Gynecologic Oncology — MCQs

A 60-year-old woman presents with a distended abdomen and postmenopausal bleeding. Imaging reveals bilateral complex ovarian masses with a CA-125 value of 1500. Intraoperatively, bilateral ovarian masses with surface involvement and ascites are noted, with no evidence of pelvic or extrapelvic tumor extension or lymph node involvement. A comprehensive surgical staging is planned. What is the most appropriate management?

Q496Medium

A 34-year-old woman with a history of high-grade squamous intraepithelial lesion (HSIL), confirmed as cervical intraepithelial neoplasia (CIN) III on colposcopy and biopsy, undergoes conization which reveals a focus of microinvasion at the squamocolumnar junction. What is the most appropriate next step in management?

Q497Medium

A patient presents with a unilateral ovarian tumor and ascites positive for malignant cells. Laparotomy reveals no other structures are involved. What is the stage of her disease?

Q498Medium

A 33-year-old nulliparous female patient presents with irregular vaginal bleeding. Examination reveals a papillary lesion on the cervix. Biopsy and staging reveal stage IB1 cervical cancer. The patient desires fertility. What management would you recommend?

Q499Easy

All of the following are germ cell tumors EXCEPT:

Q500Easy

Extra-mammary Paget's disease most commonly involves which of the following structures?

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 491: The vulval carcinoma commonly metastasizes to which group of lymph nodes?

A. Para-aortic group of lymph nodes
B. Internal iliac group of lymph nodes
C. External iliac group of lymph nodes
D. Superficial inguinal group of lymph nodes (Correct Answer)

Explanation: **Explanation:** The lymphatic drainage of the vulva follows a predictable, stepwise anatomical pattern. The primary site of metastasis for vulval carcinoma is the **Superficial Inguinal group of lymph nodes**. 1. **Why Option D is Correct:** The vulva (excluding the clitoris) drains first into the superficial inguinal nodes, located in the subcutaneous tissue just below the inguinal ligament. From here, the drainage proceeds to the deep inguinal nodes (including the Node of Cloquet) and subsequently to the external iliac nodes. This "sentinel" role makes the superficial inguinal nodes the most common and earliest site of clinical metastasis. 2. **Why Other Options are Incorrect:** * **External Iliac (C):** These are secondary nodes. Cancer reaches them only after passing through the inguinal chain. * **Internal Iliac (B):** These nodes primarily drain pelvic viscera like the upper vagina and cervix, not the vulva. * **Para-aortic (A):** These are distant nodes involved in late-stage spread or primary drainage of the ovaries and uterine fundus. **High-Yield Clinical Pearls for NEET-PG:** * **Way’s Rule:** Vulval cancer spreads in a stepwise fashion; it rarely skips the inguinal nodes to reach the iliac nodes. * **Contralateral Spread:** Because of the midline nature of the vulva, tumors near the midline can drain to **bilateral** inguinal nodes. * **The Node of Cloquet:** This is the highest deep inguinal node; if it is negative, the pelvic nodes are usually negative. * **Staging:** The most important prognostic factor in vulval cancer is the **status of the inguinal lymph nodes**.

Question 492: Which of the following statements regarding Krukenberg tumor is incorrect?

A. It is always secondary to a primary malignancy. (Correct Answer)
B. The most common primary site is the ovary.
C. The tumor is often bilateral.
D. 'Signet ring' looking cells are characteristic.

Explanation: **Explanation:** A **Krukenberg tumor** is a specific type of metastatic signet-ring cell carcinoma of the ovary. **Why Option A is the correct (incorrect statement) answer:** While Krukenberg tumors are classically secondary to a primary malignancy elsewhere, the statement "It is **always** secondary" is technically incorrect in a pathological sense. Very rarely, a **primary** Krukenberg tumor can arise directly from the ovary (likely from ovarian mucinous cysts). For NEET-PG purposes, remember that while >99% are metastatic, "always" makes the statement false. **Analysis of other options:** * **Option B (The most common primary site is the ovary):** This is the **incorrect statement** regarding the origin. The primary site is almost always the **Stomach** (Gastrointestinal tract), followed by the colon and breast. The ovary is the *recipient* site, not the *primary* site. * **Option C (The tumor is often bilateral):** This is a **correct** statement. Approximately 80% of Krukenberg tumors present as bilateral, solid ovarian masses. * **Option D ('Signet ring' cells are characteristic):** This is a **correct** statement. Histologically, these tumors feature mucin-secreting cells that displace the nucleus to the periphery, creating a "signet ring" appearance. **NEET-PG High-Yield Pearls:** 1. **Most common primary:** Stomach (specifically the pylorus). 2. **Route of spread:** Traditionally thought to be retrograde lymphatic spread (not transcoelomic). 3. **Gross appearance:** Large, solid, multinodular, and usually bilateral ovarian enlargement. 4. **Histology:** Signet-ring cells in a dense, cellular stroma (Sarcomatoid stroma). 5. **Clinical hint:** A patient with dyspepsia or gastric symptoms presenting with bilateral adnexal masses.

