Gynecologic Oncology Practice Questions

Q: Prophylactic chemotherapy in Gestational Trophoblastic Disease (GTD) is indicated for which of the following?

High initial beta-hCG level. **Explanation:** Gestational Trophoblastic Disease (GTD) carries a risk of progressing to Gestational Trophoblastic Neoplasia (GTN). While routine prophylactic chemotherapy after the evacuation of a hydatidiform mole is controversial and not universally recommended, it is specifically considered for **"High-Risk" Complete Moles** where the risk of malignant transformation exceeds 20%. **Why Option C is Correct:** A **high initial beta-hCG level (>100,000 mIU/mL)** is a primary indicator of high trophoblastic proliferation. Along with excessive uterine size for gestational age and large theca lutein cysts, it categorizes a patient as "High-Risk." In such cases, a single dose of Methotrexate or Actinomycin-D may be administered to reduce the incidence of post-molar GTN, especially if reliable follow-up is unavailable. **Analysis of Incorrect Options:** * **A & B (Theca lutein cysts and Hyperthyroidism):** While these are clinical features of a "High-Risk" mole (due to high hCG levels), they are considered **symptoms/complications** rather than independent indications for chemotherapy. They usually resolve spontaneously following the evacuation of the mole. * **D (Partial mole):** Partial moles have a very low risk of malignant transformation ( 40 years, hCG >100,000 mIU/mL, uterine size >20 weeks, and theca lutein cysts >6 cm. * **Standard Management:** Suction and evacuation is the treatment of choice for all molar pregnancies. * **Follow-up:** Weekly beta-hCG monitoring until three consecutive negative results, then monthly for 6 months. * **Contraception:** Combined Oral Contraceptive Pills (COCs) are preferred during follow-up to prevent pregnancy from confusing hCG interpretation.

Q: Which of the following is NOT true regarding Brenner tumor?

It is usually found in postmenopausal women.. **Explanation:** The **Brenner tumor** is a rare surface epithelial-stromal tumor of the ovary, characterized by transitional epithelium (urothelium). **1. Why Option D is the correct answer (The False Statement):** While Brenner tumors can occur at any age, they are **most commonly diagnosed incidentally in women between 40–60 years of age (perimenopausal)**. The statement that they are "usually" found in postmenopausal women is considered less accurate in the context of standard textbook descriptions compared to the other definitive features listed. (Note: In some clinical contexts, this question highlights that they are often asymptomatic and found during surgery for other reasons). **2. Analysis of other options:** * **Option A:** Brenner tumors are frequently associated with other epithelial tumors, most commonly **Mucinous cystadenomas**. If a mucinous component is present and ruptures, it can lead to **Pseudomyxoma peritonei**. * **Option B:** This is the classic histological hallmark. They consist of **Walthard cell nests** (transitional epithelium) embedded in a dense fibromatous stroma. The nuclei often show a longitudinal groove, giving them the characteristic **"coffee bean" appearance**. * **Option C:** The stroma of a Brenner tumor can be **thecal/functionally active**, producing estrogen. This estrogenic stimulation can lead to endometrial hyperplasia, resulting in **postmenopausal or abnormal vaginal bleeding**. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Arises from the surface epithelium or urogenital remnants. * **Gross Appearance:** Usually small, solid, unilateral, and grayish-white (resembles a fibroma). * **Markers:** Positive for **GATA3** and **p63** (markers of transitional differentiation). * **Nature:** Majority (>95%) are **benign**. Malignant Brenner tumors are extremely rare.

Q: Which of the following is the most common primary site for a metastasis that presents as a Krukenberg tumor?

