Gynecologic Oncology Practice Questions

Q: Which of the following malignant ovarian germ cell tumor variants has the best prognosis?

Dysgerminoma. **Explanation:** **Dysgerminoma** is the most common malignant ovarian germ cell tumor (OGCT) and carries the **best prognosis** among all malignant variants. The primary reason for its excellent survival rate (over 95% in early stages) is its extreme **radiosensitivity** and **chemosensitivity**. Unlike other germ cell tumors, dysgerminomas are often diagnosed at Stage I and respond exceptionally well to the BEP (Bleomycin, Etoposide, Cisplatin) regimen. **Analysis of Incorrect Options:** * **Yolk Sac Tumor (Endodermal Sinus Tumor):** This is highly aggressive and spreads rapidly. While chemotherapy has improved outcomes, it historically had a much poorer prognosis than dysgerminoma. It is characterized by elevated **AFP** and **Schiller-Duval bodies**. * **Immature Teratoma:** The prognosis depends strictly on the **histological grade** (amount of immature neural tissue). While treatable, Grade 2 and 3 tumors are more aggressive than dysgerminomas. * **Mature Teratoma (Dermoid Cyst):** This is a **benign** tumor. The question specifically asks for the "malignant" variant with the best prognosis. While its prognosis is technically "best" because it is non-cancerous, it does not fit the category of malignant germ cell tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Dysgerminoma is associated with elevated **LDH** and sometimes hCG. * **Association:** It is the most common malignancy found in patients with **gonadal dysgenesis** (e.g., Swyer syndrome). * **Microscopy:** Look for "Fried egg appearance" (clear cytoplasm, central nuclei) and **lymphocytic infiltration** of the stroma. * **Management:** Fertility-sparing surgery (Unilateral Salpingo-oophorectomy) is the standard of care for young patients.

Q: Attacks of flushing and cyanosis occur in which type of ovarian tumors?

Carcinoid tumors of ovary. **Explanation:** The correct answer is **D. Carcinoid tumors of ovary**. **Mechanism:** Ovarian carcinoid tumors are rare germ cell tumors (often arising within a mature cystic teratoma). They secrete vasoactive substances, primarily **serotonin (5-HT)**, bradykinin, and histamine, directly into the systemic circulation. Unlike intestinal carcinoids, which must metastasize to the liver to cause symptoms (due to the "first-pass effect" where the liver inactivates serotonin), **primary ovarian carcinoids** bypass the portal circulation. This allows the secretagogues to reach the systemic circulation directly, leading to **Carcinoid Syndrome**, characterized by episodic **flushing, cyanosis, diarrhea, and bronchospasm.** **Analysis of Incorrect Options:** * **A. Struma ovarii:** This is a specialized teratoma composed primarily of thyroid tissue. It presents with features of **hyperthyroidism** (tachycardia, tremors, weight loss), not carcinoid flushing. * **B. Krukenberg's tumor:** This is a metastatic signet-ring cell carcinoma, usually originating from the stomach. It typically presents with bilateral ovarian enlargement and ascites, not hormonal flushing. * **C. Arrhenoblastoma (Sertoli-Leydig Cell Tumor):** These are sex cord-stromal tumors that secrete androgens. They lead to **virilization** (hirsutism, clitoromegaly, deepening of voice), not vasomotor symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Primary vs. Secondary:** Primary ovarian carcinoid can cause carcinoid syndrome **without liver metastasis**, whereas GI carcinoids require liver metastasis to manifest the syndrome. * **Histology:** Look for "Insular" or "Trabecular" patterns and Argentaffin/Argyrophil positivity. * **Diagnostic Marker:** Elevated 24-hour urinary **5-HIAA** (5-Hydroxyindoleacetic acid). * **Cardiac Involvement:** Long-standing cases can lead to right-sided heart valve fibrosis (Tricuspid regurgitation/Pulmonary stenosis).

Q: What percentage of ovarian tumors of non-epithelial origin occur in childhood?

