Gynecologic Oncology Practice Questions

Q: Most common gestational trophoblastic disease following hydatidiform mole is?

Invasive mole. **Explanation:** Gestational Trophoblastic Disease (GTD) encompasses a spectrum of tumors arising from the placenta. When these conditions become malignant or persist after a pregnancy, they are termed **Gestational Trophoblastic Neoplasia (GTN)**. **1. Why Invasive Mole is Correct:** The most common form of GTN following a hydatidiform mole is an **Invasive Mole** (accounting for approximately 70–80% of cases). It is characterized by the presence of hydropic villi that invade the myometrium. It occurs almost exclusively after a molar pregnancy (more commonly after a complete mole than a partial mole). **2. Why Incorrect Options are Wrong:** * **Choriocarcinoma:** While it is the most aggressive form of GTN, it is less common than an invasive mole following a hydatidiform mole. Notably, choriocarcinoma can follow *any* type of pregnancy (abortion, ectopic, or term birth), whereas invasive moles are specific to post-molar sequences. * **Placental Site Trophoblastic Tumor (PSTT):** This is a rare variant arising from intermediate trophoblasts. It typically follows a term pregnancy and is characterized by low hCG levels and relative resistance to chemotherapy. * **Placental Nodule:** This is generally a benign, incidental finding representing a remnant of a previous pregnancy and does not signify malignant transformation. **High-Yield Clinical Pearls for NEET-PG:** * **Risk of GTN:** After a Complete Hydatidiform Mole, the risk of developing GTN is **15–20%**, whereas after a Partial Mole, it is only **0.5–5%**. * **Diagnosis:** The most important tool for diagnosing post-molar GTN is the **plateau or rise of serial β-hCG levels**. * **Treatment:** Most cases of Invasive Mole are highly sensitive to chemotherapy (Methotrexate is the first-line agent for low-risk cases). * **Metastasis:** The most common site of metastasis for GTN is the **Lungs**, followed by the Vagina.

Q: What is the drug of choice for Choriocarcinoma?

Methotrexate. **Explanation:** **Choriocarcinoma** is a highly malignant, epithelial tumor arising from the trophoblastic cells. It is characterized by high levels of beta-hCG and a remarkable sensitivity to chemotherapy, making it one of the most curable solid tumors. **Why Methotrexate is the Correct Answer:** **Methotrexate (MTX)**, a folate antagonist, is the **drug of choice** for low-risk Gestational Trophoblastic Neoplasia (GTN), including Choriocarcinoma. It works by inhibiting the enzyme dihydrofolate reductase, thereby arresting DNA synthesis in rapidly dividing trophoblastic cells. In low-risk cases (WHO score <7), it is used as single-agent therapy, often administered with Folinic acid (Leucovorin) to minimize systemic toxicity. **Why Other Options are Incorrect:** * **Nitrosourea (e.g., Lomustine):** These are alkylating agents primarily used for brain tumors due to their ability to cross the blood-brain barrier; they have no role in the primary treatment of GTN. * **Gemcitabine:** A pyrimidine antimetabolite used for pancreatic, bladder, and lung cancers, but not indicated for choriocarcinoma. * **Melphalan:** An alkylating agent used mainly in Multiple Myeloma and Ovarian cancer, but it is not a first-line agent for trophoblastic disease. **High-Yield Clinical Pearls for NEET-PG:** * **Staging/Scoring:** Treatment is decided based on the **WHO Modified FIGO Scoring System**. * **Low-Risk (<7):** Single-agent **Methotrexate** or Actinomycin-D. * **High-Risk (≥7):** Multi-agent chemotherapy, with **EMA-CO** (Etoposide, Methotrexate, Actinomycin-D, Cyclophosphamide, Oncovin/Vincristine) being the gold standard. * **Follow-up:** Serial **weekly beta-hCG levels** are mandatory until three consecutive normal values are obtained. * **Metastasis:** The most common site of metastasis for Choriocarcinoma is the **Lungs** (presents as "cannonball" shadows on X-ray).

