Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 201: Which stage of ovarian tumor involves the bladder?

A. Stage IIB (Correct Answer)
B. Stage IIIA
C. Stage IIIB
D. Stage IVA

Explanation: ### Explanation The staging of ovarian cancer follows the **FIGO (International Federation of Gynecology and Obstetrics) system**, which is primarily surgical. **1. Why Stage IIB is correct:** Stage II ovarian cancer is defined by growth involving one or both ovaries with **pelvic extension** (below the pelvic brim). * **Stage IIA:** Extension/metastases to the uterus or fallopian tubes. * **Stage IIB:** Extension to **other pelvic intraperitoneal tissues**, which specifically includes the **bladder** (serosa/surface) and the rectum. **2. Why the other options are incorrect:** * **Stage IIIA & IIIB:** These represent Stage III, which involves spread to the **peritoneum outside the pelvis** (extrapelvic) and/or metastasis to the retroperitoneal lymph nodes. Stage IIIA involves microscopic extrapelvic peritoneal involvement, while IIIB involves macroscopic involvement ≤ 2 cm. * **Stage IVA:** This represents distant metastasis. Specifically, Stage IVA is defined by **pleural effusion** with positive cytology. Stage IVB involves parenchymal metastases (liver/spleen) or extra-abdominal organ involvement. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Presentation:** Most ovarian cancers (approx. 75%) are diagnosed at **Stage III** because they remain asymptomatic until peritoneal seeding occurs. * **CA-125:** While used for monitoring, it is not specific for diagnosis as it can be elevated in endometriosis, PID, and pregnancy. * **Lymphatic Spread:** The primary lymphatic drainage of the ovaries is via the infundibulopelvic ligament to the **para-aortic lymph nodes**. * **Important Distinction:** If the tumor involves the bladder **mucosa** (transmural), it is still generally staged based on the extent of peritoneal spread, but Stage II specifically covers the pelvic organ surfaces.

Question 202: In carcinoma of the cervix, what is the primary causative etiological factor?

A. Condyloma acuminata
B. Human Papillomavirus (HPV) types 16 and 18 (Correct Answer)
C. Human Papillomavirus (HPV) types 6 and 11
D. Herpes Simplex Virus (HSV) 1 and 2

Explanation: **Explanation:** The primary etiological factor in the development of cervical carcinoma is persistent infection with **High-Risk Human Papillomavirus (HR-HPV)**. Among the various high-risk strains, **HPV types 16 and 18** are the most oncogenic, responsible for approximately 70% of all cervical cancer cases worldwide. HPV 16 is most commonly associated with squamous cell carcinoma, while HPV 18 has a higher predilection for adenocarcinoma. The oncogenesis is driven by the viral oncoproteins **E6 and E7**, which inhibit the host tumor suppressor proteins **p53 and pRb**, respectively, leading to uncontrolled cell proliferation. **Analysis of Incorrect Options:** * **Option A & C:** **HPV types 6 and 11** are considered "low-risk" types. They are the primary cause of **Condyloma acuminata** (anogenital warts) and Recurrent Respiratory Papillomatosis. They rarely integrate into the host genome and do not typically lead to malignancy. * **Option D:** **Herpes Simplex Virus (HSV-2)** was historically suspected as a co-factor, but it is not a primary causative agent. It may act as a promoter by causing chronic inflammation, but it cannot induce cervical cancer independently. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** HPV 16 is the single most common type found in cervical cancer. * **Screening:** The transformation zone is the most common site for cervical neoplasia. * **Vaccination:** The Quadrivalent vaccine (Gardasil) covers types 6, 11, 16, and 18; the Nonavalent vaccine covers five additional high-risk types (31, 33, 45, 52, 58). * **Pathogenesis:** Integration of the viral genome into the host DNA is a hallmark of progression from CIN (Cervical Intraepithelial Neoplasia) to invasive cancer.

Question 203: What is the first gene to be knocked out in the carcinogenesis of the endometrium?

