Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 21: A 30-year-old woman's Pap smear results are provided below. What is your next recommended approach?

A. Continue routine screening
B. Advise loop electrosurgical excision procedure (Correct Answer)
C. Hysterectomy
D. Cryotherapy

Explanation: ***Advise loop electrosurgical excision procedure*** - **HSIL (CIN 2/3)** on Pap smear requires excisional treatment, and **LEEP** is the preferred first-line procedure for diagnosis and treatment. - LEEP provides complete **histopathological evaluation** to rule out **invasive carcinoma** and ensures adequate treatment of high-grade lesions. *Continue routine screening* - Routine screening is appropriate only for **normal cytology** or **ASCUS** with negative HPV testing. - **High-grade lesions (HSIL)** have significant **malignant potential** and require immediate intervention, not observation. *Hysterectomy* - Reserved for **invasive cervical cancer**, **recurrent CIN** after failed conservative treatment, or when fertility preservation is not desired. - **Primary hysterectomy** for CIN 2/3 is excessive and removes fertility potential unnecessarily in a 30-year-old woman. *Cryotherapy* - Suitable only for **small CIN 1** lesions or **CIN 2** lesions covering less than 2 quadrants with visible transformation zone. - **Cannot provide tissue sample** for histopathological confirmation and may be inadequate for extensive CIN 2/3 lesions.

Question 22: A 53-year-old woman with an ovarian tumor presents with breathlessness and right-sided chest pain. The chest X-ray shows obliteration of the right costophrenic angle. What is the most likely diagnosis?

A. Pleurisy (Correct Answer)
B. Pericarditis
C. Myocardial infarction
D. Parapneumonic effusion

Explanation: **Explanation:** The clinical presentation describes a classic case of **Meigs’ Syndrome**, which is a triad of a benign ovarian tumor (most commonly a **Fibroma**), ascites, and pleural effusion. **1. Why Pleurisy (Pleural Effusion) is correct:** The patient has an ovarian tumor and presents with breathlessness and chest pain. The "obliteration of the costophrenic angle" on a chest X-ray is the hallmark sign of a **pleural effusion**. In Meigs’ Syndrome, the fluid is typically an exudate or transudate that migrates from the peritoneum to the pleural space (most commonly on the **right side**) through transdiaphragmatic lymphatics or small congenital defects in the diaphragm. While "Pleurisy" technically refers to inflammation of the pleura, in the context of this specific NEET-PG question format, it is used to denote the pleural involvement/effusion associated with the ovarian pathology. **2. Why the other options are incorrect:** * **Pericarditis:** Usually presents with central, sharp chest pain relieved by leaning forward and diffuse ST-elevation on ECG, not costophrenic angle obliteration. * **Myocardial Infarction:** Presents with crushing retrosternal pain and autonomic symptoms; it does not cause localized pleural fluid collection. * **Parapneumonic effusion:** This is an effusion secondary to pneumonia. While it causes costophrenic angle obliteration, the primary history of an ovarian tumor strongly points toward Meigs’ Syndrome rather than an infectious etiology. **Clinical Pearls for NEET-PG:** * **Meigs’ Syndrome Triad:** Benign Ovarian Tumor (Fibroma > Thecoma > Brenner) + Ascites + Pleural Effusion. * **Pseudo-Meigs’ Syndrome:** Similar presentation but associated with other benign tumors (leiomyomas) or malignant ovarian tumors. * **Key Feature:** The ascites and pleural effusion **resolve completely** after the surgical removal of the ovarian tumor. * **Side Predilection:** The pleural effusion in Meigs’ is right-sided in 70% of cases.

Question 23: Which of the following indications usually warrants the institution of single-agent chemotherapy following evacuation of a hydatidiform mole?

