Gynecologic Oncology Practice Questions

Q: A 50-year-old woman presents with postcoital bleeding. A visible growth on the cervix is detected on per speculum examination. What is the next investigation?

Punch biopsy. **Explanation:** The clinical presentation of postcoital bleeding in a 50-year-old woman with a **visible growth** on the cervix is highly suspicious for cervical carcinoma. **1. Why Punch Biopsy is correct:** When a gross, visible lesion is present on the cervix, the immediate next step is a **direct punch biopsy** from the growth. This provides a tissue diagnosis to confirm malignancy. In the presence of a visible lesion, screening or diagnostic aids like Pap smears or colposcopy are bypassed because the goal is histological confirmation of the obvious pathology. **2. Why other options are incorrect:** * **Pap smear:** This is a **screening tool** for asymptomatic women or those with a healthy-looking cervix. In the presence of a visible growth, a Pap smear has a high false-negative rate (due to necrosis and blood) and unnecessarily delays the definitive diagnosis. * **Colposcopic biopsy:** Colposcopy is indicated when the cervix appears **grossly normal** but there is an abnormal Pap smear or high-risk HPV DNA. It helps localize "occult" or pre-invasive lesions (CIN). It is not required when the lesion is already visible to the naked eye. * **Cone biopsy:** This is a diagnostic and therapeutic procedure used when the entire lesion cannot be visualized (e.g., endocervical involvement) or when there is a discrepancy between cytology and biopsy. It is more invasive and not the initial step for a visible growth. **Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** Histopathology (Biopsy). * **Staging of Cervical Cancer:** It is primarily **clinically staged** (FIGO staging), though imaging (MRI/CT) is now incorporated in the 2018 FIGO revision. * **Most common symptom:** Postcoital bleeding. * **Most common histological type:** Squamous cell carcinoma.

Q: On follow-up study, elevated CA 125 in a case of epithelial ovarian tumor should be further evaluated with what?

CT Scan. **Explanation:** In the management of epithelial ovarian cancer (EOC), **CA 125** is the primary biomarker used for monitoring treatment response and detecting recurrence. According to standard oncological protocols (including NCCN and FIGO guidelines), if a patient shows an asymptomatic rise in CA 125 levels during follow-up, the immediate next step is to perform imaging to localize the recurrence. **Why CT Scan is the Correct Choice:** A **Contrast-Enhanced CT (CECT) of the Abdomen and Pelvis** is the gold standard imaging modality for evaluating suspected recurrence. It is highly effective at detecting peritoneal implants, lymphadenopathy, and visceral metastases. While PET-CT is more sensitive for metabolic activity, CECT remains the initial investigation of choice due to its accessibility and anatomical detail. **Analysis of Incorrect Options:** * **MRI (A):** While excellent for pelvic soft tissue, MRI is generally not the first-line screening tool for systemic recurrence in ovarian cancer compared to CT. * **Yearly follow-up (C):** This is inappropriate. An elevated CA 125 indicates a high probability of biochemical relapse, requiring active investigation rather than observation. * **Clinical examination and serial CA 125 monitoring (D):** While part of routine follow-up, once the CA 125 is already elevated, monitoring alone delays the diagnosis of a macroscopic recurrence that may be surgically resectable (secondary cytoreduction). **Clinical Pearls for NEET-PG:** * **Rustin’s Criteria:** Defines biochemical recurrence as a CA 125 level rising to twice the upper limit of normal on two occasions. * **Lead-time bias:** Rising CA 125 often precedes clinical or radiological recurrence by 3–5 months. * **Germ Cell Tumors:** Monitor with AFP and hCG. * **Granulosa Cell Tumors:** Monitor with Inhibin B.

Q: A 36-year-old woman presents with vaginal bleeding, nausea, and pelvic pain. Her uterus is larger than expected for gestational age, and fetal heart tones are absent. Which of the following is most likely to be true?

b-hCG levels will be higher than normal. **Explanation:** The clinical presentation of vaginal bleeding, nausea (hyperemesis), a uterus "larger than dates," and absent fetal heart tones is classic for a **Hydatidiform Mole (Molar Pregnancy)**, a type of Gestational Trophoblastic Disease (GTD). **1. Why Option A is Correct:** In a complete hydatidiform mole, there is abnormal proliferation of trophoblastic tissue (specifically syncytiotrophoblasts). Since these cells are responsible for secreting **beta-hCG**, the levels are characteristically **markedly elevated** (often >100,000 mIU/mL). This extreme elevation is responsible for the exaggerated pregnancy symptoms like severe nausea/vomiting and the development of theca lutein cysts. **2. Why the Other Options are Incorrect:** * **Option B:** Low b-hCG levels are typically associated with ectopic pregnancies or threatened/inevitable abortions, not molar pregnancies. * **Option C:** In approximately 50% of complete mole cases, the uterus is **larger than expected** for gestational age due to the rapid proliferation of chorionic villi and accumulated blood (clots) within the uterine cavity. * **Option D:** High levels of b-hCG have a structural similarity to TSH (sharing the same alpha subunit). This causes b-hCG to act as a weak thyroid stimulator, leading to increased T3/T4 and a **decreased (suppressed) TSH** level, potentially causing clinical hyperthyroidism. **Clinical Pearls for NEET-PG:** * **USG Finding:** "Snowstorm appearance" or "Bunch of grapes" appearance (vesicular pattern). * **Karyotype:** Complete Mole is most commonly **46, XX** (diploid, purely paternal origin); Partial Mole is **69, XXY** (triploid). * **Complication:** Risk of progression to Choriocarcinoma is higher in complete moles (up to 15-20%). * **Management:** Suction and evacuation is the treatment of choice, followed by weekly b-hCG monitoring until three consecutive negative results are obtained.

