Gynecologic Oncology — MCQs
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Which of the following statements is true about hydatidiform mole?
Carcinoma cervix is associated with all except:
A 22-year-old woman has an abnormal cervical Pap smear. A biopsy is obtained from a suspicious area on the cervix. The pathology report states: "There is a loss of the normal orientation of the squamous cells. Atypical cells with wrinkled nuclei and perinuclear halos involve the full thickness of the squamous epithelium. The basement membrane is intact." What is your diagnosis?
The best method to confirm the diagnosis of carcinoma cervix is:
What is the most common site of metastasis in choriocarcinoma?
A unilateral ovarian tumor has spread to the peritoneum but not to the uterus. What is the FIGO staging of this ovarian neoplasm?
Metastases from a granulosa cell tumor most commonly involve which of the following?
Schiller-Duval bodies are characteristically seen in which of the following ovarian tumors?
True about Ca vulva associated/predisposed by Vulval intraepithelial neoplasia?
Fibroma belongs to which of the following categories of ovarian tumors?
Gynecologic Oncology Indian Medical PG Practice Questions and MCQs
Question 41: Which of the following statements is true about hydatidiform mole?
- A. Always associated with raised uterine size for gestational age.
- B. Raised hCG.
- C. Hysterectomy in selected cases. (Correct Answer)
- D. Chemotherapy is the treatment of choice.
Explanation: ### Explanation **1. Why Option C is Correct:** While suction evacuation is the standard treatment for hydatidiform mole, **hysterectomy** is a recognized management option in **selected cases**. It is specifically indicated for women who have completed their childbearing (parity fulfilled) and are of advanced maternal age (usually >40 years). Hysterectomy with the mole in situ reduces the risk of post-molar Gestational Trophoblastic Neoplasia (GTN) from approximately 15-20% to 3.5%, although it does not eliminate the need for follow-up. **2. Why the Other Options are Incorrect:** * **Option A:** Uterine size is larger than gestational age in only about 50% of cases. In many instances, the uterus may be small for dates or equal to dates, particularly in partial moles. * **Option B:** While hCG is typically elevated in molar pregnancies, this statement is considered "less correct" in a competitive MCQ context because hCG is elevated in all normal pregnancies as well. It is the **disproportionately high** levels (often >100,000 mIU/mL) that are characteristic, but not pathognomonic, of a mole. * **Option C vs B:** In NEET-PG, when choosing between a physiological fact (hCG) and a definitive management guideline (Hysterectomy), the management guideline is often the intended "best" answer. * **Option D:** Chemotherapy is the treatment of choice for **Gestational Trophoblastic Neoplasia (GTN)** (malignant), not for a benign hydatidiform mole. Prophylactic chemotherapy for moles is generally not recommended. **Clinical Pearls for NEET-PG:** * **Gold Standard Treatment:** Suction and Evacuation (S&E). * **Most Common Site of Metastasis (GTN):** Lungs (80%), followed by the Vagina. * **Snowstorm Appearance:** Classic ultrasound finding (due to hydropic villi). * **Theca Lutein Cysts:** Occur in 25-30% of cases due to high hCG; they usually regress spontaneously after evacuation. * **Follow-up:** Weekly hCG until three consecutive normal values, then monthly for 6 months. Avoid pregnancy during this period (OCPs are the preferred contraceptive).
