Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 241: According to the FIGO staging, what is the characteristic of Grade 3 endometrial tumors?

A. <5% non-squamous or non-morular growth pattern
B. 6%-50% non-squamous or non-morular growth pattern
C. >50% non-squamous or non-morular growth pattern (Correct Answer)
D. >75% non-squamous or non-morular growth pattern

Explanation: The FIGO (International Federation of Gynecology and Obstetrics) grading system for endometrial carcinoma is based on the architectural growth pattern of the tumor, specifically the proportion of **solid, non-glandular, non-squamous growth**. ### **Explanation of the Correct Answer** **Grade 3 (High Grade)** is defined as a tumor where **>50%** of the growth pattern is solid (non-squamous or non-morular). These tumors are poorly differentiated, exhibit significant nuclear atypia, and carry a worse prognosis compared to lower grades. ### **Analysis of Incorrect Options** * **Option A (<5%):** This defines **Grade 1 (Well-differentiated)**. The tumor is composed almost entirely of well-formed glands with minimal solid growth. * **Option B (6%-50%):** This defines **Grade 2 (Moderately differentiated)**. There is a noticeable solid component, but it does not exceed half of the tumor volume. * **Option D (>75%):** This is not a standard FIGO cutoff. The FIGO system strictly uses the 5% and 50% thresholds for grading. ### **High-Yield Clinical Pearls for NEET-PG** 1. **The "Nuclear Rule":** If there is significant (Grade 3) nuclear atypia (large, pleomorphic nuclei with prominent nucleoli) in a tumor that otherwise looks like Grade 1 or 2, the overall FIGO grade is **increased by one**. 2. **Non-endometrioid subtypes:** Serous, clear cell, and carcinosarcomas are considered **Grade 3 by definition** regardless of their growth pattern. 3. **Squamous differentiation:** Solid areas of squamous differentiation (morules) are **excluded** from the percentage calculation when determining the grade. 4. **Prognostic Significance:** Grade is one of the most important predictors of lymph node metastasis and overall survival in endometrial cancer.

Question 242: A 45-year-old female presents with bilateral ovarian mass, ascites, and omental caking on CT scan. What is the most likely diagnosis?

A. Benign ovarian tumor
B. Malignant epithelial ovarian tumor (Correct Answer)
C. Dysgerminoma of the ovary
D. Lymphoma of the ovary

Explanation: **Explanation:** The clinical presentation of **bilateral ovarian masses**, **ascites**, and **omental caking** (thickening of the omentum due to metastatic infiltration) is the classic triad for advanced-stage **Malignant Epithelial Ovarian Tumor (EOC)**. EOC is the most common type of ovarian cancer in women over 40. It typically spreads via exfoliation of cells into the peritoneal cavity (seeding), leading to peritoneal carcinomatosis, ascites, and the characteristic "omental cake" seen on imaging. **Analysis of Options:** * **Option A (Benign ovarian tumor):** Benign tumors (like serous cystadenomas) are usually unilateral, slow-growing, and do not cause omental caking or significant ascites. * **Option C (Dysgerminoma):** This is a Germ Cell Tumor (GCT) typically seen in younger women (adolescents/early 20s). While it can be bilateral (10-15%), it usually presents as a solid mass rather than widespread peritoneal disease. * **Option D (Lymphoma):** Primary ovarian lymphoma is extremely rare. While it can be bilateral, it does not typically present with the classic omental caking seen in epithelial carcinomas. **NEET-PG High-Yield Pearls:** * **Most common EOC:** Serous cystadenocarcinoma (often bilateral). * **Tumor Marker:** **CA-125** is the primary marker for EOC monitoring. * **Omental Caking:** This is a pathognomonic radiological sign for peritoneal carcinomatosis, most commonly secondary to ovarian, gastric, or colonic malignancy. * **Risk Factors:** Nulliparity, early menarche, late menopause, and BRCA1/BRCA2 mutations. Combined Oral Contraceptive Pills (COCPs) are protective.

Question 243: A 20-year-old female is diagnosed to have a molar pregnancy. All of the following are features of a molar mole, EXCEPT?

