Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 381: Colposcopy shows a CIN-III grade lesion in a 45-year-old multiparous lady. What is the next line of management?

A. Repeat Pap smear
B. Hysterectomy (Correct Answer)
C. Cone biopsy
D. None of the above

Explanation: **Explanation:** The management of **CIN-III (Cervical Intraepithelial Neoplasia Grade III)** depends on the patient's age, parity, and desire for future fertility. CIN-III is considered a high-grade squamous intraepithelial lesion (HSIL) and is a direct precursor to invasive cervical cancer. **Why Hysterectomy is the Correct Answer:** In this clinical scenario, the patient is **45 years old and multiparous**, implying she has likely completed her family. For women who have completed their childbearing and present with CIN-III, **Total Hysterectomy** is considered the definitive treatment. It eliminates the risk of recurrence and progression to invasive carcinoma, providing a permanent solution compared to conservative excisional procedures. **Analysis of Incorrect Options:** * **A. Repeat Pap smear:** This is incorrect. A Pap smear is a screening tool, not a treatment. Once a high-grade lesion (CIN-III) is confirmed via colposcopy/biopsy, active intervention is required. * **C. Cone biopsy:** While LEEP (Loop Electrosurgical Excision Procedure) or Cone Biopsy is the treatment of choice for younger patients who wish to **preserve fertility**, it is not the "best" definitive management for a 45-year-old multiparous woman where the risk of recurrence outweighs the need for uterine preservation. **High-Yield Clinical Pearls for NEET-PG:** * **CIN-I:** Usually managed by observation (repeat Pap/HPV testing in 1 year) as most regress spontaneously. * **CIN-II/III (Young/Fertile):** Cervical Conization or LEEP is preferred to preserve the cervix for pregnancy. * **CIN-III (Completed Family):** Hysterectomy is the definitive management. * **Gold Standard for Diagnosis:** Colposcopy-directed biopsy. * **Most common site for CIN:** The Transformation Zone (Squamocolumnar junction).

Question 382: Which of the following is true about cervical cancer?

A. Associated with Human Papillomavirus (HPV)
B. Nulliparity
C. Oral contraceptive pills (OCP)
D. Immunocompromised patients (Correct Answer)

Explanation: **Explanation:** Cervical cancer is primarily caused by persistent infection with high-risk **Human Papillomavirus (HPV)**, particularly types 16 and 18. However, the question asks for the "true" statement among the provided options regarding risk factors and associations. **1. Why "Immunocompromised patients" is the correct answer:** The immune system plays a critical role in clearing HPV infections. In immunocompromised individuals (e.g., those with HIV/AIDS or transplant recipients), the body cannot effectively clear the virus, leading to persistent infection and rapid progression from Cervical Intraepithelial Neoplasia (CIN) to invasive cancer. Notably, Cervical Cancer is an **AIDS-defining illness**. **2. Analysis of Incorrect Options:** * **Option A (Associated with HPV):** While HPV is the primary causative agent, in the context of multiple-choice questions where "Immunocompromised" is marked correct, it often refers to the most significant clinical vulnerability or the specific focus of the examiner. *Note: In many standard exams, both A and D are technically true, but D highlights a high-yield clinical association frequently tested in NEET-PG.* * **Option B (Nulliparity):** This is incorrect. **Multiparity** (having many children) is a risk factor for cervical cancer. Nulliparity is actually a risk factor for Breast, Endometrial, and Ovarian cancers. * **Option C (OCPs):** While long-term use of OCPs (>5 years) is associated with a slight increase in cervical cancer risk, it is generally considered a secondary factor compared to viral and immune factors. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (80-85%). * **Transformation Zone:** The most common site of origin for cervical cancer. * **Screening:** Pap smear (cytology) and HPV DNA testing are the gold standards. * **Vaccination:** Recommended age is 9–14 years (2 doses); 15–45 years (3 doses). * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), though imaging (MRI/CT) is now incorporated in the 2018 update.

Question 383: Which of the following statements is NOT true regarding choriocarcinoma?

A. It is an aggressive malignancy.
B. It is associated with raised hCG levels.
C. It is common below 20 years of age.
D. It is a gonadal type that is chemosensitive. (Correct Answer)

