Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 31: In perimenopausal women with menorrhagia, all carcinomas are ruled out except:

A. Ovary (Correct Answer)
B. Uterus
C. Fallopian tube
D. Endometrium

Explanation: In perimenopausal women presenting with **menorrhagia** (heavy menstrual bleeding), the primary clinical objective is to rule out malignancies of the female reproductive tract. **Explanation of the Correct Answer:** * **Ovary (Option A):** Ovarian cancer is often referred to as the "silent killer" because it typically remains asymptomatic until it reaches an advanced stage. Crucially, ovarian tumors **do not typically present with menorrhagia**. While some functional (estrogen-secreting) ovarian tumors may cause endometrial hyperplasia leading to bleeding, primary ovarian carcinoma itself does not manifest as heavy menstrual flow. Therefore, even if a woman has menorrhagia, a standard workup (like a D&C or biopsy) may rule out uterine causes but **cannot rule out ovarian carcinoma**, as the two are not directly linked by that symptom. **Analysis of Incorrect Options:** * **Endometrium (Option D) & Uterus (Option B):** These are the most critical cancers to rule out in perimenopausal bleeding. Endometrial carcinoma (or uterine sarcoma) directly involves the uterine lining; thus, abnormal uterine bleeding (AUB) is the hallmark presenting symptom. A diagnostic D&C or endometrial biopsy is the gold standard to rule these out. * **Fallopian Tube (Option C):** While rare, fallopian tube carcinoma typically presents with the classic triad (Latzko’s triad), which includes intermittent profuse serosanguinous vaginal discharge (*hydrops tubae profluens*). Because the discharge passes through the uterus, it is considered part of the differential for abnormal vaginal bleeding/discharge and can be investigated via uterine sampling and imaging. **NEET-PG High-Yield Pearls:** * **Investigation of Choice:** For perimenopausal AUB, the first-line investigation is **Transvaginal Ultrasound (TVS)** to measure endometrial thickness (ET). * **Gold Standard:** If ET >4mm in postmenopausal women or if there is persistent bleeding in perimenopausal women, **Endometrial Biopsy/Fractional Curettage** is mandatory to rule out malignancy. * **Ovarian Cancer Screening:** There is no effective routine screening for ovarian cancer; it is usually detected via CA-125 and imaging (USG/CT), not by evaluating menstrual symptoms.

Question 32: What is the most common type of benign ovarian tumor during pregnancy?

A. Simple serous cystadenoma (Correct Answer)
B. Mucinous cystadenoma
C. Teratoma
D. Papillary cystadenoma

Explanation: **Explanation:** The correct answer is **Simple serous cystadenoma**. **1. Why it is correct:** In the general population and during pregnancy, **Serous cystadenoma** is the most common benign epithelial ovarian tumor. While mature cystic teratomas (dermoid cysts) are frequently cited as the most common *germ cell* tumors found in pregnancy, large-scale epidemiological data and standard textbooks (like Williams Obstetrics) indicate that simple serous cysts/cystadenomas are the most frequently encountered benign ovarian neoplasms overall during the gestational period. **2. Why the other options are incorrect:** * **B. Mucinous cystadenoma:** These are the second most common epithelial tumors. They tend to be much larger than serous tumors and are more likely to cause pressure symptoms or undergo torsion, but their incidence is lower than serous cystadenomas. * **C. Teratoma (Dermoid Cyst):** This is the most common **germ cell tumor** in pregnancy. It is highly high-yield because it is the most common tumor to undergo **torsion** during pregnancy (especially in the first trimester or puerperium), but it ranks second to serous cystadenomas in overall frequency. * **D. Papillary cystadenoma:** This is a histological variant of serous tumors. While benign, it is less common than the simple (smooth-walled) serous cystadenoma. **Clinical Pearls for NEET-PG:** * **Most common ovarian mass in pregnancy:** Corpus luteum cyst (functional). * **Most common benign neoplasm in pregnancy:** Serous cystadenoma. * **Most common tumor to undergo torsion in pregnancy:** Dermoid cyst (Teratoma). * **Management:** Most cysts <6 cm resolve spontaneously. If a persistent neoplasm is suspected, the ideal time for surgical intervention (Laparoscopy/Laparotomy) is the **second trimester (14–18 weeks)** to minimize miscarriage risk and technical difficulty.

