Gynecologic Oncology — MCQs
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A 50-year-old lady presents with a two-month history of postmenopausal bleeding. On vaginal examination, a 1 x 2 cm growth is found on the anterior lip of the cervix. The uterus is of normal size, and rectal examination reveals free rectal mucosa and parametrium. Punch biopsy of the lesion establishes a diagnosis of cervical cancer. What is the recommended management?
What is the element most commonly used in brachytherapy of carcinoma cervix?
An 18-year-old female presents with an ovarian mass, and her serum LDH and placental alkaline phosphatase are found to be elevated. What is the treatment of choice in this condition?
Which of the following is true regarding the cervical cancer vaccine?
A patient with carcinoma of the cervix presents with altered sensorium and hiccups. What is the likely cause?
Which tumor marker is associated with Granulosa cell tumor?
Induration in the rectal pouch on a rectal examination in a 65-year-old woman with bilateral ovarian masses is an example of?
Sentinel lymph node biopsy is indicated in which of the following gynecological malignancies, except?
Which tumor marker is used for the follow-up of ovarian cancer?
What is used for post-evacuation surveillance of molar pregnancy?
Gynecologic Oncology Indian Medical PG Practice Questions and MCQs
Question 211: A 50-year-old lady presents with a two-month history of postmenopausal bleeding. On vaginal examination, a 1 x 2 cm growth is found on the anterior lip of the cervix. The uterus is of normal size, and rectal examination reveals free rectal mucosa and parametrium. Punch biopsy of the lesion establishes a diagnosis of cervical cancer. What is the recommended management?
- A. Conization
- B. Type 1 Hysterectomy
- C. Radical hysterectomy and pelvic lymphadenectomy (Correct Answer)
- D. Concurrent chemoradiation
Explanation: ### Explanation **Clinical Staging and Diagnosis:** The patient presents with a visible cervical lesion (1 x 2 cm) and postmenopausal bleeding. Based on the clinical findings: * **Size:** 2 cm (limited to the cervix). * **Parametrium:** Free (no involvement). * **Vaginal/Rectal mucosa:** Free. This corresponds to **FIGO Stage IB1** (clinically visible lesion ≤ 2 cm in greatest dimension, limited to the cervix). **Why Option C is Correct:** For early-stage cervical cancer (Stage IA2 to IB2), the standard of care is **Radical Hysterectomy (Type III/Wertheim’s) with Pelvic Lymphadenectomy**. This procedure is preferred in fit, younger patients (like this 50-year-old) to preserve vaginal function and avoid the long-term sequelae of radiation. **Why Other Options are Incorrect:** * **Option A (Conization):** This is only indicated for Stage IA1 (microinvasive) disease when fertility preservation is desired. It is insufficient for a 2 cm visible lesion. * **Option B (Type 1 Hysterectomy):** Simple hysterectomy is inadequate for Stage IB1 as it does not address the parametrium or pelvic lymph nodes, leading to a high risk of recurrence. * **Option D (Concurrent Chemoradiation):** This is the treatment of choice for **locally advanced cervical cancer (Stage IIB to IVA)**. While it is as effective as surgery for Stage IB1, surgery is generally preferred to avoid radiation-induced vaginal atrophy and menopause. **NEET-PG High-Yield Pearls:** 1. **Staging:** Cervical cancer is staged **clinically** (FIGO). 2. **Cut-off for Surgery:** Stage IIB (parametrial involvement) is the "point of no return" for surgery; these patients must receive Chemoradiation. 3. **Most Common Node:** The **Obturator node** is the most common lymph node involved in cervical cancer. 4. **Triad of Stage IIIB:** Hydronephrosis, non-functioning kidney, or involvement of the pelvic wall.
Question 212: What is the element most commonly used in brachytherapy of carcinoma cervix?
