Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 191: Which of the following tumors does NOT metastasize to the ovary?

A. Gastric carcinoma
B. Colonic carcinoma
C. Cervical carcinoma (Correct Answer)
D. Breast carcinoma

Explanation: **Explanation:** The ovary is a common site for metastatic spread from various primary malignancies. Metastatic tumors to the ovary are known as **secondary ovarian tumors**, accounting for approximately 10–25% of all ovarian malignancies. **Why Cervical Carcinoma is the Correct Answer:** Cervical carcinoma (Option C) rarely metastasizes to the ovary. Squamous cell carcinoma of the cervix, the most common histological type, has an extremely low incidence of ovarian metastasis (<1%). While adenocarcinoma of the cervix has a slightly higher risk, it is still clinically rare compared to the other options. Cervical cancer primarily spreads via direct extension to the parametrium and vagina or through the lymphatic system to the pelvic and para-aortic nodes. **Analysis of Incorrect Options:** * **Gastric Carcinoma (A):** This is the classic primary site for a **Krukenberg tumor**. It spreads to the ovaries via retrograde lymphatic spread or transcoelomic seeding. * **Colonic Carcinoma (B):** Large bowel malignancies are a frequent source of ovarian metastases. They often mimic primary mucinous ovarian cystadenocarcinomas. * **Breast Carcinoma (D):** Breast cancer is the most common non-gastrointestinal source of ovarian metastasis. It often presents as bilateral, small, solid ovarian masses. **High-Yield NEET-PG Pearls:** 1. **Krukenberg Tumor:** Characterized by bilateral ovarian involvement, "signet-ring" cells on histology, and a primary site usually in the **stomach** (most common) or colon. 2. **Common Primaries:** The most frequent sources of ovarian metastases are the **Stomach, Colon, and Breast**. 3. **Route of Spread:** Most secondary ovarian tumors spread via the **lymphatic route** rather than direct seeding. 4. **Clinical Clue:** If an ovarian mass is **bilateral and solid**, always suspect a metastatic origin and perform a thorough gastrointestinal and breast evaluation.

Question 192: Which condition is associated with the largest ovarian tumors?

A. Pseudomucinous cystadenoma (Correct Answer)
B. Serous cystadenoma
C. Papillary cystadenoma
D. Dysgerminoma

Explanation: **Explanation:** **Pseudomucinous cystadenoma** (Mucinous cystadenoma) is the correct answer because these tumors are notorious for reaching massive proportions, often filling the entire abdominal cavity. They are the **largest tumors occurring in the human body**, sometimes weighing over 20–30 kg. **Why it is correct:** Mucinous cystadenomas are lined by tall columnar epithelium (resembling endocervical or intestinal mucosa) that secretes thick, viscous mucin. Unlike serous tumors, they are typically **multiloculated** with smooth surfaces and rarely present bilaterally (only 5–10%). Their ability to remain asymptomatic while slowly expanding allows them to reach a giant size before the patient seeks medical attention due to abdominal girth increase. **Why other options are incorrect:** * **Serous cystadenoma:** These are the most common benign ovarian tumors. While they can be large, they are generally smaller than mucinous types and are more frequently bilateral (25%). * **Papillary cystadenoma:** This is a morphological variant (often of serous tumors) characterized by internal projections. They are associated with a higher risk of malignancy but do not typically reach the "giant" dimensions of mucinous tumors. * **Dysgerminoma:** This is a germ cell tumor. While it can grow rapidly, it usually presents in younger women as a solid mass and does not reach the massive cystic proportions seen in mucinous cystadenomas. **High-Yield Clinical Pearls for NEET-PG:** * **Pseudomyxoma Peritonei:** A rare complication where a mucinous tumor (often from the appendix) ruptures, filling the peritoneal cavity with "jelly belly." * **Microscopic Hallmark:** Tall columnar cells with apical mucin and basal nuclei. * **Size Fact:** If a question mentions a "huge abdominal mass" or "giant cyst" in a middle-aged woman, think Mucinous Cystadenoma.

