Gynecologic Oncology Practice Questions

Q: A patient with endometrial cancer involving >50% of the myometrium and extending to the vagina, but with no pelvic extension and no involvement of pre and para-aortic lymph nodes, is staged based on peritoneal lavage being positive. What is the correct stage?

Stage III b. ### Explanation The staging of endometrial cancer follows the **FIGO 2023 (and 2009)** classification. This case describes a tumor that has spread beyond the uterus but remains within the pelvis. **Why Stage IIIb is correct:** Stage III is defined by local and/or regional spread of the tumor. Specifically: * **Stage IIIa:** Involvement of the uterine serosa and/or adnexa (fallopian tubes/ovaries). * **Stage IIIb:** Vaginal and/or parametrial involvement. In this scenario, the tumor extends to the **vagina**, which automatically classifies it as Stage IIIb. Note that under the updated FIGO 2023 guidelines, positive peritoneal cytology (lavage) is no longer used to change the stage but is recorded as a separate finding; however, the vaginal involvement remains the primary staging determinant here. **Analysis of Incorrect Options:** * **Stage IIIa:** Incorrect because there is no mention of serosal or adnexal involvement. * **Stage IIIc1:** Incorrect because this stage requires metastasis to the **pelvic lymph nodes**. The question explicitly states there is no pelvic extension/nodal involvement. * **Stage IIIc2:** Incorrect because this stage requires metastasis to the **para-aortic lymph nodes**, which the question states are uninvolved. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Spread:** Endometrial cancer primarily spreads via direct extension, but lymphatic spread is the most important prognostic factor. * **FIGO Staging:** Endometrial cancer is **surgically staged**. * **Myometrial Invasion:** Involvement of >50% of the myometrium (as seen in this patient) would be Stage Ib if confined to the uterus, but the vaginal extension "upstages" the disease to Stage IIIb. * **Lymph Node Levels:** Pelvic nodes = IIIc1; Para-aortic nodes = IIIc2. Remember: "1 is lower (pelvis), 2 is higher (aorta)."

Q: A 45-year-old female diagnosed with cervical carcinoma of stage IIIB. What is the best line of management for this patient?

Concurrent chemoradiation. **Explanation:** The management of cervical carcinoma is primarily determined by the FIGO stage. This patient is diagnosed with **Stage IIIB**, which is classified as **Locally Advanced Cervical Cancer (LACC)**. **1. Why Concurrent Chemoradiation (CCRT) is correct:** For stages IIB through IVA, the standard of care is **Concurrent Chemoradiation**. This involves external beam radiotherapy (EBRT) combined with weekly **Cisplatin** (the radiosensitizer), followed by brachytherapy. Surgery is generally avoided in these stages because it cannot achieve clear margins once the disease involves the parametrium (Stage IIB) or the pelvic wall/lower third of the vagina (Stage IIIB), and combining surgery with radiation significantly increases morbidity. **2. Why the other options are incorrect:** * **A & B (Wertheim’s and Schauta’s Hysterectomy):** These are radical hysterectomies (Type III). Surgery is only indicated for **Early Stage Cervical Cancer (Stage IA to IIA1)**. Once the disease reaches Stage IIB (parametrial involvement) or IIIB (pelvic wall involvement), surgery is no longer the primary treatment. * **C (Chemotherapy):** While chemotherapy is used, it is not used as a standalone treatment for Stage IIIB. It is used either as a sensitizer during radiation (CCRT) or as palliative therapy for Stage IVB (metastatic disease). **High-Yield Clinical Pearls for NEET-PG:** * **Stage IIB:** The earliest stage where surgery is replaced by CCRT (due to parametrial involvement). * **Stage IIIB:** Defined by extension to the pelvic wall, hydronephrosis/non-functioning kidney, or involvement of the lower 1/3rd of the vagina. * **Drug of Choice:** Cisplatin is the most common radiosensitizer used in CCRT. * **Most common cause of death:** Uremia due to bilateral ureteric obstruction (post-renal failure).

Q: Which of the following is NOT used for carcinoma cervix screening?

