Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 481: Which of the following is a germ cell tumor?

A. Brenner tumor
B. Granulosa cell tumor
C. Leydig cell tumors
D. Yolk sac tumor (Correct Answer)

Explanation: **Explanation:** Ovarian tumors are classified based on their tissue of origin into three main categories: Surface Epithelial, Germ Cell, and Sex Cord-Stromal tumors. **Correct Option: D. Yolk sac tumor** Yolk sac tumors (Endodermal Sinus Tumors) are highly aggressive **Germ Cell Tumors (GCTs)** derived from the primitive germ cells of the embryonic gonad. They are the second most common malignant GCT. A key diagnostic feature is the presence of **Schiller-Duval bodies** on histology and significantly elevated serum **Alpha-fetoprotein (AFP)** levels. **Incorrect Options:** * **A. Brenner tumor:** This is a **Surface Epithelial-Stromal tumor**. It is characterized by "Walthard cell nests" and transitional epithelium resembling the bladder urothelium. * **B. Granulosa cell tumor:** This is a **Sex Cord-Stromal tumor**. It is known for producing estrogen (leading to endometrial hyperplasia) and histologically features **Call-Exner bodies**. * **C. Leydig cell tumors:** These are also **Sex Cord-Stromal tumors** (specifically pure stromal tumors). They are androgen-secreting and often contain pathognomonic **Reinke crystals**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common Germ Cell Tumor:** Mature Cystic Teratoma (Dermoid cyst). * **Most common malignant GCT:** Dysgerminoma (associated with LDH and hCG). * **Tumor Markers:** * Yolk Sac Tumor → **AFP** * Dysgerminoma → **LDH** * Choriocarcinoma → **beta-hCG** * Granulosa Cell Tumor → **Inhibin B** (most sensitive) and Estrogen.

Question 482: In Dysgerminoma stage 1A, what is the treatment of choice?

A. Total abdominal hysterectomy with bilateral salpingo-oophorectomy
B. Unilateral ovariotomy with preservation of the uterus (Correct Answer)
C. Bilateral ovariotomy with preservation of the uterus
D. Bilateral salpingo-oophorectomy

Explanation: **Explanation:** **Dysgerminoma** is the most common malignant germ cell tumor (GCT) of the ovary. A defining characteristic of these tumors is that they typically occur in young women (adolescents and young adults) and are highly sensitive to both chemotherapy and radiotherapy. **Why Option B is Correct:** In **Stage 1A** (tumor limited to one ovary, capsule intact, no ascites), the standard of care is **Unilateral Salpingo-oophorectomy (USO)**—referred to here as unilateral ovariotomy—with preservation of the contralateral ovary and the uterus. This "fertility-sparing surgery" is preferred because: 1. The tumor is usually unilateral (85-90% of cases). 2. Dysgerminomas are highly chemo-sensitive; even if a recurrence occurs, it can often be managed successfully without compromising survival. 3. Preserving fertility is a primary clinical goal in this age demographic. **Why Other Options are Incorrect:** * **Option A & D:** Total abdominal hysterectomy (TAH) and Bilateral salpingo-oophorectomy (BSO) are considered "radical surgery." These are unnecessary for Stage 1A and would cause permanent infertility and premature menopause, which is avoided unless the disease is advanced or the patient has completed her family. * **Option C:** Bilateral ovariotomy is incorrect because Dysgerminomas are rarely bilateral in Stage 1A. Removing a healthy contralateral ovary provides no survival benefit and terminates fertility. **NEET-PG High-Yield Pearls:** * **Tumor Marker:** LDH (Lactate Dehydrogenase) is the specific marker for Dysgerminoma. * **Association:** Highly associated with **gonadal dysgenesis** (Swyer Syndrome); if a Y-chromosome is present, bilateral gonadectomy is indicated to prevent gonadoblastoma. * **Radiosensitivity:** It is the **most radiosensitive** of all ovarian tumors, though chemotherapy (BEP regimen) is now preferred to preserve ovarian function. * **Microscopy:** Characterized by large, round cells with clear cytoplasm ("fried egg appearance") and fibrous septa infiltrated with **lymphocytes**.

Question 483: What is the management of stage II endometrial cancer?

A. Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO)
B. Unilateral salpingo-oophorectomy with TAH
C. Modified radical hysterectomy (Correct Answer)
D. Chemotherapy only

Explanation: ### Explanation **Correct Answer: C. Modified radical hysterectomy** **Understanding the Concept:** Endometrial cancer is staged surgically (FIGO Staging). **Stage II** is defined as the tumor invading the **cervical stroma**, but not extending beyond the uterus. Because the cervix is involved, the surgical approach must ensure wider parametrial margins and vaginal cuffs to achieve clearance, similar to the management of early-stage cervical cancer. Therefore, a **Modified Radical Hysterectomy (Type II Hysterectomy)** along with Bilateral Salpingo-Oophorectomy (BSO) and pelvic/para-aortic lymphadenectomy is the standard of care. **Analysis of Options:** * **A. TAH + BSO:** This is the treatment for **Stage I** endometrial cancer (confined to the corpus uteri). In Stage II, simple hysterectomy is insufficient because it does not address the potential microscopic spread in the parametria associated with cervical stromal involvement. * **B. Unilateral salpingo-oophorectomy with TAH:** This is incorrect as bilateral removal of adnexa is mandatory in endometrial cancer due to the high risk of micrometastasis and the estrogen-dependent nature of the tumor. * **D. Chemotherapy only:** Chemotherapy is typically reserved for advanced stages (Stage III and IV) or as adjuvant therapy for high-risk histological subtypes. It is not a primary treatment for resectable Stage II disease. **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Staging (2023 Update):** While the question follows the classic surgical paradigm, remember that Stage II specifically involves cervical stromal invasion. * **Lymphadenectomy:** Pelvic and para-aortic lymph node dissection is a crucial part of the surgical staging for Stage II to determine the need for adjuvant radiation. * **Radiation:** Most Stage II patients will require post-operative **External Beam Radiation Therapy (EBRT)** or brachytherapy to reduce local recurrence. * **Most common histological type:** Endometrioid adenocarcinoma.

Question 484: All of the following ovarian neoplasms secrete hormones, except?

A. Granulosa cell tumor
B. Dysgerminoma (Correct Answer)
C. Hilus cell tumor
D. Theca cell tumor

Explanation: **Explanation:** The core concept tested here is the distinction between **functioning (hormone-secreting)** and **non-functioning** ovarian tumors. **Why Dysgerminoma is the correct answer:** Dysgerminoma is the most common germ cell tumor of the ovary. It is typically **hormonally inert**, meaning it does not produce estrogen, androgens, or progesterone. While it is a classic marker for **LDH (Lactate Dehydrogenase)** and occasionally produces low levels of hCG (if syncytiotrophoblastic giant cells are present), it does not secrete steroid hormones that cause systemic endocrine effects. **Analysis of Incorrect Options:** * **Granulosa Cell Tumor:** A sex cord-stromal tumor known for secreting high levels of **Estrogen**. Clinical presentations include precocious puberty in children or postmenopausal bleeding/endometrial hyperplasia in adults. (Marker: Inhibin). * **Hilus Cell Tumor:** A subtype of Leydig cell tumor. These are pure steroid cell tumors that secrete **Androgens** (testosterone), leading to rapid virilization (hirsutism, clitoromegaly). * **Theca Cell Tumor (Thecoma):** Another sex cord-stromal tumor that is almost always benign and characteristically produces **Estrogen**. **NEET-PG High-Yield Pearls:** 1. **Dysgerminoma Markers:** LDH (Best), Placental Alkaline Phosphatase (PLAP), and hCG (only if syncytiotrophoblastic cells are present). 2. **Most common hormone-secreting tumor:** Granulosa cell tumor (Estrogen). 3. **Struma Ovarii:** A specialized teratoma that secretes **Thyroid hormone**, leading to hyperthyroidism. 4. **Sertoli-Leydig Cell Tumor:** The most common virilizing (Androgen-secreting) tumor of the ovary.

Question 485: Which of the following is NOT an indication for radiotherapy in carcinoma of the endometrium?

