Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 371: Mucinous cystadenoma of the ovary arises from which of the following?

A. Cystic teratoma
B. Surface coelomic epithelium (Correct Answer)
C. Sex cord stromal cells
D. Ectopic mucin secreting glands

Explanation: **Explanation:** **1. Why Option B is Correct:** Ovarian tumors are classified based on their tissue of origin. **Surface Epithelial-Stromal Tumors** are the most common type of ovarian neoplasms (65–70%) and arise from the **surface coelomic epithelium** (mesothelium) covering the ovary. Through a process of metaplasia, this epithelium transforms into various types of Müllerian-like epithelium: * **Serous:** Resembles fallopian tube lining. * **Mucinous:** Resembles endocervical or intestinal lining. * **Endometrioid:** Resembles endometrium. Therefore, Mucinous Cystadenoma is a benign surface epithelial tumor characterized by multiloculated cysts lined by mucin-secreting cells. **2. Why Other Options are Incorrect:** * **Option A (Cystic Teratoma):** This is a **Germ Cell Tumor**. While a teratoma can rarely contain mucinous elements (or even give rise to a mucinous tumor), the primary and most common origin for mucinous cystadenomas is the surface epithelium. * **Option C (Sex Cord Stromal Cells):** These give rise to tumors like Granulosa cell tumors, Sertoli-Leydig tumors, and Fibromas. They do not produce mucinous epithelial structures. * **Option D (Ectopic Mucin Secreting Glands):** There are no "ectopic glands" naturally present in the ovary that serve as a standard origin for these tumors; the pathology is driven by metaplasia of the surface epithelium. **3. NEET-PG High-Yield Pearls:** * **Gross Appearance:** Mucinous cystadenomas are often **massive** (can fill the entire abdomen) and are typically **unilateral** (95%). * **Microscopy:** Lined by a single layer of tall columnar cells with apical mucin and basal nuclei. * **Complication:** Rupture of a mucinous tumor (usually malignant/borderline) can lead to **Pseudomyxoma Peritonei** ("Jelly Belly"). * **Marker:** CA-125 is the general marker for epithelial tumors, but it is less specific for mucinous types compared to serous tumors.

Question 372: The HPV vaccine Cervarix is protective against which subtypes?

A. 6 and 11
B. 6 and 18
C. 16 and 18 (Correct Answer)
D. 6, 11, 16 and 18

Explanation: **Explanation:** The correct answer is **C (16 and 18)**. Cervarix is a **bivalent vaccine** specifically designed to target the two most common high-risk Human Papillomavirus (HPV) genotypes. HPV 16 and 18 are responsible for approximately 70% of all cervical cancer cases globally. By utilizing recombinant DNA technology to produce virus-like particles (VLPs) of the L1 capsid protein, the vaccine induces high titers of neutralizing antibodies against these specific oncogenic strains. **Analysis of Options:** * **Option A (6 and 11):** These are low-risk HPV types primarily responsible for 90% of genital warts (Condyloma acuminata) but are not targeted by the bivalent vaccine. * **Option B (6 and 18):** This is an incorrect combination. While 18 is high-risk, 6 is low-risk. No current vaccine targets only these two. * **Option D (6, 11, 16, and 18):** This describes the **Quadrivalent vaccine (Gardasil)**. While it covers 16 and 18, it also includes 6 and 11 to prevent genital warts. **High-Yield Clinical Pearls for NEET-PG:** * **Types of Vaccines:** * **Bivalent (Cervarix):** 16, 18. * **Quadrivalent (Gardasil):** 6, 11, 16, 18. * **Nonavalent (Gardasil 9):** 6, 11, 16, 18, 31, 33, 45, 52, 58. * **Dosage Schedule:** For ages 9–14 years, a **2-dose schedule** (0 and 6 months) is recommended. For those 15 years and older or immunocompromised, a **3-dose schedule** (0, 1–2, and 6 months) is required. * **Target Age:** The ideal age for administration is 9–13 years (before sexual debut). * **Adjuvant:** Cervarix uses the **AS04 adjuvant** system, which enhances the immune response compared to standard aluminum salts.