Q: Postmenopausal bleeding is associated with all of the following except:

Cervical intraepithelial neoplasia (CIN). **Explanation:** Postmenopausal bleeding (PMB) is defined as vaginal bleeding occurring after 12 months of amenorrhea in a woman of menopausal age. It is a "red flag" symptom that must always be investigated to rule out malignancy. **Why CIN is the correct answer:** **Cervical Intraepithelial Neoplasia (CIN)** is a pre-invasive, asymptomatic condition. By definition, the neoplastic cells are confined to the epithelium and have not breached the basement membrane. Therefore, CIN does not cause spontaneous bleeding or tissue friability significant enough to manifest as postmenopausal bleeding. It is typically detected via screening (Pap smear) rather than clinical symptoms. **Analysis of incorrect options:** * **Carcinoma of Cervix:** This is a common cause of PMB in developing countries. Invasive growth leads to surface ulceration and friability of the cervical tissue, resulting in intermenstrual, post-coital, or postmenopausal bleeding. * **Carcinoma of Ovary:** While less common than endometrial causes, certain ovarian tumors (especially Estrogen-secreting Germ Cell or Sex Cord-Stromal tumors like Granulosa cell tumors) can cause endometrial hyperplasia, leading to PMB. * **Endometrial Carcinoma:** This is the most critical diagnosis to exclude in any case of PMB. Approximately 10% of women with PMB will be diagnosed with endometrial cancer. **NEET-PG High-Yield Pearls:** * **Most common cause of PMB:** Senile/Atrophic vaginitis (followed by endometrial polyps and atrophy). * **Most serious cause of PMB:** Endometrial Carcinoma. * **First-line investigation for PMB:** Transvaginal Ultrasound (TVUS). An **endometrial thickness (ET) ≤ 4 mm** has a high negative predictive value for malignancy. * **Gold Standard investigation:** Endometrial biopsy (Pipelle or D&C).

Q: Which of the following ovarian neoplasms shows Rokitansky's protuberance?

Dermoid cyst. ### Explanation **Correct Answer: C. Dermoid cyst** **Why it is correct:** A **Dermoid cyst** (Mature Cystic Teratoma) is a germ cell tumor containing tissues from all three germ layers (ectoderm, mesoderm, and endoderm). The **Rokitansky protuberance** (also known as the *dermoid plug*) is a focal solid projection arising from the inner wall of the cyst. This protuberance is a high-yield diagnostic feature as it typically contains the most diverse tissues, such as hair follicles, sebaceous glands, bone, or even rudimentary teeth. On imaging (USG/CT), it appears as a solid nodule within the fluid-filled cyst. **Why the other options are incorrect:** * **A. Androblastoma (Sertoli-Leydig Cell Tumor):** This is a sex cord-stromal tumor that produces androgens. It is typically solid and does not feature the cystic architecture or the specific protuberance seen in teratomas. * **B. Mucinous cystadenoma:** These are large, multiloculated cysts filled with thick, gelatinous mucoid material. They lack the solid, tissue-rich "plug" characteristic of dermoids. * **D. Papillary serous cystadenoma:** While these may show "papillary projections," these are distinct from Rokitansky’s protuberance. Serous tumors are characterized by Psammoma bodies and thin, watery fluid. **NEET-PG High-Yield Pearls:** * **Most common ovarian tumor in young women:** Dermoid cyst. * **Most common complication:** Torsion (due to high fat content making it buoyant). * **Malignant transformation:** Occurs in <2% of cases, most commonly into **Squamous Cell Carcinoma** (usually arising from the Rokitansky protuberance). * **Radiological Sign:** "Tip of the iceberg" sign on ultrasound (due to acoustic shadowing from hair/sebum).

Q: CA-125 is associated with which of the following?

All of the above. **Explanation:** CA-125 (Cancer Antigen 125) is a high-molecular-weight glycoprotein produced by derivatives of the **coelomic epithelium**. While it is most famously associated with epithelial ovarian cancer, it is **not organ-specific**. It is expressed by various normal tissues (pleura, pericardium, peritoneum, and fallopian tubes) and can be elevated in several malignancies and benign conditions. **Why "All of the above" is correct:** 1. **Ovarian Cancer:** CA-125 is the primary tumor marker for monitoring epithelial ovarian cancer (especially the serous subtype). It is elevated in approximately 80% of advanced cases. 2. **Colon and Breast Cancer:** Because CA-125 is a non-specific marker of epithelial cell turnover and peritoneal irritation, it can be elevated in various non-gynecological malignancies, including colorectal, breast, lung, and pancreatic cancers. **Clinical Pearls for NEET-PG:** * **Specificity:** CA-125 has low specificity. It is elevated in **benign conditions** such as endometriosis, pelvic inflammatory disease (PID), pregnancy, menstruation, and liver cirrhosis. * **Role in Screening:** It is **not** used for mass screening in the general population due to high false-positive rates. It is used for monitoring treatment response and detecting recurrence. * **Post-menopausal Significance:** A high CA-125 in a post-menopausal woman with an adnexal mass is highly suggestive of malignancy. * **Other Markers:** Remember **HE4** (Human Epididymis Protein 4), which is more specific than CA-125 as it is not elevated in endometriosis. The **ROMA index** (Risk of Ovarian Malignancy Algorithm) combines CA-125 and HE4.

