Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 221: What is the staging of carcinoma of the cervix with parametrial involvement?

A. Stage III C
B. Stage II B (Correct Answer)
C. Stage III A
D. Stage III B

Explanation: **Explanation:** The staging of cervical cancer is primarily clinical and follows the **FIGO (2018) classification**. Understanding the anatomical spread is key to identifying the correct stage. **1. Why Stage II B is Correct:** Stage II is defined as carcinoma that extends beyond the uterus but has not reached the pelvic wall or the lower third of the vagina. Specifically, **Stage II B** indicates **parametrial involvement** that does not extend to the pelvic sidewall. This is a critical clinical distinction because Stage II B is generally treated with primary chemoradiation rather than surgery. **2. Why the Other Options are Incorrect:** * **Stage III A:** Involves the lower third of the vagina but does **not** extend to the pelvic sidewall. * **Stage III B:** Extension to the **pelvic sidewall** and/or causes hydronephrosis or a non-functioning kidney. While it involves the parametrium, it is more advanced than simple parametrial involvement. * **Stage III C:** This stage is reserved for metastasis to the **pelvic (III C1) or para-aortic (III C2) lymph nodes**, regardless of the size of the primary tumor. **Clinical Pearls for NEET-PG:** * **The "Cut-off" for Surgery:** Generally, Stage I A to II A can be treated surgically (e.g., Radical Hysterectomy). From **Stage II B onwards**, the standard of care shifts to **Concurrent Chemoradiation**. * **Hydronephrosis:** If a patient has parametrial involvement and hydronephrosis, the stage automatically upgrades to **III B**. * **FIGO 2018 Update:** Remember that lymph node status (Stage III C) and imaging/pathology are now included in staging, unlike the older clinical-only versions.

Question 222: Which of the following is the commonest genetic mutation in a 50-year-old obese female presenting with postmenopausal bleeding and diagnosed with endometrial cancer?

A. P53
B. PTEN (Correct Answer)
C. CHD4
D. Beta catenin

Explanation: **Explanation:** The clinical presentation describes a classic case of **Type I Endometrial Carcinoma** (Endometrioid adenocarcinoma). This type typically occurs in peri- or postmenopausal women and is strongly associated with obesity, which leads to chronic unopposed estrogen stimulation. **Why PTEN is correct:** The **PTEN (Phosphatase and Tensin homolog)** gene is a tumor suppressor gene located on chromosome 10q23. Mutations in PTEN are the most common genetic alteration in Type I endometrial cancer, occurring in **30–80%** of cases. It is often an early event in carcinogenesis, frequently seen even in the precursor lesion, atypical endometrial hyperplasia. **Analysis of Incorrect Options:** * **A. P53:** Mutations in the *TP53* gene are the hallmark of **Type II Endometrial Carcinoma** (Serous and Clear cell types). These occur in older, non-obese women, are estrogen-independent, and carry a much poorer prognosis. * **C. CHD4:** While mutations in *CHD4* (Chromodomain Helicase DNA Binding Protein 4) are identified in serous carcinomas, they are significantly less common than PTEN in the endometrioid subtype. * **D. Beta-catenin:** Mutations in *CTNNB1* (encoding Beta-catenin) occur in about 15–20% of Type I cases. While relevant, it is not the *most* common mutation compared to PTEN. **High-Yield Clinical Pearls for NEET-PG:** * **Type I (Endometrioid):** Estrogen-dependent, associated with obesity/PCOS, PTEN mutation (most common), Microsatellite Instability (MSI), and KRAS. Good prognosis. * **Type II (Serous/Clear Cell):** Estrogen-independent, associated with p53 mutation and HER2/neu amplification. Poor prognosis. * **Lynch Syndrome:** Always suspect if a young patient (<50 years) presents with endometrial cancer; it involves germline mutations in DNA mismatch repair (MMR) genes (MLH1, MSH2, MSH6, PMS2).

Question 223: Which of the following is NOT a risk factor for endometrial carcinoma?