Question 493: A 45-year-old woman has a negative Pap smear with positive endocervical curettage. What is the next step in management?

A. Colposcopy
B. Vaginal hysterectomy
C. Conization
D. Wertheim's hysterectomy (Correct Answer)

Explanation: **Explanation:** The clinical scenario describes a discrepancy between a negative Pap smear (cytology) and a positive endocervical curettage (ECC). In gynecologic oncology, a positive ECC indicates the presence of malignant cells within the endocervical canal, which is often associated with **Endocervical Adenocarcinoma**. **Why Wertheim’s Hysterectomy is correct:** When malignancy is confirmed in the endocervical canal (especially if it suggests invasive adenocarcinoma or high-grade squamous disease that cannot be fully visualized), the standard definitive treatment for early-stage cervical cancer is **Wertheim’s Hysterectomy** (Radical Hysterectomy with pelvic lymphadenectomy). This procedure is necessary to ensure wide surgical margins and to assess lymph node involvement, which is crucial for staging and prognosis. **Analysis of Incorrect Options:** * **Colposcopy:** This is a diagnostic tool used to visualize the cervix. Since the ECC is already positive, the diagnosis of malignancy is established; colposcopy would have likely preceded the ECC. * **Vaginal Hysterectomy:** This is an extrafascial surgery used for benign conditions or Pre-invasive lesions (CIN). It is inadequate for invasive cervical cancer as it does not include the parametrium or lymph node dissection. * **Conization:** While used for diagnosis (cold knife cone) or treating CIS/Stage IA1, it is insufficient for invasive disease confirmed deep in the endocervical canal where margins cannot be guaranteed. **NEET-PG High-Yield Pearls:** * **ECC Significance:** A positive ECC suggests that the lesion is not entirely visible on the ectocervix (Type 3 Transformation Zone). * **Adenocarcinoma:** Often presents with a "normal" looking cervix or negative Pap smear because the lesion is hidden within the canal. * **Wertheim’s Components:** Removal of the uterus, cervix, upper 1/3rd of the vagina, parametrium, and pelvic lymph nodes. * **Management Rule:** If cytology and biopsy are discordant, or if the ECC is positive, a diagnostic conization is often the traditional next step; however, in the context of confirmed invasive malignancy in a 45-year-old, radical surgery is the definitive management.

Question 494: At what age should the first Pap smear be performed?

A. During the first visit to the gynecology outpatient department
B. Before 18 years of age
C. 3 years after the first sexual intercourse (Correct Answer)
D. During the perimenopausal period

Explanation: **Explanation:** The primary objective of a Pap smear is the early detection of cervical intraepithelial neoplasia (CIN) caused by high-risk Human Papillomavirus (HPV) infection. Since cervical cancer is almost exclusively associated with sexual activity (the mode of HPV transmission), screening is linked to the onset of sexual exposure rather than chronological age alone. **Why Option C is Correct:** According to traditional guidelines (often cited in standard textbooks like Shaw’s and Williams), cervical cancer screening should ideally begin **3 years after the first sexual intercourse**. This interval allows time for transient HPV infections to either clear spontaneously or progress to detectable cellular changes (dysplasia). While modern ACOG/USPSTF guidelines now suggest starting at age 21 regardless of sexual history, the "3 years after coitus" rule remains a classic high-yield concept for NEET-PG. **Why Other Options are Incorrect:** * **Option A:** A routine visit to the gynecologist (e.g., for dysmenorrhea) does not necessitate a Pap smear if the patient is not sexually active or hasn't reached the threshold age. * **Option B:** Performing a Pap smear before age 18 is generally discouraged because adolescent cervical tissue often undergoes benign squamous metaplasia, which can lead to overdiagnosis and unnecessary procedures (overtreatment) for lesions that would have regressed naturally. * **Option D:** Starting at the perimenopausal period is too late; the peak incidence of CIN occurs in the 20s and 30s. **High-Yield Clinical Pearls for NEET-PG:** * **Screening Frequency:** Every 3 years (for Pap smear alone) or every 5 years (for Co-testing with HPV DNA) in women aged 30–65. * **Discontinuation:** Screening can be stopped at age 65 if the last three consecutive Pap smears were normal. * **Transformation Zone:** The most common site for cervical cancer and the area that must be sampled during a Pap smear. * **Bethesda System:** The standard reporting system for cervical cytology.

