Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 341: During surgical staging of an ovarian tumor, a surgical spill occurs intraoperatively. What is the FIGO stage of this patient?

A. Stage 1C1 (Correct Answer)
B. Stage 1C2
C. Stage 1C3
D. Stage II

Explanation: **Explanation:** The FIGO staging for ovarian cancer was revised in 2014 to specifically differentiate the timing and nature of tumor rupture, as it impacts prognosis. **1. Why Stage 1C1 is Correct:** Stage I denotes cancer limited to the ovaries or fallopian tubes. **Stage 1C1** is specifically defined as **surgical spill intraoperatively**. This means the tumor was intact before surgery but ruptured during the procedure. This carries a slightly better prognosis than spontaneous rupture, hence its distinct classification. **2. Why the Other Options are Incorrect:** * **Stage 1C2:** This refers to a tumor where the **capsule is ruptured before surgery** (spontaneous rupture) or there is tumor on the ovarian surface. * **Stage 1C3:** This stage is assigned when **malignant cells are found in the ascites** or in peritoneal washings. * **Stage II:** This stage involves tumor extension beyond the ovaries/tubes to **pelvic organs** (e.g., uterus, bladder, rectum). A simple spill without pelvic organ involvement does not qualify for Stage II. **Clinical Pearls for NEET-PG:** * **Stage 1A:** Tumor limited to one ovary/tube, capsule intact, no tumor on surface, negative washings. * **Stage 1B:** Tumor involves both ovaries/tubes, capsule intact, no tumor on surface, negative washings. * **High-Yield Fact:** The most common site of metastasis for ovarian cancer is the **peritoneum** (seeding/exfoliation). * **Management Note:** Even for Stage 1C1, adjuvant chemotherapy (usually Paclitaxel + Carboplatin) is generally indicated due to the risk of recurrence from the spill.

Question 342: What is the most common malignant ovarian tumor seen in dysgenetic gonads?

A. Serous cystadenocarcinoma
B. Endodermal sinus tumor
C. Granulosa cell tumor
D. Dysgerminoma (Correct Answer)

Explanation: **Explanation:** The correct answer is **Dysgerminoma**. **Why it is correct:** Dysgerminoma is the most common malignant germ cell tumor of the ovary. It is uniquely associated with **gonadal dysgenesis** (e.g., Swyer syndrome, Turner syndrome mosaicism) and **gonadoblastoma**. In patients with dysgenetic gonads containing a Y chromosome, there is a high risk of developing a gonadoblastoma, which acts as a precursor lesion. In approximately 50% of these cases, the gonadoblastoma undergoes malignant transformation into a **Dysgerminoma**. **Why the other options are incorrect:** * **Serous cystadenocarcinoma (A):** This is the most common malignant epithelial ovarian tumor overall, typically seen in postmenopausal women, but it is not specifically associated with dysgenetic gonads. * **Endodermal sinus tumor (B):** Also known as Yolk Sac Tumor, this is the second most common malignant germ cell tumor. While it can occur in young patients, it is less frequently associated with dysgenetic gonads compared to dysgerminoma. It is characterized by high Alpha-Fetoprotein (AFP) levels. * **Granulosa cell tumor (C):** This is a sex cord-stromal tumor known for producing estrogen. It is not linked to chromosomal dysgenesis or Y-chromosome-related gonadal streaks. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Dysgerminoma is associated with elevated **LDH** (Lactic Dehydrogenase) and sometimes hCG. * **Radiosensitivity:** It is the most radiosensitive ovarian tumor, though fertility-sparing surgery followed by chemotherapy (BEP regimen) is the current standard. * **Histology:** Look for "large cells with clear cytoplasm and central nuclei, separated by fibrous septa containing lymphocytes." * **Management Tip:** In any phenotypic female with primary amenorrhea and a Y chromosome, prophylactic gonadectomy is recommended to prevent the development of Dysgerminoma.

