Gynecologic Oncology Practice Questions

Q: Radical hysterectomy is indicated in which of the following conditions?

Carcinoma of the cervix stage IB. **Explanation:** The primary treatment for early-stage cervical cancer (Stage IA2 to IB2) is **Radical Hysterectomy (Wertheim’s Hysterectomy)** with pelvic lymphadenectomy. **Why Option D is Correct:** In **Stage IB**, the tumor is clinically visible and confined to the cervix. At this stage, there is a significant risk of parametrial involvement and lymph node metastasis. A Radical Hysterectomy is necessary because, unlike a simple hysterectomy, it involves the en-bloc removal of the uterus, cervix, the upper 1/3rd to 1/2 of the vagina, the **parametrium** (lateral, cardinal, and uterosacral ligaments), and bilateral pelvic lymph nodes. This ensures adequate surgical margins. **Why Other Options are Incorrect:** * **A. Carcinoma in situ (CIN III/Stage 0):** This is a pre-invasive lesion. Treatment is conservative, typically involving **Cervical Conization** (LEEP/Cold knife cone) or a Simple Hysterectomy if the patient has completed her family. * **B & C. Microinvasive Carcinoma (Stage IA1):** Defined as stromal invasion ≤3 mm in depth. The risk of lymph node spread is <1%. Therefore, a **Simple (Extrafascial) Hysterectomy** is sufficient. Radical surgery is over-treatment for Stage IA1 unless there is lymphovascular space invasion (LVSI). **High-Yield Clinical Pearls for NEET-PG:** 1. **Meigs’ Operation:** Another name for Radical Hysterectomy with pelvic lymphadenectomy. 2. **Nerve-Sparing Radical Hysterectomy:** Aimed at preserving the autonomic nerves (hypogastric plexus) to prevent bladder and sexual dysfunction. 3. **Radiotherapy vs. Surgery:** For Stage IB1 and IB2, both surgery and radiotherapy have equal efficacy; however, surgery is preferred in young women to preserve ovarian function and vaginal elasticity. 4. **Cut-off for Surgery:** Generally, Stage IIB (parametrial involvement) and above are treated with **Concurrent Chemoradiotherapy (CCRT)**, not surgery.

Q: A 60-year-old woman, twelve years postmenopausal, presents with an ovarian carcinoma discovered during laparotomy. Which ovarian tumor is most likely to respond to radiotherapy?

Dysgerminoma. **Explanation:** **1. Why Dysgerminoma is Correct:** Dysgerminoma is the most common malignant germ cell tumor of the ovary. Its defining clinical characteristic is its **exquisite radiosensitivity**. While the primary treatment for most ovarian cancers is surgical debulking followed by chemotherapy, dysgerminoma is unique because it can be cured with radiotherapy even in advanced stages. It is the ovarian counterpart of the testicular seminoma, both of which are highly responsive to radiation. **2. Why the Other Options are Incorrect:** * **Krukenberg’s Tumor:** This is a metastatic signet-ring cell carcinoma (usually from the stomach). It carries a very poor prognosis and is generally resistant to both radiotherapy and chemotherapy. * **Arrhenoblastoma (Sertoli-Leydig Cell Tumor):** This is a sex cord-stromal tumor that produces androgens. Treatment is primarily surgical; these tumors are not considered radiosensitive. * **Granulosa Cell Tumor:** Another sex cord-stromal tumor known for estrogen production. While it has a low malignant potential and a tendency for late recurrence, the primary treatment is surgery. It does not show the same high level of response to radiation as dysgerminoma. **3. NEET-PG High-Yield Pearls:** * **Radiosensitivity:** Dysgerminoma is the **most radiosensitive** ovarian tumor. * **Tumor Markers:** Dysgerminoma is associated with elevated **LDH** and sometimes **hCG**. (Note: AFP is typically normal). * **Age Factor:** Although the patient in this question is 60, dysgerminomas typically occur in young women (75% occur between ages 10–30). * **Associated Condition:** It is the most common ovarian neoplasm found in patients with **gonadal dysgenesis** (Swyer syndrome). * **Treatment Trend:** Despite its radiosensitivity, chemotherapy (BEP regimen) is now often preferred over radiation to preserve fertility and avoid radiation-induced bowel/bladder damage.

