Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 91: What is the management for stage IIB cancer of the cervix?

A. Radiotherapy
B. Radiotherapy with combination with chemotherapy (Correct Answer)
C. Chemotherapy
D. Hysterectomy

Explanation: **Explanation:** The management of cervical cancer is primarily determined by the **FIGO staging**. Stage IIB is defined as carcinoma that has extended beyond the uterus to the **parametrium**, but not reaching the pelvic side wall. **1. Why Option B is Correct:** For **locally advanced cervical cancer (LACC)**, which includes stages **IIB to IVA**, the standard of care is **Concurrent Chemoradiotherapy (CCRT)**. * **Radiotherapy** consists of External Beam Radiation Therapy (EBRT) followed by Brachytherapy. * **Chemotherapy** (typically weekly **Cisplatin**) acts as a radiosensitizer, enhancing the lethal effects of radiation on tumor cells. Large clinical trials have proven that CCRT significantly improves overall survival compared to radiation alone. **2. Why Other Options are Incorrect:** * **Option A (Radiotherapy alone):** While radiation is the primary modality, using it without chemotherapy is suboptimal and no longer the gold standard for Stage IIB. * **Option C (Chemotherapy alone):** Chemotherapy is used as a primary treatment only in Stage IVB (metastatic disease) for palliation; it cannot cure Stage IIB in isolation. * **Option D (Hysterectomy):** Surgery (Wertheim’s Radical Hysterectomy) is generally reserved for **early-stage disease (up to Stage IIA1)**. In Stage IIB, the involvement of the parametrium makes it difficult to achieve clear surgical margins, and primary surgery followed by adjuvant radiation significantly increases morbidity. **High-Yield Clinical Pearls for NEET-PG:** * **Cut-off for Surgery:** Stage IIA1 (size ≤ 4cm, no parametrial involvement). * **Most Common Histology:** Squamous Cell Carcinoma. * **Drug of Choice for Radiosensitization:** Cisplatin. * **Stage IIB Definition:** Parametrial involvement present (diagnosed via per-rectal examination).

Question 92: Choriocarcinoma commonly metastasizes to which organ?

A. Brain
B. Lung (Correct Answer)
C. Vagina
D. Ovary

Explanation: **Explanation:** Choriocarcinoma is a highly malignant epithelial tumor arising from chorionic villi. It is characterized by its **early and rapid hematogenous spread** (via the bloodstream) rather than lymphatic spread. **1. Why Lung is Correct:** The lungs are the most common site of metastasis in gestational trophoblastic neoplasia (GTN), occurring in approximately **80% of metastatic cases**. Because the tumor cells invade the venous sinuses of the uterus, they are carried directly through the systemic venous circulation to the right side of the heart and trapped in the pulmonary capillary bed. On imaging, these often appear as classic "cannonball metastases." **2. Analysis of Incorrect Options:** * **Vagina (Option C):** This is the **second most common** site of metastasis (approx. 30%). These lesions are typically highly vascular and appear as bluish-purple nodules; they should never be biopsied due to the risk of torrential hemorrhage. * **Brain (Option A):** This is a late-stage metastatic site (approx. 10%). While clinically devastating, it usually occurs only after pulmonary or vaginal involvement has already been established. * **Ovary (Option D):** While theca lutein cysts are common in Choriocarcinoma due to high β-hCG levels, direct metastasis to the ovary is relatively uncommon compared to distant hematogenous sites. **Clinical Pearls for NEET-PG:** * **Route of Spread:** Primarily hematogenous (unlike most gynecological cancers which spread lymphatically). * **Tumor Marker:** Serum **β-hCG** is the gold standard for diagnosis, monitoring, and detecting recurrence. * **Treatment:** It is highly chemosensitive. The primary treatment for low-risk disease is Methotrexate; high-risk disease requires the EMA-CO regimen. * **Rule of Thumb:** In any female of reproductive age presenting with hemoptysis and a history of pregnancy/miscarriage, always rule out pulmonary metastasis of Choriocarcinoma.

Question 93: Which isotope is most commonly used in brachytherapy for carcinoma of the cervix?

