Gynecologic Oncology Practice Questions

Q: A 65 year old postmenopausal lady presents in Gynaecology OPD with abdominal distension and weight loss. On investigation she was diagnosed to have an ovarian tumour. The most common type of ovarian tumour in this woman would be

Epithelial tumor. ***Epithelial tumor*** - **Epithelial ovarian tumors** are the most common type of ovarian cancer, accounting for about **90%** of all cases. - Their incidence significantly increases with age, particularly in **postmenopausal women**, making them the most likely diagnosis in a 65-year-old presenting with abdominal distension and weight loss. *Sex cord tumor* - **Sex cord-stromal tumors** are rare, comprising about **5-8%** of ovarian neoplasms. - While they can occur at any age, they are less common than epithelial tumors and often present with **hormonal symptoms** due to their steroidogenic capacity. *Germ cell tumor* - **Germ cell tumors** are also rare, primarily affecting **younger women and adolescents**, typically under 30 years old. - They tend to grow rapidly and can present with acute symptoms like sudden onset abdominal pain, which is less characteristic for a 65-year-old postmenopausal woman. *Trophoblastic tumor* - **Trophoblastic tumors** (specifically **gestational trophoblastic disease**) are primarily related to pregnancy and occur when there is abnormal proliferation of trophoblastic tissue, such as in a **hydatidiform mole** or **choriocarcinoma**. - These are extremely rare in a postmenopausal woman without a recent pregnancy history and are not considered ovarian tumors in the traditional sense.

Q: Carcinoma of endometrium is associated with the following risk factors except:

Multiparity. ***Multiparity*** - **Multiparity**, defined as having given birth to multiple children, is generally considered a protective factor or to have no significant association with endometrial cancer. - Reduced exposure to unopposed **estrogen** due to more frequent anovulation or hormonal changes during and after pregnancy may contribute to this protective effect. *Hypertension* - **Hypertension** is a known risk factor for endometrial cancer, possibly due to its association with **obesity** and metabolic syndrome, which increase endogenous estrogen levels. - The exact mechanism is not fully understood, but it is thought to be part of the complex interplay of metabolic factors. *Obesity* - **Obesity** is a strong and well-established risk factor for endometrial cancer, as adipose tissue converts androgens into **estrogens** (via aromatase), leading to unopposed estrogen stimulation of the endometrium. - Higher levels of **insulin-like growth factors** in obese individuals may also promote endometrial cell proliferation. *Diabetes* - **Diabetes mellitus**, particularly type 2, is associated with an increased risk of endometrial cancer, largely due to **hyperinsulinemia** and insulin resistance. - **Insulin** acts as a growth factor, promoting endometrial cell proliferation and potentially contributing to malignant transformation.

Q: A 35 year old married woman with no risk factors for cervical cancer is having Pap smear showing 'atypical squamous cells of undetermined significance (ASCUS)' for the first time. What is the further step in the management?

To follow up with Pap test at 6 months. ***To follow up with Pap test at 6 months*** - For **ASCUS** (atypical squamous cells of undetermined significance) in women with **no risk factors** and a first-time finding, **repeat Pap testing** in 6-12 months is the recommended initial follow-up strategy. - This approach allows for the possibility of **spontaneous regression** of minor cellular changes, avoiding unnecessary immediate interventions. *Cryotherapy* - **Cryotherapy** is a treatment for **cervical intraepithelial neoplasia (CIN)**, a more severe finding than ASCUS. - It would be **premature and excessive** for an initial finding of ASCUS, which may resolve on its own. *Large loop excision of the transformation zone* - **LLETZ** is a procedure used to **remove abnormal cervical cells**, typically for **high-grade CIN** or persistent CIN, not for ASCUS. - Performing LLETZ for ASCUS would be an **overtreatment** and carries procedural risks without clear benefit. *Repeat Pap immediately* - Repeating the Pap smear **immediately** after an ASCUS finding is generally **not recommended** as it is unlikely to provide new diagnostic information due to the rapid cellular turnover. - A 6-month interval allows for potential cellular changes to become more definitive, whether for improvement or progression.

