Gynecologic Oncology Practice Questions

Q: The procedure shown below is

Large loop excision of transformation zone. ***Large loop excision of transformation zone*** - **LLETZ** uses a **wire loop electrode** with electrical current to excise abnormal cervical tissue at the **transformation zone**. - It is the standard procedure for treating **cervical intraepithelial neoplasia (CIN)** and obtaining tissue for histological diagnosis. *Radical trachelectomy* - This is a **fertility-sparing surgery** for **early cervical cancer** that removes the cervix and upper vagina while preserving the uterus. - It requires **open surgical approach** or **laparoscopy**, not a simple outpatient electrosurgical procedure. *Partial hysterectomy* - Involves **surgical removal** of the **uterine body** while leaving the cervix intact (also called supracervical hysterectomy). - This is a **major surgical procedure** requiring general anesthesia, not an office-based cervical treatment. *Dilatation and curettage* - **D&C** involves **dilating the cervix** and **scraping the endometrial lining** using a curette for diagnostic or therapeutic purposes. - This procedure targets the **uterine cavity**, not the cervical transformation zone where CIN occurs.

Q: What is the commonest tumor of the ovary occurring in a young woman?

Dysgerminoma. **Explanation:** The correct answer is **Dysgerminoma**. **1. Why Dysgerminoma is correct:** Germ Cell Tumors (GCTs) are the most common ovarian neoplasms in children and young women (under age 30). Among malignant GCTs, **Dysgerminoma** is the most frequent subtype, accounting for approximately 50% of cases. It is the female counterpart of the testicular seminoma. It typically presents in the second and third decades of life and is highly radiosensitive and chemosensitive. **2. Why the other options are incorrect:** * **Immature Teratoma:** While this is a common malignant GCT in young women, it is less frequent than Dysgerminoma. It is characterized by the presence of primitive neuroectodermal tissue. * **Yolk Sac Tumor (Endodermal Sinus Tumor):** This is the second most common malignant GCT. It is highly aggressive and characterized by elevated **AFP** levels and the presence of **Schiller-Duval bodies** on histology. * **Endometrioid Tumor:** This is a subtype of Surface Epithelial Tumors. These occur predominantly in peri-menopausal or post-menopausal women (ages 50–60) and are often associated with endometriosis. **3. NEET-PG High-Yield Pearls:** * **Most common ovarian tumor overall:** Serous Cystadenoma (Benign). * **Most common malignant ovarian tumor overall:** Serous Cystadenocarcinoma (Epithelial). * **Tumor Marker for Dysgerminoma:** LDH (Lactate Dehydrogenase) and sometimes hCG. * **Association:** Dysgerminomas are associated with gonadal dysgenesis (Swyer Syndrome). * **Bilateralism:** Dysgerminoma is the only malignant GCT that is frequently bilateral (10-15%).

Q: What is the treatment of choice for hydatiform mole with a uterine size of 28 weeks?

Suction evacuation. **Explanation:** The treatment of choice for a hydatidiform mole, regardless of the uterine size, is **Suction Evacuation**. This is the gold standard because it allows for rapid, controlled removal of molar tissue while minimizing the risk of uterine perforation and excessive blood loss. Even in cases where the uterus is significantly enlarged (e.g., 28 weeks), suction evacuation is preferred over medical or surgical induction. **Analysis of Options:** * **Option A (Correct):** Suction evacuation is the definitive management. A large-bore cannula (10–12 mm) is used. It is recommended to start an Oxytocin infusion *after* the evacuation has begun to ensure uterine contraction and reduce hemorrhage. * **Option B & C (Incorrect):** Medical induction using saline, oxytocin, or prostaglandins (Misoprostol/Mifepristone) is **contraindicated**. These methods increase the risk of uterine contractions forcing trophoblastic tissue into the systemic circulation, potentially leading to **trophoblastic embolization** and respiratory distress. Furthermore, medical methods often result in incomplete evacuation. * **Option D (Incorrect):** Methotrexate is a chemotherapeutic agent used for Gestational Trophoblastic Neoplasia (GTN) or ectopic pregnancy. It is not the primary treatment for an evacuation of a molar pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** "Snowstorm appearance" on USG and disproportionately high Beta-hCG levels. * **Theca Lutein Cysts:** Often associated with large moles; these usually regress spontaneously after evacuation and do not require surgery. * **Follow-up:** Essential to monitor Beta-hCG levels weekly until three consecutive negatives are achieved to rule out progression to Choriocarcinoma. * **Hysterectomy:** May be considered an alternative to suction evacuation only in women >40 years who have completed their family, to reduce the risk of post-molar GTN.

