Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 351: Ovarian tumor involving retroperitoneal lymph nodes is seen in which stage?

A. Stage IIB
B. Stage IIIA (Correct Answer)
C. Stage IIIB
D. Stage IIIC

Explanation: In ovarian cancer staging (FIGO 2014), the involvement of **retroperitoneal lymph nodes** signifies a shift from Stage II (pelvic extension) to **Stage III** (extrapelvic spread). ### Why Stage IIIA is Correct According to the FIGO staging system, **Stage IIIA1** is specifically defined by metastasis to retroperitoneal lymph nodes only, without intraperitoneal involvement. It is further subdivided based on the size of the nodal involvement: * **Stage IIIA1(i):** Metastasis ≤ 10 mm. * **Stage IIIA1(ii):** Metastasis > 10 mm. Since Stage IIIA is the first stage where retroperitoneal nodal involvement is categorized, it is the most accurate answer. ### Why Other Options are Incorrect * **Stage IIB:** This involves extension to other pelvic intraperitoneal tissues (e.g., bladder, rectum) but is confined to the **pelvis**. It does not involve lymph nodes. * **Stage IIIB:** This stage is characterized by **microscopic** extrapelvic (peritoneal) involvement beyond the pelvis, with or without retroperitoneal lymph nodes. * **Stage IIIC:** This involves **macroscopic** extrapelvic peritoneal metastasis > 2 cm, with or without retroperitoneal lymph nodes. ### NEET-PG High-Yield Pearls * **Most common route of spread:** Ovarian cancer primarily spreads via **exfoliation/seeding** (peritoneal) rather than lymphatic spread. * **Lymphatic Drainage:** The primary lymphatic drainage of the ovary is via the **infundibulopelvic ligament** to the **para-aortic lymph nodes** (at the level of the renal hilum). * **Staging:** Ovarian cancer is staged **surgically**. * **Stage IV:** Distant metastasis, including parenchymal liver/splenic metastasis or pleural effusion with positive cytology. Note: Involvement of inguinal nodes is Stage IVB.

Question 352: A 40-year-old woman presents with endometrial carcinoma. Her family history reveals that her mother died of endometrial cancer at age 50, while her 42-year-old brother was recently diagnosed with colon cancer. What gene is most likely to be mutated in this family?

A. WT-1
B. APC
C. MSH2 (Correct Answer)
D. p53

Explanation: **Explanation:** The clinical presentation and family history are classic for **Lynch Syndrome** (Hereditary Non-Polyposis Colorectal Cancer - HNPCC). This autosomal dominant condition is characterized by a high risk of colorectal, endometrial, and ovarian cancers. In women with Lynch Syndrome, the lifetime risk of endometrial cancer (40-60%) often equals or exceeds the risk of colorectal cancer. **Why MSH2 is correct:** Lynch Syndrome is caused by germline mutations in **DNA Mismatch Repair (MMR) genes**, most commonly **MLH1** and **MSH2** (accounting for ~90% of cases), followed by MSH6 and PMS2. These mutations lead to microsatellite instability (MSI). Given the combination of early-onset endometrial and colon cancer in first-degree relatives, a mutation in a mismatch repair gene like **MSH2** is the most likely etiology. **Analysis of Incorrect Options:** * **WT-1:** Associated with Wilms tumor and certain syndromic renal/gonadal anomalies (e.g., WAGR, Denys-Drash syndrome), not adult-onset epithelial cancers. * **APC:** Mutated in Familial Adenomatous Polyposis (FAP). While it causes profuse colorectal polyps and cancer, it is not typically associated with endometrial carcinoma. * **p53:** The "guardian of the genome," mutated in Li-Fraumeni syndrome. While it increases the risk of many cancers (sarcomas, breast, brain), it is not the primary driver of the specific colon-endometrial cluster seen here. **High-Yield Clinical Pearls for NEET-PG:** * **Amsterdam II Criteria:** Used to identify Lynch Syndrome (3-2-1 rule: 3 relatives with HNPCC-associated cancer, 2 generations, 1 diagnosed before age 50). * **Screening:** Women with Lynch Syndrome require annual endometrial biopsies starting at age 30–35 and may consider prophylactic hysterectomy and bilateral salpingo-oophorectomy (BSO) after completing childbearing. * **Most common extra-colonic malignancy** in Lynch Syndrome is Endometrial Carcinoma.

