Gynecologic Oncology Practice Questions

Q: Which of the following is NOT true regarding Brenner tumor?

It is usually found in postmenopausal women.. **Explanation:** The **Brenner tumor** is a rare surface epithelial-stromal tumor of the ovary, characterized by transitional epithelium (urothelium). **1. Why Option D is the correct answer (The False Statement):** While Brenner tumors can occur at any age, they are **most commonly diagnosed incidentally in women between 40–60 years of age (perimenopausal)**. The statement that they are "usually" found in postmenopausal women is considered less accurate in the context of standard textbook descriptions compared to the other definitive features listed. (Note: In some clinical contexts, this question highlights that they are often asymptomatic and found during surgery for other reasons). **2. Analysis of other options:** * **Option A:** Brenner tumors are frequently associated with other epithelial tumors, most commonly **Mucinous cystadenomas**. If a mucinous component is present and ruptures, it can lead to **Pseudomyxoma peritonei**. * **Option B:** This is the classic histological hallmark. They consist of **Walthard cell nests** (transitional epithelium) embedded in a dense fibromatous stroma. The nuclei often show a longitudinal groove, giving them the characteristic **"coffee bean" appearance**. * **Option C:** The stroma of a Brenner tumor can be **thecal/functionally active**, producing estrogen. This estrogenic stimulation can lead to endometrial hyperplasia, resulting in **postmenopausal or abnormal vaginal bleeding**. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Arises from the surface epithelium or urogenital remnants. * **Gross Appearance:** Usually small, solid, unilateral, and grayish-white (resembles a fibroma). * **Markers:** Positive for **GATA3** and **p63** (markers of transitional differentiation). * **Nature:** Majority (>95%) are **benign**. Malignant Brenner tumors are extremely rare.

Q: Which of the following is the most common primary site for a metastasis that presents as a Krukenberg tumor?

Stomach. **Explanation:** A **Krukenberg tumor** refers specifically to a metastatic signet-ring cell carcinoma of the ovary, where the primary malignancy arises from a gastrointestinal tract site or other mucosal tissues. 1. **Why Stomach is Correct:** The **stomach (gastric adenocarcinoma)** is the most common primary site, accounting for approximately 70% of all Krukenberg tumors. The mechanism of spread is traditionally thought to be via retrograde lymphatic dissemination, though transcoelomic (surface seeding) and hematogenous routes also occur. Histologically, these tumors are characterized by **signet-ring cells** (mucin-filled cytoplasm displacing the nucleus to the periphery) within a cellular stroma. 2. **Why Other Options are Incorrect:** * **Colon:** This is the second most common source. While colorectal cancer frequently metastasizes to the ovary, it often presents as a non-signet ring adenocarcinoma, which does not strictly meet the classic definition of a Krukenberg tumor. * **Breast:** Lobular carcinoma of the breast can metastasize to the ovary and may show signet-ring features, but it is significantly less common than gastric sources. * **Uterus:** Primary uterine malignancies (like endometrial carcinoma) typically spread to the ovaries via direct extension or lymphatics, but they do not form the classic signet-ring morphology associated with Krukenberg tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Bilateralism:** 80% of Krukenberg tumors are bilateral. * **Imaging:** On ultrasound/CT, they typically appear as solid, bosselated masses (unlike primary epithelial ovarian cancers which are often complex/cystic). * **Diagnosis:** If a bilateral solid ovarian mass is found, the first step is often a **diagnostic upper GI endoscopy** to rule out a gastric primary. * **Prognosis:** Generally poor, as it represents Stage IV systemic disease.

Q: In a patient with a vulvar ulcer, which of the following is most associated with leading to malignancy?