Question 343: What is true about endodermal sinus tumors?

A. Schiller-Duval bodies are seen. (Correct Answer)
B. It is a benign tumor.
C. It is associated with hCG.
D. It is seen in young individuals.

Explanation: **Explanation:** **Endodermal Sinus Tumor (Yolk Sac Tumor)** is the most common malignant germ cell tumor in children and young adults. 1. **Why Option A is correct:** The hallmark histopathological feature of this tumor is the **Schiller-Duval body**. These are characteristic structures consisting of a central blood vessel surrounded by germ cells within a space lined by flattened cells, mimicking a primitive glomerulus. Their presence is pathognomonic for Yolk Sac Tumors. 2. **Why Option B is incorrect:** Endodermal sinus tumors are **highly malignant** and aggressive. They grow rapidly and require prompt surgical intervention followed by chemotherapy (usually the BEP regimen). 3. **Why Option C is incorrect:** This tumor is associated with elevated levels of **Alpha-fetoprotein (AFP)**, not hCG. hCG is the characteristic marker for Choriocarcinoma or some cases of Dysgerminoma. 4. **Why Option D is incorrect:** While the question asks for the *most* true statement, Option A is the definitive pathological feature. While it is seen in young individuals (children and adolescents), Option A is the classic "textbook" answer for identifying this specific pathology in exams. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** AFP is used for both diagnosis and monitoring recurrence. * **Gross Appearance:** Often presents as a large, solid, encapsulated mass with areas of hemorrhage and necrosis. * **Treatment:** Standard treatment is unilateral salpingo-oophorectomy (to preserve fertility) followed by **BEP chemotherapy** (Bleomycin, Etoposide, and Platinum/Cisplatin). * **Histology Tip:** Look for "lace-like" (reticular) patterns and intracellular/extracellular **hyaline droplets** (PAS positive) in addition to Schiller-Duval bodies.

Question 344: An obese woman with type 2 diabetes and hypertension is diagnosed with endometrioid type of endometrial carcinoma. What is the most probable gene defect expected in this condition?

A. PTEN (Correct Answer)
B. p53
C. MSH2
D. BRCA2

Explanation: **Explanation:** The clinical presentation describes a classic case of **Type I Endometrial Carcinoma**. This type is estrogen-dependent, occurs in younger or perimenopausal women, and is strongly associated with the "metabolic syndrome" triad of **obesity, diabetes, and hypertension**. **1. Why PTEN is correct:** The most common genetic mutation in Type I (Endometrioid) endometrial carcinoma is the inactivation of the **PTEN tumor suppressor gene** (seen in 30–80% of cases). PTEN normally inhibits the PI3K/Akt signaling pathway; its loss leads to uncontrolled cell proliferation and survival, often preceded by atypical endometrial hyperplasia. **2. Why the other options are incorrect:** * **p53:** Mutations in the *TP53* gene are the hallmark of **Type II Endometrial Carcinoma** (e.g., Serous or Clear cell types). These occur in older, thin women, are estrogen-independent, and carry a much poorer prognosis. * **MSH2:** This is a DNA mismatch repair (MMR) gene associated with **Lynch Syndrome** (HNPCC). While Lynch syndrome increases the risk of endometrial cancer, PTEN remains the most frequent sporadic mutation in the general population presenting with the described metabolic risk factors. * **BRCA2:** Primarily associated with hereditary breast and ovarian cancer syndromes (HBOC), not typically linked to the endometrioid type of endometrial carcinoma. **High-Yield Pearls for NEET-PG:** * **Type I (Endometrioid):** Estrogen-linked, PTEN mutation, favorable prognosis, precursor is Atypical Hyperplasia. * **Type II (Serous):** Non-estrogen linked, p53 mutation, aggressive, precursor is Serous Endometrial Intraepithelial Carcinoma (SEIC). * **Most common histological type:** Endometrioid adenocarcinoma. * **Protective factors:** Combined oral contraceptives (COCs), smoking (decreases estrogen, though harmful otherwise), and multiparity.