Q: Follow-up of low-risk gestational trophoblastic neoplasia (GTN) is done for how long?

12 months. ### Explanation **1. Why 12 months is the correct answer:** Gestational Trophoblastic Neoplasia (GTN) is highly sensitive to chemotherapy, but there is a risk of recurrence, most of which occurs within the first year after achieving remission. For **low-risk GTN** (FIGO Score 0-6), the standard protocol involves monitoring serum **beta-hCG levels** until they normalize (usually three consecutive weekly normal values). Once normalization is achieved, follow-up continues for **12 months**. During this period, hCG is monitored monthly to ensure early detection of relapse. **2. Why the other options are incorrect:** * **3 months (A) & 6 months (B):** These durations are insufficient. While the risk of relapse drops significantly after 6 months, the standard of care remains 12 months to capture late recurrences and ensure a sustained remission before allowing a subsequent pregnancy. * **24 months (D):** This is generally reserved for **high-risk GTN** (FIGO Score ≥7) or patients with placental site trophoblastic tumors (PSTT). High-risk cases have a higher relapse rate and require more prolonged surveillance (often 12–24 months). **3. Clinical Pearls & High-Yield Facts for NEET-PG:** * **Contraception:** Reliable contraception (preferably **Combined Oral Contraceptive Pills**) is mandatory during the entire 12-month follow-up period to prevent pregnancy, which would confound hCG monitoring. * **FIGO Scoring:** Low-risk GTN is defined by a FIGO score of **0–6**; the primary treatment is single-agent chemotherapy (usually **Methotrexate** or Actinomycin-D). * **Remission Definition:** Remission is defined as three consecutive weekly normal hCG levels. * **Follow-up Schedule:** Monthly hCG for 12 months (Low-risk); Monthly hCG for 24 months (High-risk). * **Post-Molar Pregnancy Follow-up:** Note the difference—follow-up for a simple **Hydatidiform Mole** (not yet GTN) is usually 6 months after the first normal hCG.

Q: What is the procedure of choice in a woman with 12 weeks pregnancy and an atypical Pap smear?

Colposcopy. **Explanation:** The management of an abnormal Pap smear in pregnancy follows a conservative approach to prioritize the safety of the fetus while excluding invasive malignancy. **1. Why Colposcopy is the Correct Choice:** In any pregnant patient with an abnormal Pap smear (ASC-US with high-risk HPV, LSIL, HSIL, or ASC-H), the primary goal is to **rule out invasive cervical cancer**. Colposcopy is the gold standard for evaluation. In pregnancy, colposcopy is safe and highly accurate because the transformation zone is usually more visible due to physiological eversion (ectropion). The goal is to identify suspicious areas; biopsies are only performed if invasion is suspected. **2. Why Other Options are Incorrect:** * **Cone Biopsy (A):** This is contraindicated in pregnancy unless there is a strong suspicion of invasive cancer that cannot be confirmed by simple biopsy. It carries a high risk of hemorrhage, miscarriage, and preterm labor. * **MTP with Cone Biopsy (B):** Pregnancy is not an indication for termination in the case of a pre-invasive lesion (CIN). Treatment is typically deferred until 6–8 weeks postpartum. * **Hysterectomy (C):** This is an overtreatment for an atypical Pap smear and would result in fetal loss. It is only considered in advanced, invasive stages where the mother’s life is at immediate risk. **Clinical Pearls for NEET-PG:** * **Biopsy in Pregnancy:** Perform only if colposcopy suggests **invasive disease**. Avoid endocervical curettage (ECC) as it carries a risk of membrane rupture. * **Follow-up:** If CIN II or III is found, the patient is monitored with repeat colposcopy and cytology every 12–24 weeks. Definitive treatment (LEEP/Conization) is deferred until the **postpartum period**. * **Mode of Delivery:** Vaginal delivery is generally safe unless there is clinical evidence of invasive cervical cancer.

