Gynecologic Oncology Practice Questions

Q: What is the next line of management for a perimenopausal woman who has an ASCUS (atypical squamous cells of unknown significance) reported on a Pap smear?

Colposcopy. **Explanation:** The management of an abnormal Pap smear follows a risk-based triage system. **ASCUS (Atypical Squamous Cells of Undetermined Significance)** is the most common abnormal finding. According to the ASCCP guidelines, the management for ASCUS depends on the patient's age and HPV status. **1. Why Colposcopy is the correct answer:** In a perimenopausal woman with ASCUS, the standard "next step" is either **HPV DNA testing (Reflex HPV)** or **repeat cytology**. However, if HPV testing is positive for high-risk types, or if the clinical scenario dictates immediate further evaluation (as often tested in NEET-PG scenarios where triage isn't specified), **Colposcopy** is the definitive diagnostic procedure. It allows for direct visualization of the transformation zone and directed biopsies to rule out Cervical Intraepithelial Neoplasia (CIN) or malignancy. **2. Why the other options are incorrect:** * **A & B (Loop excision/Conization):** These are therapeutic/excisional procedures. They are indicated only after a biopsy confirms high-grade dysplasia (CIN II/III) or if there is a discrepancy between cytology and colposcopy. Performing them for ASCUS is "over-treatment." * **D (Hysterectomy):** This is never the primary management for an abnormal Pap smear. It is only considered for confirmed invasive cancer or specific cases of recurrent high-grade dysplasia where fertility is not desired. **High-Yield Clinical Pearls for NEET-PG:** * **ASCUS Triage:** If HPV negative → Repeat Pap in 3 years. If HPV positive → Proceed to **Colposcopy**. * **LSIL/HSIL:** Generally proceed directly to colposcopy (except in specific age groups like adolescents). * **Pregnancy:** If ASCUS is found during pregnancy, colposcopy is safe, but endocervical curettage and biopsies are generally avoided unless invasive cancer is suspected. * **Bethesda System:** Remember that ASCUS is the most common but least specific abnormality on a Pap smear.

Q: What is the earliest symptom of cervical cancer?

Bleeding per vagina. **Explanation:** The earliest and most characteristic clinical presentation of cervical cancer is **abnormal vaginal bleeding**. This occurs because the malignant cells invade the cervical stroma, leading to increased vascularity and friability of the tissue. Even minor trauma to the cervix causes these fragile surface vessels to rupture. * **Post-coital bleeding:** This is the most specific early sign in sexually active women. * **Intermenstrual bleeding:** Irregular spotting between periods. * **Post-menopausal bleeding:** Any vaginal bleeding in a post-menopausal woman must be investigated for malignancy (cervical or endometrial). **Analysis of Incorrect Options:** * **Leukorrhoea (D):** While a foul-smelling, serosanguinous (blood-tinged) discharge is a common early symptom, frank bleeding usually precedes or accompanies it as the primary complaint. * **Dyspareunia (A):** This refers to painful intercourse. While it can occur due to local tumor bulk or infection, it is typically a secondary symptom rather than the earliest sign. * **Pain (C):** Pain is a **late feature** of cervical cancer. It signifies advanced disease (Stage IIB or higher) where the tumor has infiltrated the pelvic wall, compressed nerve plexuses, or caused hydronephrosis by obstructing the ureters. **High-Yield Clinical Pearls for NEET-PG:** * **Screening:** The most effective screening tool is the **Pap Smear** (starting at age 21) or **HPV DNA testing** (starting at age 30). * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), unlike endometrial or ovarian cancers which are staged surgically. * **Most Common Histology:** Squamous cell carcinoma (80-85%). * **Risk Factor:** Persistent infection with High-Risk HPV types **16 and 18**.

Q: Which of the following is a feature of stage lb2 cancer of the cervix?

