Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 361: Human papilloma virus is associated with which carcinoma?

A. Carcinoma of the cervix (Correct Answer)
B. Carcinoma of the uterus
C. Fibroids
D. None of the above

Explanation: **Explanation:** **1. Why Option A is Correct:** Human Papillomavirus (HPV) is the primary etiological agent in the development of **Cervical Carcinoma**. High-risk HPV strains (primarily **16 and 18**) produce oncoproteins **E6 and E7**. E6 binds to and degrades the **p53** tumor suppressor protein, while E7 binds to and inactivates the **Retinoblastoma (Rb)** protein. This leads to uncontrolled cell cycle progression and malignant transformation of the cervical transformation zone. **2. Why Other Options are Incorrect:** * **Option B (Carcinoma of the uterus):** Endometrial carcinoma is primarily associated with prolonged exposure to **unopposed estrogen**, metabolic syndrome (obesity, diabetes), and Lynch syndrome, rather than viral infections. * **Option C (Fibroids):** Uterine leiomyomas (fibroids) are **benign** monoclonal tumors of smooth muscle cells. Their growth is hormone-dependent (estrogen and progesterone) and not associated with HPV. **3. NEET-PG High-Yield Pearls:** * **Most Common Strains:** HPV 16 is the most common cause of Squamous Cell Carcinoma; HPV 18 is more frequently associated with Adenocarcinoma. * **Low-Risk Strains:** HPV 6 and 11 cause Genital Warts (Condyloma acuminata). * **Screening:** The primary screening tool is the Pap smear (cytology) or HPV DNA testing. * **Vaccination:** The ideal age for HPV vaccination is 9–14 years (before sexual debut). * **Other Associations:** HPV is also linked to cancers of the vulva, vagina, anus, penis, and oropharynx.

Question 362: What is the best investigation to diagnose carcinoma cervix in early stages?

A. Colposcopic biopsy
B. Aceto-white test over lesion
C. Pap smear (Correct Answer)
D. Hysteroscopy

Explanation: **Explanation:** **Correct Answer: C. Pap smear** The primary goal in diagnosing early-stage carcinoma cervix (specifically pre-invasive lesions or Stage IA) is **screening and early detection**. The Pap smear (Exfoliative Cytology) is the gold standard screening tool. It is designed to detect cytological changes (dysplasia) in asymptomatic women *before* a visible lesion develops. In the context of "early stages" and population-based diagnosis, the Pap smear is the most effective initial investigation to identify at-risk patients. **Analysis of Incorrect Options:** * **A. Colposcopic biopsy:** While a biopsy is the *confirmatory* test (Gold Standard for diagnosis), it is a secondary step. It is performed only after an abnormal Pap smear or if a lesion is clinically visible. It is not the primary investigation for early-stage detection in the general population. * **B. Aceto-white test:** This is a component of Visual Inspection with Acetic Acid (VIA) or Colposcopy. While it helps identify the transformation zone and suspicious areas, it is a subjective finding and not a definitive diagnostic investigation on its own. * **C. Hysteroscopy:** This is used to visualize the uterine cavity (endometrium). It has no role in the routine diagnosis of cervical carcinoma, which involves the ectocervix and endocervical canal. **Clinical Pearls for NEET-PG:** * **Screening Gold Standard:** Pap Smear (starts at age 21, every 3 years). * **Confirmatory Gold Standard:** Colposcopy-directed biopsy. * **Most common site for CA Cervix:** Transformation Zone (Squamocolumnar junction). * **Bethesda System:** Used for reporting Pap smear cytology. * **High-risk HPV:** Types 16 (most squamous cell CA) and 18 (most adenocarcinoma) are the primary etiological factors.

Question 363: Which tumor is associated with an increased risk of endometrial carcinoma?

