Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 311: Which of the following is NOT a type of primary uterine carcinoma?

A. Adenocarcinoma
B. Adenosquamous carcinoma
C. Clear cell type
D. Large cell keratinising type (Correct Answer)

Explanation: **Explanation:** The question asks to identify which histological subtype is **not** a primary uterine (endometrial) carcinoma. **Why Option D is the Correct Answer:** **Large cell keratinising type** is a histological subtype of **Squamous Cell Carcinoma (SCC)**, which is classically associated with the **uterine cervix**, not the endometrium. While primary SCC of the endometrium exists, it is extremely rare and must meet strict criteria (e.g., no connection to the cervical epithelium). In standard oncological classification, "Large cell keratinising" is a hallmark descriptor for cervical malignancy. **Analysis of Incorrect Options:** * **A. Adenocarcinoma:** This is the most common primary uterine cancer. The **Endometrioid adenocarcinoma** subtype accounts for approximately 75-80% of all endometrial carcinomas. * **B. Adenosquamous carcinoma:** This is a recognized variant of endometrial carcinoma containing both malignant glandular (adenocarcinoma) and malignant squamous components. To be classified as such, the squamous component must be histologically malignant. * **C. Clear cell type:** This is a **Type II (Non-endometrioid)** endometrial carcinoma. It is highly aggressive, occurs in older postmenopausal women, and is not associated with hyperestrogenism. **High-Yield NEET-PG Pearls:** * **Bokhman’s Classification:** * **Type I (Endometrioid):** Estrogen-dependent, arises from hyperplasia, good prognosis, PTEN mutation. * **Type II (Serous/Clear Cell):** Estrogen-independent, arises from atrophic endometrium, p53 mutation, poor prognosis. * **Most common site of metastasis:** The lungs are the most common site of distant spread for endometrial cancer. * **Precursor lesion:** Endometrial Intraepithelial Neoplasia (EIN).

Question 312: Which of the following is a marker for carcinoma of the ovary?

A. CA 19-9
B. CD 99
C. CD 34
D. CA 125 (Correct Answer)

Explanation: **Explanation:** **CA 125 (Cancer Antigen 125)** is the most widely used tumor marker for **Epithelial Ovarian Cancer (EOC)**, particularly the serous subtype. It is a high-molecular-weight glycoprotein produced by derivatives of the coelomic epithelium (pleura, pericardium, peritoneum, and Müllerian tract). While highly sensitive for monitoring treatment response and detecting recurrence, its specificity is limited in premenopausal women as it can be elevated in benign conditions like endometriosis, PID, and pregnancy. **Analysis of Incorrect Options:** * **CA 19-9:** Primarily a marker for **pancreatic and hepatobiliary malignancies**. In gynecology, it may be elevated in mucinous ovarian tumors or mature cystic teratomas. * **CD 99:** A characteristic immunohistochemical marker for **Ewing’s sarcoma** and PNET. In gynecology, it is a specific marker for **Granulosa Cell Tumors** of the ovary. * **CD 34:** An endothelial marker used to identify angiogenesis and vascular tumors (e.g., angiosarcoma) or dermatofibrosarcoma protuberans. **High-Yield Clinical Pearls for NEET-PG:** * **Germ Cell Tumor Markers:** * Dysgerminoma: LDH (most specific), hCG. * Yolk Sac Tumor: Alpha-fetoprotein (AFP). * Choriocarcinoma: beta-hCG. * **Granulosa Cell Tumor:** Inhibin (most specific) and CD 99. * **Meigs Syndrome:** Triad of benign ovarian fibroma, ascites, and pleural effusion; CA 125 can be falsely elevated here. * **Risk of Malignancy Index (RMI):** Uses CA 125 levels, ultrasound findings, and menopausal status to predict the nature of an adnexal mass.

Question 313: Which of the following conditions is typically NOT responsive to medical therapy?