A. Pelvic node involvement
B. Deep myometrial involvement
C. Enlarged uterine cavity (Correct Answer)
D. Poor differentiation

Explanation: **Explanation:** In endometrial carcinoma, the decision to administer adjuvant radiotherapy (RT) is based on the risk of recurrence, which is determined by surgical-pathological staging. **Why "Enlarged uterine cavity" is the correct answer:** An enlarged uterine cavity is a clinical or radiological finding often associated with the bulk of the tumor or associated leiomyomas. However, it is **not** an independent prognostic factor or a recognized indication for adjuvant radiotherapy in current FIGO guidelines. Management is dictated by the depth of invasion and histological characteristics, not the size of the uterus itself. **Analysis of Incorrect Options (Indications for RT):** * **Deep Myometrial Involvement (Option B):** Invasion of more than 50% of the myometrium (Stage IB) significantly increases the risk of lymph node metastasis and local recurrence, making it a standard indication for RT. * **Poor Differentiation (Option D):** Grade 3 (G3) tumors are biologically aggressive. High-grade histology, even with superficial invasion, often warrants adjuvant treatment (Brachytherapy or External Beam RT). * **Pelvic Node Involvement (Option A):** Positive nodes (Stage IIIC1) indicate regional spread. These patients require External Beam Radiotherapy (EBRT) often combined with chemotherapy to control pelvic disease. **Clinical Pearls for NEET-PG:** * **Standard Treatment:** The primary treatment for endometrial cancer is **Extrafascial Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy (TAH+BSO)** with pelvic/para-aortic lymphadenectomy. * **Risk Stratification:** Adjuvant RT is indicated for "High-Intermediate Risk" factors, often remembered by the **GOG-99 criteria**: Age >60, Grade 2 or 3, presence of Lymphovascular Space Invasion (LVSI), and Deep myometrial invasion. * **Type II Endometrial CA:** Serous and Clear Cell carcinomas are high-risk regardless of stage and almost always require adjuvant therapy.

Question 486: A postmenopausal woman who is obese, hypertensive, and diabetic presents with postmenopausal bleeding. What is the most probable cause?

A. Malignant ovarian tumor
B. Endometrial cancer (Correct Answer)
C. Endocervical cancer
D. Brenner tumor

Explanation: ### Explanation **Correct Option: B. Endometrial cancer** The clinical presentation described—**postmenopausal bleeding (PMB)** in a patient with the "Corpus Uteri Cancer Syndrome" triad (**Obesity, Hypertension, and Diabetes**) — is a classic textbook scenario for **Endometrial Carcinoma**. The underlying pathophysiology involves **unopposed estrogen**. Obesity leads to increased peripheral conversion of androstenedione to estrone in adipose tissue. Chronic exposure to estrogen without the counter-effect of progesterone causes endometrial hyperplasia, which can progress to malignancy. In any postmenopausal woman presenting with vaginal bleeding, endometrial cancer must be ruled out first via endometrial biopsy or transvaginal ultrasound (TVS). **Why other options are incorrect:** * **A. Malignant ovarian tumor:** While some functional ovarian tumors (like Granulosa cell tumors) can secrete estrogen and cause PMB, they typically present with an adnexal mass and are less common than primary endometrial pathology in this demographic. * **C. Endocervical cancer:** While it can cause bleeding, it is more frequently associated with post-coital bleeding and is not specifically linked to the metabolic triad of obesity and diabetes. * **D. Brenner tumor:** This is a rare, usually benign fibroepithelial ovarian tumor. While it can occasionally be hormonally active, it is a much less probable cause of PMB compared to endometrial cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of PMB:** Senile/Atrophic vaginitis (however, malignancy must be excluded first). * **Risk Factors:** Nulliparity, early menarche, late menopause, PCOS, and Tamoxifen use. * **Investigation of Choice:** Endometrial Biopsy (Pipelle biopsy) is the gold standard. * **TVS Cut-off:** An endometrial thickness (ET) of **>4 mm** in a postmenopausal woman warrants further evaluation.

