Endometrial Cancer — MCQs
Risk of endometrial cancer is least in:
This type of endometrial hyperplasia leads to an increased risk of endometrial cancer.
Which cancer is most commonly associated with increased estrogen levels?
A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :
The gene most commonly involved in endometrial carcinoma is:
What is the investigation of choice in postmenopausal bleeding?
A Post-Menopausal woman complains of spotting per vaginum after 5 years of menopause. USG reveals endometrial thickness of 7 mm and an intramural fibroid of size 3cm. Next step in management is?
A woman with postmenopausal bleeding has thickened endometrium. Which approach is most suitable for evaluating malignancy risk?
Which of the following screening methods is NOT effective for early detection of cancer in asymptomatic women?
What is the stage of endometrial carcinoma when it involves the cervix?
Endometrial Cancer Indian Medical PG Practice Questions and MCQs
Question 1: Risk of endometrial cancer is least in:
- A. Late menopause
- B. A positive family history
- C. Obesity
- D. Multipara (Correct Answer)
Explanation: ***Multipara*** - **Multiparity** (having multiple successful pregnancies) is associated with a reduced risk of **endometrial cancer**. Each pregnancy provides a period of reduced estrogen exposure and increased progesterone, which is protective against endometrial hyperplasia. - The protective effect is thought to be cumulative, with **higher parity** correlating with a lower risk. *Late menopause* - **Late menopause** prolongs the duration of lifetime exposure to endogenous unopposed estrogen, which significantly increases the risk of **endometrial cancer**. - Estrogen stimulates **endometrial proliferation**, and continued exposure without the counter-regulatory effects of progesterone (as seen in later menopause) can lead to atypical hyperplasia and malignancy. *A positive family history* - A **positive family history** of endometrial cancer suggests a genetic predisposition, which is a significant **risk factor**. - Conditions like **Lynch syndrome** (hereditary non-polyposis colorectal cancer or HNPCC) are strongly associated with an increased risk of endometrial cancer. *Obesity* - **Obesity** is a major risk factor for **endometrial cancer** due to increased peripheral conversion of androgens to estrogens in adipose tissue. - This leads to higher levels of **unopposed estrogen**, promoting endometrial proliferation and increasing cancer risk.
Question 2: This type of endometrial hyperplasia leads to an increased risk of endometrial cancer.
- A. Simple
- B. Atypical (Correct Answer)
- C. Complex
- D. Secretory
Explanation: ***Atypical*** - **Atypical endometrial hyperplasia** shows both glandular architectural abnormalities and features of cellular atypia, such as nuclear pleomorphism and prominent nucleoli [1]. - The presence of cellular atypia is the key differentiator and significantly increases the risk of progression to **endometrial adenocarcinoma**, with up to 30% progressing to cancer [2]. *Simple* - **Simple endometrial hyperplasia** involves an increase in the number of endometrial glands, which retain their normal shape and uniform distribution [1]. - While it represents abnormal proliferation, the risk of progression to **endometrial cancer** is very low (less than 1%) [2]. *Complex* - **Complex endometrial hyperplasia** shows architectural crowding and branching of glands, but without cellular atypia [2]. - The glands are no longer uniformly spaced, creating a more complex pattern, but the individual cells do not show features of malignancy; therefore, the risk of progression to **endometrial cancer** is low (around 3%) [2]. *Secretive* - **Secretory endometrium** is a normal physiological phase of the menstrual cycle, occurring after ovulation under the influence of progesterone. - This term describes the histological appearance of the endometrium, not a type of hyperplasia or a premalignant condition. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1016-1018. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 473-475.
Question 3: Which cancer is most commonly associated with increased estrogen levels?
