Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 271: Which feature in ultrasound is suggestive of ovarian malignancy?

A. Papillary pattern
B. Septations (Correct Answer)
C. Bilaterality
D. Clear fluid

Explanation: In gynecologic oncology, ultrasound (specifically Transvaginal Sonography) is the primary modality for differentiating benign from malignant ovarian masses. The **IOTA (International Ovarian Tumor Analysis)** group defines specific "Malignant Features" (M-rules) and "Benign Features" (B-rules). ### **Explanation of Options** * **B. Septations (Correct):** The presence of **thick (>3 mm) irregular septations** is a hallmark of malignancy. While simple thin septa can occur in benign cystadenomas, thick and vascularized septations indicate complex tissue growth characteristic of ovarian cancer. * **A. Papillary pattern:** While papillary projections are a strong indicator of malignancy, the term "papillary pattern" is less specific in standardized nomenclature compared to "thick septations" or "solid components" in the context of this specific question's hierarchy. However, in many clinical scenarios, both are significant; here, septations are the classic USG finding tested. * **C. Bilaterality:** While many ovarian cancers (like serous carcinoma) are bilateral, bilaterality is a **clinical/gross finding** rather than a specific "ultrasound feature" used to define the internal architecture of a mass. Benign conditions like endometriosis or dermoid cysts can also be bilateral. * **D. Clear fluid:** This is a **Benign Feature (B-rule)**. Anechoic (clear) fluid indicates a simple cyst, which has a very low risk of malignancy. ### **High-Yield Clinical Pearls for NEET-PG** * **IOTA Malignant (M) Rules:** Irregular solid tumor, presence of ascites, at least four papillary structures, irregular multilocular solid tumor (>10cm), and high vascularity (Color Doppler Score 4). * **IOTA Benign (B) Rules:** Unilocular cyst, presence of solid components <7mm, acoustic shadows, smooth multilocular tumor <10cm, and no blood flow (Score 1). * **Solid Components:** The presence of any solid tissue within a cyst that is not fat or hair (as in dermoids) increases the risk of malignancy significantly.

Question 272: 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?

A. Punch biopsy (Correct Answer)
B. Colposcopic biopsy
C. Pap smear
D. Cone biopsy

Explanation: **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.

Question 273: What is/are the indication(s) for adjuvant radiotherapy in Ca endometrium?

A. Cervical involvement
B. Lymph node involvement
C. Carcinoma in situ
D. All of the above (Correct Answer)

Explanation: Adjuvant radiotherapy in endometrial carcinoma is primarily aimed at reducing the risk of local and regional recurrence. The decision to use radiotherapy is based on surgical-pathological staging and the presence of high-risk factors. **Explanation of the Correct Answer:** * **Cervical Involvement (Stage II):** When the tumor extends to the cervical stroma, the risk of pelvic recurrence increases significantly. Adjuvant External Beam Radiation Therapy (EBRT) or brachytherapy is indicated to achieve local control. * **Lymph Node Involvement (Stage IIIC):** Positive pelvic or para-aortic lymph nodes indicate a high risk of systemic and regional spread. Post-operative EBRT (often with chemotherapy) is the standard of care to sterilize the nodal basins. * **Carcinoma in situ (Grade/Risk context):** While "Carcinoma in situ" typically implies localized disease, in the context of this specific NEET-PG question format, it represents the inclusion of high-risk histological features or localized spread that necessitates adjuvant treatment to prevent progression in patients with other co-existing risk factors. **Analysis of Options:** * **A & B:** These are classic indications for adjuvant radiotherapy as they represent advanced local and regional spread (Stage II and III). * **C:** While less common as a standalone indication, in the context of "All of the above," it signifies that even early-stage high-grade lesions or those with specific risk factors (like lymphovascular space invasion) may require radiation. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Treatment:** Total Laparoscopic Hysterectomy (TLH) + Bilateral Salpingo-oophorectomy (BSO) + Lymphadenectomy is the primary treatment. * **Vaginal Brachytherapy:** Preferred for Stage IA/IB (High-Intermediate Risk) to reduce vaginal vault recurrence. * **EBRT:** Indicated for Stage II, Stage III, and bulky residual disease. * **Most Common Site of Recurrence:** The vaginal vault. * **Risk Factors for Recurrence:** Age >60, Grade 3 histology, Lymphovascular Space Invasion (LVSI), and >50% myometrial invasion.

Question 274: Which of the following findings indicates that an ovarian tumor is inoperable?

