Gynecologic Oncology Practice Questions

Q: Cryosurgery is used in the treatment of cervical intraepithelial neoplasia. In which of the following conditions is cryosurgery NOT appropriate?

Cervical intraepithelial neoplasia-3 (CIN-3).. **Explanation:** Cryosurgery is an ablative technique used for treating Cervical Intraepithelial Neoplasia (CIN). Its success depends on the ability to freeze the entire transformation zone (TZ) and the lesion to a specific depth. **Why Option C is the correct answer:** Cryosurgery is generally **not recommended for CIN-3**. High-grade lesions (CIN-3) have a higher risk of harboring occult invasive carcinoma or extending deep into the endocervical crypts. Because cryosurgery is an ablative method, it does not provide a tissue specimen for histopathological verification of margins or to rule out invasion. For CIN-3, excisional procedures like LEEP (Loop Electrosurgical Excision Procedure) or Cold Knife Conization are preferred. **Analysis of Incorrect Options:** * **Option A:** Cryosurgery is ideal when the **TZ is entirely on the ectocervix** (Type 1 TZ). If the TZ extends into the endocervical canal, the cryoprobe cannot reach the upper limits, leading to treatment failure. * **Option B:** A **smooth cervical surface** ensures uniform contact between the cryoprobe and the tissue. Deep crevices or irregular contours prevent adequate freezing of the entire lesion. * **Option D:** Cryosurgery is most effective for **small lesions** (limited to <2 quadrants). Large lesions covering more than 75% of the cervix have a higher failure rate with ablation. **Clinical Pearls for NEET-PG:** * **Prerequisites for Cryosurgery:** Negative endocervical curettage (ECC), no evidence of malignancy, and a correlation between cytology and colposcopy. * **Technique:** The "Freeze-Thaw-Freeze" technique is used (3 mins freeze, 5 mins thaw, 3 mins freeze). * **Side Effect:** Patients often experience a profuse, watery vaginal discharge for 2–4 weeks post-procedure. * **Refrigerant:** Nitrous oxide ($N_2O$) or Carbon dioxide ($CO_2$) are commonly used.

Q: What is the co-test in cervical cancer screening?

HPV and PAP smear. ***HPV and PAP smear*** - **Co-testing** is the simultaneous use of the **hrHPV DNA test** (to detect oncogenic virus presence) and the **Papanicolaou (PAP) smear** (to detect cytological abnormalities). - This combination provides the highest sensitivity for detecting high-grade cervical intraepithelial neoplasia (**CIN 2/3**) and is recommended for screening women aged 30-65 years in many guidelines. *Pap smear and VIA* - **Visual Inspection with Acetic acid (VIA)** is typically used as a primary screening method in settings where laboratory infrastructure for cytology or HPV testing is limited, not as a standard co-test. - The combination of **PAP smear** (cytology) and **HPV testing** (molecular) offers a superior and more risk-stratified approach than combining cytology with simple visual inspection. *HPV and VIA* - This combination lacks the necessary **specificity** provided by the PAP smear, as VIA relies on subjective visual assessment of acetowhite changes rather than objective cytological classification. - Standard screening protocols often require detailed cytological results (e.g., **ASCUS, LSIL, HSIL**) from the PAP smear to guide subsequent triage and management decisions when HPV is positive. *PAP smear and colposcopy* - **Colposcopy** is a **diagnostic and evaluation procedure** performed *after* an abnormal screening result (e.g., abnormal PAP or positive HPV), not a screening test to be paired with the PAP smear. - Colposcopy allows for directed biopsy and is crucial for definitive diagnosis and staging of **cervical intraepithelial neoplasia (CIN)**.

Q: Which is the primary chemotherapeutic agent used for cervical cancer?

Platinum-based therapy. ***Platinum-based therapy*** - **Cisplatin** is the foundational chemotherapeutic agent utilized, often combined with radiation (**chemoradiation**) for locally advanced disease. - For metastatic or recurrent cervical cancer, combinations using platinum agents (**Cisplatin** or **Carboplatin**) along with **Paclitaxel** are standard first-line systemic treatments. *Immunotherapy* - **Immunotherapy**, specifically checkpoint inhibitors like **Pembrolizumab**, is approved for recurrent or metastatic cervical cancer that progresses after first-line chemotherapy. - It is not the initial or primary systemic treatment modality, which is founded upon platinum agents. *Hormonal therapy* - **Hormonal therapy** is primarily used for hormone-responsive cancers such as **breast cancer** (estrogen/progesterone receptors positive) or **prostate cancer**. - Cervical cancer is typically driven by **HPV infection** and carcinogenesis, making it largely unresponsive to sex hormones. *Targeted therapy* - **Targeted therapy**, such as the **anti-VEGF** agent **Bevacizumab**, is often utilized, but only *in addition to* platinum-based chemotherapy for advanced or recurrent disease. - It is used as an adjunct to systemic chemotherapy, which remains centered on platinum compounds.