- A. Ovarian
- B. GTN
- C. Breast (Correct Answer)
- D. Cervix
Explanation: ***Breast*** - Many breast cancers, particularly **estrogen receptor-positive (ER+)** tumors, are fueled by **estrogen**. - Prolonged exposure to high estrogen levels, such as early menarche, late menopause, or obesity, is a known risk factor for breast cancer. *Ovarian* - While estrogen does play a role in ovarian function, the link between **increased estrogen levels** and ovarian cancer risk, while present, is **less direct and less significant** than for breast cancer. - Ovarian cancer is associated with other risk factors like **nulliparity**, **endometriosis**, and certain genetic mutations. *GTN* - **Gestational trophoblastic neoplasia (GTN)** is an abnormal proliferation of trophoblastic tissue, commonly occurring after pregnancy. - Its development is primarily linked to **abnormal fertilization**, not directly to independently increased estrogen levels. *Cervix* - **Cervical cancer** is overwhelmingly caused by **persistent human papillomavirus (HPV) infection**. - While hormonal factors can influence HPV progression, increased estrogen levels are **not considered a primary cause** or strongly associated risk factor for cervical cancer.
Question 4: A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :
- A. Malignancy of the vulva
- B. Malignancy of the cervix
- C. Malignancy of the endometrium (Correct Answer)
- D. Malignancy of the ovary
Explanation: ***Malignancy of the endometrium*** - **Postmenopausal bleeding** is the classic presenting symptom of **endometrial cancer**, which must be ruled out in all such cases. - **Diabetes** is a known risk factor for endometrial cancer, along with obesity, hypertension, and unopposed estrogen exposure. *Malignancy of the vulva* - Vulvar cancer typically presents with a **pruritic lesion**, lump, or ulcer on the vulva, rather than solely with vaginal bleeding. - While bleeding can occur from an advanced vulvar lesion, it is not the primary or most common presentation for new onset postmenopausal bleeding. *Malignancy of the cervix* - Cervical cancer often presents with **postcoital bleeding** or irregular vaginal bleeding in premenopausal women, or less commonly, postmenopausal bleeding. - Screening with **Pap smears** typically detects precancerous changes or early cervical cancer, making it less likely to be the first presentation with postmenopausal bleeding in a well-screened population. *Malignancy of the ovary* - Ovarian cancer is often asymptomatic in its early stages and presents with non-specific symptoms like **abdominal distension**, bloating, or pelvic pain. - **Vaginal bleeding** is not a typical symptom of ovarian cancer, unless the tumor is very large, involves adjacent structures, or is a hormone-producing tumor.
Question 5: The gene most commonly involved in endometrial carcinoma is:
- A. PTEN (Correct Answer)
- B. BRAF
- C. KRAS
- D. Mismatch repair genes
Explanation: ***PTEN*** - **PTEN** (phosphatase and tensin homolog) is a **tumor suppressor gene** frequently inactivated in **endometrial carcinoma**, particularly in cases of **endometrioid histology**. - Loss of PTEN function leads to uncontrolled cell proliferation and survival by activating the **PI3K/Akt signaling pathway**, contributing to tumor development. *BRAF* - **BRAF mutations** are most commonly associated with **melanoma** and certain types of **thyroid cancer**, specifically papillary thyroid carcinoma. - While BRAF mutations can be found in a small subset of other cancers, they are not a primary driver or common gene in endometrial carcinoma. *KRAS* - **KRAS mutations** are frequently observed in **colorectal cancer**, **pancreatic cancer**, and **non-small cell lung cancer**. - Though KRAS can be mutated in various cancers, it is not the most commonly involved gene in endometrial carcinoma. *Mismatch repair genes* - Mutations in **mismatch repair (MMR) genes** (e.g., MLH1, MSH2, MSH6, PMS2) are characteristic of **Lynch syndrome** and lead to **microsatellite instability (MSI)**. - While MSI is observed in a significant subset of endometrial cancers (especially those associated with Lynch syndrome), PTEN mutations are more broadly common across all types of endometrial carcinoma.
Question 6: What is the investigation of choice in postmenopausal bleeding?