Human Papillomavirus (HPV). **Explanation:** The correct answer is **Human Papillomavirus (HPV)**. The development of vulvar squamous cell carcinoma (SCC) follows two distinct pathways. The first, and most common in younger patients, is the **HPV-associated pathway**, specifically linked to high-risk strains like **HPV 16 and 18**. These viruses integrate into the host genome, leading to the overexpression of E6 and E7 oncoproteins, which inactivate tumor suppressor proteins p53 and pRb, respectively. This process leads to **Vulvar Intraepithelial Neoplasia (VIN)**, the precursor lesion to malignancy. **Analysis of Incorrect Options:** * **HSV-1 and HSV-2 (Options A & B):** While Herpes Simplex Virus causes painful, recurrent vulvar ulcers, it is not oncogenic. Chronic inflammation from any source can theoretically increase cell turnover, but HSV has no direct causal link to vulvar malignancy. * **Sexually Transmitted Disease (Option C):** This is a broad category. While many vulvar cancers are associated with STIs (specifically HPV), the term itself is too non-specific. Other STIs like Syphilis (chancre) or Chancroid cause ulcers but do not lead to neoplastic transformation. **NEET-PG High-Yield Pearls:** * **Two Pathways of Vulvar Cancer:** 1. **HPV-Dependent:** Seen in younger women, associated with smoking and multiple partners (precursor: VIN). 2. **HPV-Independent:** Seen in elderly women, associated with **Lichen Sclerosus** and differentiated VIN (dVIN). * **Most Common Histology:** Squamous Cell Carcinoma (90%). * **Most Common Symptom:** Long-standing pruritus (itching), though it can present as an ulcer or mass. * **Staging:** Vulvar cancer is staged **surgically** (FIGO). The most important prognostic factor is the status of the **inguinal lymph nodes**.

Q: CA-125 is a marker antigen for the diagnosis of which type of cancer?

Ovarian cancer. **Explanation:** **CA-125 (Cancer Antigen 125)** is a high-molecular-weight glycoprotein produced by derivatives of the **coelomic epithelium**, which includes the lining of the fallopian tubes, endometrium, endocervix, and the peritoneum/pleura. It is the most widely used tumor marker for **epithelial ovarian cancer (EOC)**, particularly the serous subtype. While not specific enough for primary screening in the general population, it is invaluable for monitoring treatment response and detecting recurrence. **Analysis of Options:** * **Ovarian Cancer (Correct):** Elevated levels (>35 U/mL) are found in 80% of women with advanced epithelial ovarian cancer. It is particularly useful in postmenopausal women with an adnexal mass. * **Colon Cancer:** The primary tumor marker is **CEA (Carcinoembryonic Antigen)**. While CA-125 can rise in any peritoneal irritation (including metastatic colon cancer), it is not the diagnostic marker for the primary site. * **Breast Cancer:** The most specific markers are **CA 15-3** and **CA 27-29**. * **Brain Cancer:** There are no specific serum markers like CA-125 for primary brain tumors; diagnosis relies on neuroimaging and biopsy. **NEET-PG High-Yield Pearls:** 1. **Physiological elevations:** CA-125 can be elevated in menstruation, pregnancy, and endometriosis. 2. **Benign conditions:** It rises in PID, fibroids, and cirrhosis with ascites. 3. **Germ Cell Tumors:** Remember other markers—**LDH** (Dysgerminoma), **AFP** (Yolk sac tumor), and **hCG** (Choriocarcinoma). 4. **Mucinous Ovarian Cancer:** Often shows elevated **CEA** and **CA 19-9** rather than CA-125.

Q: The drug of choice in choriocarcinoma is:

Methotrexate. **Explanation:** **Choriocarcinoma** is a highly malignant form of Gestational Trophoblastic Neoplasia (GTN). It is uniquely characterized by its extreme sensitivity to chemotherapy, making it one of the few metastatic cancers that can be cured even in advanced stages. **Why Methotrexate is the Correct Answer:** Methotrexate (MTX), a folate antagonist, is the **first-line drug of choice** for low-risk non-metastatic or metastatic GTN (WHO score 0–6). It works by inhibiting dihydrofolate reductase, thereby halting DNA synthesis in the rapidly dividing trophoblastic cells. It is preferred due to its high efficacy, predictable toxicity profile, and the availability of Leucovorin (Folinic acid) as a rescue agent to minimize systemic side effects. **Analysis of Incorrect Options:** * **B. Actinomycin–D:** This is the second-line agent for low-risk GTN. It is typically reserved for patients who develop resistance to Methotrexate or have hepatic dysfunction (as MTX is hepatotoxic). It is also a component of the EMA-CO regimen used for high-risk cases. * **C. Vincristine & D. 6–Thioguanine:** These are not used as single-agent primary treatments. Vincristine is part of the multi-drug EMA-CO regimen (the 'O' stands for Oncovin/Vincristine), while 6-Thioguanine is rarely used in modern GTN protocols. **High-Yield Clinical Pearls for NEET-PG:** * **Staging:** GTN is staged using the **FIGO Staging** and the **WHO Modified Prognostic Scoring System**. * **Treatment Protocol:** * **Low Risk (Score <7):** Single-agent chemotherapy (Methotrexate is #1, Actinomycin-D is #2). * **High Risk (Score ≥7):** Multi-agent chemotherapy (EMA-CO regimen: Etoposide, Methotrexate, Actinomycin-D, Cyclophosphamide, and Oncovin). * **Follow-up:** The most sensitive tumor marker for monitoring treatment response and recurrence is **serum β-hCG**.

