Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 521: Which of the following is a premalignant lesion of the vulva?

A. Kraurosis
B. Leukoplakia (Correct Answer)
C. Condyloma acuminata
D. Localized scleroderma

Explanation: ### Explanation **Correct Answer: B. Leukoplakia** **Why it is correct:** In the context of vulvar pathology, **Leukoplakia** is a clinical term describing a "white patch" that cannot be scraped off. Pathologically, it often represents **Vulvar Intraepithelial Neoplasia (VIN)** or hyperplastic dystrophy with atypia. These lesions are considered premalignant because they exhibit cellular atypia and disordered maturation, which can progress to squamous cell carcinoma (SCC) of the vulva. Modern terminology often classifies these under **differentiated VIN** (associated with Lichen Sclerosus) or **HSIL/uVIN** (associated with high-risk HPV). **Why the other options are incorrect:** * **A. Kraurosis:** This is an archaic term for the clinical appearance of shriveling or atrophy of the vulva, often seen in advanced **Lichen Sclerosus**. While Lichen Sclerosus carries a small risk (approx. 3-5%) of progressing to SCC, the term "Kraurosis" refers to the physical state of atrophy rather than a specific premalignant cellular change. * **C. Condyloma acuminata:** These are genital warts caused by **HPV types 6 and 11** (low-risk). They are benign proliferative lesions and are not considered precursors to malignancy. * **D. Localized scleroderma:** Also known as Morphea, this is a connective tissue disorder characterized by skin thickening. It is an autoimmune/inflammatory condition and has no association with vulvar malignancy. **NEET-PG High-Yield Pearls:** 1. **Most common type of Vulvar Cancer:** Squamous Cell Carcinoma (SCC). 2. **Two Pathways for Vulvar SCC:** * **HPV-related:** Seen in younger women, associated with HPV 16, 18 (uVIN/HSIL). * **Non-HPV related:** Seen in elderly women, associated with Lichen Sclerosus (differentiated VIN). 3. **Paget’s Disease of the Vulva:** Presents as a "red velvety lesion" with white islands. Unlike Paget’s of the breast, it is rarely associated with an underlying internal malignancy (only ~20-30% cases).

Question 522: Carcinoma of the cervix is predisposed by all of the following except:

A. Early marriage
B. Multiparity
C. Nulliparity (Correct Answer)
D. Herpes simplex type II

Explanation: **Explanation:** Carcinoma of the cervix is primarily an **infectious-driven malignancy**, strongly associated with the **Human Papillomavirus (HPV)**. The risk factors are generally linked to early and frequent exposure to the virus through sexual activity. **Why Nulliparity is the Correct Answer:** **Nulliparity** (never having given birth) is actually a **protective factor** for cervical cancer. Conversely, it is a well-known risk factor for *Endometrial* and *Ovarian* cancers. Cervical cancer risk increases with **multiparity** because repeated trauma to the cervix during childbirth, combined with hormonal changes during pregnancy, can facilitate the persistence of HPV infection and the development of lesions at the transformation zone. **Analysis of Other Options:** * **Early Marriage/Early Coitus:** This is a major risk factor because the adolescent cervix has a large area of **ectopy** (columnar epithelium), which is highly susceptible to HPV infection. * **Multiparity:** High parity (usually ≥3 deliveries) increases the risk due to cervical trauma and immunosuppression during pregnancy. * **Herpes Simplex Type II (HSV-2):** While HPV is the primary causative agent, HSV-2 acts as a **co-factor** that promotes oncogenesis by inducing inflammation and cellular damage. **NEET-PG High-Yield Pearls:** * **Most common risk factor:** Early age at first intercourse (usually <18 years). * **Most common HPV types:** 16 (Squamous cell CA) and 18 (Adenocarcinoma). * **Other risk factors:** Multiple sexual partners, smoking (specifically for squamous cell), low socioeconomic status, and long-term OCP use. * **Protective factors:** Barrier contraception (condoms) and HPV vaccination.

Question 523: Which of the following is true about Carcinoma of the cervix?

A. Approximately 90% are associated with HPV infection. (Correct Answer)
B. Nulliparity is a risk factor.
C. Androgens are implicated in its development.
D. It predominantly affects immunocompetent patients.

