Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 301: Which of the following is NOT a precursor of endometrial carcinoma?

A. Atypical adenomatous hyperplasia
B. Atrophic endometrium (Correct Answer)
C. Adenocarcinoma in situ
D. Cystic hyperplasia

Explanation: **Explanation:** Endometrial carcinoma (specifically Type I) is primarily driven by **unopposed estrogen** stimulation, which leads to a spectrum of precursor lesions known as endometrial hyperplasia. **1. Why Atrophic Endometrium is the Correct Answer:** Atrophic endometrium (Option B) is characterized by a thin, inactive lining with exhausted glands and stroma, typically seen in postmenopausal women with low estrogen levels. It is a **benign, regressive state** and does not possess the cellular atypia or proliferative capacity required to be a precursor for malignancy. While postmenopausal bleeding can occur due to atrophy, it is not a premalignant condition. **2. Analysis of Incorrect Options:** * **Cystic Hyperplasia (Option D):** Also known as simple hyperplasia without atypia. While it has a low progression rate to cancer (approx. 1%), it represents the earliest stage of estrogen-driven overgrowth and is considered a precursor. * **Atypical Adenomatous Hyperplasia (Option A):** This is the most significant precursor (Complex Atypical Hyperplasia). It carries a high risk of progression to malignancy (up to 29%) and often coexists with occult carcinoma. * **Adenocarcinoma in situ (Option C):** This represents a localized neoplastic change within the endometrial glands that has not yet invaded the stroma. It is the immediate precursor to invasive Type I endometrial cancer. **NEET-PG High-Yield Pearls:** * **WHO Classification (2014):** Hyperplasia is now simplified into two categories: **Hyperplasia without atypia** (1-3% risk) and **Atypical hyperplasia/EIN** (25-30% risk). * **Type I vs. Type II:** Type I (Endometrioid) arises from hyperplasia due to estrogen. Type II (Serous/Clear cell) arises from **atrophic endometrium** via a precursor called **Serous Endometrial Intraepithelial Carcinoma (SEIC)**, but the atrophy itself is not the precursor. * **Most common symptom:** Postmenopausal bleeding (PMB). Always rule out malignancy in PMB even if atrophy is the most common cause.

Question 302: A patient is diagnosed to have CIN II. She approaches you for advice. What is the risk of malignancy?

A. 15%
B. 60%
C. 30%
D. 5% (Correct Answer)

Explanation: **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, <56% persist, and **>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.

Question 303: Both BRCA-1 and BRCA-2 are associated with which of the following carcinomas?

A. Endometrial carcinoma
B. Colon carcinoma
C. Ovarian carcinoma (Correct Answer)
D. Testicular carcinoma

Explanation: **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.

Question 304: Which of the following are true for complete hydatidiform mole?

A. Triploid
B. Diploid (Correct Answer)
C. Increased β-HCG
D. 2% cases may convert to carcinoma

Explanation: ### 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.

Question 305: Which lymph nodes are involved in cervical cancer?

A. External Iliac lymph nodes
B. Obturator lymph nodes
C. Hypogastric lymph nodes
D. All of the above (Correct Answer)

Explanation: **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**.

Question 306: Which stage of carcinoma of the cervix involves endometrial involvement?

A. Stage 1
B. Stage 2 (Correct Answer)
C. Stage 3
D. Stage 4

Explanation: **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.

Question 307: True about endometrial carcinoma?

A. Predisposed by diabetes mellitus, hypertension, and obesity. (Correct Answer)
B. Adenosquamous type is most common.
C. Commonly associated with cancer of the cervix.
D. Common age group affected is between 20 and 40 years.

