Gynecologic Oncology — MCQs

A 43-year-old woman with a BMI of 32 presents with abnormal uterine bleeding. An endometrial biopsy reveals endometrial adenocarcinoma of endometrioid histology. Her family history is significant for colon cancer (mother diagnosed at 66) and endometrial cancer (paternal aunt diagnosed at 67). Suspecting a hereditary condition, which of the following DNA repair mechanisms is likely defective?

Q237Easy

Ovarian tumors commonly arise from which part of the ovary?

Q238Easy

What is the standard treatment for stage-I endometrial carcinoma?

Q239Medium

Which of the following is NOT a common histological type of 'Bartholin gland carcinoma'?

Q240Easy

All of the following are sex-cord tumors, EXCEPT:

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 231: During population-based screening programs, a 40-year-old lady was found to have cervical intraepithelial neoplasia. Which of the following is the appropriate treatment modality for this patient?

A. Cryotherapy
B. Loop electrosurgical excision procedure (LEEP)
C. Cold knife conization
D. All of the above (Correct Answer)

Explanation: **Explanation:** The management of Cervical Intraepithelial Neoplasia (CIN) is determined by the grade of the lesion, the visibility of the transformation zone (TZ), and the patient's clinical profile. Treatment modalities are broadly classified into **Ablative** and **Excisional** techniques. 1. **Ablative Techniques (e.g., Cryotherapy):** These destroy the abnormal tissue in situ. Cryotherapy is highly effective for low-grade lesions (CIN 1) or CIN 2/3 when the entire lesion is visible, the transformation zone is Type 1 (fully ectocervical), and there is no suspicion of glandular or invasive disease. 2. **Excisional Techniques (e.g., LEEP and Cold Knife Conization):** These remove the abnormal tissue, providing a specimen for histopathological review. * **LEEP (Loop Electrosurgical Excision Procedure):** The most common treatment for CIN 2/3. It is quick, can be done under local anesthesia, and preserves the specimen. * **Cold Knife Conization (CKC):** The gold standard for suspected microinvasion, glandular disease (AIS), or when the squamocolumnar junction is not visible (Type 3 TZ). **Why "All of the above" is correct:** The question mentions "Cervical Intraepithelial Neoplasia" generally. Depending on the specific grade (CIN 1, 2, or 3) and the visibility of the transformation zone, any of these three modalities could be the "appropriate" choice. In a screening program context, the choice is tailored to the patient's specific diagnostic findings. **High-Yield Clinical Pearls for NEET-PG:** * **See-and-Treat:** LEEP is often preferred in "see-and-treat" protocols to reduce loss to follow-up. * **Transformation Zone (TZ):** Ablative methods (Cryotherapy) are **contraindicated** if the TZ is not fully visible (Type 3). * **Pregnancy:** Treatment of CIN is generally deferred until postpartum, unless invasive cancer is suspected. * **Follow-up:** Post-treatment follow-up involves HPV testing or Co-testing at 12 months.

Question 232: Which of the following is the most reliable test for the follow-up of a hydatidiform mole?

A. Beta-hCG levels (Correct Answer)
B. Ultrasound (US)
C. Clinical examination
D. Serum estradiol levels

Explanation: **Explanation:** The most reliable test for the follow-up of a hydatidiform mole is the serial measurement of **Serum Beta-hCG levels**. **Why Beta-hCG is the Correct Answer:** Hydatidiform moles are characterized by the abnormal proliferation of trophoblastic tissue, which produces Human Chorionic Gonadotropin (hCG). Following suction evacuation, the disappearance of hCG reflects the successful removal of all trophoblastic cells. Serial monitoring is essential to detect **Gestational Trophoblastic Neoplasia (GTN)** early. According to FIGO guidelines, hCG should be monitored weekly until three consecutive normal results are obtained, followed by monthly monitoring for 6 months. **Why Other Options are Incorrect:** * **Ultrasound (US):** While US is the gold standard for the *initial diagnosis* (showing the classic "snowstorm appearance"), it is not sensitive enough to detect microscopic residual disease or early malignant transformation during follow-up. * **Clinical Examination:** Physical exams (checking for uterine involution or vaginal metastasis) are part of the workup but lack the sensitivity and quantification required to track biochemical regression. * **Serum Estradiol Levels:** Estradiol is not a specific marker for trophoblastic activity and has no clinical utility in the management of molar pregnancies. **NEET-PG High-Yield Pearls:** * **Half-life of hCG:** Approximately 24–36 hours. * **GTN Diagnosis (FIGO Criteria):** hCG levels plateauing (4 values over 3 weeks) or rising (3 values over 2 weeks), or if hCG remains elevated 6 months post-evacuation. * **Contraception:** Patients must use reliable contraception (preferably OCPs) during the follow-up period to avoid a new pregnancy, which would confuse hCG interpretation.

