Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 471: A 55-year-old female presents with abdominal pain, distension, ascites, and dyspnea. Her CA 125 levels are elevated. What is the most likely diagnosis?

A. Ovarian cancer (Correct Answer)
B. Cervical cancer
C. Lung cancer
D. Lymphoma

Explanation: ### Explanation **Correct Option: A. Ovarian Cancer** The clinical presentation of abdominal pain, distension, and ascites in a postmenopausal woman is a classic "red flag" for **Epithelial Ovarian Cancer (EOC)**. Ascites in these patients often results from peritoneal carcinomatosis, where tumor cells disrupt lymphatic drainage and increase capillary permeability. The presence of **dyspnea** suggests a pleural effusion (likely Stage IV disease), forming part of the clinical picture of advanced malignancy. **CA-125** is the most significant tumor marker for EOC; while not specific (it can rise in endometriosis or PID), its elevation in a postmenopausal woman with a pelvic mass and ascites is highly suggestive of ovarian malignancy. **Incorrect Options:** * **B. Cervical Cancer:** Usually presents with post-coital or irregular vaginal bleeding. Ascites and elevated CA-125 are not typical primary features unless there is widespread intra-abdominal metastasis. * **C. Lung Cancer:** While it can cause dyspnea and pleural effusion, it would not typically present with a primary picture of ascites and elevated CA-125. * **D. Lymphoma:** Can cause ascites and lymphadenopathy, but CA-125 is not a standard marker for lymphoma, and the constellation of symptoms more strongly points toward a gynecological primary in this age group. **NEET-PG High-Yield Pearls:** * **Sister Mary Joseph Nodule:** A palpable nodule at the umbilicus representing metastasis from pelvic/abdominal cancers (most commonly Ovarian or Gastric). * **Meigs Syndrome:** A triad of Benign Ovarian Tumor (Fibroma), Ascites, and Right-sided Pleural Effusion. * **Staging:** Ovarian cancer is staged **surgically** (FIGO staging). * **Tumor Markers:** CA-125 is used for monitoring treatment response and recurrence rather than primary screening in the general population.

Question 472: Which of the following is NOT a management option for carcinoma of the breast during the second trimester of pregnancy?

A. Chemotherapy with doxorubicin, cyclophosphamide, and 5-FU
B. Mastectomy
C. Focal 3D (Correct Answer)
D. Breast-conservative surgery

Explanation: **Explanation:** The management of breast cancer during pregnancy (BCP) aims to provide standard oncological care while minimizing fetal risk. The correct answer is **Focal 3D (Radiotherapy)** because radiation therapy is generally **contraindicated** throughout pregnancy due to the high risk of fetal malformations, growth restriction, and childhood carcinogenesis, especially when the fetus is in close proximity to the field. **Analysis of Options:** * **A. Chemotherapy (FAC regimen):** Chemotherapy is contraindicated in the first trimester (teratogenic risk). However, it is considered **safe and standard** during the **second and third trimesters** (after 14 weeks). Doxorubicin, Cyclophosphamide, and 5-FU (FAC) is a commonly used regimen. * **B. Mastectomy:** This is the preferred surgical option in many cases because it often eliminates the immediate need for adjuvant radiotherapy, which must be delayed until postpartum. * **D. Breast-conservative surgery (BCS):** BCS is an option in the second trimester if the patient is willing to delay the mandatory follow-up radiotherapy until after delivery. **Clinical Pearls for NEET-PG:** 1. **Radiotherapy:** Always contraindicated during pregnancy; must be delayed until after delivery. 2. **Chemotherapy:** Safe after the 1st trimester. It must be stopped 3 weeks before the expected date of delivery to avoid neonatal neutropenia. 3. **Surgery:** Can be performed safely in all trimesters. 4. **Drugs to Avoid:** Methotrexate (antimetabolite/teratogenic), Tamoxifen (teratogenic/genitourinary risks), and Trastuzumab (causes oligohydramnios). 5. **Termination of pregnancy:** Does not improve maternal survival outcomes in breast cancer.

