Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 111: Meig's syndrome consists of the following except?

A. Ascites
B. Hydrothorax
C. Benign ovarian tumor
D. Alkalosis (Correct Answer)

Explanation: **Explanation:** Meigs’ syndrome is a classic clinical triad characterized by the presence of a **benign ovarian tumor** (most commonly an **Ovarian Fibroma**), **ascites**, and **pleural effusion (hydrothorax)**. **Why Alkalosis is the correct answer:** Alkalosis is not a component of Meigs’ syndrome. While patients with massive ascites or pleural effusion may occasionally develop respiratory or metabolic disturbances due to physical discomfort or underlying pathology, there is no specific association between Meigs’ syndrome and systemic alkalosis. **Analysis of other options:** * **Ascites:** Present in nearly all cases. It is thought to be caused by the release of inflammatory mediators (like VEGF) or fluid transudation from the surface of the tumor. * **Hydrothorax:** Typically a right-sided pleural effusion. Fluid moves from the peritoneum to the pleural space through transdiaphragmatic lymphatics or small diaphragmatic defects. * **Benign Ovarian Tumor:** By definition, the tumor must be benign. While **Fibroma** (a sex cord-stromal tumor) is the most common, other tumors like thecoma, cystadenoma, or granulosa cell tumors can also be involved. **High-Yield Clinical Pearls for NEET-PG:** * **The "Pseudo-Meigs" Syndrome:** This refers to the same triad (ascites + hydrothorax) but associated with other pelvic masses such as **uterine leiomyomas**, germ cell tumors, or **malignant** ovarian tumors. * **Resolution:** A hallmark of Meigs’ syndrome is that both the ascites and hydrothorax resolve completely and permanently following the **surgical removal** of the tumor. * **Nature of Fluid:** The fluid in both the abdomen and chest is typically a **transudate**. * **Tumor Marker:** CA-125 levels may be elevated in Meigs’ syndrome, which can falsely mimic ovarian malignancy. Always correlate clinically.

Question 112: CA-125 is a marker antigen for the screening of which malignancy?

A. Prostate cancer
B. Breast cancer
C. Brain cancer
D. Ovarian cancer (Correct Answer)

Explanation: **Explanation:** **Correct Answer: D. Ovarian Cancer** CA-125 (Cancer Antigen 125) is a high-molecular-weight glycoprotein produced by derivatives of the **coelomic epithelium** (including the endometrium, fallopian tubes, and peritoneum). It is the most widely used tumor marker for **Epithelial Ovarian Cancer (EOC)**, particularly the serous subtype. While not specific enough for screening the general asymptomatic population due to low positive predictive value, it is gold-standard for monitoring treatment response and detecting recurrence in known cases. **Analysis of Incorrect Options:** * **A. Prostate Cancer:** The primary marker is **PSA (Prostate-Specific Antigen)**. CA-125 has no clinical utility here. * **B. Breast Cancer:** Common markers include **CA 15-3** and **CA 27-29**. While CA-125 can sometimes be elevated in advanced breast cancer, it is not used for screening or primary diagnosis. * **C. Brain Cancer:** There are no established serum protein markers for brain tumors; diagnosis relies on neuroimaging (MRI) and biopsy. **High-Yield Clinical Pearls for NEET-PG:** 1. **Cut-off Value:** The standard upper limit of normal is **35 U/mL**. 2. **Specificity Issues:** CA-125 is often elevated in **benign conditions** (Endometriosis, Pelvic Inflammatory Disease, Fibroids, and Pregnancy) and other malignancies (Endometrial, Pancreatic, and Lung cancer). 3. **Post-menopausal Significance:** A raised CA-125 in a post-menopausal woman with an adnexal mass is highly suspicious of malignancy (90% predictive value). 4. **Mucinous Tumors:** CA-125 is less sensitive for mucinous ovarian tumors; **CEA** and **CA 19-9** are more relevant in such cases. 5. **RMI (Risk of Malignancy Index):** CA-125 is a key component of the RMI score used to triage pelvic masses.

Question 113: What is the most common presenting feature of a complete mole?

