Gynecologic Oncology — MCQs
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What is the indication for adjuvant radiotherapy in endometrial cancer?
In microinvasive cervical cancer, what is the most common treatment?
A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. What is your diagnosis?
What is the treatment of choice for stage 1A grade 1 endometrial carcinoma?
Endocervical curettage shows malignant cells in a 40-year-old lady. What is the next line of management?
What is the most common ovarian tumor to undergo torsion?
Regarding vaccination for carcinoma cervix, all of the following statements are true EXCEPT:
What is the best method for screening for cancer of the cervix?
What is the most common histology of carcinoma of the endometrium?
All of the following are germ cell tumors except?
Gynecologic Oncology Indian Medical PG Practice Questions and MCQs
Question 141: What is the indication for adjuvant radiotherapy in endometrial cancer?
- A. Cervical involvement, lymph node involvement, and carcinoma in situ (Correct Answer)
- B. Lymph node involvement and carcinoma in situ
- C. Cervical involvement, carcinoma in situ, and papillary serous tumor
- D. Lymph node involvement, papillary serous tumor, and estrogen receptor positive
Explanation: **Explanation:** The management of endometrial cancer is primarily surgical (Total Laparoscopic/Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy). Adjuvant radiotherapy (RT) is indicated when there is a high risk of local or regional recurrence based on surgical-pathological staging. **Why Option A is Correct:** Adjuvant radiotherapy is indicated in the following scenarios: 1. **Cervical Involvement (Stage II):** Extension to the cervical stroma significantly increases the risk of pelvic recurrence, necessitating external beam radiotherapy (EBRT) or brachytherapy. 2. **Lymph Node Involvement (Stage IIIC):** Positive pelvic or para-aortic nodes indicate regional spread, requiring systemic therapy and/or regional radiation. 3. **Carcinoma in situ (CIS) / High-grade features:** While "carcinoma in situ" is an unusual term for the endometrium (usually referred to as EIN), in the context of this specific question, it refers to high-risk histological subtypes or localized aggressive cells that warrant adjuvant treatment to prevent recurrence. **Analysis of Incorrect Options:** * **Options B, C, and D:** These are incorrect because they either omit critical indications (like cervical involvement) or include factors that do not specifically dictate radiotherapy. For instance, **Estrogen Receptor (ER) positivity** is a favorable prognostic factor often managed with hormonal therapy (Progestins), not radiation. While **Papillary Serous** tumors (Option C/D) are aggressive and require chemotherapy, the specific triad in Option A represents the classic indications for regional control via RT. **NEET-PG High-Yield Pearls:** * **Standard Treatment:** Surgery is the mainstay. Adjuvant RT is decided based on the **FIGO Staging**. * **Vaginal Brachytherapy:** Preferred for Stage IA/IB (high grade) to reduce vaginal vault recurrence with fewer side effects than EBRT. * **EBRT:** Indicated for Stage II and III disease to cover pelvic side walls. * **Most Common Type:** Endometrioid adenocarcinoma (Type I), associated with estrogen excess. * **Most Aggressive Type:** Clear cell and Papillary serous (Type II), which require aggressive adjuvant management regardless of depth of invasion.
Question 142: In microinvasive cervical cancer, what is the most common treatment?
- A. Conization
- B. Laser therapy
- C. Simple hysterectomy (Correct Answer)
- D. Radical hysterectomy
Explanation: **Explanation:** Microinvasive cervical cancer is defined as **Stage IA1** (FIGO classification), where the depth of stromal invasion is **≤ 3 mm** and the horizontal spread is ≤ 7 mm. **1. Why Simple Hysterectomy is Correct:** For Stage IA1 disease without lymphovascular space invasion (LVSI), the risk of lymph node metastasis is extremely low (<1%). Therefore, a **Simple (Extrafascial) Hysterectomy** is the standard treatment of choice for women who have completed their childbearing. It removes the entire uterus and cervix, providing a definitive cure with minimal morbidity compared to radical procedures. **2. Why the Other Options are Incorrect:** * **Conization (Option A):** While conization is the treatment of choice for Stage IA1 patients who **desire fertility preservation**, it is not the "most common" or definitive treatment for the general population in this category. * **Laser Therapy (Option B):** Ablative techniques like laser therapy are used for Cervical Intraepithelial Neoplasia (CIN/Pre-cancer) but are contraindicated once invasive cancer (even microinvasive) is diagnosed, as they do not provide a tissue specimen for margin assessment. * **Radical Hysterectomy (Option D):** This involves the removal of parametria and the upper vagina. It is indicated for **Stage IA2** (invasion 3–5 mm) or Stage IA1 with positive LVSI, where the risk of nodal spread is higher. **High-Yield Clinical Pearls for NEET-PG:** * **Stage IA1:** Invasion ≤ 3mm. Treatment: Simple Hysterectomy (or Cone biopsy if fertility is desired). * **Stage IA2:** Invasion 3–5mm. Treatment: Modified Radical Hysterectomy + Pelvic Lymphadenectomy. * **Gold Standard for Diagnosis:** Microinvasion can *only* be diagnosed via a **Cone Biopsy**, not a punch biopsy, as the entire lesion must be mapped to rule out deeper invasion.
