OG33.1-5,OG34.1-5 | Gynaecological Oncology and Operative Gynaecology — Graded Quiz

Correct. A 2.8 cm tumour confined to the cervix is Stage IB2 (FIGO 2018: IB2 = 2–4 cm, cervix-confined). Stage IB2 can be treated with either concurrent chemoradiation (external beam + brachytherapy + cisplatin) or radical hysterectomy (Wertheim's) with bilateral pelvic lymph node dissection — both are acceptable with equivalent outcomes. IB1 is <2 cm; IB3 is ≥4 cm. IIA requires upper vaginal involvement.

FIGO 2018 IB2 (2–4 cm, cervix-confined): management options are equivalent — radical hysterectomy + pelvic lymph node dissection OR concurrent chemoradiation. Typically one modality is chosen to avoid combining surgery + radiation (increased morbidity).

FIGO 2018 IB sub-staging: IB1 <2 cm, IB2 2–4 cm (this case), IB3 ≥4 cm. For IB2, both radical surgery and chemoradiation are valid. IIA requires upper vaginal extension beyond the cervix.

Correct. Para-aortic nodal involvement = FIGO 2018 Stage IIIC2 (IIIC1 = pelvic nodes; IIIC2 = para-aortic nodes). Stage IVB requires distant metastasis beyond lymph nodes. The correct management is extended-field chemoradiation encompassing the para-aortic region plus the standard pelvic field, with concurrent platinum-based chemotherapy.

FIGO 2018 IIIC2 = para-aortic nodal metastasis. Management: extended-field chemoradiation (para-aortic + pelvic field) with concurrent cisplatin. Must NOT be confused with IIIC1 (pelvic nodes only, standard pelvic field radiation).

FIGO 2018 Stage IIIC: C1 = pelvic lymph node metastasis; C2 = para-aortic lymph node metastasis. Para-aortic nodal disease is NOT Stage IVB (which requires haematogenous/distant metastasis). Management of IIIC2 requires extended-field radiation.

Correct. A VIA-negative result is one where there is no acetowhite lesion near the transformation zone — the cervix appears normal, pale pink, with the SCJ clearly visible and no significant acetowhite change. Option A describes VIA-positive. Option C (dense acetowhite fading in 30 seconds) could represent a false positive (e.g., immature metaplasia or mucus). Satellite lesions away from the TZ are generally not VIA-positive.

VIA interpretation requires knowing both positive and negative criteria. VIA-negative = no acetowhite change near the SCJ. VIA-positive = well-defined acetowhite lesion touching or near the SCJ. Screen-and-treat programmes (single-visit approach) treat all VIA-positive women directly.

VIA-negative means no acetowhite lesion is identified near the transformation zone. VIA-positive is a well-defined acetowhite area at or near the squamocolumnar junction persisting after acetic acid application.

Correct. CIN 3 requires treatment — surveillance alone is not appropriate given the 30-year cumulative progression risk of approximately 30–40% if untreated. LEEP/LLETZ is the treatment of choice: it is excisional (provides histological specimen to exclude microinvasion), fertility-preserving, and achieves high cure rates. Cryotherapy is ablative (no specimen) and is less preferred for CIN 3 (risk of inadequate treatment). Hysterectomy is over-treatment for CIN 3 in a woman desiring fertility.

CIN 3 = obligatory treatment. LEEP/LLETZ is the gold standard — excisional, fertility-preserving, specimen obtained. Cryotherapy is ablative and NOT preferred for CIN 3. Hysterectomy is reserved for non-fertility-desiring women after failed conservative treatment or coincident uterine pathology.

CIN 3 must be treated, not observed. LEEP is preferred over cryotherapy for CIN 3 because it is excisional and provides a specimen. Hysterectomy is not indicated as first-line treatment for CIN 3 when fertility is desired.

Correct. Under the FIGO 2023 system for endometrial cancer, Stage IA = tumour confined to the endometrium or invading less than 50% of the myometrium (with no other high-risk features for low-grade disease). Stage IB = invasion ≥50% myometrium. Stage II = cervical stromal involvement. Stage IIIA = uterine serosa, adnexa, or positive peritoneal cytology. This is Stage IA endometrial cancer (FIGO 2023).

FIGO endometrial cancer staging (2023) is a COMPLETELY SEPARATE system from cervical (FIGO 2018) and ovarian (FIGO 2014) staging. Stage IA: uterine-confined, <50% myometrial invasion (low/intermediate grade). Do not import stage definitions from other FIGO systems.

FIGO 2023 endometrial cancer: Stage IA = uterine-confined, <50% myometrial invasion. Stage IB = ≥50% myometrial invasion. Stage II = cervical stromal involvement. This case has <50% invasion and no cervical or nodal involvement = Stage IA.

Correct. FIGO ovarian cancer staging (2014): Stage III = peritoneal involvement beyond the pelvis and/or retroperitoneal lymph node metastasis. Stage IIIC = peritoneal metastasis beyond the pelvis measuring >2 cm (macroscopic), including omental involvement. Upper-abdominal peritoneal implants + omental involvement with grossly positive disease = Stage IIIC. Stage IV requires distant metastasis (pleural effusion with positive cytology, liver/spleen parenchyma, or inguinal/supraclavicular nodes).

FIGO ovarian IIIC (2014) = macroscopic peritoneal metastasis >2 cm beyond the pelvis, including the omentum. This is the most common stage at diagnosis. Treatment: debulking surgery (aim residual <1 cm or no visible disease) + platinum-taxane chemotherapy.

FIGO ovarian (2014): Stage IIIA2 = microscopic peritoneal metastasis beyond pelvis. IIIB = macroscopic ≤2 cm. IIIC = macroscopic >2 cm (and/or positive retroperitoneal nodes). IVA = pleural effusion with positive cytology. Gross upper-abdominal peritoneal + omental disease = IIIC.

