Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

CHAPTER 37
Gestational Trophoblastic Disease

37–1. Epidemiologic factors that carry a higher risk of gestational trophoblastic disease include all EXCEPT which of the following?

a. Older maternal age

b. Younger paternal age

c. Use of oral contraceptives

d. Native Americans living in the United States

37–2. By what factor is the risk of molar pregnancy increased with a prior history of spontaneous abortion?

a. Double

b. Triple

c. Quadruple

d. Risk is not increased.

37–3. With regard to molar pregnancies, what does the term androgenesis refer to?

a. Development of theca-lutein cysts

b. Absence of fetal tissue and amnion

c. Development of a zygote that contains only maternal chromosomes

d. Development of a zygote that contains only paternal chromosomes

37–4. All EXCEPT which of the following features are characteristic of complete hydatidiform molar pregnancies?

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Photograph contributed by Dr. Brian Levenson.

a. Diploid karyotype

b. Absent fetal tissue

c. Focal villous edema

d. 15-percent risk of postmolar malignant sequelae

37–5. All EXCEPT which of the following signs or symptoms are typically seen in the presentation of a complete hydatidiform molar pregnancy?

a. Preeclampsia

b. Vaginal bleeding

c. Increased plasma thyroxine levels

d. Greater than expected serum β-human chorionic gonadotropin (β-hCG) levels

37–6. This finding, if found bilaterally in the adnexa of a patient with a molar pregnancy, increases the risk of which of the following?

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a. Preeclampsia

b. Thyroid storm

c. Hyperemesis gravidarum

d. Gestational trophoblastic neoplasia

37–7. All EXCEPT which of the following features are characteristic of partial hydatidiform molar pregnancies?

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a. Triploid karyotype

b. Focal villous edema

c. Present fetal tissue

d. 25-percent risk of postmolar malignant sequelae

37–8. Which of the following signs or symptoms are typically seen in the presentation of a partial hydatidiform molar pregnancy?

a. Theca-lutein cysts

b. Higher than expected β-human chorionic gonadotropin (β-hCG) levels

c. Uterine enlargement in excess of gestational age

d. None of the above

37–9. Sonographic features of a complete mole (shown here) include which of the following?

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a. Absent fetal and amnionic tissues

b. Hydropic changes of the trophoblastic tissue

c. Inhomogeneous and echogenic endometrial mass

d. All of the above

37–10. Which of the following treatments is most appropriate for the patient with the sonographic findings in Question 37-9?

a. Observation

b. Hysterectomy

c. Suction curettage

d. Prostanoid induction

37–11. Your patient, who is pregnant with an estimated gestational age (EGA) of 7 to 8 weeks by last menstrual period, presents to the emergency department with heavy vaginal bleeding and passage of tissue. Sonography reveals no intrauterine pregnancy and an endometrial cavity filled with blood and tissue exhibiting inhomogeneous echoes and some hydropic changes. You perform a dilatation and curettage (D&C) with no complications. A week later, you receive the pathology report for the evacuated products of conception:

Specimen: uterine contents

DNA interpretation by image cytometry: diploid Immunostaining: p57KIP2 positive

These histologic findings are consistent with which of the following diagnoses?

a. Partial mole

b. Complete mole

c. Spontaneous abortion

d. None of the above

37–12. All EXCEPT which of the statements below are true regarding surveillance practices following evacuation of a molar pregnancy?

a. Serial quantitative serum β-human chorionic gonadotropin (β-hCG) levels are the standard.

b. A single blood sample demonstrating an undetectable level of β-human chorionic gonadotropin (β-hCG) following molar evacuation is sufficient.

c. Serum β-human chorionic gonadotropin (β-hCG) levels should be monitored every 1 to 2 weeks until undetectable, after which monthly levels are drawn for the next 6 months.

d. None of the above

37–13. Which of the following statements is true regarding contraceptive practices after evacuation of a molar pregnancy?

a. Intrauterine devices should not be inserted until the β-human chorionic gonadotropin (β-hCG) level is undetectable.

b. Pregnancies that occur during the monitoring period increase the risk of progression to gestational trophoblastic neoplasia.

c. Hormonal contraception, such as oral contraceptive pills and injectable medroxyprogesterone acetate, should not be initiated until the β-human chorionic gonadotropin (β-hCG) level is undetectable.

d. None of the above

37–14. Gestational trophoblastic neoplasia (GTN) includes all EXCEPT which of the following histologies?

a. Invasive mole

b. Choriocarcinoma

c. Hydatidiform mole

d. Placental site trophoblastic tumor

37–15. Which of the following histologic types of gestational trophoblastic neoplasia (GTN) rarely develops metastases?

a. Invasive mole

b. Gestational choriocarcinoma

c. Epithelioid trophoblastic tumor

d. Placental site trophoblastic tumor

37–16. Evaluation of abnormal bleeding for more than 6 weeks following any pregnancy may include which of the following?

a. Transvaginal sonography

b. β-Human chorionic gonadotropin (β-hCG) levels to exclude choriocarcinoma

c. Endometrial biopsy to exclude placental site trophoblastic tumor or epithelioid trophoblastic tumor

d. All of the above

37–17. Compared with its postmolar gestational trophoblastic neoplasia (GTN) counterpart, which of the following is true for placental site trophoblastic tumor (PSTT)?

a. Unlike choriocarcinoma, PSTT rarely follows a term pregnancy.

b. Metastatic PSTT has a much better prognosis than metastatic choriocarcinoma.

c. The pattern of metastasis for PSTT differs from that of gestational choriocarcinoma.

d. Surgery is the primary treatment for PSTT due to its relative insensitivity to chemotherapy.