Question 33: A 35-year-old patient presents with a 3 x 4 cm clear ovarian cyst on right side as noted on ultrasound. What is the next line of management?

A. Laparoscopy
B. Oral contraceptive pills
C. Watchful waiting (Correct Answer)
D. CA-125 estimation

Explanation: ### Explanation **Correct Answer: C. Watchful waiting** The management of an ovarian cyst depends on the patient's age, the size of the cyst, and its sonographic features. In this case, the patient is of reproductive age (35 years) and the cyst is **small (3-4 cm)** and **unilocular/clear** (simple cyst). According to current guidelines (ACOG and RCOG), asymptomatic simple cysts less than 5 cm in premenopausal women are almost always functional (follicular or corpus luteum cysts). These typically resolve spontaneously within 1–2 menstrual cycles. Therefore, the most appropriate next step is **watchful waiting** with a follow-up ultrasound in 6–12 weeks. **Why other options are incorrect:** * **Laparoscopy (A):** Surgical intervention is reserved for cysts that are large (>7–10 cm), symptomatic, persistent, or show suspicious features (solid components, septations) on imaging. * **Oral Contraceptive Pills (B):** While OCPs prevent the formation of *new* functional cysts by suppressing ovulation, they do not hasten the resolution of an *existing* cyst. * **CA-125 estimation (D):** CA-125 is not recommended in premenopausal women with simple cysts because it has low specificity; it can be elevated in benign conditions like endometriosis, PID, or fibroids, leading to unnecessary anxiety and intervention. **High-Yield Clinical Pearls for NEET-PG:** 1. **Premenopausal:** Simple cysts <5 cm need no follow-up; 5–7 cm require yearly USG; >7 cm require MRI or surgery. 2. **Postmenopausal:** Simple cysts <1 cm can be ignored; 1–7 cm require yearly USG and CA-125. 3. **The "Rule of 5":** Cysts <5 cm in reproductive age are usually functional; cysts >5 cm or those persisting beyond 2–3 months warrant further investigation. 4. **IOTA Simple Rules:** Used to differentiate benign from malignant masses on ultrasound.

Question 34: Invasive molar tissue is most commonly found in which of the following locations?

A. Myometrium (Correct Answer)
B. Vaginal wall
C. Ovary
D. Liver

Explanation: ### Explanation **Invasive Mole (Chorioadenoma Destruens)** is a type of Gestational Trophoblastic Neoplasia (GTN) characterized by the presence of hydropic chorionic villi that invade deep into the uterine wall. **1. Why Myometrium is Correct:** The hallmark of an invasive mole is the **direct extension and penetration** of molar tissue into the **myometrium** or its vascular spaces. Unlike a complete or partial hydatidiform mole, which is confined to the uterine cavity, an invasive mole is locally aggressive. It develops in approximately 15% of patients following the evacuation of a complete mole. **2. Analysis of Incorrect Options:** * **Vaginal wall:** While the vagina is the most common site for *metastatic* GTN (specifically Choriocarcinoma), an invasive mole is primarily a locally invasive process within the uterus. * **Ovary:** The ovaries are frequently affected by theca lutein cysts due to high hCG levels, but they are not a primary or common site for the invasion of molar villi. * **Liver:** The liver is a site for distant metastasis, typically seen in advanced stages of Choriocarcinoma (FIGO Stage IV). Invasive moles rarely metastasize to distant organs like the liver. **3. Clinical Pearls for NEET-PG:** * **Diagnostic Feature:** The presence of **chorionic villi** within the myometrium distinguishes an invasive mole from Choriocarcinoma (which lacks villi). * **Clinical Presentation:** Persistent bleeding and a sub-involuted uterus following molar evacuation, often with plateauing or rising hCG levels. * **Risk of Rupture:** Deep myometrial invasion can lead to uterine perforation and life-threatening intraperitoneal hemorrhage. * **Treatment:** It is highly sensitive to chemotherapy (usually Methotrexate). Hysterectomy is reserved for uncontrolled hemorrhage or patients who have completed childbearing.

