Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 291: What is the commonest cause of carcinoma of the endometrium?

A. Unopposed estrogen (Correct Answer)
B. Multiple sexual partners
C. Early marriage
D. Early menarche

Explanation: **Explanation:** **Unopposed estrogen** is the most significant risk factor and the commonest cause of Type I Endometrial Carcinoma (Endometrioid adenocarcinoma). Estrogen acts as a potent mitogen for the endometrium; when its action is not balanced by progesterone (which induces differentiation and shedding), it leads to persistent endometrial proliferation. This progression follows a predictable sequence: **Simple Hyperplasia → Complex Hyperplasia → Atypical Hyperplasia → Carcinoma.** Common clinical scenarios include PCOS, obesity (peripheral conversion of androstenedione to estrone in adipose tissue), estrogen-only HRT, and functional ovarian tumors (e.g., Granulosa cell tumor). **Analysis of Incorrect Options:** * **Multiple sexual partners & Early marriage:** These are classic risk factors for **Cervical Cancer**, as they increase the likelihood of exposure to High-Risk Human Papillomavirus (HPV). They have no direct correlation with endometrial malignancy. * **Early menarche:** While early menarche (and late menopause) increases the total lifetime exposure to estrogen, it is a secondary risk factor. "Unopposed estrogen" is the broader, more definitive physiological cause that encompasses various hormonal imbalances. **NEET-PG High-Yield Pearls:** * **Protective Factors:** Combined Oral Contraceptive Pills (COCPs), multiparity, and smoking (though harmful otherwise, it decreases estrogen levels). * **Lynch Syndrome (HNPCC):** The most common inherited predisposition to endometrial cancer. * **Investigation of Choice:** Fractional Curettage or Pipelle Biopsy (Gold standard for diagnosis). * **Most Common Type:** Endometrioid Adenocarcinoma (Type I). Type II (Serous/Clear cell) is estrogen-independent and carries a poorer prognosis.

Question 292: Which of the following is a risk factor for the development of Choriocarcinoma?

A. Presence of Lung metastasis
B. Onset following term gestation (Correct Answer)
C. b-hCG level < 40,000 mIU/mL
D. None of the above

Explanation: **Explanation:** Choriocarcinoma is a highly malignant form of Gestational Trophoblastic Neoplasia (GTN). The correct answer is **B. Onset following term gestation.** **1. Why Option B is Correct:** While choriocarcinoma most commonly follows a hydatidiform mole (50% of cases), it can also occur after abortions (25%), ectopic pregnancies (5%), or **term gestations (20%)**. Crucially, choriocarcinoma that develops after a term pregnancy carries a **worse prognosis** and is considered a significant risk factor for high-risk disease according to the FIGO/WHO scoring system. This is because it often presents later, may be overlooked initially, and is biologically more aggressive than post-molar GTN. **2. Why Other Options are Incorrect:** * **Option A (Lung Metastasis):** Lung metastasis is a common site of spread for choriocarcinoma, but it is categorized as a **low-risk** metastatic site in the FIGO scoring system (Score 0). In contrast, metastases to the liver or brain are high-risk factors. * **Option C (b-hCG < 40,000 mIU/mL):** A low b-hCG level is actually a favorable prognostic indicator. According to FIGO staging, a pretreatment b-hCG level **> 100,000 mIU/mL** is the threshold for a higher risk score. **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Scoring:** A score of **≥ 7** indicates High-Risk GTN, usually requiring multi-agent chemotherapy (EMA-CO regimen). * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%). * **Characteristic Histology:** Absence of chorionic villi; presence of sheets of anaplastic syncytiotrophoblasts and cytotrophoblasts with extensive hemorrhage and necrosis. * **The "Great Imitator":** Choriocarcinoma is known for its tendency to bleed; always consider it in a reproductive-age woman with unexplained hemoptysis or stroke.

Question 293: Good prognosis in gestational trophoblastic disease is seen with which organ metastasis?