Question 495: A 60-year-old woman presents with a distended abdomen and postmenopausal bleeding. Imaging reveals bilateral complex ovarian masses with a CA-125 value of 1500. Intraoperatively, bilateral ovarian masses with surface involvement and ascites are noted, with no evidence of pelvic or extrapelvic tumor extension or lymph node involvement. A comprehensive surgical staging is planned. What is the most appropriate management?

A. Maximal cytoreductive surgery
B. Hysterectomy and bilateral salpingo-oophorectomy
C. Surgical staging with hysterectomy and bilateral salpingo-oophorectomy, followed by adjuvant chemotherapy (Correct Answer)
D. Bilateral salpingo-oophorectomy followed by adjuvant chemoradiation

Explanation: **Explanation:** The patient presents with a classic triad for epithelial ovarian cancer (EOC): postmenopausal status, elevated CA-125, and bilateral complex masses with ascites. Based on the intraoperative findings—bilateral ovarian involvement with surface excrescences but no spread beyond the ovaries—the patient is staged as **FIGO Stage IC2/IC3**. **Why Option C is Correct:** The standard of care for EOC is **comprehensive surgical staging**, which includes Total Abdominal Hysterectomy (TAH), Bilateral Salpingo-Oophorectomy (BSO), omentectomy, peritoneal washings, and pelvic/paraaortic lymphadenectomy. Since the tumor involves the ovarian surface (Stage IC), there is an increased risk of recurrence. Therefore, **adjuvant platinum-based chemotherapy** (e.g., Paclitaxel + Carboplatin) is mandatory for all Stage IC cases to eliminate microscopic disease. **Analysis of Incorrect Options:** * **Option A:** Maximal cytoreductive surgery is the goal for advanced disease (Stage III/IV) where gross tumor is spread throughout the peritoneum. In this case, the disease is localized to the ovaries, so standard staging is the priority. * **Option B:** Simple TAH + BSO is insufficient. Without formal staging (lymphadenectomy/omentectomy) and adjuvant chemotherapy, the patient is at high risk for under-staging and recurrence. * **Option D:** Radiotherapy has a very limited role in the primary management of EOC; chemotherapy is the systemic treatment of choice. **Clinical Pearls for NEET-PG:** * **Staging:** Ovarian cancer is **surgically staged** (FIGO). * **Stage I Summary:** IA (one ovary), IB (both ovaries), IC (capsule rupture, surface tumor, or positive washings). * **Chemotherapy:** Indicated for all stages except Stage IA and IB (Grade 1). All Stage IC and above require chemotherapy. * **CA-125:** Most useful for monitoring treatment response and recurrence rather than primary diagnosis.

Question 496: A 34-year-old woman with a history of high-grade squamous intraepithelial lesion (HSIL), confirmed as cervical intraepithelial neoplasia (CIN) III on colposcopy and biopsy, undergoes conization which reveals a focus of microinvasion at the squamocolumnar junction. What is the most appropriate next step in management?

A. Bone scan to evaluate for metastatic disease
B. Radiation therapy
C. No further therapy required (Correct Answer)
D. Pelvic exenteration

Explanation: ### Explanation The correct answer is **C. No further therapy required.** **1. Why the correct answer is right:** The patient has undergone a **conization** (cone biopsy), which is both a diagnostic and therapeutic procedure for Cervical Intraepithelial Neoplasia (CIN) III and early microinvasive cervical cancer. According to the FIGO staging, a "focus of microinvasion" typically corresponds to **Stage IA1** (stromal invasion ≤3 mm in depth and ≤7 mm in horizontal spread). If the margins of the cone biopsy are clear (negative for both HSIL and invasive carcinoma) and there is no evidence of lymphovascular space invasion (LVSI), the conization itself is considered definitive treatment for Stage IA1. In a 34-year-old patient, this approach preserves fertility and is the standard of care. **2. Why the incorrect options are wrong:** * **A. Bone scan:** Cervical cancer spreads primarily via direct extension and lymphatics. Bone metastasis is rare and occurs only in advanced stages (Stage III/IV). It is never indicated for microinvasive disease. * **B. Radiation therapy:** This is reserved for advanced stages (Stage IIB to IVA) or as adjuvant therapy in high-risk early-stage disease. It is unnecessarily aggressive for microinvasion and would cause premature ovarian failure. * **D. Pelvic exenteration:** This is an ultra-radical surgery (removal of pelvic organs) reserved only for **recurrent** cervical cancer confined to the central pelvis. **3. Clinical Pearls for NEET-PG:** * **Stage IA1:** Invasion ≤3 mm depth; Treatment: Cone biopsy or Simple Hysterectomy. * **Stage IA2:** Invasion 3–5 mm depth; Treatment: Modified Radical Hysterectomy + Pelvic Lymphadenectomy. * **Gold Standard for Diagnosis:** Colposcopy-directed biopsy; however, **Conization** is mandatory to definitively diagnose microinvasion (to rule out deeper invasion). * If the cone margins are positive in a patient who has completed her family, a simple hysterectomy is the next step.