A. Radium-226
B. Cobalt-60
C. Gold-198
D. Cesium-137 (Correct Answer)

Explanation: **Explanation:** Brachytherapy is a cornerstone in the management of cervical cancer, allowing for the delivery of high-dose radiation directly to the tumor while sparing adjacent organs like the bladder and rectum. **Why Cesium-137 is the Correct Answer:** **Cesium-137 ($^{137}Cs$)** is the most widely used isotope for traditional Low Dose Rate (LDR) brachytherapy. It replaced Radium-226 because it offers a favorable balance between half-life and safety. It has a **half-life of approximately 30 years**, providing a long shelf-life for clinical use, and emits gamma rays with lower energy than Radium, making it easier to shield and safer for healthcare personnel. **Analysis of Incorrect Options:** * **Radium-226:** Historically the first isotope used (by Marie Curie), but it is no longer used due to significant safety risks. It decays into **Radon gas**, which poses a high risk of leakage and atmospheric contamination. * **Cobalt-60:** While used in external beam radiotherapy (teletherapy), its high energy and shorter half-life (5.27 years) make it less ideal for standard intracavitary brachytherapy compared to Cesium. * **Gold-198:** This is a short-lived isotope (half-life ~2.7 days) used primarily for permanent interstitial implants (e.g., prostate or head and neck), not for the temporary intracavitary applications required in cervical cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Current Trend:** While Cesium-137 is the classic answer for LDR, **Iridium-192 ($^{192}Ir$)** is now the isotope of choice for **High Dose Rate (HDR)** brachytherapy due to its high specific activity and small source size. * **Point A vs. Point B:** In cervical brachytherapy (Manchester System), **Point A** (2cm superior and 2cm lateral to the external os) is the primary reference for dosage, representing where the uterine artery crosses the ureter. * **Rule of Thumb:** Brachytherapy is typically initiated after external beam radiation (EBRT) to "boost" the dose to the central tumor.

Question 94: Meigs syndrome is associated with which of the following ovarian tumors?

A. Teratoma
B. Brenner tumor
C. Theca cell tumor
D. Fibroma (Correct Answer)

Explanation: **Explanation:** **Meigs Syndrome** is a classic clinical triad characterized by the presence of a **benign ovarian tumor**, **ascites**, and **pleural effusion** (usually right-sided). The hallmark of this syndrome is that both the ascites and the effusion resolve completely following the surgical removal of the tumor. 1. **Why Fibroma is Correct:** The **Ovarian Fibroma** (a benign sex cord-stromal tumor) is the most common tumor associated with Meigs syndrome. It is thought that the tumor's large size or surface irritation leads to the production of peritoneal fluid (ascites), which then migrates into the pleural cavity through transdiaphragmatic lymphatics or small diaphragmatic defects. 2. **Analysis of Incorrect Options:** * **Teratoma:** While mature cystic teratomas are the most common germ cell tumors, they are not typically associated with the Meigs triad. * **Brenner Tumor:** These are rare epithelial tumors. While they can occasionally cause "Pseudo-Meigs syndrome," they are not the classic association. * **Theca Cell Tumor (Thecoma):** These are estrogen-producing sex cord-stromal tumors. While they can rarely be associated with Meigs syndrome, the **Fibroma** is the definitive and most frequent association tested in exams. **High-Yield Clinical Pearls for NEET-PG:** * **Pseudo-Meigs Syndrome:** This term is used when the triad (ascites + pleural effusion + tumor) is caused by other pelvic masses, such as leiomyomas, or other ovarian tumors like Mucinous cystadenomas or Brenner tumors. * **Demons-Meigs Syndrome:** Another name for the same condition. * **Pleural Effusion:** In Meigs syndrome, the effusion is typically a **transudate** and is found on the **right side** in approximately 70% of cases. * **CA-125:** Levels may be elevated in Meigs syndrome, which can falsely mimic ovarian malignancy; however, the condition remains benign.

Question 95: A 60-year-old lady is diagnosed with carcinoma of the endometrium with involvement of more than 50% of the myometrium and vagina. The carcinoma has not involved pelvic and para-aortic lymph nodes, and peritoneal cytology is positive. What is the stage of her malignancy?