Explanation: **Explanation:** **Correct Option: A. Approximately 90% are associated with HPV infection.** Human Papillomavirus (HPV) is the primary causative agent in cervical carcinogenesis. High-risk strains, specifically **HPV 16 and 18**, are responsible for about 70% of cases, while overall, HPV DNA is detected in approximately **90–99%** of all cervical cancers. The viral oncoproteins **E6 and E7** bind to and inactivate host tumor suppressor proteins **p53 and Rb**, respectively, leading to uncontrolled cell proliferation. **Why other options are incorrect:** * **B. Nulliparity is a risk factor:** This is incorrect. **Multiparity** (having multiple births) is a known risk factor for cervical cancer. Nulliparity is actually a risk factor for *endometrial* and *ovarian* cancers. * **C. Androgens are implicated:** There is no established link between androgens and cervical cancer. Risk factors are primarily related to sexual behavior (early age at first intercourse, multiple partners) and lifestyle (smoking). * **D. Predominantly affects immunocompetent patients:** While it can affect anyone, **immunocompromised** individuals (e.g., those with HIV/AIDS or transplant recipients) are at a significantly higher risk. In these patients, the immune system fails to clear the HPV infection, leading to persistent infection and rapid progression to malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Screening:** The most common screening method is the **Pap smear** (cytology); however, **HPV DNA testing** is now preferred as the primary screening tool in many guidelines. * **Vaccination:** The **9-valent vaccine (Gardasil 9)** provides the broadest protection. The ideal age for vaccination is 9–14 years. * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), though imaging (MRI/CT) is now incorporated into the 2018 FIGO revision. * **Most common histological type:** Squamous cell carcinoma (~80%).

Question 524: What is the most common pure germ cell tumor of the ovary?

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

Explanation: **Explanation:** **Dysgerminoma** is the most common malignant (pure) germ cell tumor of the ovary, accounting for approximately 50% of all cases. It is the female counterpart of the testicular seminoma. These tumors typically occur in young women (adolescents and those in their 20s) and are characterized by their exquisite sensitivity to radiotherapy and chemotherapy. **Why the other options are incorrect:** * **Choriocarcinoma (Nongestational):** This is an extremely rare and highly aggressive germ cell tumor that secretes high levels of hCG. It is much less common than dysgerminoma. * **Embryonal Cell Tumor:** This is a rare, highly malignant tumor often seen in children and young adults. It usually presents as part of a mixed germ cell tumor rather than a pure form. * **Malignant Teratoma (Immature Teratoma):** While teratomas are common, the malignant (immature) variety is the second most common germ cell malignancy after dysgerminoma, but it does not surpass it in frequency. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Markers:** Dysgerminoma is associated with elevated **LDH** (Lactate Dehydrogenase) and occasionally alkaline phosphatase. * **Histology:** Look for "large round cells with clear cytoplasm and central nuclei" arranged in nests separated by fibrous septa containing **lymphocytes**. * **Association:** It is the most common germ cell tumor associated with **gonadal dysgenesis** (e.g., Swyer syndrome). * **Management:** It is highly radiosensitive, but fertility-sparing surgery followed by chemotherapy (BEP regimen) is the standard of care to preserve reproductive function.

Question 525: What is the primary treatment for stage I carcinoma of the cervix in a 47-year-old female patient?

A. Radiotherapy
B. Chemotherapy
C. Abdominal hysterectomy (Correct Answer)
D. Cone biopsy

Explanation: **Explanation:** The management of Stage I cervical carcinoma depends on the specific sub-stage and the patient's desire to preserve fertility. For a **47-year-old female** (who is likely completed her family), the primary treatment for early-stage disease is surgical. **Why Abdominal Hysterectomy is correct:** In Stage IA1 (microinvasive carcinoma), a **Type I Total Abdominal Hysterectomy (TAH)** is the treatment of choice if fertility is not desired. For Stage IA2 to IB1, a **Radical Hysterectomy (Wertheim’s Hysterectomy)** with pelvic lymphadenectomy is preferred. Since the question specifies Stage I generally and the patient is 47, surgical removal of the uterus is the definitive standard of care. **Why other options are incorrect:** * **Radiotherapy:** While equally effective as surgery for early-stage cervical cancer, it is usually reserved for patients who are medically unfit for surgery or have advanced disease (Stage IIB onwards). In a 47-year-old, surgery is preferred to avoid radiation-induced vaginal fibrosis and to preserve ovarian function (if ovaries are transposed). * **Chemotherapy:** This is not a primary treatment for Stage I. It is used as "concurrent chemoradiation" (usually with Cisplatin) for Stage IIB to IVA or as adjuvant therapy if high-risk factors are found post-surgery. * **Cone Biopsy:** This is a fertility-sparing procedure. It is only indicated for Stage IA1 patients who wish to maintain childbearing potential. At age 47, a more definitive hysterectomy is indicated. **High-Yield Clinical Pearls for NEET-PG:** * **Stage IA1:** Treatment is TAH (if family complete) or Cone biopsy (if fertility desired). * **Stage IB1 to IIA1:** Radical Hysterectomy (Wertheim’s) is the gold standard. * **Stage IIB onwards:** The treatment of choice shifts to **Concurrent Chemoradiotherapy (CCRT)**. * **The most common cause of death** in cervical cancer is uremia due to ureteric obstruction.

