Gynecologic Oncology — MCQs

A 25-year-old woman, 15 weeks pregnant, presents with uterine bleeding and passage of a small amount of watery fluid and tissue. Her uterus is found to be much larger than estimated by her gestational dates. Ultrasound reveals the uterus is filled with cystic, avascular, grapelike structures that do not penetrate the uterine wall. No fetal parts are visualized. What is the most likely diagnosis?

Q429Easy

What is the most common malignant ovarian tumor in young individuals?

Q430Medium

A 50-year-old nulliparous, diabetic, and obese woman presents with post-menopausal bleeding. What is the most likely diagnosis?

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 421: An intravenous pyelogram (IVP) showing hydronephrosis in the work up of a patient with cervical cancer otherwise confined to a cervix of normal size would indicate which stage?

A. Stage I
B. Stage II
C. Stage III (Correct Answer)
D. Stage IV

Explanation: **Explanation:** The correct answer is **Stage III**. According to the FIGO staging for carcinoma cervix (revised 2018), the presence of **hydronephrosis or a non-functioning kidney** due to tumor extension automatically upgrades the disease to **Stage IIIB**, regardless of the size of the primary cervical lesion. **Why Stage III is correct:** In cervical cancer, hydronephrosis indicates that the tumor has extended laterally to the pelvic sidewall, causing compression or infiltration of the ureter. Under the FIGO staging system, Stage III includes involvement of the lower third of the vagina (IIIA), extension to the pelvic sidewall, and/or hydronephrosis/non-functioning kidney (IIIB), or involvement of pelvic/paraaortic lymph nodes (IIIC). **Why other options are incorrect:** * **Stage I:** The tumor is strictly confined to the cervix. Even if the cervix appears "normal size" on examination, the presence of hydronephrosis signifies extra-cervical spread to the pelvic wall. * **Stage II:** The tumor extends beyond the uterus but has not reached the pelvic sidewall or the lower third of the vagina. Hydronephrosis is a defining feature that pushes the stage beyond Stage II. * **Stage IV:** This stage involves invasion of the mucosa of the bladder or rectum (IVA) or distant metastasis (IVB). While hydronephrosis involves the urinary tract, it is considered a regional complication (Stage III) rather than distant spread or mucosal invasion. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Staging:** Carcinoma cervix is primarily staged **clinically**. However, FIGO 2018 now allows the use of imaging (MRI, CT, PET) and pathology to supplement staging. * **The "Ureter" Rule:** If the ureter is obstructed (hydronephrosis), it is Stage IIIB. * **Most Common Cause of Death:** Uremia (due to bilateral ureteric obstruction leading to post-renal renal failure) is the most common cause of death in cervical cancer patients.

Question 422: Struma ovarii is a type of:

A. Metastatic tumor
B. Teratoma (Correct Answer)
C. Sex cord tumor
D. Surface epithelial tumor

Explanation: **Explanation:** **Struma ovarii** is a highly specialized or monodermal form of a **Mature Cystic Teratoma** (Germ Cell Tumor). By definition, it is a teratoma in which thyroid tissue comprises more than 50% of the tumor mass. 1. **Why Teratoma is correct:** Teratomas are germ cell tumors derived from all three germ layers (ectoderm, mesoderm, and endoderm). Struma ovarii represents an extreme case of endodermal differentiation where thyroid tissue predominates. 2. **Why other options are incorrect:** * **Metastatic tumor:** These are secondary tumors (e.g., Krukenberg tumor) spreading from sites like the GI tract or breast. Struma ovarii is a primary ovarian tumor. * **Sex cord tumor:** These arise from the ovarian stroma (e.g., Granulosa cell tumor, Sertoli-Leydig tumor) and often produce hormones like estrogen or androgens, not thyroid tissue. * **Surface epithelial tumor:** These arise from the ovarian lining (e.g., Serous or Mucinous cystadenoma) and are the most common type of ovarian neoplasms, but they do not contain thyroid elements. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Most are asymptomatic, but 5–10% of patients present with clinical **hyperthyroidism** (thyrotoxicosis). * **Imaging:** On ultrasound/CT, it may appear as a complex mass with a "struma pearl" (solid, vascularized component). * **Ascites:** Interestingly, about 1/3rd of cases are associated with ascites, and rarely, it can present as **Pseudo-Meigs Syndrome**. * **Malignancy:** While usually benign, the thyroid tissue can rarely undergo malignant transformation (most commonly Papillary Thyroid Carcinoma).