Q: A 28-year-old woman underwent fertility-sparing surgery for a 6x6 cm granulosa cell ovarian tumor. Which one of the following will you monitor for detection of recurrence?

Inhibin B. **Explanation:** **Granulosa Cell Tumors (GCTs)** are the most common type of Sex Cord-Stromal Tumors. These tumors arise from the granulosa cells, which are responsible for producing estrogen and the peptide hormone **Inhibin**. **Why Inhibin B is the correct answer:** Inhibin exists in two forms, A and B. In GCTs, **Inhibin B** is considered a more sensitive and specific marker than Inhibin A. It is secreted directly by the tumor cells in proportion to the tumor mass. Following surgery, levels should drop to undetectable; a subsequent rise is a highly reliable indicator of recurrence, often preceding clinical or radiological detection by months. **Analysis of Incorrect Options:** * **CA 19-9:** Primarily a marker for pancreatic and biliary tract cancers. In gynecology, it may be elevated in mucinous ovarian tumors, but not GCTs. * **LDH (Lactate Dehydrogenase):** A characteristic marker for **Dysgerminomas** (Germ Cell Tumors). * **PLAP (Placental Alkaline Phosphatase):** Also a marker associated with **Dysgerminomas** and occasionally seminomas. **High-Yield Clinical Pearls for NEET-PG:** 1. **Estrogen Secretion:** GCTs are "functioning tumors." Excess estrogen often leads to **Endometrial Hyperplasia** or **Endometrial Carcinoma** (must perform an endometrial biopsy if the patient has abnormal bleeding). 2. **Call-Exner Bodies:** The pathognomonic histological finding (small fluid-filled spaces between granulosa cells). 3. **Antimüllerian Hormone (AMH):** Another highly specific marker for GCTs, often used alongside Inhibin B. 4. **Prognosis:** GCTs are known for **late recurrence** (even 10–20 years later), necessitating lifelong follow-up.

Q: What is the investigation of choice for cervical carcinoma?

MRI. ### Explanation **Correct Option: B. MRI** **Why MRI is the Investigation of Choice:** In the management of cervical carcinoma, **MRI (Magnetic Resonance Imaging)** is the gold standard for **local staging**. It provides superior soft-tissue contrast compared to other modalities, allowing for precise evaluation of: 1. **Tumor size and volume.** 2. **Parametrial invasion:** This is the most critical factor in determining management (Surgery vs. Radiotherapy). 3. **Vaginal and stromal involvement.** 4. **Invasion of adjacent organs** (bladder or rectum). While FIGO staging for cervical cancer was historically clinical, the 2018 update allows the use of imaging. MRI is now the preferred modality to decide if a patient is a candidate for radical surgery (Stage ≤IIA1) or requires primary chemoradiation (Stage ≥IIB). **Why Other Options are Incorrect:** * **A. CECT Pelvis:** While CT is excellent for evaluating distant metastasis, retroperitoneal lymphadenopathy, and hydronephrosis, it has poor sensitivity for detecting early parametrial invasion or small primary tumors. * **C & D. TVS/TAS (Ultrasound):** Transvaginal and Transabdominal scans are useful for initial screening or evaluating the uterus/adnexa, but they lack the resolution and depth required for accurate staging and parametrial assessment in cervical cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Best Screening Test:** Pap Smear (Cytology). * **Confirmatory Diagnostic Test:** Colposcopy-directed biopsy. * **Investigation for Distant Metastasis:** PET-CT (most sensitive for nodal and distant spread). * **FIGO 2018 Update:** Staging is now "Clinical + Imaging + Pathological." * **Parametrial Involvement:** If MRI shows parametrial invasion (Stage IIB), the treatment of choice shifts from Radical Hysterectomy to **Concurrent Chemoradiotherapy (CCRT)**.

