Gynecologic Oncology Practice Questions

Q: What is the standard dose of radiation delivered to Point B in the treatment of carcinoma of the cervix?

6000 cGy. In the management of Carcinoma Cervix, radiation therapy typically involves a combination of **External Beam Radiotherapy (EBRT)** and **Brachytherapy**. To standardize dosing, the Manchester system defines two specific points: * **Point A:** Located 2 cm superior to the external os and 2 cm lateral to the uterine canal. It represents the paracervical triangle where the uterine artery crosses the ureter. The standard curative dose to Point A is **7500–8500 cGy**. * **Point B:** Located 3 cm lateral to Point A (5 cm lateral to the midline). This point represents the **pelvic wall nodes** (obturator nodes). The standard dose delivered to Point B is approximately **6000 cGy** (usually 1/3rd less than Point A). **Analysis of Options:** * **Option B (6000 cGy):** Correct. This is the standard target dose for the pelvic side walls to ensure sterilization of regional lymph nodes while respecting the tolerance of surrounding structures. * **Option A (7000 cGy):** Incorrect. This dose is too high for the pelvic side wall (Point B) and may lead to significant morbidity, though it is closer to the dose required for the primary tumor at Point A. * **Option C (5000 cGy):** Incorrect. While 4500–5000 cGy is the standard dose for EBRT alone, the cumulative dose (EBRT + Brachytherapy) to Point B reaches 6000 cGy. * **Option D (10,000 cGy):** Incorrect. This exceeds the tolerance of pelvic tissues and would cause severe radiation necrosis. **High-Yield Clinical Pearls for NEET-PG:** * **Point A** is the primary site for calculating the dose to the central tumor. * **Point B** is used to assess the dose to the pelvic lymph nodes and the lateral spread. * The most common cause of death in Carcinoma Cervix is **Uremia** (due to ureteric obstruction). * The most common histological type is **Squamous Cell Carcinoma**.

Q: Incidence of choriocarcinoma is seen more after which of the following events?

Spontaneous abortion. **Explanation:** Choriocarcinoma is a highly malignant germ cell tumor arising from the trophoblastic epithelium. It can follow any type of pregnancy, but its incidence varies significantly depending on the preceding gestational event. **Why Spontaneous Abortion is the Correct Answer:** Statistically, approximately **50%** of choriocarcinoma cases follow a **hydatidiform mole**. However, among the options provided (which exclude molar pregnancy), **spontaneous abortion** accounts for about **25%** of cases. This makes it the most frequent precursor among the non-molar options listed. The underlying concept is that any pregnancy event where trophoblastic tissue is retained or undergoes malignant transformation can lead to choriocarcinoma. **Analysis of Incorrect Options:** * **Normal Delivery & Cesarean Section (Term Pregnancy):** Approximately **20-25%** of choriocarcinomas follow a full-term pregnancy. While significant, the incidence is statistically lower than the combined risk associated with molar pregnancies and abortions. * **Ectopic Pregnancy:** This is the rarest precursor, accounting for only about **2-5%** of choriocarcinoma cases. **NEET-PG High-Yield Pearls:** 1. **Distribution of Preceding Events:** Molar pregnancy (50%) > Spontaneous abortion (25%) > Term pregnancy (20-25%) > Ectopic pregnancy (2-5%). 2. **Tumor Marker:** Serum **beta-hCG** is the primary marker for diagnosis and monitoring treatment response. 3. **Metastasis:** Choriocarcinoma is characterized by early hematogenous spread, most commonly to the **lungs** (producing "cannonball" appearances on X-ray) and the **vagina**. 4. **Treatment:** It is highly chemosensitive; **Methotrexate** is the first-line agent for low-risk cases.

Q: A 35-year-year-old woman had been exposed in-utero to Diethylstilbestrol (DES), administered to her mother for a history of recurrent spontaneous abortion. This history suggests that the patient might be at increased risk of which of the following?

Clear cell adenocarcinoma. **Explanation:** The correct answer is **Clear cell adenocarcinoma (CCA)**. **1. Why Clear Cell Adenocarcinoma is correct:** Diethylstilbestrol (DES) is a synthetic non-steroidal estrogen that was historically prescribed to pregnant women to prevent miscarriages. Female offspring exposed to DES *in-utero* have a significantly increased risk (approximately 40-fold) of developing **Clear cell adenocarcinoma of the vagina and cervix**. The peak incidence occurs in the late teens and early twenties, though cases are reported into the 40s. The mechanism involves the disruption of the normal replacement of glandular epithelium by squamous epithelium in the fetal vagina, leading to **vaginal adenosis**, which serves as a precursor to CCA. **2. Why the other options are incorrect:** * **Adenomyosis:** This is the presence of endometrial glands within the myometrium. While DES exposure is linked to structural uterine anomalies (e.g., T-shaped uterus), it is not a primary risk factor for adenomyosis. * **Lichen sclerosus:** This is a chronic inflammatory skin condition of the vulva, typically seen in postmenopausal women. It is not associated with hormonal exposure *in-utero*. * **Squamous cell carcinoma (SCC):** SCC of the vagina/cervix is primarily associated with high-risk Human Papillomavirus (HPV) infection, not DES exposure. **3. NEET-PG High-Yield Pearls for DES Exposure:** * **Vaginal Findings:** Vaginal adenosis (most common), cervical cockscomb, collars, and pseudopolyps. * **Uterine Findings:** **T-shaped uterine cavity** (classic imaging finding) and hypoplastic uterus, leading to increased risk of ectopic pregnancy and preterm labor. * **Male Offspring:** Increased risk of cryptorchidism, epididymal cysts, and microphallus. * **Screening:** DES-exposed daughters require annual cytology from both the cervix and the vaginal walls (four-quadrant Pap smear).