A. A rise in hCG titers (Correct Answer)
B. A plateau of hCG titers for 1 week
C. Return of hCG titer to normal at 6 weeks after evacuation
D. Appearance of liver metastasis

Explanation: In the management of Gestational Trophoblastic Disease (GTD), the primary goal after suction evacuation is the monitoring of serum β-hCG levels to detect malignant transformation into Gestational Trophoblastic Neoplasia (GTN). ### **Explanation of the Correct Answer** **Option A (A rise in hCG titers)** is a definitive FIGO criterion for diagnosing post-molar GTN. Specifically, a rise of **10% or greater** across three consecutive weekly titers (days 1, 7, and 14) indicates active trophoblastic proliferation. Once GTN is diagnosed, chemotherapy (usually single-agent Methotrexate or Actinomycin-D for low-risk disease) is mandatory to prevent local invasion and distant metastasis. ### **Analysis of Incorrect Options** * **Option B:** A plateau of hCG is indeed an indication for chemotherapy, but the duration must be for **at least 3 weeks** (4 values on days 1, 7, 14, and 21), not just 1 week. * **Option C:** This represents a normal physiological recovery. If hCG returns to normal, the patient is monitored but does not require chemotherapy. * **Option D:** The appearance of liver metastasis classifies the patient as **High-Risk GTN** (WHO Score ≥7). Such cases warrant **multi-agent chemotherapy** (e.g., EMA-CO regimen) rather than the single-agent therapy specified in the question. ### **High-Yield Clinical Pearls for NEET-PG** * **FIGO Criteria for GTN:** 1. hCG plateau for 4 values over 3 weeks. 2. hCG rise (≥10%) for 3 values over 2 weeks. 3. Persistence of hCG 6 months after evacuation. 4. Histological diagnosis of Choriocarcinoma. * **Investigation of Choice for Follow-up:** Serial quantitative serum β-hCG. * **Contraception:** Combined Oral Contraceptive Pills (COCs) are preferred after evacuation once hCG levels normalize; avoid IUCDs until hCG is undetectable due to the risk of perforation.

Question 24: Which ovarian tumor is typically bilateral?

A. Dysgerminoma (Correct Answer)
B. Endodermal sinus tumor
C. Immature teratoma
D. Embryonal cell carcinoma

Explanation: **Explanation:** **Dysgerminoma** is the most common malignant germ cell tumor (GCT) of the ovary. Its defining clinical characteristic among germ cell tumors is its tendency for **bilaterality**, occurring in approximately **10–15%** of cases. In contrast, almost all other malignant germ cell tumors are almost always unilateral. Dysgerminomas are radiosensitive, chemo-sensitive, and often associated with gonadal dysgenesis (e.g., Swyer syndrome). **Analysis of Incorrect Options:** * **Endodermal Sinus Tumor (Yolk Sac Tumor):** This is the second most common malignant GCT. It is highly aggressive, rapidly growing, and virtually always **unilateral**. It is characterized by elevated **AFP** levels and Schiller-Duval bodies on histology. * **Immature Teratoma:** These tumors contain tissues from all three germ layers (predominantly neuroepithelium). They are almost always **unilateral**, though the contralateral ovary may occasionally harbor a *benign* cystic teratoma. * **Embryonal Cell Carcinoma:** A rare, highly malignant GCT that produces both AFP and hCG. It typically presents as a large **unilateral** mass. **NEET-PG High-Yield Pearls:** * **Most common malignant GCT:** Dysgerminoma. * **Tumor Markers:** Dysgerminoma is associated with elevated **LDH** and occasionally hCG. * **Microscopy:** Look for "large cells with clear cytoplasm and central nuclei (fried-egg appearance) separated by fibrous septa infiltrated with lymphocytes." * **Rule of Thumb:** If a malignant germ cell tumor is bilateral, the answer is almost always Dysgerminoma. If an epithelial tumor is bilateral, consider Serous Cystadenocarcinoma or Krukenberg tumor.

Question 25: Molar pregnancy can be best diagnosed by?

