Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 251: A female patient with a solid ovarian neoplasm developed Meigs syndrome. Which of the following are the components of this triad, EXCEPT?

A. Pulmonary edema (Correct Answer)
B. Pleural effusion
C. Ascites
D. Solid ovarian mass

Explanation: **Explanation:** **Meigs Syndrome** is a classic clinical triad characterized by the presence of a **benign solid ovarian tumor**, **ascites**, and **pleural effusion**. The syndrome is unique because these features typically suggest advanced malignancy, yet in Meigs syndrome, the condition resolves completely following the surgical removal of the tumor. 1. **Why "Pulmonary Edema" is the correct answer:** Pulmonary edema refers to fluid accumulation within the lung parenchyma (alveoli), usually due to heart failure or systemic fluid overload. In Meigs syndrome, the fluid is **extrapulmonary** (pleural effusion), located in the pleural space. Therefore, pulmonary edema is not a component of the triad. 2. **Analysis of incorrect options:** * **Solid ovarian mass:** The most common tumor associated is an **Ovarian Fibroma** (a benign sex cord-stromal tumor). Other solid tumors like thecomas or Brenner tumors can also cause it. * **Ascites:** Fluid accumulation in the peritoneal cavity is a hallmark. It is thought to result from the tumor surface oozing fluid or pressure on pelvic lymphatics. * **Pleural effusion:** This is typically a **transudate** and is more commonly found on the **right side** (70% of cases). It occurs due to the transfer of ascitic fluid through transdiaphragmatic lymphatics or small diaphragmatic defects. **High-Yield Pearls for NEET-PG:** * **Pseudo-Meigs Syndrome:** A similar triad but associated with other pelvic masses (e.g., ovarian cysts, leiomyomas) or malignant tumors. * **Demons-Meigs Syndrome:** Another name for the same condition. * **Management:** The definitive treatment is **Surgical Excision** of the tumor, which leads to spontaneous resolution of both ascites and effusion. * **Key Histology:** Ovarian fibromas show spindle-shaped cells producing collagen.

Question 252: A 40-year-old woman presents with abnormal cervical cytology on PAP smear suggestive of CIN (III). What is the next best step in management?

A. Hysterectomy
B. Colposcopy and LEEP (Correct Answer)
C. Colposcopy and cryotherapy
D. Conization

Explanation: **Explanation:** The management of cervical intraepithelial neoplasia (CIN) follows a "see-and-treat" or "biopsy-and-treat" algorithm. When a PAP smear indicates a high-grade squamous intraepithelial lesion (HSIL) or **CIN III**, the objective is to visualize the lesion and provide definitive treatment while preserving the uterus. **Why Option B is Correct:** **Colposcopy** is the essential next step to visualize the transformation zone and assess the extent of the lesion. **LEEP (Loop Electrosurgical Excision Procedure)** is the preferred treatment for CIN III because it is both diagnostic and therapeutic. Unlike ablative methods, LEEP provides a tissue specimen for histopathological examination to rule out occult invasive carcinoma, which is critical in high-grade lesions. **Analysis of Incorrect Options:** * **A. Hysterectomy:** This is considered overtreatment for CIN III. Hysterectomy is only indicated if there are coexisting gynecological issues, recurrent CIN after excision, or if invasive cancer is confirmed and staged. * **C. Colposcopy and Cryotherapy:** Cryotherapy is an ablative technique. It is generally avoided in CIN III because it does not provide a tissue sample for pathology and has a higher failure rate for high-grade lesions compared to excisional methods. * **D. Conization (Cold Knife):** While effective, it is usually reserved for cases where the transformation zone is not fully visible, if adenocarcinoma in situ is suspected, or if LEEP is unavailable. It requires general anesthesia and has higher morbidity (e.g., cervical stenosis) compared to LEEP. **Clinical Pearls for NEET-PG:** * **CIN I:** Usually managed by observation (repeat PAP/HPV testing in 1 year) as most regress spontaneously. * **CIN II/III:** Requires treatment (Excision or Ablation). Excision (LEEP) is preferred for CIN III. * **Major Risk Factor:** Persistent infection with high-risk HPV types 16 and 18. * **Transformation Zone:** The most common site for cervical neoplasia; it must be fully visualized during colposcopy for the exam to be considered "satisfactory."