A. Fetus is present
B. Amnion is present
C. Karyotype is usually 69 XXY
D. Greater risk of persistent trophoblastic disease (Correct Answer)

Explanation: This question tests the ability to differentiate between a **Partial Hydatidiform Mole** and a **Complete Hydatidiform Mole**. ### **Explanation of the Correct Answer** The correct answer is **D**. The question asks for the feature that is **NOT** characteristic of a partial mole. While both types of molar pregnancies can lead to Gestational Trophoblastic Neoplasia (GTN), the risk of **persistent trophoblastic disease** is significantly lower in partial moles (approx. 1–5%) compared to complete moles (approx. 15–20%). Therefore, "greater risk" is an incorrect statement regarding partial moles. ### **Analysis of Incorrect Options** * **A & B (Fetus and Amnion present):** Unlike complete moles, partial moles result from **dispermy** (two sperm fertilizing one normal egg). This allows for the development of embryonic tissues. Therefore, a non-viable fetus, fetal red blood cells, and amniotic membranes are characteristically present. * **C (Karyotype 69, XXY):** Partial moles are almost always **triploid**. The most common karyotype is 69, XXY, followed by 69, XXX or 69, XYY. (Complete moles are typically 46, XX and diploid). ### **NEET-PG High-Yield Pearls** | Feature | Partial Mole | Complete Mole | | :--- | :--- | :--- | | **Karyotype** | Triploid (69, XXY) | Diploid (46, XX) | | **Fetal Tissue** | Present | Absent | | **Villi Swelling** | Focal | Diffuse/Generalized | | **Trophoblastic Hyperplasia** | Mild/Focal | Marked/Diffuse | | **hCG Levels** | Less elevated | Markedly elevated | | **Risk of Malignancy** | Low (1-5%) | High (15-20%) | | **USG Appearance** | "Swiss cheese" placenta | "Snowstorm" appearance |

Question 244: According to cancer cervix tumor size, which of the following is the cut-off size of tumor up till which primary surgical treatment is the best option?

A. All sizes of tumors have good results
B. Less than 5 mm depth of invasion
C. Less than 2 cm tumor size
D. Less than 4 cm tumor size (Correct Answer)

Explanation: **Explanation:** The management of cervical cancer is primarily determined by the **FIGO staging**, which dictates whether a patient is a candidate for surgery or primary chemoradiation. **Why Option D is correct:** The cut-off for primary surgical treatment (Radical Hysterectomy with Pelvic Lymphadenectomy) is generally **Stage IIA1**, which includes tumors **≤ 4 cm** in greatest dimension that have not involved the parametrium. Once a tumor exceeds 4 cm (Stage IIA2) or involves the parametrium (Stage IIB), the standard of care shifts to **Concurrent Chemoradiotherapy (CCRT)**. This is because larger tumors have a higher risk of positive surgical margins and lymph node metastasis, often requiring "triple modality" therapy (surgery followed by radiation), which significantly increases patient morbidity without improving survival. **Analysis of Incorrect Options:** * **Option A:** Incorrect. Large tumors (bulky) and those with parametrial involvement (Stage IIB onwards) respond better to radiation than surgery. * **Option B:** This describes **Microinvasive Carcinoma (Stage IA1)**. While surgery is the treatment, it is not the "cut-off" for all surgical candidates; surgery remains viable for much larger visible lesions up to 4 cm. * **Option C:** While tumors < 2 cm (Stage IB1) have an excellent prognosis and may be eligible for fertility-sparing surgery (Trachelectomy), the absolute upper limit for radical surgery remains 4 cm. **High-Yield Clinical Pearls for NEET-PG:** * **Stage IA1:** Treatment is simple hysterectomy (or conization if fertility is desired). * **Stage IB1 to IIA1 (≤ 4 cm):** Radical Hysterectomy (Wertheim’s/Meigs' operation). * **Stage IIB onwards:** Primary Chemoradiation (Cisplatin is the drug of choice). * **Most common cause of death:** Uremia due to bilateral ureteric obstruction. * **Gold Standard Investigation for Staging:** Clinical evaluation (FIGO is a clinical staging system, though imaging like MRI/CT is now incorporated).