Q: Carcinoma of the cervix is commonest at which location?

Squamocolumnar junction. **Explanation:** The correct answer is **D. Squamocolumnar junction (SCJ)**. **Why it is correct:** The cervix is lined by two types of epithelium: the stratified squamous epithelium of the ectocervix and the simple columnar epithelium of the endocervix. The point where these two meet is the **Squamocolumnar Junction (SCJ)**. This area is physiologically dynamic; under the influence of acidity and hormones, the columnar cells undergo **squamous metaplasia** to become squamous cells, creating an area known as the **Transformation Zone (TZ)**. This zone is highly metabolically active and is the site where Human Papillomavirus (HPV) preferentially infects basal cells. Consequently, over 90% of cervical neoplasias (both CIN and invasive carcinoma) originate at the SCJ/Transformation Zone. **Why the other options are incorrect:** * **A. Polo of the vagina:** This is not a standard anatomical term related to cervical cancer pathogenesis. While advanced cervical cancer can involve the vaginal vaults, it does not originate there. * **B. Endocervix:** While Adenocarcinomas arise from the endocervical canal, they represent only about 10-15% of cervical cancers. The majority (Squamous Cell Carcinoma) start at the SCJ. * **C. Erosion:** Cervical erosion (ectropion) is a physiological condition where endocervical columnar epithelium is visible on the ectocervix. While the SCJ is located at the edge of an erosion, the cancer originates from the junctional activity itself, not the "erosion" per se. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (SCC). * **Most common site:** Transformation Zone (specifically the new SCJ). * **Screening:** Pap smears and HPV DNA testing specifically target cells from the Transformation Zone. * **HPV Strains:** HPV 16 (most common for SCC) and HPV 18 (most common for Adenocarcinoma).

Q: A post-menopausal woman presents with a 4-year history of itching over the labia majora, with minimal relief from topical medications. Examination reveals an indurated lesion on the right labia with palpable inguinal lymph nodes. What is the most appropriate management?

Biopsy. ### Explanation The clinical presentation of a post-menopausal woman with chronic, refractory vulvar pruritus (itching) and an indurated lesion is highly suspicious for **Vulvar Carcinoma**. **1. Why Biopsy is the Correct Answer:** In any post-menopausal woman presenting with a chronic vulvar lesion, especially one that is indurated, ulcerated, or non-responsive to medical therapy, the gold standard and mandatory first step is a **wedge biopsy** or **Punch biopsy**. This is essential to rule out malignancy (Squamous Cell Carcinoma) or its precursors (Vulvar Intraepithelial Neoplasia - VIN). The presence of palpable inguinal lymph nodes further increases the suspicion of metastatic spread, making histological confirmation the priority before planning definitive surgical management (like radical vulvectomy and lymphadenectomy). **2. Why Other Options are Incorrect:** * **Options A & B:** Topical steroids (Beclomethasone) or estrogens are used for benign conditions like Lichen Sclerosus or Atrophic Vaginitis. However, using them without a diagnosis in the presence of an indurated lesion delays the diagnosis of cancer. * **Option C:** While lymphadenopathy can be inflammatory, "watchful waiting" with antibiotics is inappropriate when a suspicious primary lesion is present. Malignancy must be ruled out first. **3. Clinical Pearls for NEET-PG:** * **Most common type:** Squamous Cell Carcinoma (SCC) is the most common histological type of vulvar cancer. * **Risk Factors:** HPV (16, 18) in younger patients; Lichen Sclerosus in elderly patients. * **Lymphatic Spread:** Vulvar cancer spreads primarily via lymphatics to the **Inguinal-Femoral nodes** (Sentinel nodes). * **Rule of Thumb:** Any vulvar "wart" or "ulcer" in a post-menopausal woman that does not heal within 2 weeks of conservative treatment must be biopsied.

Q: Which of the following strategies has been recommended to reduce the hereditary risk for ovarian cancer in women with BRCA-1 and BRCA-2 mutations?

