Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 161: Which of the following statements regarding the treatment of cervical cancer is FALSE?

A. Radiotherapy is helpful in all stages. (Correct Answer)
B. The prognosis of surgery is good if performed in early stages.
C. When radiotherapy is given, para-aortic lymph nodes should be included.
D. Chemotherapy is reserved for late stages.

Explanation: **Explanation:** The correct answer is **A**, as the statement "Radiotherapy is helpful in all stages" is technically **false** in the context of clinical practice. While radiotherapy (RT) is the mainstay for locally advanced cervical cancer (Stage IIB to IVA), it is generally **not** the preferred primary treatment for Stage IA1 (microinvasive) or Stage IVB (distant metastasis). In Stage IVB, treatment is primarily palliative chemotherapy, and RT is reserved only for local symptom control (e.g., bleeding or bone pain), rather than being "helpful" in a curative or stage-wide capacity. **Analysis of Options:** * **Option B (True):** Surgery (e.g., Radical Hysterectomy) is the treatment of choice for early stages (IA2, IB1, IB2, and IIA1). The 5-year survival rate for early-stage disease treated surgically is excellent (>90%). * **Option C (True):** In advanced cases or when imaging/biopsy suggests lymph node involvement, the radiation field must be extended to include the para-aortic lymph nodes (Extended Field Radiotherapy) to prevent systemic spread. * **Option D (True):** Primary chemotherapy is typically reserved for Stage IVB (recurrent or metastatic disease). In earlier stages (IB3–IVA), it is used as a "radiosensitizer" (Concurrent Chemoradiotherapy) rather than a standalone treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Standard of Care:** Concurrent Chemoradiotherapy (CCRT) using **Cisplatin** is the gold standard for Stage IIB to IVA. * **Surgery vs. RT:** Both have equal efficacy in Stage IB and IIA, but surgery is preferred in young women to preserve ovarian function and vaginal elasticity. * **Most Common Cause of Death:** Uremia due to bilateral ureteric obstruction (post-renal failure). * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), though imaging (MRI/PET-CT) is now integrated into the 2018 revised staging.

Question 162: A 45-year-old female presents with postcoital bleeding. On per speculum examination, a friable mass is found in the cervix. What is the next step in management?

A. Colposcopy directed biopsy
B. 6-monthly Pap smear
C. Observation only
D. Punch biopsy (Correct Answer)

Explanation: **Explanation:** The clinical presentation of postcoital bleeding associated with a visible, friable mass on the cervix is highly suspicious for **Cervical Carcinoma**. **Why Punch Biopsy is the correct answer:** In the presence of a **grossly visible lesion** or a suspicious growth, the gold standard and immediate next step is a **Punch Biopsy**. This provides a tissue diagnosis to confirm malignancy and determine the histological type. When a lesion is clinically obvious, screening or diagnostic aids like Pap smears or colposcopy are bypassed in favor of direct tissue sampling. **Analysis of Incorrect Options:** * **A. Colposcopy directed biopsy:** Colposcopy is indicated when there is an abnormal Pap smear but **no visible growth**. It helps localize "occult" or microscopic lesions. Since a mass is already visible here, colposcopy is unnecessary and may delay diagnosis. * **B. 6-monthly Pap smear:** This is a screening/follow-up tool. Using it in the presence of a symptomatic mass is a clinical error, as it has a significant false-negative rate in invasive cancer due to necrosis and blood. * **C. Observation only:** This is inappropriate as it ignores a classic "red flag" symptom of malignancy, allowing the cancer to progress to a higher stage. **NEET-PG Clinical Pearls:** * **Rule of Thumb:** If you can see it, biopsy it. Never perform a Pap smear on a visible growth. * **Most common histological type:** Squamous cell carcinoma (80-85%). * **Staging:** Cervical cancer is now primarily **clinically staged** (FIGO), but the 2018 update allows for imaging and pathological findings to be incorporated where available. * **Postcoital bleeding** is the most common presenting symptom of cervical cancer in perimenopausal women.

