Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 451: Systemic metastasis is commonest in which of the following gynecologic malignancies?

A. Ovarian Carcinoma
B. Endometrial Carcinoma
C. Choriocarcinoma (Correct Answer)
D. Carcinoma of the cervix

Explanation: **Explanation:** The correct answer is **Choriocarcinoma**. This is because choriocarcinoma is a highly malignant, germ-cell-derived tumor characterized by early and extensive **hematogenous spread** (blood-borne metastasis). Unlike most other gynecologic cancers that spread primarily through direct extension or the lymphatic system, choriocarcinoma lacks an intrinsic stroma and directly invades blood vessels, leading to rapid systemic dissemination. **Why the other options are incorrect:** * **Ovarian Carcinoma:** Primarily spreads via **exfoliation** and intraperitoneal seeding (transcoelomic spread). While it can spread lymphatically, systemic (extra-abdominal) metastasis usually occurs late in the disease. * **Endometrial Carcinoma:** Most commonly spreads by **direct extension** to the myometrium and cervix, or via lymphatics. Systemic hematogenous spread is less common and typically occurs in high-grade variants. * **Carcinoma of the Cervix:** Predominantly spreads by **direct local invasion** into the parametrium and vagina, followed by predictable **lymphatic spread** to pelvic and para-aortic nodes. Hematogenous spread is a late-stage event. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** For choriocarcinoma, the **lungs** are the most common site (80%), followed by the vagina (30%), liver, and brain. * **Characteristic Sign:** "Cannon-ball" opacities on a chest X-ray are classic for pulmonary metastasis from choriocarcinoma. * **Tumor Marker:** Serum **beta-hCG** is the highly sensitive marker used for diagnosis, monitoring, and follow-up. * **Treatment:** It is one of the most chemo-sensitive tumors; even with systemic metastasis, the cure rate is high using the EMA-CO regimen.

Question 452: Which Human Papillomavirus (HPV) type is most commonly implicated in genital (vulval) warts?

A. HPV 16
B. HPV 18
C. HPV 31
D. HPV 6 (Correct Answer)

Explanation: **Explanation:** The correct answer is **HPV 6**. Genital warts, also known as **Condyloma acuminata**, are benign epithelial proliferations caused by "low-risk" types of Human Papillomavirus. **HPV 6 and 11** are responsible for approximately 90% of all genital wart cases. These types have a low potential for malignant transformation but are highly contagious and associated with significant morbidity. **Analysis of Options:** * **HPV 6 (Correct):** This is the most common type associated with genital warts. It targets the squamous epithelium of the vulva, vagina, and perianal region. * **HPV 16 & 18 (Incorrect):** These are "high-risk" oncogenic types. HPV 16 is the most common cause of **Cervical Cancer** (squamous cell carcinoma) and Vulvar Intraepithelial Neoplasia (VIN). HPV 18 is strongly associated with cervical **adenocarcinoma**. * **HPV 31 (Incorrect):** This is another high-risk type associated with cervical dysplasia and cancer, but it is less common than types 16 and 18 and rarely causes benign warts. **High-Yield Clinical Pearls for NEET-PG:** * **Low-risk HPV (6, 11):** Associated with Condyloma acuminata and Recurrent Respiratory Papillomatosis (RRP). * **High-risk HPV (16, 18, 31, 33, 45):** Associated with Cervical, Vaginal, Vulvar, Anal, and Oropharyngeal cancers. * **Histology:** The hallmark of HPV infection is **Koilocytosis** (cells with perinuclear halos and wrinkled "raisinoid" nuclei). * **Vaccination:** The Quadrivalent (Gardasil) and Nonavalent vaccines protect against types 6 and 11, thereby preventing genital warts.

Question 453: Which of the following is NOT a poor prognostic factor in the management of cancer of the cervix?