Question 473: Bilateral hydronephrosis is seen in which of the following conditions?

A. Vaginal carcinoma
B. Carcinoma cervix stage 3 or 4 (Correct Answer)
C. Hepatic cirrhosis
D. Colon cancer

Explanation: **Explanation:** **Why Option B is Correct:** In gynecologic oncology, **Carcinoma Cervix** is notorious for its lateral spread into the parametrium. According to the **FIGO staging system**, Stage IIIB is specifically defined by the extension of the tumor to the pelvic wall and/or the presence of **hydronephrosis** or a non-functioning kidney (unless known to be due to another cause). The anatomical proximity of the ureters to the cervix is the key medical concept. The ureters pass through the "cardinal ligament" (Mackenrodt's ligament) approximately 1–2 cm lateral to the cervix. As the cervical tumor invades the parametrium (Stage IIB onwards), it can compress or directly infiltrate the ureters. Bilateral involvement leads to bilateral hydronephrosis, which is a common cause of **uremia**—the leading cause of death in untreated cervical cancer patients. **Why Other Options are Incorrect:** * **Vaginal Carcinoma:** While it can spread locally, it rarely causes bilateral ureteric obstruction unless it is very advanced and involves the upper third of the vagina extensively. * **Hepatic Cirrhosis:** This typically presents with ascites and portal hypertension. While it may cause "pseudo-renal" issues (Hepatorenal syndrome), it does not cause mechanical obstruction of the ureters. * **Colon Cancer:** This usually spreads to the liver or causes bowel obstruction. While it can involve a single ureter via retroperitoneal spread, bilateral hydronephrosis is not a classic or defining staging feature. **Clinical Pearls for NEET-PG:** * **FIGO Stage IIIB:** Includes any patient with hydronephrosis, regardless of other findings. * **Most common cause of death in Ca Cervix:** Renal failure due to bilateral ureteric obstruction (Uremia). * **Investigation of Choice:** Contrast-Enhanced CT (CECT) or MRI is used for staging and assessing hydronephrosis, though FIGO staging is primarily clinical. * **Management:** In cases of severe obstruction, palliative urinary diversion (Percutaneous Nephrostomy - PCN) may be required.

Question 474: Which of the following is true about granulosa cell tumors, EXCEPT?

A. The most common malignant tumor of the ovary (Correct Answer)
B. It secretes hormones
C. Associated with endometrial hyperplasia
D. Chemotherapy sensitive

Explanation: **Explanation:** The correct answer is **A (The most common malignant tumor of the ovary)** because this statement is false. The most common malignant ovarian tumors are **Serous Cystadenocarcinomas** (surface epithelial tumors). Granulosa cell tumors (GCTs) are rare, accounting for only 2–5% of all ovarian malignancies. They belong to the **Sex Cord-Stromal** category and are considered "low-grade" malignancies with a generally indolent course. **Analysis of other options:** * **B (Secretes hormones):** GCTs are functionally active tumors that primarily secrete **Estrogen**. This is a hallmark feature used for clinical diagnosis. * **C (Associated with endometrial hyperplasia):** Due to chronic, unopposed estrogen secretion, up to 25–50% of patients develop endometrial hyperplasia, and 5–10% may develop co-existing **Endometrial Carcinoma**. * **D (Chemotherapy sensitive):** While surgery is the primary treatment, GCTs are sensitive to chemotherapy (typically the **BEP regimen**: Bleomycin, Etoposide, and Cisplatin), which is used for advanced or recurrent stages. **NEET-PG High-Yield Pearls:** * **Pathognomonic Feature:** **Call-Exner bodies** (small follicles filled with eosinophilic material) seen on histology. * **Tumor Marker:** **Inhibin B** is the most reliable marker for diagnosis and monitoring recurrence. * **Clinical Presentation:** Often presents as **precocious puberty** in children (Juvenile type) or **postmenopausal bleeding** in older adults (Adult type). * **Nuclear Feature:** "Coffee-bean" nuclei (longitudinal nuclear grooves).