A. PI3KCA
B. PTEN (Correct Answer)
C. KRAS
D. p53

Explanation: **Explanation:** The development of **Type I Endometrial Carcinoma** (Endometrioid adenocarcinoma) follows a well-defined multi-step genetic pathway, often associated with unopposed estrogen stimulation. **Why PTEN is correct:** The **PTEN (Phosphatase and Tensin homolog)** gene is a tumor suppressor gene located on chromosome 10q23. It is the **earliest and most common** genetic alteration in endometrial carcinogenesis. PTEN mutations are found in approximately 40–80% of endometrioid carcinomas and, crucially, in about 20% of cases of **endometrial hyperplasia**, indicating it is the "initiating event" or the first gene to be knocked out. **Analysis of Incorrect Options:** * **PI3KCA:** This is an oncogene involved in the same signaling pathway as PTEN. While mutations are common in endometrial cancer (approx. 30%), they typically occur later in the progression compared to PTEN. * **KRAS:** Mutations in KRAS occur in about 10–30% of Type I cancers. It is considered a secondary event that promotes further cellular proliferation. * **p53:** Mutations in the TP53 gene are the hallmark of **Type II Endometrial Carcinoma** (Serous carcinoma). In Type I, p53 mutations are rare and usually signify a late-stage, high-grade transformation. **High-Yield Clinical Pearls for NEET-PG:** * **Cowden Syndrome:** A germline mutation in PTEN that leads to an increased risk of endometrial, breast, and thyroid cancers. * **Type I vs. Type II:** Type I is estrogen-dependent (PTEN, KRAS, MSI); Type II is estrogen-independent (p53, HER2/neu). * **Precursor Lesion:** PTEN loss is frequently seen in **EIN (Endometrial Intraepithelial Neoplasia)**, the immediate precursor to endometrioid adenocarcinoma.

Question 204: Tamoxifen is known to predispose patients to which of the following conditions?

A. Endometrial cancer (Correct Answer)
B. Ovarian cancer
C. Cervical cancer
D. Vaginal cancer

Explanation: **Explanation:** Tamoxifen is a **Selective Estrogen Receptor Modulator (SERM)**. Its mechanism of action is tissue-specific: it acts as an **antagonist** in the breast (used for treating ER-positive breast cancer) but acts as a **partial agonist** in the uterus. 1. **Why Endometrial Cancer is Correct:** In the postmenopausal uterus, Tamoxifen’s estrogenic effect leads to endometrial proliferation. Chronic stimulation can result in endometrial hyperplasia, polyps, and a 2- to 3-fold increased risk of **Endometrial Adenocarcinoma** (specifically Type I). 2. **Why Other Options are Incorrect:** * **Ovarian Cancer:** Tamoxifen does not have a significant stimulatory effect on the ovarian epithelium; in fact, some studies suggest it may have a protective or neutral effect. * **Cervical and Vaginal Cancer:** These are primarily associated with High-risk HPV infection (Cervical) or DES exposure in utero (Clear cell adenocarcinoma of the vagina), rather than SERM therapy. **High-Yield Clinical Pearls for NEET-PG:** * **Raloxifene:** Unlike Tamoxifen, Raloxifene is an estrogen antagonist in both the breast and the uterus, meaning it **does not** increase the risk of endometrial cancer. * **Monitoring:** Routine endometrial biopsy or ultrasound is not recommended for asymptomatic women on Tamoxifen. However, any **postmenopausal bleeding** in these patients must be investigated immediately with Transvaginal Ultrasound (TVS) and biopsy. * **Other Side Effects:** Tamoxifen increases the risk of **Thromboembolism** (DVT/PE) and causes vasomotor symptoms (hot flashes). * **Benefit vs. Risk:** Despite the risk of endometrial cancer, the benefit of Tamoxifen in preventing breast cancer recurrence far outweighs the risk in most patients.

Question 205: Monitoring of beta-hCG is useful in the management of which of the following conditions?