Question 423: A 20-year-old female complains of vaginal bleeding. Diagnostic workup reveals clear cell adenocarcinoma of the vagina. What drug exposure in utero is associated with this diagnosis?

A. Thalidomide
B. Diethylstilbestrol (DES) (Correct Answer)
C. Loss of sensation in the scrotum
D. Absent bulbocavernosus reflex

Explanation: **Explanation:** **Correct Answer: B. Diethylstilbestrol (DES)** **Medical Concept:** Clear cell adenocarcinoma (CCAC) of the vagina is a rare malignancy, but it is strongly associated with **in utero exposure to Diethylstilbestrol (DES)**. DES was a synthetic non-steroidal estrogen prescribed to pregnant women between 1938 and 1971 to prevent miscarriages. Female fetuses exposed to DES in the first trimester are at a significantly higher risk of developing CCAC of the vagina or cervix, typically diagnosed during adolescence or early adulthood (peak incidence around age 19). **Analysis of Incorrect Options:** * **A. Thalidomide:** This drug is a potent teratogen known for causing **Phocomelia** (limb reduction defects) when taken during pregnancy, not gynecological malignancies. * **C & D (Neurological signs):** "Loss of sensation in the scrotum" and "Absent bulbocavernosus reflex" are clinical signs associated with **cauda equina syndrome** or sacral nerve root injuries. They are irrelevant to the etiology of vaginal adenocarcinoma and appear to be distractor options from a different clinical context (neurosurgery/urology). **High-Yield Clinical Pearls for NEET-PG:** 1. **DES-related Structural Anomalies:** In addition to CCAC, DES exposure is associated with a **T-shaped uterine cavity**, cervical collars (cockscomb cervix), and vaginal adenosis (presence of glandular epithelium in the vagina). 2. **Vaginal Adenosis:** This is the precursor lesion for clear cell adenocarcinoma in DES-exposed individuals. 3. **Most Common Vaginal Cancer:** While CCAC is associated with DES, the **most common** primary vaginal cancer overall is **Squamous Cell Carcinoma** (associated with high-risk HPV). 4. **Sarcoma Botryoides:** The most common vaginal cancer in infants and children (presents as "grape-like" masses).

Question 424: Which type of Human Papillomavirus (HPV) is most strongly associated with adenocarcinoma of the cervix?

A. Type 6
B. Type 18 (Correct Answer)
C. Type 11
D. Type 42

Explanation: **Explanation:** The correct answer is **Type 18**. While HPV 16 is the most common cause of cervical cancer overall (especially squamous cell carcinoma), **HPV 18** has a specific and disproportionately strong association with **adenocarcinoma** of the cervix. 1. **Why Type 18 is correct:** HPV 18 is found in approximately 50–60% of cervical adenocarcinomas, compared to only about 10–15% of squamous cell carcinomas. It is considered more aggressive, often associated with a faster progression from infection to malignancy and a poorer prognosis compared to HPV 16. 2. **Why the others are incorrect:** * **Types 6 and 11:** These are "low-risk" HPV types. They are primarily responsible for benign lesions like **Condyloma Acuminata** (genital warts) and Recurrent Respiratory Papillomatosis. They do not cause cervical cancer. * **Type 42:** This is also a low-risk HPV type and is not associated with the development of cervical malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **HPV 16:** Most common type in **Squamous Cell Carcinoma** (approx. 60%) and the most common type found in cervical cancer globally. * **HPV 18:** Most common type in **Adenocarcinoma** and **Small Cell Carcinoma** of the cervix. * **Oncogenic Proteins:** HPV E6 inhibits the **p53** tumor suppressor protein, while HPV E7 inhibits the **pRb** (Retinoblastoma) protein. * **Screening:** The transformation zone is the most common site for cervical cancer; however, adenocarcinoma arises from the glandular epithelium of the endocervix, making it harder to detect via routine Pap smear compared to squamous lesions.