- A. Carbon
- B. Technetium
- C. Nitrogen
- D. Cesium (Correct Answer)
Explanation: **Explanation:** **Correct Answer: D. Cesium** In the management of Carcinoma Cervix, brachytherapy (internal radiation) is a cornerstone of treatment, typically following External Beam Radiation Therapy (EBRT). **Cesium-137 ($^{137}Cs$)** is the most commonly used radioisotope for traditional Low Dose Rate (LDR) brachytherapy. It is preferred because it has a long half-life (approximately 30 years), emits gamma rays with sufficient energy to penetrate tumor tissue, and requires less frequent source replacement compared to older elements like Radium-226. **Why other options are incorrect:** * **A. Carbon:** Carbon-14 is used in radiocarbon dating, and Carbon-11 is used in PET scans, but carbon has no role as a radiation source in brachytherapy. * **B. Technetium:** Technetium-99m is the most common radioisotope used in **diagnostic nuclear medicine** (e.g., bone scans, thyroid scans) due to its short half-life (6 hours), but it is not used for therapeutic radiation. * **C. Nitrogen:** Nitrogen is not a radioactive isotope used in radiotherapy. Liquid nitrogen is used in cryosurgery, but not for brachytherapy. **High-Yield Clinical Pearls for NEET-PG:** * **Historical Context:** **Radium-226** was the first element used (pioneered by Marie Curie), but it has been largely replaced by Cesium-137 due to the safety risks of Radon gas leakage. * **Modern Shift:** While Cesium-137 is the classic answer for LDR, **Iridium-192 ($^{192}Ir$)** is now the gold standard for **High Dose Rate (HDR)** brachytherapy, which is increasingly common in modern oncology centers. * **Point A vs. Point B:** In cervical brachytherapy dosimetry, **Point A** (2cm superior and 2cm lateral to the external os) represents the dose to the paracervical triangle and is the primary prescription point. **Point B** (3cm lateral to Point A) represents the dose to the pelvic lymph nodes.
Question 213: An 18-year-old female presents with an ovarian mass, and her serum LDH and placental alkaline phosphatase are found to be elevated. What is the treatment of choice in this condition?
- A. Bilateral oophorectomy and postoperative radiotherapy
- B. Oophorectomy on the involved side (Correct Answer)
- C. Chemotherapy only
- D. Hysterectomy with bilateral salpingo-oophorectomy
Explanation: ### Explanation **Diagnosis: Dysgerminoma** The clinical presentation of an 18-year-old female with an ovarian mass and elevated **Serum LDH** and **Placental Alkaline Phosphatase (PLAP)** is pathognomonic for a **Dysgerminoma**. This is the most common malignant germ cell tumor (GCT) in young women. **Why Option B is Correct:** Malignant germ cell tumors, unlike epithelial ovarian cancers, are usually unilateral (except dysgerminoma, which is bilateral in 10-15% of cases) and occur in women of reproductive age. The standard of care is **Unilateral Salpingo-oophorectomy (USO)** to preserve fertility, even if the tumor is large, as these tumors are highly chemosensitive. **Why Other Options are Incorrect:** * **Option A:** Bilateral oophorectomy is avoided to preserve hormonal and reproductive function. While dysgerminomas are highly radiosensitive, radiotherapy is no longer the primary treatment because it causes permanent infertility. * **Option C:** Surgery is the primary step for diagnosis, staging, and debulking. Chemotherapy (usually the BEP regimen) is used as adjuvant therapy for higher stages, not as a standalone primary treatment. * **Option D:** Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy (TAH+BSO) is the treatment for epithelial ovarian cancer in postmenopausal women but is considered overtreatment for a young patient with a germ cell tumor. **Clinical Pearls for NEET-PG:** * **Tumor Markers:** LDH and PLAP (Dysgerminoma), AFP (Yolk Sac Tumor), hCG (Choriocarcinoma). * **Most common GCT in pregnancy:** Dysgerminoma. * **Associated Condition:** Dysgerminomas are frequently associated with **gonadal dysgenesis** (Swyer Syndrome); if a Y-chromosome is present, a bilateral gonadectomy is indicated. * **Chemotherapy:** The **BEP regimen** (Bleomycin, Etoposide, Cisplatin) is the gold standard for malignant GCTs.
Question 214: Which of the following is true regarding the cervical cancer vaccine?
- A. Bivalent and quadrivalent vaccines are available.
- B. It is given to married women in the 20-45 years age group.
- C. The most common causative subtypes are HPV 16 and 18. (Correct Answer)
- D. Two doses are given.