Q: What is the most common cause of failure of radiotherapy for stage II cervical carcinoma?

Para-aortic node metastasis. **Explanation:** The primary goal of radiotherapy in Stage II cervical carcinoma is to treat the central tumor and the regional pelvic lymph nodes. The standard radiation field (pelvic field) typically extends up to the level of the L4-L5 vertebrae. **Why Para-aortic node metastasis is the correct answer:** The most common reason for radiotherapy failure in locally advanced cervical cancer is the presence of disease **outside the standard radiation field**. Para-aortic lymph nodes are located superior to the pelvic field. If a patient has occult or documented para-aortic metastasis, standard pelvic radiotherapy will fail to sterilize these nodes, leading to disease progression or recurrence. In Stage IIB, the incidence of para-aortic node involvement is approximately 10-20%, and these nodes act as a reservoir for systemic spread. **Analysis of Incorrect Options:** * **A & B (Liver and Bone Metastasis):** These represent distant hematogenous spread. While they signify failure, they occur less frequently as the *initial* site of failure compared to lymphatic spread in Stage II disease. * **D (Resistance of the central tumor):** With modern chemoradiation (Cisplatin-based), local control of the central tumor is generally high. Failure is more often due to "geographic miss" (nodes outside the field) than inherent radioresistance of the primary mass. **Clinical Pearls for NEET-PG:** * **Spread Pattern:** Cervical cancer spreads primarily via direct extension and the lymphatic system (Obturator → External Iliac → Internal Iliac → Common Iliac → Para-aortic). * **Extended Field Radiotherapy (EFRT):** If para-aortic nodes are positive on imaging (PET-CT/MRI), the radiation field must be extended upward to include the para-aortic region. * **Staging:** Remember that according to FIGO 2018 staging, involvement of para-aortic nodes automatically upgrades the disease to **Stage IIIC2**.

Q: What is the treatment of choice for placental site trophoblastic disease?

Surgery. **Explanation:** Placental Site Trophoblastic Tumor (PSTT) is a rare variant of Gestational Trophoblastic Neoplasia (GTN) arising from intermediate trophoblastic cells. Unlike Hydatidiform mole or Choriocarcinoma, PSTT is characterized by low production of hCG and, most importantly, **marked chemoresistance**. **Why Surgery is the Correct Answer:** The treatment of choice for PSTT is **Total Abdominal Hysterectomy (TAH)** with or without pelvic lymphadenectomy. Because the tumor is relatively insensitive to standard chemotherapy regimens (like EMA-CO), surgical resection of the primary disease is the only definitive way to achieve a cure in localized cases. Ovarian conservation is generally acceptable in young patients as adnexal involvement is rare. **Why Other Options are Incorrect:** * **Observation:** PSTT is a malignant condition with the potential for local invasion and distant metastasis; observation would lead to disease progression. * **Chemotherapy:** While the mainstay for Choriocarcinoma, it is only used as an adjuvant in PSTT for high-risk or metastatic disease (Stage II-IV). It is not the primary treatment of choice due to high resistance. * **Radiotherapy:** PSTT is not a primary radiosensitive tumor. Radiation is rarely used, except occasionally for palliation in brain metastases. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Intermediate trophoblasts at the placental site. * **Marker:** Characterized by **Human Placental Lactogen (hPL)**; serum β-hCG levels are typically low. * **Histology:** Absence of chorionic villi; presence of mononuclear trophoblastic cells infiltrating the myometrium. * **Prognostic Factor:** The most important prognostic factor is the **interval since the last pregnancy** (>2 years indicates a poor prognosis).

Q: Surgical staging of ovarian cancer includes all of the following except?