Stomach. **Explanation:** A **Krukenberg tumor** refers specifically to a metastatic signet-ring cell carcinoma of the ovary, where the primary malignancy arises from a gastrointestinal tract site or other mucosal tissues. 1. **Why Stomach is Correct:** The **stomach (gastric adenocarcinoma)** is the most common primary site, accounting for approximately 70% of all Krukenberg tumors. The mechanism of spread is traditionally thought to be via retrograde lymphatic dissemination, though transcoelomic (surface seeding) and hematogenous routes also occur. Histologically, these tumors are characterized by **signet-ring cells** (mucin-filled cytoplasm displacing the nucleus to the periphery) within a cellular stroma. 2. **Why Other Options are Incorrect:** * **Colon:** This is the second most common source. While colorectal cancer frequently metastasizes to the ovary, it often presents as a non-signet ring adenocarcinoma, which does not strictly meet the classic definition of a Krukenberg tumor. * **Breast:** Lobular carcinoma of the breast can metastasize to the ovary and may show signet-ring features, but it is significantly less common than gastric sources. * **Uterus:** Primary uterine malignancies (like endometrial carcinoma) typically spread to the ovaries via direct extension or lymphatics, but they do not form the classic signet-ring morphology associated with Krukenberg tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Bilateralism:** 80% of Krukenberg tumors are bilateral. * **Imaging:** On ultrasound/CT, they typically appear as solid, bosselated masses (unlike primary epithelial ovarian cancers which are often complex/cystic). * **Diagnosis:** If a bilateral solid ovarian mass is found, the first step is often a **diagnostic upper GI endoscopy** to rule out a gastric primary. * **Prognosis:** Generally poor, as it represents Stage IV systemic disease.

Q: In a patient with a vulvar ulcer, which of the following is most associated with leading to malignancy?

Human Papillomavirus (HPV). **Explanation:** The correct answer is **Human Papillomavirus (HPV)**. The development of vulvar squamous cell carcinoma (SCC) follows two distinct pathways. The first, and most common in younger patients, is the **HPV-associated pathway**, specifically linked to high-risk strains like **HPV 16 and 18**. These viruses integrate into the host genome, leading to the overexpression of E6 and E7 oncoproteins, which inactivate tumor suppressor proteins p53 and pRb, respectively. This process leads to **Vulvar Intraepithelial Neoplasia (VIN)**, the precursor lesion to malignancy. **Analysis of Incorrect Options:** * **HSV-1 and HSV-2 (Options A & B):** While Herpes Simplex Virus causes painful, recurrent vulvar ulcers, it is not oncogenic. Chronic inflammation from any source can theoretically increase cell turnover, but HSV has no direct causal link to vulvar malignancy. * **Sexually Transmitted Disease (Option C):** This is a broad category. While many vulvar cancers are associated with STIs (specifically HPV), the term itself is too non-specific. Other STIs like Syphilis (chancre) or Chancroid cause ulcers but do not lead to neoplastic transformation. **NEET-PG High-Yield Pearls:** * **Two Pathways of Vulvar Cancer:** 1. **HPV-Dependent:** Seen in younger women, associated with smoking and multiple partners (precursor: VIN). 2. **HPV-Independent:** Seen in elderly women, associated with **Lichen Sclerosus** and differentiated VIN (dVIN). * **Most Common Histology:** Squamous Cell Carcinoma (90%). * **Most Common Symptom:** Long-standing pruritus (itching), though it can present as an ulcer or mass. * **Staging:** Vulvar cancer is staged **surgically** (FIGO). The most important prognostic factor is the status of the **inguinal lymph nodes**.

Q: A 28-year-old woman underwent fertility-sparing surgery for a 6x6 cm granulosa cell ovarian tumor. Which one of the following will you monitor for detection of recurrence?