Question 35: Rokitansky Protuberance is associated with which of the following?

A. Seminoma
B. Leiomyoma
C. Dermoid cyst (Correct Answer)
D. Choriocarcinoma

Explanation: **Explanation:** **Rokitansky Protuberance** (also known as a **dermoid plug**) is the hallmark pathological feature of a **Mature Cystic Teratoma (Dermoid Cyst)**. 1. **Why Dermoid Cyst is Correct:** A dermoid cyst is a germ cell tumor containing tissues from all three germ layers (ectoderm, mesoderm, and endoderm). The Rokitansky protuberance is a solid prominence projecting from the inner cyst wall into the lumen. It is clinically significant because it typically contains the most diverse organized tissues, such as hair follicles, sebaceous glands, bone, or even rudimentary teeth. On imaging (Ultrasound/CT), identifying this solid plug within a fatty cyst is diagnostic. Notably, malignant transformation (most commonly Squamous Cell Carcinoma) usually arises from this specific protuberance. 2. **Why Other Options are Incorrect:** * **Seminoma (Dysgerminoma in females):** These are solid germ cell tumors characterized by "fried-egg" appearance on histology, not cystic structures with protuberances. * **Leiomyoma:** These are benign smooth muscle tumors of the uterus (fibroids). They are solid, whorled masses and do not contain ectodermal elements like hair or sebum. * **Choriocarcinoma:** A highly malignant gestational trophoblastic neoplasm characterized by sheets of trophoblasts and extensive hemorrhage/necrosis, lacking organized tissue plugs. **High-Yield Clinical Pearls for NEET-PG:** * **Most common ovarian tumor in young women:** Dermoid Cyst. * **Most common complication:** Torsion (due to high fat content making it buoyant). * **Tip-of-the-Iceberg Sign:** An ultrasound finding in dermoid cysts where the acoustic shadowing from the hair/sebum obscures the posterior wall. * **Malignant transformation:** Occurs in <2% of cases, usually in postmenopausal women.

Question 36: A patient who underwent surgery for stage IA grade 3 carcinoma of the endometrium requires postoperative adjuvant therapy. What is the preferred mode of treatment?

A. External pelvic radiation
B. External field radiation
C. Vaginal brachytherapy (Correct Answer)
D. Observation

Explanation: **Explanation:** The management of endometrial carcinoma depends on the risk of recurrence, which is determined by the stage, grade, and depth of myometrial invasion. **Why Vaginal Brachytherapy (VBT) is correct:** According to the FIGO and NCCN guidelines, **Stage IA Grade 3** (High-intermediate risk) involves a high-grade tumor limited to the inner half of the myometrium. In these cases, the primary site of recurrence is the **vaginal vault**. VBT is the preferred adjuvant treatment because it provides excellent local control at the vault while minimizing radiation exposure to the bladder and rectum, thereby reducing long-term morbidity compared to external beam radiation. **Why other options are incorrect:** * **A & B (External Pelvic/Field Radiation):** EBRT is generally reserved for Stage IB Grade 3 or Stage II disease (cervical involvement). While it reduces pelvic recurrence, it does not improve overall survival in Stage IA and carries a higher risk of gastrointestinal and urinary toxicity. * **D (Observation):** Observation is only appropriate for Stage IA Grade 1 or 2 tumors with no other risk factors. Grade 3 histology is an independent risk factor that necessitates adjuvant therapy to prevent local recurrence. **Clinical Pearls for NEET-PG:** * **Stage IA:** Tumor limited to the endometrium or <50% myometrial invasion. * **Stage IB:** Tumor invades ≥50% of the myometrium. * **High-Intermediate Risk Factors:** Age >60, Grade 3, Lymphovascular space invasion (LVSI), and outer 1/3 myometrial invasion. * **Gold Standard Surgery:** Total Laparoscopic/Abdominal Hysterectomy + Bilateral Salpingo-oophorectomy (TLH/TAH + BSO) with lymphadenectomy or sentinel lymph node mapping.