Question 233: Point B in the treatment of carcinoma of the cervix by radiotherapy corresponds to which anatomical structure?

A. Obturator nodes (Correct Answer)
B. Machenrodt's ligament
C. Ischial tuberosity
D. Round ligament

Explanation: ### Explanation In the Manchester system of brachytherapy for cervical cancer, **Point B** is a crucial dosimetric landmark used to assess the dose delivered to the lateral pelvic walls and regional lymph nodes. **Why Option A is Correct:** Point B is located **2 cm superior** to the external cervical os (or the lateral vaginal fornix) and **5 cm lateral** to the midline. Anatomically, this point represents the **obturator lymph nodes** and the lateral pelvic wall. While Point A represents the paracervical area (where the ureter and uterine artery cross), Point B is designed to monitor the dose to the pelvic side wall to ensure adequate treatment of the primary lymphatic drainage sites while avoiding toxicity to the surrounding structures. **Why the Other Options are Incorrect:** * **B. Mackenrodt’s ligament (Cardinal ligament):** This structure is located more medially and is better represented by **Point A** (2 cm superior and 2 cm lateral to the midline), which corresponds to the paracervical triangle. * **C. Ischial tuberosity:** This is a bony landmark of the pelvis used in clinical pelvimetry but is not a reference point for radiotherapy dosing in the Manchester system. * **D. Round ligament:** This ligament extends from the uterine horns to the labia majora; it is not a primary target or a reference landmark for cervical brachytherapy. **High-Yield Clinical Pearls for NEET-PG:** * **Point A:** 2 cm up, 2 cm lateral. Represents the crossing of the **Ureter and Uterine Artery**. It is the point of "dosage prescription." * **Point B:** 2 cm up, 5 cm lateral. Represents **Obturator nodes**. It is the point of "dosage monitoring." * **ICRU 38/89:** Modern radiotherapy is shifting from these 2D points toward 3D volume-based planning (GEC-ESTRO guidelines), but Point A and B remain high-yield for exams. * The dose at Point B is typically **1/3rd to 1/4th** of the dose at Point A.

Question 234: A patient presents with an ovarian mass and a plain radiograph of the pelvis reveals a radio-opaque shadow. What is the most probable diagnosis?

A. Mucinous cystadenoma
B. Serous cystadenoma
C. Dysgerminoma
D. Dermoid cyst (Correct Answer)

Explanation: **Explanation:** The presence of a **radio-opaque shadow** on a plain pelvic radiograph in a patient with an ovarian mass is a classic diagnostic sign for a **Dermoid Cyst (Mature Cystic Teratoma)**. **Why Dermoid Cyst is correct:** A dermoid cyst is a germ cell tumor containing tissues from all three germ layers (ectoderm, mesoderm, and endoderm). The radio-opacity observed on X-ray typically represents **well-formed teeth** or **calcified bone** within the tumor. Additionally, the high fat content (sebum) within the cyst may sometimes create a characteristic radiolucent background, making the calcified structures even more prominent. **Analysis of Incorrect Options:** * **Mucinous cystadenoma:** These are large, multiloculated epithelial tumors filled with mucoid material. They do not typically contain calcified structures visible on a plain X-ray. * **Serous cystadenoma:** While these can contain microscopic calcifications called **Psammoma bodies**, these are generally too small to be visualized as a distinct radio-opaque shadow on a conventional radiograph. * **Dysgerminoma:** This is a malignant germ cell tumor. While it may show non-specific calcification in rare cases, it does not contain the organized dental or bony tissue characteristic of a dermoid cyst. **NEET-PG High-Yield Pearls:** * **Most common ovarian tumor in young women:** Dermoid Cyst. * **Most common complication:** Torsion (due to its high fat content and buoyancy). * **Rokidansky’s Protuberance:** A solid nodule within the cyst where most hair and teeth arise (seen on Ultrasound/CT). * **Malignant transformation:** Occurs in <2% of cases, most commonly into **Squamous Cell Carcinoma**. * **Tip of the Iceberg sign:** An ultrasound finding where the highly echogenic sebaceous material and hair obscure the posterior wall of the cyst.