Inhibin B. **Explanation:** **Granulosa Cell Tumors (GCTs)** are the most common type of Sex Cord-Stromal Tumors. These tumors arise from the granulosa cells, which are responsible for producing estrogen and the peptide hormone **Inhibin**. **Why Inhibin B is the correct answer:** Inhibin exists in two forms, A and B. In GCTs, **Inhibin B** is considered a more sensitive and specific marker than Inhibin A. It is secreted directly by the tumor cells in proportion to the tumor mass. Following surgery, levels should drop to undetectable; a subsequent rise is a highly reliable indicator of recurrence, often preceding clinical or radiological detection by months. **Analysis of Incorrect Options:** * **CA 19-9:** Primarily a marker for pancreatic and biliary tract cancers. In gynecology, it may be elevated in mucinous ovarian tumors, but not GCTs. * **LDH (Lactate Dehydrogenase):** A characteristic marker for **Dysgerminomas** (Germ Cell Tumors). * **PLAP (Placental Alkaline Phosphatase):** Also a marker associated with **Dysgerminomas** and occasionally seminomas. **High-Yield Clinical Pearls for NEET-PG:** 1. **Estrogen Secretion:** GCTs are "functioning tumors." Excess estrogen often leads to **Endometrial Hyperplasia** or **Endometrial Carcinoma** (must perform an endometrial biopsy if the patient has abnormal bleeding). 2. **Call-Exner Bodies:** The pathognomonic histological finding (small fluid-filled spaces between granulosa cells). 3. **Antimüllerian Hormone (AMH):** Another highly specific marker for GCTs, often used alongside Inhibin B. 4. **Prognosis:** GCTs are known for **late recurrence** (even 10–20 years later), necessitating lifelong follow-up.

Q: What is the investigation of choice for cervical carcinoma?

MRI. ### Explanation **Correct Option: B. MRI** **Why MRI is the Investigation of Choice:** In the management of cervical carcinoma, **MRI (Magnetic Resonance Imaging)** is the gold standard for **local staging**. It provides superior soft-tissue contrast compared to other modalities, allowing for precise evaluation of: 1. **Tumor size and volume.** 2. **Parametrial invasion:** This is the most critical factor in determining management (Surgery vs. Radiotherapy). 3. **Vaginal and stromal involvement.** 4. **Invasion of adjacent organs** (bladder or rectum). While FIGO staging for cervical cancer was historically clinical, the 2018 update allows the use of imaging. MRI is now the preferred modality to decide if a patient is a candidate for radical surgery (Stage ≤IIA1) or requires primary chemoradiation (Stage ≥IIB). **Why Other Options are Incorrect:** * **A. CECT Pelvis:** While CT is excellent for evaluating distant metastasis, retroperitoneal lymphadenopathy, and hydronephrosis, it has poor sensitivity for detecting early parametrial invasion or small primary tumors. * **C & D. TVS/TAS (Ultrasound):** Transvaginal and Transabdominal scans are useful for initial screening or evaluating the uterus/adnexa, but they lack the resolution and depth required for accurate staging and parametrial assessment in cervical cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Best Screening Test:** Pap Smear (Cytology). * **Confirmatory Diagnostic Test:** Colposcopy-directed biopsy. * **Investigation for Distant Metastasis:** PET-CT (most sensitive for nodal and distant spread). * **FIGO 2018 Update:** Staging is now "Clinical + Imaging + Pathological." * **Parametrial Involvement:** If MRI shows parametrial invasion (Stage IIB), the treatment of choice shifts from Radical Hysterectomy to **Concurrent Chemoradiotherapy (CCRT)**.

Q: Which of the following syndromes is associated with an increased risk of endometrial and ovarian cancer?