Question 425: "EMA-CO regimen" is useful in the treatment of which of the following conditions?

A. Metastatic breast cancer
B. Advanced endometrial sarcoma
C. Gestational trophoblastic neoplasia (Correct Answer)
D. Ovarian tumor with peritoneal implants

Explanation: **Explanation:** The **EMA-CO regimen** is the gold-standard multi-agent chemotherapy for **High-Risk Gestational Trophoblastic Neoplasia (GTN)**. GTN is classified as high-risk when the FIGO/WHO score is **7 or higher**. **Why it is the correct answer:** EMA-CO is an acronym for a two-part drug combination: * **EMA:** Etoposide, Methotrexate, and Actinomycin-D (given on Days 1 and 2). * **CO:** Cyclophosphamide and Oncovin (Vincristine) (given on Day 8). This regimen is highly effective, with survival rates exceeding 70-90% even in metastatic cases. It is specifically indicated for patients who are resistant to single-agent Methotrexate or those initially categorized as high-risk. **Why other options are incorrect:** * **Metastatic Breast Cancer:** Common regimens include AC (Adriamycin, Cyclophosphamide), CAF, or Taxane-based therapies. * **Advanced Endometrial Sarcoma:** Usually treated with surgery followed by Ifosfamide, Doxorubicin, or Gemcitabine/Docetaxel. * **Ovarian Tumor with Peritoneal Implants:** The standard of care is **BEP** (Bleomycin, Etoposide, Cisplatin) for germ cell tumors or **Paclitaxel + Carboplatin** for epithelial ovarian cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Low-risk GTN (Score <7):** Treated with single-agent **Methotrexate** (most common) or Actinomycin-D. * **Monitoring:** The most sensitive marker for treatment response and follow-up in GTN is **serum β-hCG**. * **Resistance:** If EMA-CO fails, the next line is often **EMA-EP** (where CO is replaced by Etoposide and Cisplatin). * **Placental Site Trophoblastic Tumor (PSTT):** Unlike other GTNs, PSTT is relatively chemoresistant; **Surgery (Hysterectomy)** is the primary treatment.

Question 426: A 35-year-old pregnant patient is at the highest risk for the concurrent development of which of the following malignancies?

A. Cervix (Correct Answer)
B. Ovary
C. Uterus
D. Vagina

Explanation: **Explanation:** **Cervical cancer** is the most common gynecological malignancy diagnosed during pregnancy. This is primarily because the peak incidence of cervical cancer (30–40 years) overlaps significantly with the reproductive years. Routine prenatal care often involves a pelvic examination and Pap smear, leading to increased detection of cervical dysplasia or early-stage carcinoma in pregnant women. **Analysis of Options:** * **A. Cervix (Correct):** It accounts for nearly 70-80% of all gynecological cancers associated with pregnancy. The incidence is approximately 1 to 10 per 10,000 pregnancies. * **B. Ovary:** Ovarian cancer is the second most common gynecological malignancy in pregnancy. While adnexal masses are frequently found on routine ultrasound, most are functional cysts (like corpus luteum) or benign dermoids rather than malignancies. * **C. Uterus:** Endometrial cancer is extremely rare during pregnancy because high levels of progesterone exert a protective effect against the estrogen-driven proliferation of the endometrium. Furthermore, the presence of a malignancy in the uterine lining usually precludes successful implantation. * **D. Vagina:** Primary vaginal cancer is rare in the general population and exceptionally rare in the pregnant age group, as it typically affects postmenopausal women. **High-Yield Clinical Pearls for NEET-PG:** * **Most common non-gynecological cancer in pregnancy:** Breast cancer (followed by melanoma and lymphomas). * **Diagnosis:** Pregnancy does not change the diagnostic criteria for cervical cancer; colposcopy is safe, but endocervical curettage (ECC) is strictly **contraindicated**. * **Management:** For early-stage disease diagnosed in the first trimester, treatment can often be delayed until fetal maturity if the patient desires to continue the pregnancy.

Question 427: What are the advantages of hysterectomy in molar pregnancy?