50%. **Explanation:** The correct answer is **50% (Option D)**. **Understanding the Concept:** Ovarian tumors in children and adolescents differ significantly from those in adults. While epithelial tumors are the most common type in adult women (representing ~90% of cases), they are rare in the pediatric population. In children and adolescents, **Germ Cell Tumors (GCTs)**—a subset of non-epithelial tumors—are the most prevalent. Specifically, approximately **50% of all ovarian tumors occurring in childhood and adolescence are of non-epithelial origin**, with Germ Cell Tumors being the dominant histological type. **Analysis of Options:** * **Option A, B, and C (20%, 30%, 40%):** These percentages underestimate the prevalence. While non-epithelial tumors are rare in the general population (only about 10% of all ovarian cancers), their relative frequency is dramatically higher in the pediatric age group due to the near-absence of epithelial surface tumors before puberty. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Ovarian Tumor in Children:** Mature Cystic Teratoma (Dermoid cyst). * **Most Common Malignant Ovarian Tumor in Children:** Dysgerminoma. * **Tumor Markers:** Always correlate non-epithelial tumors with markers: * **Dysgerminoma:** LDH and hCG. * **Yolk Sac Tumor:** Alpha-fetoprotein (AFP). * **Choriocarcinoma:** beta-hCG. * **Granulosa Cell Tumor:** Inhibin. * **Management:** Unlike epithelial cancers, most malignant non-epithelial tumors in children are highly chemosensitive (e.g., BEP regimen) and are often treated with fertility-sparing surgery (unilateral salpingo-oophorectomy).

Q: The performance of a prophylactic salpingo-oophorectomy reduced the risk of BRCA-related gynaecologic cancer by what percentage?

96%. **Explanation:** The correct answer is **96% (Option D)**. Risk-reducing Salpingo-oophorectomy (RRSO) is the gold standard for preventing gynecologic cancers in women with **BRCA1 and BRCA2** mutations. Since most "ovarian" cancers in these patients actually originate in the fimbrial end of the fallopian tube (Serous Tubal Intraepithelial Carcinoma - STIC), removing both the tubes and ovaries drastically reduces the risk. Large-scale clinical studies (such as those by Rebbeck et al.) have demonstrated that RRSO reduces the risk of BRCA-related ovarian and fallopian tube cancers by approximately **80% to 96%**. **Analysis of Options:** * **Option A (15%) & B (28%):** These values are far too low. RRSO is highly effective because it removes the primary tissue at risk before malignant transformation occurs. * **Option C (54%):** This figure is more closely associated with the reduction in **breast cancer risk** if the oophorectomy is performed pre-menopausally (approximately 50% reduction), but it underestimates the protection against gynecologic cancers. * **Option D (96%):** This represents the upper limit of efficacy reported in literature. The risk does not drop to 0% because of the residual risk of **Primary Peritoneal Carcinoma (PPC)**, which can arise from the peritoneal lining even after the ovaries are removed. **High-Yield Clinical Pearls for NEET-PG:** * **Timing of Surgery:** For BRCA1, RRSO is recommended between ages **35–40**. For BRCA2 (which has a later onset of cancer), it can be delayed until ages **40–45**. * **Breast Cancer Link:** RRSO in pre-menopausal BRCA carriers also reduces the risk of breast cancer by ~50%. * **OCPs:** Combined Oral Contraceptive Pills reduce ovarian cancer risk in BRCA carriers by ~50% if used for 5 years or more. * **Screening:** For those deferring surgery, screening with **TVUS and CA-125** every 6 months is often done, though its efficacy in detecting early-stage disease is limited.

Q: All of the following are prognostic factors of carcinoma endometrium, EXCEPT:

Enlarged uterine cavity. In endometrial carcinoma, prognosis is primarily determined by factors that reflect the **surgical-pathological stage** and the biological aggressiveness of the tumor. **Why "Enlarged uterine cavity" is the correct answer:** While an enlarged uterus may be a clinical finding during examination, the **size of the uterine cavity** is no longer considered a significant prognostic factor in modern FIGO staging. Historically, it was part of the 1971 clinical staging, but it has been replaced by more precise pathological markers that correlate better with survival and recurrence. **Explanation of incorrect options (Prognostic Factors):** * **Pelvic node involvement:** This is one of the most critical prognostic factors. Lymph node metastasis automatically upgrades the disease to Stage IIIC, significantly decreasing the 5-year survival rate. * **Deep myometrial involvement:** Invasion into the outer half of the myometrium (Stage IB) increases the risk of lymphovascular space invasion (LVSI) and lymph node metastasis. * **Poor differentiation (Grade 3):** Histological grade is a major predictor of outcome. High-grade tumors are more likely to be aggressive, non-endometrioid (like serous or clear cell), and have a higher propensity for distant spread. **High-Yield Clinical Pearls for NEET-PG:** * **Most important prognostic factor:** Histological type and grade. * **Most common site of distant metastasis:** Lungs. * **Staging:** Endometrial cancer is **surgically staged** (FIGO). * **Risk Factors:** Obesity (most common), nulliparity, late menopause, and Lynch Syndrome (HNPCC). * **Protective Factors:** Combined oral contraceptives and smoking (due to anti-estrogenic effects, though not recommended for health).