Q: What is the percentage change of cystic glandular hyperplasia turning to malignancy?

1%. **Explanation:** The risk of progression from endometrial hyperplasia to malignancy is primarily determined by the presence of **cellular atypia**. This classification is based on the classic **Kurman’s criteria**, which is a high-yield topic for NEET-PG. **1. Why Option C (1%) is Correct:** Cystic glandular hyperplasia (also known as **Simple Hyperplasia without atypia**) is characterized by an increase in the number of glands which may be dilated (cystic), but the cells lining these glands do not show any nuclear features of malignancy. Because there is no atypia, the risk of progression to endometrial carcinoma is very low, historically cited as **1%**. **2. Analysis of Incorrect Options:** * **Option A (0.10%):** This value is too low; while the risk is minimal, it is clinically recognized as 1% over a long-term follow-up. * **Option B (2%):** While close, 1% is the standard textbook figure for simple hyperplasia without atypia. * **Option D (10%):** This figure is more representative of **Complex Hyperplasia without atypia** (which has a ~3% risk) or approaching the risk of **Simple Hyperplasia with atypia** (~8-10%). **3. Clinical Pearls & High-Yield Facts:** To master this topic for the exam, remember the **"1, 3, 8, 29" rule** for progression to cancer: * **Simple Hyperplasia (without atypia):** 1% risk. * **Complex Hyperplasia (without atypia):** 3% risk. * **Simple Hyperplasia with atypia:** 8% risk. * **Complex Hyperplasia with atypia:** 29% risk (often rounded to 30%). **Management Tip:** For hyperplasia without atypia, the treatment of choice is Progestogens (Medroxyprogesterone acetate). For hyperplasia with atypia (especially in postmenopausal women), the treatment of choice is Total Hysterectomy due to the high risk of coexisting or future malignancy.

Q: A 38-year-old woman with a history of multiple sexual partners is most at risk for which of the following?

Cervical carcinoma. **Explanation:** The correct answer is **Cervical Carcinoma**. **1. Why Cervical Carcinoma is Correct:** Cervical cancer is strongly associated with persistent infection by high-risk strains of **Human Papillomavirus (HPV)**, most commonly types 16 and 18. HPV is a sexually transmitted infection. Risk factors that increase the likelihood of HPV exposure and persistence include **multiple sexual partners**, early age at first intercourse, a high-risk male partner, and smoking. In this clinical scenario, the patient’s sexual history is the primary driver for cervical malignancy. **2. Why Other Options are Incorrect:** * **Bladder Carcinoma:** The primary risk factors are cigarette smoking and occupational exposure to aromatic amines (e.g., aniline dyes). It is not linked to sexual behavior. * **Endometrial Carcinoma:** This is primarily driven by **unopposed estrogen**. Risk factors include obesity, nulliparity, early menarche, late menopause, and PCOS. Sexual history is not a risk factor. * **Ovarian Carcinoma:** Risk is associated with "incessant ovulation." Factors like nulliparity and family history (BRCA mutations) increase risk, while combined oral contraceptives (COCs) and multiparity are protective. **3. NEET-PG High-Yield Pearls:** * **HPV 16** is the most common cause of Squamous Cell Carcinoma (SCC) of the cervix. * **HPV 18** is more frequently associated with Adenocarcinoma of the cervix. * The **Transformation Zone (Squamocolumnar Junction)** is the most common site for cervical neoplastic changes. * **Screening:** PAP smear (cytology) and HPV DNA testing are the gold standards for early detection. * **Vaccination:** The ideal age for HPV vaccination is 9–14 years (before sexual debut).

Q: Intrauterine exposure of diethylstilbestrol is associated with which of the following conditions?

