Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 261: A young girl shows severe dysplasia on cervical cytology. What is the treatment of choice?

A. Conisation (Correct Answer)
B. Schiller's test
C. Colposcopy
D. Repeat pap smear

Explanation: **Explanation:** The management of cervical dysplasia depends on the severity of the lesion and the patient's clinical profile. In this scenario, **Severe Dysplasia** (equivalent to CIN 3 or HSIL) in a young girl requires definitive diagnostic and therapeutic intervention. **1. Why Conisation is the Correct Answer:** Conisation (Cold Knife Cone or LEEP) is both a diagnostic and therapeutic procedure. For severe dysplasia, it is the treatment of choice because it allows for the complete excision of the **Transformation Zone (TZ)** and the lesion. In young patients, preserving fertility is crucial; conisation removes the abnormal tissue while maintaining the structural integrity of the uterus. It also provides a tissue specimen to rule out occult invasive carcinoma, which cannot be excluded by cytology alone. **2. Why Other Options are Incorrect:** * **Schiller’s Test:** This is a clinical test using Lugol’s iodine to identify non-staining (iodine-negative) areas of the cervix. It is a screening aid, not a treatment. * **Colposcopy:** This is the next step for *evaluating* an abnormal Pap smear to guide biopsies. While essential for diagnosis, it is not a "treatment" for severe dysplasia. * **Repeat Pap Smear:** Severe dysplasia (HSIL) carries a high risk of progression to malignancy. Observation or repeating the smear is inappropriate; immediate histological evaluation and treatment are mandatory. **High-Yield Clinical Pearls for NEET-PG:** * **CIN 1 (Mild):** Usually managed by observation (regresses in 60-80% of cases). * **CIN 2/3 (Moderate to Severe):** Requires excision (Conisation/LEEP) or ablation (Cryotherapy/Laser). * **Transformation Zone:** The most common site for cervical neoplasia; its complete removal is the goal of conisation. * **Young Patients:** Hysterectomy is avoided in young girls to preserve reproductive function unless invasive cancer is confirmed.

Question 262: Granulosa cell tumors primarily secrete which hormone?

A. Progesterone
B. Estrogen (Correct Answer)
C. hCG
D. Calcitonin

Explanation: **Explanation:** **Granulosa Cell Tumors (GCTs)** are the most common type of sex cord-stromal tumors. They are considered "functioning tumors" because they primarily secrete **Estrogen**. This occurs because the tumor cells mimic the function of normal follicular granulosa cells, which convert androgens to estrogens via the aromatase enzyme. **Why Estrogen is the Correct Answer:** The hyperestrogenism associated with GCTs leads to distinct clinical presentations based on age: * **Pre-pubertal girls:** Presents as precocious puberty. * **Reproductive age:** Presents as menstrual irregularities (menorrhagia/metrorrhagia). * **Post-menopausal women:** Presents as post-menopausal bleeding. * *Crucial Link:* Chronic estrogen stimulation often leads to endometrial hyperplasia or even **Endometrial Carcinoma** (seen in up to 5% of cases). **Why Other Options are Incorrect:** * **Progesterone:** While some luteinized granulosa cells may produce small amounts, it is not the primary or characteristic hormone. * **hCG:** This is a marker for germ cell tumors, specifically **Choriocarcinoma**. * **Calcitonin:** This is the classic marker for **Medullary Carcinoma of the Thyroid**, not ovarian tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** **Inhibin (Inhibin B)** is the most sensitive and specific marker for diagnosis and monitoring recurrence. * **Histopathology:** Look for **Call-Exner bodies** (small follicles filled with eosinophilic material) and "coffee-bean" nuclei. * **Prognosis:** They are generally low-grade malignancies but are notorious for **late recurrence** (even after 10–20 years).

Question 263: Schiller-Duval bodies are characteristically seen in which of the following gynecologic tumors?

