Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 401: What are the treatment options for stage IV endometrial carcinoma?

A. Surgery alone
B. Chemotherapy alone
C. Radiotherapy alone
D. Surgery, Radiotherapy, Chemotherapy, and Hormonal therapy (Correct Answer)

Explanation: **Explanation:** Stage IV endometrial carcinoma represents advanced disease where the tumor has spread to the bladder/bowel mucosa (Stage IVA) or distant organs/lymph nodes (Stage IVB). Because the disease is both locally extensive and systemic, a **multimodal treatment approach** is required to achieve cytoreduction and palliation. **Why Option D is Correct:** The management of Stage IV disease is rarely curative and focuses on a combination of therapies: * **Surgery:** Cytoreductive surgery (debulking) is performed if feasible to reduce tumor burden. Palliative surgery may also be needed to address complications like bowel obstruction. * **Chemotherapy:** This is the mainstay for systemic control. The standard regimen is typically **Carboplatin and Paclitaxel**. * **Radiotherapy:** Used for local pelvic control or to palliate symptomatic bone or brain metastases. * **Hormonal Therapy:** Progestins (e.g., Medroxyprogesterone acetate) are used, especially in patients with low-grade, hormone-receptor-positive tumors or those who cannot tolerate aggressive chemotherapy. **Why Other Options are Incorrect:** * **Option A, B, & C:** These represent monotherapies. While surgery, chemo, or radiation may be used individually in early stages (Stage I/II), they are insufficient alone for Stage IV. Using only one modality fails to address both the local primary site and the distant metastatic spread characteristic of advanced disease. **High-Yield NEET-PG Pearls:** * **Most common histological type:** Endometrioid adenocarcinoma. * **Precursor lesion:** Atypical Endometrial Hyperplasia (EIN). * **Staging System:** Endometrial cancer is **surgically staged** (FIGO staging). * **Drug of choice for hormonal therapy:** High-dose Progestins. * **Lynch Syndrome (HNPCC):** Always screen for this in young patients with endometrial cancer; it carries a significantly increased lifetime risk.

Question 402: A 15 cm x 15 cm ovarian cyst has been diagnosed in an 8-week pregnant lady. Further management includes:

A. Only follow-up without surgical intervention
B. Laparotomy at 14-16 weeks (Correct Answer)
C. Cesarean delivery and ovariotomy at term
D. Surgery after delivery

Explanation: ### Explanation The management of an adnexal mass in pregnancy depends on the size of the cyst, its sonographic features, and the gestational age. **Why Option B is Correct:** A 15 cm ovarian cyst is considered large (typically >6–10 cm) and carries a high risk of **torsion, rupture, or labor obstruction**. The ideal time for surgical intervention is the **early second trimester (14–16 weeks)**. * By this time, the **luteo-placental shift** is complete (the placenta has taken over progesterone production from the corpus luteum), significantly reducing the risk of miscarriage. * The uterus is not yet large enough to technically obstruct the surgical field, making the procedure safer than in the third trimester. **Why Other Options are Incorrect:** * **Option A:** Observation is reserved for simple cysts <6 cm, which often resolve spontaneously. A 15 cm cyst is unlikely to resolve and poses an immediate risk of torsion. * **Option C & D:** Delaying surgery until term or postpartum increases the risk of emergency complications (torsion/rupture) throughout the pregnancy and may necessitate an emergency laparotomy, which carries higher maternal and fetal morbidity than an elective mid-trimester procedure. **High-Yield Clinical Pearls for NEET-PG:** * **Most common ovarian cyst in pregnancy:** Corpus luteum cyst (usually regresses by 12–14 weeks). * **Most common benign neoplasm in pregnancy:** Mature cystic teratoma (Dermoid). * **Indications for surgery:** Size >10 cm, solid components/papillary projections on ultrasound (suspicion of malignancy), or acute complications (torsion). * **Laparoscopy vs. Laparotomy:** While laparotomy is the traditional answer, laparoscopy is now considered safe in the second trimester if performed by an expert.

Question 403: Which of the following is NOT an investigation for early-stage carcinoma of the cervix?