Question 245: During screening for cervical cancer in a community, a Pap smear of a 51-year-old female shows abnormal cytology. What is the best next logical procedure?

A. Conization
B. Colposcopy and biopsy (Correct Answer)
C. Hysterectomy
D. HPV viral DNA testing

Explanation: **Explanation:** The management of cervical cancer screening follows a specific diagnostic hierarchy: **Screening → Diagnosis → Treatment.** **1. Why Colposcopy and Biopsy is correct:** A Pap smear is a **screening tool**, not a diagnostic one. It identifies cytological abnormalities but cannot confirm the histological grade of the lesion or the presence of invasion. According to the standard management algorithms (ASCCP guidelines), any high-grade or persistent low-grade abnormality on a Pap smear must be evaluated by **Colposcopy**. This allows for a magnified visualization of the cervix and the performance of a **directed biopsy** of the most suspicious areas (e.g., acetowhite epithelium, punctations, or mosaicism). This is the "Gold Standard" for confirming a diagnosis before definitive treatment. **2. Why other options are incorrect:** * **Conization (Option A):** This is a therapeutic or diagnostic procedure (if colposcopy is unsatisfactory). It is more invasive and is generally reserved for when the entire transformation zone cannot be visualized or when there is a discrepancy between cytology and biopsy. * **Hysterectomy (Option C):** This is a major surgical treatment. It is never performed based solely on a screening Pap smear without a histological diagnosis of malignancy or severe dysplasia. * **HPV DNA Testing (Option D):** While used for primary screening or triaging "ASC-US" (Atypical Squamous Cells of Undetermined Significance), it does not provide a tissue diagnosis. In a 51-year-old with an already "abnormal" smear, the next step is visualization, not further screening. **Clinical Pearls for NEET-PG:** * **Transformation Zone:** The most common site for cervical cancer; must be fully visualized during colposcopy. * **Schiller’s Test:** Uses Lugol’s iodine; normal cells turn brown (glycogen-rich), while abnormal cells remain pale/yellow (iodine-negative). * **Management Rule:** "See and Treat" is only considered in specific high-grade cases, but the standard sequence remains **Cytology → Colposcopy → Histology.**

Question 246: Cigarette smoking and long-term use of oral contraceptives in a woman would most likely predispose to primary cancer in which of the following sites?

A. Breast
B. Ovary
C. Endometrium
D. Cervix (Correct Answer)

Explanation: **Explanation:** The correct answer is **Cervix**. This question tests the understanding of risk factors for gynecological malignancies, specifically the unique profile of cervical cancer compared to other hormone-dependent cancers. **Why Cervix is Correct:** * **Oral Contraceptive Pills (OCPs):** Long-term use of OCPs (typically >5 years) is a well-established risk factor for **Cervical Cancer**. While the mechanism is multifactorial, it is believed that OCPs may increase the susceptibility of cervical cells to persistent High-Risk HPV infection and enhance the expression of HPV E6 and E7 oncogenes. * **Cigarette Smoking:** Smoking is a major co-factor for **Cervical Squamous Cell Carcinoma**. Carcinogens (like nicotine and cotinine) concentrate in the cervical mucus, damaging the DNA of epithelial cells and local immunity (Langerhans cells), which prevents the clearance of HPV. **Why Other Options are Incorrect:** * **Ovary & Endometrium:** OCPs are actually **protective** against these cancers. OCPs reduce the risk of ovarian cancer by suppressing ovulation and endometrial cancer by providing progestin to counteract estrogenic stimulation. Smoking has a complex relationship with these but is generally considered to have a slight protective effect on the endometrium due to its anti-estrogenic properties. * **Breast:** While OCPs may cause a very slight, transient increase in breast cancer risk during use, smoking is not a primary established risk factor for breast cancer in the same definitive way it is for the cervix. **NEET-PG High-Yield Pearls:** * **OCP Protection:** 5 years of use reduces Ovarian cancer risk by ~50% and Endometrial cancer risk by ~50%. * **Smoking & Cervix:** Smoking specifically increases the risk of **Squamous Cell Carcinoma**, but notably *not* Adenocarcinoma of the cervix. * **Most Important Risk Factor:** For cervical cancer, the most important risk factor remains persistent infection with **High-Risk HPV (16 and 18)**. OCPs and smoking are considered significant "co-factors."