Explanation: ### Explanation The correct answer is **D**, as the statement "It is a gonadal type that is chemosensitive" is incorrect in the context of the question's likely intent regarding the distinction between gestational and non-gestational choriocarcinoma. **1. Why Option D is the correct choice (The "Not True" statement):** Choriocarcinoma is classified into two types: **Gestational** (arising from a pregnancy) and **Non-gestational** (gonadal/germ cell origin). While both are chemosensitive, the **gonadal type** (non-gestational) is notoriously **less responsive** to chemotherapy and carries a much poorer prognosis compared to the gestational type. In NEET-PG contexts, the hallmark of choriocarcinoma is its extreme sensitivity to methotrexate/EMA-CO; however, this "miracle" responsiveness applies primarily to the gestational variety. **2. Analysis of Incorrect Options:** * **Option A:** Choriocarcinoma is indeed a highly **aggressive malignancy** characterized by rapid growth and early hematogenous spread (especially to the lungs). * **Option B:** It is a tumor of syncytiotrophoblasts, which produce **hCG**. Monitoring serum β-hCG is the gold standard for diagnosis and tracking treatment response. * **Option C:** While it can occur at any reproductive age, there is a bimodal distribution; it is more common at the extremes of age (**below 20** and above 40 years). **3. Clinical Pearls for NEET-PG:** * **Metastasis:** The most common site of metastasis is the **Lungs** (80%), followed by the vagina (the "cannonball" appearance on CXR is a classic finding). * **Histology:** Characterized by a dimorphic population of **syncytiotrophoblasts and cytotrophoblasts** with *absence* of chorionic villi (if villi are present, think Invasive Mole). * **Treatment:** It is one of the few solid tumors curable even in the presence of widespread metastasis due to its high chemosensitivity (Gestational type).

Question 384: What is the karyotype of a partial mole?

A. 46XY
B. 46XX
C. 69XXY (Correct Answer)
D. 23X

Explanation: ### Explanation **Correct Answer: C. 69XXY** **Underlying Medical Concept:** A **Partial Hydatidiform Mole** is characterized by **triploidy**. It occurs when a normal haploid ovum (23X) is fertilized by two sperm (dispermy) or by one sperm that duplicates its chromosomes. This results in 69 chromosomes. The most common karyotype is **69,XXY** (70%), followed by 69,XXX and 69,XYY. Unlike complete moles, partial moles contain fetal tissue and some normal chorionic villi alongside hydropic changes. **Analysis of Incorrect Options:** * **A & B (46,XY and 46,XX):** These are **diploid** karyotypes. A **Complete Hydatidiform Mole** is typically 46,XX (90%) or 46,XY (10%). Complete moles result from "empty egg" fertilization (androgenesis), where maternal nuclear DNA is absent, and all genetic material is paternal. * **D (23,X):** This is a normal **haploid** gamete. A molar pregnancy requires fertilization and abnormal chromosomal multiplication or addition. **High-Yield Clinical Pearls for NEET-PG:** * **Paternal vs. Maternal:** Complete moles are 100% paternal in origin; Partial moles have both maternal and paternal DNA (2:1 paternal-to-maternal ratio). * **Malignancy Risk:** Complete moles have a higher risk of progressing to Choriocarcinoma (15–20%) compared to partial moles (<5%). * **Clinical Presentation:** Partial moles often present as an "incomplete abortion," and the diagnosis is frequently made only after histopathology. * **p57 Expression:** Partial moles are **p57 positive** (stains for maternal DNA), whereas complete moles are **p57 negative**.

Question 385: What is the most common tumor of the ovary found in pregnancy?

A. Sex cord tumor
B. Epithelial tumor
C. Dysgerminoma
D. Dermoid cyst (Correct Answer)

Explanation: **Explanation:** The most common ovarian tumor encountered during pregnancy is the **Dermoid cyst (Mature Cystic Teratoma)**. This is a germ cell tumor that typically occurs during the reproductive years, coinciding with the peak age of pregnancy. While most are asymptomatic and discovered incidentally during routine prenatal ultrasound, they carry a risk of complications like **ovarian torsion** (most common in the second trimester) or rupture. **Analysis of Options:** * **Dermoid Cyst (Correct):** It accounts for approximately 25–40% of all ovarian masses identified during pregnancy. They are usually benign and unilateral. * **Epithelial Tumors:** While common in the general population, they are less frequent than dermoids in pregnant women. Serous cystadenomas are the second most common benign tumors after dermoids. * **Dysgerminoma:** This is the most common **malignant** germ cell tumor found in pregnancy, but it is far less common than the benign dermoid cyst. * **Sex Cord Tumors:** These (e.g., Granulosa cell tumors) are rare during pregnancy. **NEET-PG High-Yield Pearls:** * **Most common ovarian mass in pregnancy:** Corpus Luteum Cyst (Functional). * **Most common benign neoplasm in pregnancy:** Dermoid Cyst. * **Most common malignancy in pregnancy:** Dysgerminoma. * **Management:** If an ovarian mass is >5–6 cm or symptomatic, the ideal time for surgical intervention (Laparoscopy/Laparotomy) is the **early second trimester (14–18 weeks)** to minimize miscarriage risk and avoid technical difficulties of a large uterus. * **Complication:** Torsion is the most frequent complication of ovarian cysts during pregnancy.

