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OG33.1-5,OG34.1-5 | Gynaecological Oncology and Operative Gynaecology — Practice Quiz
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A 45-year-old woman is diagnosed with cervical carcinoma. On examination the tumour measures 3.2 cm, is confined to the cervix, and there is no parametrial involvement or nodal spread. Which FIGO 2018 stage is correct?
Correct. Under FIGO 2018, Stage IB is tumour confined to the cervix. IB1 = <2 cm, IB2 = 2–4 cm (this tumour at 3.2 cm), IB3 = ≥4 cm. There is no vaginal or parametrial involvement to justify Stage II.
FIGO 2018 introduced the three-tier IB sub-staging based on tumour size: IB1 <2 cm, IB2 2–4 cm, IB3 ≥4 cm — all confined to the cervix.
Review the FIGO 2018 IB sub-staging: IB1 <2 cm, IB2 2–4 cm, IB3 ≥4 cm. IIA requires spread to the upper two-thirds of the vagina without parametrial involvement.
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A woman with cervical cancer has imaging evidence of pelvic lymph node metastasis but no para-aortic involvement and no distant metastasis. Which FIGO 2018 stage applies?
Correct. The FIGO 2018 staging added Stage IIIC to recognise nodal involvement: IIIC1 = pelvic lymph node metastasis (regardless of tumour size/local extent); IIIC2 = para-aortic nodal involvement.
FIGO 2018 introduced Stage IIIC for nodal involvement: IIIC1 (pelvic nodes) and IIIC2 (para-aortic nodes). This can upstage a tumour regardless of local extent.
FIGO 2018 Stage IIIC was added specifically for nodal spread. IIIC1 = pelvic nodes positive; IIIC2 = para-aortic nodes positive. IIIB is ureteric obstruction or non-functional kidney; IVB is distant metastasis.
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A 38-year-old woman undergoes cervical cancer screening with VIA. The result is VIA-positive. Which of the following describes a correct VIA-positive finding?
Correct. VIA-positive is defined as a well-defined, distinct acetowhite lesion appearing near the transformation zone (squamocolumnar junction) within approximately 1 minute of 3–5% acetic acid application. The acetate reaction indicates increased nuclear protein density characteristic of dysplastic cells.
VIA-positive = a sharply demarcated acetowhite lesion near the transformation zone (squamocolumnar junction) appearing within 1 minute of acetic acid application. Compare with VILI-positive (iodine non-uptake = mustard/saffron colour).
Option A describes a non-specific response (physiological columnar epithelium also turns whitish). Option C describes VILI (iodine-staining), not VIA. VIA-positive specifically requires a well-defined acetowhite lesion close to the transformation zone.
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A colposcopy-directed biopsy shows CIN 2 in a 30-year-old woman who wishes to preserve fertility. She has no evidence of microinvasive disease. Which treatment modality is most appropriate?
Correct. LLETZ (LEEP) is the preferred treatment for CIN 2 as it is both therapeutic and provides an excisional specimen for histological assessment (ruling out microinvasion), and preserves fertility. Cryotherapy is ablative (no specimen), acceptable for CIN 1/small CIN 2 but LLETZ is preferred. Hysterectomy is not indicated for CIN 2 in a young woman.
CIN 2 and CIN 3 require treatment. LLETZ (LEEP) is the excisional method of choice — it treats the lesion AND provides a specimen. Ablative methods (cryotherapy, thermal ablation) can be used for CIN 1–2 only when invasive disease is excluded colposcopically.
For CIN 2, LLETZ is preferred over ablative methods because it yields a histological specimen to exclude microinvasion. Cryotherapy is ablative (no specimen obtained) and less preferred for CIN 2/3. Surveillance alone is not appropriate for CIN 2.
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A 62-year-old woman presents with postmenopausal bleeding. Transvaginal ultrasound shows endometrial thickness of 14 mm. Which investigation should be performed next to confirm the diagnosis?
Correct. The definitive investigation for suspected endometrial cancer is histological tissue sampling — either Pipelle endometrial aspiration (outpatient) or D&C under anaesthesia. MRI is used for staging after histological confirmation. CA-125 is a tumour marker for ovarian cancer and is not diagnostic for endometrial disease. Hysteroscopy-directed biopsy is also acceptable but is the same principle — tissue diagnosis.
Postmenopausal bleeding + endometrial thickness >4–5 mm on TVU mandates endometrial sampling for histological diagnosis. Pipelle aspiration is the first-line outpatient method; D&C under anaesthesia if aspiration is inadequate.
MRI is a staging tool, not a diagnostic tool for endometrial cancer. CA-125 is primarily used for ovarian malignancy. Histological sampling (Pipelle or D&C) is mandatory to confirm endometrial cancer.
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A 55-year-old woman undergoes surgical exploration for an ovarian mass. At surgery, the tumour is found to involve both ovaries, with tumour deposits on the pelvic peritoneum (serosa of the uterus) but no spread beyond the pelvis and no retroperitoneal lymph node involvement. Using the FIGO ovarian cancer staging system, what is the correct stage?