Question 345: What is the treatment of choice for stage III CIN in a 40-year-old female?

A. Hysterectomy (Correct Answer)
B. Laser coagulation
C. Cryocoagulation
D. Cone excision

Explanation: **Explanation:** The treatment of choice for **CIN III (Cervical Intraepithelial Neoplasia Grade 3)** depends heavily on the patient’s age and fertility requirements. In a **40-year-old female** who has likely completed her family, **Total Hysterectomy** is considered the definitive treatment of choice. **Why Hysterectomy is correct:** CIN III is a high-grade premalignant lesion (Carcinoma-in-situ). While conservative methods are preferred in younger women to preserve fertility, a 40-year-old patient is at a higher risk for recurrence or progression to invasive squamous cell carcinoma. Hysterectomy provides the lowest recurrence rate and eliminates the risk of future cervical or uterine pathologies, making it the most definitive surgical management in this age group. **Analysis of Incorrect Options:** * **Laser coagulation & Cryocoagulation (Ablative methods):** These are generally reserved for CIN I or CIN II where the entire transformation zone is visible. They are less ideal for CIN III because they do not provide a tissue specimen for histopathological examination to rule out occult invasive cancer. * **Cone excision (Excisional method):** This is the treatment of choice for CIN III in **younger patients** who wish to preserve fertility. However, in a 40-year-old, the risk-to-benefit ratio shifts toward definitive surgery (Hysterectomy). **Clinical Pearls for NEET-PG:** * **CIN I:** Observation or local destruction (Cryo/Laser). * **CIN II/III (Younger/Fertility desired):** LEEP (Loop Electrosurgical Excision Procedure) or Cold Knife Conization. * **CIN III (Older/Completed family):** Hysterectomy. * **Microinvasive Carcinoma (Stage IA1):** Simple Hysterectomy is sufficient. * **Key Risk Factor:** Persistent infection with High-risk HPV (Types 16 and 18).

Question 346: A 31-year-old female, P1L1, underwent a routine Papanicolaou smear which was reported as CIN III (High Grade Squamous Intraepithelial Lesion/HSIL). What is the next step in management?

A. Trachelectomy
B. Hysterectomy
C. Conization
D. Colposcopy with biopsy (Correct Answer)

Explanation: **Explanation:** The management of an abnormal cervical cytology (Pap smear) follows the principle of **"See, See, and Treat."** A Pap smear is a screening tool, not a diagnostic one. When a result shows HSIL (CIN III), the next mandatory step is to visualize the cervix under magnification and obtain a tissue diagnosis. **1. Why Colposcopy with Biopsy is correct:** According to the ASCCP guidelines, any high-grade cytological abnormality (HSIL/CIN II/CIN III) requires **Colposcopy** to identify the most suspicious areas (using acetic acid and Lugol’s iodine) and a **directed biopsy** to confirm the histological grade of the lesion. Treatment can only be initiated once a definitive tissue diagnosis is established. **2. Why other options are incorrect:** * **Trachelectomy (A):** This is a radical surgery (removal of the cervix) used for early-stage cervical cancer (IA2-IB1) in patients wishing to preserve fertility. It is overtreatment for a cytological finding. * **Hysterectomy (B):** This is never the first-line management for CIN III. Even if the patient has completed her family, a histological diagnosis must be confirmed first to rule out invasive cancer, which would require more radical surgery. * **Conization (C):** While conization (LEEP/Cold knife) is the definitive *treatment* for biopsy-confirmed CIN III, it is generally not the immediate *next* step unless the colposcopy is unsatisfactory or there is a cyto-histological discrepancy. **Clinical Pearls for NEET-PG:** * **Bethesda System:** HSIL on Pap smear has a high risk of underlying CIN II/III or occult invasive cancer. * **Satisfactory Colposcopy:** Defined as the visualization of the entire **Transformation Zone (TZ)** and the squamocolumnar junction. * **Pregnancy Exception:** If HSIL is found in a pregnant patient, colposcopy is done, but biopsy is only performed if invasive cancer is suspected. Endocervical curettage (ECC) is strictly contraindicated in pregnancy.

