Gynecologic Oncology Practice Questions

Q: Which of the following tests detects the presence of glycogen in the superficial cells of the vaginal epithelium?

Schiller Test. ### Explanation **Correct Answer: B. Schiller Test** The **Schiller Test** is a clinical diagnostic tool used to identify suspicious areas on the cervix. It relies on the principle that **mature, healthy squamous epithelium** of the cervix and vagina contains high levels of **glycogen**. * **Mechanism:** When Lugol’s iodine (aqueous iodine) is applied to the cervix, the iodine reacts with glycogen to produce a deep mahogany brown color (**Iodine-positive**). * **Clinical Significance:** Precancerous cells (CIN) and cancerous cells are metabolically active and lack glycogen; therefore, they do not take up the stain and appear pale or yellowish (**Iodine-negative**). These "Schiller-positive" (unstained) areas are then targeted for biopsy. **Why other options are incorrect:** * **A. Pap Smear:** This is a cytological screening test used to detect cellular atypia or malignancy by examining exfoliated cells under a microscope. It does not specifically test for glycogen presence. * **C. Benzidine Test:** This is a chemical test used to detect the presence of **occult blood** (hemoglobin). It is not used in cervical screening. * **D. Seliwanoff's Test:** This is a biochemical test used to distinguish between aldose and **ketose sugars** (specifically detecting fructose). **High-Yield Pearls for NEET-PG:** * **Lugol’s Iodine Composition:** 5% Iodine and 10% Potassium Iodide in distilled water. * **VIA/VILI:** Visual Inspection with Acetic Acid (VIA) and Visual Inspection with Lugol's Iodine (VILI) are low-cost screening alternatives to Pap smears in resource-limited settings. * **False Positives:** Inflammatory conditions, atrophy (menopause), and columnar epithelium (ectropion) also lack glycogen and may appear iodine-negative, mimicking malignancy.

Q: A 55-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal examination reveal the parametrium is free of disease but the upper part of the vagina is involved with tumor. Intravenous pyelogram and sigmoidoscopy are negative, but a CT scan of the abdomen and pelvis shows grossly enlarged pelvic and para-aortic nodes. Thus, the patient is classified as Stage:

IIa. ### Explanation The staging of cervical cancer is primarily based on the **FIGO Staging System**. In this case, the patient is classified as **Stage IIa** based on the clinical findings of vaginal involvement without parametrial extension. **1. Why Stage IIa is Correct:** According to FIGO staging, **Stage II** involves the tumor extending beyond the uterus but not to the pelvic wall or the lower third of the vagina. * **Stage IIa:** Involvement of the upper two-thirds of the vagina without parametrial involvement. * **Stage IIb:** Involvement of the parametrium. Since the pelvic/rectal exam confirms the parametrium is free but the upper vagina is involved, it fits the criteria for IIa. **2. Why the other options are incorrect:** * **Stage IIb:** Incorrect because the clinical exam specifically stated the parametrium is free of disease. * **Stage IIIa:** Incorrect because this stage requires involvement of the **lower third** of the vagina. * **Stage IIIb:** Incorrect because this involves extension to the pelvic wall and/or causes hydronephrosis/non-functioning kidney (IVP was negative here). **3. The "CT Scan" Trap (High-Yield Concept):** A crucial point for NEET-PG is that FIGO staging for cervical cancer was traditionally **clinical**. While the 2018 FIGO update allows imaging (CT/MRI) to assign a stage (Stage IIIC for nodal involvement), many exam questions still test the classic clinical staging rules or specific anatomical extensions. In the context of this classic question, **lymph node status on CT does not change the T-stage (local extension)** unless specifically asked for the 2018 IIIC revision. **Clinical Pearls for NEET-PG:** * **Stage IIa1:** Lesion ≤ 4 cm. * **Stage IIa2:** Lesion > 4 cm. * **Most common site of spread:** Direct extension (lateral into parametrium). * **Investigation of choice for staging (2018):** MRI is preferred for local tumor extent; PET-CT for nodal/distant spread.

Q: A 23-year-old pregnant woman at 16 weeks gestation presents with vaginal spotting. Her uterus is enlarged to 28 weeks' size, and no fetal heart sounds are audible with a fetal Doppler. Her serum human chorionic gonadotropin (hCG) levels are 100,000 mIU/mL. Which of the following tests is most appropriate at this time?