Microinvasive carcinoma with stromal invasion > 5 mm. This question tests your knowledge of the **FIGO 2018 Staging for Cervical Cancer**, which is a high-yield topic for NEET-PG. ### **Explanation of the Correct Answer** According to the FIGO 2018 classification, **Stage IB** refers to invasive carcinomas limited to the cervix with deeper invasion than Stage IA. * **Stage IB1:** Invasive carcinoma $\ge$ 5 mm depth of stromal invasion and $<2$ cm in greatest dimension. * **Stage IB2:** Invasive carcinoma **$\ge$ 5 mm depth of stromal invasion** and **$\ge$ 2 cm to $<4$ cm** in greatest dimension. Therefore, any lesion in Stage IB (including IB2) must have a stromal invasion **greater than 5 mm**, as lesions with $\le$ 5 mm invasion are classified under Stage IA. ### **Analysis of Incorrect Options** * **Options A & B:** These represent **Stage IA**. Specifically, Stage IA1 is invasion $ 4$ cm is classified as **Stage IB3**. ### **High-Yield Clinical Pearls for NEET-PG** 1. **FIGO 2018 Update:** The most significant change from the 2009 staging is that **Stage IB is now divided into three subgroups** (IB1, IB2, IB3) based on 2 cm increments in size. 2. **Imaging & Pathology:** Unlike previous versions, FIGO 2018 allows the use of **radiological imaging** (MRI/CT) and **pathological findings** to assign the stage. 3. **Lymphovascular Space Invasion (LVSI):** While noted in reports, LVSI **does not change the FIGO stage**. 4. **Stage IA Diagnosis:** Stage IA1 and IA2 must be diagnosed via microscopy (usually a cone biopsy). If a lesion is visible to the naked eye, it is at least Stage IB.

Q: A patient presents with bilateral ovarian cancer with capsule breached and ascites positive for malignant cells. What is the clinical stage?

Stage I. This question tests your knowledge of the **FIGO Staging for Ovarian Cancer**. The correct answer is **Stage I** because the disease is strictly confined to the ovaries. ### Explanation of the Correct Answer According to the FIGO staging system: * **Stage IA:** Tumor limited to one ovary, capsule intact, no tumor on surface, no malignant cells in ascites/peritoneal washings. * **Stage IB:** Tumor limited to **both ovaries**, capsules intact, no tumor on surface, no malignant cells in ascites. * **Stage IC:** Tumor limited to one or both ovaries with any of the following: * IC1: Surgical spill. * IC2: Capsule ruptured before surgery or tumor on ovarian surface. * **IC3: Malignant cells in the ascites or peritoneal washings.** In this scenario, since the cancer is bilateral and the ascites is positive for malignant cells, it is classified as **Stage IC3**, which falls under the broader category of **Stage I**. ### Why Other Options are Incorrect * **Stage II:** Requires pelvic extension (e.g., involvement of uterus, fallopian tubes, bladder, or rectum) below the pelvic brim. * **Stage III:** Involves spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes. * **Stage IV:** Represents distant metastasis (e.g., pleural effusion with positive cytology, parenchymal metastases to liver/spleen, or extra-abdominal organs). ### NEET-PG High-Yield Pearls 1. **Most Common Presentation:** Most ovarian cancers (approx. 75%) are diagnosed at **Stage III** because they are asymptomatic in early stages. 2. **Prognostic Factor:** The presence of malignant cells in ascites (Stage IC3) significantly worsens the prognosis compared to Stage IA or IB. 3. **Lymph Node Involvement:** If only retroperitoneal lymph nodes are involved, it is **Stage IIIA1**. 4. **Liver Involvement:** Liver **surface** involvement is Stage III; Liver **parenchymal** involvement is Stage IVB.

Q: Which of the following is NOT an investigation for early-stage carcinoma of the cervix?