Question 487: CA-125 is increased in all of the following conditions EXCEPT:

A. Tuberculosis of the genital organ
B. Ovarian cancer
C. Endometriosis
D. Stein-Leventhal syndrome (Correct Answer)

Explanation: **Explanation:** CA-125 (Cancer Antigen 125) is a high-molecular-weight glycoprotein produced by derivatives of the **coelomic epithelium** (peritoneum, pleura, pericardium) and the **Müllerian epithelium** (fallopian tubes, endometrium, endocervix). It is a non-specific marker that increases whenever there is inflammation, irritation, or malignancy involving these surfaces. **Why Stein-Leventhal Syndrome is the correct answer:** Stein-Leventhal syndrome, commonly known as **Polycystic Ovary Syndrome (PCOS)**, is a metabolic and endocrine disorder characterized by hyperandrogenism and anovulation. It does not involve inflammation or destruction of the coelomic epithelium or Müllerian structures. Therefore, CA-125 levels typically remain within the normal range. **Analysis of Incorrect Options:** * **Ovarian Cancer:** CA-125 is the primary tumor marker for **epithelial ovarian tumors** (especially serous cystadenocarcinoma). It is used for monitoring treatment response and detecting recurrence. * **Tuberculosis of the genital organ:** Pelvic TB causes significant peritoneal inflammation and "millet-seed" granulomas on the serosa, leading to markedly elevated CA-125 levels (often mimicking ovarian cancer). * **Endometriosis:** This is an inflammatory condition where ectopic endometrial tissue bleeds and irritates the peritoneum, leading to moderate elevations in CA-125. **High-Yield Clinical Pearls for NEET-PG:** * **Normal Value:** <35 U/mL. * **Specificity:** CA-125 is highly sensitive but has **low specificity** in premenopausal women because it rises in benign conditions like menstruation, pregnancy, and PID. * **Meigs’ Syndrome:** Characterized by a benign ovarian fibroma, ascites, and pleural effusion; CA-125 is often elevated here despite the tumor being benign. * **Best Marker for Mucinous Ovarian Cancer:** CEA and CA 19-9 (CA-125 is often low in mucinous types).

Question 488: In the Bethesda System for reporting cervical cytology, a low-grade squamous intraepithelial lesion (LSIL) involves which of the following?

A. CIN I (Correct Answer)
B. CIN II
C. CIN III
D. Squamous metaplasia

Explanation: The Bethesda System (TBS) is the standardized nomenclature for reporting cervical cytology. It categorizes squamous cell abnormalities into two main tiers based on their clinical management and biological behavior: **LSIL** and **HSIL**. ### Explanation of the Correct Answer **LSIL (Low-grade Squamous Intraepithelial Lesion)** corresponds to **CIN I** (Cervical Intraepithelial Neoplasia Grade I). It represents a transient infection with Human Papillomavirus (HPV) and mild dysplasia involving the lower one-third of the cervical epithelium. Cytologically, LSIL is characterized by **koilocytosis** (perinuclear halo and nuclear wrinkling), which is the hallmark of HPV infection. ### Analysis of Incorrect Options * **B and C (CIN II and CIN III):** These are categorized under **HSIL (High-grade Squamous Intraepithelial Lesion)** in the Bethesda System. CIN II (moderate dysplasia) and CIN III (severe dysplasia/carcinoma in situ) carry a higher risk of progression to invasive cancer and require more aggressive management (e.g., LEEP or cold knife conization). * **D (Squamous Metaplasia):** This is a **physiological** process where the columnar epithelium of the endocervix is replaced by squamous epithelium at the transformation zone. It is a benign finding and not a dysplastic lesion. ### High-Yield Clinical Pearls for NEET-PG * **LSIL Management:** In women >25 years, LSIL is generally managed with colposcopy. However, in adolescents (21–24 years), observation with repeat cytology at 12 months is preferred due to high regression rates. * **CIN Classification:** * **CIN I:** Dysplasia in the lower 1/3rd of the epithelium. * **CIN II:** Dysplasia in the lower 2/3rd. * **CIN III:** Dysplasia involving >2/3rd or the full thickness (Carcinoma in situ). * **Key Marker:** **p16** is a surrogate biomarker for high-risk HPV; it is typically negative/focal in LSIL but shows strong, diffuse staining in HSIL.

Question 489: Carcinoma of the endometrium involving the uterine cavity more than 10 cm long with early myometrial involvement is classified as which stage?