A. Vomiting
B. Amenorrhoea
C. Headache
D. Bleeding per vaginum (Correct Answer)

Explanation: **Explanation:** A **Complete Hydatidiform Mole** is a gestational trophoblastic disease characterized by the proliferation of trophoblastic tissue and hydropic swelling of chorionic villi. **Why Bleeding per vaginum is correct:** **Vaginal bleeding** is the most common presenting symptom, occurring in over 80–90% of cases. It typically occurs in the first trimester (around 6–16 weeks). The bleeding results from the separation of the molar vesicles from the decidua, often described as "prune juice" discharge due to the oxidation of retained blood. **Analysis of Incorrect Options:** * **Amenorrhoea:** While patients with a mole will have a history of amenorrhoea (as it is a pregnancy-related condition), it is the *precursor* to the pathology, not the *presenting feature* that brings the patient to the clinic. * **Vomiting (Hyperemesis):** This occurs due to abnormally high levels of hCG. While common in molar pregnancies, it is a secondary feature and less frequent than vaginal bleeding. * **Headache:** This is usually a sign of pre-eclampsia. While molar pregnancy is a known risk factor for early-onset pre-eclampsia (before 20 weeks), it is a complication rather than the primary presenting feature. **NEET-PG High-Yield Pearls:** * **Karyotype:** Complete mole is usually **46, XX** (diploid, purely paternal origin); Partial mole is **69, XXX/XXY** (triploid). * **USG Finding:** Classic **"Snowstorm appearance"** (due to multiple hydropic villi). * **Ovarian Finding:** Bilateral **Theca Lutein Cysts** may be present due to high hCG levels. * **Management:** Suction and Evacuation is the treatment of choice. * **Risk of Malignancy:** Higher in complete moles (~15–20%) compared to partial moles (<5%).

Question 114: Which of the following is NOT true regarding endometrial carcinoma in clinical stage III?

A. Vaginal metastasis
B. Para-aortic lymph node involvement
C. Peritoneal involvement (Correct Answer)
D. Pelvic lymph node involvement

Explanation: This question tests your knowledge of the **FIGO Staging for Endometrial Carcinoma** (revised in 2009 and 2023). ### **Why "Peritoneal Involvement" is the Correct Answer** In the FIGO staging system for endometrial cancer, **Stage III** represents local and/or regional spread of the tumor. While Stage III includes spread to the serosa, adnexa, vagina, and lymph nodes, **peritoneal involvement (specifically malignant peritoneal implants/carcinomatosis)** is classified as **Stage IVB**. Spread to the peritoneal surface signifies distant abdominal metastasis, moving the disease beyond regional confinement. ### **Analysis of Incorrect Options (Why they are Stage III)** * **A. Vaginal metastasis:** This is classified as **Stage IIIB**. It represents direct extension or lymphatic spread to the lower reproductive tract. * **B. Para-aortic lymph node involvement:** This is classified as **Stage IIIC2**. * **D. Pelvic lymph node involvement:** This is classified as **Stage IIIC1**. *(Note: Involvement of any regional lymph nodes—pelvic or para-aortic—automatically places the patient in Stage IIIC).* ### **High-Yield Clinical Pearls for NEET-PG** * **Staging Method:** Endometrial cancer is primarily **surgically staged** (unlike cervical cancer, which was historically clinically staged). * **Stage IIIA:** Tumor involves the uterine serosa and/or adnexa (direct extension). * **Stage IV Breakdown:** * **IVA:** Invasion of bladder and/or bowel mucosa. * **IVB:** Distant metastasis, including **peritoneal involvement**, inguinal lymph nodes, or lung/liver/bone metastasis. * **Prognostic Factor:** Lymph node status (Stage IIIC) is one of the most significant prognostic factors for survival. * **Cytology:** Positive peritoneal cytology no longer changes the FIGO stage (since 2009) but should be recorded separately.

Question 115: What is the most common presentation of vulval carcinoma?