A. Chance of choriocarcinoma becomes nil
B. Follow up is not required
C. Enlarged ovaries can be removed during operation
D. Chance of pulmonary embolisation is minimal (Correct Answer)

Explanation: **Explanation:** In the management of molar pregnancy (Hydatidiform mole), suction evacuation is the standard treatment. However, in women who have completed their family and are over 40 years of age, **hysterectomy** is a viable alternative. **Why Option D is Correct:** The primary advantage of hysterectomy (with the mole *in situ*) over suction evacuation is the **reduction in the risk of pulmonary embolization** of trophoblastic tissue. During suction evacuation, the manipulation of the bulky, vascular uterus can force trophoblastic cells into the systemic circulation, leading to respiratory distress or metastatic seeding. Hysterectomy allows for the removal of the intact uterus with minimal intrauterine manipulation, thereby significantly lowering this risk. **Analysis of Incorrect Options:** * **Option A:** Hysterectomy reduces the risk of post-molar Gestational Trophoblastic Neoplasia (GTN) from approximately 15-20% to about 3-5%, but it **does not eliminate it (nil)**. Viable trophoblastic cells may have already entered the circulation before surgery. * **Option B:** Since the risk of GTN persists even after hysterectomy, **strict follow-up with serial serum β-hCG monitoring is mandatory** until levels normalize and remain so for the prescribed duration. * **Option C:** The enlarged ovaries in molar pregnancy (Theca Lutein cysts) are due to high hCG levels. They are benign and **should not be removed**; they regress spontaneously once the hCG levels drop after the mole is evacuated. **High-Yield Clinical Pearls for NEET-PG:** * **Indication:** Hysterectomy is preferred in patients >40 years who have completed their family (due to a higher risk of malignant transformation in this age group). * **GTN Risk:** Hysterectomy reduces the risk of local invasion but not distant metastasis. * **Theca Lutein Cysts:** These are often bilateral and multiloculated; surgical intervention is only indicated if there is torsion or rupture.

Question 428: A 25-year-old woman, 15 weeks pregnant, presents with uterine bleeding and passage of a small amount of watery fluid and tissue. Her uterus is found to be much larger than estimated by her gestational dates. Ultrasound reveals the uterus is filled with cystic, avascular, grapelike structures that do not penetrate the uterine wall. No fetal parts are visualized. What is the most likely diagnosis?

A. Partial hydatidiform mole
B. Complete hydatidiform mole (Correct Answer)
C. Invasive mole
D. Placental site trophoblastic tumor

Explanation: **Explanation:** The clinical presentation is classic for a **Complete Hydatidiform Mole (CHM)**. The key diagnostic features provided are the "size-date discrepancy" (uterus larger than dates), the passage of "grapelike structures," and the characteristic ultrasound finding of a cystic, avascular mass with the absence of fetal parts. **1. Why Complete Mole is correct:** In a complete mole, fertilization of an "empty" egg (lacking maternal chromosomes) by one or two sperm results in a 46,XX or 46,XY karyotype of purely paternal origin. This leads to generalized hydropic degeneration of chorionic villi and diffuse trophoblastic proliferation. The absence of fetal tissue and the "snowstorm" appearance on ultrasound (cystic spaces) are pathognomonic. **2. Why other options are incorrect:** * **Partial Hydatidiform Mole:** This involves fertilization of a normal egg by two sperm (Triploidy: 69,XXX or 69,XXY). Crucially, **fetal parts** are usually present, and the uterus is often small for dates or normal-sized, unlike this case. * **Invasive Mole:** While it shares features with CHM, it is characterized by **myometrial invasion**. The question explicitly states the structures "do not penetrate the uterine wall." * **Placental Site Trophoblastic Tumor (PSTT):** A rare form of Gestational Trophoblastic Neoplasia (GTN) that arises from intermediate trophoblasts. It typically presents with low hCG levels and lacks the "grapelike" cystic villi seen here. **High-Yield Clinical Pearls for NEET-PG:** * **Karyotype:** Complete Mole = 46,XX (most common, paternal); Partial Mole = 69,XXY. * **hCG Levels:** Markedly elevated in Complete Mole (>100,000 mIU/mL), often leading to theca lutein cysts and hyperemesis. * **Risk of Malignancy:** Complete Mole has a higher risk (15–20%) of progressing to choriocarcinoma compared to Partial Mole (<5%). * **Management:** Suction evacuation followed by weekly hCG monitoring until three consecutive negative results.