A. Liver
B. Kidney
C. Brain
D. Lung (Correct Answer)

Explanation: **Explanation:** Gestational Trophoblastic Neoplasia (GTN) is unique among malignancies because it is highly chemosensitive, even in the presence of distant metastases. The prognosis is determined using the **WHO Modified FIGO Staging and Risk Factor Scoring System**. **Why Lung is the Correct Answer:** The **lungs** are the most common site of metastasis in GTN (occurring in approximately 80% of metastatic cases). According to the FIGO scoring system, the site of metastasis significantly impacts the prognosis score. Metastasis to the **lungs** is assigned a score of **0**, indicating the lowest risk and the best prognosis. Patients with isolated lung involvement often achieve nearly 100% remission with appropriate chemotherapy (e.g., Methotrexate or EMA-CO). **Analysis of Incorrect Options:** * **Kidney (Option B):** Renal involvement is assigned a score of **2**. It represents a higher tumor burden than lung involvement and carries a moderate risk. * **Liver (Option A) and Brain (Option C):** These are considered **high-risk sites**. Metastasis to the liver or brain is assigned a score of **4** (the highest possible for a single site). These patients have a significantly poorer prognosis, higher rates of chemoresistance, and often require multi-modal therapy including radiation or surgery. **High-Yield Clinical Pearls for NEET-PG:** * **Commonest site of metastasis:** Lung (80%), followed by the Vagina (30%). * **Low-risk GTN (Score 0-6):** Usually treated with single-agent chemotherapy (Methotrexate). * **High-risk GTN (Score ≥7):** Requires multi-agent chemotherapy (EMA-CO regimen). * **Choriocarcinoma** is the most common histological type to metastasize hematogenously. * **Vaginal metastasis** typically presents as highly vascular, "blue-domed" nodules; biopsy should be avoided due to the risk of torrential hemorrhage.

Question 294: Which of the following statements about squamous cell carcinoma of the cervix is false?

A. Common at the squamocolumnar junction.
B. CT scan is mandatory for staging. (Correct Answer)
C. Postcoital bleeding is a common symptom.
D. HPV 16 and 18 are associated with a high risk of carcinogenesis.

Explanation: **Explanation:** **1. Why Option B is the correct (False) statement:** The staging of Cervical Cancer is primarily **clinical**, according to the **FIGO (International Federation of Gynecology and Obstetrics) classification**. While the 2018 FIGO update allows the use of imaging (MRI, CT, or PET-CT) and pathology to assign the stage where available, they are **not mandatory**. In resource-limited settings, staging can still be performed using clinical examination (under anesthesia), colposcopy, biopsy, cystoscopy, and proctosigmoidoscopy. Therefore, a CT scan is a helpful tool but not a mandatory requirement for staging. **2. Analysis of other options:** * **Option A:** The **Transformation Zone (Squamocolumnar Junction)** is the most metabolically active area of the cervix where columnar epithelium undergoes metaplasia into squamous epithelium. This is the site where HPV integration and neoplastic changes most frequently occur. * **Option C:** **Postcoital bleeding** is the most characteristic clinical presentation of cervical cancer. Other symptoms include intermenstrual bleeding and foul-smelling vaginal discharge. * **Option D:** **HPV 16 and 18** are "high-risk" genotypes responsible for approximately 70% of all cervical cancer cases globally. HPV 16 is most commonly associated with squamous cell carcinoma, while HPV 18 is more frequently linked to adenocarcinoma. **Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous cell carcinoma (80-85%). * **FIGO 2018 Update:** Imaging and surgical findings can now be used to stage the disease (unlike the older 2009 purely clinical staging). * **Stage IIB:** The presence of parametrial involvement; this is the threshold where management shifts from surgery (Wertheim’s Hysterectomy) to **Concurrent Chemoradiotherapy (CCRT)**. * **Screening:** The primary screening tool is the Pap smear or HPV DNA testing.