Question 353: A 35-year-old female presents with postcoital bleeding. What is the next step in management?

A. Pap smear and colposcopy (Correct Answer)
B. Visual inspection with acetic acid
C. Visual inspection with Lugol's iodine
D. Colposcopy-directed biopsy

Explanation: **Explanation:** **1. Why Option A is Correct:** Postcoital bleeding is a classic "red flag" symptom of cervical cancer. In a symptomatic patient, the primary goal is to rule out malignancy. According to standard clinical guidelines, the initial evaluation of postcoital bleeding involves a thorough physical examination and a **combination of Pap smear (cytology) and Colposcopy**. While the Pap smear screens for cellular abnormalities, colposcopy allows for a magnified visualization of the transformation zone to identify suspicious areas. This dual approach ensures high sensitivity in detecting pre-invasive or invasive lesions. **2. Why Other Options are Incorrect:** * **Options B & C (VIA/VILI):** Visual Inspection with Acetic Acid (VIA) and Lugol’s Iodine (VILI) are primarily used as low-cost screening tools in resource-limited settings. They are not the gold standard for a symptomatic patient in a clinical setup where colposcopy is available. * **Option D (Colposcopy-directed biopsy):** This is the "gold standard" for diagnosis, but it is the *next* step only **after** an abnormal area is identified during the colposcopy. You cannot perform a directed biopsy without first performing the colposcopy to locate the lesion. **Clinical Pearls for NEET-PG:** * **Most common cause** of postcoital bleeding in reproductive-age women: Cervical ectopy or cervicitis. * **Most serious cause** to rule out: Cervical carcinoma. * If a **gross growth** is visible on the cervix during speculum examination, the next step is a **direct punch biopsy**, bypassing the Pap smear and colposcopy. * **Bethesda System** is used for reporting cervical cytology (Pap smear).

Question 354: Adenocarcinoma of the uterus along with rhabdomyosarcoma of the uterus is seen. What is this condition called?

A. Homologous sarcoma
B. Heterologous sarcoma
C. Mixed Mullerian tumour (Correct Answer)
D. Carcinoma botryoides

Explanation: **Explanation:** The condition described is a **Malignant Mixed Mullerian Tumour (MMMT)**, also known as **Carcinosarcoma**. These are highly aggressive neoplasms that contain both a malignant epithelial component (**Adenocarcinoma**) and a malignant mesenchymal component (**Sarcoma**). **1. Why Mixed Mullerian Tumour is correct:** MMMTs are "biphasic" tumors. The term "Mixed" refers to the presence of both epithelial and stromal malignancies. Because the uterus is a Mullerian duct derivative, these tumors are classified as Mixed Mullerian Tumours. **2. Analysis of Incorrect Options:** * **Homologous Sarcoma:** This refers to a mixed tumor where the sarcomatous component is tissue normally found in the uterus (e.g., leiomyosarcoma or endometrial stromal sarcoma). * **Heterologous Sarcoma:** This is a subtype of MMMT where the sarcomatous component consists of tissues *not* normally found in the uterus (e.g., **Rhabdomyosarcoma**, Chondrosarcoma, or Osteosarcoma). While the question describes a heterologous element, "Mixed Mullerian Tumour" is the overarching clinical diagnosis for the combination of adenocarcinoma and sarcoma. * **Carcinoma Botryoides:** This is a variant of Embryonal Rhabdomyosarcoma typically seen in young children (infants/toddlers), presenting as "grape-like" masses protruding from the vagina. It does not contain an adenocarcinoma component. **Clinical Pearls for NEET-PG:** * **Risk Factors:** Postmenopausal age, long-term Tamoxifen use, and prior pelvic radiation. * **Pathogenesis:** Most evidence suggests these are "metaplastic" carcinomas (monoclonal origin) rather than true collisions of two different cell types. * **Prognosis:** Extremely poor; they spread primarily via lymphatics like high-grade endometrial carcinomas but are more aggressive.

