Gynecologic Oncology Practice Questions

Q: A 35-year-old woman who has completed her family shows a positive Pap smear (Cervical intraepithelial neoplasia III (CIN III)). What is to be done next?

Simple hysterectomy. ***Simple hysterectomy*** - **Simple (total) hysterectomy** is the **definitive treatment of choice** for **CIN III** in a woman who has **completed her family**. - It removes the **entire uterus and cervix**, eliminating the risk of **recurrence or progression** to invasive cancer. - This provides a **permanent cure** without the need for long-term surveillance required after excisional procedures. - Preferred over conisation in this scenario as **fertility preservation is not needed**. *Conisation* - **Conisation** (cone biopsy) is an excisional procedure that removes a cone-shaped piece of cervical tissue and is the **treatment of choice for CIN III when fertility preservation is desired**. - While it can be both diagnostic and therapeutic, it has a **10-15% recurrence rate** and requires **lifelong cervical surveillance**. - In a patient who has **completed her family**, a more definitive treatment (hysterectomy) is preferred over conisation. *Wertheim's hysterectomy* - **Wertheim's hysterectomy** (radical hysterectomy with pelvic lymphadenectomy) is indicated for **invasive cervical cancer** (Stage IA2-IIA). - **CIN III is a pre-invasive lesion**, not invasive cancer, making this procedure unnecessarily radical and associated with significant morbidity. - This would only be considered if invasion is confirmed on histopathology. *Cryotherapy* - **Cryotherapy** is an **ablative treatment** that destroys abnormal cervical tissue by freezing. - It is suitable for **CIN I or CIN II** with small lesions but is **inadequate for CIN III** due to: - Higher risk of **residual disease** (cannot assess depth of involvement) - **No histological specimen** obtained for margin assessment - Higher recurrence rates compared to excisional procedures

Q: The risk of progression to endometrial cancer from simple hyperplasia without atypia is

1%. ***1%*** - The risk of **simple endometrial hyperplasia without atypia** progressing to endometrial cancer is very low, typically cited as less than 1%. - This low risk is why conservative management and surveillance are often sufficient for this type of hyperplasia. *8-10%* - This percentage is more indicative of the risk of progression for **complex endometrial hyperplasia without atypia**, which has a higher propensity for malignant transformation. - Simple hyperplasia without atypia carries a much lower risk due to its less abnormal glandular architecture and lack of cytologic atypia. *25-30%* - This value represents the risk of progression for **atypical endometrial hyperplasia (endometrial intraepithelial neoplasia)**, which is considered a precursor lesion to endometrial cancer. - The presence of **cytological atypia** significantly increases the risk of malignant transformation. *3-5%* - This risk range is typically associated with **complex endometrial hyperplasia without atypia**, which is higher than simple hyperplasia but considerably lower than atypical hyperplasia. - While it has abnormal architectural features, the absence of **cellular atypia** keeps the risk below that of atypical lesions.

Q: A 26 year old woman P1L1 reports with High Grade Squamous Intraepithelial Lesion (HGSIL) on Pap smear (Papanicolaou smear). Further management for her is:

Colposcopy and directed biopsy. ***Colposcopy and directed biopsy*** - A diagnosis of **High-Grade Squamous Intraepithelial Lesion (HGSIL)** from a Pap smear necessitates further investigation with **colposcopy**. - **Colposcopy** allows for direct visualization of the cervix, and **directed biopsies** are taken from suspicious areas to confirm the diagnosis and assess the extent of the lesion. *Conisation* - **Conisation (cone biopsy)** is a surgical procedure to remove a cone-shaped piece of tissue from the cervix. - It is typically performed *after* colposcopy and biopsy have confirmed a high-grade lesion or cervical cancer, not as the initial diagnostic step for HGSIL. *VIA, VILI* - **Visual inspection with acetic acid (VIA)** and **visual inspection with Lugol's iodine (VILI)** are screening methods for cervical cancer, particularly in resource-limited settings. - While useful for screening, they are not appropriate for managing a confirmed HGSIL diagnosis, which requires a more precise evaluation. *LEEP* - **LEEP (Loop Electrosurgical Excision Procedure)** is a common treatment for HGSIL. - Like conisation, LEEP is a therapeutic procedure used *after* a definitive diagnosis has been made through colposcopy and biopsy, not as the initial step for evaluating an HGSIL Pap smear.

Q: Surgical staging is done for all the genital malignancies EXCEPT:

Gestational trophoblastic neoplasia. ***Gestational trophoblastic neoplasia*** - Gestational trophoblastic neoplasia (GTN) is primarily staged **clinically** and **biochemically** using beta-human chorionic gonadotropin (β-hCG) levels. - **Surgical staging is not typically performed** for GTN due to its high sensitivity to chemotherapy and its hematogenous spread pattern. *Fallopian tube malignancy* - **Surgical staging is essential** for fallopian tube malignancy to determine disease extent and guide treatment. - Staging often involves **laparotomy**, histological examination, and evaluation of surrounding tissues. *Endometrial carcinoma* - **Surgical staging is the cornerstone of management** for endometrial carcinoma, as it provides crucial prognostic information. - This typically includes **hysterectomy**, bilateral salpingo-oophorectomy, and lymph node dissection. *Ovarian malignancy* - **Comprehensive surgical staging** is standard for ovarian malignancy to assess the spread of the disease within the peritoneal cavity. - This involves **laparotomy**, biopsies, and often extensive debulking procedures.