A. Young age
B. Well-differentiated squamous cell carcinoma (Correct Answer)
C. Hydroureter
D. Adenocarcinoma

Explanation: In cervical cancer, prognosis is determined by the tumor's biological behavior, stage, and histological characteristics. **Explanation of the Correct Answer:** * **Well-differentiated squamous cell carcinoma (Option B):** Histological grading refers to how much the tumor resembles the parent tissue. Well-differentiated (Grade 1) tumors grow and spread more slowly than poorly differentiated (Grade 3) ones. In cervical cancer, high-grade (undifferentiated) tumors have a higher risk of lymph node metastasis and recurrence. Therefore, being "well-differentiated" is a **favorable** prognostic factor, not a poor one. **Analysis of Incorrect Options (Poor Prognostic Factors):** * **Young age (Option A):** Paradoxically, cervical cancer in very young women (especially <35 years) often presents with more aggressive biological behavior, larger tumor volume, and a higher incidence of lymph node involvement compared to older post-menopausal women. * **Hydroureter (Option C):** The presence of hydroureter or hydronephrosis indicates that the tumor has spread laterally to the pelvic wall, compressing the ureters. This automatically classifies the disease as **Stage IIIB** (FIGO 2018), which carries a significantly lower 5-year survival rate compared to earlier stages. * **Adenocarcinoma (Option D):** While Squamous Cell Carcinoma (SCC) is the most common type, Adenocarcinoma is associated with a worse prognosis. It is more likely to have "skip lesions," early lymph node metastasis, and a poorer response to radiotherapy compared to SCC. **NEET-PG High-Yield Pearls:** * **Most important prognostic factor:** The **Stage** of the disease at the time of diagnosis. * **Most common site of metastasis:** Pelvic lymph nodes (Obturator node is the most common). * **FIGO 2018 Update:** Imaging (MRI/CT) and pathological findings can now be used for staging, unlike the previous clinical-only staging. * **Triad of Stage IIIB:** Hydronephrosis, non-functioning kidney, or involvement of the pelvic wall.

Question 454: The HPV triage strategy includes all of the following except?

A. Conventional Pap smear (Correct Answer)
B. Liquid-based cytology
C. Hybrid Capture 2 for HPV DNA
D. Colposcopy

Explanation: The core concept of **HPV Triage** is the use of HPV DNA testing to manage women with minor cytological abnormalities (like ASC-US) or, conversely, using cytology to manage women who test positive for high-risk HPV. **Why Conventional Pap Smear is the Correct Answer (The "Except"):** In a triage setting, the same sample used for the initial test is ideally used for the follow-up test to avoid recalling the patient. **Conventional Pap smears** do not allow for "reflex testing" because the cells are fixed directly onto a slide, leaving no residual material for HPV DNA testing. Therefore, it is not part of a modern HPV triage strategy. **Explanation of Other Options:** * **Liquid-based cytology (LBC):** This is the gold standard for triage. The cells are suspended in a preservative medium, allowing the lab to perform HPV DNA testing (Reflex HPV) from the same vial if the cytology shows ASC-US. * **Hybrid Capture 2 (HC2):** This is the FDA-approved "gold standard" molecular test for detecting 13-14 high-risk HPV types. It is the primary tool used to triage women with ASC-US to determine if they need colposcopy. * **Colposcopy:** This is the diagnostic endpoint of the triage algorithm. If a triage test (like HC2) is positive, the patient is referred for colposcopy to identify CIN lesions. **High-Yield Clinical Pearls for NEET-PG:** * **ASC-US Management:** If LBC shows ASC-US, the preferred next step is **Reflex HPV testing**. If HPV is positive $\rightarrow$ Colposcopy; if HPV is negative $\rightarrow$ Repeat cytology in 3 years. * **Primary Screening:** In many modern guidelines, HPV DNA testing is now the primary screening tool for women $>30$ years. * **HC2 vs. PCR:** Hybrid Capture 2 is the most widely used clinical test, whereas PCR is more sensitive but often used in research.

Question 455: A 45-year-old female diagnosed with breast carcinoma underwent surgery and has been on tamoxifen therapy for one year. She now presents with complaints of bleeding per vaginum. If this is due to an adverse effect of tamoxifen, what is the most likely cause?