Question 42: Carcinoma cervix is associated with all except:
- A. Multiparity
- B. Herpes simplex virus
- C. Early coitus
- D. Diabetes mellitus (Correct Answer)
Explanation: **Explanation:** Carcinoma cervix is primarily an **infectious-driven malignancy**, with Human Papillomavirus (HPV) infection being the necessary precursor. The risk factors are generally associated with increased exposure to HPV or a compromised immune response to the virus. **Why Diabetes Mellitus is the correct answer:** Diabetes mellitus is **not** a recognized risk factor for cervical cancer. While diabetes is strongly associated with **Endometrial Carcinoma** (as part of the metabolic triad: obesity, diabetes, and hypertension), it does not play a direct role in the pathogenesis of cervical squamous cell carcinoma. **Analysis of other options:** * **Multiparity:** High parity is a known risk factor. It is thought that repeated cervical trauma during delivery and the hormonal changes of pregnancy (which may increase the vulnerability of the transformation zone) facilitate HPV persistence. * **Herpes Simplex Virus (HSV):** Specifically HSV-2 acts as a **co-factor**. While it doesn't cause cervical cancer alone, it promotes inflammation and facilitates the integration of HPV DNA into the host genome. * **Early Coitus:** Early age at first intercourse is a major risk factor because the adolescent cervix has a large area of **ectopy** (columnar epithelium), which is highly susceptible to HPV infection during the process of squamous metaplasia. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Squamous cell carcinoma (80-85%). * **Most common HPV strains:** HPV 16 (most oncogenic) and HPV 18 (associated with adenocarcinoma). * **Other Risk Factors:** Smoking (doubles the risk), low socioeconomic status, multiple sexual partners, and long-term OCP use (>5 years). * **Protective Factor:** Barrier contraceptives (condoms) and male circumcision reduce the risk of HPV transmission.
Question 43: A 22-year-old woman has an abnormal cervical Pap smear. A biopsy is obtained from a suspicious area on the cervix. The pathology report states: "There is a loss of the normal orientation of the squamous cells. Atypical cells with wrinkled nuclei and perinuclear halos involve the full thickness of the squamous epithelium. The basement membrane is intact." What is your diagnosis?
- A. Cervical intraepithelial neoplasia (CIN) I with koilocytic atypia
- B. CIN II with koilocytic atypia
- C. CIN III with koilocytic atypia (Correct Answer)
- D. Inflammatory atypia secondary to colposcopy
Explanation: **Explanation:** The diagnosis of **Cervical Intraepithelial Neoplasia (CIN)** is based on the extent of epithelial involvement by atypical cells and the loss of cellular maturation. 1. **Why Option C is Correct:** The pathology report describes atypical cells involving the **full thickness** of the squamous epithelium. By definition, if cellular atypia (pleomorphism, increased N:C ratio, and loss of polarity) involves more than two-thirds of the epithelium or the full thickness, it is classified as **CIN III** (which includes Carcinoma in situ). The "wrinkled nuclei and perinuclear halos" are classic morphological hallmarks of **koilocytic atypia**, indicating Human Papillomavirus (HPV) infection. The "intact basement membrane" confirms that the lesion is pre-invasive and not yet invasive squamous cell carcinoma. 2. **Why Other Options are Incorrect:** * **Option A (CIN I):** Atypia is limited to the **lower one-third** of the epithelium. * **Option B (CIN II):** Atypia involves the **lower two-thirds** of the epithelium. * **Option D:** Inflammatory atypia shows reactive changes but does not involve full-thickness loss of orientation or specific koilocytic features. **NEET-PG High-Yield Pearls:** * **Koilocytes:** Pathognomonic for HPV infection (usually types 16 and 18 for high-grade lesions). * **Bethesda System:** CIN II and CIN III are grouped together as **High-grade Squamous Intraepithelial Lesions (HSIL)**, while CIN I is **Low-grade (LSIL)**. * **Management:** For CIN II/III (HSIL) in a 22-year-old, treatment options include LEEP (Loop Electrosurgical Excision Procedure) or cold knife conization, though conservative management may be considered in specific young patients to preserve cervical integrity.
Question 44: The best method to confirm the diagnosis of carcinoma cervix is:
- A. Physical examination
- B. Pap smear
- C. Cervical biopsy (Correct Answer)
- D. Curettage
Explanation: **Explanation:** The gold standard for the diagnosis of any malignancy, including carcinoma cervix, is histopathological examination. Therefore, a **Cervical Biopsy** is the best method to confirm the diagnosis. * **Why Cervical Biopsy is correct:** A biopsy provides a tissue sample that allows a pathologist to visualize cellular architecture, basement membrane invasion, and grading. In clinical practice, if a gross lesion is visible, a **punch biopsy** is performed. If no lesion is visible but screening is positive, a **colposcopy-directed biopsy** is the preferred approach. **Analysis of Incorrect Options:** * **Physical Examination (A):** While essential for clinical staging (FIGO staging), it cannot provide a definitive histological diagnosis. * **Pap Smear (B):** This is a **screening tool**, not a diagnostic one. It identifies cytological abnormalities (shed cells) but has a significant false-negative rate and cannot confirm invasion. * **Curettage (D):** Endocervical curettage (ECC) is used to sample the endocervical canal when the transformation zone is not fully visible, but it is not the primary method for confirming a suspected cervical growth. **High-Yield Clinical Pearls for NEET-PG:** * **Screening:** Pap smear (starts at age 21) or HPV DNA testing (preferred primary screen for ages 30-65). * **Staging:** Carcinoma cervix is staged **clinically** (FIGO Staging), though the 2018 update now allows the use of imaging and pathology where available. * **Schiller’s Test:** Uses Lugol’s iodine; cancerous cells are iodine-negative (remain pale/yellow) because they lack glycogen. * **Punch Biopsy:** The most common instrument used is the **Tischler biopsy forceps**.