Question 526: Cervical carcinoma arises from which anatomical location?

A. Squamocolumnar junction (Correct Answer)
B. Isthmus
C. Cervical anterior lip
D. Internal os

Explanation: **Explanation:** **Cervical carcinoma** most commonly arises from the **Squamocolumnar Junction (SCJ)**, specifically within the **Transformation Zone**. This is the dynamic area where the original stratified squamous epithelium of the ectocervix meets the simple columnar epithelium of the endocervix. The SCJ is physiologically active; under the influence of puberty and pregnancy (acidity), the columnar epithelium undergoes **squamous metaplasia**. This high rate of cell turnover makes the cells highly susceptible to oncogenic triggers, primarily **High-Risk Human Papillomavirus (HPV 16 and 18)**. The integration of viral DNA into these metaplastic cells leads to dysplasia (CIN) and, eventually, invasive carcinoma. **Analysis of Incorrect Options:** * **B. Isthmus:** This is the narrow transition zone between the corpus of the uterus and the cervix. It does not possess the specific metaplastic activity characteristic of the SCJ. * **C. Cervical anterior lip:** While a tumor may physically manifest on the anterior lip, it is a gross anatomical description, not the cellular site of origin. * **D. Internal os:** This marks the upper limit of the endocervical canal. While adenocarcinoma can occur higher in the canal, the vast majority of cervical cancers (especially squamous cell type) originate at the SCJ, which is usually located near the external os in reproductive-aged women. **High-Yield NEET-PG Pearls:** * **Transformation Zone:** The area between the original SCJ and the new SCJ. This is the site sampled during a **Pap Smear**. * **Most common histological type:** Squamous cell carcinoma (80-85%). * **Screening:** The goal of screening is to identify pre-malignant changes at the SCJ before they breach the basement membrane.

Question 527: Which agent is most strongly associated with carcinoma of the cervix?

A. Human Papilloma Virus (Correct Answer)
B. Trichomoniasis
C. Herpes Simplex Virus
D. Calymmatobacterium granulomatis

Explanation: **Explanation:** **Human Papilloma Virus (HPV)** is the primary and essential causative agent for the development of cervical intraepithelial neoplasia (CIN) and invasive cervical carcinoma. High-risk genotypes, specifically **HPV 16 and 18**, are responsible for approximately 70% of all cervical cancers worldwide. The oncogenic potential lies in the viral proteins **E6 and E7**, which bind to and inactivate host tumor suppressor proteins **p53 and pRb**, respectively, leading to uncontrolled cell proliferation. **Analysis of Incorrect Options:** * **Trichomoniasis (B):** Caused by *Trichomonas vaginalis*, this is a common protozoal sexually transmitted infection (STI) that causes vaginitis but has no proven oncogenic potential. * **Herpes Simplex Virus (C):** While HSV-2 was historically considered a potential co-factor, it is not a primary cause of cervical cancer. It typically causes painful vesicular genital lesions. * **Calymmatobacterium granulomatis (D):** Now known as *Klebsiella granulomatis*, this agent causes **Granuloma Inguinale (Donovanosis)**, characterized by painless, beefy-red ulcerative lesions. It is not associated with malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common genotype:** HPV 16 is most associated with Squamous Cell Carcinoma; HPV 18 is more strongly associated with Adenocarcinoma. * **Screening:** The Pap smear targets the **Transformation Zone**, where most cancers arise. * **Vaccination:** The ideal age for HPV vaccination (e.g., Gardasil-9) is 9–14 years, before the onset of sexual activity. * **Co-factors:** Smoking, early age of first intercourse, multiple sexual partners, and immunosuppression (HIV) increase the risk of HPV persistence and progression to cancer.

Question 528: Which of the following statements is NOT related to clear cell carcinoma of the vagina?

A. Common in individuals whose mothers were given diethylstilbestrol during early pregnancy.
B. Vaginal adenosis may progress to this condition.
C. The middle one-third of the vagina is the commonest site. (Correct Answer)
D. May be multicentric and may involve the cervix.