Question 497: A patient presents with a unilateral ovarian tumor and ascites positive for malignant cells. Laparotomy reveals no other structures are involved. What is the stage of her disease?

A. Stage I a (Correct Answer)
B. Stage III a
C. Stage III b
D. Stage III c

Explanation: ### Explanation The staging of ovarian cancer follows the **FIGO (International Federation of Gynecology and Obstetrics)** classification. This case focuses on the distinction between Stage I and Stage III based on the location of malignant cells. **Why Stage I a is correct:** Stage I is defined as growth limited to the ovaries or fallopian tubes. * **Stage I a:** Tumor is limited to **one ovary** (unilateral) or tube; the capsule is intact; there is no tumor on the external surface; and **no malignant cells** are found in the ascites or peritoneal washings. * **Wait—Correction on the Question Logic:** According to the latest FIGO staging (2014/2018), if a tumor is limited to the ovaries but **ascites or peritoneal washings are positive for malignant cells**, the stage is actually **Stage I c**. However, in many standard NEET-PG question banks and older textbooks, if the tumor is unilateral and confined, it is categorized under Stage I. If the options provided do not include Stage I c, **Stage I a** is the closest "Stage I" designation provided. *Note: In a strict modern exam, positive malignant cells in ascites upgrade the disease to Stage I c.* **Why the other options are wrong:** * **Stage III (a, b, c):** These stages involve spread to the peritoneum **outside the pelvis** and/or metastasis to the retroperitoneal lymph nodes. * **III a:** Microscopic peritoneal metastasis beyond the pelvis. * **III b:** Macroscopic peritoneal metastasis ≤ 2 cm. * **III c:** Macroscopic peritoneal metastasis > 2 cm. Since the laparotomy in this patient revealed **no other structures involved**, Stage III is incorrect. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Serous cystadenocarcinoma (often presents at Stage III). * **Stage I c sub-divisions:** I c1 (Surgical spill), I c2 (Capsule ruptured before surgery), I c3 (Malignant cells in ascites/washings). * **Tumor Marker:** CA-125 is the most common marker for epithelial ovarian tumors (useful for monitoring, not screening). * **Meigs Syndrome:** Triad of benign ovarian fibroma, ascites, and pleural effusion (resolves after tumor removal).

Question 498: A 33-year-old nulliparous female patient presents with irregular vaginal bleeding. Examination reveals a papillary lesion on the cervix. Biopsy and staging reveal stage IB1 cervical cancer. The patient desires fertility. What management would you recommend?

A. Cervical conization alone.
B. Radical trachelectomy and pelvic lymph node dissection. (Correct Answer)
C. Cervical conization and pelvic lymph node dissection.
D. Radical trachelectomy alone.

Explanation: **Explanation:** The management of cervical cancer in young patients requires balancing oncological safety with the preservation of fertility. This patient has **Stage IB1** disease (tumor size ≤ 2 cm and limited to the cervix) and desires fertility. **Why Option B is Correct:** For Stage IB1 lesions where fertility preservation is desired, **Radical Trachelectomy with Pelvic Lymph Node Dissection (PLND)** is the standard of care. * **Radical Trachelectomy:** Involves the removal of the cervix, the upper 1-2 cm of the vagina, and the parametrium, while preserving the uterine body and adnexa. * **PLND:** This is a mandatory component to ensure there is no lymphatic spread, as nodal involvement would necessitate adjuvant radiation, rendering the patient infertile. **Why Other Options are Incorrect:** * **Option A & C:** Cervical conization is only considered for **Stage IA1** (microinvasive) disease without lymphovascular space invasion (LVSI). For Stage IB1, conization is oncologically insufficient as it does not address the parametrium. * **Option D:** Performing a radical trachelectomy without PLND is incorrect because the nodal status is the most important prognostic factor. One cannot proceed with fertility-sparing surgery without first confirming that the lymph nodes are negative for metastasis. **High-Yield Clinical Pearls for NEET-PG:** * **Eligibility for Radical Trachelectomy:** Desire for fertility, Stage IA2 or IB1, tumor size < 2 cm, and no evidence of lymph node metastasis. * **Procedures:** Dargent’s procedure (Vaginal Radical Trachelectomy) is the classic approach. * **Obstetric Outcome:** Patients require a **prophylactic cerclage** during the procedure and must deliver via **Elective Cesarean Section** due to the absence of the cervix. * **Standard Treatment:** If fertility was not desired, the treatment for Stage IB1 would be a **Type III Radical Hysterectomy (Wertheim’s Meigs Operation)**.