A. Sertoli Leydig cell tumor
B. Immature teratoma
C. Gonadoblastoma tumor
D. Granulosa theca cell tumor (Correct Answer)

Explanation: **Explanation:** The correct answer is **Granulosa theca cell tumor**. **1. Why it is correct:** Granulosa theca cell tumors (GTCT) are the most common type of **Sex Cord-Stromal Tumors**. These tumors are functionally active and characteristically secrete high levels of **estrogen**. Chronic, unopposed estrogenic stimulation leads to endometrial hyperplasia, which can progress to **Endometrial Carcinoma** (specifically Type I endometrioid adenocarcinoma). Approximately 5–10% of women with GTCT are found to have a coexisting endometrial carcinoma, while up to 25–50% may have endometrial hyperplasia. **2. Why the other options are incorrect:** * **Sertoli-Leydig cell tumor:** These are androgen-secreting sex cord-stromal tumors. They typically cause **virilization** (hirsutism, clitoromegaly, deepening of voice) rather than estrogenic effects. * **Immature teratoma:** This is a germ cell tumor composed of tissues from all three germ layers, specifically containing immature neural elements. It is not hormonally active in a way that affects the endometrium. * **Gonadoblastoma:** This tumor usually arises in dysgenetic gonads (e.g., Turner syndrome with Y chromosome). While it can be associated with other germ cell tumors (like dysgerminoma), it does not typically secrete estrogen. **3. Clinical Pearls for NEET-PG:** * **Tumor Marker:** **Inhibin (Inhibin B)** is the most specific marker for Granulosa cell tumors. * **Histology:** Look for **Call-Exner bodies** (small follicles filled with eosinophilic material) and "coffee-bean" nuclei. * **Presentation:** In children, it causes **precocious puberty**; in postmenopausal women, it causes **postmenopausal bleeding**. * **Endometrial Biopsy:** Always mandatory in patients diagnosed with GTCT to rule out synchronous endometrial malignancy.

Question 364: Which of the following statements is true regarding carcinoma of the cervix involving the parametrium but without pelvic sidewall involvement?

A. Stage II
B. Stage IIB
C. Radiotherapy should be given (Correct Answer)
D. Hysterectomy can be useful

Explanation: **Explanation:** The clinical scenario describes cervical carcinoma with **parametrial involvement but no pelvic sidewall involvement**, which corresponds to **FIGO Stage IIB**. **1. Why "Radiotherapy should be given" is the correct answer:** According to the FIGO guidelines and NCCN protocols, the standard of care for **locally advanced cervical cancer (Stages IIB to IVA)** is **Concurrent Chemoradiotherapy (CCRT)**. Once the cancer involves the parametrium (Stage IIB), surgical margins are difficult to clear, and the risk of recurrence is high. Therefore, primary radiotherapy (External Beam Radiation + Brachytherapy) combined with weekly Cisplatin is the treatment of choice. **2. Analysis of Incorrect Options:** * **Option A (Stage II):** While technically true that it falls under Stage II, it is an incomplete classification. In competitive exams like NEET-PG, the most specific management-based answer takes precedence over broad staging categories. * **Option B (Stage IIB):** This is the correct staging, but the question asks for a "true statement" regarding the condition. In many clinical MCQ formats, if both a stage and a management plan are provided, the **definitive management** is often the intended "most true" answer, as staging is a nomenclature while radiotherapy is the clinical requirement. * **Option D (Hysterectomy can be useful):** Surgery (Radical Hysterectomy) is generally reserved for **early-stage disease (up to Stage IIA1)**. In Stage IIB, primary surgery is contraindicated because it often results in positive margins, necessitating "triple morbidity" (surgery followed by radiation and chemo). **Clinical Pearls for NEET-PG:** * **Stage IIA:** Involves upper 2/3 of the vagina (IIA1 <4cm; IIA2 >4cm). * **Stage IIB:** Parametrial involvement (The "B" stands for "Beyond" the cervix into parametria). * **Cut-off for Surgery:** Stage IIA1 is the last stage where Radical Hysterectomy (Wertheim’s) is routinely preferred. * **Most common cause of death:** Uremia due to bilateral ureteric obstruction (Stage IIIB).