A. Hydatidiform mole
B. Choriocarcinoma
C. Ectopic pregnancy
D. All of the above (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. All of the above**. Human chorionic gonadotropin (beta-hCG) is a glycoprotein hormone produced by syncytiotrophoblastic cells. It serves as a vital biochemical marker in both physiological and pathological pregnancies. 1. **Hydatidiform Mole:** Beta-hCG levels are typically disproportionately high for the period of gestation. Post-evacuation, serial monitoring is mandatory to ensure levels return to baseline, which screens for the development of Gestational Trophoblastic Neoplasia (GTN). 2. **Choriocarcinoma:** This is a highly malignant germ cell or trophoblastic tumor. Beta-hCG acts as a highly sensitive tumor marker for diagnosis, staging, and monitoring the response to chemotherapy. A rise or plateau in levels indicates persistent disease or recurrence. 3. **Ectopic Pregnancy:** Beta-hCG is used alongside transvaginal sonography (TVS) for diagnosis. The "Discriminatory Zone" (1500–2000 mIU/mL) is the level above which an intrauterine gestational sac should be visible. Furthermore, serial monitoring (doubling time) helps differentiate a viable intrauterine pregnancy from an ectopic or failing pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Doubling Time:** In a healthy pregnancy, beta-hCG levels roughly double every 48 hours. * **GTN Follow-up:** Monitoring is done weekly until three consecutive negative titers are achieved, then monthly for 6 months. * **Half-life:** The biological half-life of hCG is approximately 24–36 hours. * **Other uses:** It is also used as a marker in certain **Germ Cell Tumors** (e.g., Dysgerminoma or Non-gestational Choriocarcinoma).

Question 206: Which of the following is NOT a cause of postmenopausal bleeding?

A. Carcinoma in situ of the cervix (Correct Answer)
B. Endometrial carcinoma
C. Ovarian carcinoma
D. Fallopian tube carcinoma

Explanation: **Explanation:** Postmenopausal bleeding (PMB) is defined as vaginal bleeding occurring at least 12 months after the cessation of menstruation. It is a "red flag" symptom that must always be investigated to rule out malignancy. **Why Option A is the Correct Answer:** **Carcinoma in situ (CIS)** of the cervix refers to pre-invasive neoplastic changes where the abnormal cells are confined to the epithelium and have not breached the basement membrane. Because there is no invasion into the underlying stroma or blood vessels, CIS is typically **asymptomatic** and does not cause clinical bleeding. Bleeding in cervical cancer only occurs once the lesion becomes **invasive** (Stage I and beyond). **Why the other options are incorrect:** * **Endometrial Carcinoma (B):** This is the most common cause of PMB among gynecological malignancies. Approximately 90% of patients with endometrial cancer present with PMB. * **Ovarian Carcinoma (C):** While less common, certain ovarian tumors (especially estrogen-secreting Germ cell or Sex cord-stromal tumors like Granulosa cell tumors) can cause endometrial hyperplasia, leading to PMB. * **Fallopian Tube Carcinoma (D):** Classically presents with the **Latzko’s Triad**: intermittent profuse serosanguinous vaginal discharge (*hydrops tubae profluens*), colicky pelvic pain, and a pelvic mass. **High-Yield NEET-PG Pearls:** * **Most common cause of PMB:** Senile/Atrophic vaginitis (followed by endometrial polyps). * **Most common malignancy causing PMB:** Endometrial carcinoma. * **Investigation of choice for PMB:** Transvaginal Ultrasound (TVS). An **endometrial thickness (ET) > 4 mm** in a postmenopausal woman necessitates an endometrial biopsy to rule out malignancy. * **Gold Standard for diagnosis:** Fractional Curettage or Hysteroscopic-guided biopsy.

Question 207: Sentinel lymph node biopsy is useful for which of the following?