Question 429: What is the most common malignant ovarian tumor in young individuals?

A. Dysgerminoma (Correct Answer)
B. Dermoid cyst
C. Mucinous cystadenoma
D. Fibroma

Explanation: **Explanation:** The correct answer is **Dysgerminoma**. **1. Why Dysgerminoma is correct:** In the context of ovarian tumors in young individuals (children and adolescents), **Germ Cell Tumors (GCTs)** are the most common category. Among these, while the Benign Cystic Teratoma (Dermoid cyst) is the most common *benign* tumor, the **Dysgerminoma** is the most common **malignant** germ cell tumor. It typically affects women in their teens and early twenties. It is the female counterpart of the testicular seminoma and is highly radiosensitive and chemosensitive. **2. Why other options are incorrect:** * **Dermoid cyst (Benign Cystic Teratoma):** This is the most common ovarian tumor in young women overall, but it is **benign**, not malignant. * **Mucinous cystadenoma:** This is a surface epithelial tumor. Epithelial tumors are the most common ovarian tumors in postmenopausal women but are rare in the young. * **Fibroma:** This is a benign sex cord-stromal tumor. While it can occur at any age, it is not the most common malignancy in this demographic and is associated with Meigs’ Syndrome. **3. NEET-PG High-Yield Pearls:** * **Tumor Marker:** Dysgerminoma is associated with elevated **LDH** (Lactate Dehydrogenase) and sometimes hCG. * **Association:** It is the most common malignancy found in patients with **gonadal dysgenesis** (e.g., Swyer syndrome). * **Microscopy:** Characterized by large, round "fried-egg" cells with central nuclei and fibrous stroma infiltrated with **lymphocytes**. * **Management:** It is highly responsive to the **BEP regimen** (Bleomycin, Etoposide, Platinum).

Question 430: A 50-year-old nulliparous, diabetic, and obese woman presents with post-menopausal bleeding. What is the most likely diagnosis?

A. Carcinoma in situ of cervix
B. Endometrial carcinoma (Correct Answer)
C. Dysfunctional uterine bleeding (DUB)
D. None of the above

Explanation: ### Explanation **Correct Option: B. Endometrial carcinoma** The patient presents with the classic **"Corpus Cancer Syndrome"** triad: **Obesity, Diabetes Mellitus, and Nulliparity** in a post-menopausal woman. These factors contribute to a state of **unopposed estrogen**, which is the primary driver for Type I Endometrial Carcinoma. * **Post-menopausal bleeding (PMB)** is the hallmark clinical presentation of endometrial cancer. In any woman over 45-50 years with PMB, endometrial malignancy must be ruled out first via endometrial biopsy or fractional curettage. * **Obesity** increases peripheral conversion of androstenedione to estrone in adipose tissue, while **nulliparity** indicates a lifetime of uninterrupted estrogen exposure without the protective effect of progesterone during pregnancy. **Why other options are incorrect:** * **A. Carcinoma in situ of cervix:** While cervical cancer can cause bleeding, it typically presents as post-coital bleeding or foul-smelling discharge in a younger age group. It is not classically associated with the metabolic triad of obesity and diabetes. * **C. Dysfunctional Uterine Bleeding (DUB):** DUB (now termed AUB-E/O) is a diagnosis of exclusion. In a post-menopausal woman, any bleeding is considered malignant until proven otherwise; labeling it as DUB without investigation is a clinical error. **High-Yield NEET-PG Pearls:** 1. **Most common cause of PMB:** Senile/Atrophic vaginitis (however, **Endometrial Cancer** is the most important cause to rule out). 2. **Risk Factors (The "Hand-Lens" Mnemonic):** **H**ypertension, **A**ge, **N**ulliparity, **D**iabetes, **L**iver disease, **E**strogen (unopposed), **N**ow (Obesity), **S**tein-Leventhal Syndrome (PCOS). 3. **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the initial screening tool. An **endometrial thickness (ET) > 4 mm** in a post-menopausal woman necessitates a biopsy. 4. **Gold Standard Diagnosis:** Endometrial Biopsy (Pipelle) or Fractional Curettage.

Practice by Chapter

Cervical Cancer

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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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