Q: An adolescent girl with stage 1a dysgerminoma is managed by:

Unilateral salpingo-oophorectomy alone. ***Unilateral salpingo-oophorectomy alone*** - For **stage 1a dysgerminoma**, which is confined to one ovary, **fertility-sparing surgery** with unilateral salpingo-oophorectomy is the standard treatment, especially in young patients. - This approach aims to preserve reproductive function while effectively treating the localized tumor, given the **high radiosensitivity** and **chemosensitivity** of dysgerminomas. *Chemotherapy* - While dysgerminomas are sensitive to chemotherapy, it is typically reserved for **advanced stages** (stage 1c or higher), **recurrent disease**, or cases with **residual disease** after surgery. - It is not the primary treatment for **stage 1a disease** when complete surgical resection is achievable, especially when fertility preservation is desired. *Bilateral salpingo-oophorectomy alone* - This procedure would remove both ovaries and fallopian tubes, leading to **sterility and premature menopause**. - It is an **over-treatment** for stage 1a dysgerminoma, as the disease is localized to one ovary, and it is not fertility-sparing. *Total abdominal hysterectomy with unilateral salpingo-oophorectomy* - This extensive surgery involves the removal of the uterus and one ovary/fallopian tube, rendering the patient **infertile**. - It is an **overly aggressive** approach for stage 1a dysgerminoma in an adolescent girl, as the uterus is not involved, and fertility preservation is a crucial consideration.

Q: A diabetic obese patient comes with history of post-menopausal bleeding. On examination, there is a supra pubic mass and per vagina there is purulent discharge. The probable diagnosis is:

Carcinoma endometrium. ***Carcinoma endometrium*** - **Postmenopausal bleeding** is the hallmark symptom, and the patient's **diabetes** and **obesity** are significant risk factors for endometrial carcinoma. - The combination of a **suprapubic mass** (indicating an enlarged uterus or advanced disease) and **purulent vaginal discharge** (suggesting **pyometra** secondary to cervical stenosis caused by tumor) strongly supports this diagnosis. *Ovarian carcinoma* - Ovarian carcinoma primarily presents with vague symptoms like **abdominal distension**, **bloating**, and **pelvic pain**, not typically postmenopausal bleeding as the initial symptom. - While it can cause an abdominal mass, **purulent vaginal discharge** and direct bleeding are not common primary presentations. *Uterine myoma* - **Uterine myomas (fibroids)** are common benign tumors that can cause bleeding, but typically in premenopausal women and characterized by **menorrhagia** or intermenstrual bleeding. - While large fibroids can present as a mass, **postmenopausal bleeding** and especially **purulent discharge** point away from a simple fibroid in this context. *Carcinoma cervix* - **Cervical carcinoma** often presents with **postcoital bleeding** or irregular intermenstrual bleeding, and can cause a mass and discharge. - However, the strong risk factors of **diabetes** and **obesity** are more directly linked to **endometrial cancer** than cervical cancer, and the description of a suprapubic mass suggests a uterine origin rather than primarily cervical.

Q: The following are used in the staging of carcinoma of the cervix except:

Hydroureter. ***Hydroureter*** - While hydroureter (ureteral dilatation) can occur in advanced cervical cancer due to ureteral compression, **hydroureter alone is not a FIGO staging criterion**. - The FIGO staging system specifically uses **hydronephrosis or non-functioning kidney** as a criterion for Stage IIIB, not isolated hydroureter. - Hydronephrosis represents kidney involvement, whereas hydroureter refers only to ureteral dilatation, which may not always lead to renal compromise. - This distinction is important: the staging criterion requires **renal involvement/compromise**, not just ureteral changes. *Parametrial involvement* - **Parametrial involvement** is a crucial staging criterion indicating at least **FIGO Stage IIB** disease. - This is assessed by palpation during bimanual examination or confirmed by imaging studies. - Represents lateral extension of the tumor beyond the cervix. *Pelvic lymph node involvement* - **Pelvic lymph node involvement** is a key staging criterion in the **FIGO 2018 staging system**, classified as **Stage IIIC1**. - Assessed through imaging (CT, MRI, PET-CT) or surgical staging. - Significantly impacts prognosis and treatment planning. *Vaginal involvement* - The extent of **vaginal involvement** is a direct FIGO staging criterion. - Involvement of the upper two-thirds indicates **Stage IIA**, while extension to the lower third indicates **Stage IIIA**. - Assessed by careful pelvic examination and imaging.