Q: What is the next line of management for a perimenopausal woman who has an ASCUS (atypical squamous cells of unknown significance) reported on a Pap smear?

Colposcopy. **Explanation:** The management of an abnormal Pap smear follows a risk-based triage system. **ASCUS (Atypical Squamous Cells of Undetermined Significance)** is the most common abnormal finding. According to the ASCCP guidelines, the management for ASCUS depends on the patient's age and HPV status. **1. Why Colposcopy is the correct answer:** In a perimenopausal woman with ASCUS, the standard "next step" is either **HPV DNA testing (Reflex HPV)** or **repeat cytology**. However, if HPV testing is positive for high-risk types, or if the clinical scenario dictates immediate further evaluation (as often tested in NEET-PG scenarios where triage isn't specified), **Colposcopy** is the definitive diagnostic procedure. It allows for direct visualization of the transformation zone and directed biopsies to rule out Cervical Intraepithelial Neoplasia (CIN) or malignancy. **2. Why the other options are incorrect:** * **A & B (Loop excision/Conization):** These are therapeutic/excisional procedures. They are indicated only after a biopsy confirms high-grade dysplasia (CIN II/III) or if there is a discrepancy between cytology and colposcopy. Performing them for ASCUS is "over-treatment." * **D (Hysterectomy):** This is never the primary management for an abnormal Pap smear. It is only considered for confirmed invasive cancer or specific cases of recurrent high-grade dysplasia where fertility is not desired. **High-Yield Clinical Pearls for NEET-PG:** * **ASCUS Triage:** If HPV negative → Repeat Pap in 3 years. If HPV positive → Proceed to **Colposcopy**. * **LSIL/HSIL:** Generally proceed directly to colposcopy (except in specific age groups like adolescents). * **Pregnancy:** If ASCUS is found during pregnancy, colposcopy is safe, but endocervical curettage and biopsies are generally avoided unless invasive cancer is suspected. * **Bethesda System:** Remember that ASCUS is the most common but least specific abnormality on a Pap smear.

Q: What is the earliest symptom of cervical cancer?

Bleeding per vagina. **Explanation:** The earliest and most characteristic clinical presentation of cervical cancer is **abnormal vaginal bleeding**. This occurs because the malignant cells invade the cervical stroma, leading to increased vascularity and friability of the tissue. Even minor trauma to the cervix causes these fragile surface vessels to rupture. * **Post-coital bleeding:** This is the most specific early sign in sexually active women. * **Intermenstrual bleeding:** Irregular spotting between periods. * **Post-menopausal bleeding:** Any vaginal bleeding in a post-menopausal woman must be investigated for malignancy (cervical or endometrial). **Analysis of Incorrect Options:** * **Leukorrhoea (D):** While a foul-smelling, serosanguinous (blood-tinged) discharge is a common early symptom, frank bleeding usually precedes or accompanies it as the primary complaint. * **Dyspareunia (A):** This refers to painful intercourse. While it can occur due to local tumor bulk or infection, it is typically a secondary symptom rather than the earliest sign. * **Pain (C):** Pain is a **late feature** of cervical cancer. It signifies advanced disease (Stage IIB or higher) where the tumor has infiltrated the pelvic wall, compressed nerve plexuses, or caused hydronephrosis by obstructing the ureters. **High-Yield Clinical Pearls for NEET-PG:** * **Screening:** The most effective screening tool is the **Pap Smear** (starting at age 21) or **HPV DNA testing** (starting at age 30). * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), unlike endometrial or ovarian cancers which are staged surgically. * **Most Common Histology:** Squamous cell carcinoma (80-85%). * **Risk Factor:** Persistent infection with High-Risk HPV types **16 and 18**.

Q: Which of the following is a feature of stage lb2 cancer of the cervix?

