Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 461: Choriocarcinoma is differentiated from invasive mole (chorioadenoma destruens) by which of the following?

A. Presence of high titre of urinary chorionic gonadotrophin
B. Presence of cannon ball shadows in the lungs
C. Absence of villi structure on histological examination of the lesion (Correct Answer)
D. All of the above

Explanation: The differentiation between Gestational Trophoblastic Neoplasia (GTN) subtypes is a high-yield topic in NEET-PG. The definitive distinction between an **Invasive Mole** and **Choriocarcinoma** lies in the histopathological architecture. ### 1. Why Option C is Correct The hallmark of an **Invasive Mole** is the presence of **hydropic chorionic villi** that invade the myometrium. In contrast, **Choriocarcinoma** is a purely epithelial malignancy characterized by the sheets of malignant syncytiotrophoblasts and cytotrophoblasts with significant hemorrhage and necrosis, but **total absence of villi**. If villi are present, the diagnosis cannot be choriocarcinoma. ### 2. Why Other Options are Incorrect * **Option A:** Both conditions are derived from trophoblastic tissue and produce human chorionic gonadotrophin (hCG). While titers are often higher in choriocarcinoma, high hCG levels are seen in both and cannot be used for definitive differentiation. * **Option B:** "Cannon ball" shadows represent hematogenous pulmonary metastases. While more common and aggressive in choriocarcinoma, invasive moles are also locally aggressive and can metastasize to the lungs. Therefore, radiological findings alone are not pathognomonic for differentiation. ### Clinical Pearls for NEET-PG * **Most common site of metastasis:** Lungs (for both), followed by the vagina. * **Treatment of choice:** Both are highly chemosensitive. Methotrexate (with folinic acid) is the first-line agent for low-risk GTN. * **Diagnosis:** Unlike most cancers, choriocarcinoma is often diagnosed based on **hCG levels and clinical presentation** rather than biopsy, due to the high risk of life-threatening hemorrhage from the vascular tumor. * **Histology Rule:** Villi present = Invasive Mole; Villi absent = Choriocarcinoma.

Question 462: Human chorionic gonadotropin (HCG) is a tumor marker for which of the following conditions?

A. Choriocarcinoma (Correct Answer)
B. Colon carcinoma
C. Serous cystadenoma
D. Teratoma

Explanation: **Explanation:** **Human Chorionic Gonadotropin (HCG)** is a glycoprotein hormone normally produced by the syncytiotrophoblast cells of the placenta. In oncology, it serves as a highly sensitive and specific tumor marker for **Gestational Trophoblastic Neoplasia (GTN)**, of which **Choriocarcinoma** is the most aggressive form. Because choriocarcinoma is composed of malignant proliferation of trophoblastic tissue, it secretes massive amounts of HCG, which is used for diagnosis, monitoring treatment response, and detecting recurrence. **Analysis of Incorrect Options:** * **B. Colon carcinoma:** The primary tumor marker for colorectal cancer is **CEA (Carcinoembryonic Antigen)**. HCG is not typically associated with gastrointestinal malignancies. * **C. Serous cystadenoma:** This is a benign epithelial ovarian tumor. While its malignant counterpart (Serous Cystadenocarcinoma) uses **CA-125** as a marker, benign cystadenomas do not typically produce specific serum markers. * **D. Teratoma:** Mature cystic teratomas (dermoid cysts) usually do not have specific markers. However, if a teratoma contains immature elements (Immature Teratoma) or undergoes malignant transformation, markers like **AFP** may be elevated, but HCG is not the primary marker unless there is a co-existing germ cell component like a choriocarcinoma. **Clinical Pearls for NEET-PG:** * **HCG in Germ Cell Tumors:** HCG is also a marker for **Dysgerminoma** (occasionally) and **Nongestational Choriocarcinoma**. * **The "Hook Effect":** Extremely high HCG levels (as seen in molar pregnancies) can sometimes cause a false negative result in undiluted urine samples due to antibody saturation. * **Monitoring:** After evacuation of a hydatidiform mole, HCG levels must be monitored weekly until they are undetectable for three consecutive weeks to rule out persistent GTN.