A. Invasive mole
B. Choriocarcinoma
C. Hydatidiform mole (Correct Answer)
D. Persistent gestational trophoblastic disease

Explanation: **Explanation:** The core concept in managing Gestational Trophoblastic Disease (GTD) lies in distinguishing between **benign molar pregnancies** and **Gestational Trophoblastic Neoplasia (GTN)**. **Why Hydatidiform Mole is the correct answer:** A hydatidiform mole (whether complete or partial) is a benign condition where the primary treatment is **surgical evacuation** (Suction and Evacuation). Medical therapy (chemotherapy) is not indicated as primary treatment for a mole because the goal is to physically remove the abnormal trophoblastic tissue from the uterine cavity. Chemotherapy is only initiated if the mole progresses to malignancy (GTN). **Why the other options are incorrect:** * **Invasive Mole & Choriocarcinoma:** These are histological subtypes of GTN. They are highly vascular and biologically aggressive but are uniquely sensitive to chemotherapy (e.g., Methotrexate or Actinomycin-D). Medical therapy is the primary treatment modality for these conditions, often resulting in a cure even in metastatic stages. * **Persistent GTD:** This refers to a plateau or rise in hCG levels following the evacuation of a mole. It is treated as GTN and typically requires single-agent or multi-agent chemotherapy. **High-Yield Clinical Pearls for NEET-PG:** * **Treatment of Choice (TOC):** For Hydatidiform mole, it is **Suction and Evacuation**, regardless of uterine size. * **Follow-up:** Post-evacuation, weekly monitoring of **serum β-hCG** is mandatory until three consecutive normal values are obtained. * **FIGO Scoring:** Used for GTN to decide between single-agent (Score 0-6) and multi-agent (Score ≥7) chemotherapy. * **Lutein Cysts:** Often associated with moles due to high hCG; they usually regress spontaneously after evacuation and do not require surgery.

Question 314: What is the treatment of choice for molar pregnancy?

A. Expectant management
B. Medical termination
C. Dilatation and evacuation (Correct Answer)
D. Chemotherapy

Explanation: **Explanation:** The treatment of choice for a molar pregnancy (Hydatidiform mole) is **Suction Dilatation and Evacuation (S&E)**, regardless of the uterine size. This procedure allows for the rapid removal of the trophoblastic tissue while minimizing the risk of uterine perforation and excessive hemorrhage. * **Why Option C is correct:** Suction evacuation is the gold standard because it is the most effective way to empty the uterus completely. In cases where the patient is older (>40 years) and has completed her family, a **Total Abdominal Hysterectomy** may be considered as an alternative to reduce the risk of post-molar gestational trophoblastic neoplasia (GTN). * **Why Option A is wrong:** Expectant management is contraindicated as a molar pregnancy will not resolve safely on its own and carries a high risk of life-threatening hemorrhage or progression to malignancy. * **Why Option B is wrong:** Medical induction (using Oxytocin or Prostaglandins) is avoided because it increases the risk of **trophoblastic embolization** to the lungs and often results in incomplete evacuation. * **Why Option D is wrong:** Chemotherapy is not the primary treatment for an uncomplicated molar pregnancy. It is reserved for cases that progress to **Gestational Trophoblastic Neoplasia (GTN)**, indicated by plateauing or rising hCG levels post-evacuation. **High-Yield Clinical Pearls for NEET-PG:** * **Pre-operative:** Always perform a Chest X-ray to rule out trophoblastic embolization or metastasis. * **Intra-operative:** Start an Oxytocin infusion *after* the evacuation has begun to prevent uterine atony and minimize embolization risk. * **Follow-up:** Weekly serum β-hCG levels until three consecutive normal values are obtained, then monthly for 6 months. * **Contraception:** Combined Oral Contraceptive Pills (COCPs) are the preferred method during follow-up; IUCDs are avoided until hCG is undetectable due to the risk of perforation.

Question 315: Histopathology of staging laparotomy done for carcinoma endometrium reveals more than 50% myometrium invasion with vaginal involvement, parametrial involvement but no pelvic and paraaortic lymph node involvement. What is the stage of Ca Endometrium?

