Gynecologic Oncology Practice Questions

Q: Systemic metastasis is commonest in which of the following gynecologic malignancies?

Choriocarcinoma. **Explanation:** The correct answer is **Choriocarcinoma**. This is because choriocarcinoma is a highly malignant, germ-cell-derived tumor characterized by early and extensive **hematogenous spread** (blood-borne metastasis). Unlike most other gynecologic cancers that spread primarily through direct extension or the lymphatic system, choriocarcinoma lacks an intrinsic stroma and directly invades blood vessels, leading to rapid systemic dissemination. **Why the other options are incorrect:** * **Ovarian Carcinoma:** Primarily spreads via **exfoliation** and intraperitoneal seeding (transcoelomic spread). While it can spread lymphatically, systemic (extra-abdominal) metastasis usually occurs late in the disease. * **Endometrial Carcinoma:** Most commonly spreads by **direct extension** to the myometrium and cervix, or via lymphatics. Systemic hematogenous spread is less common and typically occurs in high-grade variants. * **Carcinoma of the Cervix:** Predominantly spreads by **direct local invasion** into the parametrium and vagina, followed by predictable **lymphatic spread** to pelvic and para-aortic nodes. Hematogenous spread is a late-stage event. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** For choriocarcinoma, the **lungs** are the most common site (80%), followed by the vagina (30%), liver, and brain. * **Characteristic Sign:** "Cannon-ball" opacities on a chest X-ray are classic for pulmonary metastasis from choriocarcinoma. * **Tumor Marker:** Serum **beta-hCG** is the highly sensitive marker used for diagnosis, monitoring, and follow-up. * **Treatment:** It is one of the most chemo-sensitive tumors; even with systemic metastasis, the cure rate is high using the EMA-CO regimen.

Q: The HPV triage strategy includes all of the following except?

Conventional Pap smear. The core concept of **HPV Triage** is the use of HPV DNA testing to manage women with minor cytological abnormalities (like ASC-US) or, conversely, using cytology to manage women who test positive for high-risk HPV. **Why Conventional Pap Smear is the Correct Answer (The "Except"):** In a triage setting, the same sample used for the initial test is ideally used for the follow-up test to avoid recalling the patient. **Conventional Pap smears** do not allow for "reflex testing" because the cells are fixed directly onto a slide, leaving no residual material for HPV DNA testing. Therefore, it is not part of a modern HPV triage strategy. **Explanation of Other Options:** * **Liquid-based cytology (LBC):** This is the gold standard for triage. The cells are suspended in a preservative medium, allowing the lab to perform HPV DNA testing (Reflex HPV) from the same vial if the cytology shows ASC-US. * **Hybrid Capture 2 (HC2):** This is the FDA-approved "gold standard" molecular test for detecting 13-14 high-risk HPV types. It is the primary tool used to triage women with ASC-US to determine if they need colposcopy. * **Colposcopy:** This is the diagnostic endpoint of the triage algorithm. If a triage test (like HC2) is positive, the patient is referred for colposcopy to identify CIN lesions. **High-Yield Clinical Pearls for NEET-PG:** * **ASC-US Management:** If LBC shows ASC-US, the preferred next step is **Reflex HPV testing**. If HPV is positive $\rightarrow$ Colposcopy; if HPV is negative $\rightarrow$ Repeat cytology in 3 years. * **Primary Screening:** In many modern guidelines, HPV DNA testing is now the primary screening tool for women $>30$ years. * **HC2 vs. PCR:** Hybrid Capture 2 is the most widely used clinical test, whereas PCR is more sensitive but often used in research.

Q: Which of the following is a poor prognostic factor for choriocarcinoma?