Question 247: Which of the following can be presenting symptoms of carcinoma of the cervix?

A. Postcoital bleeding
B. Abnormal vaginal bleeding
C. Purulent discharge per vaginum
D. All of the above (Correct Answer)

Explanation: **Explanation:** Carcinoma of the cervix is the most common gynecological malignancy in many developing countries and typically presents with symptoms related to the friability and necrosis of the cervical lesion. * **Postcoital bleeding (Option A):** This is the **most characteristic** and often the earliest symptom. The cancerous tissue is highly vascular and fragile; mechanical trauma during intercourse causes the surface capillaries to rupture, leading to bright red spotting. * **Abnormal vaginal bleeding (Option B):** As the tumor grows and undergoes spontaneous surface necrosis, patients may experience intermenstrual bleeding or heavy menstrual cycles (menorrhagia). In postmenopausal women, any vaginal bleeding is a red flag for malignancy. * **Purulent discharge per vaginum (Option C):** Large, exophytic masses often outgrow their blood supply, leading to central necrosis and secondary bacterial infection. This results in a foul-smelling, serosanguinous, or purulent vaginal discharge. **Why "All of the above" is correct:** All three symptoms are classic clinical manifestations of cervical cancer. While postcoital bleeding is the most specific "textbook" sign, abnormal bleeding and malodorous discharge are frequently encountered in clinical practice as the disease progresses. **High-Yield Clinical Pearls for NEET-PG:** * **Screening:** The most common screening method is the **Pap smear** (cytology), while the gold standard for diagnosis is a **Colposcopy-directed biopsy**. * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), though imaging (MRI/CT) is now integrated into the 2018 revised staging. * **Risk Factor:** Persistent infection with High-Risk **HPV types 16 and 18** is the primary causative factor. * **Triad of Advanced Disease:** Leg edema, hydronephrosis, and sciatic pain indicate pelvic wall involvement (Stage IIIB).

Question 248: A 45-year-old lady complains of contact bleeding and has a positive Pap smear. What is the next line of management?

A. Colposcopy-directed biopsy (Correct Answer)
B. Cone biopsy
C. Repeat Pap smear
D. Hysterectomy

Explanation: **Explanation:** The clinical presentation of **contact bleeding** (a hallmark symptom of cervical cancer) combined with an abnormal Pap smear is highly suspicious for cervical intraepithelial neoplasia (CIN) or invasive malignancy. **1. Why Colposcopy-directed Biopsy is the correct answer:** The Pap smear is a **screening tool**, not a diagnostic one. When a screening test is positive or clinical symptoms are suggestive, the standard "Next Step" in management is to visualize the cervix under magnification (Colposcopy) and take a **directed biopsy** from the most suspicious areas (e.g., acetowhite epithelium, punctations, or mosaicism). This provides a histological diagnosis, which is mandatory before planning definitive treatment. **2. Why other options are incorrect:** * **Cone Biopsy:** This is a diagnostic-cum-therapeutic procedure. It is indicated only if colposcopy is unsatisfactory (e.g., the transformation zone is not fully visible), if there is a discrepancy between cytology and biopsy, or to rule out microinvasion. It is not the immediate next step. * **Repeat Pap Smear:** Repeating a screening test in the presence of a positive result and clinical symptoms (contact bleeding) leads to a dangerous delay in diagnosis. * **Hysterectomy:** This is a major surgical treatment. It should never be performed without a confirmed histological diagnosis of the grade and stage of the lesion. **Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** Cervical Biopsy (Colposcopy-directed). * **Triad of Cervical Screening:** Cytology (Pap smear) → Colposcopy → Biopsy. * **Contact Bleeding:** In a perimenopausal woman, always rule out cervical cancer first. * **Atypical Glandular Cells (AGC) on Pap:** These require more aggressive evaluation, often including endocervical curettage and endometrial sampling.