Q: A 60 year old woman presents with postmenopausal bleeding. On endometrial curettage she is diagnosed as endometrial carcinoma. Which one of the following is a risk factor for endometrial cancer?

Diabetes mellitus. ***Diabetes mellitus*** - Diabetes is a significant risk factor for endometrial cancer, particularly due to its association with **obesity** and resulting increased **estrogen levels**. - **Insulin resistance** and elevated insulin-like growth factors can directly promote endometrial cell proliferation. *Oral contraceptive use* - Combined oral contraceptives (OCPs) are actually **protective** against endometrial cancer. - The progestin component in OCPs counteracts the unopposed estrogen effect that is a major driver of endometrial cancer. *Multiparity* - **Multiparity** (having had multiple pregnancies) is generally considered to be protective against endometrial cancer. - This protective effect is thought to be related to the hormonal changes during pregnancy, which involve a higher proportion of **progesterone**. *Smoking* - Smoking is generally associated with an **increased risk of certain cancers,** but it is **not considered a risk factor** for endometrial cancer. - Some studies suggest it might even slightly decrease risk due to anti-estrogenic effects, though this benefit is far outweighed by its many harms.

Q: Which one of the following methods is NOT used for cervical cancer screening?

Cervical biopsy. ***Cervical biopsy*** - A **cervical biopsy** is a diagnostic procedure performed after an abnormal screening result to confirm the presence of **precancerous** or **cancerous** cells. - It involves removing a tissue sample for histological examination and is not a primary screening method. *VILI* - **Visual Inspection with Lugol's Iodine** (**VILI**) is a method used for cervical cancer screening, particularly in low-resource settings. - It involves applying **Lugol's iodine** to the cervix, where normal glycogen-rich cells stain brown, while abnormal, glycogen-deficient cells remain unstained (yellow). *VIA* - **Visual Inspection with Acetic Acid** (**VIA**) is a cost-effective screening method for cervical cancer, especially in settings where cytology is not readily available. - After applying **acetic acid** to the cervix, abnormal areas with high nuclear-to-cytoplasmic ratio and increased protein content rapidly coagulate the mucus and turn white. *Pap smear* - A **Pap smear** (Papanicolaou test) is a widely used and validated screening test for cervical cancer. - It involves collecting cells from the cervix to detect **dysplastic** or **premalignant changes** and is effective in reducing cervical cancer incidence and mortality.

Q: Which one of the following is the serum marker in epithelial ovarian cancer?

CA–125. ***CA–125*** - **CA-125** (**Cancer Antigen 125**) is the most widely used serum tumor marker for **epithelial ovarian cancer**. - Its levels are often **elevated** in women with epithelial ovarian cancer, particularly in advanced stages, and it is used for **monitoring treatment response** and **detecting recurrence**. *HCG* - **Human Chorionic Gonadotropin (HCG)** is primarily associated with **pregnancy** and **gestational trophoblastic disease**. - It may also be elevated in some **germ cell tumors**, but not typically in epithelial ovarian cancer. *CEA* - **Carcinoembryonic Antigen (CEA)** is a tumor marker commonly associated with **colorectal cancer**. - While it can be elevated in other adenocarcinomas, it is **not the primary marker** for epithelial ovarian cancer. *AFP* - **Alpha-fetoprotein (AFP)** is a marker primarily associated with **hepatocellular carcinoma** and **germ cell tumors**, particularly **yolk sac tumors**. - It is not a significant marker for common **epithelial ovarian cancers**.