Microinvasive carcinoma with stromal invasion > 5 mm. This question tests your knowledge of the **FIGO 2018 Staging for Cervical Cancer**, which is a high-yield topic for NEET-PG. ### **Explanation of the Correct Answer** According to the FIGO 2018 classification, **Stage IB** refers to invasive carcinomas limited to the cervix with deeper invasion than Stage IA. * **Stage IB1:** Invasive carcinoma $\ge$ 5 mm depth of stromal invasion and $<2$ cm in greatest dimension. * **Stage IB2:** Invasive carcinoma **$\ge$ 5 mm depth of stromal invasion** and **$\ge$ 2 cm to $<4$ cm** in greatest dimension. Therefore, any lesion in Stage IB (including IB2) must have a stromal invasion **greater than 5 mm**, as lesions with $\le$ 5 mm invasion are classified under Stage IA. ### **Analysis of Incorrect Options** * **Options A & B:** These represent **Stage IA**. Specifically, Stage IA1 is invasion $ 4$ cm is classified as **Stage IB3**. ### **High-Yield Clinical Pearls for NEET-PG** 1. **FIGO 2018 Update:** The most significant change from the 2009 staging is that **Stage IB is now divided into three subgroups** (IB1, IB2, IB3) based on 2 cm increments in size. 2. **Imaging & Pathology:** Unlike previous versions, FIGO 2018 allows the use of **radiological imaging** (MRI/CT) and **pathological findings** to assign the stage. 3. **Lymphovascular Space Invasion (LVSI):** While noted in reports, LVSI **does not change the FIGO stage**. 4. **Stage IA Diagnosis:** Stage IA1 and IA2 must be diagnosed via microscopy (usually a cone biopsy). If a lesion is visible to the naked eye, it is at least Stage IB.

Q: A patient presents with bilateral ovarian cancer with capsule breached and ascites positive for malignant cells. What is the clinical stage?

Stage I. This question tests your knowledge of the **FIGO Staging for Ovarian Cancer**. The correct answer is **Stage I** because the disease is strictly confined to the ovaries. ### Explanation of the Correct Answer According to the FIGO staging system: * **Stage IA:** Tumor limited to one ovary, capsule intact, no tumor on surface, no malignant cells in ascites/peritoneal washings. * **Stage IB:** Tumor limited to **both ovaries**, capsules intact, no tumor on surface, no malignant cells in ascites. * **Stage IC:** Tumor limited to one or both ovaries with any of the following: * IC1: Surgical spill. * IC2: Capsule ruptured before surgery or tumor on ovarian surface. * **IC3: Malignant cells in the ascites or peritoneal washings.** In this scenario, since the cancer is bilateral and the ascites is positive for malignant cells, it is classified as **Stage IC3**, which falls under the broader category of **Stage I**. ### Why Other Options are Incorrect * **Stage II:** Requires pelvic extension (e.g., involvement of uterus, fallopian tubes, bladder, or rectum) below the pelvic brim. * **Stage III:** Involves spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes. * **Stage IV:** Represents distant metastasis (e.g., pleural effusion with positive cytology, parenchymal metastases to liver/spleen, or extra-abdominal organs). ### NEET-PG High-Yield Pearls 1. **Most Common Presentation:** Most ovarian cancers (approx. 75%) are diagnosed at **Stage III** because they are asymptomatic in early stages. 2. **Prognostic Factor:** The presence of malignant cells in ascites (Stage IC3) significantly worsens the prognosis compared to Stage IA or IB. 3. **Lymph Node Involvement:** If only retroperitoneal lymph nodes are involved, it is **Stage IIIA1**. 4. **Liver Involvement:** Liver **surface** involvement is Stage III; Liver **parenchymal** involvement is Stage IVB.

Q: What is the earliest symptom of carcinoma of the cervix?