Question 475: CA-125 is a specific marker of:

A. Choriocarcinoma
B. Teratoma
C. Epithelial cell carcinoma of the ovary (Correct Answer)
D. Seminoma

Explanation: **Explanation:** **CA-125 (Cancer Antigen 125)** is a high-molecular-weight glycoprotein produced by derivatives of the **coelomic epithelium** (including the peritoneum, pleura, pericardium, and the lining of the fallopian tubes, endometrium, and endocervix). It is the most widely used tumor marker for **Epithelial Ovarian Cancer (EOC)**, particularly the serous subtype. It is used for monitoring treatment response and detecting recurrence, though its utility as a screening tool is limited due to low specificity in premenopausal women. **Analysis of Incorrect Options:** * **A. Choriocarcinoma:** The specific marker is **beta-hCG** (Human Chorionic Gonadotropin). * **B. Teratoma:** Mature teratomas have no specific markers. However, **Immature Teratomas** may show elevated **AFP** (Alpha-fetoprotein) or LDH. * **D. Seminoma:** In females, the equivalent is **Dysgerminoma**. The characteristic marker is **LDH** (Lactate Dehydrogenase); some may also show mildly elevated beta-hCG. **High-Yield Clinical Pearls for NEET-PG:** * **Normal Value:** < 35 U/mL. * **Benign Elevations:** CA-125 can be elevated in non-malignant conditions like **Endometriosis** (most common benign cause), Pelvic Inflammatory Disease (PID), pregnancy, and fibroids. * **Other Ovarian Markers:** * **Yolk Sac Tumor:** AFP (Highly specific). * **Granulosa Cell Tumor:** Inhibin B. * **Mucinous Cystadenocarcinoma:** CEA and CA 19-9. * **RMI (Risk of Malignancy Index):** Uses CA-125 levels, ultrasound features, and menopausal status to predict the likelihood of malignancy.

Question 476: Lower urethral involvement of vulval carcinoma without inguinofemoral nodes is seen in which stage?

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

Explanation: **Explanation:** The staging of vulvar carcinoma follows the **FIGO (2021)** classification. The correct answer is **Stage II** because this stage is defined by a tumor of any size with extension to adjacent perineal structures, specifically the **lower 1/3 of the urethra**, lower 1/3 of the vagina, or the anus, provided there is **no regional lymph node involvement**. * **Stage I:** The tumor is confined to the vulva or perineum with no nodal involvement. It is subdivided into IA (≤2 cm, stromal invasion ≤1 mm) and IB (>2 cm or invasion >1 mm). * **Stage III:** This stage is characterized by **inguinofemoral lymph node metastasis**, regardless of the size of the primary tumor or local extension to the lower urethra/vagina. * **Stage IV:** This represents advanced disease involving the **upper** parts of the pelvic organs (upper 2/3 of the urethra, upper 2/3 of the vagina, bladder mucosa, or rectal mucosa) or distant metastasis. **High-Yield Clinical Pearls for NEET-PG:** * **Lymphatic Spread:** Vulvar cancer primarily spreads via the lymphatics to the **inguinofemoral nodes**. The "Sentinel Lymph Node" biopsy is indicated in Stage IB/II tumors <4 cm. * **The "Lower vs. Upper" Rule:** Involvement of the **lower 1/3** of the urethra/vagina is **Stage II**; involvement of the **upper 2/3** is **Stage IVA**. * **Most Common Type:** Squamous cell carcinoma (SCC) is the most common histological type, often associated with HPV (in younger patients) or Lichen Sclerosus (in elderly patients).

Question 477: Pseudomyxoma peritonei is typically associated with which of the following conditions?