Question 253: Which of the following statements is FALSE regarding vulvar carcinoma?

A. The most common type is squamous cell carcinoma.
B. Vulvar carcinoma in situ occurs more commonly in younger females. (Correct Answer)
C. Basaloid or warty types are associated with HPV.
D. The keratinizing type is associated with lichen sclerosus and occurs in older females.

Explanation: ### Explanation **1. Why Option B is the Correct (False) Statement:** While **Vulvar Intraepithelial Neoplasia (VIN)**—the precursor lesion—is increasingly seen in younger women due to HPV exposure, **Vulvar Carcinoma in situ (CIS)** or invasive carcinoma remains a disease primarily of **postmenopausal women** (peak incidence in the 7th and 8th decades). The statement is false because the actual malignancy (CIS/Invasive) is rare in young females; it is the pre-invasive VIN that is common in the younger age group. **2. Analysis of Other Options:** * **Option A:** Correct. **Squamous cell carcinoma (SCC)** accounts for approximately 90% of all vulvar malignancies. * **Option C:** Correct. There are two distinct pathways for vulvar SCC. The **Basaloid/Warty type** is seen in younger patients, is multicentric, and is strongly associated with **High-risk HPV (16, 18)**. * **Option D:** Correct. The **Keratinizing type** is the most common variant. It occurs in older women, is **not** related to HPV, and typically arises from long-standing **Lichen Sclerosus** or differentiated VIN (dVIN). **3. NEET-PG High-Yield Pearls:** * **Most common symptom:** Long-standing pruritus (itching). * **Most common site:** Labia majora. * **Staging:** Vulvar cancer is staged **Surgically** (FIGO). * **Lymphatic Spread:** The primary route of spread is via lymphatics to the **Inguinal and Femoral nodes** (Sentinel node biopsy is preferred for early stages). * **Cloquet’s Node:** The highest deep inguinal node; its involvement indicates a poor prognosis and likely pelvic node involvement.

Question 254: A woman is found to have a unilateral invasive carcinoma of the vulva that is 1 cm in diameter with no stromal invasion and is not associated with evidence of lymph node spread. What should be the initial management?

A. Chemotherapy
B. Radiation therapy
C. Wide excision and Sentinel lymph node biopsy (Correct Answer)
D. Radical vulvectomy and bilateral inguinal lymphadenectomy

Explanation: This question tests the management of early-stage vulvar cancer based on the **FIGO Staging (Stage IA/IB)**. ### **Explanation of the Correct Answer** The patient has a small (1 cm), unilateral invasive carcinoma. According to current guidelines, for **Stage IA/IB lesions** (size ≤2 cm), the goal is to minimize surgical morbidity while ensuring oncological safety. * **Wide Local Excision:** This is the preferred treatment for localized lesions to achieve a 1 cm clear margin, replacing the older, more disfiguring radical vulvectomy. * **Sentinel Lymph Node Biopsy (SLNB):** For tumors with stromal invasion >1 mm (implied by "invasive carcinoma"), nodal assessment is mandatory. SLNB is now the standard of care for tumors <4 cm with clinically negative nodes (cN0) to avoid the high morbidity of full lymphadenectomy (e.g., lymphedema). ### **Why Other Options are Incorrect** * **A & B (Chemotherapy/Radiation):** These are typically reserved for advanced stages (Stage III/IV), non-resectable tumors, or as adjuvant therapy if margins or nodes are positive. They are not primary treatments for early, localized disease. * **D (Radical Vulvectomy and Bilateral Lymphadenectomy):** This was the historical "gold standard" but is now considered overtreatment for a 1 cm unilateral lesion. Bilateral dissection is only indicated if the lesion is midline or if the ipsilateral sentinel node is positive. ### **High-Yield Clinical Pearls for NEET-PG** * **Stage IA:** Tumor ≤2 cm with stromal invasion **≤1 mm**. Management: Wide local excision **without** nodal dissection. * **Stage IB:** Tumor ≤2 cm with stromal invasion **>1 mm**. Management: Wide local excision **with** SLNB or inguinal lymphadenectomy. * **Most common histology:** Squamous Cell Carcinoma (SCC). * **Lymphatic Spread:** Vulvar cancer spreads predictably from inguinal to femoral to iliac nodes. The **Cloquet’s node** is the highest deep inguinal node; its involvement suggests pelvic node spread.