A. Carcinoma of the fallopian tube
B. Carcinoma of the endometrium
C. Carcinoma of the vagina
D. Carcinoma of the vulva (Correct Answer)

Explanation: **Explanation:** The **Sentinel Lymph Node (SLN) biopsy** is a diagnostic procedure used to identify the first node(s) receiving lymphatic drainage from a primary tumor. If the SLN is negative for metastasis, the remaining nodes in that basin are likely negative, allowing the patient to avoid the morbidity of a full lymphadenectomy. **Why Carcinoma of the Vulva is correct:** In **early-stage vulvar cancer** (Stage IB or II, lesions <4 cm, and clinically N0 nodes), SLN biopsy using technetium-99m and/or isosulfan blue dye is the **standard of care**. It significantly reduces the risk of chronic lymphedema and wound complications associated with traditional inguinofemoral lymphadenectomy while maintaining oncologic safety. **Why other options are incorrect:** * **Carcinoma of the Fallopian Tube:** Management follows ovarian cancer protocols, which typically involve comprehensive surgical staging or debulking. SLN is not a standard approach here. * **Carcinoma of the Endometrium:** While SLN mapping is increasingly used in low-risk endometrial cancer (using indocyanine green), it is not yet the "classic" or most established indication in the same way it is for vulvar cancer in standard PG textbooks. * **Carcinoma of the Vagina:** Due to the complex and unpredictable lymphatic drainage of the vagina (upper vs. lower portions), SLN biopsy is not routinely recommended or standardized. **NEET-PG High-Yield Pearls:** * **Most common site for SLN in Vulvar Cancer:** Medial to the superficial epigastric vein in the groin. * **Ideal Candidate:** Unifocal tumor, <4 cm diameter, no clinically palpable nodes (cN0). * **Tracer used:** Technetium-99 (radioactive) and Methylene blue/Isosulfan blue. * **Other Cancers where SLN is standard:** Breast cancer and Malignant Melanoma.

Question 208: CA-125 is specifically associated with which type of cancer?

A. Colon cancer
B. Breast cancer
C. Ovarian cancer (Correct Answer)
D. Bronchogenic cancer

Explanation: **Explanation:** **CA-125 (Cancer Antigen 125)** is a high-molecular-weight glycoprotein produced by derivatives of the **coelomic epithelium** (such as the peritoneum, pleura, pericardium, and the lining of the fallopian tubes, endometrium, and endocervix). It is the most widely used tumor marker for **epithelial ovarian cancer**, particularly the serous subtype. While it is not used for primary screening due to low specificity, it is gold-standard for monitoring treatment response and detecting recurrence. **Analysis of Options:** * **Ovarian Cancer (Correct):** Elevated levels (>35 U/mL) are found in 80% of women with advanced epithelial ovarian cancer. It is highly sensitive for monitoring disease progression. * **Colon Cancer:** The primary tumor marker is **CEA** (Carcinoembryonic Antigen). While CA-125 can rise in any peritoneal irritation (like metastasis), it is not specific to colon cancer. * **Breast Cancer:** The most specific markers are **CA 15-3** and **CA 27-29**. * **Bronchogenic Cancer:** Markers like **SCC** (Squamous Cell Carcinoma antigen) or **CYFRA 21-1** are more relevant, though CA-125 can be elevated in lung cancer due to pleural involvement. **NEET-PG High-Yield Pearls:** 1. **Physiological elevations:** CA-125 can be elevated in menstruation, pregnancy, and endometriosis. 2. **Benign conditions:** Pelvic Inflammatory Disease (PID) and fibroids can also cause elevations. 3. **Post-menopausal significance:** A high CA-125 in a post-menopausal woman with an adnexal mass is highly suggestive of malignancy (RMI - Risk of Malignancy Index). 4. **Mucinous Ovarian Cancer:** CA-125 is often less sensitive here; **CEA** and **CA 19-9** are more useful.

Question 209: In which of the following genital tract malignancies is the risk of metastasis to the ovary the least?

