Gynecologic Oncology Practice Questions

Q: Risk of endometrial cancer is least in:

Multipara. ***Multipara*** - **Multiparity** (having multiple successful pregnancies) is associated with a reduced risk of **endometrial cancer**. Each pregnancy provides a period of reduced estrogen exposure and increased progesterone, which is protective against endometrial hyperplasia. - The protective effect is thought to be cumulative, with **higher parity** correlating with a lower risk. *Late menopause* - **Late menopause** prolongs the duration of lifetime exposure to endogenous unopposed estrogen, which significantly increases the risk of **endometrial cancer**. - Estrogen stimulates **endometrial proliferation**, and continued exposure without the counter-regulatory effects of progesterone (as seen in later menopause) can lead to atypical hyperplasia and malignancy. *A positive family history* - A **positive family history** of endometrial cancer suggests a genetic predisposition, which is a significant **risk factor**. - Conditions like **Lynch syndrome** (hereditary non-polyposis colorectal cancer or HNPCC) are strongly associated with an increased risk of endometrial cancer. *Obesity* - **Obesity** is a major risk factor for **endometrial cancer** due to increased peripheral conversion of androgens to estrogens in adipose tissue. - This leads to higher levels of **unopposed estrogen**, promoting endometrial proliferation and increasing cancer risk.

Q: Which cancer is most commonly associated with increased estrogen levels?

Breast. ***Breast*** - Many breast cancers, particularly **estrogen receptor-positive (ER+)** tumors, are fueled by **estrogen**. - Prolonged exposure to high estrogen levels, such as early menarche, late menopause, or obesity, is a known risk factor for breast cancer. *Ovarian* - While estrogen does play a role in ovarian function, the link between **increased estrogen levels** and ovarian cancer risk, while present, is **less direct and less significant** than for breast cancer. - Ovarian cancer is associated with other risk factors like **nulliparity**, **endometriosis**, and certain genetic mutations. *GTN* - **Gestational trophoblastic neoplasia (GTN)** is an abnormal proliferation of trophoblastic tissue, commonly occurring after pregnancy. - Its development is primarily linked to **abnormal fertilization**, not directly to independently increased estrogen levels. *Cervix* - **Cervical cancer** is overwhelmingly caused by **persistent human papillomavirus (HPV) infection**. - While hormonal factors can influence HPV progression, increased estrogen levels are **not considered a primary cause** or strongly associated risk factor for cervical cancer.

Q: A Post-Menopausal woman complains of spotting per vaginum after 5 years of menopause. USG reveals endometrial thickness of 7 mm and an intramural fibroid of size 3cm. Next step in management is?

Endometrial biopsy. ***Endometrial biopsy*** - Post-menopausal **vaginal bleeding** or spotting, especially with an **endometrial thickness of ≥ 4-5 mm** on ultrasound, is highly suspicious for endometrial hyperplasia or carcinoma and warrants an endometrial biopsy for definitive diagnosis. - An endometrial biopsy is crucial to rule out endometrial malignancy, as this is the primary concern in such presentations. *CA 125 levels* - **CA 125** is primarily used as a tumor marker for **ovarian cancer** surveillance and response to treatment, not for initial diagnosis of post-menopausal bleeding or endometrial pathology. - Elevated CA 125 can be found in various benign conditions as well and is not specific enough to guide the initial management of post-menopausal bleeding without tissue sampling. *Paps smear and follow up* - A **Pap smear** screens for **cervical abnormalities** and **cervical cancer**, not endometrial pathology. - While it's part of routine gynecological care, it will not address the investigation of post-menopausal bleeding originating from the uterus. *Myomectomy* - **Myomectomy** is a surgical procedure to remove **uterine fibroids**, typically when they are causing symptoms like heavy menstrual bleeding or pressure. - In a post-menopausal woman with spotting, the intramural fibroid may or may not be directly responsible, and the priority is to exclude **endometrial cancer** before considering fibroid-specific interventions.

Q: Early age at first sexual intercourse is a risk factor for

Carcinoma cervix. ***Carcinoma cervix*** - **Early age of sexual debut** is a significant risk factor for cervical cancer due to increased exposure time to **human papillomavirus (HPV)**, the primary cause. - The immature transformation zone of the cervix in younger individuals is more vulnerable to HPV infection and subsequent dysplastic changes. *Carcinoma vagina* - While HPV can cause vaginal cancer, the association with **early sexual debut** is less direct and less prominent compared to cervical cancer. - Risk factors often include a history of **cervical cancer** or **cervical intraepithelial neoplasia (CIN)**. *Carcinoma ovary* - Ovarian cancer is primarily linked to **genetic factors** (e.g., BRCA mutations), **nulliparity**, and **endometriosis**. - There is no established link between **age of sexual debut** and the risk of ovarian cancer. *Carcinoma vulva* - Vulvar cancer is also associated with **HPV infection**, but its primary risk factors often include **lichen sclerosus**, **chronic irritation**, and **immunodeficiency**. - The link to **early sexual debut** is less strong compared to cervical cancer, which is almost exclusively HPV-driven and highly sensitive to infection duration.