A. Diabetes
B. Hypertension
C. Obesity
D. Multiparity (Correct Answer)

Explanation: **Explanation:** Endometrial carcinoma (Type I) is primarily an **estrogen-dependent** malignancy. The fundamental pathophysiology involves "unopposed estrogen" stimulation, which leads to endometrial hyperplasia and subsequent malignant transformation. **Why Multiparity is the Correct Answer:** Multiparity is a **protective factor**, not a risk factor. During pregnancy, the body is in a high-progesterone state. Progesterone antagonizes the effects of estrogen on the endometrium, promoting differentiation rather than proliferation. Therefore, multiple pregnancies reduce the lifetime exposure of the endometrium to unopposed estrogen. Conversely, **nulliparity** is a well-known risk factor. **Analysis of Incorrect Options:** * **Obesity (C):** This is the most significant modifiable risk factor. In obese individuals, adipose tissue contains the enzyme **aromatase**, which converts androstenedione into estrone (a weak estrogen), leading to chronic estrogenic stimulation. * **Diabetes (A) & Hypertension (B):** Along with obesity, these form the classic **"Corpus Uteri Cancer Syndrome"** (also known as the "Triad of Endometrial Cancer"). While obesity is the strongest link, hyperinsulinemia in diabetes and vascular changes in hypertension are independent metabolic contributors to the risk profile. **High-Yield Clinical Pearls for NEET-PG:** * **Lynch Syndrome (HNPCC):** The most common genetic predisposition; these patients require prophylactic hysterectomy by age 40-45. * **Tamoxifen:** Used in breast cancer, it acts as an estrogen *agonist* on the uterus, increasing the risk of endometrial polyps and cancer. * **PCOS:** A high-yield risk factor due to chronic anovulation (no corpus luteum = no progesterone). * **Protective Factors:** Combined Oral Contraceptive Pills (COCPs), smoking (decreases estrogen levels, though not recommended), and physical activity.

Question 224: What is the most common tumor of the cervix?

A. Squamous cell carcinoma (Correct Answer)
B. Adenocarcinoma
C. Sarcoma
D. Adenoacanthoma

Explanation: **Explanation:** **1. Why Squamous Cell Carcinoma (SCC) is correct:** Squamous cell carcinoma is the most common histological type of cervical cancer, accounting for approximately **75–80%** of all cases. It originates from the squamous epithelium of the ectocervix, typically at the **transformation zone** (the junction where columnar epithelium is replaced by squamous epithelium). The primary etiological factor is persistent infection with high-risk Human Papillomavirus (HPV) types 16 and 18. **2. Why the other options are incorrect:** * **B. Adenocarcinoma:** This is the second most common type, accounting for about **15–20%** of cases. It arises from the mucus-secreting glandular epithelium of the endocervix. Its incidence has been rising relatively due to better screening for SCC (Pap smears are more effective at detecting squamous lesions than glandular ones). * **C. Sarcoma:** Primary cervical sarcomas (e.g., leiomyosarcoma, endocervical stromal sarcoma) are extremely rare, representing less than 1% of all cervical malignancies. * **D. Adenoacanthoma:** This is a historical term for an adenocarcinoma with squamous metaplasia. It is rare in the cervix and more commonly associated with the endometrium. **3. Clinical Pearls for NEET-PG:** * **Most common site:** Transformation zone. * **Most common HPV types:** HPV 16 (most common for SCC) and HPV 18 (highly associated with Adenocarcinoma). * **Screening:** The Pap smear is the gold standard for secondary prevention; the most common finding is LSIL or HSIL. * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), though the 2018 update now allows for imaging and pathological findings where available. * **Route of spread:** The most common route is **direct extension** (into the paracervical tissues/parametrium).

Question 225: Which of the following types of ovarian tumors most frequently causes complications during pregnancy?