Question 37: What is the standard treatment for stage III B carcinoma of the cervix?

A. Wertheim procedure
B. Schauta's procedure
C. Chemotherapy
D. Intracavitary brachytherapy followed by external beam radiotherapy (Correct Answer)

Explanation: **Explanation:** The FIGO staging for **Stage IIIB** carcinoma cervix involves the tumor extending to the pelvic wall and/or causing hydronephrosis or a non-functioning kidney. According to standard management protocols, Stage IIB to IVA are classified as **locally advanced cervical cancer (LACC)**. **1. Why Option D is Correct:** The standard of care for LACC (including Stage IIIB) is **Concurrent Chemoradiotherapy (CCRT)**. This involves **External Beam Radiotherapy (EBRT)** to treat the primary tumor and pelvic nodes, followed by **Intracavitary Brachytherapy (ICBT)** to deliver a high dose of radiation directly to the cervix. While the option mentions radiotherapy components, in clinical practice, cisplatin-based chemotherapy is added as a radiosensitizer to improve survival rates. **2. Why Other Options are Incorrect:** * **Options A & B (Wertheim and Schauta's procedures):** These are radical hysterectomies (abdominal and vaginal, respectively). Surgery is generally reserved for **early-stage disease (Stage IA to IIA1)**. In Stage IIIB, the involvement of the pelvic wall makes surgical clearance impossible (R0 resection cannot be achieved). * **Option C (Chemotherapy):** Primary chemotherapy alone is not the standard curative treatment for cervical cancer; it is used either as a radiosensitizer (CCRT) or for palliation in Stage IVB. **Clinical Pearls for NEET-PG:** * **Most common cause of death** in cervical cancer: Uremia (due to bilateral ureteric obstruction/hydronephrosis). * **Stage IIA vs. IIB:** The presence of **parametrial involvement** (Stage IIB) is the clinical "cutoff" where treatment shifts from surgery to radiotherapy. * **Investigation of choice for staging:** MRI is the preferred imaging modality to assess parametrial and pelvic wall involvement.

Question 38: A 35-year-old woman is diagnosed with CIN grade III on colposcopic biopsy. Which of the following are appropriate treatment options?

A. Cold knife conization, Simple hysterectomy, Radical hysterectomy, Laparoscopic assisted hysterectomy
B. Simple hysterectomy, Radical hysterectomy, LEEP
C. Cold knife conization, Radical hysterectomy, LEEP
D. Cold knife conization, Simple hysterectomy, LEEP (Correct Answer)

Explanation: **Explanation:** **1. Why Option D is Correct:** CIN III (Cervical Intraepithelial Neoplasia Grade III) is a **pre-invasive** high-grade squamous intraepithelial lesion (HSIL). The goal of treatment is to remove the transformation zone and the lesion. * **LEEP (Loop Electrosurgical Excision Procedure):** The most common outpatient procedure for CIN III, providing both treatment and a tissue specimen for margin analysis. * **Cold Knife Conization (CKC):** Preferred when the lesion extends into the endocervical canal or if microinvasion is suspected, as it provides cleaner margins than LEEP. * **Simple Hysterectomy:** Considered an appropriate definitive treatment for women who have completed childbearing, especially if there are concomitant gynecological issues (e.g., fibroids) or if the margins of a previous cone biopsy were positive. **2. Why Other Options are Incorrect:** * **Radical Hysterectomy (Options A, B, and C):** This involves the removal of the uterus, parametrium, and upper vagina. It is indicated for **invasive cervical cancer** (Stage IA2 to IIA), not for pre-invasive lesions like CIN III. Using it for CIN III is considered "over-treatment." * **Laparoscopic Assisted Hysterectomy (Option A):** While a route for hysterectomy, the presence of "Radical Hysterectomy" in the same option makes it incorrect for CIN III management. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Colposcopy-directed biopsy. * **Management Strategy:** "See and Treat" (LEEP) is acceptable for HSIL/CIN III in non-pregnant women over 25. * **Pregnancy:** If CIN III is diagnosed during pregnancy, management is conservative (repeat colposcopy/cytology); treatment is deferred until 6–12 weeks postpartum unless invasive cancer is suspected. * **Follow-up:** Post-treatment, patients require HPV testing or co-testing at 12 and 24 months before returning to routine screening.