A. Surface biopsy
B. Ultrasound (Correct Answer)
C. Colposcopy-guided biopsy
D. Schiller's test

Explanation: **Explanation:** The diagnosis and staging of **Carcinoma Cervix** are primarily clinical. According to the **FIGO staging (revised 2018)**, while imaging like MRI or CT can be used for staging, **Ultrasound (USG)** is not a standard investigation for the primary diagnosis or evaluation of early-stage cervical cancer. USG lacks the sensitivity to detect micro-invasion or accurately delineate small cervical lesions. **Why the other options are incorrect (Used in diagnosis):** * **Schiller’s Test:** This is a screening/diagnostic aid where Lugol’s iodine is applied to the cervix. Normal squamous epithelium contains glycogen and turns mahogany brown. Dysplastic or cancerous cells are glycogen-deficient and remain **unstained (Schiller positive)**, helping to identify suspicious areas. * **Colposcopy-guided Biopsy:** This is the **Gold Standard** for diagnosing early-stage cervical cancer. Colposcopy allows for the visualization of abnormal vascular patterns (punctations, mosaicism), and a directed biopsy provides the definitive histological diagnosis. * **Surface Biopsy (Punch Biopsy):** This involves taking a tissue sample from the surface of a visible growth or a suspicious area identified during a speculum examination. It is a fundamental step in confirming malignancy. **High-Yield Clinical Pearls for NEET-PG:** 1. **FIGO Staging:** Carcinoma cervix is staged **clinically**. However, the 2018 revision allows the use of "available" imaging (MRI/CT) and pathology to supplement findings. 2. **Definitive Diagnosis:** Always requires a **histopathological examination (biopsy)**. 3. **IOC for Parametrial Involvement:** MRI is the investigation of choice to assess local spread and parametrial invasion. 4. **Screening:** Pap smear is the most common screening tool, while HPV DNA testing is the most sensitive.

Question 404: Which of the following is NOT a criterion for diagnosing gestational trophoblastic neoplasia (GTN)?

A. Persistently increasing p-hCG for 3 weeks
B. Plateau levels of p-hCG for 4 weeks
C. Theca lutein cyst > 6 cm (Correct Answer)
D. Histological criteria for choriocarcinoma

Explanation: The diagnosis of **Gestational Trophoblastic Neoplasia (GTN)** is primarily based on the FIGO (International Federation of Gynecology and Obstetrics) criteria following the evacuation of a hydatidiform mole. ### Why Option C is Correct **Theca lutein cysts** are common findings in molar pregnancies due to the massive stimulation of ovaries by high levels of β-hCG. While their presence (especially if >6 cm) indicates a high risk for subsequent malignant transformation, they are **not a diagnostic criterion** for GTN. They are considered a feature of "High-Risk Molar Pregnancy" but do not define the transition to neoplasia. ### Explanation of Incorrect Options (Diagnostic Criteria) According to FIGO, GTN is diagnosed if any of the following are present: * **Option A (Rise in hCG):** A rise in serum β-hCG levels for three consecutive weekly measurements (days 1, 7, and 14). * **Option B (Plateau in hCG):** A plateau of serum β-hCG levels (±10%) for four consecutive weekly measurements (days 1, 7, 14, and 21). * **Option D (Histology):** A histological diagnosis of **choriocarcinoma** or epithelioid trophoblastic tumor is definitive for GTN, regardless of hCG levels. ### High-Yield Clinical Pearls for NEET-PG * **Imaging:** The presence of radiological evidence of metastasis (e.g., on CXR or CT) in the presence of elevated hCG is also a criterion for GTN. * **Follow-up:** After molar evacuation, β-hCG should be monitored weekly until three consecutive samples are negative (<5 mIU/mL), then monthly for 6 months. * **Management:** Once GTN is diagnosed, the **WHO Modified FIGO Scoring System** is used to categorize patients into Low Risk (Score ≤6, treated with Methotrexate) or High Risk (Score ≥7, treated with EMA-CO regimen).

Question 405: All of the following are markers for malignant germ cell tumors of the ovary except?