Question 365: A patient complains of post-coital bleeding. On per speculum examination, no growth is seen. What is the next step in management?

A. Colposcopy with biopsy (Correct Answer)
B. Conization
C. Repeat Pap smear
D. Culdoscopy

Explanation: **Explanation:** The clinical presentation of **post-coital bleeding** is a classic "red flag" symptom for cervical pathology, most notably cervical intraepithelial neoplasia (CIN) or early-stage cervical cancer. **1. Why Colposcopy with Biopsy is correct:** In a patient with post-coital bleeding, the primary objective is to rule out malignancy. Even if the cervix appears grossly normal on per speculum examination (no visible growth), microscopic or pre-invasive lesions may still be present. **Colposcopy** allows for magnified visualization of the transformation zone, and a **directed biopsy** of any acetowhite areas or abnormal vascular patterns is the gold standard for definitive diagnosis. **2. Why other options are incorrect:** * **Conization:** This is a therapeutic or diagnostic procedure (large wedge of tissue) used when colposcopy is unsatisfactory or there is a discrepancy between cytology and biopsy. It is not the initial step. * **Repeat Pap smear:** A Pap smear is a screening tool with a significant false-negative rate. In a symptomatic patient (post-coital bleeding), one must proceed directly to a diagnostic test (colposcopy) rather than relying on screening. * **Culdoscopy:** This is an obsolete endoscopic procedure used to visualize pelvic organs through the posterior vaginal fornix; it has no role in evaluating the cervical mucosa. **Clinical Pearls for NEET-PG:** * **Most common cause of post-coital bleeding:** Cervical polyps (benign), but **Cervical Cancer** must be ruled out first. * **Management Algorithm:** Symptomatic patient → Colposcopy; Asymptomatic patient with abnormal Pap → Colposcopy. * **Transformation Zone:** This is the most common site for cervical neoplasia and the primary area of interest during colposcopy.

Question 366: Which female genital malignancy is most common in pregnancy?

A. Ovarian cancer
B. Vaginal vulvar cancer
C. Endometrial cancer
D. Cervical cancer (Correct Answer)

Explanation: **Explanation:** **Cervical cancer** is the most common gynecologic malignancy diagnosed during pregnancy, with an estimated incidence of 1 to 10 per 10,000 pregnancies. The primary reason for this is the **overlap in age demographics**: the peak incidence of cervical intraepithelial neoplasia (CIN) and early-stage cervical cancer coincides with the peak reproductive years of women. Furthermore, routine prenatal care involves a pelvic examination and often a Pap smear, leading to increased detection of asymptomatic cases. **Analysis of Incorrect Options:** * **Ovarian Cancer (Option A):** This is the second most common gynecologic malignancy in pregnancy. While adnexal masses are frequently discovered on routine prenatal ultrasound, the majority are functional cysts or benign dermoids rather than malignancies. * **Vaginal/Vulvar Cancer (Option B):** These are extremely rare in pregnancy as they typically affect older, postmenopausal women. * **Endometrial Cancer (Option C):** This is virtually incompatible with pregnancy. Endometrial cancer usually occurs in an environment of unopposed estrogen and thickened endometrium, which is physiologically inconsistent with the hormonal state and decidualization required for a successful pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common overall cancer in pregnancy:** Breast cancer (followed by cervical cancer and melanoma). * **Diagnosis:** Colposcopy is safe during pregnancy, but **endocervical curettage (ECC) is strictly contraindicated** due to the risk of membrane rupture and hemorrhage. * **Management:** For early-stage disease diagnosed in the first trimester, treatment can often be delayed until fetal maturity if the patient desires to continue the pregnancy, provided there is close monitoring. * **Mode of Delivery:** Vaginal delivery is generally contraindicated in visible cervical lesions due to the risk of massive hemorrhage and potential tumor cell seeding in the episiotomy site; Cesarean section is the preferred route.

Question 367: Which of the following is a risk factor for cervical cancer?