A. Stage Ib
B. Stage IIIb (Correct Answer)
C. Stage IIIc
D. Stage IVa

Explanation: **Explanation:** The staging of endometrial carcinoma is based on the **FIGO Staging System (Revised 2023/2009)**. In this clinical scenario, the key finding is the involvement of the **vagina**, which automatically classifies the malignancy as **Stage IIIb**. 1. **Why Stage IIIb is correct:** According to FIGO staging, Stage III denotes local and/or regional spread of the tumor. Specifically: * **Stage IIIa:** Tumor involves serosa or adnexa. * **Stage IIIb:** Tumor involves the **vagina** and/or parametrium. * Since this patient has vaginal involvement, she is classified as Stage IIIb, regardless of the myometrial invasion depth or positive peritoneal cytology (which is no longer used to upstage disease in the 2009/2023 criteria but is noted). 2. **Why other options are incorrect:** * **Stage Ib:** This involves invasion of $\geq$ 50% of the myometrium but is strictly confined to the **corpus uteri**. The presence of vaginal spread excludes Stage I. * **Stage IIIc:** This stage is reserved for metastasis to the **pelvic (IIIc1) or para-aortic (IIIc2) lymph nodes**. The question explicitly states these nodes are not involved. * **Stage IVa:** This represents advanced spread to the **bladder or bowel mucosa**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common presentation:** Postmenopausal bleeding (PMB). * **Most common histological type:** Endometrioid adenocarcinoma. * **Staging Method:** Endometrial cancer is **surgically staged** (unlike cervical cancer, which was historically clinically staged). * **Peritoneal Cytology:** While recorded, positive cytology alone does not change the FIGO stage; however, vaginal or parametrial involvement (IIIb) is a significant prognostic indicator.

Question 96: What is the investigation of choice for cervical neoplasm?

A. Speculoscopy
B. Pap smear
C. Cone biopsy (Correct Answer)
D. Cervicography

Explanation: **Explanation:** The "Investigation of Choice" (IOC) for cervical neoplasm refers to the **Gold Standard** method required for a definitive diagnosis and staging. 1. **Why Cone Biopsy is Correct:** While a punch biopsy can diagnose invasive cancer, a **Cone Biopsy** (Cold knife conization or LEEP) is the definitive investigation. It provides a large tissue specimen that allows the pathologist to evaluate the entire transformation zone, the depth of stromal invasion, and the presence of lymphovascular space invasion (LVSI). It is both diagnostic and, in cases of microinvasive carcinoma (Stage IA1), therapeutic. 2. **Why Other Options are Incorrect:** * **Pap Smear:** This is a **screening tool**, not a diagnostic one. It identifies cytological abnormalities but cannot confirm the stage or depth of invasion. * **Speculoscopy & Cervicography:** These are adjunct visual screening methods used to enhance the detection of lesions. They lack the histological precision required for a definitive diagnosis of neoplasia. **High-Yield Clinical Pearls for NEET-PG:** * **Screening Test of Choice:** Pap Smear (Liquid-based cytology is preferred). * **Best Screening Strategy:** Co-testing (Pap smear + HPV DNA testing) every 5 years for women aged 30–65. * **Initial Investigation for Abnormal Pap:** Colposcopy-directed biopsy. * **IOC for Microinvasive Carcinoma:** Cone Biopsy (to rule out deeper invasion). * **Staging:** Cervical cancer is staged **Clinically** (FIGO staging), though the 2018 update allows for imaging (MRI/CT) and pathological findings where available.

Question 97: Which of the following statements regarding vulval carcinoma is FALSE?

A. Squamous hyperplasia predisposes to vulval carcinoma.
B. Paget's disease of the vulva predisposes to vulval carcinoma.
C. Lichen planus predisposes to vulval carcinoma. (Correct Answer)
D. Condylomata acuminata predisposes to vulval carcinoma.