Q: A 58 year old woman with suspected ovarian cancer was operated for surgical staging. On laparotomy and subsequent histopathological examination of the specimen it was found that both ovaries were involved, capsule was ruptured, ascites was present containing malignant cells. Uterus and tubes were normal and there were no peritoneal implants. The FIGO stage for this patient would be:

Stage I. ***Stage I*** - This case represents **Stage IC** (specifically IC3) according to FIGO ovarian cancer staging criteria. - **Stage IC3** is defined as ovarian tumor with **capsule rupture and/or positive peritoneal washings/ascites with malignant cells**. - Key features present: both ovaries involved, **capsule ruptured**, **ascites with malignant cells**, but **no peritoneal implants**. - The absence of peritoneal implants outside the pelvis means this cannot be Stage III, making Stage IC the correct classification. *Stage II* - Stage II requires **pelvic extension** with involvement of uterus, fallopian tubes, or other pelvic structures. - In this case, the uterus and tubes are explicitly **normal**, ruling out Stage II. - Stage II does not involve malignant ascites as the primary criterion. *Stage III* - Stage III requires **peritoneal implants outside the pelvis** and/or **retroperitoneal/inguinal lymph node involvement**. - This case explicitly states there are **no peritoneal implants**, which excludes Stage III classification. - Common misconception: malignant ascites alone does NOT constitute Stage III; visible implants or lymph node involvement are required. *Stage IV* - Stage IV involves **distant metastasis** to organs such as liver parenchyma, lungs, or extra-abdominal sites, or **pleural effusion with malignant cells**. - No evidence of distant organ involvement is present in this case. - This is clearly not Stage IV disease.

Question 1

A 65 year old postmenopausal lady presents in Gynaecology OPD with abdominal distension and weight loss. On investigation she was diagnosed to have an ovarian tumour. The most common type of ovarian tumour in this woman would be

Accepted Answer

Epithelial tumor

Answer

Sex cord tumor

Answer

Germ cell tumor

Answer

Trophoblastic tumor

Question 2

Carcinoma of endometrium is associated with the following risk factors except:

Accepted Answer

Multiparity

Answer

Hypertension

Answer

Obesity

Answer

Diabetes

Question 3

A 35 year old married woman with no risk factors for cervical cancer is having Pap smear showing 'atypical squamous cells of undetermined significance (ASCUS)' for the first time. What is the further step in the management?

Accepted Answer

To follow up with Pap test at 6 months

Answer

Cryotherapy

Answer

Large loop excision of the transformation zone

Answer

Repeat Pap immediately

Question 4

An adolescent girl with stage 1a dysgerminoma is managed by:

Accepted Answer

Unilateral salpingo-oophorectomy alone

Answer

Chemotherapy

Answer

Bilateral salpingo-oophorectomy alone

Answer

Total abdominal hysterectomy with unilateral salpingo-oophorectomy

Question 5

A diabetic obese patient comes with history of post-menopausal bleeding. On examination, there is a supra pubic mass and per vagina there is purulent discharge. The probable diagnosis is:

Accepted Answer

Carcinoma endometrium

Answer

Ovarian carcinoma

Answer

Uterine myoma

Answer

Carcinoma cervix

Question 6

The following are used in the staging of carcinoma of the cervix except:

Accepted Answer

Hydroureter

Answer

Parametrial involvement

Answer

Pelvic lymph node involvement

Answer

Vaginal involvement

Question 7

A 60 year old woman presents with postmenopausal bleeding. On endometrial curettage she is diagnosed as endometrial carcinoma. Which one of the following is a risk factor for endometrial cancer?

Accepted Answer

Diabetes mellitus

Answer

Oral contraceptive use

Answer

Multiparity

Answer

Smoking

Question 8

Which one of the following methods is NOT used for cervical cancer screening?

Accepted Answer

Cervical biopsy

Answer

VILI

Answer

VIA

Answer

Pap smear

Question 9

Which one of the following is the serum marker in epithelial ovarian cancer?

Accepted Answer

CA–125

Answer

HCG

Answer

CEA

Answer

AFP

Question 10

A 58 year old woman with suspected ovarian cancer was operated for surgical staging. On laparotomy and subsequent histopathological examination of the specimen it was found that both ovaries were involved, capsule was ruptured, ascites was present containing malignant cells. Uterus and tubes were normal and there were no peritoneal implants. The FIGO stage for this patient would be:

Accepted Answer

Stage I

Answer

Stage III

Answer

Stage II

Answer

Stage IV

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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