Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 511: What is the incidence of lymph node metastasis in carcinoma cervix stage II?

A. 5-10%
B. 15-20% (Correct Answer)
C. 25-40%
D. 50-60%

Explanation: The risk of lymph node metastasis in cervical cancer is directly proportional to the clinical stage and the depth of stromal invasion. Understanding these percentages is crucial for NEET-PG as they dictate the transition from surgical management to primary chemoradiation. ### **Explanation of the Correct Answer** In **Stage II** carcinoma cervix (where the tumor extends beyond the uterus but not to the pelvic wall or lower third of the vagina), the incidence of pelvic lymph node metastasis is approximately **25–30%**, while para-aortic node involvement is about **10–15%**. However, standard textbooks (like Shaw’s and Williams Gynecology) often categorize the overall pelvic node risk for Stage II specifically in the **25-40%** range. *Note: There appears to be a discrepancy in the provided key versus standard textbook data. In most standard academic references:* * **Stage I:** 15% (Pelvic) * **Stage II: 25–30% (Pelvic)** * **Stage III:** 45% (Pelvic) If the question specifically refers to **Stage IIa** (early Stage II), the incidence is closer to **20%**. If the provided answer is **15-20%**, it likely refers to the lower end of Stage II or specifically to para-aortic involvement in advanced stages. ### **Analysis of Incorrect Options** * **A (5-10%):** This is too low for Stage II; it more closely reflects Stage IA2 (microinvasive) disease. * **C (25-40%):** This is actually the most accurate range for Stage II pelvic node involvement in major textbooks. * **D (50-60%):** This high incidence is characteristic of Stage III or Stage IV disease. ### **High-Yield Clinical Pearls for NEET-PG** 1. **Primary Route of Spread:** Cervical cancer spreads primarily by **direct extension**, followed by **lymphatic spread**. Hematogenous spread is rare and occurs late. 2. **Sentinel Nodes:** The first nodes involved are usually the **obturator nodes**, followed by external iliac and hypogastric nodes. 3. **Staging System:** Remember that FIGO staging for cervical cancer is now primarily **clinical** but allows for imaging (MRI/CT) and pathological findings where available (FIGO 2018). 4. **Management Shift:** Once lymph nodes are involved (Stage IIIC), the treatment of choice shifts from surgery (Wertheim’s Hysterectomy) to **Concurrent Chemoradiotherapy (CCRT)**.

Question 512: A patient with a history of ovarian cancer is undergoing follow-up. Her CA125 level is elevated. What is the next best step in management?

A. CT scan
B. PET scan (Correct Answer)
C. MRI scan
D. Clinical examination and serial monitoring of CA125 levels

Explanation: ### Explanation In a patient with a history of ovarian cancer, a rising CA125 level during follow-up—often termed **"biochemical recurrence"**—precedes clinical or radiological evidence of disease by several months. **Why PET Scan is the Correct Answer:** The **PET-CT (Positron Emission Tomography)** is the most sensitive imaging modality for detecting recurrent ovarian cancer, especially when CA125 is rising but conventional imaging (CT/MRI) is negative or equivocal. It identifies metabolic activity in small lymph nodes, peritoneal deposits, or distant metastases that may not meet the size criteria for "abnormal" on a standard CT scan. Identifying the exact site of recurrence is crucial to determine if the patient is a candidate for secondary cytoreductive surgery or systemic chemotherapy. **Analysis of Incorrect Options:** * **A. CT Scan:** While often the initial imaging used, CT has lower sensitivity for detecting small peritoneal implants (<1 cm) and sub-centimeter lymph node involvement compared to PET. * **C. MRI Scan:** MRI is excellent for pelvic anatomy and liver metastasis but is less effective than PET for whole-body screening of diffuse peritoneal carcinomatosis. * **D. Clinical examination and serial monitoring:** This is a passive approach. Once CA125 is significantly elevated, it indicates active disease; waiting further delays necessary intervention. **High-Yield Clinical Pearls for NEET-PG:** * **CA125** is the most reliable marker for monitoring treatment response and recurrence in epithelial ovarian cancer (especially serous types). * **Rustin’s Criteria:** Defines CA125 progression as a doubling of the upper limit of normal or a doubling of the previous nadir value. * **Lead-time bias:** While CA125 detects recurrence 3–5 months early, early initiation of chemotherapy based *solely* on CA125 (without symptoms or imaging findings) has not been shown to improve overall survival (MRC OV05 trial). However, for **localization** of disease to plan surgery, PET-CT is the gold standard.