CT and MRI. **Explanation:** The primary goal of **screening** is to detect pre-invasive lesions (CIN) or early-stage cancer in asymptomatic individuals. Screening tools must be cost-effective, accessible, and highly sensitive. **Why CT and MRI are the correct answer:** CT and MRI are **imaging modalities used for staging and treatment planning** once a diagnosis of cervical cancer has already been confirmed. According to the FIGO staging (revised 2018), imaging is used to assess tumor size, parametrial involvement, and lymph node status. They are never used as screening tools due to high costs, lack of specificity for pre-invasive lesions, and low cost-benefit ratio for the general population. **Analysis of other options:** * **Pap Smear (Exfoliative Cytology):** The traditional gold standard for screening. It involves collecting cells from the transformation zone to identify dysplastic changes. * **Liquid-based Cytology (LBC):** An improvement over conventional Pap smears. It reduces unsatisfactory samples by filtering out blood and mucus and allows for reflex HPV testing from the same vial. * **Colposcopy:** While often used as a diagnostic tool following an abnormal Pap smear, it is considered a secondary screening/triage method to identify the most suspicious areas for biopsy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type of cervical cancer:** Squamous cell carcinoma. * **Primary Screening (WHO guidelines):** HPV DNA testing is now preferred over cytology where available. * **Screening Age:** Usually starts at age 25–30 and continues until 65. * **VIA (Visual Inspection with Acetic Acid):** A low-cost screening alternative in resource-limited settings (positive result = opaque white areas).

Q: A 62-year-old woman presents with postmenopausal bleeding 13 years after menopause. She has a history of hypertension and type 2 diabetes mellitus. An endometrial biopsy reveals grade I endometrial adenocarcinoma. What is the most appropriate next step in management?

Hysterectomy. **Explanation:** The patient presents with classic risk factors for **Type I Endometrial Adenocarcinoma**, including postmenopausal status, hypertension, and diabetes mellitus (part of the metabolic syndrome). Once a diagnosis of endometrial adenocarcinoma is confirmed via biopsy, the standard of care and the definitive next step in management is surgical staging. **Why Hysterectomy is correct:** The primary treatment for clinical Stage I endometrial cancer is **Total Extraperitoneal Hysterectomy (TAH) with Bilateral Salpingo-Oophorectomy (BSO)**. In postmenopausal women, removing the ovaries is crucial as they are a source of estrogen and a potential site for metastasis. Surgical staging also typically includes pelvic and para-aortic lymphadenectomy or sentinel lymph node mapping to determine the need for adjuvant therapy. **Why incorrect options are wrong:** * **Chemotherapy (A):** This is reserved for advanced-stage disease (Stage III or IV) or recurrent cases; it is not the primary treatment for localized Grade I adenocarcinoma. * **Cone biopsy (B):** This is a diagnostic and therapeutic procedure for cervical intraepithelial neoplasia (CIN) or early cervical cancer, not endometrial cancer. * **Dilatation and curettage (C):** While D&C is a diagnostic tool used if an endometrial biopsy is inconclusive, it is not a treatment. Since the diagnosis is already confirmed as adenocarcinoma, we proceed directly to definitive surgery. **NEET-PG High-Yield Pearls:** * **Most common symptom:** Postmenopausal bleeding (PMB). * **Most common histological type:** Endometrioid adenocarcinoma (Type I), which is estrogen-dependent. * **Risk Factors:** Obesity, Nulliparity, Early menarche/Late menopause, PCOS, and Tamoxifen use. * **Investigation of choice:** Transvaginal Ultrasound (TVS) is the initial screening (Endometrial thickness >4mm in PMB is significant), but **Endometrial Biopsy** is the gold standard for diagnosis.

Q: Which of the following is FALSE regarding a hydatidiform mole?

Can be diagnosed very early by ultrasonography. In a hydatidiform mole, the characteristic ultrasonographic appearance—the **"snowstorm" or "honeycomb" pattern**—is caused by the hydropic swelling of chorionic villi. However, this classic feature typically develops only after the **first trimester (usually >10–12 weeks)**. In very early pregnancy, a molar pregnancy often lacks these diagnostic features and is frequently misdiagnosed as a missed abortion or a simple gestational sac. Therefore, it cannot be reliably diagnosed "very early" by ultrasound. **Analysis of other options:** * **Option A (True):** A **Partial Mole** is classically caused by **triploidy (69, XXX or 69, XXY)**, resulting from the fertilization of a normal ovum by two sperm (dispermy). * **Option C (True):** Many patients with molar pregnancies are asymptomatic or present with vaginal bleeding, leading to a clinical diagnosis of **missed or incomplete abortion**. The diagnosis of a mole is often only made after histopathological examination of the products of conception. * **Option D (True):** This refers specifically to **Partial Moles**, which have a low risk (approx. 1–5%) of progressing to persistent gestational trophoblastic disease (GTD) compared to Complete Moles (15–20%). **NEET-PG High-Yield Pearls:** * **Complete Mole:** 46, XX (diploid); "Snowstorm" appearance; No fetal parts; High hCG; 20% risk of malignancy. * **Partial Mole:** 69, XXY (triploid); Fetal parts present; Lower hCG; <5% risk of malignancy. * **Gold Standard Diagnosis:** Histopathology (p57 immunostaining is negative in complete moles). * **Management:** Suction evacuation followed by weekly hCG monitoring until three consecutive negative results.