Question 255: Genes most closely associated with familial cases of ovarian cancer are:

A. BRCA1 (Correct Answer)
B. WT1
C. NF2
D. VHL

Explanation: **Explanation:** **1. Why BRCA1 is the Correct Answer:** Ovarian cancer has the highest heritability among all adult cancers, with approximately 15–20% of cases being familial. The most common cause is **Hereditary Breast and Ovarian Cancer (HBOC) syndrome**, caused by germline mutations in the **BRCA1** and **BRCA2** genes. * **BRCA1 (on Chromosome 17q):** Carries a lifetime risk of ovarian cancer of approximately **40–50%**. It is more closely associated with ovarian cancer than BRCA2. * **BRCA2 (on Chromosome 13q):** Carries a lifetime risk of approximately **15–25%**. These are tumor suppressor genes involved in DNA repair via homologous recombination. **2. Why Other Options are Incorrect:** * **WT1 (Wilms Tumor 1):** Located on Chromosome 11p13, this gene is primarily associated with Wilms tumor (nephroblastoma) in children and certain syndromes like WAGR and Denys-Drash. * **NF2 (Neurofibromatosis Type 2):** Located on Chromosome 22q, it encodes the protein Merlin. Mutations lead to bilateral acoustic neuromas (vestibular schwannomas) and meningiomas. * **VHL (von Hippel-Lindau):** Located on Chromosome 3p, it is associated with VHL syndrome, characterized by hemangioblastomas, renal cell carcinoma (clear cell), and pheochromocytomas. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common histology:** BRCA-associated ovarian cancers are typically **High-Grade Serous Carcinomas (HGSC)**. * **Lynch Syndrome (HNPCC):** The second most common cause of familial ovarian cancer (associated with MSH2, MLH1, MSH6 genes). * **Prophylaxis:** Risk-reducing salpingo-oophorectomy (RRSO) is recommended by age 35–40 for BRCA1 carriers. * **Treatment:** Patients with BRCA mutations show a better response to Platinum-based chemotherapy and **PARP inhibitors** (e.g., Olaparib).

Question 256: Which statement regarding the procedure shown below is false?

A. Used to treat high grade cervical intraepithelial neoplasia (CIN) (Correct Answer)
B. Uses freeze-thaw-freeze technique
C. Destroys dysplastic epithelium up to a depth of 5mm
D. It is an outpatient procedure

Explanation: ***Used to treat high grade cervical intraepithelial neoplasia (CIN)*** - **Cervical cryotherapy** is **NOT recommended** for high-grade CIN (CIN 2/3) as it cannot ensure complete destruction of dysplastic tissue and lacks histological confirmation. - High-grade CIN requires **excisional procedures** like **LEEP/LLETZ** or **cold knife conization** to obtain tissue for histopathological examination and ensure complete removal. *Uses freeze-thaw-freeze technique* - Cryotherapy employs a **double freeze-thaw-freeze cycle** using **liquid nitrogen** or **nitrous oxide** to achieve temperatures of -60°C to -80°C. - The technique involves **freezing for 3 minutes**, allowing **thawing**, then **refreezing for 3 minutes** to ensure adequate tissue destruction. *Destroys dysplastic epithelium up to a depth of 5mm* - Cryotherapy penetrates to a depth of **4-5mm**, which is sufficient to destroy the **transformation zone** and underlying dysplastic tissue. - The **ice ball** extends beyond the visible lesion margins to ensure complete destruction of abnormal epithelium. *It is an outpatient procedure* - Cryotherapy is performed as an **outpatient procedure** in the office setting without requiring **general anesthesia**. - Patients can resume normal activities immediately with minimal **post-procedure discomfort** and **watery discharge** for 2-3 weeks.

