Gynecologic Oncology — MCQs

A study of patients with postmenopausal uterine bleeding reveals that some of them have malignant neoplasms that arise from prior atypical hyperplastic lesions. The peak incidence is between 55 and 65 years of age in women who have obesity, hypertension, and/or diabetes mellitus. Molecular analysis reveals mutations of the PTEN tumor suppressor gene in most of them. Their malignancies tend to remain localized for years before spreading to local lymphatics. Which of the following neoplasms is most likely to have these characteristics?

Q188Easy

Carcinosarcoma occurs in which of the following organs?

Q189Medium

A 25-year-old married nullipara undergoes laparoscopic cystectomy for an ovarian cyst which, on histopathology, reveals ovarian serous cystadenocarcinoma. What should be the next management step?

Q190Medium

A patient presents with stage IB carcinoma of the cervix. The tumor extends to the lower third of the vagina, the body of the uterus, and the upper part of the cervix. What is the next step in management?

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 181: CA 125 is primarily used for which of the following purposes?

A. Follow-up monitoring of ovarian cancer (Correct Answer)
B. Diagnosis of pancreatic cancer
C. Diagnosis of stomach cancer
D. Diagnosis of ovarian cancer

Explanation: **Explanation:** **CA 125 (Cancer Antigen 125)** is a high-molecular-weight glycoprotein produced by derivatives of the coelomic epithelium (pleura, pericardium, peritoneum) and the Müllerian epithelium (fallopian tube, endometrium, endocervix). **1. Why Option A is correct:** The primary clinical utility of CA 125 is the **monitoring of treatment response** and the **detection of recurrence** in patients with epithelial ovarian cancer (EOC). A decrease in levels indicates a positive response to chemotherapy or surgery, while a rising trend often precedes clinical or radiological evidence of recurrence by months. **2. Why other options are incorrect:** * **Option D (Diagnosis of Ovarian Cancer):** CA 125 is **not** a screening or definitive diagnostic tool for the general population because it lacks specificity. It is elevated in only 50% of Stage I cases and can be falsely elevated in numerous benign conditions (Endometriosis, PID, Fibroids, Pregnancy, Menstruation). * **Options B & C (Pancreatic/Stomach Cancer):** While CA 125 can be elevated in various intra-abdominal malignancies due to peritoneal irritation, it is not the marker of choice. **CA 19-9** is the primary marker for pancreatic and hepatobiliary cancers, while **CEA** is more relevant for GI malignancies. **Clinical Pearls for NEET-PG:** * **Cut-off value:** Normal is generally **<35 U/mL**. * **Post-menopausal utility:** A high CA 125 in a post-menopausal woman with an adnexal mass is highly suspicious of malignancy (high positive predictive value). * **Mucinous Tumors:** CA 125 is often normal; **CEA** and **CA 19-9** are more likely to be elevated. * **Germ Cell Tumors:** Remember other markers—**LDH** (Dysgerminoma), **AFP** (Yolk sac tumor), and **hCG** (Choriocarcinoma).

Question 182: A 55-year-old lady presents with postmenopausal bleeding for 3 months and a 1 x 1 cm nodule on the anterior lip of the cervix. What is the most appropriate investigation to be done subsequently?

A. Pap smear
B. Punch biopsy (Correct Answer)
C. Endocervical curettage
D. Colposcopy

Explanation: **Explanation:** The clinical presentation of a **visible growth or nodule** on the cervix, especially in a postmenopausal woman with bleeding, is highly suspicious for cervical malignancy until proven otherwise. **1. Why Punch Biopsy is the Correct Answer:** Whenever a **grossly visible lesion** is present on the cervix, the immediate next step is a **punch biopsy**. The primary goal is to obtain a tissue diagnosis to confirm or rule out invasive carcinoma. In the presence of a visible growth, screening or diagnostic aids like Pap smears or colposcopy are bypassed in favor of a definitive histological diagnosis. **2. Why Other Options are Incorrect:** * **A. Pap smear:** This is a screening tool for asymptomatic women or those with a normal-looking cervix. In the presence of a visible lesion, a Pap smear has a high false-negative rate (up to 20%) and should not delay a definitive biopsy. * **C. Endocervical curettage (ECC):** This is indicated when the transformation zone is not fully visible on colposcopy or to evaluate the endocervical canal. It is not the primary investigation for an ectocervical nodule. * **D. Colposcopy:** This is used to identify "suspicious areas" in patients with abnormal Pap smears but a clinically normal-looking cervix. Since the lesion is already visible to the naked eye, colposcopy is unnecessary for localization; direct biopsy is indicated. **Clinical Pearls for NEET-PG:** * **Rule of Thumb:** Never perform a Pap smear on a visible growth; always perform a biopsy. * **Postmenopausal Bleeding:** While the most common cause is atrophic vaginitis, the most important cause to rule out is malignancy (Endometrial > Cervical). * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), and a biopsy is the first step in that diagnostic pathway.