Question 347: What is the approximate percentage of ovarian malignancies in childhood?

A. 10%
B. 20%
C. 30%
D. None of the above (Correct Answer)

Explanation: **Explanation:** The correct answer is **None of the above** because ovarian malignancies are exceedingly rare in the pediatric population. Ovarian tumors in children and adolescents account for only **1–1.5%** of all childhood cancers and approximately **1%** of all ovarian malignancies across all age groups. **Detailed Breakdown:** * **Why Options A, B, and C are incorrect:** Percentages like 10%, 20%, or 30% significantly overestimate the incidence. While ovarian *cysts* are common in children, true *malignancies* are rare. Even among pediatric ovarian masses that require surgery, roughly 70–80% are benign (most commonly mature cystic teratomas). * **The Correct Figure:** In the pediatric and adolescent age group, the incidence of malignancy in an ovarian mass is approximately **20–30% of those operated upon**, but as a percentage of total childhood cancers or total ovarian cancers, it remains near **1%**. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most Common Type:** Unlike adults (where epithelial tumors predominate), the most common ovarian tumors in children are **Germ Cell Tumors (GCTs)**, accounting for 60–75% of cases. 2. **Most Common Malignant GCT:** **Dysgerminoma** is the most frequent malignant pediatric ovarian tumor. 3. **Tumor Markers:** Always correlate with markers: **LDH** (Dysgerminoma), **AFP** (Yolk Sac Tumor), and **hCG** (Choriocarcinoma). 4. **Management:** The standard of care for pediatric malignant GCTs is **Fertility-Sparing Surgery** (Unilateral Salpingo-oophorectomy) even in advanced stages, as these tumors are highly chemosensitive (BEP regimen).

Question 348: FIGO staging is used in which of the following conditions?

A. Carcinoma breast
B. Bone tumour
C. Leukaemia
D. Carcinoma cervix (Correct Answer)

Explanation: **Explanation:** The **FIGO (International Federation of Gynecology and Obstetrics)** staging system is the globally recognized standard for staging gynecological malignancies. It is specifically designed for cancers of the female reproductive tract, including the **cervix**, endometrium, ovary, vulva, and vagina. **1. Why Carcinoma Cervix is Correct:** Carcinoma cervix is staged using the FIGO system. Historically, it was staged clinically (using physical exam, colposcopy, and basic imaging), but the **2018 FIGO update** now allows for the integration of advanced imaging (MRI/CT/PET) and pathological findings to determine the stage. This makes it a classic example of a FIGO-staged malignancy. **2. Why Other Options are Incorrect:** * **Carcinoma Breast:** Staged using the **AJCC (American Joint Committee on Cancer) TNM system**, which focuses on Tumor size, Nodal involvement, and Metastasis. * **Bone Tumors:** These are typically staged using the **Enneking (MSTS) system** for surgical staging or the AJCC TNM system. * **Leukaemia:** Being a hematological malignancy, it does not form solid tumors that follow anatomical staging. It is classified based on morphology, cytogenetics, and flow cytometry (e.g., **FAB or WHO classifications**). **High-Yield Clinical Pearls for NEET-PG:** * **Clinical vs. Surgical Staging:** Carcinoma cervix is primarily a **clinical/radiological staging**, whereas Carcinoma Ovary and Carcinoma Endometrium are **surgical stagings**. * **FIGO 2018 Update (Cervix):** Note that Stage IIIC (lymph node involvement) was added in the latest update. IIIC1 denotes pelvic node involvement, and IIIC2 denotes para-aortic node involvement. * **Choriocarcinoma:** Also uses a unique FIGO scoring system (modified WHO prognostic scoring) alongside anatomical staging.