Explanation: **Explanation:** Vulval carcinoma primarily arises through two distinct pathways: the **HPV-dependent pathway** (associated with high-risk HPV types 16 and 18) and the **HPV-independent pathway** (associated with chronic inflammatory conditions). **Why Option C is the False Statement:** While **Lichen Sclerosus** is a well-documented precursor to the HPV-independent (differentiated) type of vulval squamous cell carcinoma (SCC), **Lichen Planus** is generally considered to have a negligible or questionable association with vulval malignancy. In the context of NEET-PG, Lichen Sclerosus is the high-yield "Lichen" associated with cancer, not Lichen Planus. **Analysis of Other Options:** * **Option A (Squamous Hyperplasia):** Also known as Lichen Simplex Chronicus, this condition involves chronic irritation and itching. It is frequently found in the vicinity of vulval SCC and is considered a predisposing factor. * **Option B (Paget’s Disease):** Extramammary Paget’s disease of the vulva is an intraepithelial neoplasia. In approximately 10-20% of cases, it is associated with an underlying invasive adenocarcinoma of the vulva or adnexal structures. * **Option D (Condylomata Acuminata):** These are genital warts caused by HPV (usually low-risk types 6 and 11). However, patients with Condylomata often have co-infections with high-risk HPV types, which can lead to Vulval Intraepithelial Neoplasia (VIN) and eventually invasive carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Squamous Cell Carcinoma (85-90%). * **Most common site:** Labia majora. * **Precursor lesions:** VIN (Usual type - HPV related; Differentiated type - Lichen Sclerosus related). * **Staging:** Vulval cancer is staged **Surgically** (FIGO). * **Lymphatic spread:** The primary route of spread is to the **Inguinal-Femoral lymph nodes** (Sentinel nodes are often evaluated).

Question 98: What is the ideal treatment for a 55-year-old female with endometrial hyperplasia with atypia?

A. Simple hysterectomy (Correct Answer)
B. Medroxyprogesterone acetate
C. Levonorgestrel
D. Intrauterine contraceptive device (IUCD)

Explanation: **Explanation:** The management of endometrial hyperplasia is determined by the presence or absence of **cellular atypia** and the patient’s reproductive goals. **Why Simple Hysterectomy is the Correct Choice:** Endometrial hyperplasia with atypia (EIN - Endometrial Intraepithelial Neoplasia) is considered a **premalignant lesion**. It carries a high risk (up to 30–40%) of progressing to or coexisting with an undiagnosed endometrioid adenocarcinoma. For a 55-year-old (postmenopausal) woman who has completed her family, **Total Abdominal Hysterectomy (Simple Hysterectomy)** is the definitive treatment of choice to eliminate the risk of malignancy. Bilateral Salpingo-oophorectomy (BSO) is also typically performed in this age group. **Why Other Options are Incorrect:** * **B & C (Progesterones):** Medroxyprogesterone acetate and Levonorgestrel (LNG-IUS) are the mainstays for hyperplasia **without** atypia. While they can be used for atypical hyperplasia in young patients wishing to preserve fertility or those unfit for surgery, they are not the "ideal" or first-line treatment for a postmenopausal woman due to the high risk of occult cancer. * **D (IUCD):** A standard non-medicated IUCD has no therapeutic role in treating endometrial hyperplasia. Only the hormone-releasing system (LNG-IUS) is used. **High-Yield Clinical Pearls for NEET-PG:** * **Hyperplasia WITHOUT atypia:** Risk of progression to cancer is <3%. Treatment: Progestogens (Oral or LNG-IUS). * **Hyperplasia WITH atypia:** Risk of progression to cancer is ~29–40%. Treatment: Hysterectomy. * **Most common symptom:** Abnormal Uterine Bleeding (AUB). * **Gold Standard Diagnosis:** Endometrial biopsy/Fractional Curettage. * **Postmenopausal USG Cut-off:** Endometrial thickness >4 mm in a symptomatic postmenopausal woman requires biopsy.

Question 99: Which of the following is a non-molar trophoblastic neoplasm?

