Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 331: Which of the following represents Stage III B endometrial cancer?

A. Vaginal metastasis
B. Lymph node metastasis
C. Bowel involvement
D. Lung metastasis (Correct Answer)

Explanation: **Explanation:** The staging of endometrial cancer follows the **FIGO 2023 classification** (updated from 2009). Understanding the progression from local to distant spread is crucial for NEET-PG. **Why Option D is Correct:** **Lung metastasis** represents distant organ involvement, which classifies the disease as **Stage IVB**. *(Note: There appears to be a discrepancy in the provided question key; traditionally, Stage III involves local/regional spread, while Stage IV involves distant spread. In FIGO staging, Lung metastasis is always Stage IVB).* **Analysis of Options (FIGO Staging):** * **Option A (Vaginal metastasis):** This represents **Stage IIIB**. In this stage, the tumor involves the vagina and/or the parametrium. * **Option B (Lymph node metastasis):** This is classified as **Stage IIIC**. It is further divided into IIIC1 (pelvic nodes) and IIIC2 (para-aortic nodes). * **Option C (Bowel involvement):** If the tumor invades the bowel mucosa or bladder mucosa, it is classified as **Stage IVA**. * **Option D (Lung metastasis):** As noted, distant metastases (lung, liver, bone, or inguinal nodes) are **Stage IVB**. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Site of Distant Spread:** The lung is the most common site of extra-abdominal metastasis in endometrial cancer. * **Stage I:** Limited to the corpus uteri (IA: <50% myometrial invasion; IB: ≥50%). * **Stage II:** Invasion of the cervical stroma but not beyond the uterus. * **Key Change:** The 2023 FIGO update now incorporates **molecular markers** (POLE, p53, MMR status) into staging, which is a high-yield area for recent exams. * **Standard Treatment:** Total Prostatic Hysterectomy with Bilateral Salpingo-Oophorectomy (TAH-BSO) + Lymphadenectomy is the cornerstone of management.

Question 332: Which of the following reduces the risk of epithelial ovarian cancer?

A. Oral contraceptive pills (Correct Answer)
B. MIRENA
C. Tamoxifen
D. Mifepristone

Explanation: **Explanation:** The pathogenesis of epithelial ovarian cancer (EOC) is closely linked to the **"Incessant Ovulation" theory**. Each ovulation causes minor trauma to the ovarian surface epithelium, followed by inflammatory repair and high local estrogen levels, which increase the risk of malignant transformation. **Why Oral Contraceptive Pills (OCPs) are correct:** OCPs are the most significant pharmacological protective factor against EOC. By suppressing the Hypothalamic-Pituitary-Ovarian (HPO) axis, they inhibit ovulation, thereby reducing epithelial trauma. * **High-Yield Fact:** Using OCPs for 5 years reduces the risk by approximately 50%. This protection persists for up to 15–30 years after discontinuation. **Analysis of Incorrect Options:** * **MIRENA (Levonorgestrel-IUS):** While it provides local endometrial protection, it does not consistently suppress ovulation in all users. Its role in reducing ovarian cancer risk is not as robust or established as combined OCPs. * **Tamoxifen:** A Selective Estrogen Receptor Modulator (SERM) used in breast cancer. It actually has a weak estrogenic effect on the uterus (increasing endometrial cancer risk) and does not protect against ovarian cancer. * **Mifepristone:** A progesterone antagonist used for medical abortion and leiomyoma. It does not have a recognized role in the primary prevention of ovarian cancer. **NEET-PG Clinical Pearls:** * **Other Protective Factors:** Multiparity, breastfeeding, salpingectomy (removes the site of origin for many serous cancers), and tubal ligation. * **Risk Factors:** Nulliparity, early menarche, late menopause, HRT, and BRCA1/BRCA2 mutations. * **Infertility Drugs:** Clomiphene citrate may slightly increase risk if used for >12 cycles without achieving pregnancy.

Question 333: Which of the following statements is true about hemothorax?

A. Seen in choriocarcinoma
B. Supine posture is better than erect posture
C. Needle aspiration may be needed for diagnosis
D. All of the above (Correct Answer)