A. Clinical history and examination
B. Ultrasound study (Correct Answer)
C. Laparoscopy
D. CT Scan

Explanation: **Explanation:** **Molar pregnancy (Hydatidiform mole)** is a gestational trophoblastic disease characterized by the proliferation of chorionic villi. **Why Ultrasound is the Correct Answer:** Ultrasound (USG) is the **gold standard and investigation of choice** for diagnosing molar pregnancy. * **Complete Mole:** Classically presents with a **"Snowstorm appearance"** or "Honeycombing," which represents multiple hydropic villi and intrauterine hemorrhage without a fetus. * **Partial Mole:** Shows a thickened placenta with cystic spaces (Swiss cheese appearance) and may show a growth-restricted fetus or fetal parts. * USG is non-invasive, highly sensitive, and allows for the assessment of associated theca lutein cysts in the ovaries. **Analysis of Incorrect Options:** * **A. Clinical history and examination:** While symptoms like painless vaginal bleeding ("white currant" discharge) and a "uterus larger than dates" with a "doughy feel" are suggestive, they are non-specific and cannot definitively differentiate a mole from multiple gestations or fibroids. * **C. Laparoscopy:** This is an invasive surgical procedure used for ectopic pregnancy or pelvic inflammatory disease; it has no role in diagnosing intrauterine molar tissue. * **D. CT Scan:** While useful for detecting distant metastasis in Choriocarcinoma (e.g., lungs, brain), it is not the primary modality for diagnosing the initial molar pregnancy due to radiation risks and lower soft-tissue resolution compared to USG. **High-Yield Clinical Pearls for NEET-PG:** * **Biochemical Marker:** Serum **beta-hCG** levels are disproportionately high (often >100,000 mIU/ml) in complete moles. * **Management:** The treatment of choice is **Suction and Evacuation**, regardless of uterine size. * **Follow-up:** Monitor weekly beta-hCG until three consecutive negative results to rule out Persistent Gestational Trophoblastic Neoplasia (GTN). * **Karyotype:** Complete Mole is usually **46, XX** (paternal origin); Partial Mole is usually **69, XXY** (triploid).

Question 26: What is the WHO prognostic score for high-risk gestational trophoblastic neoplasia (GTN)?

A. >= 6
B. >= 7 (Correct Answer)
C. >= 10
D. >= 15

Explanation: **Explanation:** Gestational Trophoblastic Neoplasia (GTN) is staged using the **FIGO Staging and WHO Scoring System**. Unlike other cancers, GTN management is determined by a "Prognostic Risk Score" rather than just anatomical spread. This score (0-4 points per factor) evaluates variables such as age, antecedent pregnancy, interval from index pregnancy, pretreatment hCG levels, largest tumor size, site and number of metastases, and previous chemotherapy failure. * **Correct Answer (B):** A total score of **≥ 7** is classified as **High-Risk GTN**. These patients have a higher risk of developing resistance to single-agent chemotherapy and are therefore treated primarily with **multi-agent chemotherapy** (typically the EMA-CO regimen). * **Incorrect Options (A, C, D):** A score of **0–6** is classified as **Low-Risk GTN**, usually treated with single-agent chemotherapy (Methotrexate or Actinomycin-D). Scores of 10 or 15 do not represent the standard threshold for high-risk classification, though a score ≥ 13 is sometimes used to denote "ultra-high risk" in specialized centers. **High-Yield Clinical Pearls for NEET-PG:** 1. **Low Risk (0-6):** Single-agent chemo (Methotrexate is the first choice). 2. **High Risk (≥ 7):** Multi-agent chemo (EMA-CO: Etoposide, Methotrexate, Actinomycin-D, Cyclophosphamide, Oncovin/Vincristine). 3. **Most Important Prognostic Factor:** The most significant factor in the scoring system is the **previous failure of chemotherapy**. 4. **Commonest Site of Metastasis:** The **Lungs** (80%), followed by the vagina (30%). 5. **Choriocarcinoma** is the most common histological type of GTN following a term pregnancy.

Question 27: The EMA-CO chemotherapy regimen is used in the treatment of which of the following conditions?