Question 513: Pap smear of a 45-year-old female shows CIN grade III. Which of the following is the next step in management?

A. Punch biopsy
B. Large loop excision
C. Colposcopy directed biopsy (Correct Answer)
D. Cone biopsy

Explanation: ### Explanation The management of an abnormal Pap smear follows a specific diagnostic algorithm: **Screening → Colposcopy → Biopsy → Treatment.** **1. Why Colposcopy-directed biopsy is correct:** A Pap smear is a **cytological screening tool**, not a definitive diagnosis. When a Pap smear indicates a high-grade lesion like CIN III (which falls under HSIL - High-grade Squamous Intraepithelial Lesion), the gold standard next step is to perform a **Colposcopy**. During colposcopy, the cervix is visualized under magnification using acetic acid. The most suspicious areas (acetowhite epithelium, mosaicism, or punctations) are then sampled via a **directed biopsy** to obtain a histological diagnosis. Treatment (like LEEP or Conization) should ideally only be performed after histological confirmation. **2. Why other options are incorrect:** * **A. Punch biopsy:** While a biopsy is needed, a "blind" punch biopsy is suboptimal. Biopsies must be **colposcopy-directed** to ensure the most severe area of the lesion is sampled. * **B. Large Loop Excision (LEEP/LLETZ):** This is a **treatment** modality. While a "see and treat" approach exists for high-grade lesions in some protocols, the standard academic answer for the "next step" after an abnormal smear is diagnostic colposcopy. * **D. Cone biopsy:** This is a diagnostic and therapeutic procedure used when the colposcopy is unsatisfactory (e.g., the transformation zone is not fully visible), there is a discrepancy between cytology and biopsy, or microinvasion is suspected. It is not the immediate next step. ### High-Yield Clinical Pearls for NEET-PG: * **Bethesda System:** Pap smear reports cytology; CIN (Cervical Intraepithelial Neoplasia) is a histological diagnosis. * **Acetic Acid (3-5%):** Used in colposcopy to identify acetowhite areas (reversible protein coagulation). * **Schiller’s Test:** Uses Lugol’s iodine. Normal cells (rich in glycogen) turn **mahogany brown**, while cancerous/CIN cells remain **unstained (yellow)**. * **Management Rule:** If the Pap smear shows HSIL/CIN III, the sequence is: **Colposcopy → Biopsy → LEEP/Cryosurgery/Conization.**

Question 514: Which of the following does not secrete a hormone?

A. Granulosa cell tumor
B. Dysgerminoma (Correct Answer)
C. Hilus cell tumor
D. Theca cell tumor

Explanation: **Explanation:** The correct answer is **Dysgerminoma**. In gynecologic oncology, ovarian tumors are often classified by their ability to produce hormones (functioning tumors) or their lack thereof (non-functioning tumors). **1. Why Dysgerminoma is the correct answer:** Dysgerminoma is a germ cell tumor that is histologically identical to the male seminoma. It is considered a **non-functioning tumor** because it does not inherently secrete hormones. While it is a classic marker for **LDH (Lactate Dehydrogenase)**, it does not produce estrogen or androgens. Note: In rare cases, if it contains syncytiotrophoblastic giant cells, it may secrete low levels of hCG, but it is fundamentally categorized as non-hormonal. **2. Why the other options are incorrect:** * **Granulosa Cell Tumor:** A sex cord-stromal tumor known for secreting high levels of **Estrogen**. It often presents with precocious puberty in children or postmenopausal bleeding in adults. Inhibin B is its specific tumor marker. * **Theca Cell Tumor (Thecoma):** Also a sex cord-stromal tumor, these are almost always benign and are highly associated with **Estrogen** production, often leading to endometrial hyperplasia. * **Hilus Cell Tumor:** A subtype of Sertoli-Leydig cell tumors (pure Leydig cell tumor). These are potent secretors of **Androgens** (testosterone), leading to rapid virilization and hirsutism. Reinke crystals are a pathognomonic histological finding. **NEET-PG High-Yield Pearls:** * **Dysgerminoma:** Most common malignant germ cell tumor in pregnancy and Turner syndrome (gonadal dysgenesis). Highly radiosensitive. * **Tumor Markers:** Dysgerminoma (LDH), Yolk Sac Tumor (AFP), Choriocarcinoma (hCG), Granulosa Cell Tumor (Inhibin). * **Call-Exner Bodies:** Pathognomonic for Granulosa Cell Tumors.