Question 193: A 52-year-old postmenopausal female presents with a 6 cm unilocular ovarian cyst and normal CA-125 levels. What is the most appropriate management?

A. Ultrasound-guided ovarian cyst aspiration
B. Watchful waiting (Correct Answer)
C. Surgical intervention
D. Oral contraceptive pills

Explanation: **Explanation:** The management of postmenopausal ovarian cysts depends on the risk of malignancy. According to current guidelines (RCOG and ACOG), a **simple, unilocular, asymptomatic cyst** measuring **less than 5 cm to 10 cm** in a postmenopausal woman with a **normal CA-125** level carries a very low risk of malignancy (<1%). **1. Why Watchful Waiting is Correct:** In this patient, the cyst is unilocular (low-risk morphology), relatively small (6 cm), and the CA-125 is normal. The most appropriate initial step is "Watchful Waiting" with serial transvaginal ultrasound (TVUS) every 4–6 months. Many such cysts are functional or benign (e.g., serous cystadenomas) and may resolve or remain stable without intervention. **2. Why Other Options are Incorrect:** * **A. Ultrasound-guided aspiration:** This is contraindicated in postmenopausal cysts. If the cyst is malignant, aspiration can cause intraperitoneal seeding (upstaging the cancer). Furthermore, recurrence rates are high. * **C. Surgical intervention:** Surgery (Laparoscopic oophorectomy) is reserved for cysts that are symptomatic, >10 cm, have solid components/septations (complex), or are associated with rising CA-125 levels. * **D. Oral contraceptive pills:** These are used to suppress functional cysts in premenopausal women. They have no role in treating existing cysts in postmenopausal women. **Clinical Pearls for NEET-PG:** * **RMI (Risk of Malignancy Index):** Uses Menopausal status (M), Ultrasound features (U), and CA-125 levels. A score >200 usually warrants surgical referral. * **CA-125 Cut-off:** In postmenopausal women, a CA-125 value **>35 IU/ml** is considered significant. * **Most common benign ovarian tumor in postmenopausal women:** Serous cystadenoma. * **Most common malignant ovarian tumor:** Serous cystadenocarcinoma.

Question 194: A left-sided ovarian tumor is noted with HCG 4 IU/L, normal AFP, and elevated LDH. What is the most likely diagnosis?

A. Choriocarcinoma
B. Dysgerminoma (Correct Answer)
C. Embryonal cell tumor
D. Malignant Teratoma

Explanation: **Explanation:** The correct diagnosis is **Dysgerminoma**. This is the most common malignant germ cell tumor (GCT) of the ovary, typically occurring in young women. **Why Dysgerminoma is correct:** Dysgerminomas are characterized by a specific biochemical profile: * **LDH (Lactate Dehydrogenase):** This is the most sensitive and characteristic marker for Dysgerminoma. * **HCG:** While primarily associated with choriocarcinoma, about 5% of Dysgerminomas contain syncytiotrophoblastic giant cells which produce low levels of HCG (usually <100 IU/L). The value of 4 IU/L in the question is consistent with this. * **AFP:** Dysgerminomas **never** produce AFP. A normal AFP level helps rule out yolk sac components. **Why other options are incorrect:** * **Choriocarcinoma:** Characterized by **extremely high** levels of HCG (often >100,000 IU/L). A level of 4 IU/L is too low for a primary choriocarcinoma. * **Embryonal cell tumor:** These are rare and typically secrete **both** AFP and HCG. * **Malignant Teratoma (Immature Teratoma):** These usually present with elevated **AFP** (in 50% of cases) or are non-secretory. They are not typically associated with isolated high LDH. **NEET-PG High-Yield Pearls:** 1. **Dysgerminoma** is the ovarian counterpart of testicular **Seminoma**. 2. It is the most common germ cell tumor associated with **pregnancy** and **gonadal dysgenesis** (Swyer Syndrome). 3. **Microscopy:** Look for "Fried egg appearance" (clear cytoplasm, central nuclei) and fibrous septa infiltrated with **lymphocytes**. 4. It is highly **radiosensitive**, though fertility-sparing surgery followed by chemotherapy (BEP regimen) is the standard of care.