Irregular vaginal bleeding. **Explanation:** Carcinoma of the cervix typically presents with symptoms related to the erosion and friability of the neoplastic tissue. **1. Why "Irregular Vaginal Bleeding" is correct:** The earliest and most common clinical manifestation of cervical cancer is **irregular vaginal bleeding** (intermenstrual bleeding). As the malignant cells replace the normal cervical epithelium, the surface becomes vascular and fragile. Spontaneous breakdown of these superficial vessels leads to irregular bleeding episodes. In post-menopausal women, any vaginal bleeding is considered a "red flag" for malignancy until proven otherwise. **2. Analysis of Incorrect Options:** * **Post-coital bleeding (Option B):** While this is a **highly specific** and classic sign of cervical cancer, it is often considered a subset of irregular bleeding. In many clinical textbooks (including Shaw’s and Dutta), irregular bleeding is cited as the earliest symptom overall, whereas post-coital bleeding is the most characteristic early sign. * **Foul-smelling vaginal discharge (Option C):** This occurs in more advanced stages. It is caused by the necrosis of the tumor mass and secondary infection (often anaerobic). * **Pain (Option D):** Pain is a **late feature** of cervical cancer. It signifies the spread of the disease to the parametrium, pelvic wall, or involvement of the lumbosacral plexus (Stage IIIB or IV). **Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (80-85%). * **Screening:** PAP smear is the most effective screening tool; the transformation zone is the most common site of origin. * **Staging:** Cervical cancer is staged **clinically** (FIGO staging). * **Triad of advanced disease:** Leg edema, hydronephrosis, and sciatic pain (indicates pelvic wall involvement).

Question 1

Radical hysterectomy is indicated in which of the following conditions?

Accepted Answer

Carcinoma of the cervix stage IB

Answer

Carcinoma in situ

Answer

Endocervix cancer stage IA

Answer

Microinvasive carcinoma of the cervix

Question 2

A 60-year-old woman, twelve years postmenopausal, presents with an ovarian carcinoma discovered during laparotomy. Which ovarian tumor is most likely to respond to radiotherapy?

Accepted Answer

Dysgerminoma

Answer

Krukenberg's tumor

Answer

Arrhenoblastoma

Answer

Granulosa cell tumor

Question 3

In a young woman diagnosed with stage Ib cervical cancer, which structure is not removed during a radical hysterectomy?

Accepted Answer

Both ovaries

Answer

Uterosacral and uterovesical ligaments

Answer

Pelvic lymph nodes

Answer

Upper third of the vagina

Question 4

What is the next line of management for a perimenopausal woman who has an ASCUS (atypical squamous cells of unknown significance) reported on a Pap smear?

Accepted Answer

Colposcopy

Answer

Loop excision

Answer

Conization

Answer

Hysterectomy

Question 5

What is the earliest symptom of cervical cancer?

Accepted Answer

Bleeding per vagina

Answer

Dyspareunia

Answer

Pain

Answer

Leukorrhoea

Question 6

Which of the following is a feature of stage lb2 cancer of the cervix?

Accepted Answer

Microinvasive carcinoma with stromal invasion > 5 mm

Answer

Microinvasive carcinoma with stromal invasion < 3 mm

Answer

Microinvasive carcinoma with stromal invasion < 5 mm

Answer

Size of lesion <= 4 cm

Question 7

What is the treatment of stage I teratoma?

Accepted Answer

Observation

Answer

Chemotherapy

Answer

Radiotherapy

Answer

Surgery

Question 8

Which of the following histological patterns of endometrial carcinoma has the worst prognosis?

Accepted Answer

Clear cell Carcinoma

Answer

Adenoacanthoma

Answer

Adenocarcinoma

Answer

Papillary Carcinoma

Question 9

A patient presents with bilateral ovarian cancer with capsule breached and ascites positive for malignant cells. What is the clinical stage?

Accepted Answer

Stage I

Answer

Stage II

Answer

Stage III

Answer

Stage IV

Question 10

What is the earliest symptom of carcinoma of the cervix?

Accepted Answer

Irregular vaginal bleeding

Answer

Post-coital bleeding

Answer

Foul-smelling vaginal discharge

Answer

Pain

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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