A. Stage Ia
B. Stage Ib (Correct Answer)
C. Stage IIa
D. Stage IIb

Explanation: This question tests your knowledge of the **FIGO Staging for Endometrial Carcinoma**. The staging is primarily surgical and is based on the depth of myometrial invasion. ### **Explanation of the Correct Answer** According to the FIGO staging (updated 2009/2023), Stage I is confined to the corpus uteri. It is subdivided based on the depth of invasion: * **Stage Ia:** Tumor is limited to the endometrium or invades **less than half (< 50%)** of the myometrium. * **Stage Ib:** Tumor invades **half or more (≥ 50%)** of the myometrium. In this clinical scenario, the tumor involves the uterine cavity extensively (10 cm length) and shows **early myometrial involvement**. While the length of the cavity was part of older staging systems (pre-1988), modern staging focuses on the **depth of invasion**. "Early myometrial involvement" implies the tumor has breached the endo-myometrial junction but remains in the inner half of the muscle wall. Therefore, it is classified as **Stage Ia**. *(Note: There is a discrepancy in the provided key. Based on standard FIGO criteria, "early" or <50% invasion is Stage Ia. If the question implies the tumor has reached the outer half, it would be Ib. In NEET-PG, always prioritize the <50% vs ≥50% rule.)* ### **Why Other Options are Incorrect** * **Stage Ia:** (Correct classification for <50% invasion). * **Stage II:** Involves the **cervical stroma** but does not extend beyond the uterus. * **IIa** (Old staging): Endocervical glandular involvement only. * **IIb** (Old staging): Cervical stromal invasion. Under current FIGO, Stage II simply refers to cervical stromal invasion. ### **High-Yield Clinical Pearls for NEET-PG** 1. **Most Common Type:** Adenocarcinoma (Endometrioid type) is the most common. 2. **Risk Factor:** Unopposed estrogen (Obesity, PCOD, Lynch Syndrome, Tamoxifen). 3. **Standard Treatment:** Total Laparoscopic Hysterectomy (TLH) + Bilateral Salpingo-oophorectomy (BSO) ± Lymphadenectomy. 4. **Prognostic Factor:** The most important prognostic factor is the **histological grade** and **depth of myometrial invasion**.

Question 490: What is the management of CIN III?

A. Cervical biopsy
B. Hysterectomy
C. Cone biopsy
D. LEEP conization (Correct Answer)

Explanation: **Explanation:** **CIN III (Cervical Intraepithelial Neoplasia Grade 3)** is a high-grade squamous intraepithelial lesion (HSIL) involving the full thickness of the cervical epithelium. It is considered a direct precursor to invasive cervical cancer and requires definitive treatment. **Why LEEP is the Correct Answer:** The standard management for CIN III is **excisional treatment**, of which **LEEP (Loop Electrosurgical Excision Procedure)** is the preferred modality. LEEP uses a wire loop with an electric current to remove the transformation zone and the lesion. It is favored because it is an outpatient procedure, provides a tissue specimen for histopathological confirmation (to rule out occult invasion), and has a high success rate with minimal morbidity. **Analysis of Incorrect Options:** * **A. Cervical Biopsy:** This is a diagnostic tool (usually colposcopy-directed) used to identify CIN, not a definitive treatment for a confirmed high-grade lesion. * **B. Hysterectomy:** This is considered overtreatment for CIN III. It is only reserved for cases where there are other gynecological indications, recurrent CIN, or if the margins of a cone biopsy are persistently positive and further excision is not feasible. * **C. Cone Biopsy (Cold Knife Conization):** While also an excisional treatment, it is generally reserved for cases where the squamocolumnar junction is not fully visible, there is suspected microinvasion, or glandular disease (AIS). LEEP is preferred for routine CIN III due to lower complication rates. **NEET-PG High-Yield Pearls:** * **Treatment Goal:** To remove the entire transformation zone. * **Ablative vs. Excisional:** Ablative methods (Cryotherapy/Laser) are only used if the entire lesion is visible and there is no suspicion of invasion. Excisional methods (LEEP/CKC) are mandatory if invasion cannot be excluded. * **Follow-up:** Post-treatment, patients require co-testing (Pap + HPV) at 12 and 24 months. * **Pregnancy:** In pregnant patients with CIN III, management is conservative (colposcopy/cytology every 12 weeks); treatment is deferred until 6–12 weeks postpartum unless invasive cancer is suspected.

Practice by Chapter

Cervical Cancer

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Endometrial Cancer

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Ovarian Cancer

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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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Palliative Care in Gynecologic Oncology

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