A. Gestational trophoblastic neoplasia (Correct Answer)
B. Malignant ovarian germ cell tumor
C. Endometrial carcinoma
D. Cervical carcinoma

Explanation: **Explanation:** The **EMA-CO** regimen is the gold-standard chemotherapy for **high-risk Gestational Trophoblastic Neoplasia (GTN)**, defined by a FIGO/WHO score of ≥7. **Why Option A is correct:** GTN is highly chemosensitive. While low-risk cases (score <7) are treated with single-agent Methotrexate or Actinomycin-D, high-risk cases require multi-agent therapy. EMA-CO is an acronym for: * **E**toposide * **M**ethotrexate * **A**ctinomycin-D * **C**yclophosphamide * **O**nvocin (Vincristine) This regimen is administered in alternating cycles (EMA on days 1-2 and CO on day 8) to maximize tumor kill while allowing bone marrow recovery. **Why the other options are incorrect:** * **Malignant Ovarian Germ Cell Tumors:** The standard of care is the **BEP regimen** (Bleomycin, Etoposide, and Cisplatin). * **Endometrial Carcinoma:** Advanced or recurrent cases are typically treated with **Carboplatin and Paclitaxel**. * **Cervical Carcinoma:** The primary treatment for advanced stages is **Cisplatin-based chemotherapy**, often combined with Paclitaxel or used as a radiosensitizer during radiotherapy. **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Scoring:** A score of **0-6 is Low Risk** (Single agent); **≥7 is High Risk** (Multi-agent/EMA-CO). * **Monitoring:** The most sensitive marker for treatment response and follow-up in GTN is **serum β-hCG**. * **Salvage Therapy:** For EMA-CO resistant cases, **EMA-EP** (Etoposide/Cisplatin) is often used. * **Common Side Effect:** Myelosuppression is the most significant dose-limiting toxicity of the EMA-CO regimen.

Question 28: A lesion in a female child born to a mother treated with diethylstilbestrol (DES) is most likely to be?

A. Vaginal adenosis (Correct Answer)
B. Sarcoma botryoides
C. Cervical erosion
D. Endometrial carcinoma

Explanation: **Explanation:** **Diethylstilbestrol (DES)** is a synthetic non-steroidal estrogen that was historically used to prevent miscarriages. Its use is associated with a spectrum of reproductive tract anomalies in female offspring (DES daughters). **Why Vaginal Adenosis is the correct answer:** Vaginal adenosis is the **most common** benign anomaly found in DES-exposed daughters (occurring in up to 30–90% of cases). It is characterized by the presence of glandular (columnar) epithelium in the vagina, where normally only squamous epithelium should exist. While DES exposure is famously linked to **Clear Cell Adenocarcinoma (CCAC)** of the vagina/cervix, adenosis is the precursor lesion and is statistically far more frequent than the malignancy itself. **Analysis of Incorrect Options:** * **B. Sarcoma botryoides:** This is an embryonal rhabdomyosarcoma (the most common vaginal tumor in children <5 years). It presents as a "grape-like" mass but is unrelated to DES exposure. * **C. Cervical erosion:** While DES can cause structural changes like cervical "cockscomb" or "collars," cervical erosion is a non-specific finding often related to hormonal changes or chronic cervicitis, not specifically pathognomonic for DES. * **D. Endometrial carcinoma:** DES exposure is primarily linked to vaginal and cervical pathology (CCAC), not endometrial cancer. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common lesion:** Vaginal adenosis. 2. **Most characteristic malignancy:** Clear Cell Adenocarcinoma (CCAC) of the vagina/cervix. 3. **Structural anomalies:** T-shaped uterus, cervical hoods, cockscomb cervix, and transverse vaginal septa. 4. **Mechanism:** DES interferes with the transformation of Mullerian duct columnar epithelium into squamous epithelium during fetal development.

Question 29: All of the following are known risk factors for the development of endometrial carcinoma except?