Clear cell adenocarcinoma of the vagina. **Explanation:** **Diethylstilbestrol (DES)** is a synthetic non-steroidal estrogen that was historically prescribed to pregnant women to prevent miscarriages. However, it is now a classic medical example of **transplacental carcinogenesis**. **Why Option C is Correct:** Female fetuses exposed to DES in utero (often called "DES daughters") have a significantly increased risk of developing **Clear cell adenocarcinoma (CCAC) of the vagina and cervix**. The peak incidence occurs in the late teens and early twenties. The underlying mechanism involves the failure of the normal transformation of the Müllerian duct columnar epithelium into squamous epithelium, leading to **vaginal adenosis** (the presence of glandular tissue in the vagina), which serves as a precursor to CCAC. **Why Other Options are Incorrect:** * **Option A:** Squamous cell carcinoma of the cervix is primarily associated with high-risk Human Papillomavirus (HPV) infection (Types 16, 18), not DES exposure. * **Option B:** Endometrial adenocarcinoma is linked to prolonged unopposed estrogen exposure (obesity, PCOS, HRT), but not specifically to in utero DES exposure. * **Option D:** Uterine sarcomas are rare mesenchymal tumors and do not have a documented causal link with fetal DES exposure. **High-Yield Clinical Pearls for NEET-PG:** * **Structural Abnormalities:** DES exposure is also associated with a **T-shaped uterine cavity**, cervical collars, and cockscomb cervix. * **Vaginal Adenosis:** This is the most common benign finding in DES daughters (found in >30%). * **Male Offspring:** DES exposure in males is linked to epididymal cysts, cryptorchidism, and microphallus. * **Diagnosis:** CCAC is often found on the **upper third of the anterior vaginal wall**.

Q: Which of the following is the most common form of persistent trophoblastic disease that follows a non-molar pregnancy?

Choriocarcinoma. **Explanation:** The correct answer is **Choriocarcinoma**. Gestational Trophoblastic Neoplasia (GTN) can follow any type of pregnancy. However, the distribution of histological types varies significantly based on the preceding pregnancy: 1. **Choriocarcinoma:** This is the most common form of GTN following a **non-molar pregnancy** (normal term delivery, abortion, or ectopic pregnancy). Approximately 50% of choriocarcinomas arise from hydatidiform moles, 25% from abortions, and 25% from term pregnancies. It is characterized by the absence of chorionic villi and early hematogenous spread, most commonly to the lungs. 2. **Invasive Mole:** This almost exclusively follows a **hydatidiform mole** (usually complete). It is characterized by the presence of chorionic villi within the myometrium. It does not occur after a term pregnancy or abortion. 3. **Placental Site Trophoblastic Tumor (PSTT):** This is a rare variant that arises from intermediate trophoblasts. While it can follow any pregnancy, it is much less common than choriocarcinoma. 4. **Partial Mole:** This is a type of hydatidiform mole (usually triploid 69,XXX or 69,XXY) and is a *precursor* to persistent disease, not the form of the persistent disease itself. **NEET-PG High-Yield Pearls:** * **Most common site of metastasis:** Lungs (presents as "cannonball" shadows on X-ray). * **Tumor Marker:** Beta-hCG is the sensitive marker for diagnosis and monitoring. * **PSTT characteristic:** Produces low levels of hCG but high levels of Human Placental Lactogen (hPL); it is relatively chemoresistant and often requires surgery. * **Rule of Thumb:** If GTN follows a term pregnancy, it is **always** a choriocarcinoma.

Q: A 38-year-old female has a Pap smear suggestive of HSIL. Colposcopy-directed biopsy can reveal all of the following, EXCEPT:

Cervical intraepithelial neoplasia grade 1 (CIN-1). ### Explanation The core concept here is the correlation between **Cytology** (Pap smear) and **Histology** (Biopsy). **Why Option A is the correct answer:** According to the Bethesda System, **HSIL (High-grade Squamous Intraepithelial Lesion)** on a Pap smear is a cytological category that encompasses high-grade changes. Histologically, HSIL corresponds to **CIN-2, CIN-3, and Carcinoma in situ (CIS)**. **CIN-1** is histologically classified as **LSIL (Low-grade Squamous Intraepithelial Lesion)**. While a biopsy might occasionally show a lower grade than the Pap smear due to sampling error, in the context of standardized medical examinations, HSIL is defined by the presence of CIN-2 or worse. Therefore, CIN-1 is the "odd one out" as it represents a low-grade lesion. **Analysis of Incorrect Options:** * **B & C (CIN-2 and CIN-3):** These are the classic histological findings for a patient with HSIL cytology. CIN-2 (moderate dysplasia) and CIN-3 (severe dysplasia) involve the upper two-thirds or the full thickness of the epithelium, respectively. * **D (Carcinoma in situ):** This is the most advanced stage of CIN-3 where the full thickness of the epithelium is involved but the basement membrane remains intact. It is included under the umbrella of HSIL. **High-Yield Clinical Pearls for NEET-PG:** 1. **Bethesda Correlation:** * LSIL (Cytology) $\approx$ CIN-1 (Histology). * HSIL (Cytology) $\approx$ CIN-2, CIN-3, CIS (Histology). 2. **Management:** Any HSIL on Pap smear requires mandatory **Colposcopy** and directed biopsy. In some guidelines (ASCCP), "See and Treat" (LEEP) may be considered for HSIL in non-pregnant women over 25. 3. **Hallmark of CIN:** The presence of **koilocytes** (perinuclear halo with wrinkled nuclei) is characteristic of HPV infection, typically seen in LSIL/CIN-1.

Question 1

The procedure shown below is

Accepted Answer

Large loop excision of transformation zone

Answer

Radical trachelectomy

Answer

Partial hysterectomy

Answer

Dilatation and curettage

Question 2

What is the commonest tumor of the ovary occurring in a young woman?

Accepted Answer

Dysgerminoma

Answer

Immature teratoma

Answer

Yolk sac tumor

Answer

Endometrioid tumor

Question 3

What is the treatment of choice for hydatiform mole with a uterine size of 28 weeks?

Accepted Answer

Suction evacuation

Answer

Intra-amniotic saline followed by oxytocin

Answer

Evacuation by misoprostol and Mifepristone

Answer

Methotrexate administration

Question 4

All are signs of inoperability of carcinoma of the cervix except?

Accepted Answer

Carcinoma of the cervix extending to the parametrium

Answer

Presence of extrapelvic metastasis

Answer

Involvement of the bladder

Answer

Extensive infiltration of the vagina

Question 5

What is the percentage change of cystic glandular hyperplasia turning to malignancy?

Accepted Answer

1%

Answer

0.10%

Answer

2%

Answer

10%

Question 6

A 38-year-old woman with a history of multiple sexual partners is most at risk for which of the following?

Accepted Answer

Cervical carcinoma

Answer

Bladder carcinoma

Answer

Endometrial carcinoma

Answer

Ovarian carcinoma

Question 7

Intrauterine exposure of diethylstilbestrol is associated with which of the following conditions?

Accepted Answer

Clear cell adenocarcinoma of the vagina

Answer

Squamous cell carcinoma of the cervix

Answer

Adenocarcinoma of the endometrium

Answer

Sarcoma of the uterus

Question 8

A woman presents with a 12-week pregnancy complaining of excessive vomiting and mild vaginal bleeding for two weeks. Her fundal height measures 16 weeks, and the cervical os is closed. An ultrasound reveals a snowstorm appearance in part of the uterus along with a fetus measuring 10 weeks crown-rump length. Fetal heart activity is absent. What is the best management option?

Accepted Answer

Suction evacuation

Answer

Medical termination with vaginal misoprostol

Answer

Medical termination with an oxytocin infusion

Answer

Total abdominal hysterectomy

Question 9

Which of the following is the most common form of persistent trophoblastic disease that follows a non-molar pregnancy?

Accepted Answer

Choriocarcinoma

Answer

Invasive mole

Answer

Placental site trophoblastic tumor

Answer

Partial mole

Question 10

A 38-year-old female has a Pap smear suggestive of HSIL. Colposcopy-directed biopsy can reveal all of the following, EXCEPT:

Accepted Answer

Cervical intraepithelial neoplasia grade 1 (CIN-1)

Answer

Cervical intraepithelial neoplasia grade 2 (CIN-2)

Answer

Cervical intraepithelial neoplasia grade 3 (CIN-3)

Answer

Carcinoma in situ

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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