Full term pregnancy. In Gestational Trophoblastic Neoplasia (GTN), specifically choriocarcinoma, prognosis is determined using the **WHO Modified Prognostic Scoring System (FIGO Scoring)**. This system categorizes patients into low-risk (score ≤6) or high-risk (score ≥7) groups. ### **Explanation of the Correct Option** **A. Full term pregnancy:** This is a significant poor prognostic factor. Choriocarcinoma following a term pregnancy is associated with a higher tumor burden, delayed diagnosis, and a higher likelihood of chemoresistance compared to cases following a molar pregnancy or abortion. In the FIGO scoring system, an antecedent term pregnancy is assigned **2 points**, whereas a hydatidiform mole is 0 points and an abortion is 1 point. ### **Explanation of Incorrect Options** * **B. Short duration of symptoms:** A short interval (less than 4 months) between the antecedent pregnancy and the start of chemotherapy is a **favorable** prognostic factor (0 points). A long interval (>12 months) indicates a poor prognosis. * **C. Abortion:** While an abortion carries a higher risk than a molar pregnancy, it is considered a better prognostic factor than a full-term pregnancy. * **D. Low beta-hCG levels:** Higher pretreatment serum hCG levels correlate with a larger tumor mass and poorer prognosis. Levels **>100,000 IU/L** are considered high-risk (4 points), while low levels (<1,000 IU/L) are favorable. ### **Clinical Pearls for NEET-PG** * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%). * **Brain/Liver Metastasis:** These are high-risk factors (assigned 4 points each). * **Chemotherapy:** Low-risk GTN is treated with single-agent Methotrexate; High-risk GTN requires multi-agent **EMA-CO** regimen (Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide, Vincristine). * **The "Great Imitator":** Choriocarcinoma is known for its tendency to bleed due to its highly vascular nature and lack of intrinsic villi.

Q: Which of the following are masculinizing tumors of the ovary?

Arrhenoblastoma. **Explanation:** **1. Why Arrhenoblastoma is Correct:** Arrhenoblastoma, also known as a **Sertoli-Leydig Cell Tumor**, is a sex cord-stromal tumor that typically secretes androgens (testosterone). It is the most common virilizing tumor of the ovary. Clinically, patients present with **defeminization** (amenorrhea, breast atrophy) followed by **masculinization** (hirsutism, clitoromegaly, deepening of the voice). It is usually unilateral and occurs in young women (2nd–3rd decade). **2. Why the Other Options are Incorrect:** * **Granulosa Cell Tumor:** This is also a sex cord-stromal tumor, but it is primarily **feminizing**. It secretes estrogen, leading to precocious puberty in children or postmenopausal bleeding and endometrial hyperplasia in older women. (Call-Exner bodies are a hallmark). * **Dysgerminoma:** This is a germ cell tumor (the female counterpart of seminoma). It is typically hormonally inert, though it may occasionally produce LDH or hCG. It does not cause masculinization. * **Dermoid Cyst (Mature Cystic Teratoma):** This is the most common benign germ cell tumor. It contains tissues from all three germ layers (hair, teeth, sebum) but does not have endocrine activity unless it undergoes specialized transformation (e.g., Struma ovarii causing hyperthyroidism). **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Sertoli-Leydig tumors may show elevated **Alpha-fetoprotein (AFP)** in some cases, but the definitive marker is high **Serum Testosterone**. * **Other Masculinizing Tumors:** Hilus cell tumors and Gynandroblastoma (which has both granulosa and Sertoli-Leydig elements). * **Management:** Usually surgical (Unilateral Salpingo-oophorectomy) as most are Stage I and benign/low-grade malignancy.

Q: What is the most common type of vulvar cancer?

Squamous cell carcinoma. **Explanation:** **1. Why Squamous Cell Carcinoma (SCC) is Correct:** Squamous cell carcinoma is the most common histological type of vulvar cancer, accounting for approximately **90% of all cases**. It primarily arises from the squamous epithelium that covers the labia majora, labia minora, and clitoris. There are two distinct pathways for its development: * **HPV-associated (Warty/Basaloid type):** Seen in younger women, linked to high-risk HPV types (16, 18) and smoking. * **HPV-independent (Keratinizing type):** Seen in older women, often associated with chronic inflammatory conditions like **Lichen Sclerosus**. **2. Why the other options are incorrect:** * **B. Melanoma:** This is the **second most common** vulvar malignancy (approx. 5%). It typically presents as a pigmented lesion and has a high propensity for metastasis. * **C. Adenocarcinoma:** This is rare and usually arises from the Bartholin glands or as a manifestation of Paget’s disease of the vulva. * **D. Adenosquamous carcinoma:** This is an extremely rare variant containing both glandular and squamous components, often carrying a more aggressive prognosis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Labia majora. * **Most common symptom:** Long-standing pruritus (itching) or a visible mass. * **Lymphatic Spread:** The primary route of spread is via the lymphatics, first to the **superficial inguinal nodes**, then to deep inguinal (Cloquet’s node), and finally to pelvic nodes. * **Staging:** Vulvar cancer is staged surgically (FIGO staging). * **Precursor lesion:** Vulvar Intraepithelial Neoplasia (VIN) or Differentiated VIN (dVIN).