A. Pain
B. Wart-like growth
C. Non-healing ulcer
D. Pruritus (Correct Answer)

Explanation: **Explanation:** **1. Why Pruritus is Correct:** Pruritus (itching) is the **most common presenting symptom** of vulval carcinoma, reported in approximately 60-70% of cases. This is often due to the long-standing association with chronic inflammatory conditions like **Lichen Sclerosus** or Vulvar Intraepithelial Neoplasia (VIN). Patients frequently have a history of chronic itching for years before a definitive mass or lesion is identified. **2. Analysis of Incorrect Options:** * **Pain (A):** Pain is usually a late feature, occurring only when the tumor is advanced, infected, or involves deep nerves. * **Wart-like growth (B):** While vulval cancer can present as a verrucous (warty) lesion, especially in HPV-related cases in younger women, it is less common than the symptom of pruritus. * **Non-healing ulcer (C):** An ulcerated lesion is a common physical finding upon examination, but it is typically the *sign* discovered after the patient presents with the *symptom* of itching or a palpable lump. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (SCC) accounts for >90% of cases. * **Most common site:** Labia majora (specifically the anterior two-thirds). * **Primary mode of spread:** Lymphatic spread is the most important prognostic factor. The first nodes involved are the **superficial inguinal nodes**. * **Sentinel Lymph Node Biopsy:** Indicated in Stage IA/IB (lesions <4cm and clinically node-negative). * **Staging:** Vulval cancer is staged clinically and surgically using the **FIGO system**. * **Risk Factors:** Bimodal distribution—younger women (HPV 16, 18) and older postmenopausal women (Lichen sclerosus/dystrophy).

Question 116: Carcinoma of the cervix with involvement of the upper one-third of the vagina but not the parametrium is classified as which stage?

A. Stage IIA (Correct Answer)
B. Stage IIIA
C. Stage IIB
D. Stage IIIB

Explanation: This question tests your knowledge of the **FIGO Staging for Cervical Cancer** (revised 2018). ### **Explanation of the Correct Answer** **Stage II** is defined as carcinoma that has extended beyond the uterus but has not reached the pelvic wall or the lower third of the vagina. It is subdivided based on the site of involvement: * **Stage IIA:** Involvement of the **upper two-thirds of the vagina** without parametrial involvement. * **IIA1:** Clinically visible lesion ≤ 4 cm. * **IIA2:** Clinically visible lesion > 4 cm. * **Stage IIB:** Involvement of the **parametrium** (but not reaching the pelvic side wall). Since the question specifies involvement of the upper one-third of the vagina without parametrial involvement, it falls squarely into **Stage IIA**. ### **Why Other Options are Incorrect** * **Stage IIIA (Option B):** Involves the **lower third** of the vagina, but does not extend to the pelvic wall. * **Stage IIB (Option C):** Specifically involves the **parametrium**. The presence or absence of parametrial involvement is the key clinical distinction between IIA and IIB. * **Stage IIIB (Option D):** Extension to the **pelvic wall** and/or causes hydronephrosis or a non-functioning kidney. ### **High-Yield Clinical Pearls for NEET-PG** * **Clinical Staging:** Cervical cancer is primarily staged **clinically** (using physical exam, colposcopy, cystoscopy, and proctoscopy), though the 2018 FIGO update now allows the use of imaging (MRI/CT/PET) and pathology to assign the stage. * **The "Cut-off" for Surgery:** Generally, Stage **IIA1 and below** are treated surgically (Radical Hysterectomy). Stage **IIB and above** (involving parametrium) are treated with **Concurrent Chemoradiotherapy (CCRT)**. * **Stage IVA vs. IVB:** IVA involves adjacent organs (bladder/rectum mucosa); IVB involves distant metastasis.

Question 117: Women receiving estrogen therapy have an increased risk of developing which of the following cancers?