Question 515: What is the cause of vaginal adenocarcinomas in children?

A. Virus
B. Administration of diethylstilbestrol (DES) to pregnant mothers (Correct Answer)
C. Hormonal changes
D. All of the above

Explanation: **Explanation:** The correct answer is **B. Administration of diethylstilbestrol (DES) to pregnant mothers.** **Medical Concept:** Vaginal adenocarcinoma in children and young women is specifically associated with **Clear Cell Adenocarcinoma (CCAC)**. This rare malignancy is a known complication of *in utero* exposure to **Diethylstilbestrol (DES)**, a synthetic non-steroidal estrogen prescribed between the 1940s and 1970s to prevent miscarriages. DES interferes with the normal transformation of the Müllerian epithelium into squamous epithelium in the fetal vagina, leading to **Vaginal Adenosis** (the presence of glandular epithelium in the vagina), which serves as the precursor lesion for CCAC. **Analysis of Incorrect Options:** * **A. Virus:** While Human Papillomavirus (HPV) is the primary cause of Squamous Cell Carcinoma (SCC) of the vagina and cervix, it is not linked to clear cell adenocarcinoma. * **C. Hormonal Changes:** Endogenous hormonal fluctuations during puberty or pregnancy do not cause vaginal adenocarcinoma, although the tumor itself is most commonly diagnosed around age 19 (range 7–30 years). * **D. All of the above:** Incorrect, as the etiology is specifically pharmacological/teratogenic. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** The upper third of the **anterior wall** of the vagina. * **Precursor lesion:** Vaginal Adenosis (found in 90% of DES-exposed females). * **Other DES-related anomalies:** T-shaped uterine cavity, cervical collars/cockscomb cervix, and increased risk of ectopic pregnancy and preterm labor. * **Age of onset:** Typically occurs in late teens or early twenties; any case of vaginal bleeding in a young girl with a history of maternal DES use should raise suspicion.

Question 516: What is the treatment of choice in a patient with carcinoma cervix stage II?

A. Extended hysterectomy
B. Chemotherapy
C. Intracavitatory brachytherapy
D. All of the above (Correct Answer)

Explanation: ### Explanation In the management of Carcinoma Cervix, **Stage II** is divided into IIA (no parametrial involvement) and IIB (parametrial involvement). The treatment approach for Stage II involves a combination of surgery and radiotherapy, often supplemented by chemotherapy to improve outcomes. **Why "All of the above" is correct:** The management of Stage II cervical cancer is multimodal: 1. **Extended Hysterectomy (Type II/III Radical Hysterectomy):** This is the surgical treatment of choice for **Stage IIA1** (lesion <4cm). It involves the removal of the uterus, cervix, upper vagina, and pelvic lymph nodes. 2. **Intracavitary Brachytherapy:** This is a crucial component of **Radiotherapy**, which is the primary treatment for **Stage IIA2 and IIB**. Radiotherapy consists of External Beam Radiation Therapy (EBRT) followed by Brachytherapy to deliver a high dose of radiation directly to the tumor. 3. **Chemotherapy:** For locally advanced stages (IIB onwards), **Concurrent Chemoradiotherapy (CCRT)** using Cisplatin is the gold standard. Chemotherapy acts as a radiosensitizer, enhancing the efficacy of radiation. **Analysis of Options:** * **A, B, and C** are all valid components of the management protocol depending on the specific sub-stage (IIA vs. IIB) and the patient's fitness for surgery. Since the question asks for the treatment of "Stage II" broadly, all listed modalities are utilized in its management. **High-Yield Clinical Pearls for NEET-PG:** * **Stage IIA:** Involvement of the upper 2/3rd of the vagina without parametrial involvement. * **Stage IIB:** Parametrial involvement (but not reaching the pelvic side wall). * **Treatment Cut-off:** Surgery is generally preferred up to Stage IIA1. From Stage IIA2 to IVA, **Concurrent Chemoradiotherapy (CCRT)** is the treatment of choice. * **Drug of Choice:** Cisplatin is the most common radiosensitizer used in cervical cancer.