Question 163: Which of the following hormones promotes the development of fibroids?

A. Testosterone
B. Estrogen only
C. Estrogen and Progesterone (Correct Answer)
D. Progesterone only

Explanation: **Explanation:** Uterine fibroids (leiomyomas) are benign, monoclonal tumors of the myometrium. Their growth is strictly hormone-dependent, specifically requiring the synergistic action of both **Estrogen and Progesterone**. * **Why Estrogen and Progesterone is correct:** * **Estrogen** acts as the primary initiator of growth by increasing the expression of growth factors and inducing the synthesis of **progesterone receptors (PR)**. * **Progesterone** is now recognized as the key driver of tumor proliferation. It stimulates the production of extracellular matrix and inhibits apoptosis (cell death) within the fibroid. Clinical evidence shows that fibroids shrink after menopause (when both hormones drop) and during treatment with GnRH agonists or Progesterone receptor modulators (like Ulipristal). **Analysis of Incorrect Options:** * **A. Testosterone:** Androgens do not play a primary role in the pathogenesis of fibroids; in fact, high androgen states (like PCOS) are more closely linked to endometrial hyperplasia rather than myometrial tumors. * **B & D. Estrogen/Progesterone only:** While Estrogen was historically thought to be the sole driver, modern molecular studies prove that Estrogen alone is insufficient for sustained growth. Progesterone is essential for the mitotic activity of the leiomyoma cells. **NEET-PG High-Yield Pearls:** 1. **Risk Factors:** Early menarche, obesity (increased peripheral conversion to estrogen), and nulliparity. 2. **Protective Factors:** Multiparity, menopause, and smoking (due to decreased estrogen levels). 3. **Red Degeneration:** Most common during the **second trimester** of pregnancy due to rapid growth and venous thrombosis. 4. **Medical Management:** GnRH analogues are used pre-operatively to reduce fibroid volume and correct anemia.

Question 164: Which of the following tumours commonly metastasizes to the ovary, except?

A. Malignant melanoma
B. Stomach
C. Oesophagus (Correct Answer)
D. Lymphoma

Explanation: **Explanation:** Metastatic (secondary) tumors of the ovary account for approximately 10–25% of all ovarian malignancies. The ovary is a frequent site for metastasis due to its rich vascularity and the phenomenon of "fertile soil." **Why Oesophagus is the Correct Answer:** While the gastrointestinal tract is the most common source of ovarian metastasis, the primary sites are typically the **stomach, colon, and appendix**. Oesophageal cancer rarely metastasizes to the ovary. In clinical practice and pathology series, the esophagus is not considered a "common" primary site for Krukenberg tumors or other secondary ovarian deposits compared to the other options listed. **Analysis of Incorrect Options:** * **Stomach (Option B):** This is the most common source of the classic **Krukenberg tumor** (signet-ring cell carcinoma). It spreads via retrograde lymphatic dissemination or transcoelomic shedding. * **Malignant Melanoma (Option A):** Melanoma is known for its unpredictable hematogenous spread. It is the most common non-epithelial, non-GI solid tumor to metastasize to the ovary. * **Lymphoma (Option D):** Ovarian involvement is common in systemic lymphomas (especially Non-Hodgkin Lymphoma). Burkitt lymphoma, in particular, frequently involves the ovaries in pediatric and young adult populations. **High-Yield Clinical Pearls for NEET-PG:** * **Krukenberg Tumor:** Defined pathologically by the presence of **signet-ring cells** and a sarcomatoid stroma. The most common primary is the **Stomach**, followed by the Colon. * **Laterality:** Metastatic ovarian tumors are typically **bilateral** (80% of cases) and solid, whereas primary epithelial ovarian tumors are more often unilateral (especially in early stages). * **Common Primaries:** In order of frequency: Stomach > Colon > Breast > Appendix > Pancreas. * **Pseudomyxoma Peritonei:** Often associated with mucinous tumors of the **Appendix** metastasizing to the ovary.