Q: Which of the following syndromes is associated with an increased risk of endometrial and ovarian cancer?

Hereditary nonpolyposis colorectal cancer. **Explanation:** **Hereditary Nonpolyposis Colorectal Cancer (HNPCC)**, also known as **Lynch Syndrome**, is an autosomal dominant condition caused by mutations in DNA mismatch repair (MMR) genes (MLH1, MSH2, MSH6, PMS2). While colorectal cancer is the most common malignancy, Lynch syndrome is significantly associated with extracolonic cancers. For women, the lifetime risk of **endometrial cancer** (40–60%) and **ovarian cancer** (10–12%) is markedly elevated, often occurring at a younger age than in the general population. **Analysis of Incorrect Options:** * **Peutz-Jeghers Syndrome:** Characterized by STK11 mutations, mucocutaneous pigmentation, and hamartomatous polyps. While it increases the risk of Sex Cord Tumors with Annular Tubules (SCTAT) and Cervical Minimal Deviation Adenocarcinoma, it is not primarily linked to endometrial cancer. * **Cowden’s Syndrome:** Caused by PTEN mutations. It is associated with a high risk of breast, thyroid, and endometrial cancer, but it is **not** typically associated with an increased risk of ovarian cancer. * **Ataxia Telangiectasia:** Caused by ATM gene mutations. It primarily predisposes patients to lymphomas, leukemias, and breast cancer, rather than gynecological malignancies like endometrial or ovarian cancer. **Clinical Pearls for NEET-PG:** * **Lynch II Syndrome:** Specifically refers to the variant associated with high risks of endometrial, ovarian, gastric, and small bowel cancers. * **Screening:** Women with Lynch syndrome should undergo annual endometrial biopsy and transvaginal ultrasound starting at age 30–35. * **Prophylaxis:** Risk-reducing Total Laparoscopic Hysterectomy and Bilateral Salpingo-oophorectomy (TLH+BSO) is recommended after completion of childbearing (usually age 40).

Q: All of the following are seen in McCune Albright Syndrome except?

GnRH-dependent sexual precocity. **Explanation:** McCune-Albright Syndrome (MAS) is a rare genetic disorder caused by a post-zygotic somatic mutation in the **GNAS gene**. This mutation leads to constitutive activation of the **Gs-alpha protein**, resulting in the overproduction of cAMP. This stimulates various endocrine glands to function independently of their stimulating hormones. **Why Option D is the Correct Answer:** In MAS, the ovaries produce estrogen autonomously without stimulation from the pituitary gland. Therefore, it causes **GnRH-independent (Peripheral) Precocious Puberty**. Because the high levels of peripheral estrogen suppress the hypothalamic-pituitary axis via negative feedback, GnRH levels remain low. **GnRH-dependent (Central) precocity** is not a primary feature of the syndrome. **Analysis of Incorrect Options:** * **A. Polyostotic fibrous dysplasia:** This is a classic component of the MAS triad where normal bone is replaced by fibrous tissue, leading to fractures and deformities. * **B. Cafe-au-lait spots:** These are hyperpigmented skin lesions characterized by irregular "Coast of Maine" borders (unlike the smooth "Coast of California" borders seen in Neurofibromatosis). * **C. GnRH-independent sexual precocity:** This is the hallmark endocrine manifestation of MAS. In girls, it typically presents as recurrent follicular cysts and vaginal bleeding. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of MAS:** Polyostotic fibrous dysplasia, Cafe-au-lait spots, and Hyperfunctioning endocrinopathies (most commonly Peripheral Precocious Puberty). * **Genetic Basis:** Somatic mutation in GNAS1 gene (not inherited). * **Other Endocrine Associations:** Hyperthyroidism, Growth Hormone excess (Acromegaly), and Cushing Syndrome. * **Treatment for Precocity:** Aromatase inhibitors (e.g., Letrozole) or Estrogen receptor modulators (e.g., Tamoxifen) are used to block the effects of autonomous estrogen.