Correct. In the FIGO ovarian cancer staging system (2014), Stage II involves one or both ovaries with extension to the pelvis. Stage IIA = extension to or implants on uterus and/or tubes; Stage IIB = extension to other pelvic intraperitoneal tissues. Here, pelvic peritoneal deposits confined to the pelvis = Stage IIB. Stage III involves peritoneal involvement beyond the pelvis or retroperitoneal nodes.
FIGO ovarian cancer staging (2014) is a SEPARATE system from cervical and endometrial staging. Stage IIB = extension to pelvic peritoneum (beyond uterus/tubes but still within the pelvis). Do not confuse with cervical FIGO 2018 stages.
Remember: ovarian FIGO staging (2014) — Stage I = ovary only; Stage II = pelvic spread; Stage III = peritoneal spread beyond pelvis or retroperitoneal nodes; Stage IV = distant metastasis. This case has pelvic but not extra-pelvic spread.
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A 24-year-old woman had evacuation of a complete hydatidiform mole 8 weeks ago. Post-evacuation serum β-hCG has shown a plateau (less than 10% decline over 3 consecutive weekly measurements). What is the most appropriate next step?
Correct. A plateau of β-hCG (defined as less than 10% decline over 3 consecutive weekly measurements, or four values over 3 weeks) after molar evacuation fulfils the criteria for post-molar gestational trophoblastic neoplasia (GTN). The next step is WHO/FIGO prognostic scoring to determine risk. A low-risk score (≤6) is treated with single-agent methotrexate. EMA-CO is reserved for high-risk GTN (score ≥7). Second evacuation is not standard first-line treatment for GTN.
Post-molar GTN is diagnosed by β-hCG kinetics alone: plateau (<10% decline over 3 weekly measurements) or rise, or failure to normalise. Treatment = WHO/FIGO risk scoring then single-agent (low risk) or multi-agent (high risk) chemotherapy.
β-hCG plateau post-molar evacuation = GTN diagnosis. Treatment depends on WHO prognostic score: ≤6 = single-agent (methotrexate or actinomycin-D); ≥7 = combination (EMA-CO or EMA-EP). Second evacuation is not standard therapy for GTN.
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During a D&C procedure for abnormal uterine bleeding, the surgeon suddenly finds the instrument passes with no resistance and the patient complains of sudden severe pain, with peritoneal signs developing shortly after. What is the most likely complication and the immediate management?
Correct. Sudden loss of resistance during D&C with peritoneal signs indicates uterine perforation — the most serious intraoperative complication of D&C. Immediate management: stop the procedure, monitor vital signs, and proceed to diagnostic laparoscopy (or laparotomy if haemodynamically unstable) to assess and manage any associated bowel or vascular injury.
Uterine perforation is the most serious complication of D&C. Risk is highest in a retroverted uterus or postmenopausal uterus. Two safety rules: always sound before dilating; use graduated dilators. Management after perforation: stop, vitals, laparoscopy.
Sudden loss of resistance during uterine instrumentation = uterine perforation until proven otherwise. The management priority is haemodynamic assessment and laparoscopy/laparotomy to exclude bowel injury, not continuing the procedure.
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During a total abdominal hysterectomy, the surgeon needs to identify the ureter to avoid injury. At which anatomical point is the ureter closest to the uterine artery in the pelvis?
Correct. The ureter runs in the base of the broad ligament, approximately 1–1.5 cm lateral to the cervix. At this point, the uterine artery crosses over the ureter — the surgical aphorism is 'water under the bridge' (ureter = water, uterine artery = bridge). This is the classic site of ureteric injury during hysterectomy.
The ureter is most vulnerable during hysterectomy at the point in the base of the broad ligament (~1.5 cm lateral to cervix) where the uterine artery crosses above it ('water under the bridge'). Always identify before clamping the uterine artery.
The ureter crosses the pelvic brim at the bifurcation of the common iliac artery, but the point of greatest surgical risk is in the base of the broad ligament (~1.5 cm lateral to cervix) where the uterine artery crosses ABOVE the ureter — the mnemonic 'water under the bridge'.
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A post-menopausal woman is found to have an adnexal mass on ultrasound. The Risk of Malignancy Index (RMI) calculation uses three variables. Which of the following correctly states the three components of RMI?
Correct. The Risk of Malignancy Index (RMI) = U × M × CA-125. U is the ultrasound score (0–3 based on features: multilocular, solid areas, bilateral, ascites, intraperitoneal metastases); M is menopausal status (1 = premenopausal, 3 = postmenopausal); CA-125 is in U/mL. RMI >200 suggests high risk of malignancy.
The Risk of Malignancy Index (RMI) = U × M × CA-125. A score >200 indicates high risk for malignancy. It is used to triage women with adnexal masses for specialist referral.
RMI uses three specific variables: Ultrasound score (U), Menopausal status (M), and CA-125 level — combined as U × M × CA-125. AFP and LDH are germ-cell tumour markers; CEA is not part of the standard RMI.
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