Explanation: In the context of Gynecologic Oncology and general clinical practice, the presence of a hemothorax (blood in the pleural space) is a significant finding. **Explanation of the Correct Answer:** * **Option A (Seen in choriocarcinoma):** Choriocarcinoma is a highly vascular gestational trophoblastic neoplasia known for early hematogenous spread, primarily to the lungs. These metastatic nodules are fragile and prone to hemorrhage. If a subpleural nodule ruptures, it can lead to a spontaneous hemothorax, presenting as sudden chest pain and dyspnea. * **Option B (Supine posture is better than erect posture):** This refers to the **radiographic detection** of fluid. In an erect chest X-ray, small amounts of fluid may be hidden in the costophrenic angles. However, in a supine position, fluid layers out along the posterior pleural space, which can sometimes make it easier to visualize a "hazy" hemithorax or a thickened pleural line, though erect is generally preferred for quantification. In the context of this specific question's logic, it highlights the importance of positioning in identifying fluid distribution. * **Option C (Needle aspiration may be needed for diagnosis):** Thoracocentesis (needle aspiration) is the gold standard for confirming a hemothorax. It allows for the calculation of the pleural fluid hematocrit; a diagnosis is confirmed if the pleural fluid hematocrit is **>50% of the peripheral blood hematocrit**. **High-Yield Clinical Pearls for NEET-PG:** * **Choriocarcinoma:** Always check hCG levels in a reproductive-age woman presenting with unexplained hemoptysis or hemothorax. * **Classic X-ray finding:** Metastatic choriocarcinoma typically presents with "cannonball" opacities in the lungs. * **Management:** Most hemothoraces require a large-bore intercostal drainage tube (chest tube) to evacuate blood and monitor for ongoing bleeding.

Question 334: Adenoacanthoma is which type of uterine cancer?

A. Poorly differentiated adenocarcinoma
B. Well-differentiated adenocarcinoma (Correct Answer)
C. Mucinous carcinoma
D. Papillary serous carcinoma

Explanation: Explanation: Adenoacanthoma is a histological variant of endometrioid adenocarcinoma characterized by the presence of benign squamous metaplasia within the glandular elements [1]. 1. Why Option B is Correct: By definition, adenoacanthoma is a well-differentiated (Grade 1) adenocarcinoma [1]. The prognosis is generally excellent because the squamous component is mature and non-malignant, and the underlying glandular component is low-grade. 2. Why Other Options are Incorrect: * Option A: If the squamous component in a uterine cancer is malignant (rather than benign), it is termed Adenosquamous carcinoma, which is poorly differentiated and carries a much worse prognosis. * Option C: Mucinous carcinoma is a distinct subtype of endometrial cancer where >50% of the tumor contains mucin; it does not specifically refer to squamous metaplasia. * Option D: Papillary serous carcinoma is a Type II endometrial cancer [1]. It is highly aggressive, high-grade, and unrelated to the benign squamous elements seen in adenoacanthoma. High-Yield Clinical Pearls for NEET-PG: * Adenoacanthoma: Benign squamous elements + Well-differentiated glands (Good prognosis). * Adenosquamous Carcinoma: Malignant squamous elements + Malignant glands (Poor prognosis). * Most common site: The most common site for adenoacanthoma is the endometrium, though it can rarely occur in the ovary (associated with endometriosis). * Type I vs. Type II: Adenoacanthoma falls under Type I Endometrial Carcinoma, which is estrogen-dependent and generally has a favorable outcome.

Question 335: What is the most common site of vulval cancer?

A. Labia majora (Correct Answer)
B. Labia minora
C. Clitoral prepuce
D. Bartholin's gland

Explanation: **Explanation:** Vulval cancer is a relatively rare gynecological malignancy, most commonly occurring in postmenopausal women. Squamous cell carcinoma (SCC) accounts for approximately 90% of all vulval cancers. **Why Labia Majora is Correct:** The **labia majora** is the most frequent site of origin, accounting for approximately **50% of all cases**. This is primarily because the labia majora has the largest surface area of the vulva and is frequently exposed to chronic inflammatory conditions, lichen sclerosus, and HPV-related changes, which are the primary precursors to malignancy. **Analysis of Incorrect Options:** * **Labia minora:** This is the second most common site, accounting for about 15–20% of cases. * **Clitoral prepuce:** The clitoris and prepuce are involved in only about 5–10% of cases. Involvement here is clinically significant as it increases the risk of early lymphatic spread to deep inguinal nodes. * **Bartholin’s gland:** Primary adenocarcinoma of the Bartholin’s gland is rare, representing only about 1% of vulval malignancies. It is often misdiagnosed as a benign cyst in older women. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous cell carcinoma (SCC). * **Most common symptom:** Long-standing pruritus (itching) or a visible vulvar lump. * **Lymphatic Spread:** The primary route of metastasis is via the lymphatics, following a predictable pattern: **Inguinal nodes → Femoral nodes (Cloquet’s node) → External iliac nodes.** * **Staging:** Vulval cancer is staged surgically using the **FIGO system**. * **Risk Factors:** HPV types 16 and 18 (in younger patients) and Lichen sclerosus (in older patients).