A. Dysgerminoma
B. Brenner's Tumor
C. Teratoma
D. Endodermal Sinus Tumor (Correct Answer)

Explanation: **Explanation:** **Endodermal Sinus Tumor (Yolk Sac Tumor)** is the correct answer. This is a highly aggressive germ cell tumor, typically occurring in young women and children. The pathognomonic histological feature is the **Schiller-Duval body**. These structures consist of a central capillary surrounded by visceral and parietal layers of neoplastic cells, resembling a primitive glomerulus. Clinically, these tumors are associated with a rapid increase in abdominal girth and a characteristic elevation of the tumor marker **Alpha-Fetoprotein (AFP)**. **Analysis of Incorrect Options:** * **A. Dysgerminoma:** The most common malignant germ cell tumor. Histology shows large, clear cells with central nuclei and prominent nucleoli, separated by fibrous septa containing lymphocytes. It is associated with elevated **LDH**. * **B. Brenner’s Tumor:** Usually a benign surface epithelial tumor. Histology reveals nests of transitional epithelium (resembling bladder mucosa) within a dense fibromatous stroma, often showing **"coffee bean" nuclei**. * **C. Teratoma:** Mature teratomas contain tissues from all three germ layers (ectoderm, mesoderm, endoderm). Immature teratomas are graded based on the amount of **primitive neuroepithelium**. **NEET-PG High-Yield Pearls:** * **Schiller-Duval Body = Endodermal Sinus Tumor (Yolk Sac Tumor).** * **Tumor Marker:** AFP is the gold standard for monitoring Yolk Sac Tumors. * **Call-Exner Bodies:** Seen in Granulosa Cell Tumors (associated with Inhibin and Estrogen). * **Psammoma Bodies:** Seen in Serous Cystadenocarcinoma. * **Reinke Crystals:** Seen in Leydig Cell Tumors.

Question 264: Women receiving Tamoxifen should be periodically screened with which of the following?

A. Mammography
B. Pap smear
C. Ca-125 level
D. Endometrial sampling (Correct Answer)

Explanation: **Explanation:** **1. Why Endometrial Sampling 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 agonist on the endometrium**. This estrogenic stimulation leads to endometrial hyperplasia, polyp formation, and a 2–3 fold increased risk of **Endometrial Carcinoma**. Therefore, any woman on Tamoxifen who presents with abnormal uterine bleeding (AUB) must undergo **endometrial sampling** (biopsy) to rule out malignancy. **2. Why Other Options are Incorrect:** * **A. Mammography:** While women with a history of breast cancer require annual mammograms, this is for monitoring the primary disease/recurrence, not a specific screening requirement *caused* by the side effects of Tamoxifen itself. * **B. Pap Smear:** This is a screening tool for cervical cancer. Tamoxifen does not increase the risk of cervical dysplasia or malignancy. * **C. CA-125:** This is a tumor marker primarily used for monitoring epithelial ovarian cancer. Tamoxifen is not associated with an increased risk of ovarian cancer. **3. Clinical Pearls for NEET-PG:** * **Asymptomatic Screening:** Routine ultrasound or biopsy is **not recommended** for asymptomatic women on Tamoxifen. Investigation is only triggered by **postmenopausal bleeding** or spotting. * **ACOG Guidelines:** Postmenopausal women on Tamoxifen should be closely monitored for symptoms of endometrial hyperplasia and cancer. * **Alternative:** **Raloxifene** is another SERM used for osteoporosis that acts as an antagonist in both breast and endometrial tissue, thus it does *not* increase the risk of endometrial cancer. * **Key Side Effect:** Apart from endometrial cancer, Tamoxifen also increases the risk of **Venous Thromboembolism (VTE)** and hot flashes.

Question 265: Which type of trophoblastic disease has the worst prognosis?