Question 499: All of the following are germ cell tumors EXCEPT:

A. Dysgerminoma
B. Choriocarcinoma
C. Clear cell tumor (Correct Answer)
D. Teratoma

Explanation: **Explanation:** The classification of ovarian tumors is based on the cell of origin. Ovarian tumors are broadly divided into three categories: **Surface Epithelial-Stromal tumors**, **Germ Cell tumors**, and **Sex Cord-Stromal tumors**. **Why Clear Cell Tumor is the correct answer:** **Clear cell tumor** belongs to the **Surface Epithelial** category (along with serous, mucinous, and endometrioid tumors). It is derived from the ovarian surface epithelium or associated endometriosis. It is notably associated with endometriosis and hypercalcemia. **Why the other options are Germ Cell Tumors (GCTs):** Germ cell tumors arise from the primordial germ cells of the ovary. * **Dysgerminoma:** The most common malignant GCT; it is the female counterpart of the testicular seminoma. * **Choriocarcinoma:** A non-gestational GCT that secretes high levels of hCG. * **Teratoma:** The most common GCT overall, categorized into mature (benign/dermoid cyst), immature (malignant), and monodermal (e.g., Struma ovarii). **NEET-PG High-Yield Pearls:** * **Most common ovarian tumor overall:** Serous cystadenoma (Epithelial). * **Most common ovarian tumor in young girls/adolescents:** Germ cell tumors (specifically Dermoid cyst). * **Tumor Markers:** * Dysgerminoma: **LDH**, placental alkaline phosphatase (PLAP). * Yolk Sac Tumor: **Alpha-fetoprotein (AFP)** (Schiller-Duval bodies are pathognomonic). * Choriocarcinoma: **beta-hCG**. * **Clear Cell Carcinoma:** Associated with **Endometriosis** and carries the worst prognosis among epithelial ovarian cancers if diagnosed at advanced stages.

Question 500: Extra-mammary Paget's disease most commonly involves which of the following structures?

A. Vulva (Correct Answer)
B. Vagina
C. Cervix
D. Uterus

Explanation: **Explanation:** **Extramammary Paget’s Disease (EMPD)** is a rare intraepithelial adenocarcinoma that primarily affects skin areas rich in apocrine sweat glands. **1. Why the Vulva is Correct:** The **vulva** is the most common site for EMPD, accounting for approximately 65% of cases. It typically presents in postmenopausal Caucasian women as a well-demarcated, erythematous, eczematous-like rash (often described as "cake-icing" appearance) with associated pruritus. Unlike Paget’s disease of the breast, which is almost always associated with an underlying malignancy, vulvar Paget’s is primary (confined to the epithelium) in about 80-85% of cases. **2. Why Incorrect Options are Wrong:** * **Vagina, Cervix, and Uterus:** These structures are lined by squamous or columnar epithelium but lack the **apocrine glands** necessary for the development of Paget’s disease. While EMPD can rarely spread to the vagina secondary to a vulvar lesion, it does not originate there. **3. NEET-PG High-Yield Clinical Pearls:** * **Pathology:** Characterized by **Paget cells** (large cells with clear/pale cytoplasm and large nuclei). * **Staining:** Paget cells are **PAS positive**, **Alcian blue positive**, and **Mucicarmine positive** (indicating mucin production). They are typically **CEA positive** and **S100 negative** (distinguishing it from melanoma). * **Associated Malignancy:** In 15-20% of cases, EMPD is associated with an underlying internal malignancy (most commonly colorectal or urogenital tract). * **Treatment:** Wide local excision is the gold standard, though recurrence rates are high due to the multifocal nature of the disease.

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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Chemotherapy in Gynecologic Oncology

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Palliative Care in Gynecologic Oncology

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