Gynecologic Oncology Practice Questions

Q: Which of the following is FALSE regarding a hydatidiform mole?

Can be diagnosed very early by ultrasonography. In a hydatidiform mole, the characteristic ultrasonographic appearance—the **"snowstorm" or "honeycomb" pattern**—is caused by the hydropic swelling of chorionic villi. However, this classic feature typically develops only after the **first trimester (usually >10–12 weeks)**. In very early pregnancy, a molar pregnancy often lacks these diagnostic features and is frequently misdiagnosed as a missed abortion or a simple gestational sac. Therefore, it cannot be reliably diagnosed "very early" by ultrasound. **Analysis of other options:** * **Option A (True):** A **Partial Mole** is classically caused by **triploidy (69, XXX or 69, XXY)**, resulting from the fertilization of a normal ovum by two sperm (dispermy). * **Option C (True):** Many patients with molar pregnancies are asymptomatic or present with vaginal bleeding, leading to a clinical diagnosis of **missed or incomplete abortion**. The diagnosis of a mole is often only made after histopathological examination of the products of conception. * **Option D (True):** This refers specifically to **Partial Moles**, which have a low risk (approx. 1–5%) of progressing to persistent gestational trophoblastic disease (GTD) compared to Complete Moles (15–20%). **NEET-PG High-Yield Pearls:** * **Complete Mole:** 46, XX (diploid); "Snowstorm" appearance; No fetal parts; High hCG; 20% risk of malignancy. * **Partial Mole:** 69, XXY (triploid); Fetal parts present; Lower hCG; <5% risk of malignancy. * **Gold Standard Diagnosis:** Histopathology (p57 immunostaining is negative in complete moles). * **Management:** Suction evacuation followed by weekly hCG monitoring until three consecutive negative results.

Q: Sarcoma botryoides is most commonly seen in which age group?

Children under 2 years. **Explanation:** **Sarcoma botryoides** (Embryonal Rhabdomyosarcoma) is a highly malignant tumor derived from primitive mesenchymal cells. It is the most common vaginal tumor found in infants and children. 1. **Why Option B is Correct:** The peak incidence of Sarcoma botryoides occurs in children **under the age of 2 years**, with over 90% of cases diagnosed before age 5. It typically originates in the **anterior vaginal wall** (near the cervix) in young children, whereas in older girls or adolescents, it more commonly arises from the cervix itself. 2. **Why Other Options are Incorrect:** * **A (Neonates):** While it can occur shortly after birth, it is not the most common age group compared to the broader "under 2 years" category. * **C & D (Adults/Post-menopausal):** Vaginal malignancies in adults are predominantly **Squamous Cell Carcinomas** (linked to HPV) or **Adenocarcinomas** (historically linked to DES exposure). Sarcoma botryoides is extremely rare in adults. **High-Yield Clinical Pearls for NEET-PG:** * **Gross Appearance:** Classically presents as a **"bunch of grapes"** (polyps) protruding from the vagina. * **Clinical Presentation:** Often presents as blood-stained vaginal discharge or a visible mass at the introitus. * **Histology:** Characterized by the **Cambium layer** (a dense subepithelial layer of spindle-shaped tumor cells) and the presence of **rhabdomyoblasts** (strap or tadpole cells) with cytoplasmic cross-striations. * **Immunohistochemistry (IHC):** Positive for **Desmin**, Myogenin, and Myo-D1. * **Treatment:** Multimodal approach involving surgery (local excision) and chemotherapy (VAC regimen: Vincristine, Actinomycin-D, Cyclophosphamide).

Q: What is the primary treatment for Stage IB cervical cancer?