Question 183: Presence of hydronephrosis in the staging of carcinoma cervix denotes which FIGO stage?

A. Stage II-B
B. Stage III-A
C. Stage III-B (Correct Answer)
D. Stage IV-A

Explanation: **Explanation:** In the FIGO staging of cervical cancer (updated in 2018), the presence of **hydronephrosis** or a non-functioning kidney is a defining criterion for **Stage III-B**. **1. Why Stage III-B is correct:** Stage III-B is defined by the extension of the tumor to the pelvic wall and/or the presence of hydronephrosis or a non-functioning kidney (regardless of whether the other criteria for Stage III are met). Hydronephrosis occurs when the tumor compresses the ureter as it traverses the paracervical tissue toward the bladder. This indicates advanced local spread to the lateral pelvic structures. **2. Why other options are incorrect:** * **Stage II-B:** This stage involves parametrial involvement but **not** extending to the pelvic sidewall. Hydronephrosis implies more extensive lateral spread than Stage II-B. * **Stage III-A:** This stage involves the lower third of the vagina but **without** extension to the pelvic wall or causing hydronephrosis. * **Stage IV-A:** This stage involves the spread of the growth to the mucosa of the bladder or rectum (confirmed by biopsy) or extension beyond the true pelvis. **Clinical Pearls for NEET-PG:** * **FIGO 2018 Update:** Unlike older versions, the current staging allows for the use of imaging (MRI, CT, PET) and pathology to assign the stage. * **Stage III-C:** This is a newer addition based on lymph node status (III-C1 for pelvic nodes, III-C2 for para-aortic nodes). * **Management:** Stage III-B is considered "Locally Advanced Cervical Cancer" (LACC). The standard of care is **Concurrent Chemoradiotherapy (CCRT)**, typically using Cisplatin as the radiosensitizer. Surgery is generally not the primary treatment for Stage II-B and above.

Question 184: Which of the following is a cause of post-menopausal bleeding?

A. Arrhenoblastoma
B. Cystadenoma
C. Granulosa cell tumor (Correct Answer)
D. Hilus cell tumor

Explanation: **Explanation:** Post-menopausal bleeding (PMB) is most commonly caused by atrophic changes, but when associated with ovarian pathology, it is typically due to **estrogen-secreting tumors**. **Why Granulosa Cell Tumor is Correct:** Granulosa cell tumors (GCT) are the most common type of **Sex Cord-Stromal Tumors**. They are functionally active and primarily secrete **estrogen**. In post-menopausal women, this excess estrogen causes endometrial hyperplasia, which often manifests as abnormal uterine bleeding or PMB. GCTs are considered tumors of "low malignant potential" and are characterized histologically by **Call-Exner bodies** and "coffee-bean" nuclei. **Analysis of Incorrect Options:** * **Arrhenoblastoma (Sertoli-Leydig Cell Tumor):** These are androgen-secreting tumors. They cause virilization (hirsutism, clitoromegaly) and amenorrhea rather than post-menopausal bleeding. * **Cystadenoma (Serous/Mucinous):** These are common epithelial tumors. They are generally non-functional (do not produce hormones) and typically present as an asymptomatic pelvic mass or with pressure symptoms, not PMB. * **Hilus Cell Tumor:** A subtype of Leydig cell tumor that is androgenic. While they occur in post-menopausal women, they cause masculinization due to testosterone production. **NEET-PG High-Yield Pearls:** 1. **Tumor Marker:** **Inhibin (Inhibin B)** is the specific tumor marker used for the diagnosis and monitoring of Granulosa cell tumors. 2. **Endometrial Association:** Approximately 5–10% of patients with GCT may have a co-existing **Endometrial Carcinoma** due to prolonged estrogen stimulation. 3. **Most common cause of PMB:** Overall, the most common cause is **Atrophic Vaginitis/Endometritis**, but the most important cause to rule out is Endometrial Carcinoma.