Q: What is the primary group of lymph nodes affected in cervical carcinoma?

Obturator nodes. ### Explanation **1. Why Obturator nodes are correct:** Cervical carcinoma primarily spreads via the lymphatic system in an orderly, stepwise fashion. The **Obturator nodes** (part of the external iliac group) are considered the **primary/sentinel station** for cervical drainage. The cervix drains first into the primary group, which includes the paracervical, obturator, external iliac, and internal iliac nodes. Among these, the obturator nodes are the most frequently involved early in the disease process. **2. Analysis of incorrect options:** * **A. Common iliac group:** These are considered **secondary nodes**. They receive drainage from the primary groups (external/internal iliacs). Involvement usually indicates more advanced disease (Stage IIIB/IVA). * **B. Inguinal nodes:** These nodes typically drain the lower third of the vagina, the vulva, and the skin below the umbilicus. They are not a primary site for cervical cancer unless there is significant vaginal extension. * **C. Para-aortic nodes:** These are **tertiary nodes**. Involvement of para-aortic nodes represents distant metastasis (Stage IVB in FIGO 2018, though now specifically noted in surgical staging). They receive drainage from the common iliac nodes. **3. NEET-PG High-Yield Pearls:** * **Order of Spread:** Primary (Obturator/External/Internal Iliac) → Secondary (Common Iliac) → Tertiary (Para-aortic). * **Most common site of distant metastasis:** Lungs. * **Ureteric involvement:** The most common cause of death in cervical cancer is **Uremia** due to bilateral ureteric obstruction (post-renal failure). * **FIGO Staging:** Remember that cervical cancer staging is now primarily **clinical** but allows for imaging (MRI/CT) and pathological findings where available. * **Sentinel Lymph Node (SLN) Mapping:** Usually uses Technetium-99 or Indocyanine Green (ICG) to identify the first node (often the obturator) to avoid complete lymphadenectomy morbidity.

Q: What is the recommended initial management for atypical hyperplasia?

Hysterectomy. **Explanation:** **Atypical Hyperplasia (AH)**, also known as Endometrioid Intraepithelial Neoplasia (EIN), is a premalignant condition with a high risk of progressing to or harboring coexistent malignancy. **Why Hysterectomy is the Correct Answer:** The definitive management for atypical hyperplasia is **Total Hysterectomy** (usually with bilateral salpingo-oophorectomy in postmenopausal women). This is because approximately **40% of women** diagnosed with AH on a biopsy are found to have a concurrent, undiagnosed endometrial carcinoma in the final hysterectomy specimen. Surgery eliminates the risk of progression and provides a definitive diagnosis. **Why Other Options are Incorrect:** * **Options A & B (Cyclical/Continuous Progestogens):** While progestogens can reverse hyperplasia without atypia, they are not the first-line treatment for atypical hyperplasia due to the high failure rate and the risk of underlying malignancy. * **Option C (LNG-IUS/Mirena):** The LNG-IUS is highly effective for *non-atypical* hyperplasia. In atypical cases, it is only reserved for patients who strongly desire **fertility preservation** or those who are **medically unfit** for surgery. It is not the "recommended initial management" for the general population. **NEET-PG High-Yield Pearls:** * **Risk of Malignancy:** Hyperplasia *without* atypia has a <3% risk of progression; Hyperplasia *with* atypia has a ~29-40% risk. * **Fertility Sparing:** If a patient with AH desires pregnancy, management involves high-dose oral progestogens or LNG-IUS with mandatory endometrial sampling every 3 months. * **Postmenopausal Bleeding:** Always the first symptom to rule out endometrial hyperplasia/carcinoma. * **Gold Standard Diagnosis:** Endometrial biopsy or D&C (Dilatation and Curettage).