Explanation: **Explanation:** Clear cell carcinoma (CCC) of the vagina is a rare but high-yield malignancy in NEET-PG, primarily associated with **in utero exposure to Diethylstilbestrol (DES)**. **1. Why Option C is the Correct Answer (The False Statement):** The most common site for clear cell carcinoma is the **upper one-third of the anterior vaginal wall**. In contrast, squamous cell carcinoma of the vagina (the most common overall type) typically involves the posterior wall of the upper third. Stating that the middle one-third is the commonest site is anatomically incorrect for CCC. **2. Analysis of Other Options:** * **Option A:** DES was historically prescribed to prevent miscarriages. Female fetuses exposed before the 18th week of gestation have a significantly higher risk of developing CCC, usually between ages 15 and 20. * **Option B:** Vaginal adenosis (the presence of glandular epithelium in the vagina) is a precursor lesion found in nearly all cases of DES-related CCC. While most adenosis is benign, it provides the soil for malignant transformation. * **Option C:** CCC is often **multicentric** and frequently involves the **ectocervix** in addition to the vagina, making it difficult sometimes to determine the exact primary site. **High-Yield Clinical Pearls for NEET-PG:** * **T-shaped uterus:** The most common structural uterine anomaly associated with DES exposure. * **Cockscomb appearance:** A characteristic structural abnormality of the cervix in DES-exposed daughters. * **Microscopic hallmark:** "Hobnail cells" (cells with bulbous nuclei protruding into the lumen). * **Age Distribution:** Unlike other vaginal cancers (which affect postmenopausal women), DES-related CCC peaks in **adolescents and young women**.

Question 529: Cervical intraepithelial neoplasia grade III (CIN III) progresses to invasive carcinoma in what percentage of cases?

A. 25% (Correct Answer)
B. 5%
C. 0%
D. 60%

Explanation: **Explanation:** The progression of Cervical Intraepithelial Neoplasia (CIN) to invasive cervical cancer is a slow, multi-step process. According to classic longitudinal studies (such as those by Richart and Barron), **approximately 25% to 30% of patients with untreated CIN III (High-grade Squamous Intraepithelial Lesion/HSIL) will progress to invasive carcinoma** over a period of 10 to 20 years. * **Why 25% is correct:** While CIN III is a precursor to malignancy, it does not inevitably become cancer in every patient. About 30% may undergo spontaneous regression, and a significant portion remains persistent without invading the basement membrane. The 25% figure represents the established risk of progression if the lesion is left untreated. * **Why 5% is incorrect:** This figure is too low for CIN III; it more closely reflects the progression rate of CIN I (Low-grade Squamous Intraepithelial Lesion). * **Why 0% is incorrect:** CIN III is a high-grade pre-malignant lesion with significant genomic instability; it has a high potential for invasion. * **Why 60% is incorrect:** While the risk is high, 60% overestimates the progression rate. Most CIN III lesions either persist or are cleared by the immune system before reaching the stage of frank invasion. **High-Yield Clinical Pearls for NEET-PG:** * **CIN I:** 60% regress, 30% persist, 10% progress to CIN III, and only 1% progress to cancer. * **CIN II:** 40% regress, 40% persist, 20% progress to CIN III, and 5% progress to cancer. * **CIN III:** 33% regress, <1% progress to cancer (if treated), but **~25-30% progress to cancer (if untreated)**. * **Management:** The standard of care for CIN II and CIN III is **LLETZ/LEEP** or Cold Knife Conization to prevent this progression.

Question 530: Which of the following is NOT an indication for adjuvant radiotherapy in carcinoma of the endometrium?

A. Cervical involvement
B. Lymph node involvement
C. Grade I without myometrial involvement (Correct Answer)
D. Papillary serous tumor

Explanation: **Explanation:** In endometrial carcinoma, the decision to administer adjuvant radiotherapy (RT) is based on the risk of recurrence, which is determined by the FIGO stage, histological grade, and specific high-risk features. **Why Option C is the correct answer:** Grade I tumors without myometrial involvement (Stage IA, Grade 1) are classified as **low-risk**. These patients have an excellent prognosis with surgery alone (total hysterectomy with bilateral salpingo-oophorectomy). The risk of recurrence is minimal (<5%), making adjuvant radiotherapy unnecessary as it would provide no survival benefit while increasing morbidity. **Analysis of Incorrect Options:** * **Cervical involvement (Option A):** This indicates Stage II disease. Involvement of the cervical stroma significantly increases the risk of pelvic recurrence, making adjuvant pelvic radiotherapy a standard recommendation. * **Lymph node involvement (Option B):** This indicates Stage IIIC disease. Positive nodes are a high-risk feature requiring adjuvant therapy (often a combination of chemotherapy and radiation) to control regional and systemic spread. * **Papillary serous tumor (Option D):** This is a Type II endometrial cancer. Regardless of the stage or depth of invasion, these are considered high-grade, aggressive histologies with a high propensity for extrauterine spread, necessitating adjuvant treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Type I Endometrial Cancer:** Estrogen-dependent, endometrioid histology, better prognosis. * **Type II Endometrial Cancer:** Estrogen-independent, Serous/Clear cell histology, p53 mutations, poor prognosis. * **Adjuvant RT Indications:** Generally indicated for Stage IB (Grade 3), Stage II, and Stage III. * **Vaginal Brachytherapy:** Often used for intermediate-risk patients to reduce local vault recurrence. * **Most common site of recurrence:** The vaginal vault.

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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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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