A. Postpartum (Correct Answer)
B. After spontaneous abortion
C. After ectopic pregnancy
D. Hydatidiform mole

Explanation: **Explanation:** The prognosis of Gestational Trophoblastic Neoplasia (GTN) is heavily influenced by the nature of the preceding pregnancy. **Postpartum choriocarcinoma** (occurring after a full-term pregnancy) carries the **worst prognosis** among all types of trophoblastic diseases. **1. Why Postpartum is the Correct Answer:** * **Biological Aggression:** Choriocarcinoma following a term pregnancy is often more biologically aggressive and associated with early hematogenous spread. * **Delayed Diagnosis:** Symptoms like irregular vaginal bleeding are often mistaken for normal lochia or retained products of conception, leading to advanced stage at presentation. * **WHO Scoring:** According to the FIGO/WHO scoring system for GTN, a "Term Pregnancy" is assigned the highest risk score (2 points) compared to an abortion (1 point) or a hydatidiform mole (0 points). **2. Analysis of Incorrect Options:** * **B & C (After Spontaneous Abortion/Ectopic Pregnancy):** These carry an intermediate risk. While they can lead to choriocarcinoma, the interval between the event and diagnosis is usually shorter than term pregnancies, and the biological behavior is generally less aggressive. * **D (Hydatidiform Mole):** This has the **best prognosis**. Most cases of Gestational Trophoblastic Disease (GTD) are benign moles. Even if they progress to Gestational Trophoblastic Neoplasia (Persistent Trophoblastic Disease), they are highly sensitive to chemotherapy and often diagnosed early through routine hCG monitoring. **Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%). * **FIGO Scoring:** A score of **≥7** indicates High-Risk GTN, requiring multi-agent chemotherapy (EMA-CO regimen). * **Pathognomonic Feature:** Choriocarcinoma is characterized by the absence of chorionic villi and the presence of sheets of syncytiotrophoblasts and cytotrophoblasts with extensive hemorrhage and necrosis.

Question 266: What is the approximate risk of complex hyperplasia of the endometrium with atypia progressing to malignancy in a postmenopausal woman?

A. 3%
B. 8%
C. 15%
D. 28% (Correct Answer)

Explanation: ### Explanation The progression of endometrial hyperplasia to carcinoma is primarily determined by the presence of **cellular atypia**. This classification is traditionally based on the **Kurman classification (1985)**, which remains a high-yield topic for NEET-PG. **1. Why 28% is Correct:** Complex hyperplasia with atypia (also known as Atypical Endometrial Hyperplasia) is the most advanced precursor to Type I Endometrial Adenocarcinoma. Studies by Kurman et al. demonstrated that if left untreated, approximately **29% (rounded to 28% in many texts)** of these cases progress to invasive cancer. Furthermore, there is a high "co-existence" rate; up to 40% of women with this diagnosis are found to have a concurrent invasive carcinoma upon hysterectomy. **2. Analysis of Incorrect Options:** * **3% (Option A):** This represents the risk for **Simple Hyperplasia without atypia**. It has the lowest malignant potential. * **8% (Option B):** This is the risk associated with **Complex Hyperplasia without atypia**. While the architecture is crowded, the lack of nuclear atypia keeps the risk relatively low. * **15% (Option C):** This is the risk for **Simple Hyperplasia with atypia**. The presence of atypia significantly jumps the risk from 1% to 8%–15%. **3. Clinical Pearls for NEET-PG:** * **Gold Standard Treatment:** For postmenopausal women with atypical hyperplasia, **Total Laparoscopic/Abdominal Hysterectomy** is the treatment of choice due to the high risk of progression and occult malignancy. * **WHO 2014 Classification:** The newer classification simplifies this into two categories: (1) Hyperplasia without atypia (<3% risk) and (2) Atypical Hyperplasia/Endometrial Intraepithelial Neoplasia (EIN) (~30% risk). * **Most Common Symptom:** Abnormal Uterine Bleeding (AUB) or postmenopausal bleeding. * **Risk Factor:** Unopposed estrogen (PCOS, Obesity, Estrogen-only HRT, Granulosa cell tumors).