A. Teratoma (Correct Answer)
B. Mucinous cystadenoma
C. Serous cystadenocarcinoma
D. Brenner's tumor

Explanation: **Explanation:** **1. Why Teratoma is the Correct Answer:** Mature cystic teratoma (Dermoid cyst) is the most common germ cell tumor and the most frequent ovarian neoplasm encountered during pregnancy. Its high complication rate is primarily due to its **propensity for torsion**. Because teratomas contain heavy sebaceous material and hair, they are often buoyant and have a long pedicle, making them prone to twisting. Torsion most commonly occurs during the **first trimester** (as the uterus rises) or the **puerperium** (as the uterus rapidly involutes, creating space in the pelvis). Rupture, though rare, can lead to chemical peritonitis. **2. Analysis of Incorrect Options:** * **B. Mucinous cystadenoma:** While these can occur in pregnancy and grow to massive sizes, they are less common than teratomas and have a lower incidence of acute torsion. * **C. Serous cystadenocarcinoma:** Malignant ovarian tumors are rare during pregnancy (only 2–5% of cases). Serous cystadenocarcinoma is more common in postmenopausal women. * **D. Brenner’s tumor:** These are rare fibroepithelial tumors, usually asymptomatic and small, and are typically incidental findings in older women rather than pregnancy-related complications. **3. NEET-PG High-Yield Clinical Pearls:** * **Most common ovarian tumor in pregnancy:** Mature Cystic Teratoma. * **Most common complication:** Torsion (followed by rupture and labor obstruction). * **Management:** If an ovarian mass is >5–6 cm or symptomatic, the ideal time for surgical intervention (Laparoscopy/Laparotomy) is the **second trimester (16–20 weeks)** to minimize miscarriage risk and avoid the technical difficulty of a large third-trimester uterus. * **Emergency:** Acute torsion at any gestation requires immediate surgical intervention regardless of the trimester.

Question 226: Which of the following is NOT an advantage of surgery over radiotherapy in the management of carcinoma of the cervix?

A. Low operative mortality (Correct Answer)
B. Conservation of ovaries
C. Preservation of sexual function
D. None of the above

Explanation: In the management of early-stage carcinoma of the cervix (Stage IA2 to IIA), both radical surgery (Wertheim’s hysterectomy) and radiotherapy (RT) offer comparable survival rates. However, the choice between them depends on the specific advantages each modality offers. **Explanation of the Correct Option:** **A. Low operative mortality:** This is **NOT** an advantage of surgery over radiotherapy. While modern surgical techniques have improved, radical surgery still carries an inherent risk of intraoperative and postoperative mortality (0.5–1%). In contrast, radiotherapy is a non-invasive procedure with virtually zero immediate mortality. Therefore, "low mortality" is an advantage of radiotherapy, not surgery. **Explanation of Incorrect Options:** * **B. Conservation of ovaries:** In young women, surgery allows for the preservation of ovarian function (as cervical cancer rarely spreads to the ovaries in early stages). Radiotherapy inevitably causes permanent ovarian failure and premature menopause. * **C. Preservation of sexual function:** Surgery preserves the length and elasticity of the vagina. Radiotherapy often leads to vaginal stenosis, fibrosis, and dryness, which significantly impairs sexual function. * **D. None of the above:** This is incorrect as Option A is a clearly defined disadvantage of surgery compared to RT. **High-Yield Clinical Pearls for NEET-PG:** * **Surgery (Radical Hysterectomy)** is preferred in young, fit patients to preserve ovaries and vaginal health. * **Radiotherapy** is preferred in elderly, obese patients or those with co-morbidities (high surgical risk). * **Bladder and Bowel dysfunction:** Surgery is more likely to cause bladder dysfunction (due to nerve injury), whereas RT is more likely to cause late bowel complications (proctitis/fistula). * **Stage IB1 and IIA1:** Both surgery and RT are equally effective. For Stage IIB and beyond, **Concurrent Chemoradiotherapy (CCRT)** is the gold standard.

Question 227: Which of the following statements are true about dermoid cysts of the ovary?