Question 165: A 55-year-old woman undergoing tamoxifen therapy for breast cancer presents with vaginal bleeding. What is the best explanation for this symptom?

A. Tamoxifen acts as an estrogen antagonist in both the breast and uterus, leading to a loss of endometrial cells.
B. Tamoxifen has an antagonist effect on the breast but an agonist effect on the uterus. (Correct Answer)
C. Tamoxifen has an estrogen agonist effect on both the breast and uterus, leading to endometrial hyperplasia.
D. Tamoxifen has no effect on the uterus, and the vaginal bleeding is caused by an unrelated condition.

Explanation: **Explanation:** The correct answer is **B**. This question tests the understanding of **Selective Estrogen Receptor Modulators (SERMs)**, specifically Tamoxifen. **Mechanism of Action:** Tamoxifen is a SERM that exhibits tissue-specific activity. It acts as a competitive **estrogen antagonist in the breast**, making it highly effective in treating ER-positive breast cancer. However, it acts as a **partial estrogen agonist in the uterus**, bone, and liver. In postmenopausal women, this agonistic effect on the endometrium stimulates cell proliferation, which can lead to endometrial hyperplasia, polyps, and an increased risk of **endometrioid adenocarcinoma**. **Analysis of Incorrect Options:** * **Option A:** Incorrect because Tamoxifen is an agonist, not an antagonist, in the uterus. Antagonism would cause atrophy, not bleeding. * **Option C:** Incorrect because Tamoxifen is an antagonist in the breast; an agonist effect there would promote breast cancer growth. * **Option D:** Incorrect because Tamoxifen has a well-documented, significant effect on the uterine lining. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Ratio:** Tamoxifen increases the risk of endometrial cancer by approximately 2–3 times in postmenopausal women. * **Screening:** Routine ultrasound or biopsy is **not** recommended for asymptomatic women on Tamoxifen. However, any episode of **postmenopausal bleeding** must be investigated promptly with Transvaginal Ultrasound (TVS) and endometrial biopsy. * **Alternative:** **Raloxifene**, another SERM used for osteoporosis, acts as an antagonist in both the breast and the uterus, thus it does not increase the risk of endometrial cancer. * **Other Benefits:** Due to its agonistic effect on bone, Tamoxifen helps prevent osteoporosis in postmenopausal women.

Question 166: Abnormal rise of HCG in a female of reproductive age group may indicate which of the following malignancies?

A. Choriocarcinoma (Correct Answer)
B. Colon carcinoma
C. Serous cystadenoma
D. Teratoma

Explanation: **Explanation:** **1. Why Choriocarcinoma is correct:** Human Chorionic Gonadotropin (hCG) is a glycoprotein hormone primarily produced by syncytiotrophoblastic cells. **Choriocarcinoma** is a highly malignant germ cell or gestational trophoblastic neoplasm characterized by the proliferation of these cells. Consequently, it serves as a highly sensitive and specific tumor marker for the diagnosis, staging, and monitoring of treatment response in Choriocarcinoma. An abnormal rise in hCG in a reproductive-age female, in the absence of pregnancy, is pathognomonic for this condition. **2. Why the other options are incorrect:** * **Colon Carcinoma:** This is a GI malignancy typically associated with **CEA (Carcinoembryonic Antigen)**, not hCG. * **Serous Cystadenoma:** This is a benign epithelial ovarian tumor. While its malignant counterpart (Serous Cystadenocarcinoma) is associated with **CA-125**, benign cystadenomas do not typically secrete specific biomarkers like hCG. * **Teratoma:** Mature cystic teratomas (dermoid cysts) are benign and do not secrete hCG. While rare *immature* teratomas or those with a choriocarcinoma component might show elevated hCG, "Choriocarcinoma" is the more direct and classic association for an abnormal hCG rise. **NEET-PG High-Yield Pearls:** * **Tumor Markers for Germ Cell Tumors:** * **Yolk Sac Tumor:** Alpha-fetoprotein (AFP) – *Schiller-Duval bodies.* * **Dysgerminoma:** LDH (most common), hCG (if syncytiotrophoblastic giant cells are present). * **Choriocarcinoma:** hCG (Always elevated). * **Clinical Tip:** In Choriocarcinoma, the hCG levels are usually much higher than those seen in normal pregnancy or hydatidiform moles. * **Metastasis:** Choriocarcinoma is known for early **hematogenous spread**, most commonly to the **lungs** (presenting as "cannonball" secondaries on X-ray).