A. Human Papillomavirus (HPV) infection (Correct Answer)
B. Smoking
C. Late menarche
D. Nulliparity

Explanation: **Explanation:** **Correct Option: A. Human Papillomavirus (HPV) infection** HPV infection is the most significant and necessary causative factor for the development of cervical cancer. High-risk strains, specifically **HPV 16 and 18**, are responsible for approximately 70% of cases worldwide. The virus integrates into the host genome, where its oncoproteins **E6 and E7** inhibit tumor suppressor proteins **p53 and Rb**, respectively. This leads to uncontrolled cell proliferation and the progression of Cervical Intraepithelial Neoplasia (CIN) to invasive carcinoma. **Analysis of Incorrect Options:** * **B. Smoking:** While smoking is a recognized co-factor that doubles the risk of squamous cell carcinoma of the cervix (by concentrating nicotine in cervical mucus and depleting Langerhans cells), it is secondary to HPV infection. In the context of this question, HPV is the primary etiological agent. * **C. Late menarche:** Early menarche and late menopause are risk factors for estrogen-dependent cancers (Endometrial and Breast). They are not significantly associated with cervical cancer. * **D. Nulliparity:** Nulliparity is a risk factor for Endometrial and Ovarian cancers. Conversely, **high parity** (multiple births) is a known risk factor for cervical cancer due to hormonal changes and cervical trauma during delivery. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous cell carcinoma (80-85%). * **Screening:** Pap smear (cytology) and HPV DNA testing. The "Transformation Zone" is the most common site of origin. * **Vaccination:** The ideal age for HPV vaccination (e.g., Gardasil-9) is 9–14 years, before the onset of sexual activity. * **Other Risk Factors:** Early age at first intercourse, multiple sexual partners, and immunosuppression (HIV).

Question 368: All of the following are true about Krukenberg's tumor except?

A. Has a rough surface (Correct Answer)
B. Shape of ovary is maintained
C. Usually bilateral
D. Arises usually from stomach carcinoma

Explanation: **Explanation:** Krukenberg tumor is a metastatic signet-ring cell carcinoma of the ovary, most commonly originating from a primary site in the gastrointestinal tract. **Why Option A is the correct answer (The Exception):** Krukenberg tumors are characterized by a **smooth, bosselated (knobby) surface**. The capsule remains intact, and the tumor does not typically show surface adhesions or a "rough" texture unless there is extensive peritoneal carcinomatosis. Therefore, the statement that it has a rough surface is incorrect. **Analysis of Incorrect Options:** * **Option B (Shape maintained):** Despite significant enlargement, the tumor typically replaces the ovarian stroma while preserving the overall **kidney-shaped or ovoid contour** of the ovary. * **Option C (Usually bilateral):** In over **80% of cases**, Krukenberg tumors are bilateral. This is a hallmark feature of metastatic ovarian tumors compared to primary epithelial ovarian tumors, which are more often unilateral. * **Option D (Arises from stomach):** The most common primary site is the **stomach (pylorus)**, followed by the colon, breast, and appendix. The spread occurs via retrograde lymphatic dissemination. **High-Yield Clinical Pearls for NEET-PG:** * **Microscopy:** Characterized by **signet-ring cells** (mucin-filled cytoplasm displacing the nucleus to the periphery) and dense stromal hyperplasia. * **Primary vs. Secondary:** If a signet-ring cell tumor is found in the ovary, a gastroscopy/colonoscopy is mandatory to find the primary. * **Age:** Often affects younger women compared to primary ovarian cancer, frequently presenting during the reproductive years. * **Diagnosis:** Immunohistochemistry (IHC) typically shows **CK7 negative and CK20 positive** if the primary is colorectal, or **CK7 positive** if the primary is gastric.

Question 369: Why is conventional cytogenetics difficult in solid tumors, particularly in carcinoma of the cervix?