Question 195: Colposcopic features suggestive of malignancy are all except:

A. Condyloma (Correct Answer)
B. Vascular atypia
C. Punctation
D. White epithelium

Explanation: In colposcopy, the primary goal is to identify **Atypical Transformation Zones (ATZ)** that suggest Cervical Intraepithelial Neoplasia (CIN) or invasive cancer. ### **Explanation of the Correct Answer** **A. Condyloma:** These are genital warts caused by low-risk HPV types (6 and 11). On colposcopy, they appear as exophytic, cauliflower-like, or micropapillary lesions. While they are an abnormal finding, they are considered **benign** and are not markers of malignancy or high-grade dysplasia. ### **Analysis of Incorrect Options (Features of Malignancy)** The following are hallmarks of high-grade lesions (CIN II/III) or malignancy: * **D. White Epithelium (Acetowhite):** When acetic acid (3-5%) is applied, areas with high nuclear density and protein content coagulate, appearing white. Thick, opaque, "leathery" acetowhite areas with rapid uptake are highly suggestive of high-grade lesions. * **C. Punctation:** This represents dilated capillaries reaching the surface in a "dotted" pattern. Coarse punctation (large, widely spaced dots) is a sign of high-grade dysplasia. * **B. Vascular Atypia:** This is the most concerning feature. It refers to "atypical vessels" that are irregular in size, shape, and course (e.g., comma-shaped, corkscrew, or spaghetti-like vessels). These indicate neoangiogenesis associated with invasive cancer. ### **High-Yield Clinical Pearls for NEET-PG** * **Reid’s Colposcopic Index (RCI):** A scoring system (0-8) used to grade the severity of lesions based on color, margin, vessels, and iodine staining. * **Schiller’s Test:** Uses Lugol’s iodine. Normal cells (rich in glycogen) stain mahogany brown (**Iodine positive**). Malignant/dysplastic cells (glycogen depleted) do not take up the stain and appear yellow/pale (**Iodine negative**). * **Mosaicism:** Another feature of ATZ where capillaries form a "tile-like" or "honeycomb" pattern. Coarse mosaicism suggests high-grade disease.

Question 196: True about Meigs syndrome?

A. Lymphatic dysplasia
B. 2-30 years of age
C. Associated with ascites and pleural effusion (Correct Answer)
D. No treatment required

Explanation: **Explanation:** **Meigs Syndrome** is a classic clinical triad characterized by the presence of a **benign ovarian tumor** (most commonly a **Fibroma**), **ascites**, and **pleural effusion**. 1. **Why Option C is correct:** The hallmark of Meigs syndrome is the accumulation of fluid in the peritoneal and pleural cavities. The pleural effusion is typically **exudative** and more common on the **right side** (due to transdiaphragmatic lymphatic channels). Crucially, both the ascites and effusion resolve spontaneously following the surgical removal of the tumor. 2. **Why other options are incorrect:** * **Option A:** Lymphatic dysplasia is associated with *Hennekam syndrome* or primary lymphedema, not Meigs. In Meigs, the fluid shift is thought to be due to pressure on pelvic lymphatics or secretion from the tumor surface. * **Option B:** Meigs syndrome typically occurs in **postmenopausal women**, with a peak incidence around the **5th decade (50s)**. It is very rare in children or young women. * **Option D:** Treatment is mandatory. The definitive management is **surgical resection** of the ovarian mass (usually cystectomy or oophorectomy), which leads to complete resolution of symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **The Triad:** Benign Ovarian Tumor (Fibroma > Thecoma > Brenner) + Ascites + Pleural Effusion. * **Pseudo-Meigs Syndrome:** When the triad is associated with other pelvic masses (e.g., Leiomyoma, Teratoma, or Mucinous Cystadenoma) instead of a Fibroma. * **Pseudo-Pseudo Meigs (Tjalma Syndrome):** Seen in patients with Systemic Lupus Erythematosus (SLE). * **Tumor Marker:** CA-125 can be elevated in Meigs syndrome, which may falsely mimic ovarian malignancy; however, the benign histology confirms the diagnosis.