Question 235: Which tumor marker is secreted in choriocarcinoma?

A. CEA
B. Prolactin
C. HCG (Correct Answer)
D. Alpha-fetoprotein

Explanation: **Explanation:** **Choriocarcinoma** is a highly malignant germ cell tumor or gestational trophoblastic neoplasm (GTN) arising from the chorionic epithelium. The correct answer is **HCG (Human Chorionic Gonadotropin)** because the tumor is composed of syncytiotrophoblasts and cytotrophoblasts. Syncytiotrophoblasts are physiologically responsible for the secretion of HCG. In choriocarcinoma, HCG levels are typically markedly elevated and serve as a sensitive marker for diagnosis, monitoring treatment response, and detecting recurrence. **Analysis of Incorrect Options:** * **A. CEA (Carcinoembryonic Antigen):** This is a non-specific oncofetal antigen primarily used as a marker for colorectal carcinoma and other GI tract malignancies. * **B. Prolactin:** This is a hormone secreted by the anterior pituitary gland. While elevated in prolactinomas, it has no diagnostic association with choriocarcinoma. * **C. Alpha-fetoprotein (AFP):** This is the characteristic marker for Yolk Sac Tumors (Endodermal Sinus Tumors) and Hepatocellular Carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Golden Rule:** HCG is the "universal marker" for Gestational Trophoblastic Disease (Hydatidiform mole, Invasive mole, and Choriocarcinoma). * **Histology:** Choriocarcinoma is unique because it is characterized by a **dimorphic population** of cells (syncytiotrophoblasts and cytotrophoblasts) and a distinct **absence of chorionic villi**. * **Metastasis:** It spreads hematogenously; the **lung** is the most common site of metastasis (look for "cannonball secondaries" on X-ray). * **Treatment:** It is highly chemosensitive; **Methotrexate** is the first-line agent for low-risk cases.

Question 236: A 43-year-old woman with a BMI of 32 presents with abnormal uterine bleeding. An endometrial biopsy reveals endometrial adenocarcinoma of endometrioid histology. Her family history is significant for colon cancer (mother diagnosed at 66) and endometrial cancer (paternal aunt diagnosed at 67). Suspecting a hereditary condition, which of the following DNA repair mechanisms is likely defective?

A. Nucleotide excision repair
B. Homologous recombination
C. Mismatch repair (Correct Answer)
D. Base excision repair

Explanation: **Explanation:** The patient presents with endometrial adenocarcinoma and a family history suggestive of **Lynch Syndrome** (Hereditary Non-Polyposis Colorectal Cancer - HNPCC). Lynch syndrome is the most common hereditary cause of endometrial cancer, often preceding the development of colon cancer in female carriers. **1. Why Mismatch Repair (MMR) is correct:** Lynch syndrome is caused by germline mutations in **DNA Mismatch Repair genes** (primarily *MLH1, MSH2, MSH6,* and *PMS2*). When the MMR system is defective, errors (mismatches) that occur during DNA replication are not corrected, leading to **Microsatellite Instability (MSI)** and subsequent oncogenesis. In women with Lynch syndrome, the lifetime risk of endometrial cancer (40–60%) equals or exceeds the risk of colorectal cancer. **2. Why other options are incorrect:** * **Nucleotide Excision Repair (A):** Defective in **Xeroderma Pigmentosum**. It repairs bulky DNA lesions caused by UV radiation. * **Homologous Recombination (B):** Defective in **BRCA1/2 mutations**. This pathway repairs double-strand breaks; defects are associated with hereditary breast and ovarian cancer (HBOC) syndromes. * **Base Excision Repair (D):** Defective in **MUTYH-associated polyposis (MAP)**. It repairs small, non-bulky DNA damage (e.g., oxidative damage). **Clinical Pearls for NEET-PG:** * **Amsterdam II Criteria:** Used to identify Lynch syndrome families (3-2-1 rule: 3 relatives with Lynch-associated cancers, 2 generations, 1 diagnosed before age 50). * **Screening:** For Lynch syndrome carriers, annual endometrial sampling is recommended starting at age 30–35. * **Sentinel Cancers:** In 50% of women with Lynch syndrome, endometrial cancer is the "sentinel" (first) malignancy diagnosed. * **Histology:** Lynch-associated endometrial cancers are often found in the lower uterine segment and may show prominent tumor-infiltrating lymphocytes.