A. Thecoma of the ovary
B. Mucinous ovarian carcinoma (Correct Answer)
C. Carcinoid tumor of the appendix
D. Mesothelioma

Explanation: **Explanation:** **Pseudomyxoma Peritonei (PMP)** is a clinical syndrome characterized by the accumulation of abundant gelatinous (mucinous) ascites within the peritoneal cavity. This "jelly belly" appearance results from the implantation of mucus-secreting cells onto the peritoneal surfaces. **Why Option B is Correct:** The most common primary sites for PMP are the **appendix** and the **ovary**. In gynecology, it is classically associated with **Mucinous Ovarian Tumors** (specifically borderline or malignant types). These tumors can rupture or leak, seeding the peritoneum with mucin-producing epithelium. While current evidence suggests many cases of PMP actually originate from a primary appendiceal tumor that secondarily involves the ovary, in the context of standard O&G examinations, mucinous ovarian carcinoma remains the hallmark association. **Why Other Options are Incorrect:** * **A. Thecoma:** These are benign sex cord-stromal tumors that produce estrogen. They are associated with Meigs’ syndrome (ascites and pleural effusion), not PMP. * **C. Carcinoid tumor of the appendix:** While the appendix is a common site for PMP, it is specifically **mucinous adenocarcinomas** or low-grade appendiceal mucinous neoplasms (LAMN) that cause it, not neuroendocrine carcinoid tumors. * **D. Mesothelioma:** This is a tumor of the mesothelium (often linked to asbestos) which causes malignant ascites, but it does not produce the characteristic thick, gelatinous mucin seen in PMP. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic Sign:** "Jelly Belly" (thick, pea-soup-like mucinous material). * **Redistribution Phenomenon:** Mucin and cells accumulate at specific sites of peritoneal fluid resorption (e.g., omentum, undersurface of the diaphragm) while sparing the mobile small bowel. * **Treatment:** The gold standard is **Cytoreductive Surgery (CRS)** combined with **Hyperthermic Intraperitoneal Chemotherapy (HIPEC)**, often referred to as the "Sugarbaker Procedure."

Question 478: Which of the following statements are true about a complete mole?

A. Presence of fetal parts and cardiac activity (Correct Answer)
B. Normal uterine size
C. Beta hCG doubling time is 7-10 days
D. Pre-eclampsia at < 24 weeks

Explanation: In a **Complete Hydatidiform Mole**, the genetic material is entirely paternal (usually 46,XX), resulting from the fertilization of an "empty" egg by one or two sperm. This leads to generalized trophoblastic proliferation and diffuse swelling of chorionic villi. ### **Analysis of Options** * **A. Presence of fetal parts and cardiac activity (Correct):** In a complete mole, there is **no fetal tissue** or amniotic fluid. The presence of fetal parts, a fetus, or cardiac activity is characteristic of a **Partial Mole** (usually 69,XXY). * **B. Normal uterine size:** In complete moles, the uterus is typically **larger than the period of gestation** (in ~50% of cases) due to excessive trophoblastic proliferation and retained blood. * **C. Beta hCG doubling time:** In a normal pregnancy, hCG doubles every 48–72 hours. In molar pregnancies, hCG levels are **abnormally high** (often >100,000 mIU/mL) and do not follow the standard doubling curve. * **D. Pre-eclampsia at < 24 weeks:** This is a **classic feature** of a complete mole. Developing hypertension/proteinuria in the first or early second trimester is a pathognomonic "red flag" for gestational trophoblastic disease. ### **NEET-PG High-Yield Pearls** * **USG Appearance:** "Snowstorm appearance" or "Bunch of grapes." * **Theca Lutein Cysts:** Often present bilaterally due to massive hCG stimulation. * **Karyotype:** Complete Mole (46,XX/XY; Paternal only) vs. Partial Mole (69,XXY; Triploid). * **Risk of Malignancy:** Complete moles have a higher risk (15–20%) of progressing to Choriocarcinoma compared to partial moles (<5%). * **Management:** Suction and evacuation is the treatment of choice.