Question 463: What is the most common type of vulvar cancer?

A. Squamous cell carcinoma (Correct Answer)
B. Melanoma
C. Adenocarcinoma
D. Adenosquamous carcinoma

Explanation: **Explanation:** **1. Why Squamous Cell Carcinoma (SCC) is Correct:** Squamous cell carcinoma is the most common histological type of vulvar cancer, accounting for approximately **90% of all cases**. It primarily arises from the squamous epithelium that covers the labia majora, labia minora, and clitoris. There are two distinct pathways for its development: * **HPV-associated (Warty/Basaloid type):** Seen in younger women, linked to high-risk HPV types (16, 18) and smoking. * **HPV-independent (Keratinizing type):** Seen in older women, often associated with chronic inflammatory conditions like **Lichen Sclerosus**. **2. Why the other options are incorrect:** * **B. Melanoma:** This is the **second most common** vulvar malignancy (approx. 5%). It typically presents as a pigmented lesion and has a high propensity for metastasis. * **C. Adenocarcinoma:** This is rare and usually arises from the Bartholin glands or as a manifestation of Paget’s disease of the vulva. * **D. Adenosquamous carcinoma:** This is an extremely rare variant containing both glandular and squamous components, often carrying a more aggressive prognosis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Labia majora. * **Most common symptom:** Long-standing pruritus (itching) or a visible mass. * **Lymphatic Spread:** The primary route of spread is via the lymphatics, first to the **superficial inguinal nodes**, then to deep inguinal (Cloquet’s node), and finally to pelvic nodes. * **Staging:** Vulvar cancer is staged surgically (FIGO staging). * **Precursor lesion:** Vulvar Intraepithelial Neoplasia (VIN) or Differentiated VIN (dVIN).

Question 464: What is the commonest complication of a mature teratoma?

A. Torsion (Correct Answer)
B. Rupture
C. Hemorrhage
D. Malignancy

Explanation: **Explanation:** **Mature Cystic Teratoma (Dermoid Cyst)** is the most common germ cell tumor of the ovary. Understanding its complications is high-yield for NEET-PG: **1. Why Torsion is the Correct Answer:** **Torsion** is the most common complication, occurring in approximately **15%** of cases. This happens because dermoid cysts are often pedunculated, have a high fat content (making them buoyant), and are frequently of moderate size (5–10 cm). These factors allow the cyst to rotate around its pedicle, leading to vascular compromise and acute pelvic pain. **2. Why the Other Options are Incorrect:** * **Rupture:** This is rare (approx. 1–2%). If it occurs, the leakage of sebaceous material can cause a severe chemical peritonitis (granulomatous peritonitis). * **Hemorrhage:** Unlike functional cysts (like corpus luteum cysts), hemorrhage is an uncommon primary complication of a teratoma. * **Malignancy:** Malignant transformation occurs in only **1–2%** of cases, most commonly into **Squamous Cell Carcinoma** (usually in postmenopausal women). **Clinical Pearls for NEET-PG:** * **Most common site:** Right ovary (due to the presence of the sigmoid colon on the left limiting space). * **Radiological Sign:** **Rokitansky protuberance** (a solid nodule projecting into the cyst cavity) and the presence of teeth or calcification on X-ray/CT. * **Treatment of Choice:** Cystectomy is preferred over oophorectomy in women of reproductive age to preserve ovarian reserve. * **Tip:** If a question asks for the "most common complication of *any* benign ovarian tumor," the answer is almost always **Torsion**.

Question 465: A fifty-year-old woman presents with bilateral solid ovarian tumors and ascites. Upper gastro-intestinal endoscopy reveals an ulcerative growth in the pyloric region of the stomach. What is the most likely diagnosis?