Question 295: A perimenopausal lady with well-differentiated adenocarcinoma of the uterus has more than half myometrial invasion, vaginal metastasis, and inguinal lymph node metastasis. What is the stage of this patient?

A. Stage IIIB
B. Stage IIIC
C. Stage IVA
D. Stage IVB (Correct Answer)

Explanation: ### Explanation The staging of endometrial carcinoma is based on the **FIGO (2023/2009) surgical staging system**. This patient has three key findings: deep myometrial invasion (>50%), vaginal metastasis, and inguinal lymph node metastasis. **Why Stage IVB is Correct:** The defining feature for this patient’s stage is the **inguinal lymph node metastasis**. According to FIGO staging: * **Stage IVB** includes distant metastasis, which encompasses spread to intra-abdominal lymph nodes (other than para-aortic/pelvic), **inguinal lymph nodes**, lung, liver, or bone. Even though she has local spread (vagina), the presence of distant nodal involvement automatically upgrades her to IVB. **Analysis of Incorrect Options:** * **Stage IIIB:** This involves spread to the **vagina** and/or parametrium. While this patient has vaginal metastasis, the presence of inguinal node involvement (distant spread) makes this stage too low. * **Stage IIIC:** This stage is reserved for metastasis to the **pelvic (IIIC1)** or **para-aortic (IIIC2)** lymph nodes. Inguinal nodes are considered "distant" rather than "regional" in endometrial cancer. * **Stage IVA:** This involves tumor invasion of the **bladder mucosa** and/or **rectal mucosa**. There is no mention of transmural organ involvement in this case. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of distant metastasis:** Lungs. * **Lymphatic spread:** Usually follows a predictable pattern (Pelvic → Para-aortic). Inguinal node involvement is rare and signifies advanced disease. * **Myometrial invasion:** <50% is Stage IA; ≥50% is Stage IB. * **Staging Method:** Endometrial cancer is **surgically staged**, unlike cervical cancer which was historically clinically staged (though FIGO 2018 now allows imaging/pathology for cervix too).

Question 296: What is the size of an ovary, in cm, above which it is considered to be malignant?

A. 2 cm
B. 5 cm (Correct Answer)
C. 8 cm
D. 10 cm

Explanation: **Explanation:** In gynecologic oncology, the size of an ovarian mass is a critical predictor of malignancy, particularly in postmenopausal women. The threshold of **5 cm** is widely accepted as the clinical cutoff for concern. **1. Why 5 cm is the Correct Answer:** According to the **RCOG and ACOG guidelines**, simple ovarian cysts smaller than 5 cm in diameter in postmenopausal women are almost always benign and can be managed conservatively with serial ultrasounds. However, once a cyst exceeds **5 cm**, the risk of malignancy increases significantly, necessitating further investigation (like CA-125 levels) or surgical intervention (Laparoscopy/Laparotomy). In premenopausal women, while functional cysts can be larger, a persistent mass >5 cm still warrants close monitoring to rule out neoplasia. **2. Analysis of Incorrect Options:** * **A. 2 cm:** This is too small. Small "inclusion cysts" are common and physiologically insignificant. * **C. 8 cm & D. 10 cm:** While masses of this size are highly suspicious and often require surgery, they are well above the initial threshold for malignancy concern. Using 8 or 10 cm as a cutoff would result in missing many early-stage cancers. **3. NEET-PG High-Yield Pearls:** * **Risk of Malignancy Index (RMI):** Uses three variables: Ultrasound features (U), Menopausal status (M), and Serum CA-125 levels. * **Postmenopausal Palpable Ovary Syndrome:** Any palpable ovary in a postmenopausal woman is considered abnormal and must be investigated for malignancy, as ovaries should normally be atrophic and non-palpable. * **Most Common Ovarian Cancer:** Serous cystadenocarcinoma. * **Best Initial Investigation:** Transvaginal Ultrasound (TVUS).

Question 297: Which of the following is a feminizing ovarian tumor?