Question 197: Which ovarian tumor is most likely to be associated with virilization?

A. Granulosa cell tumor
B. Sertoli-Leydig cell tumor (Correct Answer)
C. Immature teratoma
D. Gonadoblastoma

Explanation: **Explanation:** The correct answer is **Sertoli-Leydig cell tumor (SLCT)**. These are rare sex cord-stromal tumors that account for less than 0.5% of all ovarian neoplasms. **1. Why Sertoli-Leydig cell tumor is correct:** SLCTs are the most common virilizing tumors of the ovary. They contain Leydig cells that actively secrete androgens (primarily testosterone). Clinically, this manifests in two stages: **defeminization** (amenorrhea, breast atrophy, loss of female fat distribution) followed by **virilization** (hirsutism, clitoromegaly, deepening of the voice, and frontal balding). Elevated serum testosterone levels (>200 ng/dL) in a woman with rapid-onset virilization are highly suggestive of this tumor. **2. Why the other options are incorrect:** * **Granulosa cell tumor:** These are also sex cord-stromal tumors but are typically **estrogenic**. They present with abnormal uterine bleeding, endometrial hyperplasia, or precocious puberty. They rarely cause virilization. * **Immature teratoma:** These are germ cell tumors containing tissues from all three germ layers (predominantly neuroectoderm). They do not typically produce hormones and present as a rapidly growing pelvic mass in young girls. * **Gonadoblastoma:** While these can occur in dysgenetic gonads (e.g., Swyer syndrome) and may be associated with virilization due to the presence of a Y chromosome, the tumor itself is usually benign and serves as a precursor to dysgerminoma rather than being the primary cause of androgen excess compared to SLCT. **High-Yield Clinical Pearls for NEET-PG:** * **Reinke crystals:** Pathognomonic histological finding in Leydig cell tumors. * **DICER1 mutation:** Frequently associated with familial Sertoli-Leydig cell tumors. * **Most common virilizing tumor overall:** Polycystic Ovary Syndrome (PCOS), but among **ovarian neoplasms**, SLCT is the classic answer. * **Tumor Marker:** Inhibin can be elevated in both Granulosa cell tumors and SLCTs.

Question 198: Who invented the Papanicolaou smear test?

A. John Papanicolaou
B. George Papanicolaou (Correct Answer)
C. Vladimir Papanicolaou
D. Ben Papanicolaou

Explanation: **Explanation:** The correct answer is **George Papanicolaou** (Option B). Dr. George Nicholas Papanicolaou (1883–1962), a Greek physician and pioneer in cytopathology, developed the Papanicolaou smear (Pap test) in the 1920s. His groundbreaking research demonstrated that malignant cells from the cervix could be identified in vaginal smears, providing a non-invasive method for the early detection of cervical cancer and its precursor lesions. This discovery revolutionized preventive oncology, significantly reducing the mortality rate of cervical cancer worldwide. **Analysis of Incorrect Options:** * **Options A, C, and D:** These are distractors. While they share the surname "Papanicolaou," no individuals by these names are associated with the invention of the Pap smear or significant contributions to gynecologic oncology. **Clinical Pearls for NEET-PG:** * **Screening Guidelines:** According to ACOG/ASCCP, screening typically begins at age 21. For women aged 30–65, "co-testing" (Pap smear + HPV DNA testing) every 5 years is the preferred strategy. * **Transformation Zone:** This is the most critical area to sample during a Pap smear, as it is the site where over 90% of cervical neoplasias arise. * **Staining Components:** The Pap stain is a multichromatic stain consisting of Hematoxylin (nuclear stain), Orange G, and Eosin Azure (cytoplasmic stains). * **Bethesda System:** This is the standard reporting system used for cervical cytology (e.g., LSIL, HSIL, ASC-US).