Question 267: Which proteins of Human Papillomavirus (HPV) play a role in the pathogenesis of cervical cancer?

A. E3 and E4
B. E5 and E6
C. E6 and E7 (Correct Answer)
D. E8 and E10

Explanation: ### Explanation The pathogenesis of cervical cancer is primarily driven by the integration of high-risk Human Papillomavirus (HPV) DNA (most commonly types 16 and 18) into the host genome. This integration leads to the over-expression of two key viral oncoproteins: **E6 and E7**. **1. Why E6 and E7 are correct:** These proteins disrupt the host cell cycle by neutralizing tumor suppressor proteins: * **E6 (Six-P):** Binds to and degrades the **p53** protein via ubiquitin-mediated proteolysis. Loss of p53 prevents apoptosis and allows the accumulation of DNA mutations. * **E7 (Seven-R):** Binds to and inactivates the **Retinoblastoma (Rb)** protein. This releases the E2F transcription factor, pushing the cell prematurely into the S-phase of the cell cycle. * *Mnemonic:* **E6** affects **p53**; **E7** affects **Rb**. **2. Why other options are incorrect:** * **E3, E4, E5, E8, E10:** While other early (E) proteins exist, they are not the primary drivers of malignancy. **E4** is involved in viral release and is a marker of productive infection. **E5** enhances growth factor signaling but is often lost when the virus integrates into the host genome. E8 and E10 are not significant in the context of human oncogenesis. **3. NEET-PG High-Yield Pearls:** * **HPV 16** is the most common type associated with Squamous Cell Carcinoma. * **HPV 18** is more frequently associated with Adenocarcinoma. * **L1 Protein:** This is the major capsid protein used to develop HPV vaccines (e.g., Gardasil). * **Koilocytosis:** The hallmark cytological finding of HPV infection (perinuclear halo with nuclear wrinkling/raisinoid appearance). * **Screening:** The primary screening tool is the Pap smear, but HPV DNA testing is now preferred for primary screening in women over 30.

Question 268: A 12-year-old female patient presents with a 4 x 5 cm dysgerminoma of the right ovary with an intact capsule. What is the best treatment?

A. Ovarian cystectomy
B. Oophorectomy on the involved side (Correct Answer)
C. Bilateral oophorectomy
D. Hysterectomy with bilateral salpingo-oophorectomy

Explanation: **Explanation:** The patient is a 12-year-old with a **Dysgerminoma**, which is the most common malignant germ cell tumor (GCT) of the ovary. These tumors typically occur in children and young adults, making **fertility preservation** a primary goal of management. **Why Option B is Correct:** For a Stage IA dysgerminoma (limited to one ovary with an intact capsule), the standard of care is a **Unilateral Salpingo-Oophorectomy (USO)**. Since dysgerminomas are highly chemosensitive and often unilateral (85-90%), removing only the affected adnexa preserves the contralateral ovary and uterus, allowing for future fertility without compromising survival rates. **Why Other Options are Incorrect:** * **Option A (Cystectomy):** This is inadequate for a malignant germ cell tumor. There is a high risk of capsule rupture and peritoneal seeding, which would upstage the disease. * **Option C & D (Bilateral Oophorectomy/Hysterectomy):** These are overly aggressive "radical" surgeries. They result in permanent sterility and premature menopause, which is unnecessary for Stage IA disease, especially in a pediatric patient. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Dysgerminoma is associated with elevated **LDH** (Lactate Dehydrogenase). It may also show mild elevations in hCG. * **Radiosensitivity:** It is the most **radiosensitive** gynecological malignancy, though chemotherapy (BEP regimen) is now preferred to preserve ovarian function. * **Association:** Dysgerminomas are frequently associated with **gonadal dysgenesis** (e.g., Swyer Syndrome); if a Y-chromosome is present, a bilateral gonadectomy is indicated due to the risk of gonadoblastoma. * **Lymphatic Spread:** Unlike other GCTs, dysgerminomas have a higher propensity for lymphatic spread, necessitating careful retroperitoneal node palpation during surgery.