A. High mitotic rate
B. Bacterial contamination of the specimen (Correct Answer)
C. Poor metaphase activity
D. All of the above

Explanation: **Explanation:** Conventional cytogenetics (karyotyping) requires the culture of live cells to obtain metaphase spreads. In the context of solid tumors, particularly **carcinoma of the cervix**, this process faces unique challenges. **Why Option B is Correct:** The cervix is an anatomically "non-sterile" site, naturally colonized by vaginal flora. Furthermore, cervical malignancies are often bulky, exophytic, and prone to necrosis and ulceration. These necrotic areas are heavily contaminated with **bacteria and fungi**. When these tissues are placed in a culture medium for cytogenetic analysis, the microorganisms grow much faster than the tumor cells, leading to culture overgrowth and failure of the specimen. **Analysis of Incorrect Options:** * **A. High mitotic rate:** This is actually a *desirable* feature for cytogenetics. A high mitotic rate provides more cells in the metaphase stage, making it easier to visualize chromosomes. * **C. Poor metaphase activity:** While some slow-growing tumors have poor metaphase activity, cervical cancer generally has a high proliferative index. The primary barrier is not the lack of activity, but the inability to reach the analysis stage due to contamination. **NEET-PG High-Yield Pearls:** * **Alternative Technique:** Because of the difficulties with conventional cytogenetics in solid tumors, **FISH (Fluorescence In Situ Hybridization)** or **CGH (Comparative Genomic Hybridization)** are often preferred as they do not always require live cell cultures. * **Cervical Cancer Genetics:** The most common genetic alterations involve the integration of **HPV 16/18 DNA** into the host genome, specifically affecting the **E6 (inhibits p53)** and **E7 (inhibits Rb)** proteins. * **Specimen Handling:** To minimize contamination in solid tumors, samples should be taken from the viable "leading edge" of the tumor rather than the necrotic center.

Question 370: Which of the following statements regarding choriocarcinoma is true?

A. It has the worst prognosis.
B. The treatment of choice is hysterectomy.
C. Lung metastasis can cause hemoptysis. (Correct Answer)
D. Radiotherapy is the preferred treatment.

Explanation: **Explanation:** **Choriocarcinoma** is a highly malignant, epithelial tumor arising from chorionic villi. It is characterized by the absence of villi and the presence of sheets of anaplastic syncytiotrophoblasts and cytotrophoblasts. **1. Why Option C is Correct:** Choriocarcinoma is a highly vascular tumor that spreads primarily via the **hematogenous route**. The **lungs** are the most common site of metastasis (80%). These metastatic lesions are often hemorrhagic; when they erode into the bronchial tree, they present clinically as cough, dyspnea, or **hemoptysis**. On a chest X-ray, these typically appear as "cannonball metastases." **2. Why Other Options are Incorrect:** * **Option A:** While aggressive, choriocarcinoma is considered one of the most **curable** cancers due to its extreme sensitivity to chemotherapy. It does not have the "worst" prognosis compared to other gestational trophoblastic neoplasias (GTN) like Placental Site Trophoblastic Tumor (PSTT), which is chemoresistant. * **Option B & D:** The primary treatment for choriocarcinoma is **chemotherapy** (e.g., Methotrexate for low-risk or EMA-CO regimen for high-risk). Surgery (Hysterectomy) and Radiotherapy are generally reserved for chemoresistant cases or localized complications (e.g., uncontrollable uterine hemorrhage). **Clinical Pearls for NEET-PG:** * **Tumor Marker:** Serum **beta-hCG** is the most sensitive marker for diagnosis and monitoring. * **Common Sites of Metastasis:** Lungs (80%) > Vagina (30%) > Pelvis (20%) > Liver (10%) > Brain (10%). * **Vaginal Metastasis:** Often presents as highly vascular, "purplish" nodules; biopsy should be avoided due to the risk of torrential hemorrhage. * **FIGO Staging:** Uses the WHO Prognostic Scoring System to categorize patients into Low-risk (<7) or High-risk (≥7).

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

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Radiation Therapy in Gynecologic Malignancies

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Chemotherapy in Gynecologic Oncology

Practice Questions

Palliative Care in Gynecologic Oncology

Practice Questions

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