Question 199: A patient presents with abdominal discomfort, bloating, and pain. An MRI shows bilateral ovarian tumors with involvement of pelvic lymph nodes and the liver capsule. What is the appropriate staging of this ovarian tumor?

A. Stage 1
B. Stage 2A
C. Stage 2B
D. Stage 3 (Correct Answer)

Explanation: ### Explanation The staging of ovarian cancer follows the **FIGO (International Federation of Gynecology and Obstetrics) system**, which is primarily surgical but can be assessed via imaging for clinical management. **Why Stage 3 is Correct:** Stage 3 is defined by the spread of the tumor to the **peritoneum outside the pelvis** and/or involvement of the **retroperitoneal lymph nodes**. * **Liver Capsule Involvement:** According to FIGO staging, involvement of the liver capsule (surface) is classified as **Stage 3C**. This is distinct from liver parenchyma involvement, which would be Stage 4. * **Lymph Nodes:** Involvement of pelvic or para-aortic lymph nodes also places the disease in Stage 3 (specifically Stage 3A1). Since this patient has both pelvic lymph node involvement and liver capsule spread, Stage 3 is the most accurate classification. **Why Other Options are Incorrect:** * **Stage 1:** The tumor is strictly limited to one or both ovaries or fallopian tubes. This patient has spread beyond the adnexa. * **Stage 2A:** Involvement is limited to the uterus and/or fallopian tubes. * **Stage 2B:** Involvement extends to other pelvic intraperitoneal tissues (e.g., bladder, rectum) but remains **within the true pelvis**. The liver capsule is an extrapelvic site, ruling out Stage 2. **High-Yield Clinical Pearls for NEET-PG:** * **Stage 3C vs. Stage 4:** Remember the "Capsule vs. Parenchyma" rule. Spread to the **liver capsule** is Stage 3C; spread to the **liver parenchyma** (internal tissue) or pleural effusion with positive cytology is Stage 4. * **Most Common Presentation:** Most ovarian cancers (approx. 75%) are diagnosed at Stage 3 or 4 because early stages are often asymptomatic. * **CA-125:** While not used for staging, it is the most important marker for monitoring treatment response in epithelial ovarian tumors.

Question 200: What is the most common histopathological variety of carcinoma of the vulva?

A. Squamous cell carcinoma (Correct Answer)
B. Basal cell carcinoma
C. Adenocarcinoma
D. Lymphoma

Explanation: **Explanation:** **Squamous cell carcinoma (SCC)** is the most common histopathological variety of vulvar cancer, accounting for approximately **90% of all cases**. It primarily affects postmenopausal women and arises from the squamous epithelium that covers the majority of the vulvar surface. There are two distinct pathways for its development: one associated with **Human Papillomavirus (HPV)** infection (typically types 16 and 18) seen in younger patients, and another associated with **Lichen Sclerosus** or differentiated Vulvar Intraepithelial Neoplasia (dVIN) seen in older patients. **Analysis of Incorrect Options:** * **B. Basal cell carcinoma:** While it is the second most common skin cancer globally, it is rare in the vulva (approx. 2-4%). It typically presents as a "rodent ulcer" with pearly borders and rarely metastasizes. * **C. Adenocarcinoma:** This is rare and usually arises from the Bartholin’s glands or as a manifestation of Paget’s disease of the vulva. * **D. Lymphoma:** Primary vulvar lymphoma is extremely rare; the vulva is an uncommon site for extranodal lymphoma. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Labia majora (followed by labia minora). * **Most common symptom:** Long-standing pruritus (itching) or a visible mass. * **Staging:** Vulvar cancer is staged **surgically** (FIGO staging). * **Lymphatic Spread:** The primary route of spread is via the lymphatics to the **inguinal and femoral nodes** (Sentinel lymph node biopsy is the standard for early-stage disease). * **Cloquet’s Node:** The highest deep inguinal node; its involvement indicates a poor prognosis and potential pelvic node spread.

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