A. Complete hydatidiform mole
B. Partial hydatidiform mole
C. Invasive mole
D. Choriocarcinoma (Correct Answer)

Explanation: ### Explanation Gestational Trophoblastic Disease (GTD) is a spectrum of tumors arising from the placenta. It is broadly categorized into **Hydatidiform Moles** (benign) and **Gestational Trophoblastic Neoplasia (GTN)** (malignant/potentially invasive). **Why Choriocarcinoma is the Correct Answer:** Choriocarcinoma is a highly malignant, **non-molar** trophoblastic neoplasm. Unlike moles, it is characterized by the absence of chorionic villi. It consists of a dimorphic population of syncytiotrophoblasts and cytotrophoblasts with significant cellular atypia and hemorrhage. It can follow a molar pregnancy, a normal term pregnancy, or an abortion. **Analysis of Incorrect Options:** * **A & B (Complete and Partial Hydatidiform Mole):** These are **molar** pregnancies. They are characterized by the presence of hydropic (swollen) chorionic villi and trophoblastic proliferation. They are generally considered benign, though they have the potential to become malignant. * **C (Invasive Mole):** While this is a form of GTN, it is a **molar** neoplasm. It is defined by the presence of edematous chorionic villi that invade the myometrium. It almost always arises following a hydatidiform mole. **High-Yield Clinical Pearls for NEET-PG:** * **GTN Classification:** Includes Invasive mole, Choriocarcinoma, Placental Site Trophoblastic Tumor (PSTT), and Epithelioid Trophoblastic Tumor (ETT). * **PSTT/ETT:** These are unique because they produce **low levels of hCG** but high levels of **Human Placental Lactogen (hPL)**. They are relatively resistant to chemotherapy and often require surgery. * **Metastasis:** Choriocarcinoma spreads primarily via the **hematogenous route**. The most common site of metastasis is the **Lungs** (80%), followed by the vagina. * **Snowstorm Appearance:** Classic ultrasound finding for a Complete Hydatidiform Mole.

Question 100: What is the most common site of metastasis for carcinoma of the cervix?

A. Lymph nodes
B. Lungs (Correct Answer)
C. Bone
D. Abdominal cavity

Explanation: **Explanation:** In the context of **distant (hematogenous) metastasis**, the **lungs** are the most common site for carcinoma of the cervix. While cervical cancer primarily spreads via direct local extension and the lymphatic system, once it enters the bloodstream, the pulmonary vasculature acts as the first filter, making the lungs the most frequent site for distant deposits. **Analysis of Options:** * **B. Lungs (Correct):** Studies and clinical data consistently show that the lungs are the most frequent site of extra-pelvic, distant spread (followed by the liver and bone). * **A. Lymph Nodes:** While lymph nodes are the **most common overall route of spread** (starting with paracervical, then obturator and external iliac nodes), the question specifically asks for a "site of metastasis." In standard oncology nomenclature for NEET-PG, when "site of metastasis" is used in this context, it refers to distant organ involvement rather than the primary mode of spread. * **C. Bone:** This is the third most common site for distant metastasis. Bone involvement (usually the spine or pelvis) typically occurs in advanced stages and carries a poor prognosis. * **D. Abdominal Cavity:** While peritoneal seeding can occur in advanced stages (Stage IVB), it is less common than hematogenous spread to the lungs. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Route of Spread:** Direct extension (most common) > Lymphatic > Hematogenous. * **First Lymph Node Involved:** Paracervical/Obturator nodes. * **Sentinel Node:** The node most likely to first receive drainage (usually the medial external iliac or obturator node). * **Staging:** Cervical cancer is now staged **clinically and radiologically** (FIGO 2018), allowing for MRI/CT findings to influence the stage. * **Most Common Cause of Death:** Uremia due to bilateral ureteric obstruction (leading to post-renal renal failure).

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

Vulvar and Vaginal Cancer

Practice Questions

Gestational Trophoblastic Disease

Practice Questions

Screening for Gynecologic Cancers

Practice Questions

Principles of Gynecologic Oncology Surgery

Practice Questions

Radiation Therapy in Gynecologic Malignancies

Practice Questions

Chemotherapy in Gynecologic Oncology

Practice Questions

Palliative Care in Gynecologic Oncology

Practice Questions

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