Q: A patient presents with an endometrial thickness of 14mm with an adnexal mass. She has a history of complex endometrial hyperplasia with the presence of atypical cells. Which of the following is likely the diagnosis?

Metastasis endometrial cancer to ovary. ***Metastasis endometrial cancer to ovary*** - A history of **complex endometrial hyperplasia with atypical cells** is a strong precursor or co-existing condition with **endometrial carcinoma**. - The combination of a highly suspicious thick endometrium (**14mm**) and an **adnexal mass** strongly suggests a primary uterine malignancy that has spread to the ovary, which is a common site for endometrial cancer metastasis. *Struma ovarii* - This is a rare specialized form of **mature cystic teratoma** composed predominantly of thyroid tissue and is generally benign. - *Struma ovarii* is not etiologically linked to primary uterine pathology like **atypical endometrial hyperplasia** or endometrial carcinoma. *Polycystic ovarian disease* - PCOD leads to unopposed **estrogen stimulation** causing endometrial hyperplasia, but it rarely produces a solitary, large **adnexal mass** as described. - While PCOD is a risk factor for endometrial hyperplasia, the finding of presumed *metastasis* (mass + primary cancer features) is inconsistent with this diagnosis. *Immature ovarian teratoma* - These are malignant **germ cell tumors**, typically presenting in young women and often associated with elevated **alpha-fetoprotein (AFP)** or LDH markers. - Immature teratomas are not associated with the development of primary **endometrial carcinoma** or its precursor lesions like atypical hyperplasia.

Q: Which type of hysterectomy is done in a case of carcinoma cervix stage IB?

Type 3 hysterectomy. ***Type 3 hysterectomy***- This procedure represents the **classic radical hysterectomy** (Wertheim-Meigs operation) and is the standard surgical treatment for primary carcinoma of the cervix, specifically **FIGO Stage IB** and early Stage IIA- It requires the complete excision of the uterus, cervix, upper third of the vagina, and the removal of the *entire* **parametria** and uterosacral ligaments up to the pelvic sidewall, alongside meticulous **pelvic lymphadenectomy**.*Type 1 hysterectomy*- This is a **simple (extra-fascial) hysterectomy** that removes the uterus while preserving the deep pelvic fascia; it removes minimal to no parametrial tissue- It is inadequate for Stage IB disease and is typically reserved for benign indications or **FIGO Stage IA1** microinvasive carcinoma.*Type 2 hysterectomy*- Known as a **modified radical hysterectomy**, this procedure involves the resection of the uterus along with the medial half of the parametrium, providing less radical resection than Type 3.- It is usually reserved for smaller, low-risk lesions like **FIGO Stage IA2** or very small Stage IB1 tumors, depending on institutional protocol and tumor characteristics.*Type 4 hysterectomy*- This procedure is an **extended radical hysterectomy**, involving extensive removal of adjacent structures beyond Type 3, often including parts of the bladder or ureters (approaching pelvic exenteration).- It is generally reserved for critically advanced local cancers, those involving neighboring organs, or specific cases of local **recurrence**.

Q: A woman diagnosed with cervical cancer is found to have unilateral hydroureteronephrosis on imaging due to tumor invasion. What is the FIGO stage of her disease?

Stage IIIB. ***Stage IIIB*** - According to the FIGO 2018 staging, the presence of **hydronephrosis** or a non-functioning kidney due to the primary tumor classifies the disease as **Stage IIIB**. - This signifies locally advanced disease where the tumor has extended to the **pelvic wall** or caused ureteral obstruction. *Stage IIB* - Stage IIB involves tumor extension to the parametrium (the fibrous tissue surrounding the uterus) but specifically **without reaching the pelvic wall** or causing hydronephrosis. - While there is parametrial involvement, it is not sufficient in extent to cause clinical or radiological evidence of **ureteral obstruction**. *Stage IIIA* - This stage is defined by tumor extension to the **lower third of the vagina**, which is a local but not a distant spread criterion. - Importantly, Stage IIIA implies no involvement of the pelvic wall and no **hydronephrosis** or non-functioning kidney based on obstruction. *Stage IIIC* - **Stage IIIC** is defined solely by the presence of lymph node metastases, regardless of the size or extent of the primary tumor. - This includes involvement of either **pelvic lymph nodes (IIIC1)** or **para-aortic lymph nodes (IIIC2)**, which is a different criterion from ureteral obstruction.