Explanation: **Explanation:** **Correct Option (C):** Human Papillomavirus (HPV) is the primary etiological agent for cervical cancer. Among the high-risk oncogenic types, **HPV 16 and 18** are the most common, accounting for approximately **70% of all cervical cancer cases** worldwide. HPV 16 is specifically associated with squamous cell carcinoma, while HPV 18 is more frequently linked to adenocarcinoma. **Analysis of Incorrect Options:** * **Option A:** While bivalent (Cervarix) and quadrivalent (Gardasil) vaccines were the initial options, the **Nonavalent vaccine (Gardasil 9)** is now the standard of care in many regions, covering five additional oncogenic types (31, 33, 45, 52, 58). * **Option B:** The primary target group for the HPV vaccine is **adolescent girls (9–14 years)** before sexual debut. While catch-up vaccination is recommended up to age 26 (and can be given up to 45 years based on shared clinical decision-making), it is not specifically targeted at "married women." * **Option D:** The dosage schedule depends on age. For girls aged **9–14 years, a 2-dose schedule** (0, 6 months) is recommended. However, for those **15 years and older** or immunocompromised individuals, a **3-dose schedule** (0, 1-2, 6 months) is mandatory. **High-Yield Clinical Pearls for NEET-PG:** * **L1 Protein:** The vaccine consists of virus-like particles (VLPs) derived from the L1 capsid protein. * **HPV 6 & 11:** These are low-risk types responsible for 90% of genital warts (Condyloma acuminata), covered by quadrivalent and nonavalent vaccines. * **Screening:** Vaccination does not replace cervical cancer screening; Pap smears/HPV DNA testing should continue as per protocols. * **WHO 2022 Update:** A single-dose schedule is now considered off-label but effective for the primary target group (9-14 years) in resource-limited settings.
Question 215: A patient with carcinoma of the cervix presents with altered sensorium and hiccups. What is the likely cause?
- A. Septicemia
- B. Uremia (Correct Answer)
- C. Raised intracranial pressure
- D. None of the above
Explanation: **Explanation:** In advanced stages of **Carcinoma Cervix**, the most common cause of death is **renal failure** resulting from obstructive uropathy. **1. Why Uremia is the correct answer:** As the cervical tumor spreads laterally into the parametrium, it can cause extrinsic compression of the ureters. This leads to bilateral hydroureter and hydronephrosis, eventually resulting in post-renal acute kidney injury or chronic kidney disease. The accumulation of nitrogenous waste products (Uremia) affects the central nervous system, leading to **altered sensorium** (uremic encephalopathy). Furthermore, uremia irritates the phrenic nerve or the diaphragm, which is a classic cause of persistent **hiccups**. **2. Why other options are incorrect:** * **Septicemia:** While advanced cancer patients are prone to infections, septicemia typically presents with fever, tachycardia, and hypotension. While it can cause altered sensorium (septic encephalopathy), it is not the classic association for hiccups in this clinical context. * **Raised Intracranial Pressure (ICP):** This would suggest brain metastasis. However, Carcinoma Cervix primarily spreads locally or to regional lymph nodes; distant metastasis to the brain is extremely rare. **Clinical Pearls for NEET-PG:** * **Most common cause of death in Ca Cervix:** Uremia (Renal Failure). * **Triad of advanced Ca Cervix:** Leg edema, sciatic pain, and hydronephrosis (indicates pelvic wall involvement). * **Staging:** According to FIGO staging, hydronephrosis or a non-functioning kidney automatically classifies the disease as **Stage IIIB**, regardless of other findings. * **Management of Ureteral Obstruction:** Percutaneous Nephrostomy (PCN) or double-J (DJ) stenting is often required as palliative measures.
Question 216: Which tumor marker is associated with Granulosa cell tumor?
- A. Inhibin (Correct Answer)
- B. CA 19-9
- C. CA 15-3
- D. CA 125
Explanation: **Explanation:** **1. Why Inhibin is the Correct Answer:** Granulosa cell tumors (GCTs) are sex cord-stromal tumors that arise from the granulosa cells surrounding the oocytes. These cells naturally produce **Inhibin** (specifically Inhibin B) to regulate FSH secretion via the pituitary-ovarian axis. In GCTs, there is a neoplastic proliferation of these cells, leading to significantly elevated serum Inhibin levels. Inhibin is considered a highly specific and sensitive marker for GCTs, used both for initial diagnosis and for monitoring disease recurrence. **2. Why Other Options are Incorrect:** * **CA 19-9:** Primarily used as a marker for pancreatic and biliary tract cancers. In gynecology, it may be elevated in mucinous ovarian tumors. * **CA 15-3:** A tumor marker primarily associated with breast cancer monitoring. * **CA 125:** The "gold standard" marker for epithelial ovarian tumors (especially serous cystadenocarcinoma). While it can be elevated in many conditions (including endometriosis or PID), it is not the specific marker for sex cord-stromal tumors like GCT. **3. High-Yield Clinical Pearls for NEET-PG:** * **Other Markers for GCT:** **Anti-Müllerian Hormone (AMH)** is another highly specific marker for Granulosa cell tumors, often used alongside Inhibin. * **Histology:** Look for **Call-Exner bodies** (small fluid-filled spaces surrounded by granulosa cells) and "coffee-bean" nuclei. * **Clinical Presentation:** GCTs are estrogen-secreting. In children, they cause **precocious puberty**; in adults, they cause **postmenopausal bleeding** or endometrial hyperplasia/carcinoma. * **Genetics:** The **FOXL2 mutation** (402C→G) is a pathognomonic molecular marker for adult-type GCT.