Question 39: A 55-year-old menopausal woman complains of postcoital bleeding. What important cause of such bleeding should be ruled out?

A. Carcinoma of the cervix (Correct Answer)
B. Carcinoma of the endometrium
C. Fibroid uterus
D. Adenomyosis

Explanation: **Explanation:** **1. Why Carcinoma of the Cervix is the correct answer:** In any woman presenting with **postcoital bleeding** (bleeding triggered by vaginal intercourse), **Carcinoma of the Cervix** is considered the most critical diagnosis to rule out until proven otherwise. This occurs because the cervical surface becomes friable due to neovascularization and erosive growth associated with malignancy. When the penis or a speculum contacts the fragile, cancerous tissue, it causes immediate bleeding. In the context of NEET-PG, postcoital bleeding is the **classic clinical hallmark** of cervical cancer. **2. Why the other options are incorrect:** * **Carcinoma of the Endometrium:** This typically presents as **postmenopausal bleeding (PMB)** that is spontaneous and unrelated to intercourse. While it is a major concern in a 55-year-old, it does not classically present as postcoital bleeding. * **Fibroid Uterus:** These are benign smooth muscle tumors. They usually cause **heavy menstrual bleeding (menorrhagia)** or pelvic pressure. They rarely cause postcoital bleeding unless a pedunculated submucosal fibroid is prolapsing through the cervix. * **Adenomyosis:** This condition involves endometrial tissue within the myometrium. It typically presents with **secondary dysmenorrhea** and menorrhagia in premenopausal women, not postcoital bleeding in menopause. **Clinical Pearls for NEET-PG:** * **Most common cause** of postcoital bleeding in clinical practice: Cervical ectropion or Cervicitis. * **Most important/sinister cause** to rule out: Carcinoma of the cervix. * **Initial Investigation:** Per-speculum (PS) examination to visualize the cervix, followed by a Pap smear or biopsy if a growth is visible. * **Triad of Advanced Cervical Cancer:** Unilateral leg edema, sciatic pain, and hydronephrosis.

Question 40: What is the most common site for metastasis in choriocarcinoma?

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

Explanation: **Explanation:** Choriocarcinoma is a highly malignant, epithelial tumor arising from the trophoblastic cells. It is characterized by early and rapid **hematogenous spread** (via the bloodstream) due to the inherent nature of trophoblastic cells to invade blood vessels. **1. Why Lungs are the Correct Answer:** The lungs are the most common site of metastasis, occurring in approximately **80% of cases**. Because the tumor cells invade the venous system, they are carried directly to the right side of the heart and then trapped in the pulmonary capillary bed. On imaging, these often appear as classic "cannonball metastases." **2. Analysis of Incorrect Options:** * **B. Brain:** This is the most common site for *lethal* metastasis, but it is less frequent than pulmonary involvement (occurring in about 10% of cases). It usually occurs secondary to lung metastasis. * **C. Liver:** The liver is a common site for advanced disease (approx. 10%), but it is significantly less common than the lungs. Its presence often indicates a poor prognosis. * **D. Spine:** Bone metastasis is rare in choriocarcinoma. While it can occur, it is not a primary or common site compared to the viscera. **NEET-PG High-Yield Pearls:** * **Order of Metastasis:** Lungs (80%) > Vagina (30%) > Pelvis (20%) > Liver (10%) > Brain (10%). * **Vaginal Metastasis:** Often presents as a highly vascular, bluish/purple nodule. **Biopsy should be avoided** due to the risk of torrential hemorrhage. * **Tumor Marker:** Serum **beta-hCG** is the primary marker for diagnosis, monitoring treatment response, and detecting recurrence. * **Prognosis:** Choriocarcinoma is highly sensitive to chemotherapy (specifically Methotrexate), making it one of the most curable solid tumors even in the presence of metastasis.

Practice by Chapter

Cervical Cancer

Practice Questions

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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