Question 373: Which of the following is NOT associated with a high risk of ovarian cancer?

A. Endometriosis
B. Smoking
C. Obesity
D. Multiparity (Correct Answer)

Explanation: ### Explanation The correct answer is **Multiparity**. **1. Why Multiparity is the Correct Answer:** Multiparity is a **protective factor** against ovarian cancer. The underlying medical concept is the **"Incessant Ovulation" theory**. Each ovulation causes minor trauma to the ovarian surface epithelium, necessitating repair and increasing the risk of genetic mutations. Pregnancy and lactation suppress ovulation, providing the ovaries with "rest." Therefore, more pregnancies (multiparity) lead to fewer lifetime ovulations, significantly reducing the risk of epithelial ovarian cancer. **2. Why the Other Options are Wrong:** * **Endometriosis (Option A):** This is a known risk factor, specifically for **Clear Cell** and **Endometrioid** carcinomas. The chronic inflammatory environment and oxidative stress within endometriotic cysts (chocolate cysts) promote malignant transformation. * **Smoking (Option B):** While not strongly linked to all types, smoking is a significant risk factor for **Mucinous ovarian cancer**. * **Obesity (Option C):** A high BMI is associated with an increased risk of several cancers, including ovarian. This is likely due to chronic low-grade inflammation and increased peripheral conversion of androgens to estrone in adipose tissue. **3. NEET-PG High-Yield Clinical Pearls:** * **Most Protective Factor:** Combined Oral Contraceptive Pills (OCPs) reduce the risk by ~50% if used for 5+ years. * **Genetic Risk:** BRCA1 (40% lifetime risk) and BRCA2 (15-20% lifetime risk) are the strongest genetic predictors. * **Lynch Syndrome (HNPCC):** Associated with an increased risk of ovarian, endometrial, and colon cancers. * **Protective Factors:** Multiparity, OCPs, Breastfeeding, Salpingectomy, and Tubal Ligation. * **Risk Factors:** Nulliparity, Early menarche, Late menopause, HRT, and Family history.

Question 374: What is the stage of choriocarcinoma with lung metastasis?

A. Stage 1
B. Stage 3 (Correct Answer)
C. Stage 2
D. Stage 4

Explanation: The staging of Gestational Trophoblastic Neoplasia (GTN), which includes choriocarcinoma, follows the **FIGO Staging System**. This system is primarily anatomical and is crucial for determining prognosis and treatment protocols. ### **Explanation of the Correct Answer** * **Option B (Stage 3):** According to FIGO staging, **Stage 3** is defined as the involvement of the **lungs**, with or without genital tract involvement (vagina, uterus, or adnexa). Lung metastasis is the most common site of distant spread in choriocarcinoma, usually occurring via the hematogenous route. ### **Explanation of Incorrect Options** * **Option A (Stage 1):** The disease is strictly confined to the **uterus**. There is no spread to the adnexa or distant sites. * **Option C (Stage 2):** The tumor extends outside the uterus but is limited to the **genital structures** (adnexa, vagina, or broad ligament). It has not yet reached the lungs or other distant organs. * **Option D (Stage 4):** This represents advanced metastatic disease involving **other distant sites** such as the liver, brain, or kidneys. ### **High-Yield Clinical Pearls for NEET-PG** * **WHO Scoring System:** Staging is always followed by the **WHO Prognostic Scoring (Modified FIGO Scoring)**. A score of **0–6** is Low Risk (treated with single-agent chemotherapy like Methotrexate), while a score of **≥7** is High Risk (requires multi-agent chemotherapy like EMA-CO). * **Commonest Site of Metastasis:** Lungs (80%), followed by the vagina (30%). * **Radiology:** Lung metastases often appear as "cannonball" or "snowstorm" opacities on a chest X-ray. * **Tumor Marker:** Serum **beta-hCG** is the primary marker for diagnosis, staging, and monitoring treatment response.

Question 375: A 40-year-old female presents with abnormal cervical cytology, with a Pap smear suggestive of CIN 3. What is the next step in management?