Pelvic ultrasound. **Explanation:** The clinical presentation of a **size-greater-than-dates** uterus (28 weeks size at 16 weeks gestation), vaginal spotting, and absent fetal heart sounds is highly suggestive of a **Gestational Trophoblastic Disease (GTD)**, specifically a Hydatidiform Mole. **1. Why Pelvic Ultrasound is the Correct Answer:** Pelvic ultrasound is the **gold standard investigation** for diagnosing a molar pregnancy. It will typically reveal a characteristic **"snowstorm appearance"** (multiple echogenic areas representing hydropic villi) and the absence of a fetus in a complete mole. It is the most appropriate next step to confirm the diagnosis before proceeding to management (suction evacuation). **2. Analysis of Incorrect Options:** * **Serial clotting function studies (A):** While disseminated intravascular coagulation (DIC) can occur in molar pregnancies, it is not the primary diagnostic tool. These are done pre-operatively, not as the initial diagnostic test. * **Serial hCG estimation (C):** A single high hCG value is suggestive, but not diagnostic, as high levels can also be seen in multiple pregnancies. Serial hCG is crucial for **post-evacuation follow-up** to monitor for malignant transformation (Gestational Trophoblastic Neoplasia), but not for the initial diagnosis. * **Apt test (D):** This test is used to differentiate fetal blood from maternal blood (e.g., in suspected vasa previa). It has no role in diagnosing GTD. **Clinical Pearls for NEET-PG:** * **Most common symptom of Molar Pregnancy:** Vaginal bleeding. * **Most common sign:** Size > Dates (seen in ~50% of cases). * **Theca Lutein Cysts:** Often seen bilaterally on ultrasound due to very high hCG levels. * **Treatment of choice:** Suction and Evacuation (regardless of uterine size). * **HCG levels:** Usually >100,000 mIU/mL, but the definitive diagnosis is always radiological (USG) and confirmed by histopathology.

Q: What is the primary treatment for early-stage vulvar carcinoma?

Surgery. **Explanation:** **Surgery** is the primary treatment for early-stage vulvar carcinoma (Stage I and II). The goal is to achieve a wide local excision with at least 1 cm of tumor-free margins. For lesions with a depth of invasion >1 mm, surgical evaluation of the groin nodes (via Sentinel Lymph Node Biopsy or Inguinal-femoral Lymphadenectomy) is mandatory, as nodal status is the most important prognostic factor. **Why other options are incorrect:** * **Radiotherapy (A):** While vulvar cancer is radiosensitive, radiation is typically reserved as adjuvant therapy for positive margins, multiple positive nodes, or extracapsular spread. It may be used as primary therapy only in advanced cases where surgery is disfiguring. * **Chemotherapy (B):** Systemic chemotherapy alone is not curative for vulvar cancer. It is primarily used as a radiosensitizer or for palliative management in metastatic disease. * **Chemoradiation (D):** This is the standard of care for **locally advanced** disease (Stage III/IV) to shrink the tumor before surgery or as definitive treatment when the tumor involves the anus, urethra, or bladder. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (90%). * **Staging:** Vulvar cancer is staged **surgically** (FIGO). * **Lymphatic Spread:** Follows a predictable pattern: Superficial inguinal → Deep inguinal → Cloquet’s node → External iliac nodes. * **Sentinel Lymph Node Biopsy (SLNB):** Indicated for unifocal lesions <4 cm with clinically negative nodes.

Q: Which of the following is the treatment of choice for choriocarcinoma in a middle-aged woman?