Q: What is the commonest complication of a mature teratoma?

Torsion. **Explanation:** **Mature Cystic Teratoma (Dermoid Cyst)** is the most common germ cell tumor of the ovary. Understanding its complications is high-yield for NEET-PG: **1. Why Torsion is the Correct Answer:** **Torsion** is the most common complication, occurring in approximately **15%** of cases. This happens because dermoid cysts are often pedunculated, have a high fat content (making them buoyant), and are frequently of moderate size (5–10 cm). These factors allow the cyst to rotate around its pedicle, leading to vascular compromise and acute pelvic pain. **2. Why the Other Options are Incorrect:** * **Rupture:** This is rare (approx. 1–2%). If it occurs, the leakage of sebaceous material can cause a severe chemical peritonitis (granulomatous peritonitis). * **Hemorrhage:** Unlike functional cysts (like corpus luteum cysts), hemorrhage is an uncommon primary complication of a teratoma. * **Malignancy:** Malignant transformation occurs in only **1–2%** of cases, most commonly into **Squamous Cell Carcinoma** (usually in postmenopausal women). **Clinical Pearls for NEET-PG:** * **Most common site:** Right ovary (due to the presence of the sigmoid colon on the left limiting space). * **Radiological Sign:** **Rokitansky protuberance** (a solid nodule projecting into the cyst cavity) and the presence of teeth or calcification on X-ray/CT. * **Treatment of Choice:** Cystectomy is preferred over oophorectomy in women of reproductive age to preserve ovarian reserve. * **Tip:** If a question asks for the "most common complication of *any* benign ovarian tumor," the answer is almost always **Torsion**.

Question 1

What is the best management for a 26-year-old woman diagnosed with ovarian carcinoma and Grade I histology?

Accepted Answer

Unilateral oophorectomy and follow-up

Answer

Unilateral oophorectomy with chemotherapy

Answer

Bilateral oophorectomy

Answer

Hysterectomy and bilateral oophorectomy

Question 2

Systemic metastasis is commonest in which of the following gynecologic malignancies?

Accepted Answer

Choriocarcinoma

Answer

Ovarian Carcinoma

Answer

Endometrial Carcinoma

Answer

Carcinoma of the cervix

Question 3

Which of the following is NOT a poor prognostic factor in the management of cancer of the cervix?

Accepted Answer

Well-differentiated squamous cell carcinoma

Answer

Young age

Answer

Hydroureter

Answer

Adenocarcinoma

Question 4

The HPV triage strategy includes all of the following except?

Accepted Answer

Conventional Pap smear

Answer

Liquid-based cytology

Answer

Hybrid Capture 2 for HPV DNA

Answer

Colposcopy

Question 5

A 45-year-old female diagnosed with breast carcinoma underwent surgery and has been on tamoxifen therapy for one year. She now presents with complaints of bleeding per vaginum. If this is due to an adverse effect of tamoxifen, what is the most likely cause?

Accepted Answer

Development of endometrial carcinoma

Answer

Development of a bleeding disorder

Answer

Development of ovarian carcinoma

Answer

Development of cervical cancer

Question 6

Which of the following is a poor prognostic factor for choriocarcinoma?

Accepted Answer

Full term pregnancy

Answer

Short duration of symptoms

Answer

Abortion

Answer

Low beta-hCG levels

Question 7

Which of the following are masculinizing tumors of the ovary?

Accepted Answer

Arrhenoblastoma

Answer

Granulosa cell tumor

Answer

Dysgerminoma

Answer

Dermoid Cyst

Question 8

Criteria for diagnosis of gestational trophoblastic neoplasia includes all except?

Accepted Answer

Serum beta-human chorionic gonadotropin levels remain detectable for 3 months only

Answer

Plateau of serum beta-human chorionic gonadotropin levels for 4 measurements during a period of 3 weeks

Answer

Rise in serum beta-human chorionic gonadotropin levels > 10% during 3 weekly consecutive measurements

Answer

Histological evidence of choriocarcinoma

Question 9

What is the most common type of vulvar cancer?

Accepted Answer

Squamous cell carcinoma

Answer

Melanoma

Answer

Adenocarcinoma

Answer

Adenosquamous carcinoma

Question 10

What is the commonest complication of a mature teratoma?

Accepted Answer

Torsion

Answer

Rupture

Answer

Hemorrhage

Answer

Malignancy

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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