Question 517: A 25-year-old married nullipara undergoes laparoscopic cystectomy for an ovarian cyst which, on histopathology, reveals ovarian serous cystadenocarcinoma. What should be the next management?

A. Serial Ca-125 measurement and follow-up
B. Hysterectomy and bilateral salpingo-oophorectomy
C. Unilateral salpingo-oophorectomy (Correct Answer)
D. Radiotherapy

Explanation: ### Explanation The core management principle in this scenario is **Fertility-Sparing Surgery (FSS)** for early-stage epithelial ovarian cancer in a young patient of reproductive age. **1. Why Unilateral Salpingo-oophorectomy (USO) is correct:** The patient is a 25-year-old nullipara (desires future fertility) with a diagnosis of serous cystadenocarcinoma. In young patients with **Stage IA** (tumor limited to one ovary, capsule intact) and **Grade 1 (well-differentiated)** tumors, FSS is the standard of care. Since the initial procedure was only a cystectomy (which carries a high risk of rupture and upstaging), a formal **Unilateral Salpingo-oophorectomy** with complete surgical staging (peritoneal washings, omental biopsy, and lymphadenectomy) is required to ensure no residual disease remains while preserving the contralateral ovary and uterus. **2. Why the other options are incorrect:** * **Option A:** Serial Ca-125 is used for monitoring recurrence but is insufficient as primary treatment. A cystectomy alone is inadequate for malignancy due to the risk of microscopic residual disease. * **Option B:** Total Abdominal Hysterectomy (TAH) and Bilateral Salpingo-oophorectomy (BSO) is the standard treatment for postmenopausal women or those who have completed their family. In this 25-year-old, it would cause permanent infertility and surgical menopause. * **Option D:** Radiotherapy has a very limited role in the primary management of epithelial ovarian cancer; it is primarily a chemo-sensitive tumor. **Clinical Pearls for NEET-PG:** * **Criteria for FSS:** Stage IA, Grade 1, young patient desiring fertility, and commitment to long-term follow-up. * **Most common ovarian cancer in young girls:** Germ Cell Tumors (where FSS is possible even in advanced stages). * **Staging:** Ovarian cancer is staged **surgically** (FIGO staging). * **Inadvertent Cystectomy:** If a malignancy is found after a simple cystectomy, the patient must be taken back for completion staging.

Question 518: In cervical cancer, surgery is limited to patients with which stage?

A. Stage I to IIA (Correct Answer)
B. Stage I to IIB
C. Stage I to IIIA
D. Stage I to IIIB

Explanation: **Explanation:** In cervical cancer management, the primary treatment modality is determined by the clinical stage. Surgery is generally reserved for **early-stage disease (Stage I to IIA)**, where the tumor is confined to the cervix or the upper two-thirds of the vagina without involving the parametrium. **1. Why Stage I to IIA is correct:** At these stages, the disease is surgically resectable. Procedures like Radical Hysterectomy (Wertheim’s Hysterectomy) with pelvic lymphadenectomy can achieve clear margins and provide excellent survival rates. Once the cancer reaches **Stage IIB**, it involves the **parametrium**. Surgical clearance of the parametrium is difficult and often results in positive margins; therefore, these patients are better managed with Concurrent Chemoradiotherapy (CCRT). **2. Why other options are incorrect:** * **Stage IIB (Option B):** This stage marks the beginning of "locally advanced" disease. Parametrial involvement makes surgery technically challenging and increases morbidity without improving survival compared to radiotherapy. * **Stage IIIA/IIIB (Options C & D):** These stages involve the lower third of the vagina (IIIA) or extension to the pelvic wall/hydronephrosis (IIIB). These are strictly managed with radiotherapy as surgery is not curative. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Surgery:** Type III Radical Hysterectomy (Meigs' operation) is the classic choice for Stage IB1 and IIA1. * **Fertility Sparing:** Radical Trachelectomy can be considered for Stage IA2 to IB1 in patients wishing to preserve fertility. * **Treatment of Choice for IIB to IVA:** Concurrent Chemoradiotherapy (Cisplatin-based) is the gold standard. * **Stage IVB:** Managed with palliative chemotherapy. * **Most common cause of death:** Uremia due to bilateral ureteric obstruction (post-renal failure).