Hereditary nonpolyposis colorectal cancer. **Explanation:** **Hereditary Nonpolyposis Colorectal Cancer (HNPCC)**, also known as **Lynch Syndrome**, is an autosomal dominant condition caused by mutations in DNA mismatch repair (MMR) genes (MLH1, MSH2, MSH6, PMS2). While colorectal cancer is the most common malignancy, Lynch syndrome is significantly associated with extracolonic cancers. For women, the lifetime risk of **endometrial cancer** (40–60%) and **ovarian cancer** (10–12%) is markedly elevated, often occurring at a younger age than in the general population. **Analysis of Incorrect Options:** * **Peutz-Jeghers Syndrome:** Characterized by STK11 mutations, mucocutaneous pigmentation, and hamartomatous polyps. While it increases the risk of Sex Cord Tumors with Annular Tubules (SCTAT) and Cervical Minimal Deviation Adenocarcinoma, it is not primarily linked to endometrial cancer. * **Cowden’s Syndrome:** Caused by PTEN mutations. It is associated with a high risk of breast, thyroid, and endometrial cancer, but it is **not** typically associated with an increased risk of ovarian cancer. * **Ataxia Telangiectasia:** Caused by ATM gene mutations. It primarily predisposes patients to lymphomas, leukemias, and breast cancer, rather than gynecological malignancies like endometrial or ovarian cancer. **Clinical Pearls for NEET-PG:** * **Lynch II Syndrome:** Specifically refers to the variant associated with high risks of endometrial, ovarian, gastric, and small bowel cancers. * **Screening:** Women with Lynch syndrome should undergo annual endometrial biopsy and transvaginal ultrasound starting at age 30–35. * **Prophylaxis:** Risk-reducing Total Laparoscopic Hysterectomy and Bilateral Salpingo-oophorectomy (TLH+BSO) is recommended after completion of childbearing (usually age 40).

Q: An intravenous pyelogram (IVP) showing hydronephrosis in the work up of a patient with cervical cancer otherwise confined to a cervix of normal size would indicate which stage?

Stage III. **Explanation:** The correct answer is **Stage III**. According to the FIGO staging for carcinoma cervix (revised 2018), the presence of **hydronephrosis or a non-functioning kidney** due to tumor extension automatically upgrades the disease to **Stage IIIB**, regardless of the size of the primary cervical lesion. **Why Stage III is correct:** In cervical cancer, hydronephrosis indicates that the tumor has extended laterally to the pelvic sidewall, causing compression or infiltration of the ureter. Under the FIGO staging system, Stage III includes involvement of the lower third of the vagina (IIIA), extension to the pelvic sidewall, and/or hydronephrosis/non-functioning kidney (IIIB), or involvement of pelvic/paraaortic lymph nodes (IIIC). **Why other options are incorrect:** * **Stage I:** The tumor is strictly confined to the cervix. Even if the cervix appears "normal size" on examination, the presence of hydronephrosis signifies extra-cervical spread to the pelvic wall. * **Stage II:** The tumor extends beyond the uterus but has not reached the pelvic sidewall or the lower third of the vagina. Hydronephrosis is a defining feature that pushes the stage beyond Stage II. * **Stage IV:** This stage involves invasion of the mucosa of the bladder or rectum (IVA) or distant metastasis (IVB). While hydronephrosis involves the urinary tract, it is considered a regional complication (Stage III) rather than distant spread or mucosal invasion. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Staging:** Carcinoma cervix is primarily staged **clinically**. However, FIGO 2018 now allows the use of imaging (MRI, CT, PET) and pathology to supplement staging. * **The "Ureter" Rule:** If the ureter is obstructed (hydronephrosis), it is Stage IIIB. * **Most Common Cause of Death:** Uremia (due to bilateral ureteric obstruction leading to post-renal renal failure) is the most common cause of death in cervical cancer patients.

Q: "EMA-CO regimen" is useful in the treatment of which of the following conditions?