A. Development of a bleeding disorder
B. Development of endometrial carcinoma (Correct Answer)
C. Development of ovarian carcinoma
D. Development of cervical cancer

Explanation: **Explanation:** **1. Why Endometrial Carcinoma is the Correct Answer:** Tamoxifen is a **Selective Estrogen Receptor Modulator (SERM)**. Its mechanism of action is tissue-specific: * **In the Breast:** It acts as an **antagonist**, making it effective for ER-positive breast cancer. * **In the Uterus:** It acts as a **partial agonist**. This estrogenic effect leads to endometrial proliferation, hyperplasia, and an increased risk of **endometrial carcinoma** (specifically Type 1 endometrioid adenocarcinoma). In a postmenopausal or perimenopausal woman on tamoxifen, any new-onset vaginal bleeding must be investigated via transvaginal ultrasound (TVS) and endometrial biopsy to rule out malignancy. **2. Why Other Options are Incorrect:** * **A. Bleeding disorder:** While some chemotherapeutic agents cause thrombocytopenia, tamoxifen is not typically associated with systemic coagulopathies or bleeding disorders. * **C. Ovarian carcinoma:** Tamoxifen does not significantly increase the risk of ovarian cancer. In fact, some studies suggest it may have a protective effect or no impact on the ovaries. * **D. Cervical cancer:** Cervical cancer is primarily caused by High-Risk HPV infection. Tamoxifen’s estrogenic effects are specific to the endometrium and do not promote cervical carcinogenesis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Risk Ratio:** Tamoxifen increases the risk of endometrial cancer by approximately **2 to 3 times**. * **Other Side Effects:** Increased risk of **Thromboembolism** (DVT/PE) and **Cataracts**. It also causes vasomotor symptoms (hot flashes). * **Beneficial Side Effect:** It has a protective effect on **bone mineral density** in postmenopausal women and lowers LDL cholesterol. * **Alternative:** **Raloxifene** (another SERM) is an antagonist at both the breast and uterus, thus it does *not* increase the risk of endometrial cancer, but it is not used for breast cancer treatment (only prevention).

Question 456: Which of the following is a poor prognostic factor for choriocarcinoma?

A. Full term pregnancy (Correct Answer)
B. Short duration of symptoms
C. Abortion
D. Low beta-hCG levels

Explanation: In Gestational Trophoblastic Neoplasia (GTN), specifically choriocarcinoma, prognosis is determined using the **WHO Modified Prognostic Scoring System (FIGO Scoring)**. This system categorizes patients into low-risk (score ≤6) or high-risk (score ≥7) groups. ### **Explanation of the Correct Option** **A. Full term pregnancy:** This is a significant poor prognostic factor. Choriocarcinoma following a term pregnancy is associated with a higher tumor burden, delayed diagnosis, and a higher likelihood of chemoresistance compared to cases following a molar pregnancy or abortion. In the FIGO scoring system, an antecedent term pregnancy is assigned **2 points**, whereas a hydatidiform mole is 0 points and an abortion is 1 point. ### **Explanation of Incorrect Options** * **B. Short duration of symptoms:** A short interval (less than 4 months) between the antecedent pregnancy and the start of chemotherapy is a **favorable** prognostic factor (0 points). A long interval (>12 months) indicates a poor prognosis. * **C. Abortion:** While an abortion carries a higher risk than a molar pregnancy, it is considered a better prognostic factor than a full-term pregnancy. * **D. Low beta-hCG levels:** Higher pretreatment serum hCG levels correlate with a larger tumor mass and poorer prognosis. Levels **>100,000 IU/L** are considered high-risk (4 points), while low levels (<1,000 IU/L) are favorable. ### **Clinical Pearls for NEET-PG** * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%). * **Brain/Liver Metastasis:** These are high-risk factors (assigned 4 points each). * **Chemotherapy:** Low-risk GTN is treated with single-agent Methotrexate; High-risk GTN requires multi-agent **EMA-CO** regimen (Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide, Vincristine). * **The "Great Imitator":** Choriocarcinoma is known for its tendency to bleed due to its highly vascular nature and lack of intrinsic villi.