Question 167: Acetic acid staining of the cervix shows the following findings:

A. Squamous dysplasia
B. Cervical carcinoma in situ
C. Cervical polyp (Correct Answer)
D. Cervical dysplasia

Explanation: ***Cervical polyp*** - **Cervical polyps** appear as **smooth, rounded, non-acetowhite lesions** on acetic acid staining, maintaining their normal pink/red color. - They are **benign growths** from the endocervical canal that do not turn white with acetic acid application, distinguishing them from dysplastic lesions. *Squamous dysplasia* - Shows **acetowhite changes** with well-defined borders after acetic acid application due to increased nuclear density. - Represents **precancerous changes** in squamous epithelium that would appear as distinct white lesions, not smooth polypoidal growths. *Cervical carcinoma in situ* - Exhibits **dense acetowhite areas** with **sharp, irregular borders** and possible **coarse mosaic patterns** on colposcopy. - Represents **high-grade dysplasia** (CIN 3) that turns intensely white with acetic acid, unlike the non-reactive appearance of polyps. *Cervical dysplasia* - Demonstrates **acetowhite epithelium** with varying degrees of whiteness depending on the grade of dysplasia (CIN 1-3). - Shows **abnormal vascular patterns** like punctation or mosaicism, contrasting with the smooth, vascular appearance of benign polyps.

Question 168: What is the most common site for metastasis in choriocarcinoma?

A. Lungs (Correct Answer)
B. Brain
C. Liver
D. Spine

Explanation: **Explanation:** Choriocarcinoma is a highly malignant, epithelial tumor arising from trophoblastic cells. It is characterized by its **early and rapid hematogenous spread** (via the bloodstream) because the tumor cells naturally possess the ability to invade blood vessels, a property inherent to trophoblastic tissue. **1. Why Lungs are the Correct Answer:** Since the spread is primarily hematogenous, the venous drainage from the pelvic organs (uterus) travels via the internal iliac veins to the inferior vena cava and directly into the right side of the heart. From there, the first major capillary bed the tumor cells encounter is in the **lungs**. Consequently, the lungs are the most common site of metastasis, occurring in approximately **80% of cases**. **2. Why the Other Options are Incorrect:** * **Brain (B) and Liver (C):** These are common sites for *distant* metastasis, but they usually occur secondary to pulmonary involvement. Brain metastasis (10%) and liver metastasis (10%) signify a poor prognosis (High-Risk Gestational Trophoblastic Neoplasia). * **Spine (D):** While bone metastasis can occur, it is significantly less common than visceral spread in choriocarcinoma. **Clinical Pearls for NEET-PG:** * **Classic X-ray finding:** "Cannon-ball" opacities in the lungs. * **Vaginal Metastasis:** The second most common site (30%), often appearing as highly vascular, bluish-purple nodules. **Never biopsy** these nodules due to the risk of torrential hemorrhage. * **Tumor Marker:** Serum **beta-hCG** is the highly sensitive marker used for diagnosis, monitoring treatment response, and detecting recurrence. * **Treatment:** Choriocarcinoma is highly chemosensitive. Methotrexate is the first-line agent for low-risk cases, while the EMA-CO regimen is used for high-risk cases.