Q: A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :

Malignancy of the endometrium. ***Malignancy of the endometrium*** - **Postmenopausal bleeding** is the classic presenting symptom of **endometrial cancer**, which must be ruled out in all such cases. - **Diabetes** is a known risk factor for endometrial cancer, along with obesity, hypertension, and unopposed estrogen exposure. *Malignancy of the vulva* - Vulvar cancer typically presents with a **pruritic lesion**, lump, or ulcer on the vulva, rather than solely with vaginal bleeding. - While bleeding can occur from an advanced vulvar lesion, it is not the primary or most common presentation for new onset postmenopausal bleeding. *Malignancy of the cervix* - Cervical cancer often presents with **postcoital bleeding** or irregular vaginal bleeding in premenopausal women, or less commonly, postmenopausal bleeding. - Screening with **Pap smears** typically detects precancerous changes or early cervical cancer, making it less likely to be the first presentation with postmenopausal bleeding in a well-screened population. *Malignancy of the ovary* - Ovarian cancer is often asymptomatic in its early stages and presents with non-specific symptoms like **abdominal distension**, bloating, or pelvic pain. - **Vaginal bleeding** is not a typical symptom of ovarian cancer, unless the tumor is very large, involves adjacent structures, or is a hormone-producing tumor.

Q: In which type of hysterectomy are the uterine vessels ligated at the level of the ureter?

Type - II. ***Type - II*** - In a **Type II hysterectomy** (modified radical hysterectomy), the **uterine vessels** are ligated at the level of the **ureter** to ensure wider margins when excising the paracervical tissue. - This approach aims to resect the **medial portion of the cardinal and uterosacral ligaments**, along with the parametrial tissue, necessitating a more lateral ligation point. *Type - I* - **Type I hysterectomy** (simple or extrafascial hysterectomy) involves ligating the **uterine vessels** closer to the uterus, **medial to the ureter**, at the level of the internal os. - This type of hysterectomy is performed for benign conditions and does not require extensive paracervical tissue removal. *Type - IV* - **Type IV hysterectomy** (radical hysterectomy) involves an even wider dissection than Type III, extending to the **hypogastric vessels**, which is well beyond the ureter. - This procedure removes more of the **lateral parametrium and paravaginal tissue**, along with the superior vesical artery. *Type - III* - **Type III hysterectomy** (radical hysterectomy) involves ligating the **uterine vessels at their origin** from the internal iliac artery, which is significantly lateral to the ureter. - This extensive dissection is performed for invasive cervical cancer, requiring removal of the **entire cardinal and uterosacral ligaments** along with wide parametrial and paravaginal tissue.

Q: Which among the following is not a premalignant lesion of vulva?

Bacterial Vaginosis. ***Bacterial Vaginosis*** - This is a common **vaginal infection** caused by an imbalance of normal vaginal bacteria, characterized by specific symptoms like increased discharge and odor. - Bacterial vaginosis is not considered a premalignant lesion and does not increase the risk of developing vulvar cancer. *Paget's disease* - This is a rare form of intraepithelial adenocarcinoma that can occur on the vulva, presenting as a red, itchy, scaly rash. - While it is a **carcinoma in situ**, it has the potential to become invasive, thus considered a premalignant or pre-invasive condition. *Bowen's disease* - This is a form of **squamous cell carcinoma in situ (SCCIS)**, typically appearing as a slow-growing, red, scaly patch on the skin. - It is considered a premalignant lesion because it can progress to invasive squamous cell carcinoma if left untreated. *Lichen Sclerosus* - This is a chronic inflammatory skin condition primarily affecting the anogenital region, leading to thinning, whitening, and scarring of the skin. - Although it is a benign condition, individuals with vulvar lichen sclerosus have an increased risk (3-5%) of developing **vulvar squamous cell carcinoma**, making it a premalignant condition.