- A. PAP smear
- B. Laparoscopy
- C. Fractional curettage
- D. Ultrasound (Correct Answer)
Explanation: ***Ultrasound*** - An initial **transvaginal ultrasound** is the investigation of choice to assess the endometrial thickness in postmenopausal bleeding. An endometrial thickness of >4-5mm often warrants further investigation. - It helps in **ruling out endometrial pathologies** like hyperplasia, polyps, or carcinoma. *PAP smear* - A **PAP smear** is a screening test for cervical cancer, not typically used to investigate postmenopausal bleeding originating from the uterus. - While it can detect some endometrial cells, it is **not sensitive** or specific enough to diagnose the cause of postmenopausal bleeding. *Laparoscopy* - **Laparoscopy** is a surgical procedure used to visualize pelvic organs and is generally employed for diagnosing and treating conditions like endometriosis, ovarian cysts, or ectopic pregnancies. - It is **not the initial investigation** for postmenopausal bleeding and is too invasive for primary diagnosis unless other methods have failed or a specific pathology is suspected. *Fractional curettage* - **Fractional curettage** involves scraping the lining of the cervix and uterus to obtain tissue samples for histological examination. - While it can be diagnostic for endometrial pathology, it is typically performed **after an initial ultrasound** has identified increased endometrial thickness or other suspicious findings, and less commonly as a standalone initial investigation.
Question 7: A Post-Menopausal woman complains of spotting per vaginum after 5 years of menopause. USG reveals endometrial thickness of 7 mm and an intramural fibroid of size 3cm. Next step in management is?
- A. CA 125 levels
- B. Paps smear and follow up
- C. Myomectomy
- D. Endometrial biopsy (Correct Answer)
Explanation: ***Endometrial biopsy*** - Post-menopausal **vaginal bleeding** or spotting, especially with an **endometrial thickness of ≥ 4-5 mm** on ultrasound, is highly suspicious for endometrial hyperplasia or carcinoma and warrants an endometrial biopsy for definitive diagnosis. - An endometrial biopsy is crucial to rule out endometrial malignancy, as this is the primary concern in such presentations. *CA 125 levels* - **CA 125** is primarily used as a tumor marker for **ovarian cancer** surveillance and response to treatment, not for initial diagnosis of post-menopausal bleeding or endometrial pathology. - Elevated CA 125 can be found in various benign conditions as well and is not specific enough to guide the initial management of post-menopausal bleeding without tissue sampling. *Paps smear and follow up* - A **Pap smear** screens for **cervical abnormalities** and **cervical cancer**, not endometrial pathology. - While it's part of routine gynecological care, it will not address the investigation of post-menopausal bleeding originating from the uterus. *Myomectomy* - **Myomectomy** is a surgical procedure to remove **uterine fibroids**, typically when they are causing symptoms like heavy menstrual bleeding or pressure. - In a post-menopausal woman with spotting, the intramural fibroid may or may not be directly responsible, and the priority is to exclude **endometrial cancer** before considering fibroid-specific interventions.
Question 8: A woman with postmenopausal bleeding has thickened endometrium. Which approach is most suitable for evaluating malignancy risk?
- A. Endometrial biopsy (Correct Answer)
- B. Transvaginal ultrasound
- C. Pap smear
- D. Hysteroscopy
Explanation: ***Endometrial biopsy*** - An **endometrial biopsy** directly obtains tissue samples from the endometrial lining, allowing for histological examination to definitively diagnose or rule out **endometrial hyperplasia** or **carcinoma**. - This is the **most suitable first-line approach** when postmenopausal bleeding is coupled with a thickened endometrium, as it directly assesses for **malignancy at a cellular level**. - It is **cost-effective, minimally invasive, and can be performed in an office setting** without anesthesia. *Transvaginal ultrasound* - While a **transvaginal ultrasound** can measure endometrial thickness and identify structural abnormalities, it cannot definitively differentiate between benign and malignant changes. - It serves as an initial screening tool but requires further investigation like a **biopsy** for definitive diagnosis in cases of thickened endometrium and postmenopausal bleeding. - An endometrial thickness >4-5 mm in postmenopausal women warrants tissue diagnosis. *Pap smear* - A **Pap smear** (Papanicolaou test) is used to screen for **cervical cancer** by collecting cells from the cervix. - It is not effective for detecting **endometrial pathologies** or cancer of the uterine lining. *Hysteroscopy* - **Hysteroscopy** allows for direct visualization of the uterine cavity and directed biopsies under direct vision, which is highly accurate for identifying focal lesions such as polyps or fibroids. - While it provides excellent diagnostic accuracy, it is **more invasive, expensive, and typically requires anesthesia**. - For initial evaluation of postmenopausal bleeding with diffuse endometrial thickening, **endometrial biopsy is preferred** as the first-line approach due to its accessibility, lower cost, and adequate sensitivity (>90% for detecting endometrial cancer).