Explanation: **Explanation:** **Correct Option (A):** Endometrial carcinoma is strongly associated with the **"Corpus Cancer Syndrome"** triad, which consists of **Obesity, Hypertension, and Diabetes Mellitus**. The underlying pathophysiology is primarily related to **unopposed estrogen**. Obesity leads to increased peripheral conversion of androstenedione to estrone in adipose tissue. Hyperinsulinemia (in DM) and metabolic syndrome further promote endometrial proliferation by decreasing Sex Hormone Binding Globulin (SHBG) levels, thereby increasing free circulating estrogen. **Incorrect Options:** * **B:** The most common histological type is **Endometrioid Adenocarcinoma** (approx. 75-80%). Adenosquamous carcinoma is a rare subtype associated with a poorer prognosis. * **C:** Endometrial cancer is not commonly associated with cervical cancer. However, it is frequently associated with **Polycystic Ovary Syndrome (PCOS)** and **Lynch Syndrome (HNPCC)**, where there is a high risk of synchronous or metachronous ovarian and colon cancers. * **D:** It is primarily a disease of **postmenopausal women**. The peak incidence is between **50 and 70 years**. Only about 5% of cases occur in women under 40. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom:** Abnormal Uterine Bleeding (AUB) or Postmenopausal Bleeding (PMB). * **Protective factors:** Combined Oral Contraceptive Pills (COCPs), smoking (decreases estrogen levels), and multiparity. * **Precursor lesion:** Atypical Endometrial Hyperplasia (now termed Endometrial Intraepithelial Neoplasia - EIN). * **Investigation of choice:** Fractional Curettage or Pipelle Biopsy (Gold Standard). Transvaginal Ultrasound (TVS) showing endometrial thickness **>4mm** in a postmenopausal woman warrants biopsy.

Question 308: What is true about cervical cancer (Ca cervix)?

A. 90% are associated with HPV
B. Occurs in immunocompromised patients
C. Associated with Oral Contraceptive Pills (OCP)
D. All of the above (Correct Answer)

Explanation: **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.

Question 309: What is a common complication resulting in mortality in carcinoma of the cervix?

A. Bleeding
B. Infection
C. Renal failure (Correct Answer)
D. Weight loss

Explanation: **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 310: What is the best investigation for carcinoma of the endometrium with endocervical involvement?

A. Transvaginal ultrasound
B. Endocervical curettage (Correct Answer)
C. Punch biopsy
D. Papanicolaou smear

Explanation: **Explanation:** The primary goal in evaluating endometrial carcinoma is to determine the extent of the disease, as cervical involvement significantly alters the surgical staging (Stage II) and management plan. **Why Endocervical Curettage (ECC) is the correct answer:** Endocervical curettage is the gold standard for assessing **endocervical stromal invasion**. When endometrial cancer is suspected or diagnosed via pipelle or fractional curettage, ECC is performed to see if the malignant cells have extended into the cervix. Histopathological confirmation of cervical involvement is crucial for preoperative planning, as it may necessitate a Radical Hysterectomy (Wertheim’s) rather than a Simple Total Hysterectomy. **Analysis of Incorrect Options:** * **A. Transvaginal Ultrasound (TVUS):** While TVUS is the initial screening tool to measure endometrial thickness, it lacks the specificity to definitively distinguish between mere presence of debris in the canal and true stromal invasion. * **C. Punch Biopsy:** This is used for visible ectocervical lesions. Since endometrial cancer spreads to the *endocervical* canal (internal), a surface punch biopsy would likely miss the site of involvement. * **D. Papanicolaou (Pap) Smear:** A Pap smear is a screening tool for cervical cancer. While it may incidentally show glandular cells in endometrial cancer, it has low sensitivity and cannot be used for definitive staging or diagnosis of cervical involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Staging System:** Endometrial cancer is staged **surgically** (FIGO). * **Stage II:** Defined specifically as involvement of the cervical stroma. * **Fractional Curettage:** This procedure involves separate scraping of the endocervix followed by the endometrium; it is the traditional method to differentiate the site of origin. * **Most Common Type:** Endometrioid adenocarcinoma is the most common histological subtype. * **Risk Factor:** Unopposed estrogen is the most significant risk factor.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

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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