Gynecologic Oncology Practice Questions

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

Superficial inguinal group of lymph nodes. **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**.

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

It is always secondary to a primary malignancy.. **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.

Q: All of the following are germ cell tumors EXCEPT:

Clear cell tumor. **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.

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

Vulva. **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.

Question 1

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

Accepted Answer

Superficial inguinal group of lymph nodes

Answer

Para-aortic group of lymph nodes

Answer

Internal iliac group of lymph nodes

Answer

External iliac group of lymph nodes

Question 2

Which of the following statements regarding Krukenberg tumor is incorrect?

Accepted Answer

It is always secondary to a primary malignancy.

Answer

The most common primary site is the ovary.

Answer

The tumor is often bilateral.

Answer

'Signet ring' looking cells are characteristic.

Question 3

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

Accepted Answer

Wertheim's hysterectomy

Answer

Colposcopy

Answer

Vaginal hysterectomy

Answer

Conization

Question 4

At what age should the first Pap smear be performed?

Accepted Answer

3 years after the first sexual intercourse

Answer

During the first visit to the gynecology outpatient department

Answer

Before 18 years of age

Answer

During the perimenopausal period

Question 5

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?

Accepted Answer

Surgical staging with hysterectomy and bilateral salpingo-oophorectomy, followed by adjuvant chemotherapy

Answer

Maximal cytoreductive surgery

Answer

Hysterectomy and bilateral salpingo-oophorectomy

Answer

Bilateral salpingo-oophorectomy followed by adjuvant chemoradiation

Question 6

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?

Accepted Answer

No further therapy required

Answer

Bone scan to evaluate for metastatic disease

Answer

Radiation therapy

Answer

Pelvic exenteration

Question 7

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?

Accepted Answer

Stage I a

Answer

Stage III a

Answer

Stage III b

Answer

Stage III c

Question 8

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?

Accepted Answer

Radical trachelectomy and pelvic lymph node dissection.

Answer

Cervical conization alone.

Answer

Cervical conization and pelvic lymph node dissection.

Answer

Radical trachelectomy alone.

Question 9

All of the following are germ cell tumors EXCEPT:

Accepted Answer

Clear cell tumor

Answer

Dysgerminoma

Answer

Choriocarcinoma

Answer

Teratoma

Question 10

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

Accepted Answer

Vulva

Answer

Vagina

Answer

Cervix

Answer

Uterus

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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