A. Breast cancer
B. Endometrial carcinoma
C. Carcinoma of the gall bladder (Correct Answer)
D. Hepatocellular carcinoma

Explanation: **Explanation:** The correct answer is **Carcinoma of the gall bladder (Option C)**. **Why it is correct:** Estrogen therapy significantly alters bile composition. Estrogens increase the expression of hepatic LDL receptors, leading to increased cholesterol uptake and subsequent hypersecretion of cholesterol into the bile (lithogenic bile). Furthermore, estrogens decrease bile acid synthesis and impair gallbladder motility (stasis). This triad leads to a significantly higher incidence of **cholelithiasis** (gallstones). Chronic irritation and inflammation from long-standing gallstones are the primary risk factors for the development of gallbladder carcinoma. **Why other options are incorrect:** * **A. Breast Cancer:** While combined Hormone Replacement Therapy (Estrogen + Progesterone) is linked to an increased risk, **unopposed estrogen** therapy primarily increases breast density but has a less definitive causal link to carcinoma compared to the gallbladder/endometrial risks in the context of this specific question's hierarchy. * **B. Endometrial Carcinoma:** Unopposed estrogen is a major risk factor for endometrial hyperplasia and cancer. However, in modern clinical practice, estrogen is rarely given "unopposed" to women with an intact uterus; it is co-administered with progesterone to neutralize this risk. * **D. Hepatocellular Carcinoma:** Estrogens (specifically OCPs) are strongly associated with **Hepatic Adenoma** (benign), but they are not a primary risk factor for hepatocellular carcinoma (which is linked to HBV, HCV, and cirrhosis). **NEET-PG High-Yield Pearls:** * **OCPs and Cancer:** OCPs *increase* the risk of Cervical Cancer and Hepatic Adenoma, but *decrease* the risk of Ovarian and Endometrial Cancer (protective effect). * **Gallstones:** The "4 F’s" (Female, Fat, Fertile, Forty) highlight the role of endogenous estrogen in gallstone pathogenesis. * **Tamoxifen:** Acts as an estrogen antagonist in the breast but an **agonist** in the uterus, increasing the risk of endometrial carcinoma.

Question 118: The process of carcinogenesis in carcinoma of the cervix begins at which anatomical location?

A. Endocervix
B. Ectocervix
C. Transformation zone (Correct Answer)
D. None of the above

Explanation: **Explanation:** The correct answer is **C. Transformation zone**. **Why it is correct:** The transformation zone (TZ) is the area of the cervix where the original **columnar epithelium** of the endocervix is replaced by **stratified squamous epithelium** through a process called **squamous metaplasia**. This region is highly metabolically active and contains undifferentiated reserve cells. When High-Risk Human Papillomavirus (HR-HPV) infection occurs, the virus preferentially integrates into the DNA of these unstable, transforming cells. This disruption of the cell cycle (via E6 and E7 oncoproteins) leads to dysplasia (CIN) and eventually invasive squamous cell carcinoma. **Why other options are incorrect:** * **A. Endocervix:** This is lined by simple columnar epithelium. While adenocarcinoma can arise here, the vast majority of cervical cancers (squamous cell type) originate at the junctional TZ. * **B. Ectocervix:** This is lined by mature, stable stratified squamous epithelium. While it can be involved as the cancer spreads, it is not the primary site where the neoplastic process initiates. **High-Yield Clinical Pearls for NEET-PG:** * **Squamocolumnar Junction (SCJ):** The TZ is located between the original SCJ and the new SCJ. Its location varies with age and hormonal status (moves inward/cephalad after menopause). * **Screening:** Pap smears and HPV DNA testing specifically aim to sample cells from the transformation zone. A Pap smear is considered "satisfactory" only if TZ cells (endocervical cells) are present. * **Colposcopy:** The primary goal of colposcopy is to visualize the entire transformation zone to identify the most dysplastic area for biopsy. * **Most Common Histology:** Squamous cell carcinoma (80-85%) is the most common type, followed by Adenocarcinoma.

Question 119: What is the most common complication after radical hysterectomy?