37–18. Serum β-human chorionic gonadotropin (β-hCG) criteria for the diagnosis of gestational trophoblastic neoplasia (GTN) include which of the following?

a. Rise of β-hCG levels

b. Plateau of β-hCG levels

c. Persistent elevation of β-hCG levels

d. All of the above

37–19. All EXCEPT which of the following tests should be part of the pretreatment assessment for gestational trophoblastic neoplasia (GTN)?

a. Pelvic sonography

b. Chest radiograph (CXR)

c. Chest computed tomography (CT)

d. Abdominopelvic computed tomography (CT)

37–20. According to the modified prognostic scoring system of the World Health Organization (WHO), patients with which of the following score category are assigned to the high-risk gestational trophoblastic neoplasia (GTN) group?

a. 0to6

b. 4to6

c. 7 or higher

d. 12 or higher

37–21. Following dilatation and curettage (D&C) for a complete mole, your patient is surveilled with serial β-human chorionic gonadotropin (β-hCG) levels. For the past 3 weeks, the β-hCG values have plateaued. Diagnostic evaluation reveals a metastatic lesion in the liver (shown here). Given the extent of the disease, what is the International Federation of Gynecology and Obstetrics (FIGO) stage?

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Photograph contributed by Dr. John Schorge.

a. Stage I

b. Stage II

c. Stage III

d. Stage IV

37–22. What is the approximate survival rate (percent) for women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage III gestational trophoblastic neoplasia (GTN), that is, metastases to the lungs with or without genital tract involvement?

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Photograph contributed by Dr. John Schorge.

a. 5

b. 25

c. 50

d. 100

37–23. What is the most common site of metastatic spread of choriocarcinoma?

a. Brain

b. Liver

c. Lungs

d. Vagina

37–24. Your patient has been diagnosed with postmolar choriocarcinoma gestational trophoblastic neoplasia (GTN). She is presently asymptomatic. What is the most appropriate treatment in her management?

a. Radiation

b. Chemotherapy

c. Hysterectomy

d. Dilatation and curettage (D&C)

37–25. Which of the following chemotherapeutic agents is most commonly used as primary treatment for low-risk gestational trophoblastic neoplasia (GTN)?

a. Etoposide

b. Pulse dactinomycin

c. Intravenous (IV) methotrexate

d. Intramuscular (IM) methotrexate

37–26. Which of the following symptoms is the most common side effect of methotrexate?

a. Pleurisy

b. Stomatitis

c. Pneumonitis

d. Pericarditis

37–27. Chemotherapy agents in the EMA/CO regimen for high-risk gestational trophoblastic neoplasia (GTN) include all EXCEPT which of the following?

a. Cisplatin

b. Etoposide

c. Methotrexate

d. Dactinomycin

37–28. Patients with brain metastases may present with which of the following symptoms?

a. Seizures

b. Headaches

c. Hemiparesis

d. All of the above

37–29. Compared with a molar pregnancy, how long are β-human chorionic gonadotropin (β-hCG) measurements used to monitor patients with gestational trophoblastic neoplasia (GTN) posttreatment?

a. Shorter amount of time (3 months)

b. The same length of time (6 months)

c. Longer amount of time (12–24 months)

d. β-hCG surveillance is not followed after treatment for GTN.

37–30. One year ago, your patient had a pregnancy affected by a histologically confirmed complete mole. Her β-human chorionic gonadotropin (β-hCG) levels have remained undetectable. What do you counsel her is the risk (percent) that she will have another mole in a subsequent pregnancy?

a. 1

b. 10

c. 25

d. 50

37–31. Which of the following chemotherapeutic agents used for gestational trophoblastic neoplasia (GTN) therapy has been associated with an increased risk of certain cancers in patients who received the treatment?

a. Etoposide

b. Vincristine

c. Dactinomycin

d. Methotrexate

37–32. Heterophilic antibodies can interfere with serum β-human chorionic gonadotropin (β-hCG) immunoassays, causing false-positive results. Which of the following techniques can clarify the diagnosis?

a. Perform serial dilution

b. Perform a urine pregnancy test

c. Perform specialized serum testing that blocks heterophilic antibodies

d. All of the above

Chapter 37 ANSWER KEY

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