Question 143: A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. What is your diagnosis?
- A. Carcinoma of low malignant potential
- B. Microinvasive cancer (Correct Answer)
- C. Atypical squamous cells of undetermined significance
- D. Carcinoma in situ
Explanation: **Explanation:** The diagnosis is **Microinvasive Squamous Cell Carcinoma (Stage IA1)**. According to the FIGO staging for cervical cancer, Stage IA1 is defined as invasive carcinoma that can be identified only by microscopy, with a maximum depth of invasion **≤ 3 mm**. In this case, the tumor invades only **1 mm** beyond the basement membrane, and the absence of lymphovascular space invasion (LVSI) and clear margins on the cone biopsy confirm this diagnosis. Microinvasive cancer represents a transition point where the malignant cells have breached the basement membrane but have a very low risk of pelvic lymph node metastasis (<1%). **Analysis of Incorrect Options:** * **Option A (Carcinoma of low malignant potential):** This term is typically used for borderline ovarian tumors, not cervical pathology. * **Option C (ASC-US):** This is a cytological category from a Pap smear indicating cells that do not look normal but do not meet the criteria for a definitive lesion. It is a precursor finding, not a histological diagnosis of invasion. * **Option D (Carcinoma in situ):** Also known as CIN III, this refers to full-thickness dysplasia where the basement membrane is **intact**. Once the basement membrane is breached (as the 1 mm invasion indicates here), it is no longer "in situ" but "invasive." **Clinical Pearls for NEET-PG:** * **FIGO Stage IA1:** Invasion ≤ 3 mm depth. Treatment of choice is **Extra-fascial Hysterectomy** (Type A). If the patient desires fertility, a **Cold Knife Conization** with clear margins is sufficient. * **FIGO Stage IA2:** Invasion > 3 mm to ≤ 5 mm. Requires Modified Radical Hysterectomy (Type B) with pelvic lymphadenectomy. * The most important prognostic factor in early-stage cervical cancer is **lymphovascular space invasion (LVSI)**.
Question 144: What is the treatment of choice for stage 1A grade 1 endometrial carcinoma?
- A. Radiotherapy
- B. Chemotherapy
- C. Chemotherapy plus radiotherapy
- D. None of the above (Correct Answer)
Explanation: ### Explanation The treatment of choice for **Stage 1A Grade 1 endometrial carcinoma** is **Total Extra-fascial Hysterectomy with Bilateral Salpingo-oophorectomy (TAH + BSO)**. Since this surgical management is not listed among the options, "None of the above" is the correct choice. #### Why the Correct Answer is Right Endometrial cancer is primarily a surgically staged disease. Stage 1A Grade 1 represents a low-risk profile where the tumor is limited to the endometrium or invades less than half of the myometrium (<50%) and is well-differentiated. For these patients, surgery (TAH + BSO) is both diagnostic and therapeutic. In most cases of Stage 1A Grade 1, surgery alone is curative, and the 5-year survival rate exceeds 90%. #### Why Other Options are Wrong * **A, B, & C (Radiotherapy/Chemotherapy):** These are considered **adjuvant therapies**. They are reserved for high-risk patients (high grade, deep myometrial invasion, or advanced stages). In Stage 1A Grade 1, the risk of lymph node metastasis or recurrence is extremely low (<2%), making the toxicity of radiation or chemotherapy unnecessary and unjustified. #### NEET-PG High-Yield Pearls * **Standard of Care:** The gold standard for endometrial cancer is TAH + BSO with pelvic and para-aortic lymphadenectomy (though lymphadenectomy may be omitted in very low-risk Stage 1A G1 cases). * **Fertility Sparing:** In young patients wishing to preserve fertility (Stage 1A G1 only), **high-dose Progestogens** (e.g., Megestrol acetate or Levonorgestrel IUD) can be used as an alternative to surgery, provided there is strict follow-up. * **Most Common Type:** Endometrioid adenocarcinoma (Type 1) is the most common histological subtype and is estrogen-dependent. * **Risk Factor:** Obesity is the most significant risk factor due to the peripheral conversion of androstenedione to estrone.