Question 249: What is the most common ovarian tumor in individuals less than 20 years old?

A. Epithelial tumor
B. Germ cell tumor (Correct Answer)
C. Metastatic tumor
D. Sex cord-stromal tumor

Explanation: **Explanation:** The distribution of ovarian tumors varies significantly with age. In children and adolescents (individuals <20 years old), **Germ cell tumors (GCTs)** are the most common category, accounting for approximately 60–70% of all ovarian neoplasms in this age group. This is because the ovaries in younger individuals are physiologically dominated by oocytes rather than the surface epithelium. While most GCTs in this demographic are benign (e.g., Mature Cystic Teratoma), the risk of malignancy is higher than in adults; roughly 1/3rd of GCTs in girls under 20 are malignant. **Analysis of Incorrect Options:** * **A. Epithelial tumors:** These are the most common ovarian tumors in **postmenopausal women** and the general population (accounting for 90% of all ovarian cancers). They are rare before puberty. * **C. Metastatic tumors:** Also known as Krukenberg tumors (when from the GI tract), these are more common in older adults and are rarely the primary presentation in adolescents. * **D. Sex cord-stromal tumors:** These (e.g., Granulosa cell tumors) represent only about 5–10% of all ovarian tumors and can occur at any age, but they are far less frequent than GCTs in the under-20 age group. **High-Yield Clinical Pearls for NEET-PG:** * **Most common benign GCT:** Mature Cystic Teratoma (Dermoid cyst). * **Most common malignant GCT:** Dysgerminoma (associated with LDH as a marker). * **Tumor Marker Association:** Always check AFP (Endodermal sinus tumor) and hCG (Choriocarcinoma) in young patients with adnexal masses. * **Management:** In young patients, fertility-sparing surgery (unilateral salpingo-oophorectomy) is the standard of care for malignant GCTs, as they are highly chemosensitive.

Question 250: Which stage of cervical carcinoma has a 100% cure rate?

A. Invasive carcinoma
B. Carcinoma in situ (Correct Answer)
C. Microinvasive carcinoma
D. Extensive carcinoma

Explanation: **Explanation:** **Carcinoma in situ (CIS)**, also classified as CIN 3, represents the pre-invasive stage of cervical cancer where the full thickness of the cervical epithelium is replaced by dysplastic cells. The correct answer is CIS because, by definition, the basement membrane remains intact. Since there is no invasion into the underlying stroma, there is zero access to the lymphatic or vascular systems, making metastasis impossible. When treated with local excision (like LEEP or Cold Knife Conization) or hysterectomy, the cure rate is effectively **100%**. **Analysis of Incorrect Options:** * **Invasive Carcinoma:** This implies the basement membrane has been breached. Once cells enter the stroma, they gain access to lymphatics, significantly decreasing the survival rate depending on the FIGO stage. * **Microinvasive Carcinoma (Stage IA1):** Defined as stromal invasion ≤3 mm in depth. While the prognosis is excellent (>98% survival), there is a very small but real risk (approx. 1%) of lymph node metastasis, meaning the cure rate is not a guaranteed 100%. * **Extensive Carcinoma:** This refers to advanced-stage disease (Stage III or IV) with spread to the pelvic wall, lower vagina, or distant organs, carrying a much lower survival rate. **NEET-PG High-Yield Pearls:** * **Definition of Microinvasion:** Depth of invasion ≤5 mm (FIGO 2018). Stage IA1 is ≤3 mm; Stage IA2 is >3 mm to ≤5 mm. * **Screening:** The goal of the Pap smear and HPV DNA testing is to detect CIS/CIN 3 before it progresses to invasive cancer. * **Transformation Zone:** This is the most common site for CIS to develop. * **Treatment of choice for CIS:** Cervical Conization (preserves fertility) or Simple Hysterectomy (if fertility is not desired).

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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