A. Test for HPV and follow up after 3 months
B. Colposcopy and biopsy (Correct Answer)
C. Hysterectomy
D. Surgery with adjuvant chemoradiation

Explanation: **Explanation:** The management of abnormal cervical cytology follows the principle of **"See and Treat"** or the diagnostic triad of Cytology, Colposcopy, and Histopathology. 1. **Why Option B is Correct:** CIN 3 (Cervical Intraepithelial Neoplasia Grade 3) is a high-grade squamous intraepithelial lesion (HSIL). A Pap smear is merely a screening tool and is not diagnostic. Therefore, any high-grade abnormality on cytology must be confirmed by **Colposcopy-directed biopsy**. This is the "Gold Standard" to determine the actual histological grade of the lesion and to rule out invasive malignancy before definitive treatment is planned. 2. **Why Other Options are Incorrect:** * **Option A:** HPV testing and follow-up are appropriate for low-grade lesions (like ASC-US) or as part of co-testing. For a high-grade lesion like CIN 3, delaying diagnosis by 3 months is contraindicated due to the high risk of progression to invasive cancer. * **Option C:** Hysterectomy is an over-treatment for CIN 3. The standard treatment for confirmed CIN 3 is a fertility-sparing excisional procedure like **LEEP** (Loop Electrosurgical Excision Procedure) or **Cold Knife Conization**. Hysterectomy is only considered if there are other uterine indications or if margins remain positive after conization. * **Option D:** Surgery with chemoradiation is the management for advanced invasive cervical cancer, not for a pre-invasive intraepithelial lesion. **High-Yield Clinical Pearls for NEET-PG:** * **CIN 1:** Usually managed by observation (repeat Pap in 1 year) as most regress spontaneously. * **CIN 2/3:** Requires treatment (Ablation or Excision). * **Bethesda System:** CIN 2 and CIN 3 are collectively categorized as **HSIL** (High-grade Squamous Intraepithelial Lesion). * **Transformation Zone:** The most common site for cervical cancer; this area must be visualized during colposcopy for the exam to be considered "satisfactory."

Question 376: Which of the following patients presenting for routine gynecological examination in the OPD does NOT require a Pap smear, given that none have had cervical cancer screening in the past 5 years?

A. A 35-year-old woman
B. A 60-year-old woman
C. A 28-year-old woman vaccinated for HPV
D. A 19-year-old sexually active woman (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. A 19-year-old sexually active woman.** According to current international guidelines (ACOG, ASCCP) and standard oncological protocols, cervical cancer screening should **begin at age 21**, regardless of the age of sexual debut. In women younger than 21, the prevalence of HPV is high, but the immune system usually clears the infection spontaneously. Screening this age group leads to unnecessary procedures (colposcopies/biopsies) for transient lesions that would have regressed naturally, causing potential harm like cervical insufficiency. **Analysis of Options:** * **Option A (35-year-old):** Screening is mandatory for women aged 21–65. Between ages 30–65, the preferred method is co-testing (Pap + HPV DNA) every 5 years or Pap alone every 3 years. * **Option B (60-year-old):** Screening continues until age 65. Since she hasn't been screened in 5 years, she requires a smear to ensure she meets the criteria to "exit" screening (3 consecutive negative Paps or 2 negative co-tests). * **Option C (28-year-old):** HPV vaccination does **not** change screening protocols. Vaccines do not protect against all oncogenic HPV types; therefore, vaccinated women must follow the same screening schedule as unvaccinated women. **High-Yield Clinical Pearls for NEET-PG:** * **Start Age:** 21 years (regardless of sexual activity). * **End Age:** 65 years (if adequate prior screening is documented). * **Post-Hysterectomy:** Screening is discontinued if the hysterectomy was for benign reasons and the cervix was removed. If the cervix remains (Supracervical Hysterectomy), screening continues. * **HIV/Immunocompromised:** Screening starts at the time of diagnosis/onset of sexual activity and is performed more frequently (annually).

Question 377: What is the treatment of choice in a 56-year-old woman with endometrial cancer?