Question 269: An 80-year-old female who has never taken estrogen develops pink vaginal discharge. An endometrial biopsy shows an adenocarcinoma of the endometrium. A Papanicolaou smear is negative. What is the most important indicator of prognosis?

A. Body habitus
B. Level of CA-125
C. Nutritional status
D. Histologic type of tumor (Correct Answer)

Explanation: **Explanation:** In endometrial carcinoma, the most significant prognostic factors are **histologic type** and **grade**, followed closely by the depth of myometrial invasion. **1. Why Histologic Type is Correct:** Endometrial cancers are broadly classified into two types: * **Type I (Endometrioid):** Estrogen-dependent, occurs in younger/perimenopausal women, and generally has a favorable prognosis. * **Type II (Non-endometrioid):** Includes **Serous** and **Clear Cell** carcinomas. These are estrogen-independent, occur in older patients (like the 80-year-old in this case), and are highly aggressive with a poor prognosis regardless of the stage at presentation. In an elderly patient not on HRT, the likelihood of a high-risk Type II histology is high, making it the primary determinant of her outcome. **2. Why Other Options are Incorrect:** * **Body habitus (A) and Nutritional status (C):** While obesity is a risk factor for Type I endometrial cancer and poor nutrition affects surgical recovery, they are not direct indicators of oncological prognosis or tumor behavior. * **Level of CA-125 (B):** CA-125 is useful for monitoring treatment response or detecting recurrence (especially in serous types), but it is not a primary prognostic indicator compared to the tissue diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histology:** Endometrioid adenocarcinoma. * **Most aggressive histology:** Uterine Papillary Serous Carcinoma (UPSC). * **Staging:** Endometrial cancer is staged **surgically** (FIGO staging). * **Type II characteristics:** Associated with p53 mutations and arises from atrophic endometrium. * **Papanicolaou (Pap) smear:** Not a sensitive screening tool for endometrial cancer; a negative result does not rule out the disease.

Question 270: Pseudomyxoma peritonei occurs as a complication of which of the following ovarian tumors?

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

Explanation: **Explanation:** **Pseudomyxoma peritonei (PMP)** is a clinical condition characterized by the accumulation of abundant gelatinous (mucinous) material within the peritoneal cavity, leading to "jelly belly." **Why Mucinous Cystadenoma is correct:** Pseudomyxoma peritonei occurs when a **mucinous tumor** (most commonly from the appendix or, less frequently, a **mucinous cystadenoma/cystadenocarcinoma of the ovary**) ruptures or leaks. The mucin-secreting cells implant onto the peritoneal surfaces and continue to produce thick, viscous fluid. While the appendix is now considered the primary site in most cases of PMP, in the context of ovarian pathology, it is a classic complication of mucinous tumors. **Why the other options are incorrect:** * **Serous cystadenoma:** These are the most common epithelial tumors but contain thin, watery fluid. Rupture leads to ascites or peritoneal seeding (if malignant), but not the characteristic gelatinous mucin of PMP. * **Dysgerminoma:** This is a germ cell tumor (the female counterpart of seminoma). It is a solid tumor and does not produce mucin. * **Gonadoblastoma:** This is a rare tumor usually arising in dysgenetic gonads (e.g., Turner syndrome with Y chromosome). It is a mixed germ cell-sex cord-stromal tumor and is not associated with mucin production. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Source:** If a patient presents with PMP and an ovarian mass, always check the **appendix**, as the ovary is often a secondary site of spread. * **Tumor Markers:** Mucinous tumors are often associated with elevated **CA 19-9** and **CEA**. * **Size:** Mucinous cystadenomas are known for being the **largest** tumors in the human body, often filling the entire abdomen. * **Treatment:** Management of PMP typically involves cytoreductive surgery and **HIPEC** (Hyperthermic Intraperitoneal Chemotherapy).

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

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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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