A. Ureteral injury (Correct Answer)
B. Bladder atony
C. Prolapse of vaginal vault
D. Bowel dysfunction

Explanation: **Explanation:** **Radical Hysterectomy (Wertheim’s Hysterectomy)** involves the removal of the uterus, cervix, upper part of the vagina, and the parametrium. The most critical step in this surgery is the dissection of the ureter from the **ureteric tunnel** (within the cardinal ligament) to allow for wide resection of the parametrium. **1. Why Ureteral Injury is the Correct Answer:** Ureteral injury is considered the most significant and characteristic major complication of radical hysterectomy. During the extensive dissection required to achieve clear margins in cervical cancer, the ureter is at high risk for **direct surgical trauma** (crushing or transection) or **ischemic necrosis** due to the stripping of its adventitial blood supply. While bladder dysfunction is frequent, ureteral injury remains the most feared and classically cited "most common" major surgical complication in standard textbooks (like Telinde’s) for this specific procedure. **2. Analysis of Incorrect Options:** * **B. Bladder Atony:** While neurogenic bladder dysfunction (due to damage to the pelvic autonomic nerves) is a very common *postoperative* morbidity, it is often categorized as a functional sequela rather than a primary surgical injury. * **C. Prolapse of Vaginal Vault:** This is a long-term complication of total hysterectomy but is rare after radical hysterectomy because the extensive fibrosis and scarring in the pelvis usually fix the vaginal cuff in place. * **D. Bowel Dysfunction:** While constipation or ileus can occur due to autonomic nerve disruption, it is significantly less common and less specific than urinary tract complications. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of ureteral injury:** At the level of the **infundibulopelvic ligament** or where the ureter passes under the **uterine artery** ("Water under the bridge"). * **Triad of Wertheim’s:** Removal of Uterus + Parametrium + Pelvic Lymph Nodes. * **Prevention:** Preoperative stenting (in complex cases) and meticulous identification of the ureter throughout its pelvic course.

Question 120: A 35-year-old female P3+0 is observed to have CIN grade III on colposcopic biopsy. What is the best initial management?

A. Cryosurgery
B. Conization
C. LEEP (Loop Electrosurgical Excision Procedure) (Correct Answer)
D. Hysterectomy

Explanation: ### Explanation **Correct Answer: C. LEEP (Loop Electrosurgical Excision Procedure)** **Why LEEP is the Correct Choice:** CIN III (Cervical Intraepithelial Neoplasia Grade III) is a high-grade squamous intraepithelial lesion (HSIL) that requires definitive treatment to prevent progression to invasive cervical cancer. In a 35-year-old patient, **LEEP** is the preferred initial management. It is an **excisional procedure** that serves a dual purpose: it removes the abnormal transformation zone while providing a tissue specimen for histopathological examination to rule out occult invasive carcinoma. It is preferred over ablative methods for high-grade lesions because it ensures the margins are clear and no invasive disease is missed. **Why Other Options are Incorrect:** * **A. Cryosurgery:** This is an **ablative** procedure. While it can be used for CIN I or sometimes CIN II, it is generally avoided in CIN III because it does not provide a tissue sample for biopsy, and the depth of destruction may be insufficient for high-grade lesions. * **B. Conization (Cold Knife Cone):** While also excisional, it is more invasive, requires general anesthesia, and has a higher risk of cervical stenosis and future obstetric complications (preterm labor). It is reserved for cases where the squamocolumnar junction is not visible, there is suspicion of microinvasion, or glandular disease (AIS). * **D. Hysterectomy:** This is considered "over-treatment" for CIN III. It is only indicated if there are co-existing gynecological issues (e.g., fibroids), if the patient has completed her family and specifically requests it, or if there is persistent/recurrent CIN III despite excisional procedures. **High-Yield Clinical Pearls for NEET-PG:** * **Management Goal:** The primary goal in CIN II/III is to remove the entire transformation zone. * **Excision vs. Ablation:** Excision (LEEP/Cone) is mandatory if the colposcopy is **unsatisfactory** (cannot see the entire lesion) or if **high-grade disease** is suspected. * **Follow-up:** Post-treatment, patients require co-testing (Pap + HPV) at 12 and 24 months. * **Pregnancy:** In pregnant patients with CIN III, management is conservative (repeat colposcopy/cytology); treatment is deferred until 6–8 weeks postpartum unless invasion is suspected.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

Vulvar and Vaginal Cancer

Practice Questions

Gestational Trophoblastic Disease

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Screening for Gynecologic Cancers

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Principles of Gynecologic Oncology Surgery

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Radiation Therapy in Gynecologic Malignancies

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Chemotherapy in Gynecologic Oncology

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Palliative Care in Gynecologic Oncology

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