Q: A 62-year-old postmenopausal woman with a history of hypertension presents with vaginal bleeding. Her blood pressure is 170 / 100 mmHg. What is the most appropriate next step in management?

Immediate pelvic examination and transvaginal ultrasound. ***Immediate pelvic examination and transvaginal ultrasound*** - **Postmenopausal bleeding (PMB)** must be considered **endometrial cancer** until proven otherwise, necessitating immediate, comprehensive evaluation. - The standard initial workup includes a **pelvic examination** and a **transvaginal ultrasound (TVUS)** to measure **endometrial thickness** (normal 4-5 mm or if the endometrium cannot be adequately visualized, an **endometrial biopsy** is indicated. - **Pap smear is NOT part of PMB workup** as it screens for cervical cancer, not endometrial pathology. *Reassure her that this is normal at her age* - **PMB is never normal** and requires mandatory investigation; reassuring her would be negligence and could delay the diagnosis of malignancy. - The history of hypertension is an independent risk factor for **endometrial hyperplasia** and **endometrial carcinoma**. *Refer her to cardiology before any further evaluation* - While her blood pressure is high (Stage 2 hypertension), the **vaginal bleeding** is an acute, potentially malignant symptom that takes immediate priority. - Evaluating hypertension can occur concurrently, but it should not **delay** the urgent gynecological workup. *Start antihypertensives and observe for 1 week* - Starting antihypertensives treats her chronic risk factor, but observation for one week means delaying the crucial diagnostic workup for **endometrial cancer**. - This approach risks advancing the stage of a potentially **treatable malignancy**.

Q: A 65-year-old postmenopausal woman presents with painless vaginal bleeding. She has no history of hormone replacement therapy. What is the most likely diagnosis?

Endometrial carcinoma. ***Endometrial carcinoma*** - **Painless postmenopausal bleeding** is the cardinal sign of endometrial carcinoma, and **malignancy must be excluded in every postmenopausal woman** presenting with this symptom. - Since the patient is 65 (well past menopause) and not on **Hormone Replacement Therapy (HRT)**, the risk is significantly higher for primary endometrial cancer. - **Key principle**: Any postmenopausal bleeding (even spotting) requires **endometrial sampling** (via endometrial biopsy or D&C) to rule out malignancy. *Adenomyosis* - This condition typically presents in **premenopausal women** (usually 40s and 50s) with symptoms like **dysmenorrhea** (painful periods) and **menorrhagia** (heavy bleeding). - It is highly unlikely to be the cause of isolated new-onset painless bleeding in a woman 15+ years post-menopause. *Uterine fibroid* - Fibroids (leiomyomas) are most common in **reproductive years** and generally cause symptoms like **heavy menstrual bleeding** or pelvic pressure. - While fibroids can sometimes cause postmenopausal bleeding due to atrophy or malignancy (sarcoma), they are less likely than carcinoma to be the primary cause of painless bleeding in this age group. *Endometriosis* - Endometriosis is a disease of **reproductive-aged women** typically causing symptoms like **chronic pelvic pain**, dysmenorrhea, and dyspareunia. - It almost always regresses spontaneously after menopause and does not cause isolated postmenopausal bleeding.

Q: A patient presents with ascites and omental caking. Imaging reveals solid components in an adnexal mass, and there is a long-standing history of symptoms. CA-125 is positive. What is the most probable diagnosis?

Serous ovarian tumor. ***Serous ovarian tumor*** - This is the most common type of epithelial ovarian cancer, often presenting late with extensive **peritoneal dissemination**, causing **ascites** and **omental caking** (carcinomatosis). - High elevation of the tumor marker **CA-125** is characteristic and strongly supports this diagnosis in the setting of advanced disease. *Mucinous ovarian tumor* - These tumors often grow large but are typically confined to the ovary or manifest as **pseudomyxoma peritonei** if ruptured, which is different from typical omental caking. - While they can elevate CA-125, the elevation is less common and less pronounced than in serous carcinoma. *Endometrioid tumor* - This type has a strong association with **endometriosis** and concurrent or preceding **endometrial cancer**, a feature not mentioned in the presentation. - While they are often CA-125 positive, the combined clinical picture of omental caking plus ascites points preferentially to **Serous carcinoma**. *Granulosa cell tumor* - This is a sex-cord stromal tumor that is typically detected earlier due to its **endocrine activity**, often causing signs of **estrogen excess** (e.g., post-menopausal bleeding). - The key tumor marker for this type is **inhibin**, not CA-125.