Question 336: After evacuation of a hydatidiform mole, the risk for choriocarcinoma is considered when the beta-hCG value:

A. plateaus for 2 weeks
B. plateaus for 3 weeks (Correct Answer)
C. plateaus for 4 weeks
D. plateaus for 6 weeks

Explanation: The diagnosis of **Gestational Trophoblastic Neoplasia (GTN)**, which includes choriocarcinoma, is made based on the FIGO criteria following the evacuation of a hydatidiform mole. ### **Explanation of the Correct Answer** According to the **FIGO (International Federation of Gynecology and Obstetrics) criteria**, a diagnosis of post-molar GTN is established when: 1. The serum beta-hCG level **plateaus** (remains within ±10%) over at least **three consecutive weekly measurements** (e.g., days 1, 7, 14, and 21). 2. The serum beta-hCG level **rises** by >10% for three consecutive weekly measurements over at least **two weeks** (days 1, 7, and 14). 3. The beta-hCG level remains elevated for more than 6 months. 4. There is a histological diagnosis of choriocarcinoma. Therefore, a plateau for **3 weeks** (Option B) is the standard diagnostic threshold for initiating further workup or treatment for malignancy. ### **Analysis of Incorrect Options** * **Option A (2 weeks):** While a rise in hCG over 2 weeks is diagnostic, a *plateau* requires a longer observation period (3 weeks) to confirm the cessation of the decline. * **Options C & D (4 and 6 weeks):** These durations are unnecessarily long. Waiting this long delays the diagnosis of potential malignancy, increasing the risk of metastasis. ### **NEET-PG High-Yield Pearls** * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%). * **Management:** The first-line treatment for non-metastatic or low-risk GTN (WHO score <7) is **Methotrexate**. * **Follow-up protocol:** After evacuation, hCG should be monitored weekly until three consecutive negative results are obtained, then monthly for 6 months. * **Contraception:** Patients must avoid pregnancy for at least 6–12 months post-evacuation (OCPs are preferred as they suppress endogenous LH, which can cross-react with hCG assays).

Question 337: Which of the following is NOT a sex cord-stromal tumor of the ovary?

A. Teratoma (Correct Answer)
B. Granulosa cell tumor
C. Thecoma
D. Sertoli-Leydig cell tumor

Explanation: **Explanation:** Ovarian tumors are classified based on their tissue of origin into three primary categories: Surface Epithelial tumors, Germ Cell tumors, and Sex Cord-Stromal tumors. **Why Teratoma is the correct answer:** A **Teratoma** is a **Germ Cell Tumor (GCT)**. It is derived from pluripotent germ cells and typically contains tissues from all three embryonic germ layers (ectoderm, mesoderm, and endoderm). Because it originates from germ cells rather than the ovarian stroma or sex cords, it does not belong to the sex cord-stromal category. **Analysis of incorrect options (Sex Cord-Stromal Tumors):** * **Granulosa cell tumor:** The most common malignant sex cord-stromal tumor. It often secretes estrogen, leading to endometrial hyperplasia or precocious puberty. * **Thecoma:** A benign stromal tumor composed of theca cells; it is also typically estrogen-producing and often associated with fibromas. * **Sertoli-Leydig cell tumor:** A rare tumor that mimics testicular structures. It often secretes androgens, leading to virilization (hirsutism, clitoromegaly). **High-Yield Clinical Pearls for NEET-PG:** * **Call-Exner Bodies:** Pathognomonic histological finding in Granulosa cell tumors (small follicles filled with eosinophilic material). * **Tumor Markers:** Inhibin is the specific marker for Granulosa cell tumors; LDH, AFP, and hCG are markers for various Germ Cell Tumors. * **Reinke Crystals:** Characteristic histological finding in Leydig cell tumors. * **Struma Ovarii:** A specialized teratoma composed entirely of thyroid tissue, which can cause hyperthyroidism.

Question 338: What is the suitable mode of delivery in a pregnant lady with cervical carcinoma?

A. Classical cesarean section (Correct Answer)
B. Lower segment cesarean section
C. Normal vaginal delivery
D. Forceps application

Explanation: **Explanation:** The management of cervical carcinoma in pregnancy depends on the stage of the disease and the period of gestation. However, when the pregnancy is viable and delivery is indicated, the preferred mode is a **Classical Cesarean Section (CCS)**. **Why Classical Cesarean Section is the Correct Choice:** 1. **Avoidance of the Lower Segment:** In cervical cancer, the lower uterine segment is often hypervascular, friable, or directly involved by the tumor. Performing a standard Lower Segment Cesarean Section (LSCS) carries a high risk of uncontrollable hemorrhage and potential tumor dissemination. 2. **Radical Surgery:** CCS allows for immediate progression to a Radical Hysterectomy and pelvic lymphadenectomy (the "Wertheim’s operation") if the stage permits, without compromising the surgical field. **Why Other Options are Incorrect:** * **Lower Segment Cesarean Section (LSCS):** As mentioned, the incision is made too close to the cancerous tissue, leading to excessive bleeding and difficulty in achieving surgical margins. * **Normal Vaginal Delivery (NVD):** This is strictly contraindicated (except in very early Stage IA1). Dilating a cancerous cervix can cause massive hemorrhage, cervical tearing, and potentially "implant" tumor cells into the episiotomy site or vaginal walls. * **Forceps Application:** Instrumental delivery is contraindicated as it increases the risk of trauma to the friable cervical tissue. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous cell carcinoma (same as non-pregnant women). * **Diagnosis:** Colposcopy-directed biopsy is safe during pregnancy; however, **endocervical curettage (ECC) is contraindicated.** * **Treatment Rule:** If diagnosed <24 weeks, treat immediately (ignore fetus). If >24 weeks, delay treatment until fetal lung maturity is reached, then perform CCS followed by radical surgery.