Question 185: Type 2 endometrial carcinoma is associated with what histological finding?

A. Hyperplasia
B. Hypertrophy
C. Metaplasia
D. Atrophy (Correct Answer)

Explanation: **Explanation:** Endometrial carcinoma is broadly classified into two types (Bokhman’s Classification). Understanding the distinction between them is high-yield for NEET-PG. **Why Atrophy is Correct:** **Type 2 Endometrial Carcinoma** (Non-endometrioid) typically occurs in older, postmenopausal women. Unlike Type 1, it is **estrogen-independent** and does not arise from a background of endometrial hyperplasia. Instead, it develops in a background of **atrophic endometrium**. The molecular driver is often a **p53 mutation** rather than the PTEN mutations seen in Type 1. Because the surrounding tissue is not stimulated by estrogen, it remains thin and atrophic. **Analysis of Incorrect Options:** * **A. Hyperplasia:** This is the precursor lesion for **Type 1 Endometrial Carcinoma**. Type 1 is estrogen-dependent, occurs in younger/perimenopausal women, and is associated with obesity and PCOS. * **B. Hypertrophy:** This refers to an increase in cell size. While the myometrium can undergo hypertrophy (e.g., in pregnancy), it is not a characteristic histological background for the development of endometrial malignancy. * **C. Metaplasia:** While various metaplasias (squamous, ciliated, etc.) can occur in the endometrium, they are not the defining background state for Type 2 carcinomas. **NEET-PG High-Yield Pearls:** * **Type 1:** Endometrioid histology, Estrogen-dependent, PTEN mutation, associated with **Hyperplasia**. * **Type 2:** Serous or Clear cell histology, Estrogen-independent, **p53 mutation**, associated with **Atrophy**. * **Prognosis:** Type 2 is much more aggressive, has a higher risk of lymph node metastasis, and carries a poorer prognosis compared to Type 1. * **Precursor for Type 2:** Serous Endometrial Intraepithelial Carcinoma (SEIC).

Question 186: In Hydatidiform mole, when does abortion most often occur?

A. 2-4 weeks
B. 4-6 weeks
C. 6-12 weeks
D. 4-6 months (Correct Answer)

Explanation: **Explanation:** In a **Hydatidiform mole (Molar Pregnancy)**, the pregnancy typically proceeds initially like a normal gestation. However, due to the progressive cystic degeneration of chorionic villi and the rapid accumulation of fluid, the uterine size becomes disproportionately large for the gestational age. **1. Why 4-6 months is correct:** Spontaneous expulsion (abortion) of a molar pregnancy most commonly occurs between the **16th and 24th weeks** of gestation (the 4th to 6th month). By this stage, the molar mass has expanded significantly, leading to uterine overdistension and internal hemorrhage (the "theca lutein cyst" effect and decidual sloughing), which triggers uterine contractions and subsequent expulsion of the characteristic "grape-like vesicles." **2. Why other options are incorrect:** * **A & B (2-6 weeks):** At this very early stage, the trophoblastic proliferation and villous edema are not yet advanced enough to cause uterine distension or significant clinical symptoms. * **C (6-12 weeks):** While vaginal bleeding (the most common symptom) often begins during the late first trimester (8-12 weeks), the actual spontaneous expulsion of the entire molar contents usually occurs later, once the uterine volume reaches a critical threshold. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom:** Vaginal bleeding (often described as "prune juice" discharge). * **Classic Sign:** "Snowstorm appearance" on pelvic ultrasound. * **Pathognomonic finding:** Expulsion of grape-like vesicles per vaginum. * **Uterine Size:** In 50% of cases, the uterus is **larger** than the expected period of amenorrhea. * **Associated Complications:** Early-onset pre-eclampsia (before 20 weeks), hyperemesis gravidarum, and bilateral theca lutein cysts.

Question 187: A study of patients with postmenopausal uterine bleeding reveals that some of them have malignant neoplasms that arise from prior atypical hyperplastic lesions. The peak incidence is between 55 and 65 years of age in women who have obesity, hypertension, and/or diabetes mellitus. Molecular analysis reveals mutations of the PTEN tumor suppressor gene in most of them. Their malignancies tend to remain localized for years before spreading to local lymphatics. Which of the following neoplasms is most likely to have these characteristics?