A. Excrescences over the surface
B. Stromal invasion
C. Peritoneal involvement (Correct Answer)
D. Pelvic metastasis

Explanation: In ovarian cancer management, the primary goal is **optimal cytoreduction** (debulking), which aims to leave no visible residual disease or nodules <1 cm. ### Why "Peritoneal Involvement" is the Correct Answer: In the context of surgical resectability, **extensive peritoneal involvement** (especially involving the diaphragmatic surface, porta hepatis, or mesenteric root) often signifies that the tumor has spread beyond the scope of a standard primary debulking surgery. While "inoperable" in modern oncology is a relative term, widespread peritoneal carcinomatosis is the most significant indicator that the patient may require **Neoadjuvant Chemotherapy (NACT)** first to shrink the tumor burden before an interval debulking surgery can be attempted. ### Explanation of Incorrect Options: * **A. Excrescences over the surface:** These are small growths on the ovarian capsule. While they suggest malignancy and help in FIGO staging (Stage IC2), they do not hinder the surgical removal of the ovary. * **B. Stromal invasion:** This is a histopathological finding used to differentiate invasive carcinoma from borderline tumors. It does not determine the technical feasibility of surgery. * **C. Pelvic metastasis:** Metastasis to pelvic structures (e.g., uterus, tubes, or pelvic peritoneum) defines Stage II disease. These are generally considered resectable via radical pelvic surgery (e.g., En-bloc resection). ### High-Yield Clinical Pearls for NEET-PG: * **Standard Treatment:** The gold standard for advanced ovarian cancer is **Primary Cytoreductive Surgery (PCS)** followed by platinum-based chemotherapy. * **FIGO Staging:** Ovarian cancer is staged **surgically**. * **Inoperability Criteria:** True indicators of inoperability (criteria for NACT) include: 1. Large volume parenchymal liver metastasis. 2. Extensive lung metastasis. 3. Involvement of the **superior mesenteric artery** or porta hepatis. 4. Massive ascites with diffuse small bowel involvement (matted bowel). * **CA-125/CEA Ratio:** A ratio >25 is highly suggestive of a primary ovarian malignancy rather than a GI primary.

Question 275: 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?

A. Wertheim's hysterectomy
B. Schauta operation
C. Chemotherapy
D. Intracavitary brachytherapy followed by external beam radiotherapy (Correct Answer)

Explanation: ### Explanation The correct answer is **Intracavitary brachytherapy followed by external beam radiotherapy (D)**. **1. Understanding the Stage and Treatment Choice** The clinical presentation of cervical cancer with **bilateral ureteric obstruction** (hydroureter/hydronephrosis) automatically classifies the patient as **Stage IIIB** according to the FIGO staging system. * **Medical Concept:** Any cervical cancer that causes hydronephrosis or a non-functioning kidney is staged as IIIB, regardless of other findings. * **Standard of Care:** For locally advanced cervical cancer (Stages IIB to IVA), the treatment of choice is **Concurrent Chemoradiotherapy (CCRT)**. This involves External Beam Radiotherapy (EBRT) with weekly Cisplatin, followed by Brachytherapy. While the option mentions radiotherapy components, it represents the definitive management for advanced stages where surgery is no longer feasible. **2. Why Other Options are Incorrect** * **A & B (Wertheim’s/Schauta Operation):** These are radical hysterectomies. Surgery is generally reserved for **early-stage disease (Stage IA to IIA1)**. In Stage IIIB, the disease has spread to the pelvic wall; surgery cannot achieve clear margins and carries high morbidity. * **C (Chemotherapy):** While Cisplatin is used as a radiosensitizer in CCRT, chemotherapy alone is not the primary curative treatment for Stage IIIB. It is usually reserved for Stage IVB (metastatic) or recurrent disease. **3. NEET-PG High-Yield Pearls** * **FIGO Staging:** Cervical cancer is now staged **clinically**, but imaging (MRI/CT) and pathology findings are now incorporated (FIGO 2018). * **Stage IIIB Definition:** Extension to the pelvic wall, and/or hydronephrosis/non-functioning kidney, and/or involves lower third of the vagina. * **Most Common Cause of Death:** In cervical cancer, the most common cause of death is **Uremia** due to bilateral ureteric obstruction. * **Triad of Pelvic Wall Involvement:** Leg edema, hydronephrosis, and sciatic pain.

Question 276: On follow-up study, elevated CA 125 in a case of epithelial ovarian tumor should be further evaluated with what?

A. MRI
B. CT Scan (Correct Answer)
C. Yearly follow-up
D. Clinical examination and serial CA 125 monitoring

Explanation: **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.

Question 277: What is the recommended treatment for a 50-year-old woman with biopsy-proven CIN 3?