A. Irradiation
B. Wertheim's hysterectomy
C. Panhysterectomy (Correct Answer)
D. Irradiation and later panhysterectomy

Explanation: ### Explanation **Correct Answer: C. Panhysterectomy** In endometrial cancer, the primary treatment modality is surgical. For the majority of patients, the standard of care is a **Total Extra-fascial Hysterectomy with Bilateral Salpingo-oophorectomy (Panhysterectomy)**, often accompanied by pelvic and para-aortic lymph node dissection or sentinel lymph node mapping for staging. **Why Panhysterectomy is the choice:** Endometrial cancer is primarily a disease of postmenopausal women (like the 56-year-old in this case). Since the cancer originates in the uterine lining and frequently spreads to the adnexa (ovaries/tubes), removing the entire uterus and both adnexa is curative for early-stage disease and essential for accurate surgical staging. **Analysis of Incorrect Options:** * **A. Irradiation:** Radiation is generally reserved as **adjuvant therapy** (post-surgery) to reduce local recurrence or as primary therapy only in patients who are medically unfit for surgery. * **B. Wertheim’s Hysterectomy:** This is a Radical Hysterectomy used primarily for **Cervical Cancer**. It involves removing the parametrium and a vaginal cuff, which is unnecessary for standard endometrial cancer unless there is clear cervical stromal involvement (Stage II). * **D. Irradiation and later panhysterectomy:** Pre-operative radiation followed by surgery was an older approach but is no longer the standard of care. Surgery is now performed first to determine the exact stage and grade before deciding on the need for radiation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Endometrioid adenocarcinoma. * **Risk Factors:** Obesity (most significant), nulliparity, late menopause, and Unopposed Estrogen (PCOS, Tamoxifen). * **Staging:** Endometrial cancer is **Surgically Staged** (FIGO). * **Investigation of Choice:** Fractional Curettage or Pipelle biopsy (Gold Standard: Endometrial Biopsy). * **Cardinal Symptom:** Postmenopausal bleeding (must be investigated via ultrasound/biopsy).

Question 378: What is the best management for a 40-year-old lady with CIN III?

A. Conization
B. Wertheim's hysterectomy
C. Total abdominal hysterectomy (Correct Answer)
D. Punch biopsy

Explanation: **Explanation:** **CIN III (Cervical Intraepithelial Neoplasia Grade III)** represents severe dysplasia and carcinoma in situ. The management depends significantly on the patient's age and fertility desires. **Why Total Abdominal Hysterectomy (TAH) is the correct answer:** In a 40-year-old woman who has likely completed her family, **Total Abdominal Hysterectomy** is considered the definitive treatment for CIN III. While conservative methods like conization are preferred for younger patients wishing to preserve fertility, TAH provides the lowest risk of recurrence and eliminates the need for long-term, intensive cytological follow-up in a patient of this age group. **Analysis of Incorrect Options:** * **A. Conization:** This is the treatment of choice for younger patients who desire **fertility preservation**. In a 40-year-old, it is an alternative but less definitive than TAH. * **B. Wertheim’s Hysterectomy:** This is a radical hysterectomy used for **invasive cervical cancer** (Stage IA2 to IIA). It is overtreatment for CIN III, which is a pre-invasive lesion. * **C. Punch Biopsy:** This is a **diagnostic tool**, not a therapeutic one. It is used to confirm the grade of CIN but cannot treat it. **High-Yield Clinical Pearls for NEET-PG:** * **CIN I:** Usually managed by observation (60-80% regress spontaneously). * **CIN II/III:** Requires treatment (Ablative like Cryotherapy/LASER or Excisional like LEEP/Conization). * **Definitive Treatment:** Hysterectomy is the definitive management for CIN III in women who have completed their family or where follow-up is difficult. * **Microinvasive Carcinoma (Stage IA1):** If the depth is <3mm and no LVSI, TAH is also the treatment of choice.

Question 379: A 37-year-old woman presents with an abdominal mass. Ultrasound reveals a solid tumor with elevated LDH and HCG. What is the diagnosis?