Q: What is true about a complete hydatidiform mole?

All of the above.. A **Complete Hydatidiform Mole (CHM)** is a gestational trophoblastic disease characterized by the proliferation of trophoblastic tissue and hydropic degeneration of chorionic villi. **Explanation of Options:** * **Option A (Chromosome pattern is XX):** CHM is typically diploid (46,XX). It occurs through **androgenesis**, where an "empty" egg (lacking maternal chromosomes) is fertilized by a single sperm that duplicates its DNA (90%) or, less commonly, by two sperm (dispermy, 46,XY). 46,XX is the most common karyotype. * **Option B (Associated with Preeclampsia):** CHM is a classic cause of **early-onset preeclampsia** (occurring before 20 weeks of gestation). This is due to the massive release of anti-angiogenic factors from the hyperplastic trophoblastic tissue. * **Option C (Enlarged ovarian cysts):** High levels of hCG (human chorionic gonadotropin) have an $\alpha$-subunit identical to LH and FSH. This leads to hyperstimulation of the ovaries, resulting in bilateral **Theca Lutein Cysts**. These typically resolve after the mole is evacuated. **Conclusion:** Since all statements are clinically accurate features of a complete mole, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Snowstorm Appearance:** The classic ultrasound finding for CHM. * **HCG Levels:** Markedly elevated (often >100,000 mIU/mL), unlike partial moles. * **Fetal Parts:** Absent in complete moles; present in partial moles (which are usually triploid, 69,XXX/XXY). * **Risk of Malignancy:** CHM has a higher risk (15-20%) of progressing to Gestational Trophoblastic Neoplasia (GTN) compared to partial moles (<5%). * **Treatment:** Suction and evacuation is the treatment of choice.

Question 1

Which of the following malignant ovarian germ cell tumor variants has the best prognosis?

Accepted Answer

Dysgerminoma

Answer

Yolk sac tumor

Answer

Immature teratoma

Answer

Mature teratoma

Question 2

Attacks of flushing and cyanosis occur in which type of ovarian tumors?

Accepted Answer

Carcinoid tumors of ovary

Answer

Struma ovarii

Answer

Krukenberg's tumor

Answer

Arrhenoblastoma

Question 3

A patient presents with 22 weeks of pregnancy (Gravida 4, Para 1) and carcinoma in situ. What is the preferred treatment?

Accepted Answer

Allow delivery followed by hysterectomy

Answer

Conization of the cervix

Answer

Medical termination of pregnancy (MTP) and hysterectomy

Answer

Medical termination of pregnancy (MTP) and radiotherapy

Question 4

What percentage of ovarian tumors of non-epithelial origin occur in childhood?

Accepted Answer

50%

Answer

20%

Answer

30%

Answer

40%

Question 5

The performance of a prophylactic salpingo-oophorectomy reduced the risk of BRCA-related gynaecologic cancer by what percentage?

Accepted Answer

96%

Answer

15%

Answer

28%

Answer

54%

Question 6

All of the following are prognostic factors of carcinoma endometrium, EXCEPT:

Accepted Answer

Enlarged uterine cavity

Answer

Pelvic node involvement

Answer

Deep myometrial involvement

Answer

Poor differentiation

Question 7

What is the primary group of lymph nodes affected in cervical carcinoma?

Accepted Answer

Obturator nodes

Answer

Common iliac group

Answer

Inguinal nodes

Answer

Para-aortic nodes

Question 8

What is the recommended initial management for atypical hyperplasia?

Accepted Answer

Hysterectomy

Answer

Cyclical progestogens

Answer

Continuous progestogens

Answer

Levonorgestrel-releasing intrauterine system (MIRENA)

Question 9

What is the standard treatment for Stage II carcinoma of the endometrium?

Accepted Answer

Radiotherapy followed by surgery

Answer

Surgery

Answer

Chemotherapy

Answer

Progesterone followed by surgery

Question 10

What is true about a complete hydatidiform mole?

Accepted Answer

All of the above.

Answer

Its chromosome pattern is XX.

Answer

It is associated with preeclampsia.

Answer

Enlarged ovarian cysts occur.

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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