A. Clear cell carcinoma
B. Endometrioid carcinoma (Correct Answer)
C. Leiomyosarcoma
D. Mullerian mixed tumor

Explanation: ### Explanation The clinical scenario describes **Type I Endometrial Carcinoma**, specifically the **Endometrioid** histological subtype. **Why Endometrioid Carcinoma is Correct:** Type I endometrial cancers typically arise in the setting of **unopposed estrogen** stimulation, which leads to **atypical endometrial hyperplasia** (the precursor lesion). * **Risk Factors:** Obesity (peripheral conversion of androgens to estrone), diabetes, and hypertension (the "metabolic syndrome" triad). * **Molecular Genetics:** The most common genetic alteration is the mutation of the **PTEN tumor suppressor gene** (seen in 30–80% of cases), followed by mutations in PIK3CA, KRAS, and microsatellite instability (MSI). * **Prognosis:** These tumors are usually low-grade, hormone-sensitive, and tend to remain localized to the uterus for a long period, resulting in a favorable prognosis. **Why the Other Options are Incorrect:** * **Clear Cell Carcinoma:** A Type II endometrial cancer. These are high-grade, aggressive, and arise from atrophic endometrium in older, thin women. They are *not* associated with PTEN mutations or estrogen. * **Leiomyosarcoma:** A mesenchymal tumor arising from the myometrium, not the endometrium. It does not arise from atypical hyperplasia and presents as a bulky uterine mass with high metastatic potential. * **Mullerian Mixed Tumor (MMT/Carcinosarcoma):** A high-grade biphasic tumor containing both malignant epithelial and mesenchymal components. Like Type II cancers, it is aggressive and not typically preceded by atypical hyperplasia. **NEET-PG High-Yield Pearls:** * **Most common gynecological malignancy** in developed countries: Endometrial Carcinoma. * **Type I (Endometrioid):** Estrogen-dependent, PTEN mutation, favorable prognosis. * **Type II (Serous/Clear Cell):** Estrogen-independent, **p53 mutation**, aggressive, arises from **Serous Endometrial Intraepithelial Carcinoma (SEIC)**. * **Protective factors:** Combined oral contraceptives (COCs), smoking (decreases estrogen levels), and multiparity.

Question 188: Carcinosarcoma occurs in which of the following organs?

A. Uterus (Correct Answer)
B. Liver
C. Breast
D. Lungs

Explanation: **Explanation:** **Carcinosarcoma** (formerly known as Malignant Mixed Müllerian Tumor or MMMT) is a highly aggressive neoplasm characterized by a mixture of malignant epithelial (carcinoma) and mesenchymal (sarcoma) components. **1. Why Uterus is Correct:** The uterus is the most common site for carcinosarcoma. These tumors typically arise from the endometrium in postmenopausal women. Modern molecular studies have classified these as **metaplastic carcinomas** (dedifferentiated carcinomas) rather than true sarcomas, which is why they are staged like endometrial carcinomas. Risk factors include obesity, exogenous estrogen, and a history of pelvic radiation. **2. Why Other Options are Incorrect:** * **Liver, Breast, and Lungs:** While primary sarcomas or carcinomas can occur in these organs, "Carcinosarcoma" as a specific clinical entity is classically associated with the female reproductive tract (Uterus, Ovaries, and Fallopian tubes). While rare biphasic tumors can occur in the breast (metaplastic carcinoma) or lungs, they are not the standard answer for this classic pathology question. **3. NEET-PG High-Yield Pearls:** * **Histology:** It contains **epithelial** elements (usually high-grade serous or endometrioid) and **mesenchymal** elements. * **Classification:** Mesenchymal components can be **Homologous** (tissues normally found in the uterus, e.g., leiomyosarcoma) or **Heterologous** (tissues not normally found in the uterus, e.g., rhabdomyosarcoma or chondrosarcoma). * **Clinical Presentation:** Often presents as postmenopausal bleeding with a large, polypoid mass protruding through the cervical os. * **Staging:** It follows the **FIGO staging for Endometrial Cancer**. * **Prognosis:** Very poor; the epithelial component is usually responsible for lymph node metastasis.