Question 355: Which investigation is not part of the FIGO staging of carcinoma of the cervix?

A. Cystoscopy
B. Chest X-ray
C. Pelvic ultrasound (Correct Answer)
D. Intravenous pyelogram (IVP)

Explanation: **Explanation:** The FIGO staging for carcinoma cervix is primarily **clinical**. While the staging system was updated in 2018 to allow for advanced imaging (MRI, CT, PET) and pathology where available, the "traditional" clinical staging framework remains the foundation for exams like NEET-PG. **Why Pelvic Ultrasound is the correct answer:** According to FIGO guidelines, **Pelvic Ultrasound is not a formal component** of the staging system. While it is a useful tool for initial screening or assessing pelvic masses, it lacks the standardized accuracy required for formal staging compared to the specific investigations permitted by FIGO. **Analysis of Incorrect Options:** * **Cystoscopy (A):** This is a permitted investigation to evaluate for Stage IVA (involvement of the bladder mucosa). * **Chest X-ray (B):** This is allowed to rule out distant pulmonary metastasis (Stage IVB). * **Intravenous Pyelogram (IVP) (C):** Traditionally, IVP is used to detect hydronephrosis or a non-functioning kidney, which automatically upgrades the disease to **Stage IIIB**. **High-Yield Clinical Pearls for NEET-PG:** * **Staging Method:** Carcinoma cervix is the only gynecological cancer that is staged **clinically** (most others, like endometrial and ovarian, are staged surgically). * **Permitted Investigations:** Clinical exam (under anesthesia), Colposcopy, Biopsy, Conization, Cystoscopy, Proctosigmoidoscopy, Chest X-ray, and IVP. * **2018 Update:** FIGO now allows "cross-sectional imaging" (MRI for local extent, PET-CT for nodes) to assign a stage, but if these are unavailable, the clinical investigations listed above remain the standard. * **Hydronephrosis Rule:** The presence of hydronephrosis or a non-functioning kidney on IVP/Imaging classifies the patient as **Stage IIIB**, regardless of other findings.

Question 356: Tamoxifen increases the risk of which malignancy?

A. Cervix
B. Vagina
C. Endometrium (Correct Answer)
D. Vulva

Explanation: **Explanation:** **Tamoxifen** is a Selective Estrogen Receptor Modulator (SERM) used primarily in the treatment and prophylaxis of breast cancer. Its effect on tissues is organ-specific due to its unique interaction with estrogen receptors: * **In the Breast:** It acts as an **antagonist**, inhibiting the growth of estrogen-sensitive breast cancer cells. * **In the Endometrium:** It acts as a **partial agonist**. This estrogenic stimulation leads to endometrial proliferation, increasing the risk of **endometrial hyperplasia, polyps, and endometrial carcinoma** (specifically Type 1 endometrioid adenocarcinoma). The risk is dose and duration-dependent, typically seen in postmenopausal women. **Why other options are incorrect:** * **Cervix, Vagina, and Vulva:** These tissues do not exhibit the same proliferative response to Tamoxifen as the endometrium. There is no established clinical evidence linking Tamoxifen use to an increased risk of squamous cell carcinomas or other malignancies of the lower genital tract. **High-Yield Clinical Pearls for NEET-PG:** 1. **Raloxifene:** Another SERM used for osteoporosis; unlike Tamoxifen, it acts as an **antagonist** in the endometrium and does **not** increase the risk of endometrial cancer. 2. **Monitoring:** Asymptomatic women on Tamoxifen do not require routine ultrasound or endometrial biopsy. However, any **postmenopausal bleeding** in a patient on Tamoxifen must be investigated urgently with a transvaginal scan (TVS) and biopsy. 3. **Other Side Effects:** Tamoxifen increases the risk of **thromboembolism** (DVT/PE) and **cataracts**, but it has a beneficial effect on **bone mineral density** in postmenopausal women and lowers LDL cholesterol.

Question 357: In gestational trophoblastic disease, to which site do metastases most commonly occur?