Omental biopsy. The surgical staging of ovarian cancer is primarily **surgical and pathological**, following the FIGO staging system. The goal is to identify microscopic spread that is not visible to the naked eye. ### **Explanation of the Correct Answer** **Option C (Omental biopsy)** is the correct answer because, in standard surgical staging, an **Infracolic Omentectomy** (removal of the omentum) is required, not just a biopsy. Since the omentum is a common site for "omental cakes" or microscopic seeding, removing the entire infracolic portion is mandatory to accurately stage the disease and provide a therapeutic benefit. A simple biopsy is insufficient and considered inadequate staging. ### **Analysis of Other Options** * **A. Peritoneal washing:** This is a mandatory first step upon entering the abdomen. Saline is instilled and aspirated for cytological examination to check for malignant cells (Stage IC). * **B. Peritoneal biopsy:** Random biopsies of the pelvic peritoneum, paracolic gutters, and the undersurface of the diaphragm are essential to detect occult metastasis. * **D. Palpation of organs:** A systematic exploration of the entire intra-abdominal cavity, including the liver surface, kidneys, and retroperitoneal lymph nodes, is a standard component of the staging procedure. ### **NEET-PG High-Yield Pearls** * **Staging System:** Ovarian cancer uses the **FIGO Staging** (Surgical). * **Standard Procedure:** Includes Total Abdominal Hysterectomy (TAH) + Bilateral Salpingo-Oophorectomy (BSO) + Infracolic Omentectomy + Pelvic/Para-aortic Lymphadenectomy + Peritoneal washings/biopsies. * **Most Common Spread:** Local shedding/seeding into the peritoneal cavity. * **Tumor Marker:** **CA-125** is the most common marker for epithelial ovarian cancer (useful for monitoring, not screening).

Q: Which among the following is the highest risk factor for molar pregnancy?

Advanced maternal age. **Explanation:** The risk of Gestational Trophoblastic Disease (GTD), specifically hydatidiform mole, is most significantly influenced by **extremes of maternal age**. **Why Advanced Maternal Age is the Correct Answer:** Women aged **>35 years** (and especially >40 years) have a significantly higher risk of molar pregnancy. For women over 40, the risk increases 5- to 10-fold compared to younger women. This is attributed to the declining quality of oocytes and an increased likelihood of abnormal fertilization events (such as dispermy or fertilization of an "empty" egg). Conversely, teenage pregnancy (<15-20 years) is also a recognized risk factor. **Why the Other Options are Incorrect:** * **Prior C-section:** While a prior C-section increases the risk of placenta accreta or scar ectopic pregnancy, it has no established causal link with the development of a molar pregnancy. * **Hypertension and Diabetes:** These are medical comorbidities that increase the risk of pre-eclampsia and macrosomia, respectively. While **early-onset pre-eclampsia** (before 20 weeks) is a *clinical feature* of a molar pregnancy, pre-existing hypertension or diabetes are not *risk factors* for its development. **NEET-PG High-Yield Pearls:** 1. **Most Important Risk Factor:** A **prior history of molar pregnancy** is actually the strongest risk factor (1% risk after one mole, 15-20% after two). However, among the options provided, **Advanced Maternal Age** is the correct choice. 2. **Nutritional Factors:** Low dietary intake of **Vitamin A (carotene)** and **animal fats** are also associated with an increased risk of complete moles. 3. **Blood Group:** Women with **Group A** blood type impregnated by Group O men have a slightly higher risk. 4. **Karyotype:** Remember, Complete Mole is usually **46,XX** (diploid, paternal origin), while Partial Mole is **69,XXY** (triploid).

Question 1

A patient presents with an ovarian tumor limited to the true pelvis with negative nodes and histologically confirmed seeding of the abdominal peritoneal surface. What is the exact grading?

Accepted Answer

III A

Answer

III B

Answer

III C

Answer

IV

Question 2

What is the most common ovarian cancer associated with endometriosis?

Accepted Answer

Clear cell tumor

Answer

Endometrioid tumor

Answer

Germ cell tumor

Answer

Brenner tumor

Question 3

What is the standard dose of radiation delivered to Point B in the treatment of carcinoma of the cervix?

Accepted Answer

6000 cGy

Answer

7000 cGy

Answer

5000 cGy

Answer

10,000 cGy

Question 4

Incidence of choriocarcinoma is seen more after which of the following events?

Accepted Answer

Spontaneous abortion

Answer

Ectopic pregnancy

Answer

Normal delivery

Answer

Cesarean section

Question 5

A 35-year-year-old woman had been exposed in-utero to Diethylstilbestrol (DES), administered to her mother for a history of recurrent spontaneous abortion. This history suggests that the patient might be at increased risk of which of the following?

Accepted Answer

Clear cell adenocarcinoma

Answer

Adenomyosis

Answer

Lichen sclerosus

Answer

Squamous cell carcinoma

Question 6

What is the most common cause of failure of radiotherapy for stage II cervical carcinoma?

Accepted Answer

Para-aortic node metastasis

Answer

Liver metastasis

Answer

Bone metastasis

Answer

Resistance of the central tumor

Question 7

What is the treatment of choice for placental site trophoblastic disease?

Accepted Answer

Surgery

Answer

Observation

Answer

Chemotherapy

Answer

Radiotherapy

Question 8

Surgical staging of ovarian cancer includes all of the following except?

Accepted Answer

Omental biopsy

Answer

Peritoneal washing

Answer

Peritoneal biopsy

Answer

Palpation of organs

Question 9

What is the treatment of choice in a postmenopausal lady with atypical endometrial hyperplasia?

Accepted Answer

Hysterectomy

Answer

Estrogens

Answer

Progestogens

Answer

Radiotherapy

Question 10

Which among the following is the highest risk factor for molar pregnancy?

Accepted Answer

Advanced maternal age

Answer

Prior C-section

Answer

Hypertension in pregnancy

Answer

Diabetes in pregnancy

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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