Question 386: Brenner tumor is a type of which of the following?

A. Epithelial tumors (Correct Answer)
B. Sex cord stromal tumors
C. Germ cell tumors
D. None of the above

Explanation: **Explanation:** **Brenner tumor** is a surface epithelial-stromal tumor of the ovary. The correct answer is **A (Epithelial tumors)** because these tumors are composed of nests of transitional cells (urothelium-like) embedded within a dense fibromatous stroma. This is a classic example of "transitional cell metaplasia" of the surface epithelium. **Why other options are incorrect:** * **Sex cord-stromal tumors:** These arise from the ovarian stroma or primitive sex cords (e.g., Granulosa cell tumor, Sertoli-Leydig tumor, Fibroma). While Brenner tumors have a prominent fibrous component, the defining neoplastic element is epithelial. * **Germ cell tumors:** These originate from primordial germ cells (e.g., Teratoma, Dysgerminoma, Yolk sac tumor). Brenner tumors do not share this embryological origin. **High-Yield Clinical Pearls for NEET-PG:** 1. **Histology (Most Common Question):** Characterized by **"Walthard cell rests"** and cells with a longitudinal nuclear groove, famously described as **"Coffee bean nuclei."** 2. **Nature:** Most Brenner tumors (95%) are **benign**, unilateral, and often discovered incidentally. 3. **Gross Appearance:** They are solid, firm, and pale yellow-tan, often resembling an ovarian fibroma. 4. **Association:** They are sometimes associated with mucinous cystadenomas in the same or contralateral ovary. 5. **Epithelial Subtypes:** Remember the mnemonic **"MS. BEB"** for Surface Epithelial Tumors: **M**ucinous, **S**erous, **B**renner, **E**ndometrioid, and **B**lear (Clear) cell tumors.

Question 387: What is the most common symptom of germ cell tumors?

A. Bleeding
B. Irritable Bowel Syndrome
C. Nausea and vomiting
D. Subacute abdominal pain (Correct Answer)

Explanation: **Explanation:** Ovarian germ cell tumors (GCTs) differ significantly from epithelial ovarian tumors in their clinical presentation. While epithelial tumors are often "silent killers" that present late with vague symptoms, GCTs are characterized by **rapid growth** and typically occur in younger women (adolescents and young adults). **1. Why Subacute Abdominal Pain is Correct:** The most common presenting symptom of a germ cell tumor is **subacute abdominal pain** (seen in approximately 85% of patients). This is primarily due to the rapid expansion of the tumor capsule, internal hemorrhage, or necrosis within the rapidly growing mass. In about 10% of cases, patients may present with **acute** abdominal pain due to complications like adnexal torsion, rupture, or intraperitoneal hemorrhage, which are surgical emergencies. **2. Why Other Options are Incorrect:** * **Bleeding:** Abnormal vaginal bleeding is rare in GCTs. It is more characteristic of endometrial pathology or certain sex cord-stromal tumors (like Granulosa cell tumors) that secrete estrogen. * **Irritable Bowel Syndrome (IBS):** While bloating and bowel changes can occur with large pelvic masses, these are non-specific and more commonly associated with the chronic, insidious progression of epithelial ovarian cancer. * **Nausea and Vomiting:** These are usually secondary symptoms resulting from torsion or mass effect on the GI tract, rather than the primary presenting complaint. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in the 2nd and 3rd decades of life. * **Tumor Markers:** Essential for diagnosis and follow-up (e.g., LDH for Dysgerminoma, AFP for Yolk Sac Tumor, and hCG for Choriocarcinoma). * **Most Common Type:** The most common benign GCT is the Mature Cystic Teratoma (Dermoid cyst); the most common malignant GCT is the **Dysgerminoma**. * **Management:** Most GCTs are unilateral and highly chemosensitive; therefore, fertility-sparing surgery (Unilateral Salpingo-oophorectomy) is the standard of care, even in advanced stages.

Question 388: Which of the following statements is false regarding Hydatidiform mole?

A. In complete mole, fetal parts are not seen.
B. In partial mole, all genetic material is paternally derived. (Correct Answer)
C. It increases the risk of invasive mole and choriocarcinoma.
D. The karyotype of a complete mole can be 46 XX.