Ultrasound. **Explanation:** The diagnosis and staging of **Carcinoma Cervix** are primarily clinical. According to the **FIGO staging (revised 2018)**, while imaging like MRI or CT can be used for staging, **Ultrasound (USG)** is not a standard investigation for the primary diagnosis or evaluation of early-stage cervical cancer. USG lacks the sensitivity to detect micro-invasion or accurately delineate small cervical lesions. **Why the other options are incorrect (Used in diagnosis):** * **Schiller’s Test:** This is a screening/diagnostic aid where Lugol’s iodine is applied to the cervix. Normal squamous epithelium contains glycogen and turns mahogany brown. Dysplastic or cancerous cells are glycogen-deficient and remain **unstained (Schiller positive)**, helping to identify suspicious areas. * **Colposcopy-guided Biopsy:** This is the **Gold Standard** for diagnosing early-stage cervical cancer. Colposcopy allows for the visualization of abnormal vascular patterns (punctations, mosaicism), and a directed biopsy provides the definitive histological diagnosis. * **Surface Biopsy (Punch Biopsy):** This involves taking a tissue sample from the surface of a visible growth or a suspicious area identified during a speculum examination. It is a fundamental step in confirming malignancy. **High-Yield Clinical Pearls for NEET-PG:** 1. **FIGO Staging:** Carcinoma cervix is staged **clinically**. However, the 2018 revision allows the use of "available" imaging (MRI/CT) and pathology to supplement findings. 2. **Definitive Diagnosis:** Always requires a **histopathological examination (biopsy)**. 3. **IOC for Parametrial Involvement:** MRI is the investigation of choice to assess local spread and parametrial invasion. 4. **Screening:** Pap smear is the most common screening tool, while HPV DNA testing is the most sensitive.

Q: All of the following are markers for malignant germ cell tumors of the ovary except?

CA-125. **Explanation:** The correct answer is **A. CA-125**. **1. Why CA-125 is the correct answer:** CA-125 (Cancer Antigen 125) is the primary tumor marker for **Epithelial Ovarian Tumors** (specifically serous cystadenocarcinoma), not Germ Cell Tumors (GCTs). While it can be non-specifically elevated in various conditions like endometriosis, PID, or pregnancy, it is not a diagnostic marker for the germ cell lineage. **2. Analysis of other options (Markers for GCTs):** Malignant Germ Cell Tumors (MGCTs) are characterized by the production of specific proteins depending on the tissue of origin: * **Alpha-fetoprotein (AFP):** This is the highly specific marker for **Endodermal Sinus Tumors (Yolk Sac Tumors)**. It is also elevated in immature teratomas and mixed GCTs. * **Human Chorionic Gonadotropin (HCG):** This is the classic marker for **Nongestational Choriocarcinoma**. It is also produced by syncytiotrophoblastic giant cells in some dysgerminomas. * **Lactate Dehydrogenase (LDH):** This is the characteristic marker for **Dysgerminoma**. It is useful for both diagnosis and monitoring treatment response. **3. High-Yield Clinical Pearls for NEET-PG:** * **Dysgerminoma:** Most common malignant GCT; Markers = **LDH**, Placental Alkaline Phosphatase (PLAP). * **Yolk Sac Tumor:** Most common GCT in young children; Marker = **AFP** (Schiller-Duval bodies on histology). * **Immature Teratoma:** Marker = **AFP** (sometimes LDH or CA-125, but AFP is most characteristic). * **Mixed GCT:** Often shows elevation of both AFP and HCG. * **Rule of Thumb:** In a young girl with an adnexal mass, always order AFP, HCG, and LDH to rule out MGCTs.

Q: A 40-year-old lady with breast cancer has undergone Modified Radical Mastectomy (MRM) and is on Tamoxifen for 1 year. She now presents with bleeding per vaginum 4-5 times. What is the probable cause?