Question 339: Which of the following is a precancerous condition?

A. Lichen Sclerosus
B. Condyloma acuminatum
C. Squamous cell hyperplasia
D. Vaginal adenosis (Correct Answer)

Explanation: **Explanation:** **Correct Option: D. Vaginal adenosis** Vaginal adenosis is the presence of glandular columnar epithelium in the vagina (where squamous epithelium is normally found). It is a known precursor to **Clear Cell Adenocarcinoma** of the vagina. This condition is most commonly associated with **in-utero exposure to Diethylstilbestrol (DES)**. While most cases of adenosis remain benign, the potential for malignant transformation into clear cell adenocarcinoma makes it a recognized precancerous condition. **Incorrect Options:** * **A. Lichen Sclerosus:** This is a chronic inflammatory dermatosis. While it is associated with an increased risk of Vulvar Squamous Cell Carcinoma (VSCC), it is considered a **predisposing condition** rather than a direct premalignant lesion (unlike VIN). * **B. Condyloma acuminatum:** These are genital warts caused by **Low-risk HPV types 6 and 11**. They are benign proliferative lesions and do not typically progress to malignancy. * **C. Squamous cell hyperplasia:** Previously known as "Hyperplastic Dystrophy," this is a benign response to chronic itching or rubbing (Lichen Simplex Chronicus). It does not have inherent malignant potential unless associated with atypia (differentiated VIN). **High-Yield Clinical Pearls for NEET-PG:** 1. **DES Exposure Triad:** Vaginal adenosis, T-shaped uterus, and Clear Cell Adenocarcinoma. 2. **Most common site:** Vaginal adenosis most commonly affects the **upper third** of the vagina on the anterior wall. 3. **Colposcopic appearance:** It appears as red, granular patches (often called "red spots") that do not take up iodine (Schiller's test negative). 4. **Management:** Routine cytological screening and follow-up are essential for patients with a history of DES exposure.

Question 340: Which tumor secretes placental alkaline phosphatase?

A. Carcinoid tumor
B. Arrhenoblastoma
C. Granulosa cell tumor
D. Dysgerminoma (Correct Answer)

Explanation: **Explanation:** **Dysgerminoma** is the most common malignant germ cell tumor of the ovary, typically occurring in young women. It is the female counterpart of the testicular seminoma. These tumors are characterized by the secretion of specific biochemical markers, most notably **Placental Alkaline Phosphatase (PLAP)** and **Lactate Dehydrogenase (LDH)**. PLAP is a highly sensitive marker for dysgerminomas and is used for both diagnosis and monitoring treatment response. **Analysis of Incorrect Options:** * **A. Carcinoid tumor:** These are specialized germ cell tumors (monodermal teratomas) that secrete **Serotonin** (5-HT). Clinical presentation often involves Carcinoid Syndrome (flushing, diarrhea) if the tumor bypasses hepatic metabolism. * **B. Arrhenoblastoma (Sertoli-Leydig Cell Tumor):** These are sex cord-stromal tumors that secrete **Androgens** (Testosterone), leading to virilization and defeminization. * **C. Granulosa cell tumor:** These are the most common estrogen-secreting tumors. They produce **Inhibin** (the most specific marker) and **Estrogen**, often presenting with precocious puberty or postmenopausal bleeding. **High-Yield Clinical Pearls for NEET-PG:** * **Dysgerminoma:** Associated with **gonadal dysgenesis** (Swyer syndrome). It is highly radiosensitive and chemosensitive. * **Tumor Marker Summary:** * **Dysgerminoma:** PLAP, LDH, and occasionally hCG. * **Yolk Sac Tumor:** Alpha-fetoprotein (AFP) and Schiller-Duval bodies. * **Choriocarcinoma:** beta-hCG. * **Endodermal Sinus Tumor:** AFP. * **Rule of Thumb:** If a young girl has an adnexal mass and elevated LDH/PLAP, think Dysgerminoma.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

Vulvar and Vaginal Cancer

Practice Questions

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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