Question 169: A 41-year-old woman is diagnosed with squamous cell carcinoma of the cervix and has right hydronephrosis evidenced by intravenous pyelogram (IVP). Which of the following statements regarding this patient's condition is most accurate?

A. Surgical excision is the best treatment for this patient.
B. The majority of cervical cancers are of adenomatous cell type.
C. Chemoradiation is the preferred treatment. (Correct Answer)
D. Radical hysterectomy is an option in the therapy of this patient.

Explanation: ### Explanation **1. Why the correct answer is right:** The presence of **hydronephrosis** in a patient with cervical cancer automatically classifies the disease as **Stage IIIB** according to the FIGO staging system (regardless of other physical findings). Stage IIIB represents locally advanced cervical cancer (LACC). The standard of care for LACC (Stages IIB through IVA) is **Concurrent Chemoradiation (CCRT)**, typically using Cisplatin-based chemotherapy alongside external beam radiation and brachytherapy. **2. Why the incorrect options are wrong:** * **Option A & D:** Surgical options like Radical Hysterectomy (Wertheim’s operation) are reserved for **early-stage disease** (Stage IA to IIA1). Once the disease involves the parametrium (IIB) or causes hydronephrosis (IIIB), surgery is no longer the primary treatment because it cannot ensure clear margins and significantly increases morbidity without improving survival compared to radiation. * **Option B:** This is factually incorrect. Approximately **80–90%** of cervical cancers are **Squamous Cell Carcinomas (SCC)**. Adenocarcinomas account for only about 10–20%, though their incidence is rising. **3. Clinical Pearls for NEET-PG:** * **FIGO Staging:** Cervical cancer is staged **clinically**. While the 2018 revision allows imaging (MRI/CT/PET) and pathology, the presence of hydronephrosis or a non-functioning kidney remains a hallmark of **Stage IIIB**. * **Most common cause of death:** Uremia due to bilateral ureteric obstruction (leading to post-renal renal failure). * **Triad of Stage IIIB:** Pelvic wall involvement, hydronephrosis/non-functioning kidney, and/or lower third of the vagina involvement. * **Drug of Choice:** Cisplatin is the most common radiosensitizer used in CCRT.

Question 170: Which of the following is not a predisposing factor for carcinoma of the cervix?

A. Single child birth (Correct Answer)
B. Early coitus
C. Early childbearing
D. Early marriage

Explanation: **Explanation:** Carcinoma of the cervix is primarily caused by persistent infection with High-Risk Human Papillomavirus (HPV), specifically types 16 and 18. The risk factors for cervical cancer are almost entirely related to the timing and frequency of exposure to this sexually transmitted virus. **Why "Single child birth" is the correct answer:** While pregnancy itself involves hormonal changes, a single childbirth is not a recognized risk factor. In fact, **multiparity** (having 3 or more full-term pregnancies) is the established risk factor. This is due to increased hormonal levels during repeated pregnancies, cervical trauma during multiple deliveries, and the associated immunosuppression, all of which facilitate HPV persistence and progression to malignancy. **Analysis of Incorrect Options:** * **Early coitus:** This is a major risk factor because the adolescent cervix has a large area of **ectopy** (columnar epithelium). The transformation zone is highly active and immature, making it more susceptible to HPV integration and oncogenic transformation. * **Early marriage & Early childbearing:** These are surrogate markers for early onset of sexual activity. Early marriage often implies early and frequent coitus, increasing the duration of exposure to HPV during the vulnerable years of cervical development. **NEET-PG High-Yield Pearls:** * **Most common cause:** HPV 16 (Squamous cell ca) and HPV 18 (Adenocarcinoma). * **The "Protective" Factor:** Nuns (virgins) have the lowest risk of cervical cancer. * **Other Risk Factors:** Multiple sexual partners, smoking (doubles the risk), long-term Oral Contraceptive Pill (OCP) use (>5 years), and low socioeconomic status. * **Screening:** The transformation zone is the most common site for cervical cancer; hence, it is the target area for Pap smears.

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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