A. CA-125 (Correct Answer)
B. Alpha fetoprotein
C. HCG
D. LDH

Explanation: **Explanation:** The correct answer is **A. CA-125**. **1. Why CA-125 is the correct answer:** CA-125 (Cancer Antigen 125) is the primary tumor marker for **Epithelial Ovarian Tumors** (specifically serous cystadenocarcinoma), not Germ Cell Tumors (GCTs). While it can be non-specifically elevated in various conditions like endometriosis, PID, or pregnancy, it is not a diagnostic marker for the germ cell lineage. **2. Analysis of other options (Markers for GCTs):** Malignant Germ Cell Tumors (MGCTs) are characterized by the production of specific proteins depending on the tissue of origin: * **Alpha-fetoprotein (AFP):** This is the highly specific marker for **Endodermal Sinus Tumors (Yolk Sac Tumors)**. It is also elevated in immature teratomas and mixed GCTs. * **Human Chorionic Gonadotropin (HCG):** This is the classic marker for **Nongestational Choriocarcinoma**. It is also produced by syncytiotrophoblastic giant cells in some dysgerminomas. * **Lactate Dehydrogenase (LDH):** This is the characteristic marker for **Dysgerminoma**. It is useful for both diagnosis and monitoring treatment response. **3. High-Yield Clinical Pearls for NEET-PG:** * **Dysgerminoma:** Most common malignant GCT; Markers = **LDH**, Placental Alkaline Phosphatase (PLAP). * **Yolk Sac Tumor:** Most common GCT in young children; Marker = **AFP** (Schiller-Duval bodies on histology). * **Immature Teratoma:** Marker = **AFP** (sometimes LDH or CA-125, but AFP is most characteristic). * **Mixed GCT:** Often shows elevation of both AFP and HCG. * **Rule of Thumb:** In a young girl with an adnexal mass, always order AFP, HCG, and LDH to rule out MGCTs.

Question 406: A 40-year-old lady with breast cancer has undergone Modified Radical Mastectomy (MRM) and is on Tamoxifen for 1 year. She now presents with bleeding per vaginum 4-5 times. What is the probable cause?

A. Bleeding disorder
B. Endometrial cancer (Correct Answer)
C. Ovarian cancer
D. Cervical cancer

Explanation: **Explanation:** The correct answer is **Endometrial cancer**. **1. Why Endometrial Cancer is the correct answer:** Tamoxifen is a Selective Estrogen Receptor Modulator (SERM). While it acts as an **estrogen antagonist** in breast tissue (making it effective for breast cancer treatment), it acts as a **partial estrogen agonist** in the uterus. This estrogenic stimulation leads to endometrial hyperplasia, polyp formation, and significantly increases the risk of **Endometrial Carcinoma** (specifically Type 1, endometrioid variety). In a patient on Tamoxifen presenting with postmenopausal or abnormal uterine bleeding (AUB), endometrial malignancy must be ruled out first via transvaginal ultrasound (TVS) and endometrial biopsy. **2. Why other options are incorrect:** * **Bleeding disorder:** While systemic coagulopathies can cause AUB, they are less likely in a 40-year-old with a specific pharmacological trigger (Tamoxifen). * **Ovarian cancer:** Ovarian cancer typically presents with abdominal distension, bloating, or adnexal masses rather than direct vaginal bleeding. * **Cervical cancer:** Though it causes post-coital or intermenstrual bleeding, it is not pharmacologically linked to Tamoxifen use. **Clinical Pearls for NEET-PG:** * **Tamoxifen Risk:** The risk of endometrial cancer is dose and duration-dependent (usually seen after 1–2 years of use). * **Monitoring:** Routine screening with TVS or biopsy is **not** recommended for asymptomatic women on Tamoxifen; however, any instance of abnormal bleeding requires immediate investigation. * **Alternative:** **Raloxifene**, another SERM used for osteoporosis, acts as an estrogen antagonist in both the breast and uterus, thus it does *not* increase the risk of endometrial cancer. * **Investigation of Choice:** The gold standard for diagnosing endometrial pathology in this patient is a **Fractional Curettage** or **Hysteroscopic-guided biopsy**.