A. Obesity
B. Family history
C. Use of hormone replacement therapy
D. Early menopause (Correct Answer)

Explanation: **Explanation:** The development of endometrial carcinoma (specifically Type I) is primarily driven by **unopposed estrogen** stimulation. Estrogen promotes endometrial proliferation, while progesterone acts as a protective agent by inducing differentiation and shedding. **Why Early Menopause is the Correct Answer:** Early menopause is **not** a risk factor; in fact, **late menopause** (after age 52-55) is a significant risk factor. A longer reproductive lifespan means the endometrium is exposed to estrogen for a greater number of years. Conversely, early menopause reduces the total duration of estrogen exposure, thereby decreasing the risk of endometrial cancer. **Analysis of Incorrect Options:** * **Obesity:** This is a major risk factor. In obese postmenopausal women, androstenedione is converted into estrone by the enzyme **aromatase** in peripheral adipose tissue, leading to high levels of endogenous estrogen. * **Family History:** Genetic predisposition plays a role, most notably in **Lynch Syndrome** (Hereditary Non-Polyposis Colorectal Cancer - HNPCC), which carries a 40-60% lifetime risk of endometrial cancer. * **Hormone Replacement Therapy (HRT):** The use of **unopposed estrogen** therapy in women with an intact uterus significantly increases the risk. To mitigate this, progesterone must always be added to the regimen. **High-Yield Clinical Pearls for NEET-PG:** * **Protective Factors:** Combined Oral Contraceptive Pills (COCPs), multiparity, smoking (decreases estrogen levels, though not recommended), and physical activity. * **PCOS:** A common cause of chronic anovulation leading to unopposed estrogen and increased cancer risk. * **Tamoxifen:** Used in breast cancer treatment, it acts as an estrogen agonist on the endometrium, increasing the risk of hyperplasia and carcinoma. * **Most Common Histology:** Endometrioid adenocarcinoma.

Question 30: Which of the following statements regarding sarcoma botryoides is FALSE?

A. It is typically seen in the vagina.
B. Characteristic presentation includes grape-like clusters.
C. It is commonly found in elderly women. (Correct Answer)
D. It is a type of adenocarcinoma.

Explanation: **Explanation:** **Sarcoma botryoides** (Embryonal Rhabdomyosarcoma) is a highly malignant tumor derived from primitive mesenchymal cells. 1. **Why Option C is the Correct Answer (The False Statement):** Sarcoma botryoides is a tumor of **infancy and early childhood**, typically occurring in girls **under the age of 5** (peak incidence at 2–3 years). It is almost never seen in elderly women. In older patients, the most common vaginal malignancy is Squamous Cell Carcinoma. 2. **Analysis of Other Options:** * **Option A (Typically seen in the vagina):** In infants and young children, the most common site is the **vagina**. (Note: In older children/adolescents, it may occur in the cervix or urinary bladder). * **Option B (Grape-like clusters):** The name "botryoides" is derived from the Greek word *botrys* (cluster of grapes). Grossly, the tumor appears as edematous, polypoid, friable masses resembling grapes protruding from the introitus. * **Option D (Type of adenocarcinoma):** This is technically a **distractor** in the original question format, as Sarcoma botryoides is a **mesenchymal tumor (sarcoma)**, not an epithelial tumor (adenocarcinoma). However, in the context of identifying the "most false" or primary clinical characteristic for NEET-PG, the age demographic (Option C) is the classic "false" fact tested. **High-Yield Clinical Pearls for NEET-PG:** * **Histology:** Look for the **Cambium layer** (a dense zone of undifferentiated tumor cells immediately beneath the vaginal epithelium). * **Marker:** Cells often show cross-striations and are positive for **Desmin**, **Myogenin**, and **Myo-D1**. * **Presentation:** Often presents as blood-stained vaginal discharge or a "grape-like" mass protruding from the vagina in a toddler.

Practice by Chapter

Cervical Cancer

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Endometrial Cancer

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Ovarian Cancer

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Vulvar and Vaginal Cancer

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Gestational Trophoblastic Disease

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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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