Question 217: Induration in the rectal pouch on a rectal examination in a 65-year-old woman with bilateral ovarian masses is an example of?
- A. Lymphatic spread of tumor
- B. Seeding of tumor (Correct Answer)
- C. Hematogenous spread of tumor
- D. Discontinuous spread of tumor
Explanation: **Explanation:** The clinical presentation describes a classic finding in advanced ovarian malignancy. The correct answer is **Seeding of tumor** (Option B), also known as transcoelomic spread. **Why it is correct:** Ovarian cancer most commonly spreads by the exfoliation of malignant cells into the peritoneal cavity. These cells are carried by physiological peritoneal fluid and tend to settle in dependent areas of the pelvis due to gravity. The **Pouch of Douglas (rectouterine/rectal pouch)** is the most dependent part of the female pelvis. When tumor cells implant and grow here, they form a firm, nodular sensation felt on rectal or vaginal examination, clinically referred to as a **"Blumer’s shelf"** or "rectal shelf." This is a hallmark of transcoelomic seeding. **Why other options are incorrect:** * **Lymphatic spread (A):** While ovarian cancer spreads to pelvic and para-aortic nodes, this typically presents as lymphadenopathy rather than a palpable shelf in the rectal pouch. * **Hematogenous spread (C):** This is less common in early/mid-stage ovarian cancer and usually involves distant organs like the liver parenchyma or lungs. * **Discontinuous spread (D):** This is a general term. "Seeding" is the specific pathological mechanism (transcoelomic) that describes how these "discontinuous" implants occur in the peritoneal cavity. **High-Yield NEET-PG Pearls:** * **Most common mode of spread:** Ovarian cancer spreads primarily via **transcoelomic seeding** (peritoneal surface involvement). * **Blumer’s Shelf:** A palpable nodularity in the Pouch of Douglas indicating drop metastases (commonly from Gastric [Krukenberg] or Ovarian primary). * **Sister Mary Joseph Nodule:** Metastatic implant at the umbilicus, also a result of peritoneal seeding. * **Staging:** The presence of these implants outside the pelvis but within the abdomen (up to 2cm) defines Stage IIIA2.
Question 218: Sentinel lymph node biopsy is indicated in which of the following gynecological malignancies, except?
- A. Carcinoma of the vulva
- B. Carcinoma of the cervix
- C. Carcinoma of the breast
- D. Choriocarcinoma (Correct Answer)
Explanation: ### Explanation The correct answer is **D. Choriocarcinoma**. **Why Choriocarcinoma is the correct answer:** Sentinel Lymph Node (SLN) biopsy is a technique used to identify the first node(s) receiving lymphatic drainage from a primary tumor to assess for regional spread. **Choriocarcinoma** is a highly malignant germ cell or gestational trophoblastic neoplasm characterized by early and aggressive **hematogenous spread** (primarily to the lungs and brain) rather than lymphatic spread. Therefore, surgical staging or lymph node assessment via SLN biopsy has no clinical role in its management. **Analysis of other options:** * **Carcinoma of the Vulva:** SLN biopsy is the standard of care for early-stage vulvar cancer (Stage T1/T2, <4 cm) with clinically negative nodes. It significantly reduces the morbidity associated with radical inguinofemoral lymphadenectomy. * **Carcinoma of the Cervix:** SLN mapping is increasingly used in early-stage cervical cancer (Stage IA2, IB1, and IB2) to avoid the complications of full pelvic lymphadenectomy while maintaining oncological safety. * **Carcinoma of the Breast:** This is the "gold standard" indication for SLN biopsy. It is used for clinically node-negative (cN0) patients to determine the need for axillary lymph node dissection. **High-Yield Clinical Pearls for NEET-PG:** * **Tracers used for SLN:** Technetium-99m (99mTc) sulfur colloid, Isosulfan blue/Methylene blue, or Indocyanine Green (ICG). * **Vulvar Cancer Criteria:** SLN is indicated if the tumor is unifocal, <4 cm, and has no clinical evidence of nodal involvement. * **Choriocarcinoma Marker:** The most important diagnostic and follow-up marker is **beta-hCG**. It is highly sensitive to chemotherapy (EMA-CO regimen). * **Most common site of metastasis in Choriocarcinoma:** Lungs (presents as "cannonball" appearance on X-ray).