Q: All are risk factors for carcinoma endometrium EXCEPT?

Multiple sexual partners. **Explanation:** The core pathophysiology of **Endometrial Carcinoma (Type I)** is **unopposed estrogen stimulation**. Any condition that increases lifetime exposure to estrogen or leads to chronic anovulation increases the risk of endometrial hyperplasia and subsequent malignancy. * **Why Option B is the correct answer:** **Multiple sexual partners** is a risk factor for **Cervical Cancer**, not endometrial cancer. Cervical cancer is primarily caused by persistent infection with High-Risk Human Papillomavirus (HPV), a sexually transmitted infection. Endometrial cancer is generally not associated with sexual behavior or viral infections. * **Why the other options are incorrect (Risk Factors):** * **Infertility (Option A):** Infertility is often associated with **anovulatory cycles** (e.g., PCOS). In the absence of ovulation, there is no corpus luteum to produce progesterone. This leads to "unopposed estrogen," which causes endometrial proliferation. * **Diabetes (Option C) & Hypertension (Option D):** These are classic components of the **"Corpus Uteri Cancer Syndrome"** (Obesity, Diabetes, and Hypertension). Obesity leads to increased peripheral conversion of androstenedione to estrone in adipose tissue, while hyperinsulinemia in diabetes may directly stimulate endometrial growth. **High-Yield Clinical Pearls for NEET-PG:** * **Protective Factors:** Combined Oral Contraceptive Pills (COCPs), smoking (decreases estrogen levels, though harmful otherwise), multiparity, and physical activity. * **Lynch Syndrome (HNPCC):** The most common hereditary cause of endometrial cancer. * **Tamoxifen:** A selective estrogen receptor modulator (SERM) that acts as an antagonist in the breast but an **agonist** in the uterus, increasing the risk of endometrial cancer. * **Triad of Risk:** Obesity, Diabetes, and Hypertension.

Question 1

Which feature in ultrasound is suggestive of ovarian malignancy?

Accepted Answer

Septations

Answer

Papillary pattern

Answer

Bilaterality

Answer

Clear fluid

Question 2

A 50-year-old woman presents with postcoital bleeding. A visible growth on the cervix is detected on per speculum examination. What is the next investigation?

Accepted Answer

Punch biopsy

Answer

Colposcopic biopsy

Answer

Pap smear

Answer

Cone biopsy

Question 3

What is/are the indication(s) for adjuvant radiotherapy in Ca endometrium?

Accepted Answer

All of the above

Answer

Cervical involvement

Answer

Lymph node involvement

Answer

Carcinoma in situ

Question 4

Which of the following findings indicates that an ovarian tumor is inoperable?

Accepted Answer

Peritoneal involvement

Answer

Excrescences over the surface

Answer

Stromal invasion

Answer

Pelvic metastasis

Question 5

A 43-year-old female is diagnosed with carcinoma of the cervix with obstruction of both ureters on imaging studies. What is the treatment of choice in this patient?

Accepted Answer

Intracavitary brachytherapy followed by external beam radiotherapy

Answer

Wertheim's hysterectomy

Answer

Schauta operation

Answer

Chemotherapy

Question 6

On follow-up study, elevated CA 125 in a case of epithelial ovarian tumor should be further evaluated with what?

Accepted Answer

CT Scan

Answer

MRI

Answer

Yearly follow-up

Answer

Clinical examination and serial CA 125 monitoring

Question 7

What is the recommended treatment for a 50-year-old woman with biopsy-proven CIN 3?

Accepted Answer

Colposcopy with LEEP

Answer

Conization

Answer

Hysterectomy

Answer

Trachelectomy

Question 8

A 36-year-old woman presents with vaginal bleeding, nausea, and pelvic pain. Her uterus is larger than expected for gestational age, and fetal heart tones are absent. Which of the following is most likely to be true?

Accepted Answer

b-hCG levels will be higher than normal

Answer

b-hCG levels will be lower than normal

Answer

Uterus will be of normal size for gestational age

Answer

TSH levels will be increased

Question 9

A 40-year-old woman complains of irregular bleeding for 7 months after delivery of her fourth baby. Curettage is performed and histology reveals a choriocarcinoma. Her serum beta hCG level is 2x10^5 IU/L. What is the most appropriate next step in the management?

Accepted Answer

Commence treatment with multi-agent combination chemotherapy

Answer

Commence treatment with intramuscular methotrexate

Answer

Perform a hysterectomy

Answer

Repeat serum hCG after 4 weeks

Question 10

All are risk factors for carcinoma endometrium EXCEPT?

Accepted Answer

Multiple sexual partners

Answer

Infertility

Answer

Diabetes

Answer

Hypertension

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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