Prophylactic oophorectomy. **Explanation:** The primary strategy for reducing the risk of hereditary ovarian cancer in women with **BRCA-1 and BRCA-2 mutations** is **Risk-Reducing Salpingo-Oophorectomy (RRSO)**. **Why the correct answer is right:** BRCA mutations significantly increase the lifetime risk of epithelial ovarian cancer (up to 40% for BRCA-1 and 20% for BRCA-2). Since most "ovarian" cancers in these patients actually originate in the fimbrial end of the **fallopian tube** (Serous Tubal Intraepithelial Carcinoma - STIC), removing both the ovaries and tubes is the most effective preventive measure. RRSO reduces the risk of ovarian/fallopian tube cancer by approximately **80–90%** and also reduces breast cancer risk if performed pre-menopausally. **Why the other options are incorrect:** * **A. Oral Contraceptive Pills (OCPs):** While OCPs are known to reduce the risk of ovarian cancer in the general population and BRCA carriers (by ~50% after 5 years of use), they are considered a **chemopreventive adjunct**, not the definitive risk-reduction strategy compared to surgery. * **B & C. Screening (TVS and CA-125):** Large trials (like UKCTOCS) have shown that screening with Transvaginal Ultrasound and CA-125 **does not** reliably detect ovarian cancer at an early, curable stage or reduce mortality. Therefore, screening is not a substitute for prophylactic surgery. **High-Yield Clinical Pearls for NEET-PG:** * **Timing of RRSO:** Recommended at age **35–40** for BRCA-1 and **40–45** for BRCA-2 (due to later onset of cancer in BRCA-2). * **OCP Benefit:** 5 years of OCP use reduces ovarian cancer risk by 50%. * **Breast Cancer Risk:** BRCA-1 is more strongly associated with Triple Negative Breast Cancer (TNBC).

Question 1

Most common gestational trophoblastic disease following hydatidiform mole is?

Accepted Answer

Invasive mole

Answer

Choriocarcinoma

Answer

Placental site trophoblastic tumor

Answer

Placental nodule

Question 2

What is the drug of choice for Choriocarcinoma?

Accepted Answer

Methotrexate

Answer

Nitrosourea

Answer

Gemcitabine

Answer

Melphalan

Question 3

Postmenopausal bleeding is associated with all of the following except:

Accepted Answer

Cervical intraepithelial neoplasia (CIN)

Answer

Carcinoma of cervix

Answer

Carcinoma of ovary

Answer

Endometrial carcinoma

Question 4

Which of the following ovarian neoplasms shows Rokitansky's protuberance?

Accepted Answer

Dermoid cyst

Answer

Androblastoma

Answer

Mucinous cystadenoma

Answer

Papillary serous cystadenoma

Question 5

CA-125 is associated with which of the following?

Accepted Answer

All of the above

Answer

Colon cancer

Answer

Breast cancer

Answer

Ovarian cancer

Question 6

Follow-up of low-risk gestational trophoblastic neoplasia (GTN) is done for how long?

Accepted Answer

12 months

Answer

3 months

Answer

6 months

Answer

24 months

Question 7

What is the procedure of choice in a woman with 12 weeks pregnancy and an atypical Pap smear?

Accepted Answer

Colposcopy

Answer

Cone biopsy

Answer

MTP with cone biopsy

Answer

Hysterectomy

Question 8

Carcinoma of the cervix is commonest at which location?

Accepted Answer

Squamocolumnar junction

Answer

Polo of the vagina

Answer

Endocervix

Answer

Erosion

Question 9

A post-menopausal woman presents with a 4-year history of itching over the labia majora, with minimal relief from topical medications. Examination reveals an indurated lesion on the right labia with palpable inguinal lymph nodes. What is the most appropriate management?

Accepted Answer

Biopsy

Answer

Topical beclomethasone

Answer

Topical estrogen with antibiotic

Answer

Amoxicillin with clavulanic acid and follow up for lymph node status

Question 10

Which of the following strategies has been recommended to reduce the hereditary risk for ovarian cancer in women with BRCA-1 and BRCA-2 mutations?

Accepted Answer

Prophylactic oophorectomy

Answer

Use of oral contraceptive pills

Answer

Screening with transvaginal ultrasound

Answer

Screening with CA-125

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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