Endometrial cancer. **Explanation:** The correct answer is **Endometrial cancer**. **1. Why Endometrial Cancer is the correct answer:** Tamoxifen is a Selective Estrogen Receptor Modulator (SERM). While it acts as an **estrogen antagonist** in breast tissue (making it effective for breast cancer treatment), it acts as a **partial estrogen agonist** in the uterus. This estrogenic stimulation leads to endometrial hyperplasia, polyp formation, and significantly increases the risk of **Endometrial Carcinoma** (specifically Type 1, endometrioid variety). In a patient on Tamoxifen presenting with postmenopausal or abnormal uterine bleeding (AUB), endometrial malignancy must be ruled out first via transvaginal ultrasound (TVS) and endometrial biopsy. **2. Why other options are incorrect:** * **Bleeding disorder:** While systemic coagulopathies can cause AUB, they are less likely in a 40-year-old with a specific pharmacological trigger (Tamoxifen). * **Ovarian cancer:** Ovarian cancer typically presents with abdominal distension, bloating, or adnexal masses rather than direct vaginal bleeding. * **Cervical cancer:** Though it causes post-coital or intermenstrual bleeding, it is not pharmacologically linked to Tamoxifen use. **Clinical Pearls for NEET-PG:** * **Tamoxifen Risk:** The risk of endometrial cancer is dose and duration-dependent (usually seen after 1–2 years of use). * **Monitoring:** Routine screening with TVS or biopsy is **not** recommended for asymptomatic women on Tamoxifen; however, any instance of abnormal bleeding requires immediate investigation. * **Alternative:** **Raloxifene**, another SERM used for osteoporosis, acts as an estrogen antagonist in both the breast and uterus, thus it does *not* increase the risk of endometrial cancer. * **Investigation of Choice:** The gold standard for diagnosing endometrial pathology in this patient is a **Fractional Curettage** or **Hysteroscopic-guided biopsy**.

Question 1

In a young woman diagnosed with stage Ib cervical cancer, which structure is not removed during a radical hysterectomy?

Accepted Answer

Both ovaries

Answer

Uterosacral and uterovesical ligaments

Answer

Pelvic lymph nodes

Answer

Upper third of the vagina

Question 2

What is the next line of management for a perimenopausal woman who has an ASCUS (atypical squamous cells of unknown significance) reported on a Pap smear?

Accepted Answer

Colposcopy

Answer

Loop excision

Answer

Conization

Answer

Hysterectomy

Question 3

What is the earliest symptom of cervical cancer?

Accepted Answer

Bleeding per vagina

Answer

Dyspareunia

Answer

Pain

Answer

Leukorrhoea

Question 4

Which of the following is a feature of stage lb2 cancer of the cervix?

Accepted Answer

Microinvasive carcinoma with stromal invasion > 5 mm

Answer

Microinvasive carcinoma with stromal invasion < 3 mm

Answer

Microinvasive carcinoma with stromal invasion < 5 mm

Answer

Size of lesion <= 4 cm

Question 5

What is the treatment of stage I teratoma?

Accepted Answer

Observation

Answer

Chemotherapy

Answer

Radiotherapy

Answer

Surgery

Question 6

A patient presents with bilateral ovarian cancer with capsule breached and ascites positive for malignant cells. What is the clinical stage?

Accepted Answer

Stage I

Answer

Stage II

Answer

Stage III

Answer

Stage IV

Question 7

A patient presents with postmenopausal bleeding. Endometrial biopsy should be performed if the endometrial thickness is more than:

Accepted Answer

5 mm or more

Answer

3 mm or more

Answer

7 mm or more

Answer

8 mm or more

Question 8

Which of the following is NOT an investigation for early-stage carcinoma of the cervix?

Accepted Answer

Ultrasound

Answer

Surface biopsy

Answer

Colposcopy-guided biopsy

Answer

Schiller's test

Question 9

All of the following are markers for malignant germ cell tumors of the ovary except?

Accepted Answer

CA-125

Answer

Alpha fetoprotein

Answer

HCG

Answer

LDH

Question 10

A 40-year-old lady with breast cancer has undergone Modified Radical Mastectomy (MRM) and is on Tamoxifen for 1 year. She now presents with bleeding per vaginum 4-5 times. What is the probable cause?

Accepted Answer

Endometrial cancer

Answer

Bleeding disorder

Answer

Ovarian cancer

Answer

Cervical cancer

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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