Question 9: Which of the following screening methods is NOT effective for early detection of cancer in asymptomatic women?
- A. Office endometrial washing for endometrial cancer
- B. USG in endometrial cancer
- C. CA-125 for ovarian cancer (Correct Answer)
- D. Pap smear for cervical cancer
Explanation: ***CA-125 for ovarian cancer*** - While elevated in some ovarian cancers, **CA-125 lacks sufficient sensitivity and specificity** as a stand-alone screening tool for early detection in asymptomatic women. - Its use for general population screening has **not been shown to reduce mortality** from ovarian cancer and can lead to **false positives** and unnecessary invasive procedures. - Major trials (UKCTOCS, PLCO) have not demonstrated mortality benefit from CA-125 screening. *Office endometrial washing for endometrial cancer* - While this involves collecting cells from the uterine lining for cytological analysis, **endometrial washing/cytology has poor sensitivity** and is not established as an effective screening method. - However, it has shown **some promise in research settings** for high-risk individuals, though it is not a standard or widely recommended screening approach. - **Endometrial biopsy** remains the gold standard for diagnosis in symptomatic women, but routine screening of asymptomatic women is not recommended. *USG in endometrial cancer* - **Transvaginal ultrasonography (TVUS)** can effectively measure **endometrial thickness** and is valuable for evaluating postmenopausal bleeding. - While not used for population-based screening of asymptomatic women, it aids in **risk stratification** and guiding further investigation like biopsy in symptomatic patients. - When used appropriately in symptomatic women, TVUS is a useful diagnostic adjunct. *Pap smear for cervical cancer* - The **Pap smear** is a highly effective and widely adopted screening method for **cervical cancer**, detecting precancerous and cancerous changes in cervical cells. - Its widespread use has **significantly reduced the incidence and mortality rates** of cervical cancer due to its ability to identify abnormalities early, allowing for timely intervention. - This is the gold standard for cancer screening with proven mortality benefit.
Question 10: What is the stage of endometrial carcinoma when it involves the cervix?
- A. Stage 1: Cancer confined to the uterus.
- B. Stage 3: Cancer has spread beyond the uterus but not beyond the pelvis.
- C. Stage 2: Cancer has spread to the cervix. (Correct Answer)
- D. Stage 4: Cancer has spread to distant sites.
Explanation: ***Stage 2: Cancer has spread to the cervix*** - According to the **FIGO 2009 staging system** for endometrial carcinoma (applicable at the time of this exam), involvement of the cervix with **stromal invasion** without extending beyond the uterus into the parametrium is classified as **Stage II**. - This stage indicates that the cancer remains within the confines of the uterus but has spread from the uterine corpus to the **cervical stroma**. - **Note:** FIGO staging was updated in 2023, but this question reflects the 2009 criteria used at the time. *Stage 1: Cancer confined to the uterus* - This stage indicates that the cancer is **limited to the uterine corpus (body of the uterus)**, with no spread to the cervix or beyond. - Stage 1 is further subdivided based on the **depth of myometrial invasion**, but the cervix is not involved at this stage. *Stage 3: Cancer has spread beyond the uterus but not beyond the pelvis* - Stage 3 involves spread **beyond the uterus but is still confined to the pelvis**, including parametrial involvement, vaginal or serosal invasion, or pelvic/paraaortic lymph node involvement. - This stage represents more extensive local or regional spread than simply cervical involvement. *Stage 4: Cancer has spread to distant sites* - This is the most advanced stage, indicating that the cancer has spread to **distant organs** (e.g., lungs, bone) or involves the **bladder or bowel mucosa**. - Stage 4 represents a systemic disease rather than localized pelvic spread.
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