A. Stage III B (Correct Answer)
B. Stage III A
C. Stage III C1
D. Stage III C2

Explanation: **Explanation:** The staging of Endometrial Carcinoma is surgical, based on the **FIGO 2023 (and 2009) classification**. To determine the correct stage, we must analyze the furthest anatomical extent of the tumor described in the histopathology report. **Why Stage III B is correct:** Stage III denotes local and/or regional spread of the tumor. Specifically: * **Stage III B** is defined by **vaginal and/or parametrial involvement**. * In this case, the presence of both vaginal and parametrial involvement (even without lymph node spread) automatically classifies the disease as Stage III B. The depth of myometrial invasion (>50%) would have made it Stage I B if confined to the uterus, but the extrauterine spread takes precedence. **Why other options are incorrect:** * **Stage III A:** This stage involves the tumor spreading to the **uterine serosa and/or adnexa** (fallopian tubes/ovaries). It does not include vaginal or parametrial spread. * **Stage III C1:** This stage is assigned when there is metastasis to the **pelvic lymph nodes**, regardless of local spread. The question explicitly states there is no pelvic node involvement. * **Stage III C2:** This stage involves metastasis to the **paraaortic lymph nodes** (with or without pelvic nodes). The question states there is no paraaortic involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Staging Method:** Endometrial cancer is **Surgically Staged** (unlike Cervical Cancer, which is now also surgically/radiologically staged but was traditionally clinical). * **Most Common Type:** Endometrioid adenocarcinoma (Type I). * **Risk Factor:** Unopposed estrogen (Obesity, PCOS, Nulliparity, Tamoxifen). * **Lymph Node Spread:** The primary lymphatic drainage is to the pelvic and paraaortic nodes. The presence of nodal involvement (Stage III C) is a significant prognostic factor. * **FIGO 2023 Update:** Note that the latest FIGO 2023 staging now incorporates histological grades and LVSI (Lymphovascular space invasion) into Stage I, but the criteria for Stage III B (vaginal/parametrial) remain consistent.

Question 316: A patient with endometrial cancer involving >50% of the myometrium and extending to the vagina, but with no pelvic extension and no involvement of pre and para-aortic lymph nodes, is staged based on peritoneal lavage being positive. What is the correct stage?

A. Stage III a
B. Stage III b (Correct Answer)
C. Stage III c1
D. Stage III c2

Explanation: ### Explanation The staging of endometrial cancer follows the **FIGO 2023 (and 2009)** classification. This case describes a tumor that has spread beyond the uterus but remains within the pelvis. **Why Stage IIIb is correct:** Stage III is defined by local and/or regional spread of the tumor. Specifically: * **Stage IIIa:** Involvement of the uterine serosa and/or adnexa (fallopian tubes/ovaries). * **Stage IIIb:** Vaginal and/or parametrial involvement. In this scenario, the tumor extends to the **vagina**, which automatically classifies it as Stage IIIb. Note that under the updated FIGO 2023 guidelines, positive peritoneal cytology (lavage) is no longer used to change the stage but is recorded as a separate finding; however, the vaginal involvement remains the primary staging determinant here. **Analysis of Incorrect Options:** * **Stage IIIa:** Incorrect because there is no mention of serosal or adnexal involvement. * **Stage IIIc1:** Incorrect because this stage requires metastasis to the **pelvic lymph nodes**. The question explicitly states there is no pelvic extension/nodal involvement. * **Stage IIIc2:** Incorrect because this stage requires metastasis to the **para-aortic lymph nodes**, which the question states are uninvolved. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Spread:** Endometrial cancer primarily spreads via direct extension, but lymphatic spread is the most important prognostic factor. * **FIGO Staging:** Endometrial cancer is **surgically staged**. * **Myometrial Invasion:** Involvement of >50% of the myometrium (as seen in this patient) would be Stage Ib if confined to the uterus, but the vaginal extension "upstages" the disease to Stage IIIb. * **Lymph Node Levels:** Pelvic nodes = IIIc1; Para-aortic nodes = IIIc2. Remember: "1 is lower (pelvis), 2 is higher (aorta)."

Question 317: A 45-year-old female diagnosed with cervical carcinoma of stage IIIB. What is the best line of management for this patient?