Question 407: Hydatidiform mole is principally a disease of:

A. Amnion
B. Chorion (Correct Answer)
C. Uterus
D. Decidua

Explanation: **Explanation:** Hydatidiform mole (Gestational Trophoblastic Disease) is characterized by the abnormal proliferation of the **trophoblast**, which is the cellular component of the **chorion**. **1. Why Chorion is Correct:** The fundamental pathology of a hydatidiform mole involves two key changes in the chorionic villi: **trophoblastic proliferation** (hyperplasia of cytotrophoblasts and syncytiotrophoblasts) and **hydropic degeneration** (swelling) of the stroma. Since the chorion is the outermost fetal membrane that forms these villi, the disease is fundamentally a disorder of the chorion. **2. Why Other Options are Incorrect:** * **Amnion:** This is the inner fetal membrane that surrounds the amniotic fluid. It does not contain trophoblastic tissue and is not involved in the neoplastic process of a mole. * **Uterus:** While the disease manifests *within* the uterus, the uterus is merely the site of growth. The primary pathology originates from fetal (trophoblastic) tissue, not the maternal uterine myometrium. * **Decidua:** This is the modified endometrium during pregnancy (maternal origin). While the trophoblasts invade the decidua, the disease itself does not arise from decidual cells. **Clinical Pearls for NEET-PG:** * **Karyotype:** Complete Mole is typically **46,XX** (all paternal DNA; "empty egg" fertilized by one sperm that duplicates); Partial Mole is typically **69,XXX/XXY** (triploidy; normal egg fertilized by two sperm). * **Snowstorm Appearance:** The classic ultrasound finding due to hydropic villi. * **HCG Levels:** Markedly elevated in complete moles, often exceeding 100,000 mIU/mL. * **Theca Lutein Cysts:** Often seen bilaterally due to extreme HCG stimulation of the ovaries.

Question 408: Prophylactic chemotherapy in Gestational Trophoblastic Disease (GTD) is indicated for which of the following?

A. Theca lutein cyst
B. Hyperthyroidism
C. High initial beta-hCG level (Correct Answer)
D. Partial mole

Explanation: **Explanation:** Gestational Trophoblastic Disease (GTD) carries a risk of progressing to Gestational Trophoblastic Neoplasia (GTN). While routine prophylactic chemotherapy after the evacuation of a hydatidiform mole is controversial and not universally recommended, it is specifically considered for **"High-Risk" Complete Moles** where the risk of malignant transformation exceeds 20%. **Why Option C is Correct:** A **high initial beta-hCG level (>100,000 mIU/mL)** is a primary indicator of high trophoblastic proliferation. Along with excessive uterine size for gestational age and large theca lutein cysts, it categorizes a patient as "High-Risk." In such cases, a single dose of Methotrexate or Actinomycin-D may be administered to reduce the incidence of post-molar GTN, especially if reliable follow-up is unavailable. **Analysis of Incorrect Options:** * **A & B (Theca lutein cysts and Hyperthyroidism):** While these are clinical features of a "High-Risk" mole (due to high hCG levels), they are considered **symptoms/complications** rather than independent indications for chemotherapy. They usually resolve spontaneously following the evacuation of the mole. * **D (Partial mole):** Partial moles have a very low risk of malignant transformation (<1–5%) compared to complete moles (15–20%). Therefore, prophylactic chemotherapy is never indicated for a partial mole. **NEET-PG High-Yield Pearls:** * **Risk Factors for GTN:** Age >40 years, hCG >100,000 mIU/mL, uterine size >20 weeks, and theca lutein cysts >6 cm. * **Standard Management:** Suction and evacuation is the treatment of choice for all molar pregnancies. * **Follow-up:** Weekly beta-hCG monitoring until three consecutive negative results, then monthly for 6 months. * **Contraception:** Combined Oral Contraceptive Pills (COCs) are preferred during follow-up to prevent pregnancy from confusing hCG interpretation.

Question 409: What is the serum tumor marker for trophoblastic tumors?