A. Malignant epithelial ovarian tumor with gastric metastasis
B. Germ cell ovarian tumor with concurrent gastric malignancy
C. Sex cord stromal tumor with concurrent gastric malignancy
D. Carcinoma stomach with Krukenberg's tumor (Correct Answer)

Explanation: **Explanation:** The clinical presentation of **bilateral solid ovarian tumors** associated with a **gastric lesion** (ulcerative growth in the pylorus) and ascites is a classic description of **Krukenberg’s tumor**. **1. Why Option D is Correct:** A Krukenberg tumor is a metastatic signet-ring cell adenocarcinoma of the ovary, where the primary malignancy most commonly originates in the **stomach** (approx. 70%), followed by the colon, breast, or appendix. Key diagnostic features present in this case include: * **Bilateral involvement:** Over 80% of Krukenberg tumors are bilateral. * **Solid nature:** Unlike primary epithelial tumors which are often cystic-solid, these are typically firm and solid. * **Route of spread:** Traditionally thought to occur via retrograde lymphatic spread rather than direct peritoneal seeding. **2. Why Other Options are Incorrect:** * **Option A:** While epithelial ovarian tumors can cause ascites, they rarely metastasize to the stomach mucosa. It is far more common for the stomach to be the primary site and the ovary to be the secondary site. * **Options B & C:** Germ cell tumors (common in younger women) and Sex-cord stromal tumors (like Fibromas in Meigs Syndrome) do not typically coexist with gastric malignancies. The presence of an ulcerative gastric growth strongly points toward a primary GI malignancy. **3. NEET-PG High-Yield Pearls:** * **Microscopy:** Look for **Signet-ring cells** (mucin-filled cytoplasm displacing the nucleus to the periphery). * **Primary Site:** Stomach (most common); specifically the pylorus. * **Differential:** If the patient had a solid ovarian tumor, ascites, and right-sided pleural effusion but *no* gastric growth, the diagnosis would be **Meigs Syndrome**. * **Age:** Usually presents in the 5th decade of life.

Question 466: In a retrospective study, the progeny of women who took diethylstilbestrol had an increased risk for developing which of the following cancers?

A. Bladder cancer
B. Endometrial carcinoma
C. Ovarian carcinoma
D. Vaginal clear cell adenocarcinoma (Correct Answer)

Explanation: ### Explanation **Correct Option: D. Vaginal clear cell adenocarcinoma** **Mechanism and Pathophysiology:** Diethylstilbestrol (DES) is a synthetic non-steroidal estrogen prescribed between 1938 and 1971 to prevent miscarriages. It is a classic example of a **transplacental carcinogen**. In utero exposure to DES interferes with the normal transformation of the Müllerian epithelium. Instead of the normal squamous epithelialization of the vagina, glandular tissue persists (**Vaginal Adenosis**), which serves as a precursor for **Clear Cell Adenocarcinoma (CCAC)** of the vagina and cervix. The peak incidence for this cancer occurs in the late teens and early twenties of the "DES daughters." **Analysis of Incorrect Options:** * **A. Bladder cancer:** There is no established epidemiological link between DES exposure and urothelial malignancies. * **B. Endometrial carcinoma:** While DES exposure is associated with structural uterine anomalies (e.g., T-shaped uterus), it does not significantly increase the risk of endometrial cancer in the progeny. However, the *mothers* who took DES have a slightly higher risk of breast cancer. * **C. Ovarian carcinoma:** DES exposure affects the development of the Müllerian ducts (uterus, cervix, upper vagina), but there is no proven correlation with an increased risk of epithelial ovarian tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Structural Anomalies:** DES daughters often present with a **T-shaped uterine cavity**, cervical collars (cockscomb cervix), and fallopian tube abnormalities (leading to increased ectopic pregnancy risk). * **Vaginal Adenosis:** This is the most common benign finding in DES-exposed females (present in >30%). * **Screening:** DES-exposed women require lifelong annual screening with a four-quadrant Pap smear and careful palpation of the vaginal walls. * **Male Progeny:** DES sons may show an increased risk of cryptorchidism, epididymal cysts, and hypospadias, but no proven increase in testicular cancer.