Q: Sarcoma botryoides is most commonly seen in which age group?

Children under 2 years. **Explanation:** **Sarcoma botryoides** (Embryonal Rhabdomyosarcoma) is a highly malignant tumor derived from primitive mesenchymal cells. It is the most common vaginal tumor found in infants and children. 1. **Why Option B is Correct:** The peak incidence of Sarcoma botryoides occurs in children **under the age of 2 years**, with over 90% of cases diagnosed before age 5. It typically originates in the **anterior vaginal wall** (near the cervix) in young children, whereas in older girls or adolescents, it more commonly arises from the cervix itself. 2. **Why Other Options are Incorrect:** * **A (Neonates):** While it can occur shortly after birth, it is not the most common age group compared to the broader "under 2 years" category. * **C & D (Adults/Post-menopausal):** Vaginal malignancies in adults are predominantly **Squamous Cell Carcinomas** (linked to HPV) or **Adenocarcinomas** (historically linked to DES exposure). Sarcoma botryoides is extremely rare in adults. **High-Yield Clinical Pearls for NEET-PG:** * **Gross Appearance:** Classically presents as a **"bunch of grapes"** (polyps) protruding from the vagina. * **Clinical Presentation:** Often presents as blood-stained vaginal discharge or a visible mass at the introitus. * **Histology:** Characterized by the **Cambium layer** (a dense subepithelial layer of spindle-shaped tumor cells) and the presence of **rhabdomyoblasts** (strap or tadpole cells) with cytoplasmic cross-striations. * **Immunohistochemistry (IHC):** Positive for **Desmin**, Myogenin, and Myo-D1. * **Treatment:** Multimodal approach involving surgery (local excision) and chemotherapy (VAC regimen: Vincristine, Actinomycin-D, Cyclophosphamide).

Q: What is the commonest presentation of hydatidiform mole?

Bleeding. **Explanation:** Hydatidiform mole (molar pregnancy) is a gestational trophoblastic disease characterized by the abnormal proliferation of trophoblastic tissue. **Why Bleeding is the Correct Answer:** Vaginal bleeding is the **most common clinical presentation**, occurring in approximately 85–95% of cases. It typically occurs in the first trimester (around 6–16 weeks). The bleeding results from the separation of the molar vesicles from the decidua. It is often described as "prune juice" discharge—a dark brown discharge caused by the liquefaction of intrauterine clots. **Analysis of Incorrect Options:** * **A. Hyperemesis gravidarum:** While common due to abnormally high levels of hCG, it occurs in only about 25–30% of patients. It is a classic sign but not the *most* common. * **C. Pre-eclampsia:** Development of hypertension and proteinuria in the first or early second trimester (before 20 weeks) is a diagnostic hallmark of molar pregnancy, but it occurs in only about 10–25% of cases. * **D. Choriocarcinoma:** This is a potential malignant sequela of a hydatidiform mole (seen in ~15–20% of complete moles), not a presenting symptom of the mole itself. **NEET-PG High-Yield Pearls:** * **Most common sign:** Vaginal bleeding. * **Most common symptom:** Nausea and vomiting (Hyperemesis). * **Uterine size:** In a complete mole, the uterus is often "larger than dates" (in ~50% of cases) and has a "doughy" feel. * **USG Gold Standard:** "Snowstorm appearance" (due to multiple hydropic villi). * **Theca Lutein Cysts:** Occur in 25–40% of cases due to high hCG levels; they usually regress after evacuation.

Q: What is the primary treatment for Stage IB cervical cancer?