Question 219: Which tumor marker is used for the follow-up of ovarian cancer?
- A. CEA
- B. PSA
- C. CA 125 (Correct Answer)
- D. BETA HCG
Explanation: **Explanation:** **CA 125 (Cancer Antigen 125)** is the most widely used tumor marker for the management of **Epithelial Ovarian Cancer (EOC)**, particularly the serous subtype. It is a high-molecular-weight glycoprotein produced by derivatives of the coelomic epithelium (pleura, pericardium, peritoneum, and Müllerian elements). While it has low specificity for screening (as it can be elevated in benign conditions like endometriosis or PID), it is the **gold standard for monitoring treatment response and detecting recurrence** during follow-up. A rising trend in CA 125 levels often precedes clinical or radiological evidence of recurrence by several months. **Analysis of Incorrect Options:** * **CEA (Carcinoembryonic Antigen):** Primarily used for colorectal, gastrointestinal, and sometimes mucinous ovarian cancers, but it is not the primary marker for general ovarian cancer follow-up. * **PSA (Prostate-Specific Antigen):** A specific marker for screening and monitoring **Prostate Cancer** in men; it has no clinical utility in gynecology. * **BETA HCG:** The primary marker for **Germ Cell Tumors** (specifically Choriocarcinoma and Dysgerminoma) and Gestational Trophoblastic Neoplasia (GTN), rather than epithelial ovarian cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Cut-off value:** Normal is generally **<35 U/mL**. * **Post-menopausal status:** A high CA 125 in a post-menopausal woman with an adnexal mass is highly suggestive of malignancy. * **Other markers:** For Germ Cell Tumors, remember **AFP** (Yolk Sac Tumor) and **LDH** (Dysgerminoma). * **Inhibin B:** The specific marker for **Granulosa Cell Tumors**.
Question 220: What is used for post-evacuation surveillance of molar pregnancy?
- A. AFP
- B. b-hCG (Correct Answer)
- C. LDH
- D. CA 125
Explanation: **Explanation:** **Molar pregnancy (Hydatidiform mole)** is a part of Gestational Trophoblastic Disease (GTD). The definitive management is suction and evacuation; however, there is a risk of progression to Gestational Trophoblastic Neoplasia (GTN). **Why b-hCG is the correct answer:** Human chorionic gonadotropin (hCG) is secreted by the proliferating syncytiotrophoblasts. Since molar tissue is entirely composed of trophoblastic proliferation, **serum b-hCG** serves as a highly sensitive and specific tumor marker. Post-evacuation, b-hCG levels should ideally fall to undetectable levels. Serial monitoring is mandatory to detect persistent disease or malignant transformation (Choriocarcinoma). **Why other options are incorrect:** * **AFP (Alpha-fetoprotein):** Used for monitoring germ cell tumors (Yolk sac tumor) and Hepatocellular carcinoma. * **LDH (Lactate Dehydrogenase):** A non-specific marker, though specifically elevated in Dysgerminomas. * **CA 125:** The primary marker for epithelial ovarian tumors; it has no role in trophoblastic disease. **High-Yield Clinical Pearls for NEET-PG:** * **Follow-up Protocol:** Weekly b-hCG levels until three consecutive negative results (<5 mIU/ml), followed by monthly levels for 6 months. * **Contraception:** Patients must use reliable contraception (preferably Barrier or OCPs) during the surveillance period to avoid a new pregnancy, which would confuse b-hCG interpretation. * **GTN Diagnosis:** According to FIGO criteria, GTN is diagnosed if b-hCG levels plateau (4 values over 3 weeks) or rise (3 values over 2 weeks). * **Snowstorm appearance** on ultrasound is the classic diagnostic feature of a complete mole.
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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