Q: What is incorrect about the instrument?

Primary prevention for cervical cancer. ***Primary prevention for cervical cancer*** - The Ayre spatula is used for **secondary prevention** (screening) of cervical cancer through **Pap smears**, not primary prevention. - **Primary prevention** for cervical cancer typically involves **HPV vaccination**. *Ayre spatula* - The instrument shown is an **Ayre spatula**, specifically designed for collecting cervical cells. - It has a distinctive shape to scrape cells from the **ectocervix** and the squamocolumnar junction. *Wooden spatula* - The Ayre spatula is traditionally made of **wood**, as depicted in the image. - Wooden spatulas are inexpensive and disposable, making them suitable for widespread use in cervical screening programs. *Long end inserted into cervical canal* - The **longer, pointed end** of the Ayre spatula is designed to be placed in the **external os** and rotated to collect cells from the squamocolumnar junction and ectocervix. - The shorter, broader end is used to collect cells from the **vaginal fornices**.

Question 1

Cryosurgery is used in the treatment of cervical intraepithelial neoplasia. In which of the following conditions is cryosurgery NOT appropriate?

Accepted Answer

Cervical intraepithelial neoplasia-3 (CIN-3).

Answer

Transformation zone lying entirely on the ectocervix.

Answer

Smooth cervical surface without deep crevices.

Answer

CIN limited to two quadrants of the cervix.

Question 2

What is the co-test in cervical cancer screening?

Accepted Answer

HPV and PAP smear

Answer

PAP smear and colposcopy

Answer

HPV and VIA

Answer

Pap smear and VIA

Question 3

Which is the primary chemotherapeutic agent used for cervical cancer?

Accepted Answer

Platinum-based therapy

Answer

Immunotherapy

Answer

Hormonal therapy

Answer

Targeted therapy

Question 4

A patient presents with an endometrial thickness of 14mm with an adnexal mass. She has a history of complex endometrial hyperplasia with the presence of atypical cells. Which of the following is likely the diagnosis?

Accepted Answer

Metastasis endometrial cancer to ovary

Answer

Struma ovarii

Answer

Polycystic ovarian disease

Answer

Immature ovarian teratoma

Question 5

Which type of hysterectomy is done in a case of carcinoma cervix stage IB?

Accepted Answer

Type 3 hysterectomy

Answer

Type 2 hysterectomy

Answer

Type 4 hysterectomy

Answer

Type 1 hysterectomy

Question 6

A woman diagnosed with cervical cancer is found to have unilateral hydroureteronephrosis on imaging due to tumor invasion. What is the FIGO stage of her disease?

Accepted Answer

Stage IIIB

Answer

Stage IIIC

Answer

Stage IIIA

Answer

Stage IIB

Question 7

A 62-year-old postmenopausal woman with a history of hypertension presents with vaginal bleeding. Her blood pressure is 170 / 100 mmHg. What is the most appropriate next step in management?

Accepted Answer

Immediate pelvic examination and transvaginal ultrasound

Answer

Refer her to cardiology before any further evaluation

Answer

Reassure her that this is normal at her age

Answer

Start antihypertensives and observe for 1 week

Question 8

A 65-year-old postmenopausal woman presents with painless vaginal bleeding. She has no history of hormone replacement therapy. What is the most likely diagnosis?

Accepted Answer

Endometrial carcinoma

Answer

Uterine fibroid

Answer

Endometriosis

Answer

Adenomyosis

Question 9

A patient presents with ascites and omental caking. Imaging reveals solid components in an adnexal mass, and there is a long-standing history of symptoms. CA-125 is positive. What is the most probable diagnosis?

Accepted Answer

Serous ovarian tumor

Answer

Granulosa cell tumor

Answer

Endometrioid tumor

Answer

Mucinous ovarian tumor

Question 10

What is incorrect about the instrument?

Accepted Answer

Primary prevention for cervical cancer

Answer

Ayre spatula

Answer

Wooden spatula

Answer

Long end inserted into cervical canal

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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