Question 467: What is the FIGO staging of carcinoma of the ovary with negative nodes, limited to the true pelvis, and microscopic implants on the peritoneal surface?

A. Stage III A (Correct Answer)
B. Stage III B
C. Stage III C
D. None of the above

Explanation: **Explanation:** The FIGO staging for Ovarian Cancer is primarily surgical and pathological. This question tests the specific differentiation within **Stage III**, which involves spread to the peritoneum outside the pelvis and/or regional lymph nodes. **Why Stage III A is correct:** Stage III is defined by tumor involving one or both ovaries with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes. * **Stage III A1:** Spread limited to retroperitoneal lymph nodes only. * **Stage III A2:** **Microscopic** extrapelvic (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodes. Since the question specifies **microscopic implants** on the peritoneal surface and negative nodes, it fits the criteria for Stage III A. **Why the other options are incorrect:** * **Stage III B:** This involves **macroscopic** peritoneal metastasis beyond the pelvis, where the largest diameter of the implants is **≤ 2 cm**. * **Stage III C:** This involves **macroscopic** peritoneal metastasis beyond the pelvis where the largest diameter of the implants is **> 2 cm** (may include extension to the capsule of liver/spleen). **High-Yield Clinical Pearls for NEET-PG:** * **Stage I:** Limited to ovaries/fallopian tubes. * **Stage II:** Limited to pelvic organs (uterus, tubes, bladder, rectum) below the pelvic brim. * **Stage IV:** Distant metastasis (IV A: Pleural effusion with positive cytology; IV B: Parenchymal metastasis to liver/spleen or extra-abdominal organs). * **Key Distinction:** The transition from Stage II to Stage III occurs the moment the tumor crosses the **pelvic brim** onto the abdominal peritoneal surface. If it's only visible under a microscope, it is III A2.

Question 468: What is the treatment of choice for a 28-week size molar pregnancy in a 40-year-old parous woman?

A. Vacuum extraction
B. Hysterectomy (Correct Answer)
C. Hysterotomy
D. Vaginal delivery

Explanation: **Explanation:** The management of a molar pregnancy is primarily determined by the patient's age and her desire for future fertility. **Why Hysterectomy is the Correct Choice:** In this clinical scenario, the patient is **40 years old** and **parous** (completed her family). For women over 40 years of age, the risk of developing **Gestational Trophoblastic Neoplasia (GTN)** or choriocarcinoma following a molar pregnancy increases significantly (up to 30-50%). Hysterectomy with the mole *in situ* is the treatment of choice here because it provides a permanent method of sterilization and, more importantly, reduces the risk of post-molar GTN by eliminating the primary site of trophoblastic proliferation. **Analysis of Incorrect Options:** * **A. Vacuum Extraction (Suction Evacuation):** This is the standard treatment for women who wish to preserve fertility, regardless of the uterine size. While it removes the molar tissue, it does not eliminate the high risk of malignant transformation associated with advanced maternal age. * **C. Hysterotomy:** This involves a surgical incision into the uterus to remove the mole. It is contraindicated because it increases the risk of disseminating trophoblastic cells into the peritoneal cavity and systemic circulation, raising the risk of GTN. * **D. Vaginal Delivery:** Molar pregnancies do not result in a viable fetus and cannot be managed by standard labor/delivery. Induction of labor with oxytocin or prostaglandins is avoided as it increases the risk of trophoblastic embolization to the lungs. **NEET-PG High-Yield Pearls:** * **Gold Standard:** Suction Evacuation is the overall most common treatment for molar pregnancy. * **Hysterectomy Indications:** Age >40 years, completed family, or uncontrolled hemorrhage. * **Follow-up:** Even after hysterectomy, patients must be monitored with weekly **serum β-hCG levels** until they are undetectable for three consecutive weeks, as the risk of GTN is reduced but not entirely eliminated (due to potential occult micrometastases).

Question 469: Latzko triad is characteristic of which of the following conditions?