Question 257: Which of the following is a predisposing risk factor for carcinoma of the cervix?

A. Human Papillomavirus (HPV) infection
B. Smoking
C. Alcohol consumption
D. All of the above (Correct Answer)

Explanation: **Explanation:** Carcinoma of the cervix is primarily caused by persistent infection with high-risk **Human Papillomavirus (HPV)**, but its progression is significantly influenced by various co-factors that impair local immunity or cause cellular damage. * **Option A (HPV Infection):** This is the most critical risk factor. High-risk strains (HPV 16 and 18) produce E6 and E7 oncoproteins, which inhibit tumor suppressor proteins p53 and pRb, respectively, leading to uncontrolled cell proliferation. * **Option B (Smoking):** Tobacco metabolites (cotinine) concentrate in the cervical mucus. Smoking acts as a co-carcinogen by causing DNA damage and depleting Langerhans cells (local immune cells) in the cervix, making it harder for the body to clear an HPV infection. * **Option C (Alcohol consumption):** While less frequently emphasized than smoking, chronic alcohol consumption is an established risk factor. It can lead to immunosuppression and is often associated with nutritional deficiencies (like folate) that increase the susceptibility of the cervical epithelium to neoplastic changes. **Why "All of the above" is correct:** Cervical cancer is multifactorial. While HPV is the "initiator," factors like smoking and alcohol act as "promoters" or "facilitators" of carcinogenesis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common strain:** HPV 16 (Squamous cell carcinoma); HPV 18 (Adenocarcinoma). * **Other Risk Factors:** Early age at first intercourse, multiple sexual partners, high parity, and long-term use of Oral Contraceptive Pills (OCPs). * **Protective Factor:** Barrier contraception (condoms) and Vitamin A/C/E intake. * **Screening:** The transformation zone is the most common site for cervical cancer development.

Question 258: What is considered the best screening test for cervical cancer?

A. Pap smear
B. Visual inspection with acetic acid (VIA) (Correct Answer)
C. Both Pap smear and VIA test
D. None of the above

Explanation: **Explanation:** The choice of the "best" screening test for cervical cancer often depends on the clinical setting and resource availability. In the context of national guidelines in India (and frequently in NEET-PG questions), **Visual Inspection with Acetic Acid (VIA)** is considered the preferred screening modality for mass screening programs. **Why VIA is the Correct Answer:** 1. **Feasibility and Immediate Results:** Unlike cytology, VIA provides instantaneous results ("See and Treat" approach), ensuring no loss to follow-up. 2. **Cost-Effectiveness:** It requires minimal infrastructure and can be performed by trained paramedical staff (nurses/ANMs) in low-resource settings. 3. **Sensitivity:** VIA has a comparable, and often higher, sensitivity (though lower specificity) than a single Pap smear for detecting high-grade precancerous lesions. **Analysis of Incorrect Options:** * **A. Pap Smear:** While traditionally the "gold standard" in developed countries due to high specificity, it has lower sensitivity (approx. 50-60%) for a single test. It requires specialized cytopathologists and sophisticated lab infrastructure, making it less ideal for mass screening in the Indian public health context. * **C. Both Pap smear and VIA:** While combining tests increases sensitivity, it is not cost-effective or practical for primary screening in a national program. **High-Yield Clinical Pearls for NEET-PG:** * **Procedure:** 3-5% Acetic acid is applied; a positive result is the appearance of **opaque, well-demarcated aceto-white lesions** near the squamocolumnar junction. * **Age Group:** In India, screening is recommended for women aged **30–65 years**, every 5 years. * **Gold Standard for Diagnosis:** Colposcopy-directed biopsy (Screening is VIA/Pap; Diagnosis is Biopsy). * **HPV DNA Testing:** Currently considered the most sensitive screening method and is the preferred primary screen in updated international guidelines (WHO), but VIA remains the practical answer for Indian public health questions.