A. alpha HCG
B. Calcitonin
C. beta HCG (Correct Answer)
D. gamma HCG

Explanation: **Explanation:** **Correct Answer: C. beta HCG** **Medical Concept:** Human Chorionic Gonadotropin (HCG) is a glycoprotein hormone produced by syncytiotrophoblast cells. It consists of two subunits: alpha ($\alpha$) and beta ($\beta$). While the alpha subunit is identical to those found in LH, FSH, and TSH, the **beta subunit is unique** to HCG. Therefore, the $\beta$-HCG assay is highly specific and serves as the definitive tumor marker for **Gestational Trophoblastic Neoplasia (GTN)**, including Hydatidiform mole and Choriocarcinoma. It is used for diagnosis, monitoring treatment response, and detecting recurrence. **Analysis of Incorrect Options:** * **A. alpha HCG:** This subunit is non-specific. Because it shares the same amino acid sequence as the $\alpha$-subunits of LH, FSH, and TSH, measuring it would result in cross-reactivity and false positives. * **B. Calcitonin:** This is the tumor marker for **Medullary Carcinoma of the Thyroid**, produced by the parafollicular C-cells. It has no association with trophoblastic tissue. * **D. gamma HCG:** This is a fictitious term in this context; there is no "gamma" subunit of HCG used in clinical diagnostics. **NEET-PG High-Yield Pearls:** * **Monitoring:** After evacuation of a molar pregnancy, $\beta$-HCG should be monitored weekly until three consecutive negative results are obtained, then monthly for 6 months. * **Hook Effect:** In cases of extremely high $\beta$-HCG (as in some molar pregnancies), a lab may report a false low result. Dilution of the serum is required to get an accurate reading. * **Other Markers:** While $\beta$-HCG is the primary marker for GTN, **Placental Alkaline Phosphatase (PLAP)** is a marker for Dysgerminoma, and **AFP** is for Yolk Sac Tumors.

Question 410: A 22-year-old woman with Turner syndrome has a 2.5-centimeter mass in the right adnexa. An abdominal radiograph reveals focal areas of calcification in the mass. What is the most likely diagnosis?

A. Cystic teratoma
B. Dysgerminoma
C. Fibroma
D. Gonadoblastoma (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Gonadoblastoma** The key to this diagnosis lies in the association between **Turner syndrome (45,X/46,XY mosaicism)** and the presence of a calcified adnexal mass. While most Turner syndrome patients have a 45,X karyotype, approximately 5–10% possess Y-chromosome material (mosaicism). These patients have "streak gonads" that are at a significantly high risk (up to 30%) of developing a **Gonadoblastoma**. A pathognomonic feature of Gonadoblastoma is the presence of **calcifications** (psammoma bodies), which are frequently visible on a plain abdominal radiograph. While Gonadoblastoma is a benign precursor, it has a high propensity to transform into malignant Dysgerminoma; therefore, prophylactic gonadectomy is indicated in any Turner patient with Y-chromosomal material. **Why other options are incorrect:** * **A. Cystic Teratoma:** While these are the most common germ cell tumors in young women and often contain calcifications (teeth/bone), they are not specifically associated with the dysgenetic gonads of Turner syndrome. * **B. Dysgerminoma:** This is the most common malignant germ cell tumor. While a Gonadoblastoma can progress to a Dysgerminoma, the classic radiographic finding of focal stippled calcification in a patient with Turner syndrome points primarily to Gonadoblastoma. * **C. Fibroma:** These are benign sex cord-stromal tumors usually seen in older women. While they can be associated with Meigs syndrome, they do not typically present with the focal calcifications seen in this clinical context. **NEET-PG High-Yield Pearls:** * **Karyotype Risk:** The risk of Gonadoblastoma in Turner syndrome exists only if **Y-chromosome material** is present. * **Radiology:** "Stippled calcification" in the pelvis of a young phenotypic female with primary amenorrhea is a classic "buzzword" for Gonadoblastoma. * **Management:** Prophylactic bilateral gonadectomy is recommended as soon as Y-chromosomal material is identified in a patient with gonadal dysgenesis.

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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