Question 519: CA 125 is elevated in all of the following conditions EXCEPT:

A. Tuberculosis
B. Endometriosis
C. Ovarian tumor
D. Polycystic ovarian disease (Correct Answer)

Explanation: **Explanation:** CA-125 (Cancer Antigen 125) is a high-molecular-weight glycoprotein produced by derivatives of the **coelomic epithelium**, which includes the lining of the peritoneum, pleura, pericardium, and the epithelial surface of the ovaries. **1. Why Polycystic Ovarian Disease (PCOD) is the correct answer:** In PCOD, the primary pathology involves hormonal imbalances (hyperandrogenism and insulin resistance) and follicular arrest. There is typically no inflammation, irritation, or malignant transformation of the coelomic epithelium or peritoneum. Therefore, CA-125 levels remain within the normal range. **2. Why the other options are incorrect:** * **Ovarian Tumors:** CA-125 is the classic tumor marker for **Epithelial Ovarian Cancer** (especially Serous Cystadenocarcinoma). It is used for monitoring treatment response and detecting recurrence. * **Endometriosis:** This is an inflammatory condition where endometrial tissue grows outside the uterus. The irritation of the peritoneum by ectopic tissue and associated inflammation leads to significant elevations in CA-125. * **Tuberculosis (TB):** Pelvic or peritoneal TB causes chronic inflammation and "granulomatous" irritation of the peritoneal surface. This often leads to **massively elevated CA-125 levels** (sometimes >1000 IU/mL), which can clinically mimic ovarian malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Specificity:** CA-125 is highly sensitive for ovarian cancer but has **low specificity**, as it rises in any condition causing peritoneal irritation (e.g., PID, fibroids, menstruation, pregnancy, or cirrhosis). * **Post-menopausal vs. Pre-menopausal:** A raised CA-125 is more significant for malignancy in post-menopausal women. In pre-menopausal women, benign conditions like endometriosis are more common causes of elevation. * **Marker of Choice:** While CA-125 is for epithelial tumors, remember **LDH** for Dysgerminoma and **AFP** for Yolk Sac Tumors.

Question 520: Which of the following statements about partial mole is false?

A. Usually associated with triploidy
B. Rarely causes persistent gestational trophoblastic neoplasia
C. Usually presents as missed abortions
D. Can be reliably diagnosed by ultrasound in early gestation (Correct Answer)

Explanation: **Explanation:** The correct answer is **D**. Unlike complete hydatidiform moles, which show a classic "snowstorm appearance" on ultrasound, **partial moles are difficult to diagnose reliably via ultrasound**, especially in early gestation. They often mimic a missed or incomplete abortion. Ultrasound may only show a thickened placenta with some cystic spaces or an increased gestational sac diameter, making histopathological examination the gold standard for diagnosis. **Analysis of Options:** * **Option A (True):** Partial moles are almost always **triploid (69, XXX or 69, XXY)**, resulting from the fertilization of a normal ovum by two sperm (dispermy). * **Option B (True):** The risk of persistent Gestational Trophoblastic Neoplasia (GTN) after a partial mole is very low (**<1-5%**), compared to 15-20% after a complete mole. Choriocarcinoma following a partial mole is extremely rare. * **Option C (True):** Most partial moles present clinically as a **missed or incomplete abortion**. Patients often undergo evacuation for a non-viable pregnancy, and the diagnosis of a partial mole is an incidental finding on pathology. **NEET-PG High-Yield Pearls:** * **Karyotype:** Complete Mole = 46,XX (Diploids); Partial Mole = 69,XXX/XXY (Triploid). * **Fetal Tissue:** Present in Partial Mole; Absent in Complete Mole. * **p57 Expression:** Partial moles are **p57 positive** (maternal DNA present), whereas complete moles are **p57 negative** (no maternal DNA). * **hCG Levels:** Markedly elevated in complete moles; only mildly elevated or normal in partial moles.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

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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