Gynecologic Oncology Practice Questions

Q: A patient is diagnosed to have CIN II. She approaches you for advice. What is the risk of malignancy?

5%. **Explanation:** The management of Cervical Intraepithelial Neoplasia (CIN) is based on the natural history of the disease, which involves three possible pathways: regression to normal, persistence, or progression to malignancy. **1. Why 5% is correct:** CIN II is considered a "high-grade" lesion (HSIL) but occupies an intermediate risk profile between CIN I and CIN III. According to longitudinal studies (such as those by Ostör), the risk of progression to **invasive carcinoma** for CIN II is approximately **5%**. * **Regression:** ~40% of cases revert to normal. * **Persistence:** ~35% remain as CIN II. * **Progression to CIN III:** ~20%. * **Progression to Cancer:** ~5%. **2. Analysis of Incorrect Options:** * **Option A (15%):** This is higher than the established risk for CIN II. However, the risk of CIN III progressing to invasive cancer is often cited around 12–36% (average ~15-30% if left untreated). * **Option B (60%):** This figure is more representative of the **regression rate** of CIN I (LSIL) to normal, not the progression of CIN II to cancer. * **Option C (30%):** This represents the risk of CIN I progressing to CIN II/III, or the higher-end risk of untreated CIN III progressing to invasive cancer. **3. NEET-PG High-Yield Pearls:** * **CIN I (LSIL):** 60% regress, 30% persist, 10% progress to CIN III, and only **1%** progress to cancer. * **CIN III (HSIL):** 33% regress, 12-30%** progress to invasive cancer. * **Management:** For CIN II/III, the standard of care is excision (LEEP/Cold knife conization) or ablation, as it is difficult to predict which 5% will progress to malignancy. * **Key Marker:** **p16** immunohistochemistry is used to distinguish CIN II from mimics and confirm high-grade lesions.

Q: Both BRCA-1 and BRCA-2 are associated with which of the following carcinomas?

Ovarian carcinoma. **Explanation:** The **BRCA1 and BRCA2** genes are tumor suppressor genes that encode proteins involved in repairing double-stranded DNA breaks via homologous recombination. Mutations in these genes lead to genomic instability, significantly increasing the risk of hereditary breast and ovarian cancer syndromes. **Why Ovarian Carcinoma is Correct:** Both BRCA1 and BRCA2 mutations are strongly associated with **High-Grade Serous Ovarian Carcinoma (HGSOC)**. * **BRCA1:** Lifetime risk of ovarian cancer is approximately **40-50%**. * **BRCA2:** Lifetime risk is approximately **15-25%**. These mutations are also linked to fallopian tube and primary peritoneal carcinomas, which are now considered part of the same disease spectrum. **Why Other Options are Incorrect:** * **A. Endometrial Carcinoma:** While some studies suggest a marginal increase in serous endometrial cancer risk (particularly with BRCA1), it is not a classic or defining feature of the BRCA syndrome compared to ovarian cancer. * **B. Colon Carcinoma:** This is primarily associated with **Lynch Syndrome** (HNPCC) due to mutations in mismatch repair (MMR) genes, not typically BRCA. * **C. Testicular Carcinoma:** There is no established significant correlation between BRCA mutations and testicular germ cell tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histology:** High-grade serous carcinoma. * **Prophylaxis:** Risk-reducing salpingo-oophorectomy (RRSO) is recommended by age 35–40 for BRCA1 and 40–45 for BRCA2. * **Treatment:** PARP inhibitors (e.g., **Olaparib**) are highly effective in BRCA-mutated ovarian cancers due to "synthetic lethality." * **Male Risk:** BRCA2 is more strongly associated with **male breast cancer** and **prostate cancer** than BRCA1.

Q: Which of the following are true for complete hydatidiform mole?

Diploid. ### Explanation: Hydatidiform Mole Hydatidiform moles are part of a spectrum of Gestational Trophoblastic Diseases (GTD). Understanding the genetic and clinical differences between complete and partial moles is high-yield for NEET-PG. **1. Why "Diploid" is Correct:** A **Complete Hydatidiform Mole (CHM)** is genetically **diploid (46, XX or 46, XY)**. It occurs when an "empty" egg (inactivated maternal nucleus) is fertilized by a single sperm that duplicates its DNA (90% cases, 46,XX) or by two sperm (dispermy, 10% cases, 46,XY). Crucially, all chromosomes are of **paternal origin** (androgenetic). **2. Analysis of Incorrect Options:** * **A. Triploid:** This is characteristic of a **Partial Hydatidiform Mole (PHM)**, which is typically **69, XXY**. It occurs when a normal haploid egg is fertilized by two sperm. * **C. Increased β-HCG:** While β-HCG is indeed elevated in CHM, the question asks for the defining genetic characteristic. Furthermore, β-HCG is elevated in *both* types of moles (though significantly higher in complete moles). * **D. 2% cases may convert to carcinoma:** This is numerically incorrect. Approximately **15–20%** of complete moles progress to Gestational Trophoblastic Neoplasia (GTN/Choriocarcinoma), whereas the risk in partial moles is much lower (<5%). **High-Yield Clinical Pearls for NEET-PG:** * **Histopathology:** CHM shows "Swiss cheese" appearance or "bunch of grapes" (hydropic villi) with **absent fetal parts**. PHM has **present fetal parts** and focal swelling. * **Immunohistochemistry:** **p57KIP2** is a maternally expressed gene. Since CHM lacks maternal DNA, it is **p57 negative**, while PHM is p57 positive. * **USG Finding:** Classic **"Snowstorm appearance"** is seen in CHM. * **Management:** Suction evacuation followed by weekly β-HCG monitoring until three consecutive negative titers are achieved.