Surgery. **Explanation:** The primary treatment for **Stage IB cervical cancer** (specifically IB1 and IB2) is **Radical Hysterectomy (Type III/Wertheim’s Hysterectomy)** with bilateral pelvic lymphadenectomy. In early-stage cervical cancer (Stage IA2 to IB2), surgery is preferred over radiotherapy in young, fit patients because it preserves ovarian function, maintains vaginal elasticity, and avoids the long-term sequelae of radiation. **Analysis of Options:** * **A. Surgery (Correct):** For Stage IB, a Radical Hysterectomy is the gold standard. It involves the removal of the uterus, cervix, parametrium, and the upper 1/3rd of the vagina, along with pelvic lymph nodes. * **B. Chemotherapy:** Chemotherapy is never used as a standalone primary treatment for cervical cancer. It is used as a "radiosensitizer" (Cisplatin) during Concurrent Chemoradiotherapy (CCRT) for advanced stages. * **C. Radiotherapy:** While radiotherapy has equal efficacy to surgery in Stage IB, it is generally reserved for patients who are medically unfit for surgery or have bulky tumors (Stage IB3). It becomes the primary treatment of choice from Stage IIB onwards. * **D. Cryotherapy:** This is an ablative procedure used only for pre-cancerous lesions (CIN) or Stage IA1 (if no LVSI), not for invasive Stage IB cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Stage IA1:** Simple Hysterectomy (or Conization if fertility is desired). * **Stage IB1 to IIA1:** Radical Hysterectomy is the treatment of choice. * **Stage IIB onwards:** Concurrent Chemoradiotherapy (CCRT) is the standard of care. * **Fertility Preservation:** In Stage IB1, if the lesion is <2cm, a **Radical Trachelectomy** can be considered. * **Most common cause of death** in cervical cancer: Uremia due to bilateral ureteric obstruction.

Q: A patient with carcinoma of the cervix has involvement of the parametrium and the lower one-third of the vagina. On per rectal examination, there is no free space. What is the clinical stage of this cancer?

Stage IIb. ### Explanation The clinical staging of cervical cancer follows the **FIGO (International Federation of Gynecology and Obstetrics) classification**. Staging is primarily clinical, based on physical examination (including per rectal exam), colposcopy, and basic imaging. **Why Stage IIIb is the correct answer:** The patient presents with two key clinical findings: 1. **Involvement of the lower one-third of the vagina:** This automatically classifies the cancer as at least **Stage IIIa**. 2. **No free space on per rectal (PR) examination:** This is a classic clinical description indicating that the tumor has extended to the **pelvic sidewall**. According to FIGO staging, any tumor that involves the pelvic sidewall and/or causes hydronephrosis/non-functioning kidney is classified as **Stage IIIb**. In staging, we always assign the **highest (most advanced) stage** identified. **Analysis of Incorrect Options:** * **Stage IIa:** Involves the upper two-thirds of the vagina without parametrial involvement. * **Stage IIb:** Involves the parametrium but **not** up to the pelvic sidewall (there would still be "free space" on PR exam). * **Stage IIIa:** Involves the lower one-third of the vagina but **does not** extend to the pelvic sidewall. Since this patient has no free space on PR exam, she is upstaged to IIIb. **High-Yield Clinical Pearls for NEET-PG:** * **Parametrial involvement:** Stage IIb. * **Lower 1/3 of vagina:** Stage IIIa. * **Pelvic sidewall involvement/Hydronephrosis:** Stage IIIb. * **Bullous edema of bladder mucosa:** This does **not** constitute Stage IVa; there must be biopsy-proven involvement of the bladder or rectal mucosa. * **Management:** Stages I to IIa2 can be treated surgically (Radical Hysterectomy), whereas Stage IIb to IVa are treated with **Concurrent Chemoradiotherapy (CCRT)**.

Q: What is the chemotherapeutic agent of choice for concurrent chemoradiation in carcinoma cervix?