Question 145: Endocervical curettage shows malignant cells in a 40-year-old lady. What is the next line of management?
- A. Cone biopsy (Correct Answer)
- B. Pap smear
- C. Colposcopy
- D. Repeat procedure and if positive, hysterectomy
Explanation: **Explanation:** The presence of malignant cells on **Endocervical Curettage (ECC)** indicates a high suspicion of invasive cervical cancer or high-grade glandular lesions (AIS) within the endocervical canal. However, ECC is a "blind" procedure and cannot determine the **depth of invasion** or the exact site of the lesion. **Why Cone Biopsy is the correct answer:** A cone biopsy (Cold Knife Conization or LEEP) is both diagnostic and potentially therapeutic. In this scenario, it is mandatory to obtain a larger, intact tissue specimen to: 1. Differentiate between **Micro-invasive Squamous Cell Carcinoma (Stage IA1/IA2)** and **Frankly Invasive Carcinoma**. 2. Rule out **Adenocarcinoma in situ (AIS)**. 3. Determine the margins of the lesion. Management of cervical cancer depends entirely on the stage; hence, a definitive histological diagnosis via cone biopsy is the essential next step before planning radical surgery or radiotherapy. **Analysis of Incorrect Options:** * **B. Pap Smear:** This is a screening tool, not a diagnostic one. Since malignant cells have already been identified, a smear provides no additional staging information. * **C. Colposcopy:** While colposcopy visualizes the ectocervix, it cannot adequately visualize the endocervical canal (where the malignant cells were found). If the ECC is positive, the colposcopic exam is considered "unsatisfactory" or "incomplete," necessitating a cone biopsy. * **D. Repeat procedure/Hysterectomy:** Hysterectomy is contraindicated until the depth of invasion is known. If the cancer is frankly invasive (Stage IB+), a simple hysterectomy is inadequate treatment and may compromise the patient's prognosis. **Clinical Pearls for NEET-PG:** * **Indications for Cone Biopsy:** Positive ECC, Pap smear showing HSIL/Malignancy but negative colposcopy, or a biopsy suggestive of micro-invasion. * **Transformation Zone (TZ):** Most cervical cancers arise here. In older patients, the TZ migrates into the endocervical canal, making ECC and Cone Biopsy vital. * **Gold Standard:** Cold knife conization is preferred over LEEP when glandular lesions (AIS) are suspected to ensure clear margins and thermal-artifact-free specimens.
Question 146: What is the most common ovarian tumor to undergo torsion?
- A. Pseudomucinous cystadenoma
- B. Papillary cystadenoma
- C. Dermoid cyst (Correct Answer)
- D. Mucinous cystadenoma
Explanation: **Explanation:** **1. Why Dermoid Cyst (Mature Cystic Teratoma) is correct:** Dermoid cysts are the most common ovarian tumors to undergo torsion. This high incidence is attributed to two main factors: * **Weight and Composition:** They contain heavy elements like hair, teeth, and sebum, which makes them "top-heavy." * **Mobility:** They are often pedunculated (attached by a stalk) and lack significant adhesions to surrounding pelvic structures, allowing them to rotate freely around their pedicle. Torsion is most frequent when the tumor size is between **5–10 cm**. **2. Why other options are incorrect:** * **Pseudomucinous and Mucinous Cystadenomas:** These are often very large (sometimes filling the entire abdomen). Their massive size and weight usually limit their mobility within the pelvis, making them less likely to rotate compared to the medium-sized dermoid cyst. * **Papillary Cystadenoma:** These are frequently associated with surface projections and potential malignancy, which often leads to the formation of adhesions to the broad ligament or pelvic side walls, thereby fixing the ovary in place and preventing torsion. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common complication of Dermoid Cyst:** Torsion (occurring in ~15% of cases). * **Most common ovarian tumor overall:** Serous cystadenoma. * **Most common germ cell tumor:** Dermoid cyst (Mature cystic teratoma). * **Clinical Presentation:** Sudden onset of acute lower abdominal pain, often associated with nausea and vomiting. * **Management:** Emergency laparoscopy is the gold standard. In reproductive-age women, **detorsion** (untwisting) is preferred over salpingo-oophorectomy, even if the ovary appears dusky, as functional recovery is common.