A. Ovarian carcinoma
B. Fallopian tube carcinoma (Correct Answer)
C. Endometrial carcinoma
D. Cervical carcinoma

Explanation: **Explanation:** **Latzko’s Triad** (also known as the Hydrops Tubae Profluens triad) is the classic clinical presentation of **Primary Fallopian Tube Carcinoma**. Although this triad is pathognomonic, it is seen in only about 15% of patients. The triad consists of: 1. **Intermittent profuse serosanguinous vaginal discharge:** Caused by the periodic emptying of the distended tube. 2. **Colicky pelvic pain:** Relieved by the discharge of fluid (as the pressure within the tube decreases). 3. **Palpable adnexal mass:** Which often shrinks or disappears after the discharge of fluid (**Hydrops Tubae Profluens**). **Analysis of Incorrect Options:** * **Ovarian Carcinoma:** Typically presents with vague abdominal bloating, early satiety, or a persistent solid adnexal mass. It does not feature the characteristic intermittent watery discharge seen in tubal cancer. * **Endometrial Carcinoma:** Usually presents with postmenopausal bleeding or abnormal uterine bleeding. While it involves the uterine cavity, it does not present with the specific "pain-relief-discharge" cycle of Latzko’s triad. * **Cervical Carcinoma:** Commonly presents with post-coital bleeding, foul-smelling discharge, or a visible growth on the cervix during speculum examination. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histology:** Serous adenocarcinoma (similar to ovarian cancer). * **Lynch II Syndrome & BRCA mutations:** Both increase the risk of fallopian tube carcinoma. * **STIC (Serous Tubal Intraepithelial Carcinoma):** Currently considered the precursor lesion for many "ovarian" high-grade serous carcinomas. * **Management:** Staging and debulking surgery, followed by platinum-based chemotherapy (similar to the protocol for epithelial ovarian cancer).

Question 470: What is the single most effective drug used for prophylaxis of gestational trophoblastic diseases?

A. Methotrexate (Correct Answer)
B. Cytosine arabinoside
C. L-Asparaginase
D. Procarbazine

Explanation: **Explanation:** Gestational Trophoblastic Disease (GTD), specifically hydatidiform mole, carries a risk of progressing to Gestational Trophoblastic Neoplasia (GTN). While the primary treatment for a molar pregnancy is suction evacuation, **prophylactic chemotherapy** is sometimes considered in "high-risk" complete moles (e.g., age >40, hCG >100,000 mIU/mL, or large theca lutein cysts). **1. Why Methotrexate is correct:** Methotrexate (an antimetabolite/folic acid antagonist) is the drug of choice for prophylaxis because trophoblastic tissue is highly sensitive to it. It inhibits dihydrofolate reductase, preventing DNA synthesis in rapidly dividing syncytiotrophoblasts. Clinical studies have shown that a single course of Methotrexate (with or without Folinic acid rescue) significantly reduces the incidence of post-molar GTN in high-risk patients. **2. Why other options are incorrect:** * **Cytosine arabinoside (Ara-C):** Primarily used in acute myeloid leukemia (AML); it has no established role in GTD management. * **L-Asparaginase:** Used in Acute Lymphoblastic Leukemia (ALL); it works by depleting asparagine, which is not a targeted pathway in trophoblastic tumors. * **Procarbazine:** An alkylating agent used mainly in Hodgkin’s lymphoma (MOPP regimen); it is not used for GTD due to its side effect profile and lack of efficacy compared to Methotrexate or Actinomycin-D. **Clinical Pearls for NEET-PG:** * **Standard Treatment:** Suction and Evacuation is the gold standard for molar pregnancy. * **Prophylaxis:** Only indicated if the patient is high-risk and follow-up is unlikely or impossible. * **Follow-up:** Weekly hCG levels until three consecutive negatives, then monthly for 6 months. * **Contraception:** Combined Oral Contraceptive Pills (OCPs) are preferred during the follow-up period to prevent pregnancy-related hCG confusion.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

Vulvar and Vaginal Cancer

Practice Questions

Gestational Trophoblastic Disease

Practice Questions

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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