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.

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

• a)

  PIK3CA

• b)

  KRAS

• c)

  P53

• d)

  HER2

• e)

  FGFR2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

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.

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.

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.

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.

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

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

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