A. Brain
B. Liver
C. Lungs (Correct Answer)
D. Bone

Explanation: **Explanation:** Gestational Trophoblastic Neoplasia (GTN), specifically choriocarcinoma, is characterized by its high propensity for **hematogenous spread**. Because the trophoblastic cells invade venous sinuses within the uterus, the lungs are the first major capillary bed they encounter after entering the systemic circulation. * **Lungs (Correct):** This is the most common site of metastasis, occurring in approximately **80%** of metastatic GTN cases. On chest X-ray, these typically appear as "cannon-ball" or "snowstorm" opacities. * **Brain & Liver (Incorrect):** These are considered late-stage metastatic sites. Brain involvement (10%) and liver involvement (10%) usually occur only after pulmonary metastasis has been established. Their presence signifies a poor prognosis and places the patient in the WHO High-Risk category. * **Bone (Incorrect):** Bone metastasis is extremely rare in GTN compared to other solid tumors like breast or prostate cancer. **Clinical Pearls for NEET-PG:** 1. **Order of Metastasis:** Lungs (80%) > Vagina (30%) > Pelvis (20%) > Liver (10%) > Brain (10%). 2. **Vaginal Metastasis:** Often presents as a highly vascular, bluish-purple nodule on the anterior vaginal wall. **Biopsy should be avoided** due to the risk of torrential hemorrhage. 3. **FIGO Staging:** Staging for GTN is unique as it is based on clinical and radiological findings rather than surgical pathology. 4. **Choriocarcinoma:** Unlike other malignancies, even metastatic GTN is highly curable with chemotherapy (e.g., Methotrexate or EMA-CO regimen) because it is exquisitely chemosensitive.

Question 358: Which of the following findings are indications for direct lymph node dissection in endometrial carcinoma?

A. Penetration into half of the myometrium, Clear cell carcinoma, Fundal involvement
B. Penetration into half of the myometrium, Clear cell carcinoma, Peritoneal metastasis (Correct Answer)
C. Fundal involvement, Peritoneal metastasis, Papillary serous carcinoma
D. Penetration into half of the myometrium, Fundal involvement, Peritoneal metastasis

Explanation: **Explanation:** In endometrial carcinoma, the decision to perform lymphadenectomy (lymph node dissection) is based on the risk of nodal metastasis. According to standard oncological guidelines (FIGO/GOG), patients are stratified into low-risk and high-risk categories. **1. Why the Correct Answer (B) is Right:** * **Deep Myometrial Invasion (≥50%):** Penetration into more than half of the myometrium significantly increases the risk of pelvic and para-aortic lymph node involvement. * **High-Risk Histology (Clear Cell Carcinoma):** Type II endometrial cancers (Clear cell, Papillary serous) are aggressive, regardless of the depth of invasion, and mandate full surgical staging including lymphadenectomy. * **Peritoneal Metastasis:** The presence of extrauterine spread (Stage III/IV) necessitates nodal assessment to determine the full extent of the disease and guide adjuvant therapy. **2. Analysis of Incorrect Options:** * **Fundal Involvement (Options A, C, D):** While the location of the tumor is noted, **fundal involvement is NOT a primary indication** for lymph node dissection. The depth of invasion and histological grade are far more critical prognostic factors than the specific site within the uterine cavity. * **Papillary Serous Carcinoma (Option C):** While this is an indication, the inclusion of "Fundal involvement" makes the option less accurate than Option B. **3. NEET-PG High-Yield Pearls:** * **Low-Risk Criteria (Mayo Criteria):** Lymphadenectomy may be omitted if: Tumor is Grade 1 or 2, Size ≤2 cm, and Myometrial invasion <50%. * **Sentinel Lymph Node (SLN) Mapping:** This is the emerging standard for early-stage disease to reduce the morbidity of full dissection (e.g., lymphedema). * **Type I vs. Type II:** Type I (Endometrioid) is estrogen-dependent and has a better prognosis; Type II (Serous/Clear cell) is estrogen-independent and requires aggressive staging.