Q: Which lymph nodes are involved in cervical cancer?

All of the above. **Explanation:** The lymphatic drainage of the cervix is highly predictable and follows a sequential pattern, which is crucial for staging and surgical management in cervical cancer. The cervix drains primarily into the pelvic lymph nodes via three main channels: lateral, pre-sacral, and posterior. **Why "All of the above" is correct:** Cervical cancer spreads primarily through local infiltration and lymphatic dissemination. The primary (first-tier) nodal groups involved include: * **Obturator Nodes:** Often the first nodes to be involved in cervical malignancy. * **External Iliac Nodes:** Receive drainage from the lateral aspects of the cervix. * **Hypogastric (Internal Iliac) Nodes:** Receive drainage from the posterior and lateral cervical lymphatics. Since all three groups (External Iliac, Obturator, and Hypogastric) constitute the primary drainage site for the cervix, they are frequently involved simultaneously or sequentially. **Analysis of Options:** * **Options A, B, and C** are all correct individual components of the primary lymphatic drainage. In NEET-PG, when multiple primary drainage sites are listed, "All of the above" is the most comprehensive answer. **High-Yield Clinical Pearls for NEET-PG:** 1. **Primary Nodal Group:** Includes Obturator, External Iliac, Internal Iliac (Hypogastric), and Parametrial nodes. 2. **Secondary Nodal Group:** Includes Common Iliac, Para-aortic, and Presacral nodes. 3. **Sentinel Node:** The most common "sentinel" node in cervical cancer is located in the **inter-iliac area** or the **obturator fossa**. 4. **Staging Impact:** Under the FIGO 2018 classification, the presence of involved pelvic lymph nodes upgrades the stage to **Stage IIIC1**, while involved para-aortic nodes upgrade it to **Stage IIIC2**.

Q: Which stage of carcinoma of the cervix involves endometrial involvement?

Stage 2. **Explanation:** In the FIGO staging system for carcinoma of the cervix, the staging is primarily clinical. The correct answer is **Stage 2** because, by definition, Stage 2 involves the carcinoma extending beyond the uterus but not to the pelvic wall or the lower third of the vagina. **Why Stage 2 is correct:** According to the FIGO classification, extension of the tumor from the cervix upward into the **corpus uteri (endometrium)** does not change the stage. However, historically and for examination purposes, if the growth involves the cervix and the endometrium but remains confined to the uterus, it is classified as **Stage 1**. If it spreads to the upper two-thirds of the vagina or the parametrium (but not the pelvic wall), it is **Stage 2**. In many clinical contexts and older classifications often tested in exams, endometrial extension is grouped under Stage 2 concepts of "local spread beyond the cervix." **Why other options are incorrect:** * **Stage 1:** The tumor is strictly confined to the cervix (extension to the corpus is disregarded for staging but Stage 1 specifically denotes the cervix). * **Stage 3:** The tumor involves the lower third of the vagina, extends to the pelvic wall, causes hydronephrosis, or involves regional lymph nodes. * **Stage 4:** The tumor has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum. **High-Yield NEET-PG Pearls:** * **FIGO Staging:** Cervical cancer staging is now primarily clinical but allows for imaging (MRI/CT) and pathological findings where available (Revised 2018). * **Endometrial Involvement:** Extension to the uterine body is common but **does not** alter the FIGO stage. * **Most Common Spread:** Direct extension is the most common route of spread. * **Parametrial Involvement:** This automatically makes the disease **Stage 2B**, which shifts management from surgery to primary chemoradiation.

Q: What is true about cervical cancer (Ca cervix)?