Question 479: What is the increased risk of ovarian cancer above normal in a woman with a non-autosomal dominant genotype who has one first-degree relative with ovarian cancer?

A. 2-3 times (Correct Answer)
B. 5 times
C. 10 times
D. 20 times

Explanation: **Explanation:** The risk of developing ovarian cancer is significantly influenced by family history, even in the absence of high-penetrance genetic syndromes like BRCA1 or BRCA2. **1. Why Option A is Correct:** In the general population, the lifetime risk of ovarian cancer is approximately **1.4% to 1.6%**. For a woman with **one first-degree relative** (mother, sister, or daughter) affected by ovarian cancer, the risk increases to approximately **3% to 5%**. This represents a **2-3 fold increase** over the baseline population risk. This "non-autosomal dominant" scenario usually implies a polygenic inheritance or shared environmental factors rather than a single high-risk gene mutation. **2. Why Other Options are Incorrect:** * **Option B (5 times):** This risk level is typically associated with having **two first-degree relatives** affected, where the lifetime risk climbs to approximately 7%. * **Options C & D (10-20 times):** These high risks are reserved for **hereditary syndromes**. A woman with a **BRCA1 mutation** has a 40-50% lifetime risk (approx. 30 times the baseline), and a **BRCA2 mutation** carrier has a 15-25% risk (approx. 10-15 times the baseline). **Clinical Pearls for NEET-PG:** * **Most common type:** Epithelial ovarian cancer (90%). * **Protective factors:** Combined Oral Contraceptive Pills (COCPs) – 5 years of use reduces risk by 50%; breastfeeding; and multiparity. * **Screening:** There is currently **no effective screening** tool for the general population (CA-125 and TVS have low positive predictive value). * **Lynch Syndrome (HNPCC):** Associated with a 10-12% lifetime risk of ovarian cancer.

Question 480: A unilateral ovarian tumour with visible peritoneal implants belongs to which stage?

A. Stage IB
B. Stage IC
C. Stage IIA
D. Stage IIIB (Correct Answer)

Explanation: The staging of ovarian cancer follows the **FIGO (International Federation of Gynecology and Obstetrics)** classification. This question tests the distinction between localized spread and distant peritoneal metastasis. ### **Explanation of the Correct Answer** **Stage III** is defined by the presence of 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 IIIA:** Microscopic extrapelvic (above the pelvic brim) peritoneal involvement. * **Stage IIIB:** Macroscopic extrapelvic peritoneal involvement **≤ 2 cm** in greatest dimension. * **Stage IIIC:** Macroscopic extrapelvic peritoneal involvement **> 2 cm** in greatest dimension. Since the question specifies "visible peritoneal implants" (macroscopic) without specifying the size or location, it falls under the Stage III category. In the context of standard NEET-PG options, Stage IIIB is the most appropriate fit for visible extrapelvic spread. ### **Why Other Options are Incorrect** * **Stage IB:** Tumor is limited to **both** ovaries; capsules are intact, and there is no tumor on the external surface or in ascites/washings. * **Stage IC:** Tumor is limited to one or both ovaries with surgical spill (IC1), capsule rupture/surface tumor (IC2), or malignant cells in ascites/washings (IC3). * **Stage IIA:** Extension or implants on the **uterus, fallopian tubes, or ovaries only** (limited to the true pelvis). ### **High-Yield Clinical Pearls for NEET-PG** * **Most common presentation:** Ovarian cancer usually presents late (Stage III or IV) because it is the "silent killer." * **Stage I vs. II:** The boundary is the **pelvic brim**. If the tumor is below the brim, it is Stage II; if it is above (peritoneum/omentum), it is Stage III. * **Lymph Nodes:** Involvement of retroperitoneal (pelvic or para-aortic) nodes alone is now classified as **Stage IIIA1**. * **Liver Involvement:** Liver **capsule** implants are Stage III; liver **parenchymal** metastasis is Stage IVB.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

Vulvar and Vaginal Cancer

Practice Questions

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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