Question 237: Ovarian tumors commonly arise from which part of the ovary?

A. Surface epithelium (Correct Answer)
B. Germ cell
C. Stroma of the ovary
D. None of the above

Explanation: **Explanation:** Ovarian tumors are classified based on the cell of origin. The **surface epithelium** (modified mesothelium) is the most common source, accounting for approximately **65–70% of all ovarian tumors** and nearly **90% of all malignant ovarian cancers**. **1. Why Surface Epithelium is Correct:** The surface epithelium undergoes repeated rupture and repair during ovulation. This constant cellular proliferation, combined with the entrapment of epithelial cells into the ovarian stroma (forming inclusion cysts), increases the risk of malignant transformation. Common subtypes include Serous, Mucinous, Endometrioid, and Clear cell tumors. **2. Why Other Options are Incorrect:** * **Germ Cells (Option B):** These arise from the oocytes. While they are the most common ovarian tumors in children and adolescents (e.g., Teratoma, Dysgerminoma), they account for only about 15–20% of all ovarian tumors. * **Stroma of the Ovary (Option C):** Also known as Sex Cord-Stromal tumors (e.g., Fibroma, Granulosa cell tumor, Sertoli-Leydig cell tumor), these arise from the connective tissue or hormone-producing cells. They are relatively rare, accounting for about 5–10% of cases. **High-Yield Clinical Pearls for NEET-PG:** * **Most common benign tumor:** Mature Cystic Teratoma (Dermoid cyst). * **Most common malignant tumor:** Serous Cystadenocarcinoma. * **Most common bilateral tumor:** Serous Cystadenoma/carcinoma. * **Tumor Marker:** CA-125 is the classic marker for epithelial ovarian tumors (especially serous), though it is non-specific. * **Risk Factor:** Nulliparity and early menarche/late menopause increase risk due to "incessant ovulation." Combined Oral Contraceptive Pills (COCPs) are protective.

Question 238: What is the standard treatment for stage-I endometrial carcinoma?

A. Surgery (Correct Answer)
B. Chemotherapy
C. Radiotherapy
D. Hormone therapy

Explanation: **Explanation:** The primary treatment for **Stage I endometrial carcinoma** is **Surgery**. According to FIGO staging, Stage I is confined to the corpus uteri. The standard surgical procedure is **Total Laparoscopic/Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (TAH + BSO)**. For high-risk cases, pelvic and para-aortic lymphadenectomy or sentinel lymph node mapping is also performed for surgical staging. Surgery is curative for the majority of patients in this early stage. **Why other options are incorrect:** * **Radiotherapy:** This is primarily used as **adjuvant therapy** (post-surgery) to reduce local recurrence in patients with high-risk features (e.g., deep myometrial invasion or high grade). It is only the primary treatment if the patient is medically unfit for surgery. * **Chemotherapy:** This is reserved for advanced stages (Stage III and IV) or recurrent disease. It is not the first-line treatment for Stage I. * **Hormone Therapy:** High-dose progestins (e.g., Megestrol) are used only in specific scenarios, such as fertility-sparing treatment in young patients with Grade 1 Stage IA disease or for palliation in advanced cases. **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Staging:** Endometrial cancer is **surgically staged**. * **Stage IA:** Tumor limited to <50% myometrium; **Stage IB:** Invasion ≥50% myometrium. * **Most common histological type:** Endometrioid adenocarcinoma (Type I), which is estrogen-dependent. * **Risk Factors:** Obesity (most common), Nulliparity, Early menarche/Late menopause, and Lynch Syndrome (HNPCC).