Question 457: Which of the following are masculinizing tumors of the ovary?

A. Granulosa cell tumor
B. Dysgerminoma
C. Dermoid Cyst
D. Arrhenoblastoma (Correct Answer)

Explanation: **Explanation:** **1. Why Arrhenoblastoma is Correct:** Arrhenoblastoma, also known as a **Sertoli-Leydig Cell Tumor**, is a sex cord-stromal tumor that typically secretes androgens (testosterone). It is the most common virilizing tumor of the ovary. Clinically, patients present with **defeminization** (amenorrhea, breast atrophy) followed by **masculinization** (hirsutism, clitoromegaly, deepening of the voice). It is usually unilateral and occurs in young women (2nd–3rd decade). **2. Why the Other Options are Incorrect:** * **Granulosa Cell Tumor:** This is also a sex cord-stromal tumor, but it is primarily **feminizing**. It secretes estrogen, leading to precocious puberty in children or postmenopausal bleeding and endometrial hyperplasia in older women. (Call-Exner bodies are a hallmark). * **Dysgerminoma:** This is a germ cell tumor (the female counterpart of seminoma). It is typically hormonally inert, though it may occasionally produce LDH or hCG. It does not cause masculinization. * **Dermoid Cyst (Mature Cystic Teratoma):** This is the most common benign germ cell tumor. It contains tissues from all three germ layers (hair, teeth, sebum) but does not have endocrine activity unless it undergoes specialized transformation (e.g., Struma ovarii causing hyperthyroidism). **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Sertoli-Leydig tumors may show elevated **Alpha-fetoprotein (AFP)** in some cases, but the definitive marker is high **Serum Testosterone**. * **Other Masculinizing Tumors:** Hilus cell tumors and Gynandroblastoma (which has both granulosa and Sertoli-Leydig elements). * **Management:** Usually surgical (Unilateral Salpingo-oophorectomy) as most are Stage I and benign/low-grade malignancy.

Question 458: What is the primary treatment for choriocarcinoma?

A. Chemotherapy (Correct Answer)
B. External beam radiotherapy
C. Hysterectomy
D. Intracavitary brachytherapy

Explanation: **Explanation:** Choriocarcinoma is a highly malignant, epithelial tumor arising from the chorionic villi. It is characterized by its extreme sensitivity to cytotoxic drugs, making **Chemotherapy** the primary and definitive treatment modality, even in the presence of widespread metastasis. * **Why Chemotherapy is Correct:** Choriocarcinoma is considered one of the most "chemo-curable" solid tumors. For low-risk cases (FIGO score <7), single-agent chemotherapy (usually **Methotrexate** or Actinomycin-D) is used. For high-risk cases (FIGO score ≥7), multi-agent chemotherapy (the **EMA-CO regimen**) is the standard of care. * **Why Incorrect Options are Wrong:** * **Radiotherapy (B & D):** Choriocarcinoma is generally not treated with radiation as a primary modality because it is highly vascular and responds much better to systemic chemotherapy. Radiation is reserved only for specific resistant brain or liver metastases. * **Hysterectomy (C):** Surgery is not the primary treatment because the disease is systemic and highly metastatic (often spreading to the lungs). Hysterectomy may be considered only in specific scenarios, such as uncontrollable uterine hemorrhage or for chemo-resistant localized nodules in women who have completed childbearing. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Serum **beta-hCG** is the essential marker for diagnosis, monitoring treatment response, and detecting recurrence. * **Common Site of Metastasis:** The **lungs** (80%) are the most common site, often presenting as "cannonball metastases" on X-ray. * **FIGO Scoring:** Treatment is dictated by the WHO/FIGO prognostic scoring system, which categorizes patients into low-risk or high-risk groups. * **Prognosis:** Even with metastatic disease, the cure rate for choriocarcinoma exceeds 90% with appropriate chemotherapy.

Question 459: Criteria for diagnosis of gestational trophoblastic neoplasia includes all except?