Question 45: What is the most common site of metastasis in choriocarcinoma?
- A. Liver
- B. Lungs (Correct Answer)
- C. Brain
- D. Ovaries
Explanation: **Explanation:** Choriocarcinoma is a highly malignant germ cell tumor or gestational trophoblastic neoplasm (GTN). The hallmark of this tumor is its **early and rapid hematogenous spread** (via the bloodstream) due to the inherent nature of trophoblastic cells to invade blood vessels. **1. Why Lungs are the Correct Answer:** Since the spread is primarily hematogenous, the venous drainage from the pelvic organs carries malignant cells directly into the systemic circulation, where the **lungs** act as the first major capillary bed they encounter. Consequently, the lungs are the most common site of metastasis, occurring in approximately **80% of cases**. On imaging, these often appear as characteristic "cannonball metastases." **2. Analysis of Incorrect Options:** * **A. Liver:** This is the second or third most common site (approx. 10%). Liver metastasis usually signifies a poor prognosis and a high-risk score according to the WHO scoring system. * **B. Brain:** Occurs in about 10% of cases. Like liver metastasis, it is considered a high-risk feature and often occurs secondary to lung metastasis. * **D. Ovaries:** While choriocarcinoma can arise as a primary germ cell tumor in the ovary (non-gestational), the ovary is not a primary site for distant metastasis compared to highly vascular systemic organs. **3. NEET-PG High-Yield Pearls:** * **Most common sites in order:** Lungs (80%) > Vagina (30%) > Pelvis (20%) > Liver (10%) > Brain (10%). * **Vaginal Metastasis:** Often presents as a highly vascular, bluish-purple nodule. **Biopsy is contraindicated** due to the risk of torrential hemorrhage. * **Tumor Marker:** Serum **beta-hCG** is the highly sensitive marker used for diagnosis, monitoring treatment response, and detecting recurrence. * **Treatment:** It is highly chemosensitive. Low-risk cases are treated with Methotrexate; high-risk cases require the **EMA-CO regimen**.
Question 46: A unilateral ovarian tumor has spread to the peritoneum but not to the uterus. What is the FIGO staging of this ovarian neoplasm?
- A. Stage IB
- B. Stage IC (Correct Answer)
- C. Stage IIA
- D. Stage IIB
Explanation: ### Explanation **Correct Answer: B. Stage IC** The FIGO staging for ovarian cancer is primarily surgical and pathological. According to the **FIGO 2014 classification**, Stage I is defined as a tumor limited to the ovaries or fallopian tubes. * **Stage IA:** Tumor limited to one ovary; capsule intact; no tumor on surface; no malignant cells in ascites/peritoneal washings. * **Stage IB:** Tumor limited to both ovaries; capsule intact; no tumor on surface; no malignant cells in washings. * **Stage IC:** Tumor limited to one or both ovaries **with any of the following**: * **IC1:** Surgical spill. * **IC2:** Capsule ruptured before surgery or **tumor on ovarian surface**. * **IC3:** Malignant cells in the ascites or **peritoneal washings**. In this question, the spread to the **peritoneum** (without involving pelvic organs like the uterus) implies positive peritoneal washings or surface involvement, placing it in **Stage IC**. **Why other options are incorrect:** * **Stage IB:** Requires involvement of *both* ovaries but with capsules intact and negative washings. * **Stage IIA:** Involves extension to the **uterus**, fallopian tubes, or ovaries. Since the question specifies the uterus is *not* involved, Stage IIA is excluded. * **Stage IIB:** Involves extension to other pelvic intraperitoneal tissues (e.g., bladder, rectum). **High-Yield Clinical Pearls for NEET-PG:** * **Most common spread:** Ovarian cancer spreads primarily via **exfoliation** (seeding) into the peritoneal cavity. * **Stage IC vs. Stage II:** If the tumor involves the **peritoneal surface** (washings), it is IC. If it involves **pelvic organs** (uterus/bladder), it is Stage II. If it involves **extrapelvic peritoneal surfaces** (omentum/small bowel), it is Stage III. * **CA-125:** Most useful for monitoring response to treatment rather than primary diagnosis.