Explanation: **Explanation:** The statement in **Option B** is false because it describes a **Complete Mole**, not a Partial Mole. In a **Partial Mole**, the genetic material is both maternal and paternal (usually triploid, 69 XXX or 69 XXY), resulting from the fertilization of a normal ovum by two sperm. In contrast, a **Complete Mole** is entirely paternal in origin (androgenetic), occurring when an "empty" egg (no maternal DNA) is fertilized by one or two sperm. **Analysis of other options:** * **Option A:** True. In a complete mole, there is no fetal tissue or amnion because there is no maternal genome to support embryonic development. * **Option C:** True. Both types increase the risk of Gestational Trophoblastic Neoplasia (GTN). The risk is significantly higher in complete moles (~15–20% for invasive mole, 2% for choriocarcinoma) compared to partial moles (<5%). * **Option D:** True. The most common karyotype for a complete mole is 46,XX (90%), resulting from a single sperm duplicating its DNA (monospermy) within an empty ovum. **High-Yield Clinical Pearls for NEET-PG:** * **Snowstorm Appearance:** Classic ultrasound finding for a Complete Mole. * **Swiss Cheese/Moth-eaten Appearance:** Ultrasound finding for a Partial Mole (thickened placenta with cystic spaces). * **Theca Lutein Cysts:** Common in complete moles due to extremely high hCG levels. * **HCG Levels:** Significantly higher in Complete Moles (>100,000 mIU/mL) compared to Partial Moles. * **P57 Expression:** Complete moles are **p57 negative** (since p57 is maternally expressed), while partial moles are **p57 positive**.

Question 389: Which of the following tumors is unique to pregnancy?

A. Luteoma (Correct Answer)
B. Serous cystadenoma
C. Mucinous cystadenoma
D. Teratoma

Explanation: **Explanation:** **Luteoma of Pregnancy** (Pregnancy Luteoma) is a rare, non-neoplastic, tumor-like ovarian lesion that arises exclusively during pregnancy. It is characterized by the proliferation of luteinized stromal cells under the influence of Human Chorionic Gonadotropin (hCG). These lesions are typically asymptomatic, often discovered incidentally during a Cesarean section or postpartum tubal ligation. * **Why it is unique to pregnancy:** Unlike true neoplasms, a luteoma is a physiological response to pregnancy hormones. It is not a true tumor but a hyperplastic reaction of the ovarian stroma. Crucially, it **spontaneously regresses** after delivery when hCG levels fall, making it unique to the gestational and immediate puerperal period. **Analysis of Incorrect Options:** * **Serous and Mucinous Cystadenomas:** These are true epithelial ovarian neoplasms. While they can be found during pregnancy, they occur in non-pregnant women of all ages and do not regress postpartum. * **Teratoma (Dermoid Cyst):** This is a germ cell tumor and is the most common ovarian tumor found during pregnancy. However, it is not *unique* to pregnancy, as it commonly occurs in reproductive-aged women regardless of their pregnancy status. **High-Yield Clinical Pearls for NEET-PG:** * **Virilization:** Luteomas are hormonally active; maternal virilization occurs in ~25% of cases, and there is a high risk (up to 60-70%) of virilization in female fetuses. * **Appearance:** They are often bilateral (30%) and multinodular. * **Management:** Conservative management (observation) is key because they regress spontaneously. Surgery is not indicated unless complications like torsion occur. * **Differential:** Must be distinguished from **Theca Lutein Cysts** (Hyperreactio Luteinalis), which are cystic, whereas Luteomas are solid.

Question 390: Transitional cell epithelium is seen in which ovarian tumor?

A. Granulosa cell tumor
B. Endodermal sinus tumor
C. Brenner's tumor (Correct Answer)
D. Hilus cell tumor

Explanation: **Explanation:** The correct answer is **Brenner’s Tumor**. This is a surface epithelial-stromal tumor of the ovary characterized by the presence of **transitional cell epithelium** (urothelium), similar to that found in the urinary bladder. Histologically, it features nests of these transitional cells embedded within a dense, fibrous stroma. A classic pathognomonic finding is the **"Coffee Bean" nuclei** (longitudinal nuclear grooves). **Analysis of Incorrect Options:** * **Granulosa Cell Tumor:** A sex cord-stromal tumor characterized by **Call-Exner bodies** (small follicles filled with eosinophilic material) and high estrogen production. * **Endodermal Sinus Tumor (Yolk Sac Tumor):** A germ cell tumor characterized by **Schiller-Duval bodies** (glomeruloid-like structures) and elevated **Alpha-fetoprotein (AFP)** levels. * **Hilus Cell Tumor:** A rare steroid cell tumor (pure Leydig cell tumor) that typically causes virilization and is characterized by the presence of **Reinke’s crystals** in the cytoplasm. **High-Yield Clinical Pearls for NEET-PG:** * **Brenner’s Tumor** is mostly benign and often an incidental finding. * **Walthard Cell Rests:** These are small nests of transitional epithelium found on the fallopian tubes or mesosalpinx, believed to be the precursor to Brenner’s tumors. * **Association:** It is frequently associated with **Mucinous Cystadenomas** in the same or contralateral ovary. * **Markers:** While most are non-secretory, some may rarely produce estrogen, leading to endometrial hyperplasia.

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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