A. Plateau of serum beta-human chorionic gonadotropin levels for 4 measurements during a period of 3 weeks
B. Rise in serum beta-human chorionic gonadotropin levels > 10% during 3 weekly consecutive measurements
C. Serum beta-human chorionic gonadotropin levels remain detectable for 3 months only (Correct Answer)
D. Histological evidence of choriocarcinoma

Explanation: ### Explanation Gestational Trophoblastic Neoplasia (GTN) is a clinical diagnosis made when there is evidence of persistent or malignant disease following a molar pregnancy. The diagnosis is primarily based on the **FIGO (International Federation of Gynecology and Obstetrics) criteria**, which focus on the pattern of serum beta-hCG levels. **Why Option C is the Correct Answer (The "Except"):** According to FIGO criteria, GTN is diagnosed if serum beta-hCG levels remain detectable for **6 months or more** after the evacuation of a molar pregnancy. A duration of only 3 months is insufficient for a diagnosis of GTN unless the levels are rising or plateauing. **Analysis of Other Options (FIGO Criteria for GTN):** * **Option A (Plateau):** A plateau of hCG (defined as a ±10% change) for at least four measurements over a period of 3 weeks (days 1, 7, 14, and 21) is a definitive diagnostic criterion. * **Option B (Rise):** A rise in hCG levels of >10% for at least three consecutive weekly measurements (days 1, 8, and 15) indicates progressive disease and confirms GTN. * **Option D (Histology):** While GTN is often a clinical/biochemical diagnosis, a histological diagnosis of **choriocarcinoma** is always considered diagnostic of GTN, regardless of hCG levels. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%). * **Staging:** GTN is staged using the **FIGO Anatomical Staging** and the **WHO Modified Prognostic Scoring System** (Low risk: score ≤6; High risk: score ≥7). * **Management:** Low-risk GTN is typically treated with single-agent chemotherapy (Methotrexate or Actinomycin-D), while high-risk GTN requires multi-agent chemotherapy (EMA-CO regimen). * **Contraception:** Patients must be advised to use reliable contraception (preferably OCPs) for at least 6–12 months after hCG normalization to avoid confusing a new pregnancy with a relapse.

Question 460: What is the most common site for carcinoma of the cervix?

A. Endocervix
B. Ectocervix (Correct Answer)
C. Near the internal os
D. Vault

Explanation: **Explanation:** The correct answer is **B. Ectocervix**. **Why Ectocervix is Correct:** The most common site for the development of cervical carcinoma is the **Squamocolumnar Junction (SCJ)**, specifically within the **Transformation Zone**. This is the dynamic area where the glandular epithelium of the endocervix is replaced by the stratified squamous epithelium of the ectocervix through the process of squamous metaplasia. Because this zone is highly metabolically active and sensitive to HPV (Human Papillomavirus) infection, it is the primary site for oncogenic transformation. Anatomically, in women of reproductive age, the transformation zone is located on the **ectocervix**, making it the most frequent site for the initiation of cervical cancer. **Why Other Options are Incorrect:** * **A. Endocervix:** While adenocarcinoma of the cervix arises from the endocervical glands, it accounts for only 10–20% of cases. Squamous cell carcinoma (SCC) is far more common (80–90%) and typically begins on the ectocervical side of the SCJ. * **C. Near the internal os:** The internal os is located deep within the endocervical canal. The SCJ only recedes toward the internal os in postmenopausal women; however, the majority of lesions still originate at the transformation zone, which is generally more distal. * **D. Vault:** The vaginal vault is the top portion of the vagina. While cervical cancer can *spread* to the vault, it does not originate there. **High-Yield NEET-PG Pearls:** * **Most common histological type:** Squamous Cell Carcinoma (80-90%). * **Most common site:** Transformation Zone (Ectocervix). * **Primary Risk Factor:** Persistent infection with High-Risk HPV (Types 16 and 18). * **Screening:** Pap smear samples cells specifically from the transformation zone using an Ayre’s spatula or cytobrush.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

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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