Q: A 28 year old P1L1 presents with severe pain in her abdomen and is taken for laparotomy. On opening the abdomen pseudomyxoma peritonei is present. What should be the probable reason?

Mucinous cystadenoma of ovary. ***Mucinous cystadenoma of ovary*** - **Pseudomyxoma peritonei** is most frequently caused by the rupture of a low-grade mucinous tumor, often originating from the **appendix** or, less commonly, the **ovary**. - A **mucinous cystadenoma of the ovary**, upon rupture, can release mucinous material into the peritoneal cavity, leading to the characteristic "jelly belly" appearance. *Rupture of dermoid tumor* - Rupture of a **dermoid tumor** (mature cystic teratoma) can cause **chemical peritonitis** due to the release of sebaceous material and hair, but it does not typically lead to pseudomyxoma peritonei. - The contents of a dermoid tumor are usually **fatty** or **keratinous**, not mucinous. *Endometriosis* - **Endometriosis** involves endometrial-like tissue growing outside the uterus, causing pelvic pain and adhesions. - It does not involve the production of a large volume of mucinous material and is therefore not a cause of pseudomyxoma peritonei. *Serous cystadenoma of ovary* - A ruptured **serous cystadenoma** would release serous (watery) fluid, not mucinous material. - While it can cause ascites, it does not produce the characteristic thick, gelatinous material seen in pseudomyxoma peritonei.

Q: Serum CA-125 levels can be raised in all the following except:

Mature cystic teratoma of ovary. ***Mature cystic teratoma of ovary*** - **Mature cystic teratomas** (dermoid cysts) are **germ cell tumors** of the ovary and typically produce tumor markers like **alpha-fetoprotein (AFP)** or **beta-hCG**, but not CA-125. - While they can be large, their cellular origin does not involve the epithelial cells that express CA-125. *Epithelial ovarian cancer* - **Epithelial ovarian cancer** is the most common cause of significantly elevated **CA-125**, as CA-125 is a cell surface glycoprotein produced by coelomic epithelium. - It is used in monitoring treatment response and recurrence in ovarian cancer patients. *Endometriosis* - **Endometriosis** involves the presence of endometrial-like tissue outside the uterus, which can cause local inflammation and irritation, leading to elevated **CA-125** levels. - The degree of CA-125 elevation often correlates with the extent and severity of the disease in some patients. *Tubercular ascites* - **Tubercular ascites** causes inflammation of the peritoneum, which can stimulate mesothelial cells (derived from coelomic epithelium) to produce **CA-125**. - In cases of peritoneal inflammation, such as with tuberculosis, CA-125 levels can be significantly elevated, mimicking ovarian cancer.

Q: A 47 year old post menopausal lady was on adjuvant hormonal treatment with Tamoxifen for 3 years for Carcinoma Breast. She came to Outpatient Department with history of passing blood clots per vagina. She is probably suffering from:

Carcinoma Endometrium. ***Carcinoma Endometrium*** - **Tamoxifen** acts as an **estrogen agonist** in the endometrium, increasing the risk of **endometrial hyperplasia** and **carcinoma**. - Postmenopausal vaginal bleeding or passing blood clots is a significant warning sign for **endometrial cancer**. *Uterine fibroid* - While fibroids can cause abnormal uterine bleeding, they are less likely to cause sudden, significant bleeding with clots in a **postmenopausal woman** on Tamoxifen without other symptoms. - Tamoxifen is not a direct cause of uterine fibroid development or enlargement. *Carcinoma Vagina* - **Vaginal carcinoma** is rarer than endometrial carcinoma and typically presents with a **vaginal mass** or bleeding with intercourse, not usually significant clotting in this context. - Tamoxifen is not directly linked to an increased risk of primary vaginal carcinoma. *Carcinoma Vulva* - **Vulvar carcinoma** presents as a **lesion** or **sore on the vulva** and symptoms like itching, pain, or bleeding from the lesion itself, not typically as vaginal blood clots. - The use of Tamoxifen does not significantly increase the risk of vulvar carcinoma.