Question 349: True regarding vulval cancer is all except?

A. HPV virus is a causative factor
B. Iliac group of nodes are primary site of metastasis (Correct Answer)
C. Smoking is a risk factor
D. Vulvectomy is the treatment for Bowen's disease

Explanation: **Explanation:** The lymphatic drainage of the vulva follows a predictable, stepwise pattern. The **superficial inguinal nodes** are the primary site of metastasis, followed by the deep inguinal (Cloquet’s node) and then the **external iliac nodes**. Direct metastasis to the iliac nodes without involving the inguinal nodes is extremely rare. Therefore, Option B is incorrect and the right answer for this "except" question. **Analysis of Options:** * **Option A:** HPV (specifically types 16 and 18) is a major causative factor, particularly in younger patients. It is associated with the "Basaloid/Warty" type of Vulvar Intraepithelial Neoplasia (VIN). * **Option C:** Smoking is a well-established independent risk factor for vulvar cancer and its precursors, as it impairs local mucosal immunity and acts synergistically with HPV. * **Option D:** Bowen’s disease (High-grade Squamous Intraepithelial Lesion) is a pre-cancerous condition. While wide local excision is preferred today to preserve anatomy, traditional management includes simple vulvectomy or skinning vulvectomy for multifocal disease. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common histological type:** Squamous cell carcinoma (approx. 90%). 2. **Sentinel Lymph Node Biopsy (SLNB):** Indicated in early-stage disease (Stage T1/T2, <4cm) with clinically negative nodes to reduce the morbidity of radical groin dissection. 3. **Staging:** Vulvar cancer is staged **surgically** (FIGO). 4. **The "Sentinel" Node of the Groin:** Cloquet’s node (the highest deep inguinal node, located under the inguinal ligament). If this is negative, iliac nodes are usually negative.

Question 350: Which chemotherapeutic agent must be included in the treatment of ovarian carcinoma?

A. Methotrexate
B. Cyclophosphamide (Correct Answer)
C. Fluorouracil
D. Procarbazine

Explanation: **Explanation:** The standard of care for epithelial ovarian carcinoma (EOC) involves cytoreductive surgery followed by combination chemotherapy. Historically, the combination of **Cyclophosphamide** and a platinum-based agent (like Cisplatin) was the gold standard. While modern protocols have largely replaced Cyclophosphamide with Paclitaxel (Paclitaxel + Carboplatin), Cyclophosphamide remains a classic, high-yield answer in the context of traditional ovarian cancer regimens. **Analysis of Options:** * **Cyclophosphamide (Correct):** An alkylating agent that cross-links DNA. It was a cornerstone of the "PC" (Platinum + Cyclophosphamide) regimen. It is still used in specific refractory cases or in resource-limited settings where taxanes are unavailable. * **Methotrexate:** A folate antagonist primarily used in Gestational Trophoblastic Neoplasia (GTN) and ectopic pregnancy, not epithelial ovarian cancer. * **Fluorouracil (5-FU):** An antimetabolite used primarily in gastrointestinal and breast cancers. It has a limited role in primary ovarian cancer treatment. * **Procarbazine:** An alkylating agent used mainly in the MOPP regimen for Hodgkin’s Lymphoma and certain brain tumors; it is not used for ovarian carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Current Standard:** Paclitaxel (175 mg/m²) + Carboplatin (AUC 5-6) every 3 weeks for 6 cycles. * **Germ Cell Tumors of Ovary:** The regimen of choice is **BEP** (Bleomycin, Etoposide, and Platinum/Cisplatin). * **CA-125:** The most important tumor marker for monitoring treatment response and recurrence in serous ovarian cancer. * **Side Effect:** A classic side effect of Cyclophosphamide is **hemorrhagic cystitis**, prevented by hydration and **MESNA**.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

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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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