A. It is a teratoma.
B. It frequently undergoes torsion. (Correct Answer)
C. X-ray is diagnostic.
D. It invariably turns to malignancy.

Explanation: **Explanation:** **Dermoid cysts**, also known as **Mature Cystic Teratomas**, are the most common germ cell tumors of the ovary, typically occurring during the reproductive years. 1. **Why Option B is correct:** Torsion is the most frequent complication of a dermoid cyst (occurring in about 15% of cases). This is due to the cyst's high fat/sebum content, which makes it buoyant, and its long pedicle, allowing it to float and rotate within the pelvis. 2. **Why Option A is technically incomplete/incorrect in this context:** While a dermoid cyst *is* a mature teratoma, in many competitive exams, if "torsion" is an option, it is prioritized as the most clinically significant characteristic or complication. (Note: In some formats, A could be considered true, but B is the "more" correct clinical hallmark). 3. **Why Option C is wrong:** While an X-ray may show calcifications (teeth or bone) in 30–50% of cases, it is **not diagnostic** for all dermoid cysts. Ultrasonography (showing the "Rokitansky protuberance" or "Tip of the iceberg sign") is the preferred initial imaging modality. 4. **Why Option D is wrong:** Malignant transformation is rare, occurring in only **1–2%** of cases, most commonly into Squamous Cell Carcinoma in postmenopausal women. **High-Yield NEET-PG Pearls:** * **Composition:** Derived from all three germ layers (Ectoderm, Mesoderm, Endoderm), but ectodermal elements (hair, sebum, teeth) predominate. * **Most common complication:** Torsion. * **Second most common complication:** Rupture (can lead to chemical peritonitis). * **Management:** Cystectomy is preferred over oophorectomy to preserve fertility.

Question 228: A patient presents with carcinoma endometrium involving more than 50% of the myometrium, extending to the vagina, and positive peritoneal cytology, but no involvement of para-aortic and pre-aortic nodes. What is the stage of the disease?

A. Stage III A
B. Stage III B (Correct Answer)
C. Stage III C1
D. Stage III C2

Explanation: ### Explanation The staging of endometrial carcinoma is based on the **FIGO 2023 (and 2009)** surgical staging system. To determine the correct stage, we must analyze the extent of local and regional spread. **1. Why Stage III B is correct:** Stage III indicates local and/or regional spread of the tumor. Specifically: * **Stage III A:** Involvement of the uterine serosa and/or adnexa (fallopian tubes/ovaries). * **Stage III B:** Involvement of the **vagina** and/or parametrium. In this case, the extension to the **vagina** automatically classifies the disease as **Stage III B**. **2. Why the other options are incorrect:** * **Stage III A:** This would be the answer if the tumor involved the serosa or adnexa. While the patient has positive peritoneal cytology, it is important to note that in the **FIGO 2009/2023 updates**, positive peritoneal cytology alone no longer changes the stage (though it should be recorded). * **Stage III C1:** This stage involves metastasis to the **pelvic lymph nodes**. The question states there is no nodal involvement. * **Stage III C2:** This involves metastasis to the **para-aortic lymph nodes**, with or without pelvic nodes. The question explicitly rules out para-aortic/pre-aortic involvement. **Clinical Pearls for NEET-PG:** * **FIGO Staging is Surgical:** Endometrial cancer is staged surgically (unlike Cervical Cancer, which was traditionally clinical but is now a hybrid). * **Myometrial Invasion:** Involvement of >50% myometrium (without extrauterine spread) would be **Stage I B**. * **Peritoneal Cytology:** Since 2009, positive cytology is reported but does not upstage the disease. * **Most Common Site of Spread:** Direct extension is common, but the most common site of distant metastasis is the lungs.

Question 229: Carcinoma cervix is more common in which of the following?