A. Wertheim's hysterectomy
B. Schauta's hysterectomy
C. Chemotherapy
D. Concurrent chemoradiation (Correct Answer)

Explanation: **Explanation:** The management of cervical carcinoma is primarily determined by the FIGO stage. This patient is diagnosed with **Stage IIIB**, which is classified as **Locally Advanced Cervical Cancer (LACC)**. **1. Why Concurrent Chemoradiation (CCRT) is correct:** For stages IIB through IVA, the standard of care is **Concurrent Chemoradiation**. This involves external beam radiotherapy (EBRT) combined with weekly **Cisplatin** (the radiosensitizer), followed by brachytherapy. Surgery is generally avoided in these stages because it cannot achieve clear margins once the disease involves the parametrium (Stage IIB) or the pelvic wall/lower third of the vagina (Stage IIIB), and combining surgery with radiation significantly increases morbidity. **2. Why the other options are incorrect:** * **A & B (Wertheim’s and Schauta’s Hysterectomy):** These are radical hysterectomies (Type III). Surgery is only indicated for **Early Stage Cervical Cancer (Stage IA to IIA1)**. Once the disease reaches Stage IIB (parametrial involvement) or IIIB (pelvic wall involvement), surgery is no longer the primary treatment. * **C (Chemotherapy):** While chemotherapy is used, it is not used as a standalone treatment for Stage IIIB. It is used either as a sensitizer during radiation (CCRT) or as palliative therapy for Stage IVB (metastatic disease). **High-Yield Clinical Pearls for NEET-PG:** * **Stage IIB:** The earliest stage where surgery is replaced by CCRT (due to parametrial involvement). * **Stage IIIB:** Defined by extension to the pelvic wall, hydronephrosis/non-functioning kidney, or involvement of the lower 1/3rd of the vagina. * **Drug of Choice:** Cisplatin is the most common radiosensitizer used in CCRT. * **Most common cause of death:** Uremia due to bilateral ureteric obstruction (post-renal failure).

Question 318: What is the standard treatment for stage IB carcinoma of the cervix?

A. Surgery and Chemotherapy
B. Surgery, Chemotherapy, and Radiotherapy (Correct Answer)
C. Surgery, Cryotherapy, and Radiotherapy
D. Chemotherapy, Radiotherapy, and Cryotherapy

Explanation: **Explanation:** The management of **Stage IB Carcinoma Cervix** (clinically confined to the cervix, >5mm depth) is a high-yield topic for NEET-PG. The standard of care for early-stage cervical cancer (Stage IA2 to IB2) is **Radical Hysterectomy (Type III/Wertheim’s Hysterectomy)** with bilateral pelvic lymphadenectomy. **Why Option B is Correct:** While surgery is the primary modality, the "standard treatment" package often involves a multimodal approach. If post-operative histopathology reveals high-risk factors (positive margins, parametrial involvement, or positive lymph nodes—**Peters Criteria**) or intermediate-risk factors (large tumor size, deep stromal invasion, or lymphovascular space invasion—**Sedlis Criteria**), adjuvant **Radiotherapy** or **Concurrent Chemoradiotherapy (CCRT)** is mandatory to prevent recurrence. Therefore, the combination of Surgery, Chemotherapy (as a radiosensitizer), and Radiotherapy represents the comprehensive management protocol. **Why Other Options are Incorrect:** * **Option A:** Omits Radiotherapy, which is essential if surgical margins are positive or nodes are involved. * **Option C & D:** Include **Cryotherapy**, which is a destructive procedure used only for **Pre-invasive lesions (CIN)**, never for frank invasive carcinoma (Stage IB). **High-Yield Clinical Pearls for NEET-PG:** 1. **Stage IB1 vs. IB2:** Stage IB1 (<2cm) and IB2 (2-4cm) are usually treated surgically. Stage IB3 (≥4cm) is often treated with primary CCRT. 2. **Drug of Choice:** **Cisplatin** is the most common chemotherapy agent used as a radiosensitizer in cervical cancer. 3. **Radiotherapy:** If a patient is unfit for surgery, primary Radiotherapy (External Beam + Brachytherapy) has equivalent survival rates to surgery in Stage IB. 4. **Preservation:** In young patients with Stage IB1 desiring fertility, **Radical Trachelectomy** is an option.