Chemotherapy. **Explanation:** Choriocarcinoma is a highly malignant, epithelial tumor arising from the chorionic villi. It is classified as a **Gestational Trophoblastic Neoplasia (GTN)**. **1. Why Chemotherapy is the Correct Answer:** Choriocarcinoma is uniquely characterized by its extreme sensitivity to cytotoxic drugs. Even in cases of widespread metastasis (e.g., to the lungs or brain), it remains highly curable with chemotherapy. It is one of the few solid tumors where chemotherapy is the **primary and definitive treatment**, regardless of the patient's age. Treatment is stratified based on the FIGO/WHO scoring system: * **Low-risk:** Single-agent chemotherapy (usually Methotrexate or Actinomycin-D). * **High-risk:** Multi-agent chemotherapy (EMA-CO regimen). **2. Why Other Options are Incorrect:** * **A. Dilatation and Evacuation:** While D&E is the treatment of choice for *Hydatidiform Mole*, it is contraindicated in choriocarcinoma due to the high risk of uterine perforation and severe hemorrhage, as the tumor is highly vascular and invasive. * **B. Hysterectomy:** Surgery is generally not the primary treatment because the disease is systemic. However, it may be considered as an *adjuvant* therapy in older women who have completed their family to reduce tumor burden or in cases of chemoresistance/uncontrolled uterine bleeding. * **C. Radiotherapy:** Choriocarcinoma is primarily a chemo-sensitive disease. Radiotherapy has a very limited role, reserved occasionally for brain or liver metastases. **Clinical Pearls for NEET-PG:** * **Tumor Marker:** Serum **β-hCG** is the most sensitive marker for diagnosis and monitoring. * **Common Site of Metastasis:** The **Lungs** (presents as "cannon-ball" appearances on X-ray). * **Diagnosis:** Unlike other cancers, choriocarcinoma is often diagnosed based on elevated β-hCG levels and clinical findings; **biopsy is generally avoided** due to the risk of life-threatening hemorrhage.

Q: The worst prognosis in patients with endometrial carcinoma is found in patients with tumour involvement of which of the following structures?

Bladder mucosa. **Explanation:** The prognosis of endometrial carcinoma is primarily determined by the **FIGO Staging system**. The involvement of the bladder mucosa represents **Stage IVA** disease, indicating direct extension of the tumor beyond the true pelvis to adjacent organs. **Why Bladder Mucosa is the Correct Answer:** According to the FIGO staging for endometrial cancer: * **Stage I:** Confined to the corpus uteri. * **Stage II:** Invades cervical stroma. * **Stage III:** Local/regional spread (Vagina, Parametrium, Lymph nodes). * **Stage IV:** Distant metastasis or involvement of the **bladder/bowel mucosa**. Involvement of the bladder mucosa (Stage IVA) signifies advanced, extragenital spread, which carries a significantly higher risk of mortality and a lower 5-year survival rate compared to tumors confined to the pelvic reproductive organs. **Analysis of Incorrect Options:** * **Uterine Cervix (Stage II):** This indicates cervical stromal invasion. While it carries a worse prognosis than Stage I, it is still considered "locoregional" and is surgically resectable. * **Upper Vagina (Stage IIIB):** This represents vaginal or parametrial involvement. While advanced, it is still staged lower than Stage IV. * **Parametrium (Stage IIIB):** Similar to vaginal involvement, this indicates spread within the true pelvis but does not carry the grave prognosis associated with mucosal organ invasion or distant metastasis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Endometrioid adenocarcinoma (Type I). * **Most common site of distant metastasis:** Lungs. * **Staging Method:** Endometrial cancer is **surgically staged** (unlike Cervical cancer, which is clinically staged). * **Prognostic Hierarchy:** Stage IV (Bladder/Bowel) > Stage III (Adnexa/Vagina/Nodes) > Stage II (Cervix) > Stage I (Uterus).

Q: A 28-year-old female presents with a history of oligomenorrhea. On examination, she has hirsutism and virilization. Ultrasound shows an enlarged left ovary. Her testosterone level is 4 ng/ml, and LH levels are normal. What is the most probable diagnosis?