Question 259: Alpha-fetoprotein (AFP) is increased in which of the following conditions?

A. Endodermal sinus tumor (Correct Answer)
B. Teratoma
C. Dysgerminoma
D. Choriocarcinoma

Explanation: **Explanation:** **Endodermal Sinus Tumor (Yolk Sac Tumor)** is the correct answer because it is derived from the primitive yolk sac. In fetal life, the yolk sac is the primary site of **Alpha-fetoprotein (AFP)** synthesis. Therefore, this tumor serves as a highly specific marker for AFP. It is the most common malignant germ cell tumor in children and young adults, characterized histologically by **Schiller-Duval bodies**. **Analysis of Incorrect Options:** * **Teratoma:** Mature teratomas are benign and do not typically produce markers. Immature teratomas may show a mild elevation of AFP if they contain yolk sac elements, but they are primarily associated with LDH or CA-125. * **Dysgerminoma:** This is the most common malignant germ cell tumor overall. Its characteristic markers are **LDH (Lactate Dehydrogenase)** and sometimes **hCG** (if syncytiotrophoblastic giant cells are present), but never AFP. * **Choriocarcinoma:** This tumor is characterized by the proliferation of trophoblastic tissue, making **beta-hCG** its pathognomonic marker. **High-Yield Clinical Pearls for NEET-PG:** * **AFP** is also elevated in Hepatocellular Carcinoma (HCC) and Neural Tube Defects (NTD). * **Marker Combinations:** If a tumor shows both elevated AFP and hCG, consider an **Embryonal Carcinoma** or a **Mixed Germ Cell Tumor**. * **Schiller-Duval Bodies:** Pathognomonic histological finding for Yolk Sac Tumors (resemble primitive glomeruli). * **Management:** Most malignant germ cell tumors are highly sensitive to the **BEP regimen** (Bleomycin, Etoposide, and Platinum/Cisplatin).

Question 260: A 22-year-old female underwent suction evacuation for molar pregnancy. Beta HCG levels are persistently high following evacuation. What is the next line of management?

A. Follow up at 1 year
B. Monitor until HCG becomes 0
C. Hysterectomy
D. Methotrexate (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Methotrexate** **Medical Concept:** The clinical scenario describes **Gestational Trophoblastic Neoplasia (GTN)**. Following suction evacuation of a molar pregnancy, the primary goal of follow-up is to monitor serum $\beta$-hCG levels. If these levels plateau (remain within $\pm$ 10% over three weekly measurements) or rise (increase $>10\%$ over two weekly measurements), it indicates a malignant transformation into GTN (Invasive mole or Choriocarcinoma). In a young patient (22 years old) with persistent $\beta$-hCG, the standard of care is **single-agent chemotherapy**, typically with **Methotrexate** or Actinomycin-D, to preserve fertility and achieve remission. **Analysis of Incorrect Options:** * **A & B (Follow-up/Monitoring):** While monitoring is the standard post-evacuation protocol, it is only appropriate if $\beta$-hCG levels are *falling*. Once levels become "persistently high" or rise, it signifies GTN, and active intervention is mandatory to prevent metastasis. * **C (Hysterectomy):** Although hysterectomy reduces the tumor burden, it is generally reserved for older patients who have completed their family or those with life-threatening hemorrhage. In a 22-year-old, fertility preservation is a priority, making chemotherapy the preferred first-line treatment. **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Criteria for GTN Diagnosis:** 1. $\beta$-hCG plateau for 4 readings over 3 weeks. 2. $\beta$-hCG rise of $>10\%$ for 3 readings over 2 weeks. 3. Persistence of $\beta$-hCG 6 months after evacuation. 4. Histological diagnosis of choriocarcinoma. * **WHO Scoring:** GTN is classified into Low-risk (Score $\leq$ 6) and High-risk (Score $\geq$ 7). Low-risk cases (like this patient) are treated with single-agent Methotrexate. * **Most common site of metastasis:** Lungs (80%), followed by the vagina.

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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