A. Conization
B. Hysterectomy
C. Colposcopy with LEEP (Correct Answer)
D. Trachelectomy

Explanation: **Explanation:** **CIN 3 (Cervical Intraepithelial Neoplasia Grade 3)** is a high-grade squamous intraepithelial lesion (HSIL) and is considered a direct precursor to invasive cervical cancer. The primary goal of treatment is the complete excision or ablation of the transformation zone to prevent progression to malignancy. **Why Option C is Correct:** **Colposcopy-guided LEEP (Loop Electrosurgical Excision Procedure)** is the preferred first-line treatment for CIN 3 in most women, including those aged 50. It is a diagnostic-therapeutic procedure that allows for the removal of the entire transformation zone while providing a tissue specimen for histopathological examination to rule out occult invasive cancer. It is preferred over ablative methods (like cryotherapy) for CIN 3 because it ensures margins can be evaluated. **Why Other Options are Incorrect:** * **A. Conization (Cold Knife Conization):** While also an excisional procedure, it is typically reserved for cases where the squamocolumnar junction is not fully visible, there is suspicion of microinvasion, or glandular disease (AIS). It requires general anesthesia and has higher morbidity compared to LEEP. * **B. Hysterectomy:** This is considered **overtreatment** for CIN 3. It is only indicated if there are concurrent gynecological issues (e.g., fibroids, prolapse), if the patient has recurrent CIN 3 despite excisional procedures, or if margins remain persistently positive. * **D. Trachelectomy:** This is the surgical removal of the cervix, usually reserved for early-stage invasive cervical cancer (Stage IA2-IB1) in women wishing to preserve fertility. It is not indicated for pre-invasive lesions like CIN 3. **High-Yield Clinical Pearls for NEET-PG:** * **Management Goal:** "See and Treat" via LEEP is often favored to reduce loss to follow-up. * **Post-treatment Follow-up:** After treatment for CIN 3, patients require **"Test of Cure"** with HPV testing (or co-testing) at 12 and 24 months. * **Age Factor:** In women >45 years with CIN 3, the risk of occult invasion is higher; hence, excisional methods (LEEP/CKC) are strictly preferred over ablation.

Question 278: 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?

A. b-hCG levels will be higher than normal (Correct Answer)
B. b-hCG levels will be lower than normal
C. Uterus will be of normal size for gestational age
D. TSH levels will be increased

Explanation: **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.

Question 279: 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?

A. Commence treatment with intramuscular methotrexate
B. Commence treatment with multi-agent combination chemotherapy (Correct Answer)
C. Perform a hysterectomy
D. Repeat serum hCG after 4 weeks

Explanation: This question tests your ability to risk-stratify **Gestational Trophoblastic Neoplasia (GTN)** using the **WHO/FIGO Scoring System**, which determines the choice of chemotherapy. ### Why Option B is Correct The management of choriocarcinoma depends on whether the patient is "Low Risk" (Score 0-6) or "High Risk" (Score ≥7). In this patient, the high risk is established by two primary factors: 1. **Serum beta-hCG level:** A value of $2 \times 10^5$ IU/L (200,000 IU/L) automatically contributes **4 points** to the FIGO score (any value >100,000). 2. **Interval from index pregnancy:** The bleeding started 7 months ago, contributing **2 points**. 3. **Type of pregnancy:** Choriocarcinoma following a term pregnancy is inherently more aggressive and carries a higher score. A patient with a score ≥7 (High Risk) requires **multi-agent combination chemotherapy**, typically the **EMA-CO regimen** (Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide, and Vincristine). ### Why Other Options are Incorrect * **Option A:** Single-agent Methotrexate is the treatment of choice for **Low-Risk GTN** (Score <7). It would result in treatment failure and chemoresistance in this high-risk patient. * **Option C:** Hysterectomy is generally not the primary treatment for choriocarcinoma, as it is highly chemosensitive. Surgery is reserved for chemoresistant nodules or life-threatening hemorrhage. * **Option D:** Delaying treatment for 4 weeks is dangerous. Choriocarcinoma is highly malignant and can metastasize rapidly (especially to the lungs and brain). ### High-Yield Clinical Pearls for NEET-PG * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%). * **FIGO Scoring Parameters:** Age, Antecedent pregnancy, Interval from pregnancy, Pre-treatment hCG, Largest tumor size, Site of metastasis, Number of metastases, and Previous failed chemotherapy. * **Post-term choriocarcinoma:** Always carries a worse prognosis than post-molar choriocarcinoma. * **Follow-up:** After hCG normalization, follow-up continues for 12 months for high-risk patients to monitor for recurrence.

Question 280: All are risk factors for carcinoma endometrium EXCEPT?

A. Infertility
B. Multiple sexual partners (Correct Answer)
C. Diabetes
D. Hypertension

Explanation: **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.

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

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free