Correct. If first-line single-agent methotrexate fails (β-hCG plateau or rise after 2 courses), the next step for low-risk GTN (WHO score ≤6) is to switch to second-line single-agent actinomycin-D — NOT to escalate immediately to multi-agent EMA-CO. EMA-CO is used when single-agent actinomycin-D also fails, or for high-risk GTN (WHO score ≥7) from the outset. Hysterectomy is not indicated — GTN is curable with chemotherapy in young women.

GTN treatment algorithm: Low-risk (WHO ≤6) = methotrexate → actinomycin-D if MTX fails → EMA-CO if both single agents fail. High-risk (WHO ≥7) = EMA-CO from the outset. GTN is curable in nearly all cases, even with multi-agent regimens.

For low-risk GTN failing methotrexate, switch to actinomycin-D (second-line single-agent). EMA-CO is for high-risk GTN (score ≥7) or after failure of both single agents in low-risk disease. Hysterectomy is rarely needed and not first choice in young women with GTN.

Correct. The most critical precaution for safe outpatient endometrial sampling is determining uterine position on bimanual examination BEFORE introducing any instrument. A retroverted uterus has a posteriorly directed uterine axis — if the cannula is introduced as if the uterus is anteverted (anteriorly directed), perforation of the posterior wall can occur. The cannula must be directed posteriorly to match the retroverted axis.

Before any intrauterine procedure: determine uterine position (anteverted/retroverted) on bimanual examination and direct the instrument along the correct axis. Failure to account for retroversion is a primary cause of uterine perforation during D&C and endometrial aspiration.

The critical safety step for minor gynaecological procedures is always uterine position assessment first. A retroverted uterus requires posterior cannula direction. Pipelle is a standard outpatient procedure requiring no general anaesthesia. Large-bore cannulas are not indicated for outpatient sampling.

Correct. Intraoperative recognition of ureteric injury is the best outcome — immediate repair is the standard management. If the injury is by simple ligation (no devascularisation), release of the ligature may be sufficient. If there is transaction or significant injury, ureteroneocystostomy (re-implant into bladder, preferred for lower-third injuries) or ureteroureterostomy (end-to-end anastomosis, for upper-third injuries) is performed over a ureteric stent. Delayed repair is reserved for cases discovered post-operatively; intraoperative recognition mandates immediate repair.

Ureteric injury during hysterectomy: intraoperative recognition → immediate repair (ureteroneocystostomy for distal injuries, ureteroureterostomy for proximal; always over a stent). Prevention: identify ureter at the pelvic brim and trace to the bladder before clamping uterine vessels ('water under the bridge').

Intraoperative ureteric injury = immediate repair is always the standard of care. Delayed repair is only considered if the injury is recognised postoperatively with an established urinoma/fistula. Percutaneous nephrostomy alone is not definitive management.

Correct. This is a critical staging distinction. Under FIGO staging for endometrial cancer, endocervical GLAND involvement alone (mucosal spread without stromal invasion) does NOT upgrade to Stage II. Stage II requires stromal invasion of the cervix. Mucosal-only involvement is still staged according to the myometrial invasion findings (Stage IA or IB as appropriate).

Endometrial cancer staging trap: endocervical gland/mucosal involvement alone does NOT constitute Stage II. Stage II endometrial cancer (FIGO) requires cervical STROMAL invasion. Glandular involvement only keeps the tumour in the Stage I category. This is explicitly highlighted in SDL teaching points.

The staging trap: endocervical GLAND involvement alone ≠ Stage II endometrial cancer. Stage II requires cervical STROMAL invasion. This is one of the most tested staging distinctions in endometrial cancer — glandular mucosal spread does not count.

Correct. For uterovaginal prolapse with stress urinary incontinence in a woman who does not desire future fertility, vaginal hysterectomy combined with anterior colporrhaphy (for cystocele and stress incontinence) and posterior colpoperineorrhaphy (for posterior wall prolapse/rectocele) is the standard surgical approach. This combined procedure addresses both the prolapse and the pelvic floor defects. Fothergill's is for cervical elongation with minor prolapse when fertility is desired.

Uterovaginal prolapse + SUI: vaginal hysterectomy + anterior colporrhaphy + posterior colpoperineorrhaphy. Fothergill's (amputation of elongated cervix + anterior and posterior repair) preserves the uterus and is used for cervical elongation with prolapse when uterine preservation is desired.

Vaginal hysterectomy + pelvic floor repair (anterior and posterior colporrhaphy) is the standard operation for uterovaginal prolapse. Fothergill's (Manchester) operation preserves the uterus and is for cervical elongation cases. Abdominal hysterectomy alone does not repair the pelvic floor defect.

Correct. This presentation — post-partum woman, markedly elevated β-hCG, heterogeneous uterine mass, pulmonary metastases — is classic for gestational choriocarcinoma following a term pregnancy. Retained POC would not cause pulmonary metastases. The immediate management priority is to determine the FIGO anatomical stage and WHO prognostic score, as this dictates whether single-agent or multi-agent (EMA-CO) chemotherapy is used. Pulmonary metastases with otherwise limited disease can still be low-risk depending on scoring — do not start treatment before scoring.

Post-partum GTN (choriocarcinoma) can follow any gestational event including term delivery. Always score (WHO prognostic index) before starting chemotherapy — the score determines the regimen. Pulmonary nodules in a reproductive-age woman should always trigger β-hCG measurement.

Post-partum β-hCG elevation + pulmonary metastases = choriocarcinoma until proven otherwise. The management priority is WHO/FIGO prognostic scoring to guide treatment choice (single vs multi-agent chemotherapy). Uterine evacuation is NOT the treatment for GTN with metastatic disease.