A. Granulosa cell tumor (Correct Answer)
B. Arrhenoblastoma
C. Hilus cell tumor
D. Gynandroblastoma

Explanation: **Explanation:** **1. Why Granulosa Cell Tumor is Correct:** Granulosa cell tumors (GCT) are the most common type of **Sex Cord-Stromal Tumors**. They are clinically significant because they are **estrogen-secreting (feminizing)**. The granulosa cells convert androgens into estrogens via the enzyme aromatase. * **In children:** This leads to precocious puberty. * **In reproductive age:** It causes irregular bleeding or menorrhagia. * **In postmenopausal women:** It presents as postmenopausal bleeding due to endometrial hyperplasia or even endometrial carcinoma (seen in 5% of cases). **2. Why Other Options are Incorrect:** * **Arrhenoblastoma (Sertoli-Leydig Cell Tumor):** These are **virilizing (masculinizing)** tumors. they secrete testosterone, leading to hirsutism, clitoromegaly, and voice deepening. * **Hilus Cell Tumor:** A subset of Leydig cell tumors that occur in the ovarian hilum. They are typically small but highly potent **androgen-secreting** tumors, causing rapid virilization in postmenopausal women. * **Gynandroblastoma:** An extremely rare tumor containing both feminizing (Granulosa) and masculinizing (Sertoli-Leydig) components. While it can have mixed effects, it is not primarily classified as a feminizing tumor like GCT. **3. High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** **Inhibin (Inhibin B)** is the most specific marker used for diagnosis and monitoring recurrence. * **Histopathology:** Pathognomonic **Call-Exner bodies** (small follicles filled with eosinophilic material) and "coffee-bean" nuclei. * **Risk:** Always perform an endometrial biopsy in GCT patients to rule out concurrent endometrial malignancy due to chronic estrogen exposure.

Question 298: A 42-year-old female with P3+0+0+3 is found to have carcinoma in situ. What is the best treatment?

A. Hysterectomy (Correct Answer)
B. Wertheim's hysterectomy
C. Conization
D. Wait and watch

Explanation: **Explanation:** **1. Why Hysterectomy is the Correct Answer:** Carcinoma in situ (CIS) of the cervix is synonymous with **CIN 3**. The management of CIN 3 depends primarily on the patient’s age and desire for future fertility. In this case, the patient is 42 years old and has completed her family (P3+0+0+3). For women who have **completed their family**, a **Total Abdominal Hysterectomy (TAH)** is the definitive treatment of choice as it eliminates the risk of recurrence and progression to invasive cancer. **2. Why Other Options are Incorrect:** * **Wertheim’s Hysterectomy (Radical Hysterectomy):** This is indicated for invasive cervical cancer (Stage IA2 to IIA). Since CIS is a pre-invasive lesion (Stage 0) that does not involve the stroma or lymph nodes, radical surgery is overtreatment. * **Conization:** This is a fertility-sparing procedure. While it is the treatment of choice for younger patients or those desiring more children, it carries a small risk of recurrence. In a 42-year-old with completed family, hysterectomy is preferred for its definitive nature. * **Wait and Watch:** CIS/CIN 3 is a high-grade premalignant lesion with a high risk of progression to invasive squamous cell carcinoma. Observation is contraindicated; active intervention is mandatory. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Colposcopy-directed biopsy. * **Treatment of Choice (Fertility desired):** Cervical Conization or LEEP (Large Loop Excision of the Transformation Zone). * **Treatment of Choice (Family completed):** Extrafascial (Simple) Hysterectomy. * **Microinvasive Carcinoma (Stage IA1):** If <3mm invasion and no LVSI, the treatment remains the same as CIS (Hysterectomy or Cone biopsy).

Question 299: Cervical cancer with involvement of upper vagina and parametrium is classified as which stage?