Question 47: Metastases from a granulosa cell tumor most commonly involve which of the following?
- A. The liver
- B. The contralateral ovary (Correct Answer)
- C. The mesentery
- D. The mediastinum
Explanation: **Explanation:** Granulosa cell tumors (GCTs) are the most common type of malignant sex cord-stromal tumors. Unlike epithelial ovarian cancers, which frequently present with widespread peritoneal seeding, GCTs are typically diagnosed at an early stage (Stage I) and are characterized by an indolent clinical course. **Why the contralateral ovary is correct:** The most common site of spread for a granulosa cell tumor is the **contralateral ovary**. This occurs via local extension or lymphatic spread. Because GCTs are often confined to the ovaries at the time of diagnosis, involvement of the other ovary is the most frequent finding when the disease is not strictly unilateral. **Analysis of incorrect options:** * **The Mesentery (Option C):** While GCTs can spread to the peritoneum and mesentery (late-stage or recurrence), this is less common than involvement of the opposite ovary. * **The Liver (Option A):** Hematogenous spread to the liver parenchyma is rare and usually occurs only in advanced or recurrent cases. * **The Mediastinum (Option D):** Extra-abdominal spread to the mediastinum is extremely rare for GCTs, as these tumors tend to remain localized to the pelvis for long periods. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** **Inhibin B** is the most reliable marker for diagnosis and monitoring recurrence. * **Histology:** Look for **Call-Exner bodies** (small follicles filled with eosinophilic material) and "coffee-bean" nuclei. * **Clinical Presentation:** Often associated with **hyperestrogenism**, leading to precocious puberty in children or postmenopausal bleeding/endometrial hyperplasia in adults. * **Prognosis:** Generally excellent, but they are notorious for **late recurrences** (even 10–20 years after initial treatment).
Question 48: Schiller-Duval bodies are characteristically seen in which of the following ovarian tumors?
- A. Endodermal sinus tumor (Yolk sac tumor) (Correct Answer)
- B. Embryonal carcinoma
- C. Dermoid cyst
- D. Brenner tumor
Explanation: **Explanation:** **Schiller-Duval bodies** are the pathognomonic histological hallmark of **Endodermal Sinus Tumor (Yolk Sac Tumor)**. These structures consist of a central capillary surrounded by a layer of visceral and parietal cells, resembling a primitive glomerulus. 1. **Endodermal Sinus Tumor (Correct):** This is the most common malignant germ cell tumor in children and young women. It is characterized by high levels of **Alpha-fetoprotein (AFP)**. The presence of Schiller-Duval bodies confirms the diagnosis, though they are only seen in about 50-60% of cases. 2. **Embryonal Carcinoma (Incorrect):** While also a germ cell tumor, it is characterized by sheets of undifferentiated cells and elevated levels of both **AFP and hCG**. It does not feature Schiller-Duval bodies. 3. **Dermoid Cyst (Incorrect):** Also known as a Mature Cystic Teratoma, it is a benign tumor containing tissues from all three germ layers (skin, hair, sebum). Histology shows mature, well-differentiated tissues. 4. **Brenner Tumor (Incorrect):** This is a surface epithelial tumor characterized by **"Walthard cell nests"** and cells with a "coffee-bean" nucleus appearance (similar to Granulosa cell tumors). **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** AFP is the highly specific marker for Yolk Sac Tumors. * **Histology:** Look for "Glomeruloid-like bodies" (Schiller-Duval) and intracellular/extracellular **hyaline globules** (PAS-positive). * **Age Group:** Typically affects young females (second decade of life). * **Rapid Growth:** These tumors are known for rapid growth and early lymphatic/hematogenous spread.