Q: Which of the following is NOT an epithelial cancer of the ovary?

Granulosa cell tumor. Ovarian tumors are classified based on their tissue of origin into three primary categories: **Surface Epithelial-Stromal tumors**, **Germ Cell tumors**, and **Sex Cord-Stromal tumors**. ### Why Granulosa Cell Tumor is the Correct Answer: **Granulosa cell tumors** belong to the **Sex Cord-Stromal** category. They arise from the specialized cells surrounding the oocytes (granulosa and theca cells) rather than the surface epithelium. * **High-Yield Fact:** These are the most common estrogen-secreting ovarian tumors, often presenting with precocious puberty in children or postmenopausal bleeding in adults. They are characterized histologically by **Call-Exner bodies** and are positive for the marker **Inhibin**. ### Why the Other Options are Incorrect: The following are all subtypes of **Surface Epithelial tumors**, which account for approximately 90% of all ovarian malignancies: * **A. Brenner Tumor:** A rare epithelial tumor composed of "urothelium-like" (transitional) cells. On histology, they show "coffee bean" nuclei. * **B. Endometrioid Carcinoma:** An epithelial tumor that histologically resembles the endometrium. It is frequently associated with endometriosis or a synchronous primary endometrial cancer. * **C. Mucinous Carcinoma:** An epithelial tumor characterized by cells containing abundant intracytoplasmic mucin. These can grow to be very large. ### NEET-PG Clinical Pearls: * **Most common ovarian tumor overall:** Serous Cystadenoma (Epithelial). * **Most common malignant ovarian tumor:** Serous Cystadenocarcinoma (Epithelial). * **Tumor Marker for Epithelial Ovarian Cancer:** CA-125. * **Psammoma bodies** are classically seen in Serous tumors (Epithelial).

Question 1

Which of the following is NOT true regarding Brenner tumor?

Accepted Answer

It is usually found in postmenopausal women.

Answer

It is associated with Pseudomyxoma peritonei.

Answer

Histologically, it has epithelial nests and coffee bean nuclei.

Answer

Vaginal bleeding is reported with it.

Question 2

Which of the following is the most common primary site for a metastasis that presents as a Krukenberg tumor?

Accepted Answer

Stomach

Answer

Breast

Answer

Colon

Answer

Uterus

Question 3

In a patient with a vulvar ulcer, which of the following is most associated with leading to malignancy?

Accepted Answer

Human Papillomavirus (HPV)

Answer

Herpes Simplex Virus 1 (HSV-1)

Answer

Herpes Simplex Virus 2 (HSV-2)

Answer

Sexually Transmitted Disease (general)

Question 4

CA-125 is a marker antigen for the diagnosis of which type of cancer?

Accepted Answer

Ovarian cancer

Answer

Colon cancer

Answer

Breast cancer

Answer

Brain cancer

Question 5

The drug of choice in choriocarcinoma is:

Accepted Answer

Methotrexate

Answer

Actinomycin–D

Answer

Vincristine

Answer

6–Thioguanine

Question 6

A 28-year-old woman underwent fertility-sparing surgery for a 6x6 cm granulosa cell ovarian tumor. Which one of the following will you monitor for detection of recurrence?

Accepted Answer

Inhibin B

Answer

CA 19-9

Answer

LDH

Answer

Placental Alkaline Phosphatase (PLAP)

Question 7

What is the investigation of choice for cervical carcinoma?

Accepted Answer

MRI

Answer

CECT pelvis

Answer

TVS

Answer

TAS

Question 8

Which of the following syndromes is associated with an increased risk of endometrial and ovarian cancer?

Accepted Answer

Hereditary nonpolyposis colorectal cancer

Answer

Peutz-jeghers syndrome

Answer

Cowden's syndrome

Answer

Ataxia telangiectasia

Question 9

All of the following are seen in McCune Albright Syndrome except?

Accepted Answer

GnRH-dependent sexual precocity

Answer

Polyostotic fibrous dysplasia

Answer

Cafe-au-lait spots

Answer

GnRH-independent sexual precocity

Question 10

Which of the following is NOT an epithelial cancer of the ovary?

Accepted Answer

Granulosa cell tumor

Answer

Brenner tumor

Answer

Endometrioid carcinoma

Answer

Mucinous carcinoma

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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