Question 319: Which of the following is NOT used for carcinoma cervix screening?

A. Pap smear
B. Liquid-based cytology
C. CT and MRI (Correct Answer)
D. Colposcopy

Explanation: **Explanation:** The primary goal of **screening** is to detect pre-invasive lesions (CIN) or early-stage cancer in asymptomatic individuals. Screening tools must be cost-effective, accessible, and highly sensitive. **Why CT and MRI are the correct answer:** CT and MRI are **imaging modalities used for staging and treatment planning** once a diagnosis of cervical cancer has already been confirmed. According to the FIGO staging (revised 2018), imaging is used to assess tumor size, parametrial involvement, and lymph node status. They are never used as screening tools due to high costs, lack of specificity for pre-invasive lesions, and low cost-benefit ratio for the general population. **Analysis of other options:** * **Pap Smear (Exfoliative Cytology):** The traditional gold standard for screening. It involves collecting cells from the transformation zone to identify dysplastic changes. * **Liquid-based Cytology (LBC):** An improvement over conventional Pap smears. It reduces unsatisfactory samples by filtering out blood and mucus and allows for reflex HPV testing from the same vial. * **Colposcopy:** While often used as a diagnostic tool following an abnormal Pap smear, it is considered a secondary screening/triage method to identify the most suspicious areas for biopsy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type of cervical cancer:** Squamous cell carcinoma. * **Primary Screening (WHO guidelines):** HPV DNA testing is now preferred over cytology where available. * **Screening Age:** Usually starts at age 25–30 and continues until 65. * **VIA (Visual Inspection with Acetic Acid):** A low-cost screening alternative in resource-limited settings (positive result = opaque white areas).

Question 320: A 62-year-old woman presents with postmenopausal bleeding 13 years after menopause. She has a history of hypertension and type 2 diabetes mellitus. An endometrial biopsy reveals grade I endometrial adenocarcinoma. What is the most appropriate next step in management?

A. Chemotherapy
B. Cone biopsy
C. Dilatation and curettage
D. Hysterectomy (Correct Answer)

Explanation: **Explanation:** The patient presents with classic risk factors for **Type I Endometrial Adenocarcinoma**, including postmenopausal status, hypertension, and diabetes mellitus (part of the metabolic syndrome). Once a diagnosis of endometrial adenocarcinoma is confirmed via biopsy, the standard of care and the definitive next step in management is surgical staging. **Why Hysterectomy is correct:** The primary treatment for clinical Stage I endometrial cancer is **Total Extraperitoneal Hysterectomy (TAH) with Bilateral Salpingo-Oophorectomy (BSO)**. In postmenopausal women, removing the ovaries is crucial as they are a source of estrogen and a potential site for metastasis. Surgical staging also typically includes pelvic and para-aortic lymphadenectomy or sentinel lymph node mapping to determine the need for adjuvant therapy. **Why incorrect options are wrong:** * **Chemotherapy (A):** This is reserved for advanced-stage disease (Stage III or IV) or recurrent cases; it is not the primary treatment for localized Grade I adenocarcinoma. * **Cone biopsy (B):** This is a diagnostic and therapeutic procedure for cervical intraepithelial neoplasia (CIN) or early cervical cancer, not endometrial cancer. * **Dilatation and curettage (C):** While D&C is a diagnostic tool used if an endometrial biopsy is inconclusive, it is not a treatment. Since the diagnosis is already confirmed as adenocarcinoma, we proceed directly to definitive surgery. **NEET-PG High-Yield Pearls:** * **Most common symptom:** Postmenopausal bleeding (PMB). * **Most common histological type:** Endometrioid adenocarcinoma (Type I), which is estrogen-dependent. * **Risk Factors:** Obesity, Nulliparity, Early menarche/Late menopause, PCOS, and Tamoxifen use. * **Investigation of choice:** Transvaginal Ultrasound (TVS) is the initial screening (Endometrial thickness >4mm in PMB is significant), but **Endometrial Biopsy** is the gold standard for diagnosis.

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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