Surgery. **Explanation:** The primary treatment for **Stage IB cervical cancer** (specifically IB1 and IB2) is **Radical Hysterectomy (Type III/Wertheim’s Hysterectomy)** with bilateral pelvic lymphadenectomy. In early-stage cervical cancer (Stage IA2 to IB2), surgery is preferred over radiotherapy in young, fit patients because it preserves ovarian function, maintains vaginal elasticity, and avoids the long-term sequelae of radiation. **Analysis of Options:** * **A. Surgery (Correct):** For Stage IB, a Radical Hysterectomy is the gold standard. It involves the removal of the uterus, cervix, parametrium, and the upper 1/3rd of the vagina, along with pelvic lymph nodes. * **B. Chemotherapy:** Chemotherapy is never used as a standalone primary treatment for cervical cancer. It is used as a "radiosensitizer" (Cisplatin) during Concurrent Chemoradiotherapy (CCRT) for advanced stages. * **C. Radiotherapy:** While radiotherapy has equal efficacy to surgery in Stage IB, it is generally reserved for patients who are medically unfit for surgery or have bulky tumors (Stage IB3). It becomes the primary treatment of choice from Stage IIB onwards. * **D. Cryotherapy:** This is an ablative procedure used only for pre-cancerous lesions (CIN) or Stage IA1 (if no LVSI), not for invasive Stage IB cancer. **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 treatment of choice. * **Stage IIB onwards:** Concurrent Chemoradiotherapy (CCRT) is the standard of care. * **Fertility Preservation:** In Stage IB1, if the lesion is <2cm, a **Radical Trachelectomy** can be considered. * **Most common cause of death** in cervical cancer: Uremia due to bilateral ureteric obstruction.

Question 1

A patient with endometrial cancer involving >50% of the myometrium and extending to the vagina, but with no pelvic extension and no involvement of pre and para-aortic lymph nodes, is staged based on peritoneal lavage being positive. What is the correct stage?

Accepted Answer

Stage III b

Answer

Stage III a

Answer

Stage III c1

Answer

Stage III c2

Question 2

A 45-year-old female diagnosed with cervical carcinoma of stage IIIB. What is the best line of management for this patient?

Accepted Answer

Concurrent chemoradiation

Answer

Wertheim's hysterectomy

Answer

Schauta's hysterectomy

Answer

Chemotherapy

Question 3

Which of the following is NOT used for carcinoma cervix screening?

Accepted Answer

CT and MRI

Answer

Pap smear

Answer

Liquid-based cytology

Answer

Colposcopy

Question 4

A 62-year-old woman presents with postmenopausal bleeding 13 years after menopause. She has a history of hypertension and type 2 diabetes mellitus. An endometrial biopsy reveals grade I endometrial adenocarcinoma. What is the most appropriate next step in management?

Accepted Answer

Hysterectomy

Answer

Chemotherapy

Answer

Cone biopsy

Answer

Dilatation and curettage

Question 5

Nulliparity and late menopause are risk factors for which of the following group of diseases?

Accepted Answer

Endometrial cancer and breast cancer

Answer

Cervical cancer and endometrial hyperplasia

Answer

Ovarian cancer and endometrial polyp

Answer

Vulvar cancer and endometrial cancer

Question 6

Which of the following is a protective factor for ovarian cancer?

Accepted Answer

Bilateral Tubectomy

Answer

Nulliparity

Answer

Dysgenetic gonads

Answer

Worker of asbestos industry

Question 7

Which of the following is FALSE regarding a hydatidiform mole?

Accepted Answer

Can be diagnosed very early by ultrasonography

Answer

Caused by triploidy

Answer

Can present as a missed abortion

Answer

Rarely causes persistent gestational trophoblastic disease

Question 8

Sarcoma botryoides is most commonly seen in which age group?

Accepted Answer

Children under 2 years

Answer

Neonates

Answer

Adults

Answer

Post-menopausal women

Question 9

What is the commonest presentation of hydatidiform mole?

Accepted Answer

Bleeding

Answer

Hyperemesis gravidarum

Answer

Pre-eclampsia

Answer

Choriocarcinoma

Question 10

What is the primary treatment for Stage IB cervical cancer?

Accepted Answer

Surgery

Answer

Chemotherapy

Answer

Radiotherapy

Answer

Cryotherapy

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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