Q: Possible conversion to choriocarcinoma after hydatidiform mole is denoted by all of the following, except:

Sub urethral nodule. ***Sub urethral nodule*** - A **suburethral nodule** is a sign of **metastatic choriocarcinoma**, indicating the disease has already converted and spread. - The question asks for signs indicating a *possible conversion* to choriocarcinoma, not an established metastatic disease. *More Theca lutein cysts* - **Theca lutein cysts** result from overstimulation of the ovaries by high levels of **hCG**, which is elevated in both hydatidiform mole and choriocarcinoma. - An increase in these cysts suggests persistent trophoblastic activity, raising suspicion for transition to choriocarcinoma. *Increase uterus size* - An **enlarging uterus** post-evacuation of a hydatidiform mole can indicate persistent trophoblastic tissue or the development of choriocarcinoma. - This suggests continued growth and abnormal proliferation of trophoblastic cells. *Rising hCG* - **Persistently rising or plateauing hCG levels** after evacuation of a hydatidiform mole are the most critical indicator of persistent gestational trophoblastic disease (GTD), including potential conversion to choriocarcinoma. - Serial hCG monitoring is essential for surveillance following a molar pregnancy to detect malignant transformation.

Q: In a case of molar pregnancy, the most important marker for monitoring response to treatment is:

Serum hCG. ***Serum hCG*** - **Human chorionic gonadotropin (hCG)** is produced by the trophoblastic tissue, which is overproliferated in molar pregnancies. - Monitoring **serial hCG levels** post-evacuation is the **gold standard** for detecting persistent trophoblastic disease or malignant transformation. - A rise or plateau in hCG levels indicates inadequate treatment or recurrence, requiring chemotherapy. - **Clinical protocol**: Weekly hCG monitoring until three consecutive negative results, then monthly for 6 months (FIGO guidelines). *Serum CA-125* - **CA-125** is primarily a marker for ovarian cancer and certain benign gynecologic conditions like endometriosis. - It is not a reliable marker for monitoring the response to treatment in **molar pregnancies**. *Serum estriol* - **Estriol** is a hormone produced by the placenta and fetal adrenal gland, primarily used to monitor fetal well-being during pregnancy. - It has no role in the diagnosis or monitoring of **molar pregnancies**. *Serum AFP* - **Alpha-fetoprotein (AFP)** is a tumor marker for certain germ cell tumors, liver cancer, and is also used in prenatal screening for neural tube defects. - It is not associated with the pathogenesis or monitoring of **molar pregnancies**.

Question 1

A 56-year-old woman makes an appointment with her physician to discuss the results of her cervical cancer screening. She has been menopausal for  2 years and does not take hormone replacement therapy. Her previous Pap smear showed low-grade squamous intraepithelial lesion (LSIL); no HPV testing was performed. Her gynecologic examination is unremarkable. The results of her current Pap smear is as follows:
Specimen adequacy satisfactory for evaluation
Interpretation low-grade squamous intraepithelial lesion
Notes atrophic pattern
Which option is the next best step in the management of this patient?

Accepted Answer

Colposcopy

Answer

Reflex HPV testing

Answer

Repeat HPV testing in 6 months

Answer

Immediate loop excision

Answer

Intravaginal estrogen therapy followed by repeat Pap smear in 1 week

Question 2

Risk of endometrial cancer is least in:

Accepted Answer

Multipara

Answer

Late menopause

Answer

A positive family history

Answer

Obesity

Question 3

Which cancer is most commonly associated with increased estrogen levels?

Accepted Answer

Breast

Answer

Ovarian

Answer

GTN

Answer

Cervix

Question 4

A Post-Menopausal woman complains of spotting per vaginum after 5 years of menopause. USG reveals endometrial thickness of 7 mm and an intramural fibroid of size 3cm. Next step in management is?

Accepted Answer

Endometrial biopsy

Answer

CA 125 levels

Answer

Paps smear and follow up

Answer

Myomectomy

Question 5

Early age at first sexual intercourse is a risk factor for

Accepted Answer

Carcinoma cervix

Answer

Carcinoma vagina

Answer

Carcinoma ovary

Answer

Carcinoma vulva

Question 6

A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :

Accepted Answer

Malignancy of the endometrium

Answer

Malignancy of the vulva

Answer

Malignancy of the cervix

Answer

Malignancy of the ovary

Question 7

In which type of hysterectomy are the uterine vessels ligated at the level of the ureter?

Accepted Answer

Type - II

Answer

Type - I

Answer

Type - IV

Answer

Type - III

Question 8

Which among the following is not a premalignant lesion of vulva?

Accepted Answer

Bacterial Vaginosis

Answer

Paget's disease

Answer

Bowen's disease

Answer

Lichen Sclerosus

Question 9

Possible conversion to choriocarcinoma after hydatidiform mole is denoted by all of the following, except:

Accepted Answer

Sub urethral nodule

Answer

More Theca lutein cysts

Answer

Increase uterus size

Answer

Rising hCG

Question 10

In a case of molar pregnancy, the most important marker for monitoring response to treatment is:

Accepted Answer

Serum hCG

Answer

Serum CA-125

Answer

Serum estriol

Answer

Serum AFP

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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