Gestational trophoblastic neoplasia. **Explanation:** The **EMA-CO regimen** is the gold-standard multi-agent chemotherapy for **High-Risk Gestational Trophoblastic Neoplasia (GTN)**. GTN is classified as high-risk when the FIGO/WHO score is **7 or higher**. **Why it is the correct answer:** EMA-CO is an acronym for a two-part drug combination: * **EMA:** Etoposide, Methotrexate, and Actinomycin-D (given on Days 1 and 2). * **CO:** Cyclophosphamide and Oncovin (Vincristine) (given on Day 8). This regimen is highly effective, with survival rates exceeding 70-90% even in metastatic cases. It is specifically indicated for patients who are resistant to single-agent Methotrexate or those initially categorized as high-risk. **Why other options are incorrect:** * **Metastatic Breast Cancer:** Common regimens include AC (Adriamycin, Cyclophosphamide), CAF, or Taxane-based therapies. * **Advanced Endometrial Sarcoma:** Usually treated with surgery followed by Ifosfamide, Doxorubicin, or Gemcitabine/Docetaxel. * **Ovarian Tumor with Peritoneal Implants:** The standard of care is **BEP** (Bleomycin, Etoposide, Cisplatin) for germ cell tumors or **Paclitaxel + Carboplatin** for epithelial ovarian cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Low-risk GTN (Score <7):** Treated with single-agent **Methotrexate** (most common) or Actinomycin-D. * **Monitoring:** The most sensitive marker for treatment response and follow-up in GTN is **serum β-hCG**. * **Resistance:** If EMA-CO fails, the next line is often **EMA-EP** (where CO is replaced by Etoposide and Cisplatin). * **Placental Site Trophoblastic Tumor (PSTT):** Unlike other GTNs, PSTT is relatively chemoresistant; **Surgery (Hysterectomy)** is the primary treatment.

Question 1

Prophylactic chemotherapy in Gestational Trophoblastic Disease (GTD) is indicated for which of the following?

Accepted Answer

High initial beta-hCG level

Answer

Theca lutein cyst

Answer

Hyperthyroidism

Answer

Partial mole

Question 2

A 22-year-old woman with Turner syndrome has a 2.5-centimeter mass in the right adnexa. An abdominal radiograph reveals focal areas of calcification in the mass. What is the most likely diagnosis?

Accepted Answer

Gonadoblastoma

Answer

Cystic teratoma

Answer

Dysgerminoma

Answer

Fibroma

Question 3

Which of the following is NOT true regarding Brenner tumor?

Accepted Answer

It is usually found in postmenopausal women.

Answer

It is associated with Pseudomyxoma peritonei.

Answer

Histologically, it has epithelial nests and coffee bean nuclei.

Answer

Vaginal bleeding is reported with it.

Question 4

Which of the following is the most common primary site for a metastasis that presents as a Krukenberg tumor?

Accepted Answer

Stomach

Answer

Breast

Answer

Colon

Answer

Uterus

Question 5

In a patient with a vulvar ulcer, which of the following is most associated with leading to malignancy?

Accepted Answer

Human Papillomavirus (HPV)

Answer

Herpes Simplex Virus 1 (HSV-1)

Answer

Herpes Simplex Virus 2 (HSV-2)

Answer

Sexually Transmitted Disease (general)

Question 6

A 28-year-old woman underwent fertility-sparing surgery for a 6x6 cm granulosa cell ovarian tumor. Which one of the following will you monitor for detection of recurrence?

Accepted Answer

Inhibin B

Answer

CA 19-9

Answer

LDH

Answer

Placental Alkaline Phosphatase (PLAP)

Question 7

What is the investigation of choice for cervical carcinoma?

Accepted Answer

MRI

Answer

CECT pelvis

Answer

TVS

Answer

TAS

Question 8

Which of the following syndromes is associated with an increased risk of endometrial and ovarian cancer?

Accepted Answer

Hereditary nonpolyposis colorectal cancer

Answer

Peutz-jeghers syndrome

Answer

Cowden's syndrome

Answer

Ataxia telangiectasia

Question 9

An intravenous pyelogram (IVP) showing hydronephrosis in the work up of a patient with cervical cancer otherwise confined to a cervix of normal size would indicate which stage?

Accepted Answer

Stage III

Answer

Stage I

Answer

Stage II

Answer

Stage IV

Question 10

"EMA-CO regimen" is useful in the treatment of which of the following conditions?

Accepted Answer

Gestational trophoblastic neoplasia

Answer

Metastatic breast cancer

Answer

Advanced endometrial sarcoma

Answer

Ovarian tumor with peritoneal implants

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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