Cisplatin. **Explanation:** **Cisplatin** is the gold standard and the chemotherapeutic agent of choice for concurrent chemoradiation (CCRT) in locally advanced carcinoma cervix (Stages IB3 to IVA). The underlying medical concept is **radiosensitization**: Cisplatin inhibits the repair of DNA damage caused by ionizing radiation, thereby enhancing the lethal effect of radiotherapy on tumor cells. Large-scale clinical trials (GOG) have demonstrated that Cisplatin-based CCRT significantly improves both overall survival and progression-free survival compared to radiation alone. **Analysis of Incorrect Options:** * **A. Paclitaxel:** While used in the management of metastatic or recurrent cervical cancer (often in combination with Cisplatin/Carboplatin), it is not the primary agent for concurrent sensitization in the definitive setting. * **B. Hydroxyurea:** Historically, this was the first agent used for CCRT. However, it was replaced by Cisplatin because Cisplatin showed superior efficacy and a more manageable toxicity profile in landmark trials. * **C. 5-Fluorouracil (5-FU):** 5-FU has radiosensitizing properties and was previously used in combination with Cisplatin. However, single-agent Cisplatin is now preferred due to its proven efficacy and lower risk of gastrointestinal toxicity compared to multi-drug regimens. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Dose:** Cisplatin is typically administered weekly at a dose of **40 mg/m²** during the course of external beam radiotherapy. * **Prerequisite:** Before starting Cisplatin, always check the patient's **renal function (Serum Creatinine)** and ensure adequate hydration, as it is nephrotoxic. * **Treatment of Choice:** For Stage IIB (Parametrial involvement) and above, CCRT is the treatment of choice, not surgery.

Q: What is the recommended treatment for an ovarian tumor diagnosed during the first trimester of pregnancy?

Ovarian cystectomy in the second trimester. **Explanation:** The management of an adnexal mass in pregnancy depends on the gestational age and the risk of malignancy or complications (torsion/rupture). **Why Option D is correct:** The **second trimester (specifically 14–20 weeks)** is the "golden window" for surgical intervention. By this time, the placenta has taken over progesterone production, so the removal of the corpus luteum (if necessary) will not cause a miscarriage. Additionally, the uterus is not yet large enough to obstruct the surgical field, and the risk of preterm labor is significantly lower than in the third trimester. **Why other options are incorrect:** * **Option A:** Surgery in the third trimester is technically difficult due to the large gravid uterus and carries a high risk of triggering preterm labor. * **Options B & C:** Ignoring the tumor is dangerous. Large or persistent tumors (>5–6 cm) carry a 10–15% risk of **ovarian torsion**, rupture, or labor dystocia. Furthermore, while most masses are benign (e.g., dermoid cysts), the risk of malignancy must be addressed. **NEET-PG High-Yield Pearls:** * **Most common ovarian tumor in pregnancy:** Mature cystic teratoma (Dermoid cyst). * **Most common complication:** Torsion (most frequent during the 1st trimester or early postpartum). * **Indications for surgery:** Mass >6 cm, solid components on USG, or symptoms of torsion/rupture. * **Laparoscopy vs. Laparotomy:** Laparoscopy is now considered safe in pregnancy when performed by experts, preferably in the second trimester.

Q: What is the drug of choice for chemotherapy of cervical cancer?

Cisplatin. **Explanation:** **Cisplatin** is the gold standard and drug of choice for the treatment of cervical cancer. The primary management for locally advanced cervical cancer (Stage IB3 to IVA) is **Concurrent Chemoradiotherapy (CCRT)**. In this regimen, Cisplatin acts as a potent **radiosensitizer**, enhancing the lethal effects of radiation on tumor cells by inhibiting DNA repair mechanisms. For metastatic or recurrent disease, Cisplatin remains the backbone of combination therapy (often paired with Paclitaxel and Bevacizumab). **Why other options are incorrect:** * **Vincristine:** A vinca alkaloid that inhibits microtubule polymerization. While used in some pediatric tumors and lymphomas, it has no primary role in cervical cancer management. * **Cyclophosphamide:** An alkylating agent primarily used in breast cancer (AC regimen) and certain ovarian germ cell tumors. It is not a first-line agent for squamous cell carcinoma of the cervix. * **Etoposide:** A topoisomerase II inhibitor. While used in Small Cell Neuroendocrine Carcinoma of the cervix (a rare subtype) or Gestational Trophoblastic Neoplasia (EMA-CO regimen), it is not the drug of choice for standard cervical carcinoma. **Clinical Pearls for NEET-PG:** * **Standard Dose:** Cisplatin is typically administered weekly at **40 mg/m²** during the course of external beam radiotherapy. * **Side Effects:** The most significant dose-limiting toxicity of Cisplatin is **Nephrotoxicity**. To prevent this, aggressive pre- and post-treatment hydration is mandatory. It is also highly emetogenic and can cause ototoxicity. * **Alternative:** If a patient has renal impairment (elevated Creatinine), **Carboplatin** is the preferred alternative.