Question 147: Regarding vaccination for carcinoma cervix, all of the following statements are true EXCEPT:
- A. Does not require further examinations (Correct Answer)
- B. Can be taken with other live vaccines at a different site
- C. Bivalent vaccine is more efficient than Quadrivalent
- D. Administered intramuscularly at 0, 2, and 6 months
Explanation: **Explanation:** The correct answer is **A (Does not require further examinations)** because HPV vaccination does not eliminate the need for cervical cancer screening. **1. Why Option A is the correct (False) statement:** HPV vaccines (Bivalent, Quadrivalent, or Nonavalent) protect against the most common high-risk strains (HPV 16 and 18), which cause approximately 70% of cervical cancers. However, they do not cover all oncogenic HPV types. Therefore, vaccinated women must still undergo routine **Pap smears or HPV DNA testing** according to standard guidelines to detect lesions caused by non-vaccine strains. **2. Analysis of other options:** * **Option B:** HPV vaccines are inactivated (recombinant) vaccines. They can be safely co-administered with other vaccines (live or inactivated), such as Hepatitis B or Tdap, provided they are given at different anatomical sites. * **Option C:** While both are highly effective, some studies suggest the **Bivalent vaccine (Cervarix)** may produce higher antibody titers and offer better cross-protection against non-vaccine types (like HPV 31 and 45) compared to the **Quadrivalent vaccine (Gardasil)**, though the clinical significance of this in preventing cancer is debated. * **Option D:** The standard three-dose schedule for individuals aged 15 and older is **0, 2, and 6 months** (for Gardasil) or 0, 1, and 6 months (for Cervarix), administered intramuscularly in the deltoid. **High-Yield Clinical Pearls for NEET-PG:** * **Target Age:** Best given before the first sexual encounter (9–14 years). * **Two-dose Schedule:** For children aged 9–14 years, only two doses are required (0 and 6 months). * **Catch-up Vaccination:** Recommended up to age 26; can be considered up to age 45 based on shared clinical decision-making. * **Contraindication:** Pregnancy (though it is not an indication for termination if accidentally administered). Safe during breastfeeding.
Question 148: What is the best method for screening for cancer of the cervix?
- A. Pap smear (Correct Answer)
- B. Colposcopy
- C. Biopsy
- D. Colpomicroscopy
Explanation: **Explanation:** **1. Why Pap Smear is the Correct Answer:** The **Papanicolaou (Pap) smear** is the gold standard for cervical cancer **screening**. The fundamental principle of screening is to identify asymptomatic individuals in a large population who may have a disease. The Pap smear is ideal for this because it is simple, cost-effective, non-invasive, and highly effective at detecting pre-malignant lesions (CIN) and early-stage cervical cancer. By scraping exfoliated cells from the transformation zone, clinicians can identify cytological changes before they progress to invasive carcinoma. **2. Why Other Options are Incorrect:** * **B. Colposcopy:** This is a **diagnostic aid**, not a screening tool. It is the "gold standard" for evaluating patients who have already had an abnormal screening result (e.g., abnormal Pap or positive HPV DNA test). It allows for targeted visualization of the cervix under magnification. * **C. Biopsy:** This is the **confirmatory/definitive diagnosis**. While it provides the most accurate histological information, it is invasive and cannot be used as a primary screening tool for the general population. * **D. Colpomicroscopy:** This is an obsolete technique used to examine the cervical epithelium in vivo at high magnification. It is technically difficult and has been largely replaced by colposcopy and directed biopsy. **3. NEET-PG High-Yield Pearls:** * **Primary Screening:** In modern guidelines, **HPV DNA testing** is now considered the most sensitive primary screening method, but the Pap smear remains the most widely taught and utilized "best method" in traditional exams. * **Transformation Zone:** This is the most common site for cervical neoplasia and must be sampled during a Pap smear. * **Bethesda System:** This is the standard terminology used for reporting cervical cytology. * **Screening Age:** Usually starts at age 21 (regardless of sexual activity in some guidelines, though others suggest 25) and continues until age 65 if previous tests are negative.