A. HIV patient
B. Multiparity (Correct Answer)
C. Smoking
D. Nulliparity

Explanation: **Explanation:** **Carcinoma Cervix** is the most common gynecological malignancy in India. The primary etiological agent is **High-Risk Human Papillomavirus (HPV)**, specifically types 16 and 18. **Why Multiparity is the correct answer:** Multiparity (having multiple births) is a well-established independent risk factor for cervical cancer. The underlying medical concepts include: 1. **Hormonal Influence:** High levels of estrogen and progesterone during repeated pregnancies can enhance the expression of HPV E6 and E7 oncogenes. 2. **Cervical Trauma:** Repeated deliveries cause trauma to the cervix, leading to persistent inflammation and frequent eversion of the **Transformation Zone (TZ)**. This exposes the squamocolumnar junction to HPV and other carcinogens, facilitating malignant transformation. **Analysis of Incorrect Options:** * **HIV Patient:** While HIV-positive women have a higher risk of persistent HPV infection and faster progression to invasive cancer, on a population-wide epidemiological scale (especially in the context of Indian demographics), **multiparity** remains a more prevalent and classically cited risk factor in standard textbooks like Shaw’s and Dutta. * **Smoking:** Smoking is a co-factor specifically associated with **Squamous Cell Carcinoma** (not Adenocarcinoma), but it is considered a secondary risk factor compared to parity and sexual history. * **Nulliparity:** This is actually a **protective factor** for cervical cancer. Nulliparity is instead a major risk factor for Endometrial, Ovarian, and Breast cancers. **High-Yield Clinical Pearls for NEET-PG:** * **Most common risk factor:** Early age at first coitus (before 17 years). * **Most common histological type:** Squamous cell carcinoma (80-85%). * **The "Protective" Factor:** Use of barrier contraceptives (condoms) reduces HPV transmission. * **OCP Link:** Long-term use of Oral Contraceptive Pills (>5 years) is associated with an increased risk of cervical cancer but a decreased risk of ovarian and endometrial cancer.

Question 230: Which of the following is not a risk factor for carcinoma of the cervix?

A. Low parity (Correct Answer)
B. Multiple sexual partners
C. Early sexual intercourse (before 16 years of age)
D. Smoking

Explanation: **Explanation:** The primary etiology of cervical carcinoma is persistent infection with **High-Risk Human Papillomavirus (HPV)**, specifically types 16 and 18. Therefore, risk factors are predominantly those that increase exposure to HPV or impair the body’s ability to clear the virus. **Why "Low Parity" is the correct answer:** In contrast to endometrial and ovarian cancers (where low parity is a risk factor), **High Parity (Multiparity)** is a documented risk factor for cervical cancer. Frequent pregnancies cause repeated trauma to the cervix and maintain the squamocolumnar junction (transformation zone) in an everted position on the ectocervix for longer periods, increasing susceptibility to HPV infection. Thus, low parity is actually protective or neutral, not a risk factor. **Analysis of Incorrect Options:** * **Multiple sexual partners:** This is the most significant risk factor as it directly increases the probability of exposure to HPV. * **Early sexual intercourse (<16 years):** The adolescent cervix has a large area of **metaplastic epithelium** (transformation zone), which is highly vulnerable to HPV integration. * **Smoking:** Tobacco by-products (cotinine) concentrate in the cervical mucus and damage the DNA of Langerhans cells, impairing local mucosal immunity and preventing the clearance of HPV. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous cell carcinoma (80%). * **OCP Use:** Long-term use (>5 years) is a known risk factor for cervical cancer (unlike its protective effect in ovarian/endometrial cancer). * **Immunosuppression:** HIV-positive women have a significantly higher risk and faster progression of CIN to invasive cancer. * **Screening:** The transformation zone is the most common site of origin for cervical cancer.

Practice by Chapter

Cervical Cancer

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Endometrial Cancer

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Ovarian Cancer

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Screening for Gynecologic Cancers

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Principles of Gynecologic Oncology Surgery

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Radiation Therapy in Gynecologic Malignancies

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Chemotherapy in Gynecologic Oncology

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Palliative Care in Gynecologic Oncology

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