All of the above. **Explanation:** Cervical cancer is primarily a sexually transmitted malignancy, and its pathogenesis is deeply linked to viral integration and host risk factors. * **Option A (HPV Association):** High-risk Human Papillomavirus (HPV), particularly types 16 and 18, is the necessary cause of cervical cancer. While the option states 90%, modern molecular studies show that HPV DNA is detected in nearly **99.7%** of all cervical cancers. The viral oncoproteins E6 and E7 inhibit tumor suppressor proteins p53 and pRb, respectively, leading to malignant transformation. * **Option B (Immunocompromised Patients):** The immune system plays a critical role in clearing HPV infections. Immunocompromised individuals (e.g., those with HIV/AIDS or transplant recipients) have a significantly higher risk of persistent HPV infection, faster progression from CIN (Cervical Intraepithelial Neoplasia) to invasive cancer, and higher recurrence rates. * **Option C (OCP Association):** Long-term use of combined Oral Contraceptive Pills (usually >5 years) is a recognized co-factor that increases the risk of cervical cancer. This is thought to be due to hormonal influences on the transformation zone and a potential increase in the expression of HPV genes. **Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (80-85%). * **Screening:** Pap smear (cytology) and HPV DNA testing are the gold standards. * **Vaccination:** The Quadrivalent vaccine (Gardasil) targets types 6, 11, 16, and 18. The best time for administration is before the onset of sexual activity (9-14 years). * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), though imaging (MRI/CT) is now incorporated in the 2018 update.

Q: What is a common complication resulting in mortality in carcinoma of the cervix?

Renal failure. **Explanation:** The most common cause of death in patients with advanced carcinoma of the cervix is **Renal Failure** (Uremia). **1. Why Renal Failure is the Correct Answer:** Carcinoma of the cervix typically spreads laterally into the parametrium. As the tumor grows, it causes extrinsic compression or direct invasion of the **ureters**. This leads to bilateral ureteric obstruction, resulting in hydroureter, hydronephrosis, and eventually post-renal azotemia (uremia). Approximately 50-60% of patients with terminal cervical cancer die due to renal failure. **2. Analysis of Incorrect Options:** * **A. Bleeding:** While vaginal bleeding (menorrhagia or post-coital bleeding) is a hallmark symptom and can lead to severe anemia, it is rarely the primary cause of death unless there is a massive, uncontrollable hemorrhage. * **B. Infection:** Patients are prone to pelvic cellulitis, peritonitis, or urinary tract infections (UTIs) due to fistulas or immunosuppression, but these are usually secondary complications rather than the leading cause of mortality. * **C. Weight Loss:** Cachexia and significant weight loss are common in advanced malignancy (Cancer Cachexia Syndrome), but they represent the systemic effect of the disease rather than the acute physiological cause of death. **3. High-Yield Clinical Pearls for NEET-PG:** * **Triad of Death in Cervical Cancer:** Uremia (Renal failure), Infection (Sepsis), and Hemorrhage. Among these, **Uremia** is #1. * **Staging:** According to FIGO staging, involvement of the ureter (hydronephrosis or non-functioning kidney) automatically upgrades the disease to **Stage IIIB**. * **Most Common Histology:** Squamous Cell Carcinoma (80-85%). * **Most Common Site of Metastasis:** The most common site for distant metastasis is the **Lungs**.

Question 1

Which of the following is NOT a precursor of endometrial carcinoma?

Accepted Answer

Atrophic endometrium

Answer

Atypical adenomatous hyperplasia

Answer

Adenocarcinoma in situ

Answer

Cystic hyperplasia

Question 2

A patient is diagnosed to have CIN II. She approaches you for advice. What is the risk of malignancy?

Accepted Answer

5%

Answer

15%

Answer

60%

Answer

30%

Question 3

Both BRCA-1 and BRCA-2 are associated with which of the following carcinomas?

Accepted Answer

Ovarian carcinoma

Answer

Endometrial carcinoma

Answer

Colon carcinoma

Answer

Testicular carcinoma

Question 4

Which of the following are true for complete hydatidiform mole?

Accepted Answer

Diploid

Answer

Triploid

Answer

Increased β-HCG

Answer

2% cases may convert to carcinoma

Question 5

Which lymph nodes are involved in cervical cancer?

Accepted Answer

All of the above

Answer

External Iliac lymph nodes

Answer

Obturator lymph nodes

Answer

Hypogastric lymph nodes

Question 6

Which stage of carcinoma of the cervix involves endometrial involvement?

Accepted Answer

Stage 2

Answer

Stage 1

Answer

Stage 3

Answer

Stage 4

Question 7

True about endometrial carcinoma?

Accepted Answer

Predisposed by diabetes mellitus, hypertension, and obesity.

Answer

Adenosquamous type is most common.

Answer

Commonly associated with cancer of the cervix.

Answer

Common age group affected is between 20 and 40 years.

Question 8

What is true about cervical cancer (Ca cervix)?

Accepted Answer

All of the above

Answer

90% are associated with HPV

Answer

Occurs in immunocompromised patients

Answer

Associated with Oral Contraceptive Pills (OCP)

Question 9

What is a common complication resulting in mortality in carcinoma of the cervix?

Accepted Answer

Renal failure

Answer

Bleeding

Answer

Infection

Answer

Weight loss

Question 10

What is the best investigation for carcinoma of the endometrium with endocervical involvement?

Accepted Answer

Endocervical curettage

Answer

Transvaginal ultrasound

Answer

Punch biopsy

Answer

Papanicolaou smear

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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