Q: What is the upper limit of normal for CA 125?

35 U/ml. **Explanation:** **1. Why the correct answer is right:** CA 125 (Cancer Antigen 125) is a high-molecular-weight glycoprotein used primarily as a tumor marker for epithelial ovarian cancer. The standard laboratory reference range for CA 125 defines the upper limit of normal as **35 U/ml**. This threshold was established based on the distribution of values in the healthy population, where approximately 99% of healthy women have levels below this value. In clinical practice, levels >35 U/ml are considered elevated and warrant further investigation, especially in postmenopausal women with an adnexal mass. **2. Why the incorrect options are wrong:** * **A (25 U/ml) & B (30 U/ml):** These values are within the normal physiological range. While some clinicians prefer a lower threshold for postmenopausal women to increase sensitivity, 35 U/ml remains the standard academic and board-exam answer. * **D (40 U/ml):** This value exceeds the established clinical cutoff. Using a higher cutoff like 40 U/ml would increase specificity but significantly decrease the sensitivity required for early detection or monitoring. **3. Clinical Pearls for NEET-PG:** * **Specificity:** CA 125 is **not** specific to ovarian cancer. It can be elevated in **physiological conditions** (menstruation, first trimester of pregnancy) and **benign conditions** (endometriosis, PID, fibroids, cirrhosis with ascites). * **Best Use:** It is most useful for **monitoring treatment response** and detecting **recurrence** of epithelial ovarian cancer (specifically serous cystadenocarcinoma). * **Postmenopausal Significance:** An elevated CA 125 in a postmenopausal woman with an adnexal mass has a much higher positive predictive value for malignancy than in a premenopausal woman. * **RMI (Risk of Malignancy Index):** CA 125 is a key component of the RMI score, along with ultrasound features and menopausal status.

Question 1

Nulliparity and late menopause are risk factors for which of the following group of diseases?

Accepted Answer

Endometrial cancer and breast cancer

Answer

Cervical cancer and endometrial hyperplasia

Answer

Ovarian cancer and endometrial polyp

Answer

Vulvar cancer and endometrial cancer

Question 2

Which of the following is a protective factor for ovarian cancer?

Accepted Answer

Bilateral Tubectomy

Answer

Nulliparity

Answer

Dysgenetic gonads

Answer

Worker of asbestos industry

Question 3

Which of the following is FALSE regarding a hydatidiform mole?

Accepted Answer

Can be diagnosed very early by ultrasonography

Answer

Caused by triploidy

Answer

Can present as a missed abortion

Answer

Rarely causes persistent gestational trophoblastic disease

Question 4

Sarcoma botryoides is most commonly seen in which age group?

Accepted Answer

Children under 2 years

Answer

Neonates

Answer

Adults

Answer

Post-menopausal women

Question 5

What is the primary treatment for Stage IB cervical cancer?

Accepted Answer

Surgery

Answer

Chemotherapy

Answer

Radiotherapy

Answer

Cryotherapy

Question 6

A patient with carcinoma of the cervix has involvement of the parametrium and the lower one-third of the vagina. On per rectal examination, there is no free space. What is the clinical stage of this cancer?

Accepted Answer

Stage IIb

Answer

Stage IIa

Answer

Stage IIIa

Answer

Stage IIIb

Question 7

What is the chemotherapeutic agent of choice for concurrent chemoradiation in carcinoma cervix?

Accepted Answer

Cisplatin

Answer

Paclitaxel

Answer

Hydroxyurea

Answer

5-Fluorouracil

Question 8

What is the recommended treatment for an ovarian tumor diagnosed during the first trimester of pregnancy?

Accepted Answer

Ovarian cystectomy in the second trimester

Answer

Surgery in the third trimester

Answer

No surgery is needed

Answer

Ignore the tumor

Question 9

What is the drug of choice for chemotherapy of cervical cancer?

Accepted Answer

Cisplatin

Answer

Vincristine

Answer

Cyclophosphamide

Answer

Etoposide

Question 10

What is the upper limit of normal for CA 125?

Accepted Answer

35 U/ml

Answer

25 U/ml

Answer

30 U/ml

Answer

40 U/ml

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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