Question 189: A 25-year-old married nullipara undergoes laparoscopic cystectomy for an ovarian cyst which, on histopathology, reveals ovarian serous cystadenocarcinoma. What should be the next management step?

A. Serial Ca-125 measurement and follow-up
B. Hysterectomy and bilateral salpingo-oophorectomy
C. Unilateral salpingo-oophorectomy (Correct Answer)
D. Radiotherapy

Explanation: **Explanation:** The core concept here is **Fertility-Sparing Surgery (FSS)** in young patients with early-stage epithelial ovarian cancer. **Why Option C is Correct:** The patient is a 25-year-old nullipara (desires future fertility) with a diagnosis of ovarian serous cystadenocarcinoma. In young patients with **Stage IA (Grade 1 or 2)** epithelial ovarian cancer, the standard of care is fertility-sparing surgery. This involves a **Unilateral Salpingo-oophorectomy (USO)** with surgical staging (omental biopsy, peritoneal washings, and lymph node sampling) while preserving the uterus and the contralateral ovary. Since the initial procedure was only a cystectomy (which carries a risk of tumor spillage and incomplete resection), a completion USO is necessary to ensure oncological safety. **Why Other Options are Incorrect:** * **Option A:** Serial Ca-125 is used for monitoring recurrence but is never a primary treatment for a confirmed malignancy. * **Option B:** Total Abdominal Hysterectomy (TAH) and Bilateral Salpingo-oophorectomy (BSO) is the standard treatment for postmenopausal women or those who have completed their family. In this 25-year-old nullipara, it would be unnecessarily radical. * **Option D:** Radiotherapy has a very limited role in the primary management of epithelial ovarian cancer; chemotherapy (Taxanes + Platinum) is the preferred adjuvant modality if indicated. **Clinical Pearls for NEET-PG:** * **Staging:** Ovarian cancer is staged surgically (FIGO staging). * **Fertility Sparing:** Only indicated for Stage IA/IC1 and Grade 1/2 tumors. * **Cystectomy vs. USO:** Simple cystectomy is discouraged in suspected malignancy due to the high risk of rupture and upstaging the disease from IA to IC1. * **Most common type:** Serous cystadenocarcinoma is the most common malignant epithelial ovarian tumor.

Question 190: A patient presents with stage IB carcinoma of the cervix. The tumor extends to the lower third of the vagina, the body of the uterus, and the upper part of the cervix. What is the next step in management?

A. Chemotherapy
B. Surgery followed by chemotherapy
C. Surgery (Correct Answer)
D. Surgery followed by radiotherapy

Explanation: **Explanation:** The management of cervical cancer is primarily determined by the **FIGO staging**. In this case, the patient is diagnosed with **Stage IB**. According to FIGO guidelines, Stage IA to IIA (early-stage cervical cancer) is primarily managed with **Radical Hysterectomy (Type III/Wertheim’s Hysterectomy)** and bilateral pelvic lymphadenectomy. **Why Surgery is Correct:** For Stage IB, surgery is the treatment of choice as it allows for ovarian preservation (important in young patients) and provides better assessment of lymph node status. The extension to the **body of the uterus** does not change the stage or the surgical approach. While the question mentions the "lower third of the vagina," this is a common distractor; if the tumor *originated* in the cervix and is classified as Stage IB, the primary management remains surgical. **Why Other Options are Wrong:** * **A & B (Chemotherapy):** Chemotherapy alone is not a primary treatment for early-stage cervical cancer. It is usually used as a radiosensitizer (Concurrent Chemoradiotherapy) for locally advanced stages (IIB to IVA). * **D (Surgery followed by radiotherapy):** While adjuvant radiotherapy may be required if post-operative histopathology shows high-risk features (positive margins, lymph nodes, or parametrial involvement), the **immediate next step** in management for Stage IB is the surgery itself. **High-Yield Clinical Pearls for NEET-PG:** * **Stage IA1:** Simple hysterectomy (or conization if fertility is desired). * **Stage IB1 to IIA1:** Radical Hysterectomy is the gold standard. * **Stage IIB onwards:** Concurrent Chemoradiotherapy (CCRT) is the treatment of choice. * **Extension to the Uterine Body:** This does **not** alter the FIGO stage of cervical cancer. * **Most common cause of death:** Uremia due to ureteric obstruction.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

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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