Q: Gestational trophoblastic disease is a spectrum comprising which of the following entities? 1. Complete Hydatidiform mole 2. Partial Hydatidiform mole 3. Invasive mole 4. Choriocarcinoma Select the correct answer using the code given below:

1, 2, 3 and 4. **1, 2, 3 and 4** - **Gestational trophoblastic disease (GTD)** encompasses a spectrum of conditions arising from abnormal proliferation of trophoblastic tissue, including both benign and malignant forms. - This spectrum correctly includes **complete hydatidiform mole**, **partial hydatidiform mole**, **invasive mole**, and **choriocarcinoma**, as well as the rare placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT). *1, 2 and 3 only* - This option incorrectly excludes **choriocarcinoma**, which is a highly malignant form of gestational trophoblastic neoplasia (GTN) and a crucial part of the GTD spectrum. - While complete, partial, and invasive moles are part of the spectrum, omitting choriocarcinoma makes this answer incomplete. *1 and 4 only* - This option incompletely covers the spectrum by excluding **partial hydatidiform mole** and **invasive mole**, both of which are common and important entities within GTD. - It highlights two extremes (benign complete mole and malignant choriocarcinoma) but misses intermediate forms. *2, 3 and 4 only* - This option incorrectly omits **complete hydatidiform mole**, which is the most common precursor to gestational trophoblastic neoplasia and a central component of the GTD spectrum. - Excluding complete mole would provide an incomplete understanding of the disease's origins and manifestations.

Q: Which of the following is NOT a high risk factor for developing endometrial carcinoma?

Multiparity. ***Multiparity*** - **Multiparity** (having multiple live births) is generally considered a **protective factor** against endometrial carcinoma, as it leads to periods of reduced estrogen exposure. - Frequent pregnancies interrupt prolonged exposure to unopposed estrogen, which is a major driver of endometrial proliferation. *Delayed menopause* - **Delayed menopause** increases the total lifetime exposure to **endogenous estrogen**, which is a significant risk factor for endometrial carcinoma. - Prolonged estrogen exposure without sufficient progesterone to balance its effects promotes endometrial hyperplasia and potential malignant transformation. *Hypertension* - **Hypertension** is an independent risk factor for endometrial carcinoma, often associated with other metabolic conditions like **obesity** and **diabetes**. - It contributes to a pro-inflammatory and pro-carcinogenic environment, although the exact mechanisms are complex and involve hormonal and metabolic pathways. *Obesity* - **Obesity** is a major risk factor due to the increased peripheral conversion of androgens to **estrogen** in adipose tissue. - Higher levels of estrogen lead to **unopposed estrogen stimulation** of the endometrium, promoting hyperplasia and increasing the risk of carcinoma.

Question 1

A 35-year-old woman who has completed her family shows a positive Pap smear (Cervical intraepithelial neoplasia III (CIN III)). What is to be done next?

Accepted Answer

Simple hysterectomy

Answer

Wertheim's hysterectomy

Answer

Cryotherapy

Answer

Conisation

Question 2

The risk of progression to endometrial cancer from simple hyperplasia without atypia is

Accepted Answer

1%

Answer

8-10%

Answer

25-30%

Answer

3-5%

Question 3

A 26 year old woman P1L1 reports with High Grade Squamous Intraepithelial Lesion (HGSIL) on Pap smear (Papanicolaou smear). Further management for her is:

Accepted Answer

Colposcopy and directed biopsy

Answer

Conisation

Answer

VIA, VILI

Answer

LEEP

Question 4

Surgical staging is done for all the genital malignancies EXCEPT:

Accepted Answer

Gestational trophoblastic neoplasia

Answer

Fallopian tube malignancy

Answer

Endometrial carcinoma

Answer

Ovarian malignancy

Question 5

In a 40 year old woman, pap smear shows atypical glandular cells. The next step of management should be:

Accepted Answer

Colposcopy, cervical biopsy, endocervical curettage and endometrial biopsy

Answer

Hysteroscopy and directed endometrial biopsy

Answer

Colposcopic directed cervical biopsy

Answer

Repeat pap smear after three months

Question 6

A 28 year old P1L1 presents with severe pain in her abdomen and is taken for laparotomy. On opening the abdomen pseudomyxoma peritonei is present. What should be the probable reason?

Accepted Answer

Mucinous cystadenoma of ovary

Answer

Rupture of dermoid tumor

Answer

Endometriosis

Answer

Serous cystadenoma of ovary

Question 7

Serum CA-125 levels can be raised in all the following except:

Accepted Answer

Mature cystic teratoma of ovary

Answer

Epithelial ovarian cancer

Answer

Endometriosis

Answer

Tubercular ascites

Question 8

A 47 year old post menopausal lady was on adjuvant hormonal treatment with Tamoxifen for 3 years for Carcinoma Breast. She came to Outpatient Department with history of passing blood clots per vagina. She is probably suffering from:

Accepted Answer

Carcinoma Endometrium

Answer

Uterine fibroid

Answer

Carcinoma Vagina

Answer

Carcinoma Vulva

Question 9

Gestational trophoblastic disease is a spectrum comprising which of the following entities?

1. Complete Hydatidiform mole
2. Partial Hydatidiform mole
3. Invasive mole
4. Choriocarcinoma

Select the correct answer using the code given below:

Accepted Answer

1, 2, 3 and 4

Answer

1, 2 and 3 only

Answer

1 and 4 only

Answer

2, 3 and 4 only

Question 10

Which of the following is NOT a high risk factor for developing endometrial carcinoma?

Accepted Answer

Multiparity

Answer

Delayed menopause

Answer

Hypertension

Answer

Obesity

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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