A. Carcinoma cervix (Correct Answer)
B. Carcinoma endometrium
C. Carcinoma fallopian tube
D. Uterine sarcoma

Explanation: **Explanation:** The risk of ovarian metastasis from genital tract malignancies depends on the anatomical proximity, shared lymphatic drainage, and the biological behavior of the primary tumor. **1. Why Carcinoma Cervix is the Correct Answer:** Squamous cell carcinoma (SCC) of the cervix has an exceptionally low rate of ovarian metastasis, estimated at **<1%**. Because of this low risk, **ovarian transposition** (moving the ovaries out of the pelvis) is a standard fertility-sparing procedure performed before pelvic radiation in young patients with cervical cancer. While adenocarcinoma of the cervix has a slightly higher risk (approx. 5–10%), it remains significantly lower than other uterine or tubal malignancies. **2. Why the Other Options are Incorrect:** * **Carcinoma Endometrium:** This is the most common malignancy to involve the ovaries, either via direct extension, lymphatic spread, or as a "synchronous" primary tumor. The risk is approximately **5–15%**. * **Carcinoma Fallopian Tube:** Due to direct anatomical continuity and the "fimbria-ovarian" relationship, the ovary is involved in the majority of cases. In fact, many high-grade serous "ovarian" cancers are now believed to originate in the fallopian tube (STIC lesions). * **Uterine Sarcoma:** These are aggressive tumors with a high propensity for hematogenous and local spread. The risk of ovarian involvement is roughly **5–10%**, which is significantly higher than in SCC of the cervix. **Clinical Pearls for NEET-PG:** * **Ovarian Transposition (Oopexy):** Performed in cervical cancer to preserve endocrine function before radiotherapy. * **Krukenberg Tumor:** Most commonly arises from the **Stomach** (Signet ring cells), not the genital tract. * **Most common site of metastasis to the ovary:** The **Colon** is the most common site of origin for metastatic ovarian tumors of intestinal type.

Question 210: Which of the following statements are true about Brenner tumor?

A. Usually bilateral
B. Resembles fibroma (Correct Answer)
C. Accounts for 20% of all ovarian tumors
D. Common in postmenopausal age group

Explanation: **Explanation:** The **Brenner tumor** is a rare surface epithelial-stromal tumor of the ovary, characterized by nests of transitional epithelium (urothelium) embedded within a dense fibrous stroma. **Why Option B is correct:** Grossly and histologically, Brenner tumors contain an abundant amount of dense, spindle-celled stroma. This makes them firm, gritty, and solid, closely **resembling an ovarian fibroma** or theca cell tumor on visual inspection. **Analysis of Incorrect Options:** * **Option A:** Brenner tumors are **usually unilateral** (90-95% of cases). Bilaterality is rare, occurring in only about 5-10% of patients. * **Option C:** They are uncommon, accounting for only **1–2% of all ovarian tumors**, not 20%. * **Option D:** While they can occur at any age, the majority are found incidentally in women between **40 and 60 years of age** (perimenopausal). While some occur postmenopause, "resembling a fibroma" is a more definitive diagnostic characteristic frequently tested in exams. **High-Yield Clinical Pearls for NEET-PG:** * **Histology:** Look for the pathognomonic **"Coffee-bean nuclei"** (longitudinal nuclear grooves) in the transitional epithelial cells. * **Walthard Cell Rests:** These are benign clusters of transitional cells found in the Fallopian tubes/ovary, believed to be the precursors to Brenner tumors. * **Nature:** Most are benign; however, borderline and malignant variants exist. * **Association:** They are frequently associated with other epithelial tumors, most commonly **mucinous cystadenomas** in the same or contralateral ovary.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

Vulvar and Vaginal Cancer

Practice Questions

Gestational Trophoblastic Disease

Practice Questions

Screening for Gynecologic Cancers

Practice Questions

Principles of Gynecologic Oncology Surgery

Practice Questions

Radiation Therapy in Gynecologic Malignancies

Practice Questions

Chemotherapy in Gynecologic Oncology

Practice Questions

Palliative Care in Gynecologic Oncology

Practice Questions

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