diseases.

    • b)

      Compared with laparotomy, the decrease in peri-operative complication rate in laparoscopy is mainly in the post-operative period.

    • c)

      There is no survival difference between laparoscopic and laparotomy surgery.

    • d)

      Single-port surgery is associated with higher conversion rate and more estimated blood loss than conventional laparoscopic surgery.

    • e)

      The lymphatic drainage of endometrial cancer is mainly through the cervix, parametria and pelvic lymph nodes.

  • 26.

    In ovarian cancer,

    • a)

      Laparoscopic surgery was associated with higher tumour rupture and spillage rate than laparotomy in early-stage ovarian cancer.

    • b)

      Tumour size, presence of adhesion and ascites are some of the laparoscopic parameters that can help to predict resectability in advanced ovarian cancer.

    • c)

      The incidence of port-site metastasis could be up to 30% even in early-stage ovarian cancer.

    • d)

      Advanced stage and ascites are risk factors for port-site metastasis after laparoscopic surgery.

    • e)

      There is level I evidence supporting the safety of laparoscopic surgery in early-stage ovarian cancer.

  • 27.

    Regarding newly developed technology on laparoscopic staging:

    • a)

      Robot-assisted surgery outperformed laparotomy by having less blood loss and shorter length of hospitalization.

    • b)

      Preliminary data showed that robot-assisted surgery might be safe in early-stage ovarian cancer.

    • c)

      The role of sentinel lymph node biopsy in endometrial cancer is still questionable.

    • d)

      The sensitivity of sentinel lymph node biopsy is higher for cervical cancer bigger than 2cm than for smaller tumours because the lymphatic channels are better developed in the former.

    • e)

      Although single-port surgery has similar peri-operative complication rates compared to laparoscopic surgery, the former is associated with fewer lymph nodes sampled and higher conversion rate.

  • 28.

    A 65 year old woman has been diagnosed to have free fluid in the abdomen. Contrast enhanced CT scan reveals an adnexal mass, ascites, diaphragmatic deposits, and omental caking. Her CA-125 is 546 u/ml. What would be the next most appropriate step?

    • a)

      Core biopsy from adnexal mass or from the omentum

    • b)

      Fine needle aspiration biopsy from the adnexal mass

    • c)

      Laparotomy and proceed

    • d)

      Diagnostic laparoscopy followed by laparotomy

    • e)

      Neo-adjuvant chemotherapy

  • 29.

    Which of the following is an appropriate indication for neo-adjuvant chemotherapy in a diagnosed case of epithelial ovarian cancer?

    • a)

      Massive right sided pleural effusion

    • b)

      Presence of omental caking on contrast enhanced CT scan

    • c)

      Obesity, BMI >30

    • d)

      High grade serous carcinoma

    • e)

      Known BRCA positive gene status

  • 30.

    A 45 year old lady has been diagnosed to have carcinoma of cervix FIGO stage IIB. What would be the recommended treatment for this?

    • a)

      Neo-adjuvant chemotherapy followed by radiation

    • b)

      Neo-adjuvant chemotherapy followed by concurrent chemo-radiation

    • c)

      Concurrent chemo-radiation

    • d)

      Radiation followed by chemotherapy

    • e)

      Radiation only

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Nov 6, 2017 | Posted by in OBSTETRICS | Comments Off on Staging in Gynaecological Cancers – Multiple Choice Questions for Vol. 29, No. 6

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