A. Teratoma
B. Fibroma
C. Dysgerminoma (Correct Answer)
D. Brenner tumor

Explanation: **Explanation:** The correct diagnosis is **Dysgerminoma**. This is the most common malignant germ cell tumor of the ovary, typically occurring in young women (second and third decades). **Why Dysgerminoma is correct:** Dysgerminoma is characterized by specific biochemical markers. It classically causes an elevation in **LDH (Lactate Dehydrogenase)**, which serves as a reliable tumor marker for diagnosis and monitoring recurrence. While most dysgerminomas are non-secretory, approximately 3-5% contain syncytiotrophoblastic giant cells that produce **HCG**, leading to its elevation. On ultrasound, these tumors typically appear as solid, multinodular masses with prominent fibrovascular septa. **Why other options are incorrect:** * **Teratoma:** Mature cystic teratomas (dermoid cysts) are usually cystic, not solid, and do not typically elevate LDH or HCG. Immature teratomas may elevate AFP (Alpha-fetoprotein). * **Fibroma:** A benign sex cord-stromal tumor. It is a solid tumor but is not associated with LDH or HCG markers. It is classically associated with Meigs’ Syndrome (ascites and pleural effusion). * **Brenner Tumor:** A rare surface epithelial tumor (usually benign) containing "Walthard cell rests." It does not produce LDH or HCG. **High-Yield Clinical Pearls for NEET-PG:** * **Most common** malignant germ cell tumor in pregnancy and in patients with gonadal dysgenesis (Turner Syndrome). * **Tumor Markers:** LDH (Most specific), HCG (if syncytiotrophoblastic cells present), and Alkaline Phosphatase (ALP). * **Radiosensitivity:** It is the most radiosensitive ovarian tumor, though fertility-sparing surgery and chemotherapy are preferred. * **Histology:** Characteristic "fried egg" appearance (large cells with clear cytoplasm and central nuclei) separated by fibrous septa infiltrated with lymphocytes.

Question 380: A 35-year-old P2L2 female has CIN extending to the vaginal fornix, confirmed on colposcopy. What is the best management?

A. Conization
B. LEEP (Loop Electrosurgical Excision Procedure)
C. Cryosurgery
D. Laser ablation (Correct Answer)

Explanation: **Explanation:** The management of Cervical Intraepithelial Neoplasia (CIN) depends on the extent of the lesion, the visibility of the transformation zone, and the involvement of the vaginal vault. **Why Laser Ablation is the Correct Answer:** Laser ablation (CO2 laser) is the preferred treatment when CIN extends to the **vaginal fornices**. The primary advantage of the laser is its precision and flexibility; it can be used to treat irregular, large, or multifocal lesions that extend beyond the cervix onto the vaginal walls. Unlike excisional methods, it allows for controlled destruction of tissue at a specific depth (usually 5–7 mm) over a wide surface area, making it ideal for "mapping" and treating vaginal extensions where surgical excision would be technically difficult or overly invasive. **Analysis of Incorrect Options:** * **Conization (A):** This is an excisional procedure used when the transformation zone is not fully visible (Type 3 TZ) or when microinvasion is suspected. It treats the endocervical canal but is not designed to treat lesions extending to the vaginal fornices. * **LEEP (B):** While LEEP is the most common treatment for CIN, it uses a wire loop designed for the contour of the cervix. It is difficult to use on the flat or curved surfaces of the vaginal fornix without risking injury to the bladder or rectum. * **Cryosurgery (C):** Cryotherapy is less precise in terms of depth and area control. It is generally reserved for small, low-grade lesions limited to the ectocervix and is contraindicated for large lesions or those extending to the vagina. **NEET-PG High-Yield Pearls:** * **Prerequisite for Ablation:** Before any ablative procedure (Laser or Cryo), a colposcopy must be satisfactory, and endocervical curettage (ECC) must be negative to rule out invasive cancer. * **Depth of destruction:** For CIN, the target depth of destruction is **7 mm** to ensure the involvement of deep endocervical crypts is addressed. * **Vaginal Extension:** When CIN involves the vagina, it is often referred to as **VAIN** (Vaginal Intraepithelial Neoplasia). Laser vaporization is the gold standard for VAIN.

Practice by Chapter

Cervical Cancer

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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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