Question 239: Which of the following is NOT a common histological type of 'Bartholin gland carcinoma'?

A. Adenocarcinoma
B. Squamous cell carcinoma
C. Adenosquamous carcinoma
D. Transitional cell carcinoma (Correct Answer)

Explanation: **Explanation:** Bartholin gland carcinoma is a rare malignancy, accounting for approximately 1% of all female genital tract cancers. The histology of the tumor is dictated by the anatomical structure of the Bartholin gland and its duct system. **Why Transitional Cell Carcinoma is the correct answer:** The Bartholin gland consists of a **mucinous acini** (secretory portion) and a **duct**. The duct is lined by stratified squamous epithelium at its opening, which transitions into **transitional epithelium** (urothelium) and eventually becomes simple columnar epithelium near the acini. While transitional cell elements can exist within the duct, a pure **Transitional Cell Carcinoma** is not considered a common or characteristic histological type of this gland. **Analysis of other options:** * **Adenocarcinoma (Option A):** This is one of the two most common types, typically arising from the glandular acini or the columnar epithelium of the duct. * **Squamous Cell Carcinoma (Option B):** This is the other most common histological type (often cited as the most frequent), arising from the squamous epithelium at the distal end of the duct or the overlying vulvar skin. * **Adenosquamous Carcinoma (Option C):** This is a recognized histological variant where both glandular and squamous components are present. Adenoid cystic carcinoma is another notable variant specific to this site. **High-Yield Clinical Pearls for NEET-PG:** * **Honan’s Criteria:** Used to differentiate primary Bartholin gland carcinoma from secondary vulvar/metastatic growth. * **Clinical Presentation:** Usually presents as a painless, hard, fixed mass in the posterior third of the labia majora. * **Management:** Radical local excision with ipsilateral or bilateral inguinal-femoral lymphadenectomy. * **Rule of Thumb:** Any "Bartholin cyst" appearing for the first time in a **postmenopausal woman** must be biopsied to rule out malignancy.

Question 240: All of the following are sex-cord tumors, EXCEPT:

A. Granulosa cell tumor
B. Sertoli-Leydig cell tumor
C. Dysgerminoma (Correct Answer)
D. Gynandroblastoma

Explanation: **Explanation:** The classification of ovarian tumors is based on the cell of origin. Ovarian tumors are broadly divided into Surface Epithelial tumors, Germ Cell tumors, and Sex Cord-Stromal tumors. **Why Dysgerminoma is the correct answer:** **Dysgerminoma** is a **Germ Cell Tumor (GCT)**, not a sex-cord tumor. It is the most common malignant germ cell tumor of the ovary and is the female counterpart of the testicular seminoma. It typically occurs in young women (2nd and 3rd decades) and is associated with markers like LDH and occasionally hCG. **Analysis of Incorrect Options (Sex Cord-Stromal Tumors):** * **Granulosa cell tumor:** The most common malignant sex cord-stromal tumor. It is known for producing **Estrogen**, leading to precocious puberty in children or postmenopausal bleeding in adults. Histologically, it shows **Call-Exner bodies**. * **Sertoli-Leydig cell tumor:** Also known as Arrhenoblastoma, these are virilizing tumors that produce **Androgens**, leading to hirsutism and defeminization. * **Gynandroblastoma:** A very rare sex cord-stromal tumor that contains a mixture of both Granulosa-Sertoli and Leydig cell components. **NEET-PG High-Yield Pearls:** * **Most common ovarian tumor overall:** Serous Cystadenoma (Surface epithelial). * **Most common Germ Cell Tumor:** Benign Cystic Teratoma (Dermoid cyst). * **Tumor Marker for Dysgerminoma:** **LDH** (highly specific). * **Schiller-Duval bodies:** Pathognomonic for Yolk Sac Tumor (Endodermal Sinus Tumor). * **Reinke Crystals:** Characteristic of Leydig cell tumors. * **Psammoma bodies:** Seen in Serous Cystadenocarcinoma.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

Vulvar and Vaginal Cancer

Practice Questions

Gestational Trophoblastic Disease

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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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