Question 49: True about Ca vulva associated/predisposed by Vulval intraepithelial neoplasia?
- A. Paget's disease
- B. Vulval intraepithelial neoplasia
- C. Bowen's disease
- D. All (Correct Answer)
Explanation: **Explanation:** Carcinoma of the vulva typically arises through two distinct pathways. The first is associated with **Human Papillomavirus (HPV)** infection (types 16, 18, and 33), occurring in younger women and preceded by **Vulval Intraepithelial Neoplasia (VIN)**. The second pathway is HPV-independent, seen in older women, and associated with Lichen Sclerosus or Differentiated VIN. * **Vulval Intraepithelial Neoplasia (VIN):** This is the classic precursor lesion for the "warty" or "basaloid" type of squamous cell carcinoma. It is highly associated with high-risk HPV strains and smoking. * **Bowen’s Disease:** This is a clinical term for **VIN 3 (Squamous cell carcinoma in situ)**. It presents as a well-demarcated, erythematous, scaly plaque. If left untreated, it has a significant risk of progressing to invasive squamous cell carcinoma. * **Paget’s Disease (Extramammary):** While often an intraepithelial neoplasm of glandular origin, it is frequently associated with an underlying invasive adenocarcinoma (either of the vulva or a distant site like the rectum or bladder) in approximately 20-30% of cases. **Clinical Pearls for NEET-PG:** 1. **Most common type:** Squamous cell carcinoma (90%). 2. **Most common site:** Labia majora. 3. **Staging:** Vulval cancer is staged **Surgically** (FIGO). 4. **Lymphatic Spread:** The primary route of spread is to the **Inguinal-femoral lymph nodes** (Sentinel node biopsy is the standard for early lesions >1mm invasion). 5. **Cloquet’s Node:** The highest deep inguinal node; its involvement indicates a poor prognosis and likely spread to pelvic nodes.
Question 50: Fibroma belongs to which of the following categories of ovarian tumors?
- A. Germ cell tumor
- B. Sex cord stromal tumor (Correct Answer)
- C. Surface epithelial stromal tumor
- D. Metastatic tumor from a non-ovarian primary
Explanation: **Explanation:** Ovarian tumors are classified based on the cell of origin. **Fibromas** are the most common benign solid tumors of the ovary and belong to the **Sex Cord-Stromal Tumor (SCST)** category. These tumors arise from the ovarian stroma (mesenchyme) or the primitive sex cords of the embryonic gonad. **Why the correct answer is right:** * **Sex Cord-Stromal Tumors:** This group includes tumors derived from granulosa cells, theca cells, Sertoli cells, Leydig cells, and fibroblasts. Fibromas are composed of spindle-shaped fibroblastic cells that produce collagen. Unlike other SCSTs (like Granulosa cell tumors), fibromas are typically **non-hormonal** (inactive). **Why the other options are wrong:** * **Germ Cell Tumors (A):** Arise from the oocytes (e.g., Teratoma, Dysgerminoma, Yolk sac tumor). * **Surface Epithelial Tumors (C):** Arise from the ovarian surface epithelium (e.g., Serous, Mucinous, Endometrioid tumors). This is the most common overall category of ovarian neoplasia. * **Metastatic Tumors (D):** Arise from non-ovarian primaries, such as the GI tract (Krukenberg tumor) or breast. **High-Yield Clinical Pearls for NEET-PG:** 1. **Meigs Syndrome:** A classic triad associated with ovarian fibroma consisting of: **Ovarian Fibroma + Ascites + Right-sided Pleural Effusion.** Symptoms resolve after tumor removal. 2. **Gorlin Syndrome:** Multiple ovarian fibromas at a young age are associated with Nevoid Basal Cell Carcinoma Syndrome. 3. **Gross Appearance:** Fibromas are typically unilateral, firm, chalky white, and show a "whorled" appearance on the cut surface.
Practice by Chapter
Cervical Cancer
Practice Questions
Endometrial Cancer
Practice Questions
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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Chemotherapy in Gynecologic Oncology
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Palliative Care in Gynecologic Oncology
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