Question 359: A 56-year-old woman presents with post-menopausal bleeding. Her transvaginal scan shows an endometrial thickness of 8 mm. Endometrial biopsy shows moderately differentiated adenocarcinoma cells. Which of the following is the most appropriate staging investigation?

A. CT scan of the pelvis
B. Chest X-ray
C. MRI scan of the pelvis (Correct Answer)
D. Hysterosalpingography

Explanation: **Explanation:** The patient has been diagnosed with **Endometrial Carcinoma** (Type I, based on the histology of moderately differentiated adenocarcinoma). In endometrial cancer, the staging is primarily **surgical** (FIGO staging). However, preoperative imaging is crucial for surgical planning. **Why MRI Pelvis is the Correct Answer:** MRI with contrast is the **gold standard** for the preoperative evaluation of endometrial cancer. Its superior soft-tissue contrast allows for the accurate assessment of: 1. **Myometrial invasion:** Determining if the tumor has invaded >50% of the myometrium (Stage IA vs. IB). 2. **Cervical stromal involvement:** Identifying Stage II disease. 3. **Local extension:** Assessing for bladder or rectal involvement. This information helps the surgeon decide whether to perform a standard staging laparotomy or a more radical procedure with lymphadenectomy. **Analysis of Incorrect Options:** * **A. CT scan of the pelvis:** While useful for detecting distant metastases or gross lymphadenopathy, CT is inferior to MRI in assessing the depth of myometrial invasion. * **B. Chest X-ray:** This is a routine part of the metastatic workup to rule out lung involvement, but it is not the primary investigation for local staging of the tumor itself. * **D. Hysterosalpingography:** This is contraindicated in suspected or confirmed endometrial malignancy as it can potentially cause the transtubal spread of malignant cells. **Clinical Pearls for NEET-PG:** * **Most common symptom:** Post-menopausal bleeding (PMB). * **Cut-off for ET:** In a post-menopausal woman with bleeding, an Endometrial Thickness (ET) **>4 mm** on TVS warrants a biopsy. * **Staging System:** FIGO staging for endometrial cancer is **Surgical**. * **MRI Sequence:** Dynamic Contrast-Enhanced (DCE) MRI is the most sensitive sequence for assessing myometrial invasion.

Question 360: A patient is diagnosed with endometrial carcinoma. Based on findings of bleeding per vagina (PV) and enlarged inguinal nodes, what is the most appropriate stage?

A. Stage II
B. Stage III
C. Stage IV (Correct Answer)
D. Stage I

Explanation: **Explanation:** The staging of endometrial carcinoma follows the **FIGO 2023 (and 2009) classification**, which is primarily surgical. The presence of **enlarged inguinal nodes** is the defining clinical feature in this scenario. 1. **Why Stage IV is correct:** In endometrial cancer, lymphatic spread typically follows the pelvic and para-aortic chains. Inguinal lymph nodes are considered **distant metastases** (Stage IVB). According to FIGO staging, involvement of distant organs, including inguinal lymph nodes, intraperitoneal disease beyond the pelvis, or bone/lung metastasis, upgrades the disease to **Stage IVB**. 2. **Why other options are incorrect:** * **Stage I:** The tumor is confined to the corpus uteri (myometrial invasion <50% is IA, >50% is IB). * **Stage II:** The tumor invades the cervical stroma but does not extend beyond the uterus. * **Stage III:** This involves local or regional spread. Stage IIIA involves the serosa/adnexa; IIIB involves the vagina or parametrium; IIIC involves pelvic or para-aortic lymph nodes. Crucially, **inguinal nodes are NOT regional nodes** for the endometrium; they are distant. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of distant metastasis:** Lungs. * **Lymphatic Drainage:** The fundus drains to para-aortic nodes; the lower segment drains to pelvic nodes; however, drainage via the **round ligament** can lead to isolated inguinal node involvement. * **FIGO 2023 Update:** Note that Stage IIC now exists for aggressive histological types, but distant nodes remain Stage IVB. * **Standard Treatment:** Total Prostatic Hysterectomy + Bilateral Salpingo-oophorectomy (TAH+BSO) with lymphadenectomy.

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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