A. Stage IB
B. Stage IIA
C. Stage IIB (Correct Answer)
D. Stage IIIA

Explanation: This question tests your knowledge of the **FIGO Staging for Carcinoma Cervix** (revised 2018). ### **Explanation of the Correct Answer** **Stage II** is defined as carcinoma that has extended beyond the uterus but has not reached the pelvic wall or the lower third of the vagina. It is subdivided based on the site of involvement: * **Stage IIA:** Involvement of the upper two-thirds of the vagina **without** parametrial involvement. * **Stage IIB:** Involvement of the **parametrium** but not reaching the pelvic sidewall. Since the question specifies involvement of both the upper vagina and the **parametrium**, it is classified as **Stage IIB**. ### **Why Other Options are Incorrect** * **Stage IB:** The tumor is still strictly confined to the cervix (clinically visible lesions >5mm depth). * **Stage IIA:** This stage involves the upper vagina but specifically excludes parametrial involvement. * **Stage IIIA:** The tumor involves the **lower third** of the vagina but has not extended to the pelvic sidewall. ### **High-Yield Clinical Pearls for NEET-PG** 1. **Staging Method:** FIGO staging for cervical cancer is primarily **clinical**. However, the 2018 revision allows the use of imaging (MRI/CT/PET) and pathology to assign the stage. 2. **Parametrial Assessment:** In a clinical setting, parametrial involvement is best assessed via **per-rectal examination**. 3. **Management Shift:** Stage IIB is a critical "cutoff" in management. * Stages **up to IIA1** are generally treated with **Surgery** (Radical Hysterectomy). * Stages **IIB and above** (locally advanced) are treated with **Concurrent Chemoradiotherapy (CCRT)**. 4. **Hydronephrosis:** If a patient has hydronephrosis or a non-functioning kidney due to the tumor, it is automatically classified as **Stage IIIC1/C2** (if nodal) or **Stage IIIB** (if due to pelvic wall extension), regardless of other findings.

Question 300: What is the ideal treatment for metastatic choriocarcinoma in the lungs in a young woman?

A. Chemotherapy (Correct Answer)
B. Surgery with radiation
C. Surgery
D. Wait and watch

Explanation: **Explanation:** **1. Why Chemotherapy is the Correct Answer:** Choriocarcinoma is a highly malignant, epithelial tumor arising from the trophoblast. It is characterized by its extreme sensitivity to chemotherapy, even in the presence of widespread metastasis. Because it is a systemic disease with a high propensity for hematogenous spread (most commonly to the lungs), systemic **Chemotherapy** is the primary and definitive treatment. The treatment protocol is based on the **WHO/FIGO Risk Scoring System**: * **Low-risk (Score <7):** Single-agent chemotherapy (usually Methotrexate or Actinomycin-D). * **High-risk (Score ≥7):** Multi-agent chemotherapy (EMA-CO regimen: Etoposide, Methotrexate, Actinomycin-D, Cyclophosphamide, and Vincristine). Even with lung metastasis, the cure rate remains exceptionally high (over 90%) with appropriate chemotherapy. **2. Why Other Options are Incorrect:** * **Surgery (B & C):** Choriocarcinoma is highly vascular and prone to hemorrhage. Surgery is generally avoided as a primary treatment for metastatic disease. It is reserved only for specific complications (e.g., uterine hemorrhage) or the excision of chemo-resistant nodules. * **Radiation (B):** Choriocarcinoma is relatively radioresistant. Radiation is rarely used, except occasionally for brain or liver metastases to prevent life-threatening hemorrhage. * **Wait and Watch (D):** This is a rapidly progressing, fatal malignancy if left untreated. Immediate intervention is mandatory. **3. Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** Lungs (presents as "cannonball" opacities on X-ray). * **Tumor Marker:** Serum **beta-hCG** is used for diagnosis, monitoring treatment response, and detecting recurrence. * **Characteristic Histology:** Absence of chorionic villi; presence of sheets of syncytiotrophoblasts and cytotrophoblasts with hemorrhage and necrosis. * **Prognosis:** It is considered the most curable metastatic solid tumor.

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

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