Ovarian tumor. ### Explanation The key to solving this clinical scenario lies in the **severity of androgen excess** and the **testosterone levels**. **1. Why "Ovarian Tumor" is correct:** In a female, the normal range for serum testosterone is approximately **0.2–0.8 ng/ml**. A testosterone level **>2 ng/ml** is a critical "red flag" that strongly suggests an androgen-secreting tumor (either ovarian or adrenal). Clinical signs of **virilization** (clitoromegaly, deepening of voice, male-pattern baldness) further differentiate a tumor from functional disorders like PCOS. The presence of an **enlarged left ovary** on ultrasound points specifically toward a Sertoli-Leydig cell tumor or a Hilus cell tumor. **2. Why other options are incorrect:** * **PCOS:** While PCOS causes oligomenorrhea and hirsutism, it rarely causes **virilization**. Testosterone levels in PCOS are typically mildly elevated ( 2:1), which is not the case here. * **Ovarian Stromal Hyperthecosis:** This condition can cause virilization and high testosterone in postmenopausal women. However, it usually presents with bilateral ovarian involvement and is less common in a 28-year-old compared to a neoplastic process. * **Luteoma of Pregnancy:** This is a benign tumor-like condition that occurs only during pregnancy. There is no mention of pregnancy in the history. **3. NEET-PG High-Yield Pearls:** * **Testosterone >2 ng/ml:** Suspect Ovarian Tumor (e.g., Sertoli-Leydig cell tumor). * **DHEAS >7000 ng/ml:** Suspect Adrenal Tumor. * **Rapid onset** of symptoms + **Virilization** = Neoplastic etiology. * **Sertoli-Leydig Cell Tumor:** The most common virilizing ovarian tumor; often presents with Reinke crystals on histology (if it's a Hilus cell tumor).

Question 1

Which of the following tests detects the presence of glycogen in the superficial cells of the vaginal epithelium?

Accepted Answer

Schiller Test

Answer

Pap smear

Answer

Benzidine Test

Answer

Seliwanoff's Test

Question 2

A 55-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal examination reveal the parametrium is free of disease but the upper part of the vagina is involved with tumor. Intravenous pyelogram and sigmoidoscopy are negative, but a CT scan of the abdomen and pelvis shows grossly enlarged pelvic and para-aortic nodes. Thus, the patient is classified as Stage:

Accepted Answer

IIa

Answer

IIb

Answer

IIIa

Answer

IIIb

Question 3

Which of the following is an indication for colposcopy?

Accepted Answer

Suspicious Pap smear

Answer

Obvious mass seen

Answer

Suspected invasive carcinoma

Answer

Patient who refuses biopsy

Question 4

A 23-year-old pregnant woman at 16 weeks gestation presents with vaginal spotting. Her uterus is enlarged to 28 weeks' size, and no fetal heart sounds are audible with a fetal Doppler. Her serum human chorionic gonadotropin (hCG) levels are 100,000 mIU/mL. Which of the following tests is most appropriate at this time?

Accepted Answer

Pelvic ultrasound

Answer

Serial clotting function studies

Answer

Serial hCG estimation

Answer

Apt test on vaginal blood

Question 5

What is the primary treatment for early-stage vulvar carcinoma?

Accepted Answer

Surgery

Answer

Radiotherapy

Answer

Chemotherapy

Answer

Chemoradiation

Question 6

A 30-year-old female complains of vaginal bleeding for 2 weeks. Ultrasound scanning reveals a diagnosis of hydatidiform mole. Suction evacuation is performed, and histopathological examination of curettings confirms a complete hydatidiform mole. What is the most appropriate next step in management?

Accepted Answer

Monitor serum beta-hCG levels weekly until they become negative.

Answer

Administer intramuscular methotrexate daily for 5 days.

Answer

Perform hysterectomy.

Answer

Perform repeat curettage after 2 weeks.

Question 7

A patient undergoes laparotomy for an ovarian tumor. Findings include a unilateral ovarian tumor with ascites positive for malignant cells and positive pelvic lymph nodes. All other structures are free of disease. What is the stage of her disease?

Accepted Answer

Stage II c

Answer

Stage III a

Answer

Stage III b

Answer

Stage III c

Question 8

Which of the following is the treatment of choice for choriocarcinoma in a middle-aged woman?

Accepted Answer

Chemotherapy

Answer

Dilatation and evacuation

Answer

Hysterectomy

Answer

Radiotherapy

Question 9

The worst prognosis in patients with endometrial carcinoma is found in patients with tumour involvement of which of the following structures?

Accepted Answer

Bladder mucosa

Answer

Uterine cervix

Answer

Upper vagina

Answer

Parametrium

Question 10

A 28-year-old female presents with a history of oligomenorrhea. On examination, she has hirsutism and virilization. Ultrasound shows an enlarged left ovary. Her testosterone level is 4 ng/ml, and LH levels are normal. What is the most probable diagnosis?

Accepted Answer

Ovarian tumor

Answer

Polycystic Ovary Syndrome (PCOS)

Answer

Ovarian stromal hyperthecosis

Answer

Luteoma of pregnancy

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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