Question 149: What is the most common histology of carcinoma of the endometrium?
- A. Squamous cell
- B. Clear cell
- C. Adenocarcinoma (Correct Answer)
- D. Anaplastic carcinoma
Explanation: **Explanation:** **Endometrial carcinoma** is the most common gynecological malignancy in developed countries and the second most common in India (after cervical cancer). **Why Adenocarcinoma is correct:** The endometrium is a mucosal lining composed of glandular epithelium. Therefore, malignancies arising from this tissue are predominantly **adenocarcinomas**. Specifically, the **Endometrioid** subtype of adenocarcinoma accounts for approximately **75-80%** of all cases. It is typically "Type I" endometrial cancer, which is estrogen-dependent and often preceded by endometrial hyperplasia. **Why other options are incorrect:** * **Squamous cell carcinoma:** This is extremely rare as a primary endometrial cancer. Squamous cells are not native to the endometrium; they usually occur due to squamous metaplasia or extension from the cervix. * **Clear cell carcinoma:** This is a "Type II" endometrial cancer. It is highly aggressive and carries a poor prognosis, but it accounts for only about **1-5%** of cases. * **Anaplastic carcinoma:** This represents an undifferentiated, rare, and highly malignant form of the disease, occurring in a very small percentage of patients. **High-Yield Clinical Pearls for NEET-PG:** * **Most common subtype:** Endometrioid Adenocarcinoma. * **Most common symptom:** Postmenopausal bleeding (PMB). * **Risk Factors:** Obesity (most significant), nulliparity, early menarche, late menopause, and Tamoxifen use. * **Protective Factors:** Combined Oral Contraceptive Pills (COCPs) and smoking (though smoking increases other risks, it lowers estrogen levels). * **Investigation of choice:** Fractional Curettage or Pipelle biopsy (Gold standard for diagnosis). * **Staging:** Endometrial cancer is **Surgically Staged** (FIGO staging).
Question 150: All of the following are germ cell tumors except?
- A. Mesonephroid tumors (Correct Answer)
- B. Teratoma
- C. Endodermal sinus tumor
- D. Dysgerminoma
Explanation: **Explanation:** The classification of ovarian tumors is based on the cell of origin. Ovarian tumors are primarily divided into Surface Epithelial, Germ Cell, and Sex Cord-Stromal tumors. **1. Why Mesonephroid tumors is the correct answer:** Mesonephroid tumors, also known as **Clear Cell Carcinomas**, are a subtype of **Surface Epithelial-Stromal tumors**. They are derived from the ovarian surface epithelium (coelomic epithelium) and are often associated with endometriosis. Since they are epithelial in origin, they are not classified as germ cell tumors. **2. Analysis of Incorrect Options (Germ Cell Tumors):** Germ cell tumors (GCTs) arise from the primordial germ cells of the ovary. * **Dysgerminoma:** The most common malignant germ cell tumor in women. It is the female counterpart of the male seminoma and is highly radiosensitive. * **Endodermal Sinus Tumor (Yolk Sac Tumor):** A highly aggressive malignant GCT characterized by the production of **Alpha-Fetoprotein (AFP)** and the presence of **Schiller-Duval bodies** on histology. * **Teratoma:** The most common germ cell tumor overall. It can be mature (benign/dermoid cyst) or immature (malignant), containing tissues from all three germ layers (ectoderm, mesoderm, and endoderm). **Clinical Pearls for NEET-PG:** * **Most common ovarian tumor:** Serous Cystadenoma (Epithelial). * **Most common malignant GCT:** Dysgerminoma (Marker: LDH). * **Yolk Sac Tumor Marker:** AFP. * **Choriocarcinoma Marker:** beta-hCG. * **Schiller-Duval bodies** are pathognomonic for Yolk Sac Tumors. * **Call-Exner bodies** are characteristic of Granulosa Cell Tumors (Sex cord-stromal).
Practice by Chapter
Cervical Cancer
Practice Questions
Endometrial Cancer
Practice Questions
Ovarian Cancer
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Vulvar and Vaginal Cancer
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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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